Long-term outcomes of patients with 10 or more colorectal liver metastases.

BACKGROUND: Although the number of colorectal liver metastases (CLM) is decreasingly considered as a contraindication to surgery, patients with 10 CLM or more are often denied liver surgery. This study aimed to evaluate the outcome after liver surgery and to identify prognostic factors of survival in such patients. METHODS: The study population consisted of a multicentre cohort of patients with CLM (N=12 406) operated on, with intention to resect, from January 2005-June 2013 and whose data were prospectively collected in the LiverMetSurvey registry. RESULTS: Overall, the group ⩾10 CLM (N=529, 4.3%) experienced a 5-year overall survival (OS) of 30%. A macroscopically complete (R0/R1) resection (72.8% of patients) was associated with a 3- and 5-year OS of 61% and 39% vs 29% and 5% for R2/no resection patients (P<0.0001). At multivariate analysis, R0/R1 resection emerged as the strongest favourable factor of OS (HR 0.35 (0.26-0.48)). Other independent favourable factors were as follows: maximal tumour size <40 mm (HR 0.67 (0.49-0.92)); age <60 years (HR 0.66 (0.50-0.88)); preoperative MRI (HR 0.65 (0.47-0.89)); and adjuvant chemotherapy (HR 0.73 (0.55-0.98)). The model showed that 5-year OS rates of 30% was possible provided R0/R1 resection associated with at least an additional favourable factor. CONCLUSIONS: Liver resection might provide long-term survival in patients with ⩾10 CLM staged with preoperative MRI, provided R0/R1 resection followed by adjuvant therapy. A validation of these results in another cohort is needed.

Soluble CD40-ligand (sCD40L, sCD154) plays an immunosuppressive role via regulatory T cell expansion in HIV infection.

CD40/CD40-ligand (CD40L) signalling is a key stimulatory pathway which triggers the tryptophan (Trp) catabolizing enzyme IDO in dendritic cells and is immunosuppressive in cancer. We reported IDO-induced Trp catabolism results in a T helper type 17 (Th17)/regulatory T cell (Treg ) imbalance, and favours microbial translocation in HIV chronic infection. Here we assessed the link between sCD40L, Tregs and IDO activity in HIV-infected patients with different clinical outcomes. Plasmatic sCD40L and inflammatory cytokines were assessed in anti-retroviral therapy (ART)-naive, ART-successfully treated (ST), elite controllers (EC) and healthy subjects (HS). Plasma levels of Trp and its metabolite Kynurenine (Kyn) were measured by isotope dilution tandem mass spectrometry and sCD14 was assessed by enzyme-linked immunosorbent assay (ELISA). IDO-mRNA expression was quantified by reverse transcription-polymerase chain reaction (RT-PCR). The in-vitro functional assay of sCD40L on Treg induction and T cell activation were assessed on peripheral blood mononuclear cells (PBMCs) from HS. sCD40L levels in ART-naive subjects were significantly higher compared to ST and HS, whereas EC showed only a minor increase. In ART-naive alone, sCD40L was correlated with T cell activation, IDO-mRNA expression and CD4 T cell depletion but not with viral load. sCD40L was correlated positively with IDO enzymatic activity (Kyn/Trp ratio), Treg frequency, plasma sCD14 and inflammatory soluble factors in all HIV-infected patients. In-vitro functional sCD40L stimulation induced Treg expansion and favoured Treg differentiation by reducing central memory and increasing terminal effector Treg proportion. sCD40L also increased T cell activation measured by co-expression of CD38/human leucocyte antigen D-related (HLA-DR). These results indicate that elevated sCD40L induces immunosuppression in HIV infection by mediating IDO-induced Trp catabolism and Treg expansion.

Systematic review and meta-analysis of liver resection for metastatic melanoma.

