Tumoral response factors after radiofrequency ablation of hepatocellular carcinoma in cirrhotic liver.

OBJECTIVE: Hepatocellular carcinoma (HCC) ablation by radiofrequency (RFA) is a novel technique with a great variety of methods whose efficacy and predictive factors have not been completely studied. Some of the main predictive factors in this type of treatment are analyzed in the present study. PATIENTS AND METHODS: Ninety-three patients with hepatocellular carcinoma over cirrhosis, and with no indication for surgical resection were treated by RFA. Two different types of electrodes were used for RFA (refrigerated-"Cool-Tip" and perfusion with saline solution, the approach was percutaneous, by laparoscopy or laparotomy. RESULTS: Overall survival at 1, 2 and 3 years was 88, 81, and 76%, with a free-disease survival (FDS) of 66, 31 and 17%, respectively. For tumors less than 3 cm, FDS at 1,2 and 3 years was 74, 44 and 30%, while for more than 3 cm in size FDS was 55, 12 and 0% (p = 0.02). FDS for HCC with one nodule was 70, 36 and 22%, and for more than one nodule it decreased to 50, 17 and 0% at 1, 2 and 3 years, respectively (p = 0.07). Surprisingly, the method employed for RFA has a main influence in FDS, with 0% at 3 years for perfusion electrodes and 26% for cool-tip electrodes at the same period. CONCLUSIONS: In this series, overall survival at three years was relatively high; however, tumoral size, number of nodules and RFS method were independent variables associated with disease-free survival.

Factores de respuesta tumoral tras ablación mediante radiofrecuencia del carcinoma hepatocelular sobre cirrosis / Tumoral response factors after radiofrequency ablation of hepatocellular carcinoma in cirrhotic liver

Objetivo: la ablación por radiofrecuencia del hepatocarcinoma(ARF) es una técnica de reciente adquisición, cuya eficacia yfactores predictivos no han sido suficientemente evaluados. Elpresente estudio fue diseñado para este análisis.Pacientes y métodos: se han tratado 93 pacientes con hepatocarcinomasobre hígado cirrótico sin criterios de resección nide trasplante hepático. El tratamiento se realizó mediante abordajepercutáneo, laparoscópico o mediante laparotomía con dos tiposde electrodos de radiofrecuencia, electrodo refrigerado y deperfusión respectivamente.Resultados: la supervivencia global a los 1, 2 y 3 años fue del88, 81 y 76%, con una supervivencia-libre de enfermedad (SLE)de 66, 31 y 17% respectivamente. El análisis multivariante demostrótres variables predictivas independientes: tamaño tumoral( 3 cm; SLE a 1,2 y 3 años de 74, 44 y 30%,frente a 55, 12 y 0%; HR= 2,02; IC 95% 1,10-3,70; p = 0,02),número de nódulos (uno frente a más de uno; SLE a 1,2 y 3 añosde 70, 36 y 22, frente a 50, 17 y 0%; HR= 1,92 IC 95% 0,95-3,93; p = 0,07) y tipo de electrodo (refrigerado frente a perfusión;SLE 80, 43 y 26% a 1, 2 y 3 años frente a 49, 12 y 0%;HR = 2,06; IC 95% 1,12-3,79; p = 0,02).Conclusiones: a pesar de que la ARF proporciona una supervivenciaglobal aceptable, la SLE es notablemente inferior. El tamañodel tumor, el número de nódulos y el tipo de electrodo deARF fueron variables independientes asociadas a la SLE

Objective: hepatocellular carcinoma (HCC) ablation by radiofrequency(RFA) is a novel technique with a great variety ofmethods whose efficacy and predictive factors have not beencompletely studied. Some of the main predictive factors in thistype of treatment are analyzed in the present study.Patients and methods: ninety-three patients with hepatocellularcarcinoma over cirrhosis, and with no indication for surgicalresection were treated by RFA. Two different types of electrodeswere used for RFA (refrigerated-“Cool-Tip” and perfusion withsaline solution, the approach was percutaneous, by laparoscopyor laparotomy.Results: overall survival at 1, 2 and 3 years was 88, 81, and76%, with a free-disease survival (FDS) of 66, 31 and 17%, respectively.For tumors less than 3 cm, FDS at 1,2 and 3 years was74, 44 and 30%, while for more than 3 cm in size FDS was 55,12 and 0% (p = 0.02). FDS for HCC with one nodule was 70, 36and 22%, and for more than one nodule it decreased to 50, 17and 0% at 1, 2 and 3 years, respectively (p = 0.07). Surprisingly,the method employed for RFA has a main influence in FDS, with0% at 3 years for perfusion electrodes and 26% for cool-tip electrodesat the same period.Conclusions: in this series, overall survival at three years wasrelatively high; however, tumoral size, number of nodules andRFS method were independent variables associated with diseasefreesurvival

