[Disseminated fungal infection due to Magnusiomyces capitatus in a liver graft patient]. / Infection fongique disséminée à Magnusiomyces capitatus chez un patient transplanté hépatique.

Disseminated fungal infections due to Magnusiomyces capitatus are rare, occurring exclusively in immunocompromised patients. We report the first case in a liver transplant patient with chronic rejection and portal thrombosis who had a M. capitatus fungemia with a refractory septic shock. Despite an antibacterial and antifungal treatment with caspofungin empirical treatment, the patient died from multiple organ failure. Subsequently, mycological examinations of blood cultures, bronchoalveolar lavage fluid and urine were positive to M. capitatus identified by mass spectrometry and confirmed by sequencing respectively. The stain was resistant to caspofungin and fluconazole. The best treatment appears to be the combination of amphotericin B and voriconazole or amphotericin B and 5 fluorocytosine.

Outcome of exfoliative rejection after isolated intestinal transplantation in an adult: case report.

A 34-year-old-man with short-bowel syndrome received an isolated small bowel graft. On postoperative day (POD) 11, ileal biopsy specimen demonstrated mild to moderate rejection that did not respond to corticosteroid bolus therapy. On POD 14, endoscopy and histologic examination revealed exfoliative rejection that was not controlled after 14 days of therapy with thymoglobulin. On POD 95, the patient underwent surgery again because of intestinal obstruction. The graft was removed 6 months after transplantation because of continuous severe abdominal pain with weight loss. After enterectomy, the patient developed multiple-organ failure and died on POD day 8. This case underlines the severity of exfoliative rejection and suggests that early enterectomy be performed when the diagnosis is made, before deterioration of clinical status and development of infectious and nutritional complications.

Improvement of surgical antibiotic prophylaxis: a prospective evaluation of personalized antibiotic kits.

This prospective study compared personalized surgical antibiotic prophylaxis kits (SAPKs) with freely prescribed antibiotics. SAPKs use significantly enhanced national guidelines on surgical antibiotic prophylaxis application (82% vs 41%, P < 0.001), and result in limited errors in terms of antibiotic choice (3% vs 28%, P < 0.001), timing of administration (12% vs 24%, P = 0.003) and prophylaxis duration (1.5% vs 22%, P < 0.001), thereby demonstrating their effectiveness.

Comparison of manufacturers' specifications for 44 types of heat and moisture exchanging filters.

BACKGROUND: Although heat and moisture exchanging filters (HMEF) are recommended for use during anaesthesia, the criteria for choosing a filter are not clearly defined. Manufacturers offer many different types of HMEF with various technical characteristics. We compared the technical specifications provided by the manufacturers for different types of HMEF. METHODS: Filter manufacturers were asked to provide technical information. Additional information was obtained from websites. Information about 44 filters (16 mechanical and 28 electrostatic) was collated. RESULTS: Filter performances were estimated with different sizes of microorganism and durations of challenge. Twenty-eight filters had not been tested by independent laboratories. For 12 of the filters, information obtained from websites and from the manufacturers differed. Most filter specifications claimed high efficiency, particularly for filtration, microbial challenge number and test duration. Electrostatic filters used in anaesthesia were claimed to have high filtration efficiency, similar to the efficiency provided by mechanical filters. Excluding moisture output values did not alter the general conclusions. CONCLUSIONS: Technical aspects of the tests, international standards, and independent validation should be considered when a filter is chosen.

[Assessment of 44 heat and moisture exchange filters. What to choose?]. / Evaluation de 44 filtres échangeurs de chaleur et d'humidité. Que choisir?

OBJECTIVES: If the use of heat and moisture exchange filter (HMEF) in anaesthesia is recommended by the French Society of Anaesthesia and Intensive Care (SFAR), the criteria's choice are not clearly defined. Many HMEF are proposed by manufacturers which technical characteristics are different. STUDY DESIGN: The aim of this study was to evaluate the HMEF using items of the American Association of Respiratory Care (AARC) and technical dossiers. METHODS: All manufactures producing filters have been contacted to give their technical dossiers. Forty-eight filters have been analyzed (13 mechanical filters, 31 electrostatic filters). Each item has been scaled 0, 5 or 10. The final result was on 10. RESULTS: Seventeen filters had a note superior to 5. There were 8 mechanical filters and 9 electrostatic filters. The difference between the filters was the size of the micro-organisms tested and the duration of the test. Some filters were not tested by independent laboratories (N = 8). There were differences between the commercial documentation and on Internet and the technical dossiers (N = 12). DISCUSSION: We noted the good quality of the filters particularly concerning criters recommended by the Sfar (filter medium, filtration efficiency, microbial challenge number and duration of the test). The electrostatic filters recently used in anaesthesia have high performance concerning filtration efficiency. To supprime the moisture output criteria did not change the results. CONCLUSIONS: Criteria's used by manufactures to evaluate there filters are not always precised or too restrictive. The technical tests, the international norms, the certificates of validation, the ergonomic qualities and the definition of our needs are the main elements of choice of a filter.

Hepatic disposition of alfentanil and sufentanil in patients undergoing orthotopic liver transplantation.

