De novo hepatitis B and C viral infection after liver transplantation.

Hepatitis B (HBV) and hepatitis C (HCV) viral infections often recur after orthotopic liver transplantation (OLT), but viral infections acquired with OLT have not been widely investigated. The aim of the study was to evaluate the incidence, evolution, and diagnostic problems of de novo HBV and HCV infections in liver transplant recipients with long-term follow-up. Altogether 121 transplant recipients entered the study. HBV, HDV, and HCV infections were diagnosed by means of serology and the polymerase chain reaction (PCR). Three patients became hepatitis B surface antigen (HBsAg)-positive after OLT, all of whom showed signs of persistent viral replication. Twelve patients became anti-HCV-positive after OLT: After clearance of passive antibodies, active anti-HCV seroconversion was usually delayed. The viral genome was detected in 9 of 12 patients, with fluctuations of viremia during their follow-up. The other three patients, who were HBsAg-positive before and after OLT, were repeatedly HCV-RNA-negative despite persistent anti-HCV reactivity. Four pre-OLT HBsAg-positive patients had evidence of HBV-related liver transplant disease. The remaining 8 of 12 patients experienced repeated alanine aminotransferase increases more than two times normal after transplant. De novo infections due to primary hepatotropic viruses were frequent after OLT in our experience. Early diagnosis of infection, especially when the HCV is involved, may be problematic and should be taken into account in patients showing persistent aminotransferase abnormalities. Monitoring viral markers and accurate evaluation of biopsy specimens are mandatory. The interference between HBV and HCV might play a role in the replicative cycle of one or both viruses in co-infected patients.

[Portosystemic shunts in the treatment of bleeding esophageal varices in cirrhotic patients: between sclerotherapy and transplantation]. / Gli interventi di derivazione porto-sistemica nel trattamento dell'emorragia da varici nel paziente cirrotico: tra scleroterapia e trapianto.

In view of the proven efficacy of endoscopic sclerotherapy and the even improving results of liver transplantation, the present role of porto-systemic shunt should be reconsidered. From 1986 (when our liver transplant program began), to March 1994, 59 cirrhotic patients (males = 40, females = 19, mean age 53.17 +/- 12.04) underwent a porto-systemic shunt, 22 under emergency conditions and 37 in an elective setting. Patients were subdivided according to age, emergency or elective surgery, type of operation, and liver function. In the emergency procedures previous sclerotherapy and time between admission and surgery were also considered in the assessment. Mean follow-up was 46.49 +/- 31.48 months. Overall 5-year actuarial survival was 62.5%. In the emergency porto-systemic shunts the worst short-term results were obtained in patients over 55 years of age (p < 0.05) and when operations were performed within the first 24 hours after admission (p < 0.005). Long-term survival was not significantly influenced by the variables considered although patients over 55 years of age and patients with reduced liver function (Child B and C) seemed to have a more dismal outcome. Those patients under 55 years of age, with no portal thrombosis, considered as potential liver transplant candidates, had a better short-term survival rate (p < 0.05) than that of the rest of the patient population studied, mainly because of the better outcome after emergency surgery. Our data confirm the efficacy of porto-systemic shunt procedures in preserving the patient from variceal bleeding. They have a definite role in the complex treatment strategy of portal hypertension, and they must not be considered only a rescue procedure. However, liver transplantation remains the best option to resolve both portal hypertension and the underlying liver disease.

Ruptured hepatocellular carcinoma: an important cause of spontaneous haemoperitoneum in Italy.

OBJECTIVE: To evaluate the incidence of rupture of the tumour with intraperitoneal bleeding in a series of patients with hepatocellular carcinoma and its relative incidence as a cause of spontaneous haemoperitoneum, and to evaluate the results of the surgical treatment of a consecutive series of patients who presented with spontaneous haemoperitoneum caused by ruptured hepatoma. DESIGN: Retrospective study. SETTING: University hospital, Italy. SUBJECTS: 8 patients whose hepatocellular carcinoma ruptured (out of a total of 518) and caused spontaneous haemoperitoneum, and 34 patients who were admitted with spontaneous haemoperitoneum. INTERVENTIONS: Seven hepatic resections; in one case direct haemostasis was attempted because of the poor hepatic reserve. RESULTS: Rupture of the tumour with intraperitoneal bleeding occurred in 8/518 (2%) of cases of hepatocellular carcinoma. Ruptured hepatocellular carcinoma was the second most common cause of spontaneous haemoperitoneum (8/34; 24%), after gynaecological diseases (15/34; 44%). Of the 7 patients who presented with ruptured hepatocellular carcinoma and were treated by hepatic resection, 3 are alive (one with a recurrent disease) after a mean follow-up of six months (range 3 to 12 months) and 4 died of carcinomatosis within 12 months. The patient for whom resection was not feasible died immediately postoperatively of irreversible shock. CONCLUSIONS: Rupture of hepatocellular carcinoma is a relatively common cause of spontaneous haemoperitoneum. Diagnosis at the onset of symptoms has important therapeutic implications: as the results of surgical treatment are unsatisfactory, other procedures with the limited goal of achieving satisfactory haemostasis can be considered if the hepatocellular carcinoma has been diagnosed.

Bleeding esophageal varices: today's role of portosystemic shunts.

Emergency portosystemic shunting has once again become a significant option in the management of bleeding esophageal varices and portal hypertension. The decision to perform such a shunt and the choice of shunt procedure requires a rational assessment of the pathophysiology and hepatoportal hemodynamics of the patient's disease and the manner in which it is anticipated that the selected procedure may alter portal flow. Since shunt surgery may interfere with hepatic transplantation, the patient's suitability as a future transplant recipient must also be considered in choosing a shunt procedure. Furthermore, if a shunt is to be performed on an emergency basis to control acute bleeding, this procedure must be done before the patient's condition deteriorates sufficiently to represent a prohibitive surgical risk.

[Dermatologic problems in patients undergoing liver transplantation]. / Problemi dermatologici in pazienti sottoposti a trapianto di fegato.

Skin troubles were studied in 28 liver transplant patients treated with immunosuppressive agents. Skin complications ranged from minor annoyances to life-threatening conditions. The frequency of dermatologic problems needs periodic examinations by a dermatologist.

Clinical experience with hepatic resections for hepatocellular carcinoma in patients with cirrhosis.

The results of 31 resections of the liver performed upon patients with cirrhosis and hepatocarcinoma are reported herein. The lesions were discovered mainly during routine echographic surveillance. Twenty-five of these patients with small tumors underwent a segmentary or subsegmentary resection. Intraoperative ultrasonography proved to be of paramount importance in these instances as it helped to recognize the lesion and outline the limits of the resection. In another 11 instances of primary tumors of the liver in patients with cirrhosis who underwent laparotomy, findings from intraoperative ultrasonography advised against exeretic operation because other intrahepatic lesions or neoplastic thrombi in portal branches were detected. The operative mortality rate in the 31 patients who underwent resection of the liver was 12.9 per cent. The actuarial three year survival rate is 58 per cent. The presence of an intact peritumoral capsule seems to be the best prognostic factor.