Use of the splenic artery for arterial reconstruction in living donor liver transplantation.

BACKGROUND: The present study sought to evaluate the possibility of using the splenic artery for arterialization of a living donor liver graft. PATIENTS AND METHODS: In the period between August 2004 and April 2006, we performed 31 adult-to-adult living donor liver transplantations. In 27 patients (group A), the right or left hepatic artery was used to arterialize the graft, whereas in the other four cases (group B), we used the recipient splenic artery. RESULTS: The Model for End-stage Liver Disease (MELD) score of the patients averaged 17 (17.2 and 15.2 for groups A and B, respectively) ranging between 7 and 28. We did not observe pancreatitis, splenic infarction, or other complications related to ligation of the splenic artery. Two cases (6.4%) of arterial complication were observed, both in group A patients. CONCLUSION: The use of the splenic artery is a safe, practical alternative for arterial reconstruction in living donor liver transplantation procedures, when the hepatic artery is not adequate or in cases of portal hypertension with splenomegaly.

Aqueous extract of Chrysobalanus icaco leaves, in lower doses, prevent fat gain in obese high-fat fed mice.

ETHNOPHARMACOLOGICAL RELEVANCE: Due to the rise in obesity, the necessity for resources and treatments that could reduce the morbidity and mortality associated to this pandemia has emerged. The development of new anti-obesity drugs through herbal sources has been increasing in the past decades which are being used not only as medicine but also as food supplements. Previous studies with the aqueous extract of Chrysobalanus icaco L (AECI) have demonstrated activity on lowering blood glucose levels and body weight. AIM OF THE STUDY: Investigate C. icaco effects in overall adiposity and glycemic homeostasis. MATERIAL AND METHODS: C57BL/6J mice were randomly assigned to standard chow (SC) or high-fat diet (HFD) and treated with AECI in 0.35mg/mL or 0.7mg/mL concentrations ad libitum. Food intake, feed efficiency, metabolic efficiency, body, fat pads and gastrocnemius weight, adiposity index, serum lipids, fecal lipid excretion, locomotor activity in the open field test and insulin and glucose tolerance tests were analyzed and compared. The major components of the extract were demonstrated through HPLC and its antioxidant activity analyzed through DPPH and lipid peroxidation. RESULTS: The AECI in the 0.35mg/mL concentration did not affect food intake or body weight. However, it promoted lower adipose tissue gain, TG levels, and fecal lipid excretion, increased locomotor activity and lean mass weight, and normalized insulin sensitivity and glucose tolerance. Moreover, AECI showed the presence of myricetin 3-O-glucuronide, rutin, quercitrin and myricitrin and demonstrated high-antioxidant activity. CONCLUSIONS: AECI in lower concentrations can prevent fat storage or enhance fat utilization through the increase of locomotor activity. Also, this reinforces its ability to maintain glucose homeostasis through the normalization of insulin sensitivity and glucose tolerance despite the high-fat diet intake. These activities could be associated to the extract's polyphenol content.

[Small hepatocellular carcinoma. New concepts on intrahepatic recurrence after hepatectomy in orthotopic liver transplantation]. / Pequeno carcinoma hepatocellular. Novos conceitos a propósito de recorrência intra-hepática após hepatectomia no transplante ortotópico de fígado.

Hepatocellular carcinoma is one of the most common cancers worldwide. Epidemiologic studies shows a striking correlation between areas where this tumor is prevalent and where hepatitis virus B and C are endemic, contaminations of food with mycotoxin aflatoxin B1, excessive alcohol intake, prolonged cigarette smoking, sexual hormones. Combination of chemical, physical, and genetic insults to individual hepatocytes involve changes in the genome transformed or neoplastic cell, depending to both the activation of oncogenes (e.g., ras) and the inactivation of tumor supressor genes (e.g., p53). Advances in radiologic techniques such as ultrasonography, computed tomography, angiography and dosages of tumor markers like alpha-fetoprotein offers still the best for diagnosis and screening for hepatocellular carcinoma. Then the diagnosis has become possible during the early stages, characterized to be a very well-differentiated tumour that has returned its preexisting liver structure, with a certain proportion have a multicentric origin. Hepatocellular carcinoma carries an extremely poor prognosis, with a median survival between 2-4 weeks, for those without treatment. Surgical resection are the only curative modality for this disease. In these patients two main patterns of intrahepatic recurrence after hepatectomy are defined, and depends on the growth of residual satellite tumours or synchronous and metachronous multicentric carcinogenesis. This evolution is estimated to be nearly 50%, with 5-year survival rate of nearly 30%. The presence of cirrhosis, satellite nodules, venous invasion, the absence of capsule formation and positive surgical margin (< or = 5 mm) were associated with higher intrahepatic recurrence rates.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of portal hypertension in patients with liver cirrhosis]. / Tratamento cirúrgico da hipertensão portal em cirróticos.