Alfentanil and sufentanil are used in the anesthetic management of patients undergoing orthotopic liver transplantation (OLT) and are extensively metabolized by the liver. We examined the influence of OLT on the removal of these opioids. 14 patients undergoing OLT were given either alfentanil (40 micrograms/kg intravenous [IV] bolus) or sufentanil (5 micrograms/kg IV bolus) during the induction of anesthesia, followed by infusion during surgery (1 microgram.kg-1.min-1 alfentanil or 0.01 microgram.kg-1.min-1 sufentanil) and the postoperative period (0.5 microgram.kg-1.min-1 or 0.005 microgram.kg-1.min-1). A catheter was inserted into the hepatic vein to determine the drugs' hepatic extraction coefficient and hepatic clearance. The hepatic extraction coefficient was 0.14 for alfentanil and 0.35 for sufentanil. The total and hepatic clearance of alfentanil were similar, while the hepatic clearance of sufentanil was 50% of the total clearance (P < 0.05). The total clearance of alfentanil was significantly linked to its hepatic clearance (r2 = 0.81, P < 0.001). We conclude that the total clearance of sufentanil is greater than its hepatic clearance. This difference suggests that there is extrahepatic metabolism of sufentanil in patients undergoing OLT.

Intravenous nicardipine does not alter hepatic blood flow after orthotopic liver transplant.

OBJECTIVE: To evaluate the effects of nicardipine on hepatic blood flow in patients with recent liver transplants. Secondly, to evaluate the liver extraction of nicardipine in order to determine the influence of liver transplantation on its disposition. DESIGN: Prospective self-controlled clinical study. SETTING: University hospital intensive care unit. PATIENTS: Eight patients in the early postoperative period of orthotopic liver transplantation. MEASUREMENTS AND RESULTS: Patients were given 5 mg of i.v. nicardipine. Systemic and splanchnic haemodynamic and metabolic parameters were measured before nicardipine administration (T0) and at 5 min (T1), 30 min (T2), and 120 min (T3) after administration. A catheter was inserted into a hepatic vein to determine the total hepatic blood flow (HBF) and the hepatic extraction coefficient of nicardipine. Nicardipine caused no significant changes in HBF, oxygen delivery, oxygen uptake, hepatic venous oxygen saturation, or the hepatic venous partial pressure of oxygen. Likewise, neither blood lactate concentrations nor arterial and hepatic venous lactate-pyruvate ratios were modified by nicardipine. The hepatic extraction coefficient of nicardipine was approximately 0.70 in the first 3 min after complete infusion, then decreased and remained stable at approximately 0.50, showing a non-linear first-pass metabolism pattern. CONCLUSIONS: Nicardipine administration after liver transplantation appears to have no deleterious effects on HBF. Nicardipine can be classified as a drug of intermediate hepatic extraction coefficient, whose elimination partly depends on hepatic enzyme activity.

[Course of the recurrence of hepatitis C virus infection after liver transplantation]. / Evolution de la récidive de l'infection par le virus de l'hépatite C après transplantation hépatique.

OBJECTIVES: Hepatitis C virus recurrence is frequent after orthotopic liver transplantation. The aim of this study was to evaluate the clinical, biological, and histological characteristics of recurrence. METHODS: One hundred and ten patients (91 males, mean age 49 years) with liver transplantation were followed up for more than 1 year (mean: 26 months, range: 12-71). Hepatitis C virus serologic 2nd generation tests were performed before and every 3 months after transplantation in all patients. Serum RNA was detected every 6 months after transplantation by polymerase chain reaction. A percutaneous liver biopsy was performed every year in all patients and in case of abnormal biological liver tests. RESULTS: In 44 patients (40%), hepatitis C virus serology was positive before transplantation, and was unchanged after transplantation. In this group histologic chronic hepatitis was observed in 35 patients (79.5%). The mean Knodell score was 8.4 +/- 2.3, associated with an increase in serum aminotransferases (> twice the upper limit of normal) in 26 cases (74.3%) and with serum RNA in 33 cases (94.3%). The Knodell score was not significantly higher 2 years or more after transplantation than before (9.5 +/- 3.9 vs 7.2 +/- 3.5). In 66 patients with negative hepatitis C virus serology before transplantation, no changes were noted after transplantation. In this group, histologic chronic hepatitis was found in 14 cases (21.2%) associated with serum hepatitis C virus RNA in 7 cases. Actuarial survival rates of the two groups were 97.1% and 91.2% at 2 years, and 93.5% and 86.7% at 5 years, respectively. No death clearly related to hepatitis C virus recurrence was observed. CONCLUSION: Hepatitis C virus recurrence after liver transplantation is frequently associated with chronic hepatitis, and a progressive increase in liver lesions. Nevertheless, the 5-year survival rates was not different in these patients compared to patients with negative hepatitis C virus serology before transplantation.

Recurrence of hepatitis C virus after liver transplantation.