BACKGROUND: The multidisciplinary management of metastatic melanoma now occasionally includes major hepatic resection. The objective of this work was to conduct a systematic review of the literature on liver resection for metastatic melanoma. METHODS: MEDLINE, Embase, the Cochrane Library and Scopus were searched (1990 to December 2012). Studies with at least ten patients undergoing liver resection for metastatic melanoma were included. Data on the outcomes of overall survival (OS) and/or disease-free survival (DFS) were abstracted and synthesized. Hazard ratios (HRs) were derived from survival curves and subjected to meta-analysis using random-effects models. RESULTS: Twenty-two studies involving 579 patients (13 per cent weighted resection rate) who underwent liver resection were included. Study quality was poor to moderate. Median follow-up ranged from 9 to 59 months. Median DFS ranged from 8 to 23 months, and median OS ranged from 14 to 41 months (R0, 22-66 months, R2, 10-16 months; R0 versus R1/R2: HR 0.52, 95 per cent confidence interval (c.i.) 0.37 to 0.73). The OS rate was 56-100 per cent at 1 year, 34-53 per cent at 3 years and 11-36 per cent at 5 years. Median OS with non-operative management ranged from 4 to 12 months. Comparison of OS with resection and non-operative management favoured resection (HR 0.32, 95 per cent c.i. 0.22 to 0.46). CONCLUSION: Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results.

[Outpatient laparoscopic cholecystectomy: a one year experience on unselected patients]. / Cholécystectomie coelioscopique ambulatoire: expérience d'un an sur des patients non sélectionnés.

UNLABELLED: This study reviews our experience with outpatient laparoscopic cholecystectomy (CCA) to evaluate the benefits of this approach to routine clinical practice. PATIENTS AND METHODS: Of 217 consecutive patients undergoing laparoscopic cholecystectomy over a one-year period (2002-2003) at our university medical center, 151 were selected for same day surgery and discharge according to the following selection criteria: non-urgent surgery, no major co-morbidities, domicile within one hour of the hospital. Patients were typically discharged the afternoon of their surgery if their clinical condition was stable. RESULTS: Of 151 planned outpatient CCA's, 122 (81%) were discharged on the day of surgery. Of these, 16 had a post-operative complication and three required readmission; no patient required reoperation. Univariate analysis revealed three factors predictive of failure of the outpatient strategy: age >65 (p=0.015), operative duration (p<0.0001), and surgical start time after 11 am (p<0.0001). CONCLUSIONS: Outpatient laparoscopic cholecystectomy can be routinely accomplished in unselected patients in an academic center. The low rate of in-patient admission is acceptable. The out-patient strategy for laparascopic cholecystectomy allows for a reduction in waiting time at our institution.

Immunization against endogenous retroviral tumor-associated antigens.

Endogenous retroviral gene products have been found in some human tumors, and therefore, may serve as antigens for immunotherapy approaches. The murine colorectal carcinoma CT26 and melanoma B16 have recently been found to express the endogenous retroviral gene products gp70 and p15E, respectively, that can serve as antigens recognized by T cells. To date, though, there has been no demonstration of tumor treatment using an endogenous retroviral protein. In this study, we demonstrate that mice immunized with recombinant vaccinia encoding the gp70 H2-L(d)-restricted minimal determinant were protected from CT26 tumor challenge. Splenocytes from mice immunized with vaccinia gp70 specifically secreted IFN-gamma in response to gp70 peptide-pulsed stimulators. Although this strategy could protect against subsequent tumor challenge, it was ineffective against established tumors. Therefore, to investigate the treatment of established CT26 or B16 lung metastases, mice were treated with cultured dendritic cells (DCs) pulsed with gp70 or p15E peptide. Significant inhibition of established lung metastases required immunization with peptide-pulsed DCs pretreated with CD40 ligand that has been demonstrated to increase the T-cell stimulatory activity of DCs. The ability to immunize against endogenous retroviral tumor antigens may have relevance in the induction of antitumor immunity for some human cancers.

Productive infection of normal CD40-activated human B lymphocytes by HIV-1.