Surgical options in the treatment of portal hypertension in cirrhotics are reviewed, regarding elective and emergency cases as well as the results in alcoholics and non-alcoholics. After literature review and personal experience analysis, it is concluded that endoscopic sclerotherapy should be the treatment of choice in cirrhotic patients with bleeding esophageal varices. When this fails, distal splenorenal shunt is indicated for compensated Child A and B. Regarding Child C and decompensated Child B, the choice should be a portocaval or meso caval shunts or esophageal transection with a stapler associated to splenectomy.

[Use of the Leveen shunt in the treatment of clinically intractable ascites]. / Uso da válvula de Le Veen no tratamento da ascite clinicamente intratável.

From January 1978 to August 1987, 21 patients received a peritoneovenous shunt using the Le Veen valve (LVV). The indications criteria were the long-term diuretic therapy failure (mean time = 24.4 months) or resistence to medical therapy during hospital internment. The 21 patients underwent 36 surgeries, being 4 valve position review and 11 changes of LVV. The mean age was 51.6 years. Fifteen patients had alcoholic cirrhosis, 3 postnecrotic cirrhosis, one Budd-Chiari syndrome, one mansoni Schistosomiasis, and one malignant ascites. Ten were Child B and 9 Child C patients. Eight patients with history of previous esophageal varices bleeding (EVB) underwent endoscopic sclerotherapy (EE) before LVV implantation. Seven patients died in the early postoperative period (3 Child B and 4 Child C patients). Three patients died due to EVB and the others as consequence of hepatic failure (one), cardiac insufficiency (one), sepsis (one), and bronchopneumonia (one). The mean follow-up was 19.9 months (1-61). Early LVV occlusion occurred in 4 patients and late valve occlusion in others 4 patients. The LVV changes were done at ambulatorial preceeding. Ten patients (47.6%) died in late follow-up and in these cases death was related to the main disease course. It is concluded that: 1) LVV is a useful therapy in patients with intractable ascites, since it is not the terminal manifestations of disease; 2) early mortality is related to liver function and late mortality to main disease course; 3) ascitic patients with EVB should undergo endoscopic sclerotherapy before LVV implantation.

[Hepatic functional changes induced by the combined use of isoniazid, pyrazinamide and rifampicin in the treatment of pulmonary tuberculosis]. / Alterações funcionais hepáticas induzidas pelo uso concomitante de isoniazida, pirazinamida e rifampicina no tratamento da tuberculose pulmonar.

Antituberculosis therapy commonly used for pulmonary tuberculosis in Brazil include isoniazid (440 mg), rifampicin (600 mg) both for six months plus pyrazinamide (2 g) together in the first two months. Such therapy may induce acute or chronic liver damage in some individuals. The purpose of this study is to evaluate 1096 patients treated with antituberculous drugs, being 773 males and 323 females. Clinical and laboratory signs of hepatic cell injury was present in 66 patients. Serum bilirubin and transaminase levels were evaluated in 21 (31.81%) and 45 (68.19%) respectively, with a female preponderance. Early return to normal values occurred more frequently among alcoholic drinkers and non-cigarette smokers. Liver injury was characterized as being mild and moderate and the type of injury associated was represented by pure cholestasis and hepatocanalicular lesions. Probably, rifampicin is the drug responsible for this kind of evolution aggravating the hepatotoxicity induces by isoniazid and pyrazinamide.

[Hepatic hemangiomas. The importance of the image]. / Hemangiomas hepáticos. Importância da imagem.

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.

Embolization to reverse severe recurrent hepatic encephalopathy.

