Co-existence of Echinococcus granulosus infection and cancer metastasis in the liver correlates with reduced Th1 immune responses.

A possible relationship between cancer and Echinococcus granulosus infection has been postulated. As T cells are critical players in immune responses against both infections and malignancies, in an experimental model of secondary echinococcosis and breast cancer, this study aims to observe the progression of cancer and to determine the characters of T-cell responses. 4T1 breast tumour cells were subcutaneously injected into mammary region, whereas protoscoleces were intraperitoneally inoculated into the mice. Hydatid cysts, tumours and metastases were determined with macroscopic and histopathological evaluation. T cells found in spleen, liver and tumour were characterised by flow cytometric analysis of CD3, CD4, CD8, CD25, CCR5, CCR3, IL-4 and IFN-γ. In the mice inoculated both with protoscoleces and with breast tumour cells, increased frequency of cancer metastasis was observed in the liver. The amount of CD4(+) T cells was increased in the liver and in the spleen of mice infected with E. granulosus. However, co-existence of echinococcosis and metastatic lesions in the liver was associated with significant reduction in the IFN-γ(+) and CCR5(+) Th1 cells and increase in the CD25(+) T cells. Our results may indicate an immunological link between cystic echinococcosis and cancer that allows tumour metastasis to flourish in the liver.

Is surgical treatment of liver hemangiomas effective for pain relief?

BACKGROUND: Traditional treatment for liver hemangiomas is surgery. Currently, it is controversial whether hemangioma surgeries are sufficiently beneficial for the patients. In this study, we evaluated the effectiveness of surgery in patients with liver hemangiomas. METHODS: Forty-two patients who underwent surgical operations for hepatic hemangiomas were retrospectively evaluated and interviewed. RESULTS: Study population included 36 female and 6 male patients whose ages ranged between 26 and 65 years (mean age, 47.8 +-8.7 years). Their mean duration of hospitalization was 6 days (range, 3 - 59 days). The median time since surgery was 50 months (range 0-120 months). There was a statistically significant decrease in numerical rating and adjective rating pain scale scores (p 0.05). Postoperatively, pain did not cease in 10 patients (peptic ulcers requiring medical treatment in four patients, cholelithiasis in four patients, and nephrolithiasis in two patients). CONCLUSION: Patients with cavernous hemangiomas of the liver who require surgical treatment have significant benefits in terms of pain relief following surgery. The lack of pain relief after the surgery in some patients may be related to concomitant medical problems other than the hemangioma.

Nutrition for the older adult - Current concepts. Report from an ESPEN symposium.

BACKGROUND & AIMS: In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge. METHODS: Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report. RESULTS: Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia. CONCLUSIONS: In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults.

Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view.

BACKGROUND & AIMS: Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives. RESULTS: This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum. CONCLUSION: The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

The postoperative analgesic efficacy of intraperitoneal tramadol compared to normal saline or intravenous tramadol in laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the postoperative analgesic efficacy of intraperitoneal tramadol with intravenous tramadol or normal saline in patients undergoing laparoscopic cholecystectomy. METHODS: Sixty-one patients undergoing laparoscopic cholecystectomy were randomized to one of three groups in a double-blind manner via coded syringes. All patients received an intravenous and an intraperitoneal injection after installation of the pneumoperitoneum and again before removal of the trocars. In the control group, all injections were with normal saline. In the intravenous tramadol group, patients received intravenous tramadol 100 mg and intraperitoneal saline. In the intraperitoneal tramadol group, patients received intravenous saline and intraperitoneal tramadol 100 mg. All patients had a standard anaesthetic. Postoperative analgesia was with morphine. Postoperatively, numeric pain scores for parietal and visceral pain, 1 h and 24 h morphine consumption, and adverse effects were recorded. RESULTS: Parietal and visceral pain scores were lowest in the intravenous tramadol group during the first postoperative hour (P < 0.016 compared with control). The delay until the first analgesic administration was longest in the intravenous tramadol group (median 23 min, range 1-45), when compared with the intraperitoneal tramadol group (10, 1-120 min, P = 0.263) or with the control group (1, 1-30 min, P = 0.015). One-hour morphine consumption was significantly lower in the intravenous tramadol group (mean +/- SD; 3.4 mg +/- 2.5) and in the intraperitoneal tramadol group (4.4 +/- 4.3 mg) compared with the control group (6 +/- 2 mg) (P = 0.044). There was no difference between the three groups regarding pain scores, morphine consumption and incidence of shoulder pain or adverse effects at 24 h. CONCLUSION: Intravenous tramadol provides superior postoperative analgesia in the early postoperative period after laparoscopic cholecystectomy compared with an equivalent dose of tramadol administered intraperitoneally and with normal saline in patients undergoing laparoscopic cholecystectomy.

