Rapid temporary portosystemic bypass.

Extracorporeal venovenous bypass has been almost eliminated by the use of piggyback orthotopic liver transplantation. In some instances, a temporary internal portocaval shunt is constructed to relieve hemodynamic instability. We describe a quick and simple technique in which a short plastic cannula is used to bridge the distance between portal vein and IVC.

Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.

A prospective, randomized trial to compare tacrolimus and prednisone with and without mycophenolate mofetil in patients undergoing renal transplantation: first report.

PURPOSE: Between September 20, 1995 and September 20, 1996, 120 patients were entered into a prospective, randomized trial comparing tacrolimus and prednisone with (61) and without (59) 2 gm. mycophenolate mofetil daily to determine whether mycophenolate mofetil was associated with a lower incidence of rejection. MATERIALS AND METHODS: Mean recipient age plus or minus standard deviation was 50.8+/-14.1 years (range 18.8 to 84.1). Mean donor age was 34.3+/-21.7 years (range 0.01 to 76). Of the donors 18 (15%) were older than 60 years. Mean cold ischemia time was 30.9+/-8.4 hours (range 14.2 to 49). Median followup was 8.6+/-0.5 months. RESULTS: The 6-month actuarial patient survival was 95%, 92% in the double therapy group and 98% in the triple therapy group (not significant). The 6-month actuarial graft survival was 88%, 84% in the double therapy group and 92% in the triple therapy group (not significant). The overall incidence of rejection and steroid resistant rejection was 34.2 and 4.2%, respectively. There was a strong trend toward less rejection in the mycophenolate mofetil group than in the double therapy group (26.2 versus 42.4%). Crossover was common, and was 42.6% from triple to double therapy and 18.6% from double to triple therapy. The reasons for discontinuation of mycophenolate mofetil were gastrointestinal toxicity, primarily diarrhea, or less commonly hematological toxicity, primarily neutropenia or thrombocytopenia. Gastrointestinal toxicity was ameliorated by separating the doses of tacrolimus and mycophenolate mofetil by 2 to 4 hours, and reducing the dose to 1 gm. daily. CONCLUSIONS: Mycophenolate mofetil appears to be a useful third agent with tacrolimus in patients undergoing renal transplantation, and is associated with a reduction in the rate of rejection and a low incidence of steroid resistant rejection. There is a high incidence of gastrointestinal toxicity associated with the 2 gm. daily dose but this complication is relatively straightforward to manage.

Clinical outcome of patients infected with hepatitis C virus infection on survival after primary liver transplantation under tacrolimus.

The outcome of hepatitis C virus (HCV) infection on patient and graft survival after orthotopic liver transplantation (OLT) has been controversial. An earlier experience with a higher dose of tacrolimus (>/=0.1 mg/kg/d intravenously and >/=0.2 mg/kg/d orally) was associated with a worse clinical outcome in patients infected with HCV. The clinical outcome of 183 liver transplant recipients with end-stage liver disease (ESLD) secondary to HCV infection (HCV group) was compared with a contemporary cohort of 556 patients with HCV infection who underwent transplantation for nonviral, nonmalignant ESLD (control group). All patients were prospectively screened for anti-HCV antibodies and HCV RNA by reverse-transcriptase polymerase chain reaction. All OLT patients were receiving low-dose tacrolimus immunosuppression. Cumulative patient survival rates for the HCV group were 80% after 1 year and 75% after 3 years compared with rates of 84% and 78%, respectively, in the control group (P = .452). Primary graft survival rates at the same time intervals for the HCV group and the control group were 72% and 77.5% at 1 year and 67% and 72% at 3 years, respectively (P = .144). The incidence of re-transplantation (re-OLT) in the HCV group and the control group was 12.6% and 10.4%, respectively (P = .42). Chronic HCV infection as an indication for OLT with a lower dose of tacrolimus immunosuppression (

Hepatic resection and transplantation for peripheral cholangiocarcinoma.

BACKGROUND: Recent publications have questioned the role of orthotopic liver transplantation (OLT) in treating advanced or unresectable peripheral cholangiocarcinoma (Ch-Ca). STUDY DESIGN: We reviewed our experience with Ch-Ca to determine survival rates, recurrence patterns, and risk factors in 54 patients who underwent either hepatic resection or OLT between 1981 and 1994. Liver transplantation was performed in patients with unresectable tumors (n = 12) and in those with advanced cirrhosis (n = 8). There were 33 women (61%) and 21 men (39%), with a mean age of 54.3 years. The median followup period was 6.8 years. Prognostic risk factors were analyzed by univariate and multivariate analyses. RESULTS: Mortality within 30 days was 7.4%. Overall patient and tumor-free survival rates were 64% and 57% at 1 year, 34% and 34% at 3 years, and 26% and 27% at 5 years after operation. Thirty-two patients (59.3%) experienced tumor recurrence. Univariate analysis revealed that multiple tumors, bilobar tumor distribution, regional lymph node involvement, presence of metastasis, positive surgical margins, and advanced pTNM stages were significant negative predictors of both tumor-free and patient survival. Multivariate analysis revealed that positive margins, multiple tumors, and lymph node involvement were independently associated with poor prognosis. When patients with these three negative predictors were excluded, the patient survivals at 1, 3, and 5 years were 74%, 64%, and 62%, respectively. CONCLUSIONS: Both hepatic resection and OLT are effective therapies for Ch-Ca when the tumor can be removed with adequate margins, the lesion is singular, and lymph nodes are not involved.