OBJECTIVE: Antigen-driven B-cell proliferation and maturation occur in germinal centres present in lymphoid tissues. This process is highly dependent on functional interactions between B and T lymphocytes. In vitro activation of CD40 present on B cells mimics B cell-T interactions and allows the proliferation of normal Epstein-Barr virus (EBV)-negative B lymphocytes. In HIV-1-seropositive individuals, B cells become exposed to free viral particles and to infected T lymphocytes while migrating through germinal centres. The effect of HIV-1 viral exposure on CD40-activated B lymphocytes was therefore examined. METHODS: Freshly isolated B lymphocytes were cultured in vitro through activation of CD40. B-cell proliferation, HIV-1 infectivity and viral production were monitored following B-lymphocyte exposure to HIV-1. In addition, HIV-mediated fusion between infected B cells and uninfected CD4+ T lymphocytes was assessed in a coculture assay. RESULTS: EBV-negative, CD40-activated human B lymphocytes were directly infected by HIV-1. The infection significantly reduced their proliferation rate. Viral production was detected in B-cell culture supernatant. Numerous fusion events indicated that HIV-1 infection of B lymphocytes could spread to T lymphocytes following HIV-1-mediated fusion of these two cell types. CONCLUSION: In view of the importance of B cell-T cell interactions in the maintenance of a functional immune system, disruption of B-lymphocyte development could have direct implications on the course of AIDS progression.

Interference of HIV-1 Nef in the sphingomyelin transduction pathway activated by tumour necrosis factor-alpha in human glial cells.

OBJECTIVE: The HIV-1 nef gene product, thought to interact with mediators of cell signalling, is overexpressed during the restricted HIV-1 infection of human astrocytes. This infection can be reactivated following exposure to tumour necrosis factor (TNF)-alpha. We examined the possibility that Nef alters the TNF-alpha-induced cell signalling in astroglioma cells through the sphingomyelin pathway. METHODS: Sphingomyelinase activation by TNF-alpha was analysed in U251MG glial cells constitutively expressing Nef and compared with U251MG cells stably transfected with the expression vector alone. The consequent effect on the cellular proliferative response and induction of nuclear factor NF-kappa B and AP-1 binding activities were examined. RESULTS: A marked enhancement in the levels of ceramide, a product of the sphingomyelin hydrolysis, was observed in U251MG-Nef upon stimulation with TNF-alpha. In contrast, ceramide levels in control cells were barely increased under similar conditions. A concomitant reduction of sphingomyelin level occurred in U251MG-Nef cells. In addition, the reduced survival rate of U251MG cells resulting from TNF-alpha activation was prevented in the presence of Nef. Furthermore, electrophoretic mobility shift assays indicated that nef expression inhibits AP-1 activation without altering the induction of NF-kappa B. CONCLUSION: These results strongly suggest that nef expression in U251MG cells modulates the sphingomyelinase signalling pathway triggered by TNF-alpha, thus leading to important modifications in the activation and proliferation of glial cells. They also provide new insights to explain the widespread reactive astrogliosis observed in AIDS-associated neuropathological disorders.

Efficient gene transfer to human peripheral blood monocyte-derived dendritic cells using human immunodeficiency virus type 1-based lentiviral vectors.

Dendritic cells (DCs) are potent antigen-presenting cells and are capable of activating naive T cells. Gene transfer of tumor antigen and cytokine genes into DCs could be an important strategy for immunotherapeutic applications. Dendritic cells derived from peripheral blood monocytes do not divide and are therefore poor candidates for gene transfer by Moloney murine leukemia virus (Mo-MuLV)-based retroviral vectors. Lentiviral vectors are emerging as a powerful tool for gene delivery into dividing and nondividing cells. A three-plasmid expression system pseudotyped with the envelope from vesicular stomatitis virus (VSV-G) was used to generate lentiviral vector particles expressing enhanced green fluorescent protein (EGFP). Peripheral blood monocyte-derived DCs were cultured in the presence of GM-CSF and IL-4 and transduced with lentiviral or Mo-MuLV-based vectors expressing EGFP. FACS analysis of lentiviral vector-transduced DCs derived either from normal healthy volunteers or from melanoma patients demonstrated transduction efficiency ranging from 70 to 90% compared with 2-8% using Mo-MuLV-based vectors pseudotyped with VSV-G. Comparison of lentiviral vectors expressing EGFP driven by CMV or human PGK promoters showed similar levels of transgene expression. Lentiviral vector preparations produced in the absence of HIV accessory proteins transduced DCs at efficiencies equal to vectors produced with accessory proteins. Alu-HIV-1 LTR PCR demonstrated the genomic integration of the lentiviral vector in the transduced DCs. Transduced cells showed characteristic dendritic cell phenotype and strong allostimulatory capacity and maintained the ability to respond to activation signals such as CD40 ligand and lipopolysaccharide. These results provide evidence that lentiviral vectors are efficient tools for gene transfer and expression in monocyte-derived DCs that could be useful for immunotherapeutic applications.