Renal safety and extrahepatic defluorination of sevoflurane in hepatic transplantations.

BACKGROUND: The main metabolic pathway for defluorination of sevoflurane in the liver produces inorganic fluoride (Fl). The metabolism and effect of sevoflurane on the kidney is not clear during anhepatic phase in liver transplantation. The goal of the present study was to investigate the metabolism and renal effect of sevoflurane by measuring plasma and urine inorganic fluoride, urinary N-acetyl-glucosaminidase (NAG), and plasma creatinine levels in patients undergoing liver transplantations. METHODS: After institutional approval and informed consent, we studied nine cases of orthotopic liver transplantation after anesthesia was induced with 5 mg . kg(-1) thiopental, 1 mug . kg(-1) fentanyl intravenously, the trachea was intubated after vecuronium bromide 0.1 mg . kg(-1). Anesthesia was maintained with sevoflurane (2%), O(2), and N(2)O at a total gas flow of 6 L . min(-1) using a semiclosed circle system with a sodalime canister. Blood and urine samples were obtained to measure plasma and urine fluoride concentrations and urinary NAG excretions before induction (P0), hourly during resection (P1, P2, P3), every 15 minutes during anhepatic phase (A1, A2, A3), hourly after reperfusion (neohepatic phase) (N1, N2, N3), and postoperative first hour (Po1). Preoperative (T0) and postoperative day 1 (T1), 3 (T3), 7 (T7) plasma blood urea nitrogen (BUN) and creatinine (Cr) levels were also recorded. RESULTS: Mean duration of surgery was 9:06 +/- 0:09 hours. Mean inorganic fluoride concentrations in plasma were in the range of 0.71 +/- 0.30 to 28.73 +/- 3.31 mumole . L(-1). In P3, N1, N2, N3, increases in plasma inorganic fluoride concentrations were significant (P < .05) and reached a peak value at Po1. The mean urine inorganic fluoride concentrations were 12.49 +/- 2.04 to 256.7 +/- 49.62 mumole . L(-1). In A2, A3, N1, N2, and N3, mean urine inorganic fluoride concentrations were significantly increased (P < .05) and the peak value was observed at Po1. Mean NAG concentrations in urine varied (5.6 +/- 1.6 IU . L(-1) to 12.5 +/- 1.14 IU . L(-1)) and peak level was observed at 30 minutes of the anhepatic phase (A2), which did not exceed the normal values for urine NAG levels (1.5 to 6.1 U . L(-1)). No impairment was observed in serum BUN and creatinine levels at any time. While there was only a slight increase in NAG during anhepatic phase, there was no change in plasma F1. CONCLUSIONS: Sevoflurane seemed to have minimal effect on kidney functions of BUN and Cr levels during liver transplantation. Although urine F1 and NAG levels increased during the anhepatic phase plasma F1, BUN, and Cr levels did not, suggesting that renal F1 production may occur in the absence of hepatic function. The renal effect of sevoflurane in chronic liver disease is controversial and must be investigated in further studies.

Assessment of drug administration via feeding tube and the knowledge of health-care professionals in a university hospital.

