Liver transplantation and aortic valve replacement

Surgical procedures involving heart and liver are rare and have been limited to either combined heart and liver transplantation or coronary artery bypass graft surgery [CABG] or aortic valve surgery and orthotopic liver transplantation [OLT]. Aortic valve replacement [AVR] and pulmonary valve vegetectomy for bacterial endocarditis after OLT have also been reported. There are only five cases with aortic stenosis and cirrhosis reported to have combined AVR and liver transplantation. In the presence of cirrhosis, AVR has a significant risk for mortality because of bleeding from coagulopathy, renal failure, infection, and poor post-operative wound healing. Herein, we report on a case and management analysis of combined sequential AVR, and OLT in a 40-year-old cirrhotic man with Child and MELD score of C and 29, respectively. Echocardiography detected severe aortic insufficiency [AI] with enlarged left ventricle. Due to severe AI, the cardiologist recommended AVR prior to transplantation. The patient underwent metallic AVR. 4 months later, he received OLT. Both operations were successful and uneventful. Prioritizing AVR before OLT was successful in this patient. However, each patient must be evaluated individually and multiple factors should be assessed in pre-operation evaluation

Surgical experiences of hyperparathyroidism

This retrospective article reports the diagnostic experiences of forty six cases of hyperparathyroidism confirmed by operation and pathologic examination. From 1976 to 2002, all the patients who had conventional neck exploration for hyperparathyroidism were investigated. Eleven surgeons performed the operations by doing only 1 up to 18 procedures. Experience of surgeon and the result of frozen section were determined adequacy of procedure and completeness of operation. The clinical presentation was divided into four types: 24 cases [52.17%] with bone resorption; 15 cases [32.60%] with bone lesions plus urinary calculus; 4 cases [8.69%] with urinary calculus and 3 cases [6.52%] with asymptomatic hypercalcemia. The mean age of 46 patients [35 women, 11 men] was 44 [range 1 month to 67] years. Mean preoperative serum calcium was 13 [range 10.5 to 30] mg/ 100ml. Two patients in one family had neonatal primary hyperparathyroidism. One patient had chronic renal failure. Neck sonography was done in 18 and parathyroid [Sestamibi] scan was done in 3 with accuracy of 66.66% and 100% subsequently. The pathological diagnosis was parathyroid adenoma in 37, hyperplasia in 5, parathyroid carcinoma in 1 and negative exploration in 3. The clinical picture of PHPT in south of Iran is similar to that recognized previously in west. We are expecting routine measurement of serum calcium and high suspicioun by the physician in patients with symptoms of musculoskeletal system or renal stone can lead to early diagnosis. By using parathyroid scan and sonography of neck localization of most parathyroid adenoma is possible. Therefore minimal access adenomectomy can be replaced by conventional neck exploration

Living-related liver trasplantation in children: the Shiraz experience

The liver transplantation program was established at Shiraz Nemazee Hospital in 1993. Shortage of cadaver organ supply due to various social and legal issues urged us to develop a living-related liver transplantation [LRLT] program. So far 7 [6 males, 1 female] living-related liver transplantations have been performed at this center. The mean age of patients was 8.21 years [ +/- 4.16], with a range of 4.5 to 14 years. Live donors [3 mothers, 2 fathers, and 1 brother] with a mean age of 30.83 years [ +/- 4.11] underwent procurement of the left lateral segment without mortality or any serious morbidity. The native liver disease was idiopathic cirrhosis [1 case], biliary atresia [3 cases], Budd-Chiari syndrome [1 case], neonatal cirrhosis [1 case], and cryptogenic cirrhosis [1 case]. Allografts were implanted using piggy-back surgical technique. Baseline immunosuppression consisted of a triple drug regimen including cyclosporine, mycophenolate mofetil and steroids. Acute graft rejection was treated with intra-venous bolus of methyl-prednisolone. Early death occurred in 2 patients due to vascular thrombosis. Biliary complication was observed in 1 patient. Five patients are alive with a normal functioning liver. In conclusion, LRLT program is promising in Iran. It can help to overcome the shortage of organs and minimize the mortality of patients in the waiting list

Colo-pleural fistula: a rare complication of carcinoma of colon

A 72-year-old male, a known case of non-insulin-dependent diabetes mellitus, was admitted for recurrent empyema. He was found to have developed a colo-pleural fistula, secondary to a small primary carcinoma of the splenic flexure of the colon. This rare complication should be considered in the case of chronic treatment-resistant empyema