Hypocalcemia induced during major and minor abdominal surgery in humans.

Hypocalcemia has only been rarely reported during surgical procedures not involving massive blood transfusions. The frequent observation in our hospital of a low serum ionized calcium level during surgery in nonacutely ill patients prompted us to investigate the calcium-PTH axis in three groups of subjects undergoing major (hepatectomy; n = 10), moderately severe, or minor surgery under general anesthesia (colectomy; n = 7, herniorrhaphy; n = 9) compared to that in one group of minor surgery cases under epidural anesthesia (herniorrhaphy; n = 15). Serum samples were obtained before anesthesia, after anesthesia but before surgery, and 40 and 120 min after the beginning of surgery in all groups of patients and for up to 3 days in major and moderately severe cases. Significant falls (P < 0.01), always proportional to the severity of the surgical/anesthesia procedure, were observed for ionized calcium (6-20%), total calcium (8-19%), and albumin (8-23%) accompanied by increases in intact PTH (105-635%). The decrease in ionized and total calcium correlated with a decrease in albumin (P < 0.001). Phosphorus, pH, and magnesium levels remained within the normal range. Adjustment of ionized calcium for variation in albumin revealed that 50-100% of the variation in ionized calcium could be attributed to a fall in albumin resulting from fluid administration to patients before admission to the surgery ward and between the onset of anesthesia and the end of surgery (1.2-5.6 L). Albumin- and pH-independent residual ionized calcium decreases of 12.2% in the hepatectomy group, 4.6% in the group of moderately severe and minor cases under general anesthesia, and 3.7% in the control group reflected the severity of the surgical/anesthesia procedure.

Cyclosporine metabolism and pharmacokinetics following intravenous and oral administration in the dog.

The influence of assay method on single dose cyclosporine (CsA) pharmacokinetics was studied in nine dogs receiving either i.v. or oral CsA. Samples were drawn from hepatic, portal, and systemic veins at various times after the dose and CsA levels were determined by radioimmunoassay (RIA) and high-performance liquid chromatography (HPLC). Blood concentration-time data were analyzed by nonlinear least-squares regression, using two-compartment models. RIA/HPLC ratios for all samples were greater than one, and did not change significantly over time. The mean RIA/HPLC ratios for samples drawn from all three veins were higher after oral than i.v. doses of the drug (P less than 0.05). Area under the concentration-time curve (AUC) was higher and systemic clearance (CIs) lower than calculated on the basis of RIA results, regardless of the route of administration. AUC calculated for CsA metabolites (RIA-HPLC) was highest in the portal vein after an oral dose of CsA. Bioavailability was 20.4% and 27.0% when estimated using HPLC and RIA data, respectively. The mean CsA metabolite index (CMI), when calculated for hepatic, portal, or systemic vein, was greater when the drug was administered orally. The mean hepatic extraction ratio (HER) of the parent drug and for CsA metabolites was approximately 23% in i.v. and p.o. studies. These results suggest that the gastrointestinal tract may play a role in the metabolism of CsA when the drug is administered orally. In addition, if CsA metabolites not measured by HPLC have either toxic or immunosuppressive properties, the RIA assay may be more useful for monitoring patients.