BACKGROUND/OBJECTIVES: The use of drugs via feeding tube is problematic. Appropriate techniques must be used during the administration to prevent obstruction of a feeding tube, to avoid inadequate drug effects and to minimize the risk of toxicity of the given pharmaceuticals. SUBJECTS/METHODS: In this study, medications of all the patients in a University Hospital with 1100 beds were monitored to identify the appropriateness of administration. The study was performed on 5 days each in 5 consecutive weeks to observe the current practice. After evaluation of practice, a questionnaire was given to doctors, nurses and pharmacists to determine the health-care professionals' attitudes on drug administration through a feeding tube. RESULTS: A total of 225 drugs (out of 13 935) were administered via feeding tube during the study period and 40.5% (n=91) were not administered in appropriate dosage forms. Only 86% of the doctors and 98% of the nurses stated that they pay attention to the suitability of drugs when they prescribe or administer drugs via feeding tube. Only 58% of pharmacists, 17% of nurses and 24% of doctors were aware of the fact that enteric-coated tablets should not be crushed owing to the risk of tube occlusion and lack of efficacy when they are administered via feeding tube. CONCLUSIONS: This study demonstrated the discordance between the theoretical knowledge and the practical performance of the health-care professionals in drug administration. In patients with feeding tubes, assessment of drug dosage forms by a pharmacist would be beneficial for appropriate administration and to prevent drug interactions.

Hepatorenal syndrome: combined liver kidney transplants versus isolated liver transplant.

BACKGROUND: As many as 38% of combined liver-kidney transplant (LKTx) procedures performed nationally may be done for the renal diagnosis of hepatorenal syndrome (HRS). This study was designed to compare the national results with those at our medical center and to determine if combined LKTx provides any benefit over isolated liver transplant (LTx) to HRS patients. METHODS: Data on 29 combined LKTx and 79 HRS patients at our center were collected and compared with the national data on 414 LKTx and 2442 patients with serum creatinine >2.0 mg/dl receiving isolated LTx from 1988 to 1995. RESULTS: United Network of Organ Sharing data revealed 5-year patient survival of 62.2% for LKTx recipients and 50.4% for patients with serum creatinine >2.0 mg/dl receiving isolated LTx (P=0.0001). Our center results demonstrated 5-year patient survival of 48.1% for LKTx patients, 67.1% for HRS patients receiving isolated LTx, and 70.1% for patients with serum creatinine >2.0 mg/dl receiving isolated LTx (P not significant comparing all groups). Intensive care unit status and preoperative dialysis rates were similar in those HRS patients who did and those who did not need future KTx. CONCLUSION: National data would suggest a survival benefit of combined LKTx over isolated LTx for those patients with poor renal function, specifically those with HRS, whereas our center's results suggest otherwise. Unfortunately, we could not identify any preoperative risk factors in the HRS patients, or in the broader group of patients with renal insufficiency at our center, that would indicate the need for future renal transplantation. We believe that HRS patients can be successfully managed with isolated LTx.

Ten years of liver transplantation: an evolving understanding of late graft loss.

BACKGROUND: We undertook this study to understand the causes of late graft loss and long-term outcome in orthotopic liver transplantation (OLT) recipients. METHODS: Prospectively collected data of 1174 consecutive OLT in 1045 adult patients who received liver grafts between April 1985 and August 1995 were reviewed. The causes of graft loss, pretransplant patient characteristics, and posttransplant events were analyzed in patients who survived at least 1 year after OLT, in an attempt to establish a link between these factors and graft loss. RESULTS: One hundred fifty-nine (17.9%) grafts were lost after the first year. Of these, 132 grafts were lost by death and 27 by retransplantation. Recipients who survived the first year (n=884) had 5- and 10-year survivals of 81.4% and 67.2%, respectively. Death with a functioning graft occurred in 97 (61%) patients. The main causes of late graft loss were recurrent disease (n=48), cardiovascular and cerebral vascular accidents (n=28), infections (n=24), and chronic rejection (n = 15). Pretransplant heart disease and diabetes were found to be significant risk factors for late graft loss due to cardiovascular diseases and cerebral vascular accidents. CONCLUSIONS: Survival of OLT patients who live beyond the first posttransplant year is excellent. Some patient characteristics may be associated with late graft loss. Compared with previous reports, this study shows an increased incidence of late graft loss secondary to recurrent diseases, de novo malignancies, cardiovascular diseases, and cerebral vascular accidents. Chronic rejection seems to be a less frequent cause of late graft loss. The prevention of recurrent disease and better immunosuppression may further improve these results.