The hepatitis C virus is a common cause of chronic hepatitis after orthotopic liver transplantation (OLT). We evaluated 95 consecutive patients who underwent OLT at our institute between March 1988 and November 1992 and who had a follow-up period longer than 3 months. All patients had a second-generation test (ELISA + RIBA) for HCV antibodies (HCV Ab) before and monthly after OLT; all had a polymerase chain reaction (PCR) test for detection of viral RNA after the operation. Whenever biochemical abnormalities (hypertransaminasemia 2 times the normal range) were seen, a percutaneous liver biopsy was performed. Forty-two HCV Ab+ patients before OLT remained positive after OLT. In this group the PCR test was positive in 32 cases (78.5%). In 13/42 (30.9%) cases (all PCR+) with hypertransaminasemia histological examination showed signs of viral C hepatitis (score of Knodell minimum 3, maximum 12, median 5.5). Of 53 HCV Ab patients before OLT, only 1 became HCV Ab+ and PCR+ 15 months after OLT. In the remaining 52 patients 15 were PCR+. Twenty of 53 patients (37.7%) had a liver biopsy because of hypertransaminasemia: in no case did histology show any signs of hepatitis C. In conclusion, viral C recurs often after OLT for post-hepatitic C cirrhosis. The histological graft lesions are in most cases moderate. We did not observe any deaths related to viral C infection in grafted patients. According to our results post-hepatic C cirrhosis remains a good indication for OLT.

[Biliary complications after a liver transplant]. / Complicanze biliari dopo trapianto epatico.

Biliary tract complications are still an important source of morbidity and mortality after liver transplantation. Between March 1988 and September 1991 we performed 111 liver transplants in 109 patients (84 men and 25 women, mean age 44.5 +/- 1.1 year). Biliary tract reconstruction was via a choledocho-choledochostomy (n = 107) or via a Roux limb choledochojejunostomy (n = 4). Ten biliary complications (11.9%) occurred (6 biliary leakage, 3 biliary strictures, 1 biliary cast syndrome). Five patients (5.9%) necessitated operative repair (Roux limb choledochojejunostomy). No death was related to biliary tract complication.

[Orthotopic liver transplantation and hepatocellular carcinoma]. / Trapianto ortotopico di fegato e carcinoma epatocellulare.

Nineteen orthotopic liver transplantations (OLT) were performed in patients with hepatocellular carcinoma, between March 1988 and December 1990, in our Department. Thirteen patients (68.4%), 10 men and 3 women, mean age 48.2 +/- 2.8 years, were clear cut neoplastic disease, six patients (31.6%), 4 men and 2 women, mean age 48.6 +/- 4.2 years, were incidental tumors. Three years survival rate was 20% in clear cut neoplastic diseases (4 patients died for neoplastic recurrence) and 66% in incidental tumors. Our results demonstrate that liver transplantation for hepatobiliary malignancy is still justified, patient selection is important in predicting outcome.

[Liver transplantation for hepatocellular carcinoma. Mid-term results]. / Transplantation hépatique pour carcinome hépatocellulaire. Résultats à moyen terme.

The results of liver transplantation for hepatocellular carcinoma are disappointing. Thus, in 11 patients transplanted for hepatocellular carcinoma on cirrhosis, the actuarial survival rate at 3 years was 20 percent, with a postoperative mortality of 27 percent and 4 deaths caused by recurrence of the malignancy. These poor results contrast with those we obtained after liver transplantation for cirrhosis and finding of incidental hepatocellular carcinoma in the resected part of the liver. Out of 6 patients with incidental carcinoma only 1 died postoperatively (16.6 percent), and no case of recurrent malignancy was observed. These results confirm that the malignancy recurrence rate is high after transplantation for large carcinoma. On the other hand, the absence of recurrence after transplantation for incidental hepatocellular carcinoma encourages us to look for small carcinomas on cirrhosis.

[Recurrence of virus B hepatitis after liver transplantation]. / Récidive du virus de l'hépatite B après transplantation hépatique.

Thirty-three HBs antigen positive patients without signs of viral replication underwent orthotopic liver transplantation and received long term passive immunoprophylaxis with anti-HBs immunoglobulins at high doses perioperatively and then at a dose of 10,000 IU every month. All patients became negative during the first 6 months following surgery. At 34 months the survival rate was 67 percent and the actuarial recurrence rate of serum HBs antigen was 7.1 percent. Reappearance of HBs antigen was associated with evidence of HBV replication and histological alterations of the graft. In our experience, long term passive immunoprophylaxis reduces HBV reinfection of the grafted liver.

[Treatment of duodenal ulcer by posterior trunk vagotomy and anterior fundic seromyotomy under video-laparoscopy. Preliminary note with presentation of a film]. / Traitement de l'ulcère duodénal par vagotomie tronculaire postérieure et séromyotomie fundique antérieure sous vidéo-laparoscopie. Note préliminaire avec présentation de film.

Posterior vagotomy associated with anterior fundic seromyotomy, as proposed by Taylor in 1979 and widely used since then, has been performed under video laparoscopic monitoring in 6 patients with inveterate chronic duodenal ulcer. The procedure described here produced no complications in the immediate postoperative period and early progress in the controlled healing of the ulcer and the reduction of acidity, which can be compared to those of the same procedure with laparotomy.