Liver transplantation for neonatal hepatitis as compared to the other two leading indications for liver transplantation in children.

Neonatal hepatitis is a syndrome of unknown etiology occurring in children with viral liver disease, as well as children with unidentified disorders of bile salt synthesis and other poorly understood metabolic diseases. It is characterized by jaundice, giant cell hepatitis and rare liver failure necessitating liver transplantation. In the present investigation, the outcome of liver transplantation performed in 16 children with neonatal hepatitis at the investigators' institution was determined from 1 January 1989 to 31 December 1991. The results were compared to those obtained in 288 children transplanted for biliary atresia and 66 children transplanted for recognized metabolic liver disease. The children transplanted for neonatal hepatitis (4.1 +/- 1.3 years) and metabolic liver disease (5.8 +/- 0.6 years) were older than those transplanted for biliary atresia (3.3 +/- 0.2 years) (p < 0.01), but did not differ in terms of sex, ABO type, UNOS status or year in which the transplant procedure was performed. Interestingly, first allograft survival was equal in the children with neonatal hepatitis (74%) and those with metabolic liver disease (74%), but was greater than that for children transplanted for biliary atresia (68%) (p < 0.01). Despite this significant difference in first graft survival, no differences in 5-year survival were seen for the three groups (81% for neonatal hepatitis, 68% for biliary atresia and 79% for metabolic liver disease).(ABSTRACT TRUNCATED AT 250 WORDS)

Early clinical and histologic viability of human liver-small intestinal allografts after implantation.

Our procedure for donor harvesting and preserving intestinal grafts has matured. In 27 consecutive cases, a protocol was established whose essentials consist of (a) selecting hemodynamically stable donors, (b) antibiotic pretreatment of the donor, and (c) short warm ischemic times (< 40 minutes). Assessment of graft quality can be achieved by daily inspection of stomas, inspection for diarrhea > 2.5 1/day in adults or > 300 ml in children, and weekly protocol or clinically directed endoscopic biopsies. Edema and microscopic separation of the mucosal surface and sloughing are routinely found during the first few post-engraftment days, but the crypt cells remain and regenerate a normal mucosa within a week. Recovery of a normal mucosal surface took place in all cases.

Causas de muerte posterior al transplante hepático en niños tratados con ciclosporina y esteroides / Causes of death after liver transplantation in children treated with ciclosporine and steroides

Se analiza una serie de 227 niños sometidos a trasplante ortotópico de hígado entre marzo de 1980 y febrero de 1986. Fallecieron durante el período en estudio 70 pacientes (31,7%); 9 fueron excluidos del análisis (4 murieron dentro de las primeras 24 hs. postoperatorias y 5 cuyo deceso ocurrió fuera de nuestra institución). La insuficiencia hepática por trombosis arterial, falla primaria del funcionamiento del hígado o rechazo inmunológico del mismo, motivó 25 muertes de los 61 restantes, 21 murieron por sepsis generalizada, mientras que 7 fallecieron por sangrado incontrolable y 8 fueron atribuidas a un variado grupo de causas. Los índices de mortalidad de los pacientes sometidos a 1, 2 y 3 trasplante fueron del 20, 38 y 50% respectivamente. El 85,2% de las muertes se produjo durante el 1er. semestre posterior al trasplante hepático inicial. La insuficiencia hepática fue la principal causa de muertes tempranas y las tardías se debieron en su mayoría a sepsis. El estudio de las causas de muerte posterior al trasplante hepático, revela que ciertos avances en determinadas áreas conducirán a mejores resultados.

Hiperprolactinemia y regeneración hepática / Hyperprolactinemia and liver regeneration

Se investigó en ratas el efecto regenerativo hepático de la hiperprolactinemia. En el grupo experimental se implantaron isoinjertos de hipófisis por debajo de la cápsula renal, igual procedimiento fue simulado en el grupo control. Dos semanas más tarde, ambos grupos fueron sometidos a una hepatectomía del 70 %. Los animales se sacrificaron a los 6, 24 y 48 hs. después de la hepatectomía parcial y los hígados remanentes se utilizaron para determinar los niveles ornitin-decarboxilasa y timidin-quinasa, como también la relación peso hepático/peso corporal. Los resultados obtenidos demostraron que la hiperprolactinemia no posee efectos regenerativos en hígados de ratas sometidas a resección.

