Liver transplantation for hepatocellular carcinoma--is there a risk of recurrence caused by intraoperative blood salvage autotransfusion?

BACKGROUND/AIMS: The use of intraoperative blood salvage autotransfusion (IBSA) during surgical approaches may contribute to tumour cell dissemination. Therefore, IBSA should be avoided in cases of malignancy. However, the risks of IBSA might be acceptable in liver transplantation (LT) for selected small hepatocellular carcinoma (HCC). METHODS: In total, 136 recipients of LT with histologically proven HCC in the explanted liver were included in this analysis. With regard to tumour recurrence, 40 patients receiving IBSA despite HCC (IBSA group) were compared to 96 patients without IBSA (non-IBSA group). RESULTS: Milan criteria as assessed in the explanted liver were fulfilled in 24 of 40 IBSA patients and 58 of 96 non-IBSA patients (p = 0.85). Five of 40 patients in the IBSA group and 18 of 96 patients in the non-IBSA group experienced tumour recurrence (p = 0.29). In spite the theoretical risk of tumour cell dissemination, the recurrence rate was not increased in the IBSA group. CONCLUSION: Our results indicate that IBSA does not modify the risk of HCC recurrence. Therefore, in highly selected HCC patients undergoing LT, the use of IBSA appears to be justified.

Influence of the fungal NF-kappaB inhibitor panepoxydone on inflammatory gene expression in MonoMac6 cells.

The fungal secondary metabolite panepoxydone has been recently described as an inhibitor of NF-kappaB activation which is a pivotal regulator of the inflammatory and immune response. These findings have led to propose that panepoxydone may be useful as anti-inflammatory agent. In this study we investigated for the first time the effects of panepoxydone on inflammatory gene expression in the monocytic cell line MonoMac6, stimulated with lipopolysaccharide (LPS) and the phorbolester 12-O-tetradecanoylphorbol-13-acetate (TPA). DNA microarray analysis of 110 human genes known to be strongly regulated during inflammation, combined with reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR) revealed that low micromolar concentrations (12-24 microM) of panepoxydone strongly inhibited the expression of thirty-three NF-kappaB dependent pro-inflammatory genes such as the chemokines CCL3, CCL4, CCL8; CXCL8, CXCL10, CXCL20, the cytokines IL-1, IL-6, TNF-alpha, pro-inflammatory enzymes like COX-2, and components of the REL/NF-kappaB/IkappaB family without significant effects on the expression of house-keeping genes. Panepoxydone strongly inhibited hTNF-alpha, IL-8 and NF-kappaB promoter activity in LPS/TPA stimulated MonoMac6 cells with IC(50) values of 0.5-1 microg/ml by blocking the phosphorylation of IkappaB and subsequent binding of the activated NF-kappaB transcription factor to the DNA. From our data, panepoxydone may serve as lead structure for the development of transcription-based inhibitors of pro-inflammatory gene expression.

The carotid pulse check revisited: what if there is no pulse?

This study was undertaken to evaluate the diagnostic accuracy and time required by first responders to assess the carotid pulse in potentially pulseless patients. We conducted a prospective, randomized study of first responders (n = 206; four different training levels) and were blinded as to the patients' conditions in the cardiac operating rooms of a university hospital. Sixteen patients underwent coronary artery bypass surgery on nonpulsatile cardiopulmonary bypasses. Carotid pulse check was performed either during pulsatile (spontaneous) or during nonpulsatile (extracorporeal) circulation. Patients' hemodynamic status at the time of assessment, diagnostic accuracy of the first responders, and the time required to diagnose carotid pulsatility or pulselessness were documented. Within 10 secs, only 16.5% of the participants (34 of 206) were able to reach any decision about their patients' pulse status. Assessments that were both rapid and correct (15%, i.e., 31 of 206) occurred almost exclusively in pulsatile patients. Advanced training level shortened the delay to decision and improved its accuracy. However, merely 2% of the participants (1 of 59) correctly recognized a truly pulseless patient within 10 secs. Recognition of pulselessness of the carotid artery by rescuers with basic cardiopulmonary resuscitation training is time-consuming and highly inaccurate. Although the carotid pulse check needs to be taught, its importance in the context of layperson basic life support should be de-emphasized.

Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse.

International guidelines for cardiopulmonary resuscitation (CPR) in adults advocate that cardiac arrest be recognized within 5-10 s, by the absence of a pulse in the carotid arteries. However, validation of first responders' assessment of the carotid pulse has begun only recently. We aimed (1) to develop a methodology to study diagnostic accuracy in detecting the presence or absence of the carotid pulse in unresponsive patients, and (2) to evaluate diagnostic accuracy and time required by first responders to assess the carotid pulse. In 16 patients undergoing coronary artery bypass grafting, four groups of first responders (EMT-1: 107 laypersons with basic life support (BLS) training; EMT-2: 16 emergency medical technicians (EMTs) in training; PM-1: 74 paramedics in training; PM-2: 9 certified paramedics) performed, single-blinded and randomly allocated, carotid pulse assessment either during spontaneous circulation, or during non-pulsatile cardiopulmonary bypass. Time to diagnosis of carotid pulse status, concurrent haemodynamics and diagnostic accuracy were recorded. In 10% (6/59), an absent carotid pulse was not recognized as pulselessness. In 45% (66/147), a pulse was not identified despite a carotid pulse with a systolic pressure > or = 80 mmHg. Thus, although sensitivity of all participants for central pulselessness approached 90%, specificity was only 55%. Both sensitivity and, to a lesser degree, specificity improved with increasing training; blood pressure or heart rate had no significant effect. The median diagnostic delay was 24 s (minimum 3 s). When no carotid pulse was found, delays were significantly longer (30 s: minimum 13 s), than when a carotid pulse was identified (15 s; minimum 3 s) (P < 0.0001). Of all participants, only 15% (31/206) produced correct diagnoses within 10 s. Only 1/59 (2%) identified pulselessness correctly within 10 s. Our cardiopulmonary bypass model of carotid pulse assessment proved to be feasible and realistic. We conclude that recognition of pulselessness by rescuers with basic CPR training is time-consuming and inaccurate. Both intensive retraining of professional rescuers and reconsideration of guidelines about carotid pulse assessment are warranted.