Leiomiosarcoma de la vena renal izquierda / Leiomyosarcoma of the left renal vein

Introducción. El leiomiosarcoma representa el 2 por ciento de los tumores de origen vascular. Se trata de una tumoración rara que suele afectar a pacientes de edad media, con una distribución parecida en ambos sexos. Caso clínico. Mujer de 63 años que acudió a urgencias por un dolor lumbar irradiado a la fosa renal izquierda. La ecografía abdominal reveló una masa sólida de 10 cm anterior al riñón izquierdo, cuya dependencia era difícil de establecer. La tomografía axial computarizada confirmó una masa de 12 cm, posiblemente relacionada con un sarcoma retroperitoneal. Se detectó una hidronefrosis del riñón izquierdo que obligó a la colocación de una nefrostomía percutánea. El resultado de la punción mediante aspiración con aguja fina fue compatible con leiomiosarcoma. En la cirugía se halló una tumoración de 15 cm sobre la aorta y el hilio renal izquierdo. Se realizó una disección de la tumoración y una ligadura de la arteria y la vena renal izquierda, con una nefrectomía que incluía la tumoración. El resultado definitivo de la anatomía patológica fue leiomiosarcoma dependiente de la vena renal. Conclusión. A pesar de su rareza, el leiomiosarcoma es el tumor maligno más frecuente en el territorio de la vena cava inferior. El diagnóstico se basa en la clínica y en las pruebas de imagen. Desde el punto de vista terapéutico, la cirugía es de elección. Debe ser completa, con unos márgenes de seguridad de 1 cm. El tratamiento con el que se consiguen supervivencias más prolongadas combina quimioterapia preoperatoria seguida de cirugía radical y quimioterapia posoperatoria. Desde el punto de vista evolutivo, su pronóstico es malo. La localización es el principal factor pronóstico; es peor cuanto más proximales se encuentran situados (AU)

[Bacterial translocation in intestinal transplant]. / Traslocación bacteriana en el trasplante intestinal.

OBJECTIVE: To analyse the influence of ceftriaxone on bacterial translocation and survival after small bowel transplantation in an experimental model with large animals. DESIGN: We performed 21 small bowel transplantation in pigs. Group 1 (n = 5): small bowel transplantation (SBT). Group 2 (n = 5): SBT and immunosuppression with cyclosporine, azathioprine and prednisolone. Group 3 (n = 5): SBT and ceftriaxone. Group 4 (n = 6): SBT, ceftriaxone and immunosuppression. SUBJECTS: Minipig of 25-45 Kg body weight. MEASURES: Blood, spleen, liver, and mesenteric lymph nodes for bacterial culture and biopsy of ileum on postoperative days POD 0.3 and 7. RESULTS: Cultures were positive for bacteria in 22% (10/41) before perfusion, and 43% (28/67) post-reperfusion. Groups 1 and 2: cultures were positive for bacteria in 93% (28/30) on POD 3 degrees, and in 100% (30/30) on POD 7 degrees. Cultures were positive for enterobacteria in 80% (24/30) on POD 3 degrees. Groups 3 and 4: cultures were positive for bacteria in 79.5% (33/41) on POD 3 degrees and in 100% (31/31) on POD 7 degrees. Cultures were positive for enterobacteria in 36.5% (15/41) on POD 3 degrees. Early mortality (before POD 7 degrees), not related with technical complications was 50% (5/10) in groups 1 and 2 and 0% (0/11) in groups 3 and 4. There were no differences with the use of immunosuppression. CONCLUSIONS: Ceftriaxone could decrease bacterial translocation (especially enterobacteria), and early mortality post-small bowel transplantation in pigs.