Long-term outcome of patients transplanted with livers from hepatitis C-positive donors.

BACKGROUND: The use of hepatitis C serology-positive donors has become an option in patients affected by hepatitis C (Hep C) end-stage liver disease. Previous studies with less than 1 year of follow-up have suggested that there is no difference in early patient and graft survival. The aim of our review is to confirm with a longer follow-up (a minimum of 1 year) that the use of these organs is safe and that patient and graft survival are comparable to those of patients with Hep C who received Hep C-negative grafts. METHODS: Between 1985 and 1995, 213 patients were transplanted with a diagnosis of Hep C. Seventy-six patients were excluded from the study, 47 for insufficient follow-up and 29 because the diagnosis of recurrence was not certain. Twenty-two patients received Hep C+ donor grafts and 115 patients received Hep C-donor grafts. These two groups were evaluated to assess the rate and severity of recurrence by serial biopsies and to assess patient and graft survival. RESULTS: Recurrent Hep C was documented by biopsy in 12 of 22 patients who received Hep C+ donor grafts. Of these 12 patients, 9 had mild chronic hepatitis, 2 had fibrosis, and 1 had cirrhosis. Ten of the 22 patients had normal biopsies. Of the patients who received Hep C- grafts, 48 of 115 had recurrent disease. Of these 48 patients, 23 had mild chronic hepatitis, 15 had fibrosis, and 10 had cirrhosis. Sixty-seven of 115 had normal biopsies. The recurrence rate was 54.55% in the Hep C+ donor grafts and 41.74% in the Hep C- donor grafts (P=NS). Patient and graft survival at 4 years after transplant were 83.9% and 71.9% in the Hep C+ donor grafts and 79.1% and 76.2% in the Hep C- donor grafts, respectively (P=NS). CONCLUSIONS: Our study suggests that Hep C+ donors can be used with excellent long-term results and that the progression of the recurrent disease does not seem to be affected by the pre-existence of the Hep C virus in the donor.

Influence of donor and recipient gender on the outcome of liver transplantation.

BACKGROUND: Gender is currently not a criterion in the allocation of scarce donor organs. The purpose of this study was to determine the effects of gender on patient and graft survival, incidence of rejection, and postoperative complications after orthotopic liver transplantation. METHODS: During a 10-year period, 1138 liver transplants were performed on 1010 adult patients at Baylor University Medical Center. In this study, 994 patients with at least 6 months of posttransplant follow-up were reviewed. The four combinations of gender match and mismatch included: group 1, donor female to recipient female (n=229); group 2, donor female to recipient male (n= 126); group 3, donor male to recipient female (n=247); and group 4, donor male to recipient male (n=392). These groups were evaluated for patient survival, graft survival, episodes of rejection, incidence of chronic rejection, and postoperative complications. RESULTS: All groups were similar with respect to recipient age, underlying medical condition, incidence of bacterial and viral infections, postoperative biliary complications, and the incidence of chronic rejection. Female recipients had the highest incidence of early rejection (0-6 months, 70%) compared with male recipients (60%, P<0.039). Postoperative vascular complication (10%) was highest in group 3 (P<0.01). The two-year graft survival rate for groups 1, 3, and 4 was 76.2%, 75.6%, and 73.5%, respectively. Group 2, donor female to recipient male, had a 2-year graft survival rate of 55.9% (P<0.0001). This finding is not explained by the incidence of early rejection. Chronic rejection does not appear to be contributory. The mean donor age for groups 1, 3, and 4 was 35.7, 25.8, and 30.4 years, respectively. The mean donor age for group 2 was slightly older, at 41.6 years (P<0.0001). This difference, while statistically significant, is of unknown clinical relevance. A multivariate analysis controlling for donor age confirmed the decreased graft and patient survival rates in the donor female to recipient male group. CONCLUSIONS: The decreased graft survival rate in male recipients of female livers warrants further study and may argue for modifying the current management of adult male liver transplant recipients.