Five patients with porto-systemic shunts, four spontaneous and one surgically created, presenting severe recurrent hepatic encephalopathy rebel to clinical treatment were angiographically examined. A spontaneous splenic-renal veins shunt was observed in four cases and a mesocaval shunt was identified in the remaining patient. Two thirds embolization of the spleen was able to control hepatic encephalopathy in two patients. Percutaneous transhepatic portography and selective embolization of the shunt was performed in two other patients with good results. Percutaneous transcaval embolization of the mesocaval shunt succeeded to control hepatic encephalopathy in the remaining patient. Splenic embolization is able to control hepatic encephalopathy in patients with splenomegaly and spontaneous porto-systemic shunt. Direct embolization of the shunt is also able to control hepatic encephalopathy as should be expected.

[Surgical treatment of ascites with Le Veen shunt in patients with alcoholic liver disease]. / Tratamento cirúrgico da ascite com o implante da válvula de Le Veen em pacientes com doença hepática alcoólica.

Studies were carried out on 16 alcoholic cirrhotics with clinically intractable ascites who underwent the implant of peritoneovenous (LeVeen) shunts. Our purpose was to find out how this group of patients responded to this kind of surgical treatment for ascites. Fifteen of these patients were male and one female, with a median age of 51.3 years. According to Child classification, 7 were Child B and 9 Child C. Thirty-three surgeries were conducted, in that 5 were performed for revision of the shunt positioning and 12 for the replacement of the valves. A total of 28 shunts were used. Postoperative immediate mortality occurred in 5 patients (4 Child C and one Child B). The median late postoperative follow-up of the 11 patients who survived was 25.8 months. We concluded that LeVeen shunt implantation is a valid palliative therapeutic resource for the treatment of ascites in alcoholic cirrhotics. The results obtained with this patient population are similar to those observed in cirrhotics who presented other etiologies. We also concluded that late mortality was not related to the implant of a LeVeen shunt but was due to the normal course of the disease.

Prognostic value of preoperative tests in the surgical treatment of ascites with the implant of Le Veen shunts in cirrhotics.

In the period of January 1978 to October 1988, 32 Le Veen shunts (LVS) were implanted in 20 patients, out of which 16 were alcoholic cirrhotics and 4 postnecrotic cirrhotics. In the present study, we correlated preoperative laboratory data of these patients with their postoperative evolution, comparing the clinical results of patients who survived more than 30 days (13 patients = 65%) with the results of those who died within the same period (7 patients = 35%). For that matter, 14 laboratory tests were performed in order to measure the serum levels of hematocrit, hemoglobin, urea, creatinine, sodium, potassium, bilirubin, albumin, AST, ALT, alkaline phosphatase, fibrinogen, gamma GT and prothrombin activity. After statistical analysis, we observed that 6 of the 14 tests performed could be considered of prognostic value in the following decreasing order of importance: fibrinogen, alkaline phosphatase, prothrombin activity, urea, gamma GT and bilirubin. We observed that all the 7 patients who died prematurely presented 3 or more of these levels altered, when compared with standard values. Based on these data, we concluded that serum levels of fibrinogen, alkaline phosphatase, urea, gamma GT, bilirubin and activity of prothrombin proved to be important factors in determining the prognosis of immediate survival in cirrhotic patients who underwent LVS implantation. We also concluded that when 3 or more of these factors are altered, the implant of LVS is contraindicated, whatever clinical criteria for indication and contraindication were taken into account.

[Immunological parameters in the differential diagnosis of ascites secondary to peritoneal carcinomatosis, hepatic cirrhosis, and congestive heart failure]. / Parâmetros imunológicos no diagnóstico differencial de ascite secundária à carcinomatose peritoneal, cirrose hepática e insuficiência cardíaca congestiva.

As a contribution to the study of ascites in patients with liver cirrhosis, congestive heart failure and peritoneal carcinomatosis evaluate in serum and ascites the concentrations of alphafetoprotein, carcinoembryonic antigen and fibronectin, they might suggest a diagnosis for the basic pathology. Forty-seven patients were studied, from whom 23 with cirrhosis, 17 peritoneal carcinomatosis and 7 with congestive heart failure. We conclude that: a) none of the tools usually employed in the analysis of ascitic fluid alone can make the base pathological process responsible for producing ascites; b) fibronectins were more useful for differential diagnosis between cirrhosis and carcinomatosis; c) alpha-fetoprotein and carcinoembryonic antigen were not useful for the definition for differential diagnosis.