Hepatectomy including more than half of liver volume with intermittent portal triad occlusion.

INTRODUCTION: Liver resections over 50% of hepatic volume can be achieved with a low morbi-mortality, although occasionally they are followed by severe complications. Postoperative evolution and complications after this type of hepatic resections with intermittent occlusion of the portal triad have been studied. PATIENTS AND METHODS: 13 right hepatectomies, 5 enlarged right hepatectomies and 2 enlarged left hepatectomies were performed consecutively, with intraoperative ultrasound evaluation and intermittent portal triad occlusion. RESULTS: Maximum time of continuous hepatic hilum occlusion was 15 minutes, with a mean isquemia time of 25 +/- 8.6 minutes. Peak of disturbance of hepatic function was at 24 hours and recovered totally at 7th postoperative day. Nine of the 20 patients (45%) did not need intraoperative transfusion and the average of transfusion was 1.8 +/- 1.9 blood units. Four biliary leaks (20%), with no severe hepatic disfunction were observed during postoperative period, and there was no hospital mortality. CONCLUSIONS: Intermittent portal triad occlusion during hepatic resections in more than 50% of liver volume is a safe surgical maneuver.

Combined small bowel and reduced liver transplantation in pigs.

PURPOSE: Small bowel transplantation is a last resort treatment for intestinal insufficiency. Although the disorder is occasionally associated with chronic hepatopathy of variable severity, it may require simultaneous liver transplantation. We present a new model of heterotopic small bowel and reduced partial liver transplantation to an infrahepatic site. SUBJECTS AND METHODS: "Mini-pig" breed pigs weighing 28 to 35 kg were divided into four experimental transplant groups: intestine only (IO) without immunosuppression (group 1A, n = 11); IO with immunosuppression (group 1B, n = 10); intestine + reduced liver (IRL) without immunosuppression (group 2A, n = 12); IRL with immunosuppression (group 2B, n = 10). RESULTS: Overall mortality from technical causes (first 3 days) was 23/43 animals (53.4%). All animals in group 1A displayed rejection, which was the main cause of death. Rejection occurred in 1 animal in each of the other three groups. CONCLUSIONS: Heterotopic small bowel-reduced liver transplant is a multivisceral model that has the technical advantage of not requiring hepatectomy, and the immunological advantages of delayed appearance of acute rejection and the possibility of reducing immunosuppression during the first postoperative days.

[Aneurysms of the splenic artery in patients with liver transplantation]. / Aneurismas de la arteria esplénica en pacientes con trasplante hepático.

Splenic artery aneurysms (SAA) are not uncommon in patients with hepatic transplant (HT). Three in 150 transplanted patients in our institutions were diagnosed with SAA and two of them had a spontaneous rupture. In two patients embolization with interventionist radiology was performed with excellent results. SAA should be investigated before and after HT and be treated with embolization as soon as possible because of the high risk of rupture.

[Arterial revascularization of liver graft with PTFE vascular prosthesis]. / Revascularización arterial de injerto hepático con prótesis vascular de PTFE.

When the hepatic artery is not available in liver transplantation because of its bad quality or low flow, arterial grafts from the donor have to be used to obtain arterial blood flow from the aorta. The case of use of a vascular PTFE prosthesis when no vascular grafts were available is presented, with good outcome 6 months after transplantation.

[The response to hepatitis B vaccine prior to orthotopic liver transplantation]. / Respuesta a la vacuna de la hepatitis B previa al trasplante hepático ortotópico.

UNLABELLED: HBV hepatitis is a severe complication of orthotopic liver transplantation (OLT) due to the immunosuppression therapy. OBJECTIVES: The aim of this study is to evaluate the efficacy of the active HBV immunization on these patients before OLT. PATIENTS AND METHODS: This was a prospective trial, with 34 patients (20 M and 14 F), that received a double dose (40 micrograms) of HBV surface proteic Ag, on the 0th, 30th and 60th days of the study and posterior control of anti-HBs levels. If there wasn't a response, they received two more doses on the 90th and 120th days. RESULTS: There was a seroconversion in 22 patients (64.7%). Chronic alcoholism determined a lower rate of response than other etiologies (p < 0.05); this was the same in HCV chronic liver disease (p < 0.01). During their follow up, two patients had acute HBV hepatitis: one of them presented a negative response from the beginning, and in the other, anti-HBs developed transiently, when the HBV markers appeared. CONCLUSIONS: Previous HBV active immunization in OLT patients with double dose in a quick sequence, determined a positive response in a high number of patients with a higher rate of seroconversion than in other studies. The response was not so high in patients with chronic alcoholism or HVC chronic liver disease. We conclude that HVB vaccination should be done in these patients.