Hepatic artery stenosis after liver transplantation--incidence, presentation, treatment, and long term outcome.

Little is known about hepatic artery (HA) patency and patient clinical course when the nonthrombosed HA has been revised. We undertook this study to evaluate the risk factors in the development of HA stenosis and to assess the impact of HA revision on the outcome. A total of 857 adult consecutive OLT in 780 patients performed over a 6-year period were studied. Patients who underwent revision of their nonthrombosed but stenotic HA were reviewed for patient/graft survival, method of HA revision, incidence of biliary strictures, and long-term HA patency. Overall 39 patients (5%) with 41 allografts underwent HA revision for stenosis. Median time to diagnosis was 100 days posttransplant (range 1-1220 days). HA flow at the time of OLT was found to be the only significant variable of an anastomotic stenosis. No risk factor could be identified for the graft HA stenosis. Treatment methods included resection of the stenotic segment with primary reanastomosis (n = 17), aortohepatic iliac artery graft (n = 11), interposition vein graft (n = 4), vein patch angioplasty (n = 2), interposition artery graft (n = 1), and percutaneous transluminal balloon angioplasty (n = 6). Postrevisional HA patency was demonstrated in 32 (78%) cases. At a median follow-up of 25 months, 26 patients (67%) were asymptomatic with good liver function. Nine patients had developed biliary strictures. Seven patients had undergone retransplantation and 8 patients had died. The actuarial patient and graft survivals at 4 years in the patients with revised HA were 65% and 56%, respectively. HA stenosis requiring revision is an infrequent occurrence after OLT. Long-term patency of the revised HA is good. Revision of the HA may help prevent biliary strictures and allow for good long-term graft function in the majority of patients.

Liver and kidney transplantation for polycystic disease.

BACKGROUND: With the poor results of resective and fenestration procedures for polycystic liver disease (PCLD), we present the first series of patients receiving orthotopic liver transplantation for this condition. METHODS: Five of our six patients with PCLD had polycystic kidney disease also. Three of these five received combined organ transplants, while the other two required subsequent kidney transplants. RESULTS: Forty-eight and 52 months after orthotopic liver transplantation, all surviving patients had relief of their pain, distention, and anorexia. Two patients had succumbed to infectious complications and died at 15 and 24 months after transplant. CONCLUSIONS: We conclude that patients with PCLD can be transplanted safely for the relief of their distention and anorexia, with good results. Those patients with both PCLD and polycystic kidney disease who are not dialysis dependent can be managed for several years with isolated liver transplantation and then receive kidney transplantation if needed. Those who are dialysis dependent should receive combined liver-kidney transplantation. Unfortunately, patients with polycystic disease seem to be very susceptible to infectious complications after organ transplantation.

Does intraoperative hepatic artery flow predict arterial complications after liver transplantation?

BACKGROUND: Little is known about the value of intraoperative hepatic artery (HA) flow measurement on the development of HA complications in orthotopic liver transplantation (OLT). We undertook this study to see whether assessing HA flow at the OLT helps predict posttransplant HA complications (HA thrombosis or stenosis). METHODS: Four hundred and eleven consecutive OLT in 367 adult patients who received grafts between November 1992 and August 1995 were reviewed. Of these, 259 grafts in 255 patients with at least 1 year of follow-up and with complete data were studied. HA flow, portal vein flow, percentage of cardiac index going to HA (HA/CI), HA flow per 100 g of liver tissue, mean arterial pressure, central venous pressure, and CI were analyzed. Preservation injury was assessed by posttransplant alanine aminotransferase and aspartate aminotransferase levels. RESULTS: Thirty-four patients with 35 grafts developed HA thrombosis or stenosis during a median follow-up time of 29 months. HA complications occurring within the first 100 days of OLT were classified as early complications. HA flow at the time of surgery and percentage of CI going to the liver were found to be significant variables in early HA complications. Hepatic hemodynamics were not different in the late HA complication group compared to the control. Systemic hemodynamics and posttransplant alanine amino-transferase and aspartate aminotransferase levels were similar in all three groups. Logistic regression analysis showed that patients with HA flows less than 400 ml/min were more than 5 times as likely to develop HA complications (risk ratio 5.1). CONCLUSIONS: HA flow measurement should be obtained at the time of OLT and may help to predict early but not late posttransplant HA complications. Patients with HA flows less than 400 ml/min or HA/CI values of less than 7% may carry a higher risk for HA stenosis or thrombosis and may need close surveillance to detect such problems.