[Diagnosis of hepatocellular carcinoma performed by searching for serologic tumor markers]. / O diagnóstico do carcinoma hepatocelular (CHC) realizado através da pesquisa de marcadores sorológicos tumorais.

Serum levels of alkaline phosphatase, gamma-glutamyltranspeptidase, -1 fucosidase and glutathione-S-transferase are increased in 60, 90, 75 and 64% of patients with hepatocellular carcinoma. In these patients the mean plasma fibrinogen levels is 461.78 mg/dl, while mean serum copper is 200.50 mg/dl. Serum levels of desgamma-carboxiprothrombin is over 900 mg/dl in 67% of the patients (60% of them have HB virus, mostly anti HBe positive). Forty to 95% of them have increased levels of -fetoprotein (AFP). The authors suggest that cirrhotic patients, with or without HB virus, specially those with increased AFP, should have ultrasound examination of the liver every 6 months. This method of imaging has been shown to be more sensitive than AFP (72% versus 25%) in the detection of hepatocellular carcinoma smaller than 2 cm in diameter.

[Treatment of hemorrhagic congestive gastropathy with TIPS implantation. Pilot study]. / Tratamento da gastropatia congestiva hemorrágica através do implante do TIPS. Estudo piloto.

Minimally invasive percutaneous procedures has an important place in internal medicine. In this concept is included a transjugular intrahepatic portosystemic shunts (TIPS). In this pilot study we describe the indication of this therapeutic modality in three cirrhotic patients with hemorrhagic congestive gastropathy unresponsive to infusion of drugs that reduce the portal pressure. All of them were treated by TIPS and control of gastric bleeding occurred in all. One of these showed partial stenosis of the wallstent, treated by prosthesis dilatation. Another developed portosystemic encephalopathy controlled by usual therapeutic measures in the other we implanted two TIPS to obtain a low pressure level of the hepatic-portal gradient. They had no further necessity of blood transfusion, with better hemodynamic conditions and biochemical tests with reduction of the values of the GHP. We conclude that TIPS may be useful to treat hemorrhagic congestive gastropathy acting like a bridge for subsequent elective liver transplantation under good clinical and hemodynamic conditions.

[Frantz tumor--report of 2 cases. Therapeutic approach and prognosis]. / Tumor de Frantz--relato de dois casos. Medidas terapêuticas e prognóstico.

The authors report two rare pancreatic tumor cases (Frantz's tumor), which were in different evolutionary stages, emphasizing the complexity of a precise anatomopathologic diagnosis and an aggressive surgical approach, whenever possible because the excellent prognosis. They also discuss the clinical manifestation and histological origin, as well as the prognosis factors and a new approach for the liver metastasis.

[Hepatocyte necrosis and intrahepatic cholestasis in the postoperative period of patients undergoing heart surgery with the use of extracorporeal circulation: significance of clinical, epidemiologic, surgical and laboratory parameters in evaluating prognosis]. / Necrose hepatocitária e colestase intrahepática no pós-operatório de pacientes submetidos à cirurgia cardíaca com o emprego de circulação extracorpórea: importância dos parâmetros clínicos, epidemiológicos, operatórios e laboratoriais na avaliação do prognóstico.

Sixteen patients with jaundice after heart surgery with extracorporeal circulation, were studied. They were divided in 2 groups, according to the postoperative outcome; either death (group I) or hospital discharge (group II). Clinical, epidemiological, surgical and laboratorial aspects were compared in order to ascertain their role in the outcome. The results were analysed by the Student-t test. The main cause of death was low output syndrome, which occurred in 10 cases (62.5%), 5 of them died (31%). A statistically significant difference was observed in the postoperative values of serum GOT (p less than 0.01), GPT (p less than 0.01) and total bilirubin (p less than 0.01), which were then considered prognostic indicators in these patients.

[Transjugular intrahepatic portosystemic shunts (TIPS) as a bridge for liver transplantation]. / Anastomose portossistêmica intra-hepática (TIPS) como ponte para o transplante de fígado.

