Liver transplantation with vena cava in situ and selective use of temporary portacaval shunt or portal clamping.

BACKGROUND/AIMS: The recipient hepatectomy with vena cava in situ in liver transplantation has overcome the need of venous-venous bypass thanks to temporary porta caval shunt or portal clamping. METHODOLOGY: 150 orthotopic liver transplants in 137 patients were performed and the vena cava in situ technique was used in 142 (venous bypass in 7, temporary porta caval shunt in 49, portal clamping in 87). The suprahepatic cava veins anastomosis was performed with Belghiti in 97 and piggyback techniques in 45. RESULTS: There were no differences in operative and warm ischemia times nor in blood requirements, while a greater stability of body temperature was documented in the vena cava In Situ group: in the latter temporary porta caval shunt preserved the temperature better than portal clamping (P < 0.01). In anhepatic phase mean artery pressure decreased in veno-venous bypass and increased in the vena cava In situ groups (P < 0.01). The venous return and the cardiac performances (anhepatic phase) were better preserved in the vena cava In Situ group. (P < 0.0001). CONCLUSIONS: Temporary portal caval shunt or portal clamping and piggyback or Belgiti Techniques allow a better hemodynamic stability through out the procedure, obviating the need for veno-venous bypass or fluid overload, if selectively used.

Role of transarterial chemoembolization before liver resection for hepatocarcinoma.

The aim of this study was to clarify whether chemoembolization (TACE) before liver resection (LR) can reduce postoperative hepatocellular carcinoma (HCC) recurrence and improve disease-free and overall survival. Eighty-nine patients with tumor-stage (TNM) I-II HCC were evaluated for LR. Patients were prospectively allocated to LR alone or TACE plus LR based on their place of residence. Twenty nonlocal patients (24%) were selected for LR, while 69 (77.5%) local patients were selected for TACE plus LR. Following TACE, the tumor stage could be confirmed in only 20 patients (29%) who then underwent LR. Operative mortality was 0%, but in the TACE-LR group, 3 patients died of liver failure between 2 and 5 months after surgery. Early recurrence (<24 months) was 59% for LR versus 20% for TACE plus LR (P <.05). Late recurrence was 18% for LR versus 10% for TACE plus LR (P = not significant [NS]). The overall recurrence rate was 76% for LR versus 30% for TACE plus LR (P <.02). Death due to HCC recurrence was 70% for LR versus 15% for TACE plus LR (P <.05). The overall 1- and 5-year survival rates did not differ significantly (71% to 38% for LR v 85% to 43% for TACE + LR; P = NS), whereas the difference in 1- and 5-year disease-free survival was highly significant (64% to 21% for LR v 82% to 57% for TACE + LR; P <.02). TACE was able to improve the HCC staging process and significantly reduce the incidence of early and overall HCC recurrence and related death after LR; it improved the disease-free interval, but not the overall survival, due to an increase in liver failure in the first 5 months.

Laparoscopic surgery after orthotopic liver transplantation.

Laparoscopic surgery is currently a widely accepted approach to several surgical fields because of its advantages in terms of postoperative pain reduction and easy patient recovery. This approach may be useful even in solid-organ transplantation surgery as a diagnostic or treatment procedure in some surgical complications. From July 1991 to December 1998, we performed 142 liver transplantations on 129 patients. During the postoperative period, many complications occurred. Here we report two cases of intestinal occlusion caused by adhesions and three cases of lymphocele, all approached with laparoscopic surgery. In all cases but one, we were able to complete the surgery by laparoscopic means; in one of the two occlusions, the procedure was switched to laparotomy because of a choledochojejunal anastomosis lesion. The three cases of lymphocele must be considered in a particular manner because such cases, to our knowledge, have never been described in the literature. They always presented with a late-onset right pleural effusion and were located in the retrohepatic, retrogastric, and left paracaval areas, close to the esophageal hiatus. In conclusion, we believe a laparoscopic approach is a useful strategy to solve some surgical complications in patients who underwent orthotopic liver transplantation; however, the use of laparoscopic surgery in this field is strictly connected to the surgeon's experience and versatility.

[The palliative treatment of hepatocarcinoma: chemoembolization vs. the combination of tamoxifen plus beta-interferon]. / Il trattamento palliativo dell'epatocarcinoma: la chemoembolizzazione vs l'associazione tamoxifene più beta-interferon.

Clinical and experimental data show that beta-IFN enhances the effect of tamoxifen on advanced breast cancer. There is a similarity between breast and liver as far as the proliferating effect on normal and neoplastic tissue of estrogen and progestin receptors is concerned. The authors tested this pharmacological association in unresectable liver neoplasms. They considered 76 (not randomized) patients affected with HCC; 38 were treated by trans-arterial chemoembolization (TACE) and 38 to beta-INF and tamoxifen (the 2 groups were comparable according to age, sex, Child-Pugh score, Okuda and TNM stages, cirrhosis etiology). The treatment response (positive when a tumor diameter decreased or stabilization was observed) was similar in the two groups; in the TACE group, the presence of a peritumoral capsula had a significant influence on survival (p < 0.02); on the other hand, in the patients treated with beta-INF and tamoxifen important factors for a better prognosis were the TNM stage (I and II, p < 0.02) and a symptom-free condition (p < 0.04). The authors believe the beta-INF and tamoxifen treatment could represent an effective alternative in the management of unresectable HCC. A better knowledge of the presence and meaning of estrogen and progestin receptors in the neoplastic tissue may allow a better selection of patients.

[Transplantation of isolated hepatocytes into the spleen of rats]. / Studio sul trapianto di epatociti isolati nella milza di ratto.

The effects of splenic transplantation of hepatocytes on survival time and hepatic regeneration were studied in adult rats subjected to: 1) 90% hepatectomy plus portocaval shunt (graft of 4 x 10(6) hepatocytes) and 2) 90% hepatectomy (graft of 4 x 10(6) and 8 x 10(6) hepatocytes); data were compared with those obtained in hepatectomized rats. Hepatic regeneration was significantly higher in transplanted rats and, within animals with grafted hepatocytes more pronounced in rats without porto-caval shunt. This support the hypothesis that a hepatotrophic factor is produced by grafted hepatocytes: its activity is more pronounced in the absence of porto-caval shunt since all splenic blood reach the liver. The activity of the putative hepatocyte growth factor does not depend on the number of grafted hepatocytes since no significant differences in survival time and hepatic regeneration was observed between rats grafted with 4 x 10(6) and 8 x 10(6) hepatocytes.