Recurrent primary sclerosing cholangitis after orthotopic liver transplantation: is chronic rejection part of the disease process?

BACKGROUND: The possibility of primary sclerosing cholangitis (PSC) recurrence after liver transplantation has been debated. The aim of this study is to examine whether recurrent PSC and chronic rejection (CR) are different expressions of the same disease process. METHODS: One hundred consecutive patients receiving 118 grafts for the diagnosis of PSC were reviewed and placed into three groups: group A, recurrent disease, as evidenced by cholangiographic and pathologic findings with radiographic arterial flow to the liver (n=18; 15.7%); group B, those who developed CR (n=15; 13.0%); and group C, all others (n=82; 71.3%). Cholangiograms and histopathologic specimens were examined in a blinded fashion. RESULTS: Demographic factors were similar, except for age, with a significantly younger age and more episodes of rejection in groups A and B (P<0.03). Group A had a higher incidence of cytomegalovirus hepatitis (P=0.008). Five-year graft survivals for A, B, and C were 64.6%, 33.3%, and 76.1%, respectively (P=0.0001), 5-year patient survivals were 76.2%, 66.7%, and 89.1%, respectively (P=0.0001), and repeat transplantation rates were 27.8%, 46.7%, and 8.5%, respectively (P=0.005). Radiographically, 90% of cholangiograms in patients with recurrent disease showed at least multiple intrahepatic strictures. Histopathologically, patients with recurrent disease and CR shared many features. CONCLUSIONS: We have described a high incidence of recurrent PSC and CR in patients who received transplants for PSC. Histopathologic analysis suggests that CR and recurrent PSC could represent a spectrum of indistinguishable disease. However, the distinct difference in clinical outcome, as evidenced by an increased repeat transplantation rate and lower graft and patient survival in the CR group, clearly suggests that they are two distinct entities that require very different treatment strategies.

Percutaneous treatment of abdominal hydatid cysts with hypertonic saline and alcohol. An experimental study in sheep.

RATIONALE AND OBJECTIVES: Seven naturally infected sheep with proper hepatic and peritoneal hydatid cysts were studied to assess a new percutaneous approach for cystic hydatid disease. METHODS: A needle was inserted into the cyst cavity of sheep under sonographic guidance. Immediately after instillation of hypertonic saline to inactivate protoscolices, ultrasound demonstrated that germinal and laminated membranes of the hydatid cysts were separated completely from the pericyst in all sheep. Later, a catheter was inserted into the cyst cavity using Seldinger technique. Alcohol was used as a sclerosing agent. RESULTS: Ultrasound showed reduction in cyst size and progressive solidification. No anaphylactic reaction was observed. After sonographic follow-up that lasted from 1 to 26 weeks, the sheep were killed to evaluate macroscopic and histologic changes. At autopsy, no secondary cyst formation was seen. The appearance of treated cysts was different from the others, and there were signs of involution. The histologic sections did not show any viable protoscolices or daughter cysts. The authors observed pericyst hyalinization, inflammatory cells in the cyst wall, cyst wall necrosis, calcification of cyst wall, degeneration of laminated membrane, severe degeneration or absence of germinal membrane, and inflammatory cells and necrotic material in the cyst cavity. CONCLUSIONS: Percutaneous treatment of hydatid disease was effective in the animal model. Ultrasound was useful in evaluating the intervention.

Neutropenic enterocolitis in patients without leukemia.