Altered expression of several genes in IIIManL-defective mutants of Streptococcus salivarius demonstrated by two-dimensional gel electrophoresis of cytoplasmic proteins.

Mannose, glucose and fructose are transported in Streptococcus salivarius by a phosphoenolpyruvate:mannose phosphotransferase system (PTS) which consists of a membrane-bound Enzyme II (EII) and two forms of IIIMan having molecular weights of 38,900 (IIIManH) and 35,200 (IIIManL), respectively. We have previously reported the isolation of spontaneous mutants lacking IIIManL and showed that they exhibit higher beta-galactosidase activity than the parental strain after growth on glucose, and that some of them constitutively express a fructose PTS which is induced by fructose in the parental strain. In an attempt to determine whether the expression of other genes is affected by the mutation and what the physiological link is between them, we examined three S. salivarius IIIManL-defective mutants (strains A37, B31 and G29) and the parental strain using two-dimensional gel electrophoresis after growth of the cells on a variety of sugars. After growth on glucose, five new proteins were detected in the cytoplasm of the three mutants. Two of these proteins were induced in the parental strain by galactose or oligosaccharides containing galactose, and one was specifically induced by melibiose. The other two proteins were not detected in the parental strain under any of the growth conditions tested. Two other proteins were only detected in glucose-grown cells of mutant A37, and a protein associated with the metabolism of fructose was constitutively expressed in mutants B31 and G29. Moreover, we have found that under identical growth conditions the amounts of several other proteins which were detected in the parental strain were either increased or decreased in the mutants. Globally, our results have indicated that (1) the expression of several genes was affected in the spontaneous IIIManL-defective mutants; (2) some of the proteins abnormally produced in the mutants were specifically induced in the parental strain by sugars; (3) the phenotypic modifications observed in the mutants were of two types: most were observed solely after growth of the cells on glucose whereas the others were glucose-independent; and (4) the mutants shared common phenotypic traits, but also exhibited idiosyncratic characteristics.

Transhepatic portal vein stenting for treatment of ruptured duodenopancreatic varices in a patient with chronic pancreatitis.

BACKGROUND: Portal vein obstruction with secondary variceal bleeding in the setting of chronic pancreatitis has not been recognized as frequently as splenic vein occlusion. This condition can be difficult to diagnose and treat. METHODS: A 54-year old man was referred for massive recurrent endoscopy-negative upper-gastrointestinal bleeding. The diagnosis of duodenopancreatic varices was finally made. Direct portography showed a high-grade stenosis of the proximal portal vein that was dilated and stented with a balloon expandable prosthesis. RESULTS: The gradient across the stenosis fell from 9 to 2 mm Hg. Bleeding stopped. After 7 months of follow-up, the patient has experienced no rebleeding, and a Doppler examination is normal. CONCLUSIONS: In patients with chronic pancreatitis and upper gastrointestinal tract bleeding of unknown origin, obstruction of one of the major splanchnic veins must be excluded. Portal vein dilatation and stenting appears to be a safe procedure with good short-term results.

Bronchogenic cyst of the right hemidiaphragm.

A rare case of bronchogenic cyst of the right hemidiaphragm is reported. The literature is reviewed briefly. Clinical presentation, diagnosis, and treatment of this entity are discussed further.

A case of giant cell hepatitis recurring after liver transplantation and treated with ribavirin.

A patient who underwent orthotopic liver transplantation for giant cell hepatitis with cirrhosis and in whom giant cell hepatitis recurred twice after orthotopic liver transplantation is reported. He was treated with ribavirin with an excellent result. The literature on this subject is reviewed. This observation clearly confirms the efficacy of ribavirin for the treatment of giant cell hepatitis, thus providing evidence for its viral origin.

[Technique to minimize the incidence of hepatic artery thrombosis in pediatric liver transplantation]. / Technique afin de minimiser l'incidence de la thrombose de l'artère hépatique en transplantation hépatique pédiatrique.