Transjugular intrahepatic portosystemic shunts (TIPS) represents a new surgical technique minimally invasive utilized in the treatment of portal hypertension. Such technique avoid the risks of general anesthesia, and major surgery like portocava anastomosis, reducing the hepatic-portal gradient, and help bleeding esophagogastric varices, hemorrhagic congestive gastropathy and refractary ascites. Certainly diminishes the intensity of intraperitoneal colorectal circulation and the necessity of blood transfusion during surgery for liver transplantation. In this report we reported the first case in Brazil of the implant of TIPS like preparation for liver transplantation in cirrhotic alcoholic patient. We made consideration about techniques aspects and surgery evolution. This new interesting technique applied for this type of patients is indicated as a bridge for candidates for liver transplantation.

[Ultrasonically guided needle biopsy in malignant focal solid nodules of the liver]. / Biopsia percutânea guiada por ultra-som em lesões nodulares sólidas focais malignas do fígado.

In the most of the cases, the diagnosis of focal solid hepatic lesions are performed by ultrasonography, computed tomography, magnetic resonance and hepatic angiography imagig. However, the distinction between benign and malignant neoplasias, sometimes is made after liver biopsy. This report is about 32 of these lesions, diagnosed after guided liver biopsy by ultrasonography. The efficacy of this propedeutic method, minimally invasive, is defined emphasizing that there are no mortality and low levels of morbidity.

[Intrahepatic and subcapsular hematoma of the liver after hepatic biopsy under laparoscopy. Contribution of ultrasonography]. / Hematoma intra-hepático e subcapsular do fígado após biopsia hepática sob visão laparoscópica. Contribuição ao seu estudo através da ultra-sonografia.

Over the last few years, ultrasound became important in characterization of space -occupying solid lesions of the liver. Recently, Canadian authors using this method, described a 23% incidence of intrahepatic or subcapsular hematoma after liver biopsy. We prospectively evaluated the incidence of this complication after liver biopsy under laparoscopic guidance in 8 cirrhotic patients, 7 with steatosis, 7 chronic active hepatitis and 4 with intrahepatic cholestasis. Biopsy was performed under general anesthesia provided that prothrombin activity was over 50%, serum fibrinogen was over 100% and platelets over 50.000/mm3. In none of 26 consecutive patients, was an intrahepatic or subcapsular hematoma observed.

Cholelithiasis in cirrhotic patients. (Analysis of cholelithiasis among patients with liver cirrhosis in São Paulo, Brazil).

During the past 20 years, several authors have reported increased prevalence of cholelithiasis in liver cirrhosis. This biliary disease has been implicated with the deterioration of liver function, liver disease of alcoholic origin or even the presence of hypersplenism in this patient population. This study analyzes the incidence and possible factors which are responsible for promoting cholelithiasis in cirrhosis. The study included 110 cirrhotic patients of a private center specialized in treating liver diseases. The incidence of cholelithiasis was 27.3% (25.3% in males and 33.3% in females). There was no correlation between liver function defined by Child's classification or through the laboratory examinations (AST, ALT, AP, GGT, PT, Alb, TB, DB, PA) and the presence of gallstones. No evidence was found that the etiology of cirrhosis or the presence/absence of hypersplenism affected the prevalence of cholelithiasis in this population. In conclusion, an increased prevalence of cholelithiasis was verified in this population of cirrhotics but the pathogenesis is still obscure.

[Diffuse primary malignant mesothelioma in abdominal cavity]. / Mesotelioma maligno primário difuso em cavidade abdominal.

Two cases of diffuse malignant mesothelioma of abdominal cavity were analysed. These tumors arise from the peritoneum and are also found in the parietal and visceral pleura, pericardium and in vaginal tunic. All of them, infra or supra-diaphragmatic, are associated with asbestos exposure in at least 80% of cases. It is difficult to explain how inhaled asbestos induces peritoneal neoplasms. This aspects become very important in the diagnostic, basically why it is done at laparotomy or laparoscopy. When was proceed the biopsy of the lesions, and occasionally by identification of malignant mesothelial cells in ascitic fluid. In this two cases exposed considerations about the advanced phase of diagnostic are made, the diagnostic was performed in the majority of the collected cells, showing the advanced stage of the disease. At that time of diagnosis we observed poor evolution. We call attention to the importance of precancer diagnosis, the best chance to treatment options, always based on surgical resections, radiation or chemotherapy alone or combined. If the radical surgery is not possible, this patients must be treated by chemotherapy or radiotherapy, defined after complete staging of the disease.