BACKGROUND: Neutropenic enterocolitis is a serious complication involving the bowel in patients with severe neutropenia. Most of the patients are undergoing chemotherapy for acute leukemia. METHODS: This is a report of three cases of nonleukemic neutropenic enterocolitis. In these cases neutropenia was caused by an analgesic (dipyrone), chemotherapy for multiple myeloma, and chemotherapy for lung carcinoma. Two patients were treated by surgery, one medically. RESULTS: The patient with multiple myeloma who was treated by exteriorization of the sigmoid colon died on the tenth postoperative day of multiple organ failure caused by sepsis. The other two patients survived. CONCLUSIONS: A review of the literature revealed 14 other patients without leukemia who had neutropenic enterocolitis. The cause, diagnosis, and possible treatment options of this entity are discussed.

The safety of cardiac operations in the liver transplant recipient.

BACKGROUND: Advances in surgical techniques and immunosuppressive drugs have improved the survival of patients after orthotopic liver transplantation. Enhanced survival has resulted in an increased number of patients who require medical as well as surgical management of diseases. METHODS: To contribute to the sparse literature on the surgical aspects, we reviewed our experience with 15 patients who underwent cardiac operation (1.25%) from a total of 1,200 liver transplant recipients at our center. The variables studied included the pretransplant cardiac evaluation, the interval from transplantation to cardiac operation, postoperative complications, the management of immunosuppression, and follow-up. The patients had a mean age of 52.9 years (range, 39 to 69 years) and 13 of them (86.6%) were men. Multiple cardiac risk factors were present in all 15 patients and chronic renal insufficiency was present in 7 patients. Cardiac operation was undertaken a mean of 30.4 months (range, 9 days to 62 months) after myocardial ischemia and valvular regurgitation had been ruled out at the time of transplantation. Myocardial revascularization was performed in 12 patients, 2 of whom underwent concurrent valve operation and 3 of whom underwent valve repair or replacement. Most patients had their immunosuppression regimen continued at baseline levels. RESULTS: There were no early deaths. Three patients had major complications and 4 had minor complications. There were no bleeding, infection, or healing complications. Postoperative renal parameters were persistently elevated in 5 patients and transiently elevated in 3. Liver function parameters were transiently elevated in 6 patients after the cardiac operation. No patient had hepatic rejection. A transient elevation or decrease in immunosuppressive drug levels was seen in 3 patients. Follow-up, obtained on all 15 patients, ranged from 6 to 83 months (mean, 26.5 months). There were 2 late deaths (13.3%), and 3 patients (25%) who underwent myocardial revascularization had recurrent angina. CONCLUSIONS: Cardiac operations can be undertaken safely in liver transplant recipients with good intermediate-term results. The immunosuppression regimen can be continued at preoperative levels with no need for stress-dose steroids. There were no hepatic complications among our patients, although some patients can experience worsening of renal failure.

Risk factors for vitreous loss in cataract surgery.

PURPOSE: To evaluate the risk factors for posterior capsule rupture with or without vitreous loss (PCR +/- VL) in extracapsular cataract extraction (ECCE). METHODS: The charts of 2794 consecutive patients who had ECCE with or without intraocular lens implantation between January 1992 and December 1997 were reviewed retrospectively. Probable risk factors included age, sex, operated eye (right or left), presence of diabetes mellitus, systemic hypertension, history of vitreous loss in the other eye (if operated), type of cataract, axial length of the eye, preoperative visual acuity, glaucoma, presence of pseudoexfoliation, preoperative shallow anterior chamber and experience of surgeon (resident, general ophthalmologist, cataract surgeon). We compared 192 patients who had PCR +/- VL with complete data and 275 randomly selected patients who had no complications, using multiple logistic regression analysis. RESULTS: Two hundred and fifty-four patients (9.09%) had PCR and 197 (7.05%) had PCR + VL. The surgeon's experience (p < 0.0005), glaucoma (p < 0.005), type of cataract (p < 0.005), presence of pseudoexfoliation (p < 0.05) and systemic hypertension (p < 0.05) were significant risk factors. CONCLUSIONS: Patients with risk factors such as glaucoma, pseudoexfoliation, traumatic cataract and systemic hypertension should be operated by experienced surgeons.