Hepatic artery thrombosis is a life-threatening complication after pediatric liver transplantation. We reviewed our experience in 62 children who received 72 liver transplant (69 whole grafts and 3 reduced-size grafts) between January 1984 and December 1991. They ranged in age from 6 months to 16 years (mean 5.8 years). Fifteen children (22%) were under 2 years and 10 patients (14%) were between 2 and 5 years. Forty-eight grafts in older children (age: 1-16 years, x = 7 years had an anastomosis between the donor hepatic/celiac artery and the recipient hepatic of splenic artery (A-A). Three thromboses occurred in this group for an incidence of 6.2%. Two others types of arterial reconstruction were used in 24 children who were significantly younger (6-120 months, x = 47 months, p < 0.01). Eight grafts had an anastomosis between the donor celiac artery and the recipient aorta (A-Ao). No thromboses occurred in this group. Sixteen grafts were revascularized using a donor aortic conduit anastomosed to the recipient aorta (AC) with a 12.5% (2 to 16) incidence of thrombosis. The incidence of arterial thrombosis for the entire group was 6.9%. In conclusion, by using the recipient aorta for arterial reconstruction, a low incidence of hepatic artery thrombosis can be achieved even in the group of younger patients who are the highest risk for this complication.

[Experience with the transjugular intrahepatic portocaval shunt]. / Expérience avec la dérivation portocave intrahépatique transjugulaire.

Liver transplantation and the intrahepatic shunt have changed the management of variceal hemorrhage and refractory ascites. The purpose of this work is to review the results obtained with intrahepatic shunting. From January 1991 to May 1993, 45 patients underwent a transjugular intrahepatic portosystemic shunt. In 23 patients, liver insufficiency was considered moderate and in 21 severe. Indications for the procedure were: variceal bleeding (23), refractory ascites (19) and portal hypertensive gastritis (3). The portocaval gradient was lowered from 24.2 +/- 5.1 mm Hg to 12.9 +/- 3.9 (-47%). The procedure was effective in 78% of variceal bleeders and in 89% of patients with ascites. Thirty-day mortality was 22%. One-year survival was 39%. Liver failure or severe encephalopathy occurred in 27% of patients. Four patients (9%) presented intra-abdominal bleeding. Four patients developed renal failure. Transjugular intrahepatic portosystemic shunts are effective in lowering portal pressure and controlling complications of portal hypertension. However, important side effects are present and controlled studies are required to evaluate this new treatment.

[Cystic tumors of the pancreas: apropos of 36 cases]. / Les tumeurs kystiques du pancréas: a propos de 36 cas.

Cystadenomas and cystadenocarcinomas are rare cystic tumors of pancreas. Clinicopathological features and treatment of these neoplasms have been studied in 36 patients over a 10-year period (1983-1993). There were 19 cystadenomas (CA) either serous (n = 13) or mucinous (n = 6) and 17 cystadenocarcinomas (CAC). Eighteen CA (95%) were found in women. CAC were found equally between both sexes. Median age was 63 years and was the same for CA and CAC. Ultrasound gave correct diagnosis of CA or CAC in 64% and CT-scan in 77%. The majority of CAC (n = 15) were localized in the head of the pancreas. CA had no preferential localization. 24 patients (66%) underwent including resection (n = 20) and biopsy (n = 4). Four other patients had a percutaneous biopsy and 8 were observed. Hospital mortality was 8%. Complications included gastric atony (n = 4) and pancreatic fistula (n = 2). Four-year actuarial survival is 63% for resected CAC and 100% for resected CA. In conclusion, most cystic pancreatic tumors are found in women. Malignant lesions are found predominately in the head of the pancreas. Modern imaging technics combined with clinical presentation are reliable in obtaining a diagnosis. Resection remains the treatment of choice.

[Role of extracorporeal shock wave lithotripsy in the treatment of common bile duct and intrahepatic calculi]. / Place de la lithotripsie extracorporelle par ondes de choc dans le traitement des calculs cholédociens et intrahépatiques.