[The liver transplant program of the Hospital General Universitario Gregorio Marañón: an analysis of the first 100 patients]. / Programa de trasplante hepático del Hospital General Universitario Gregorio Marañón: análisis de los 100 primeros pacientes.

During a 3-year period between 1990 and 1993, 100 patients received orthotopic liver transplantation at the "Gregorio Marañón" University General Hospital. The mean age of the patients was relatively high (46.9 +/- 10 years), with an important number of cirrhotic patients (91%). The rate of primary liver failure was relatively low (4.5% of transplantations) although 12 cases with more than 55 years were included in the present series. Eleven retransplantations were performed, 8 for early failure of the graft and 3 for chronic failure. Postoperative complications of the graft were vascular in 9 cases, biliary in 17 cases, and acute rejection (cellular) in 70 patients, although only 50 of these patients required treatment with steroid boluses. Infections were diagnosed in 60 cases with 80% of major infections, 6 of them caused by Aspergillus fumigatus that were lethal in all the cases. Postoperative survival was 82%, 72%, 69% and 69% at 1 month, 6 months, 1 year and 2 years respectively.

[Resection of recurrent hepatocarcinoma on a transplanted liver]. / Resección de hepatocarcinoma recidivante sobre hígado trasplantado.

Recurrence of hepatocellular carcinoma is rarely treated by surgical resection and has not been reported in the main series of liver transplantation. In this paper we present the case of a patient transplanted for hepatocellular carcinoma on cirrhosis who developed a tumoral recurrence in the transplanted liver four months later. The new tumor was removed by hepatectomy and the patient is free of tumor 24 months after resection. Surgical resection should be considered a treatment of tumoral recurrence after liver transplantation as is done after hepatectomy.

[Effect of antibiotic prophylaxis with vancomycin on methicillin-resistant Staphylococcus aureus infection following liver transplantation]. / Efecto de la profilaxis antibiótoca con vancomicina sobre la infección por Estafilococo aureus resistente a meticilina tras el trasplante hepático.

An epidemic outbreak of Methicillin-resistant Staphylococcus Aureus (MRSA) infections affecting liver transplantation patients was detected in our hospital. In this study we describe the special characteristics of the infections and the results of prophylactic treatment with Vancomycin. Between april 1990 and december 1991, 47 patients with mean age of 54.4 +/- 10 years underwent liver transplantation. The patients were included in two chronological groups: 1) Group I: 20 patients not treated prophylactically with Vancomycin; 2) Group II: 27 consecutive patients treated with Vancomycin. Systematical cultures of body fluids for bacteria and fungi were done in every patient, and were repeated after 24 hours. The cultures were repeated again in case of sepsis. Group I patients had a significantly higher frequency of MRSA infections than group II patients. Furthermore, in patients with MRSA infection, independently of the group, duration of transplantation (p < 0.01), reoperations (p < 0.001) and prophylactic treatment with Vancomycin (p < 0.001) were significative factors. In conclusion, Vancomycin appears to be an elective prophylactic antibiotic in case of high risk of MRSA sepsis after liver transplantation.

Evaluation of surgical and anesthetic strategy as a key factor in the postoperative results of liver transplant.