Nueva solución de preservación "Universidad de Wiscosin" / New preservation solution: \"Wiscosin University\"

Se realizaron autotrasplante de riñón en 12 perros, divididos en dos grupos iguales: en el 1ro. se utilizó eurocollins como solución de preservación y en el 2do. la solución de la Universidad de Wisconsin. Se evaluaron la sobrevida, el volúmen urinario promedio en las 3 hs. posteriores a la nueva perfusión, la creatina sérica y el flujo en la arteria renal. Los resultados fueron estadísticamente significativos a favor del 2do. grupo. Se confirman los buenos resultados en el uso clínico en la preservación de riñones, páncreas e hígado con la solución Universidad de Wisconsin.

Causas de muerte posterior al transplante hepático en niños tratados con ciclosporina y esteroides / Causes of death after liver transplantation in children treated with ciclosporine and steroides

Se analiza una serie de 227 niños sometidos a trasplante ortotópico de hígado entre marzo de 1980 y febrero de 1986. Fallecieron durante el período en estudio 70 pacientes (31,7%); 9 fueron excluidos del análisis (4 murieron dentro de las primeras 24 hs. postoperatorias y 5 cuyo deceso ocurrió fuera de nuestra institución). La insuficiencia hepática por trombosis arterial, falla primaria del funcionamiento del hígado o rechazo inmunológico del mismo, motivó 25 muertes de los 61 restantes, 21 murieron por sepsis generalizada, mientras que 7 fallecieron por sangrado incontrolable y 8 fueron atribuidas a un variado grupo de causas. Los índices de mortalidad de los pacientes sometidos a 1, 2 y 3 trasplante fueron del 20, 38 y 50% respectivamente. El 85,2% de las muertes se produjo durante el 1er. semestre posterior al trasplante hepático inicial. La insuficiencia hepática fue la principal causa de muertes tempranas y las tardías se debieron en su mayoría a sepsis. El estudio de las causas de muerte posterior al trasplante hepático, revela que ciertos avances en determinadas áreas conducirán a mejores resultados. (AU)

Hiperprolactinemia y regeneración hepática / Hyperprolactinemia and liver regeneration

Se investigó en ratas el efecto regenerativo hepático de la hiperprolactinemia. En el grupo experimental se implantaron isoinjertos de hipófisis por debajo de la cápsula renal, igual procedimiento fue simulado en el grupo control. Dos semanas más tarde, ambos grupos fueron sometidos a una hepatectomía del 70 %. Los animales se sacrificaron a los 6, 24 y 48 hs. después de la hepatectomía parcial y los hígados remanentes se utilizaron para determinar los niveles ornitin-decarboxilasa y timidin-quinasa, como también la relación peso hepático/peso corporal. Los resultados obtenidos demostraron que la hiperprolactinemia no posee efectos regenerativos en hígados de ratas sometidas a resección. (AU)

Nueva solución de preservación "Universidad de Wiscosin" / New preservation solution: "Wiscosin University"

Se realizaron autotrasplante de riñón en 12 perros, divididos en dos grupos iguales: en el 1ro. se utilizó eurocollins como solución de preservación y en el 2do. la solución de la Universidad de Wisconsin. Se evaluaron la sobrevida, el volúmen urinario promedio en las 3 hs. posteriores a la nueva perfusión, la creatina sérica y el flujo en la arteria renal. Los resultados fueron estadísticamente significativos a favor del 2do. grupo. Se confirman los buenos resultados en el uso clínico en la preservación de riñones, páncreas e hígado con la solución Universidad de Wisconsin. (AU)

Reversion by vagal reflex of a fetal paroxysmal atrial tachycardia detected by echocardiography.

We report the reversion of fetal paroxysmal atrial tachycardia with 2:1 atrioventricular block obtained by vagal maneuvers during week 35 of gestation in a 31-year-old woman. All events were documented by fetal echocardiography.

Pancreas aberrante. / Aberrant pancreas

Se presentan tres casos de pancreas aberrante, 2 situados en el estomago y 1 en la vesicula biliar, diagnosticados por estudio anatomopatologico. Se realiza una revision de los aspectos embriologicos fisio y anatomopatologicos, clinicos y terapeuticos de esta entidad

Pancreas aberrante. / Aberrant pancreas

Se presentan tres casos de pancreas aberrante, 2 situados en el estomago y 1 en la vesicula biliar, diagnosticados por estudio anatomopatologico. Se realiza una revision de los aspectos embriologicos fisio y anatomopatologicos, clinicos y terapeuticos de esta entidad

Perfil de situacion en el embarazo gemelar. / Situation profile in multiple pregnancy

En la 1a. Catedra de Obstetricia, Hospital de Clinicas "Jose de San Martin", se estudiaron 88 gemelos productos de 44 embarazos dobles durante los anos 1980-1981. La patologia mas frecuente fue la rotura prematura de membranas (40%). Hubo un 56,8% de recien nacidos de bajo peso y un 40% de preterminos. Se produjo el parto espontaneamente en el 70,4% para el primer gemelo y en el 54.5% para el segundo gemelo. El indice de operacion cesarea fue del 81.2% y el porcentaje de deprimidos un 70% mayor para el segundo gemelo que para el primero. Las tasas de mortalidad neonatal y perinatal fueron de 2.2% y 5.4% respectivamente