The management of intrahepatic and common bile duct stones has been modified by the advent of endoscopic sphincterotomy and percutaneous extraction through a T-tube tract or transhepatic access. Occasionally, nonoperative extraction is incomplete. The use of extracorporeal lithotripsy is reviewed in this setting. From May 1990 to February 1994, 18 patients (age 68.4 +/- 4.6 years) were treated by extracorporeal shockwave lithotripsy combined with endoscopic sphincterotomy and retrograde extraction or percutaneous approach. 72% of patients had previously undergone a cholecystectomy and 44% exploration of the common duct. Patients were submitted to 1.56 +/- 0.17 session of lithotripsy (5.546 +/- 701 shockwaves). Hospital stay was 19.5 +/- 3.3 days. After the lithotripsy, 1.17 +/- 0.19 endoscopic or percutaneous procedures per patient were necessary to clear the biliary tract. Seventy-eight percent of patients became stone-free. The five failures were treated by endobiliary prosthesis (n = 4) or cholecystectomy and bile duct exploration (n = 1). Lithotripsy in association with the usual therapeutic modalities contributes to clearing the bile duct from stones and avoids surgery in the majority of patients. A multidisciplinary approach is necessary in order to obtain those results.

[Reduction of blood loss in orthotopic liver transplantation with the use of aprotinin]. / Réduction des pertes sanguines en transplantation orthotopique du foie par l'utilisation d'aprotinine.

UNLABELLED: The impact of aprotinin on blood losses during orthotopic liver transplantation (OLT) has been studied retrospectively. PATIENTS AND METHODS: From September 1984 to July 1995, 152 patients underwent 168 OLT in our center. Seventy three patients (group I) received epsilon-aminocaproic acid as an antifibrinolytic agent and 95 patients (group II) received aprotinin. RESULTS: There was a significant reduction in the mean duration of the surgery (I = 743 +/- 25 min; II = 302 +/- 10 min; p < 0.001) and in the post reperfusion time (I = 282 +/- 13 min; II = 126 +/- 6 min; p < 0.001) in the group II. The need for blood products during the operation was also reduced (blood units; I = 21.7 +/- 2.3 units; II = 4.6 +/- 0.4 units; p < 0.001). There was less infectious and hemorrhagic complications requiring reoperation in group II. We have not seen an increased incidence of thrombotic complications in the patients receiving aprotinin. Other variables such as the use of hemoclips, veno-venous bypass and the type of preservation solution were also considered. CONCLUSION: Aprotinin use during OLT is efficient and superior to epsilon-aminocaproic acid in reducing blood losses. Combined with the non-utilisation of a veno-venous by-pass and the use of hemoclips, it helps reduce the operating time and the postoperative complications.

[Right diaphragmatic paralysis after liver transplantation]. / Paralysie diaphragmatique droite après transplantation hépatique.

Right hemidiaphragm paralysis has been previously documented in patients after orthotopic liver transplantation (OLT) and it may contribute to the development of postoperative pulmonary problems. It has been postulated that a crush injury to the right phrenic nerve during OLT is the cause of dysfunction of the right hemidiaphragm. To assess the incidence and effect of right phrenic nerve injury after OLT, we prospectively studied 51 adult liver recipients that we compared with twelve patients who underwent liver resection (LR) without suprahepatic vena cava clamping. We studied the diaphragm excursion by ultrasound, the pulmonary function tests and the transcutaneous phrenic nerve conduction. Righ phrenic nerve injury and hemidiaphragm paralysis occurred respectively in 79% and 38% of the liver recipients but not after LR. Conduction along the right phrenic nerve was absent in 53% of the patients and reduced in another 26%. Left phrenic nerve conduction and left hemidiaphragm excursion were normal in both groups. Liver recipients with no conduction in the right phrenic nerve had a significantly greater decrease in vital capacity in the supine position compared to those with some conduction (29% vs 14%; P < 0.001). However, neither the time on the ventilator or the hospital stay were significantly different between the two groups. Complete recovery of phrenic nerve conduction and diaphragm function may take up to nine months. Right phrenic nerve injury is common after OLT and causes right hemidiaphragm dysfunction.