Since the inauguration of our liver transplant program two years ago, retrospectively we can distinguish two different periods as regards postoperative results. The patients studied were distributed in two groups by chronological order and date of introduction of an improved surgical and anesthetic strategy: retrohepatic dissection during the veno-venous bypass phase and meticulous hemostasis in the anhepatic phase: Group A: 11 transplants in 10 patients and Group B: 22 transplants in 21 patients. Preoperatively, both groups were homogeneous with respect to the clinical situation. During the operation, significantly larger transfusion volumes were given in group A (25.4 +/- 10.5 ml/kg/hr) than in group B (10.0 +/- 5.7 ml/kg/hr) (p less than 0.01). The anhepatic phase lasted 1'50" +/- 20" in group B (p less than 0.05). The postoperative outcome of group B was better than that of A as regards hemodynamic and respiratory parameters, functional impairment of the graft and mortality (p less than 0.05). We conclude that the realization of retrohepatic dissection and careful hemostasis during the anhepatic phase, which prolongs the duration of venovenous by-pass but does not increase intraoperative morbidity, reduces the need for blood transfusion, and yields better postoperative results.

[Early and late results of orthotopic liver transplantation]. / Früh- und Spätresultate nach orthotoper Lebertransplantation.

Between 4/1986 to 1/1989, 74 orthotopic liver transplantation were performed in 62 patients (62 first liver transplants, 10 as second graft and two as a third graft); 57 in adults and 17 in children. The main indication for the operation was liver cirrhosis (61.4%) (the most frequent etiology was alcoholic cirrhosis, 28.5%). Six cirrhotic patients had a hepatocarcinoma (9.6%). Two received a liver and kidney transplant due to terminal renal insufficiency and hemodialysis. The most frequent indication in children was biliary atresia (33.3%). Six patients had a fulminal liver failure (9.6%). AB0 blood group compatibility was identical in 87.5%, compatible in six and incompatible in three patients. Total orthotopic liver transplantation was performed in 67 patients, and size-reduced liver was indicated in 7 patients. Extracorporeal veno-venous bypass was used in adults but never in children. In 93.1% of the transplants a single hepatic artery was anastomosed to the recipient and in 6.9% a double anastomosis was performed. In 62.5% of the patients a end-to-end choledocho-choledochostomy was performed and in 34.8% hepatico-jejunostomy was indicated. Three months postoperative mortality rate was 12.9%. Arterial stenosis and thrombosis were the most frequent complication.

Transplante hepatico: opcao terapeutica do trauma hepatico / Liver transplantation: a therapeutic option in the liver trauma

Um paciente com traumatismo hepatico consequente de um acidente automobilistico foi submetido a transplante hepatico como unica alternativa de tratamento. O transplante foi indicado ao associar-se uma lesao extensa do lobo hepatico direito a uma lesao irreparavel da porta hepatica esquerda. Pacientes com traumatismo hepatico extenso devem ser transferidos a um servico de transplante o mais breve possivel.

Transplante hepatico: experiencia do Hospital 12 de Octubre de Madrid / Liver transplantat: experience of the 12 de Octubre Hospital of Madrid

No periodo compreendido entre abril de 1986 e janeiro de 1989, foram realizados no Hospital 12 de Octubre de Madrid (Espanha), 74 transplantes hepaticos ortotopicos em 62 pacientes (38 do sexo masculino e 24 do sexo feminino). A idade media dos receptores foi de 35,7 por cento anos (limites de 18 meses a 62 anos). A indicacao mais frequente nos adultos foi a cirrose hepatica (61,4 por cento ), sendo que em 10 pacientes (28,5 por cento ) foi de origem etilica. Seis pacientes apresentavam hepatocarcinoma sobre um figado cirrotico (9,6 por cento ). Dois pacientes receberam duplo transplante hepato-renal. A indicacao preferente na idade pediatrica foi a atresia das vias biliares, seguida da insuficiencia hepatica primaria por hepatite fulminante. Foram realizados 68 transplantes totais e 6 parciais (figado esquerdo). Em todos os adultos e em um transplante pediatrico, se instalou o circuito extracorporeo parcial. Em 67 transplante se praticou uma unica anastomose arterial (93,1 por cento ) e nos cinco restantes, foi necessario realizar duas anastomoses independentes. As arterias dos receptores mais frequentemente utilizadas foram a arteria hepatica direita (23,6 por cento ) e a arteria hepatica primitiva (23,6 por cento ). A reconstrucao biliar foi realizada mediante coledoco-coledocostomia em 65,2 por cento dos transplantes. O retransplante foi realizado em 12 ocasioes.