[Anesthesia in endovascular treatment of aortic aneurysm. Results and perioperative risks]. / Ansthesie zur endovaskularen Therapie aortaler Aneurysmen. Verfahren und perioperative Risiken.

UNLABELLED: Surgical treatment of aortic aneurysms carries significant cardiovascular risks. Transvascular insertion of endoluminal prostheses is a new, minimally invasive treatment for aortic aneurysms. The pathophysiology of this novel procedure, risks and benefits of different anaesthetic techniques, and typical complications need to be defined. METHODS: With their informed, written consent, 19 male patients aged 48-83 years of ASA physical status III and IV with infrarenal (n = 18) or thoracic (n = 1) aortic aneurysms underwent 23 stenting procedures under general endotracheal (n = 9), epidural (n = 8), or local anaesthesia with sedation (n = 6). Intra-anaesthetic haemodynamics, indicators of postoperative (p.o.) oxygenation and systemic inflammatory response, and perioperative complications were analysed retrospectively and compared between anaesthetic regimens. RESULTS: Groups were well matched with regard to morphometry and preoperative risk profiles (Table I). The use of pulmonary artery pressure monitoring, incidence of intraoperative hypotensive episodes, and p.o. intensive care was more frequent with general anaesthesia. Groups did not differ in total duration of anaesthesia care, incidence and duration of intraoperative hypertensive, brady-, or tachycardic periods, incidence of arterial oxygen desaturation, use of vasopressors, colloid volume replacements, or antihypertensives (Table 2). Postoperatively, all groups showed a similar, significant systemic inflammatory response, i.e., rapidly spiking temperature (p.o. evening: mean peak 38.5 +/- 1.0 degrees C). leucocytosis, and rise of acute-phase proteins without bacteraernia (Table 3). During this period, despite supplemental oxygen, pulse oximetry revealed temporary arterial desaturation in 13 of 18 patients (70%) (Table 3). In 3 patients, hyperpyrexia was associated with intermittent tachyarrhythmias (n = 3) and angina pectoris (n = 1). There was no conversion to open aortic surgery, perioperative myocardial infarction, or death. CONCLUSIONS: Regional and local anaesthesia with sedation are feasible alternatives to general endotracheal anaesthesia for minimally invasive treatment of aortic aneurysms by endovascular stenting. However, invasive monitoring and close postoperative monitoring are strongly recommended with either method. Specific perioperative risks in patients with limited cardiovascular or pulmonary reserve are introduced by the abacterial systemic inflammatory response to aortic stent implantation. Hyperpyrexia increases myocardial and whole-body oxygen consumption, and can precipitate tachyarrhythmias. Hyperfibrino-genaemia may increase the risk of postoperative arterial and venous thromboses. Close monitoring of vital parameters and prophylactic measures, including oxygen supplementation, low-dose anticoagulation, antipyretics, and fluid replacement are warranted until this syndrome resolves.

[Anaphylactoid reaction to a non-ionic roentgen contrast medium in general anesthesia]. / Anaphylaktoide Reaktion auf ein nichtionisches Röntgenkontrastmittel in Allgemeinansthesie.

The occurrence of adverse reactions is decreasing since the introduction of non-ionic contrast media. Anaphylactoid reactions during general anaesthesia are rare and hitherto only documented with the administration of ionic compounds. We report an episode of hypotension, tachycardia, bronchospasm and urticaria following application of a non-ionic contrast medium (Iopamidol) during isoflurane anaesthesia. We conclude that a combinent use of anaesthesia and non-ionic contrast media does not guaranty protection from anaphylactoid reactions to iodinated radiopaque compounds.

[Prevention of adverse reactions to contrast media by means of general anesthesia?]. / Prophylaxe des "Kontrastmittelzwischenfalls" durch Allgemeinanästhesie?

Adverse reactions to systemically administered contrast media are a threat to patients as well as the responsible physician. Non-ionic media produce less side effects due to the lower osmolarity and an advantageous chemical structure. Suggested prophylactic measures include the intravenous administration of H1- and H2-receptor blockers the administration of corticosteroids, sedatives and general anaesthesia. General anaesthesia not necessarily protects from a reaction to either ionic or nonionic compounds and bears its own risks.

[Significance of panendoscopy in the search for the primary tumor in neck metastases]. / Die Bedeutung der Panendoskopie bei der Primärtumorsuche zervikaler Metastasen.

34 patients suffering from a metastatic cervical neoplasm with unknown origin of the primary tumour were examined between 1977 and 1981. The site of the primary tumour was detected in 61% (= 21 cases) of the patients. In the literature (4158 cases, 61 authors) a 32% success rate only was stated. Diagnostic improvement was achieved via "panendoscopy". This method allows a complete systematic evaluation of the upper respiratory and gastrointestinal tract.