Parathyroid-gland ultrasonography in clinical and therapeutic evaluation of renal secondary hyperparathyroidism.

PURPOSE: This study evaluated the relationship between ultrasonographic (US) parameters of parathyroid glands (PTGs) in haemodialysis patients (HDP) and degree of secondary hyperparathyroidism (SHPT), therapeutic responsiveness and type of PTG hyperplasia (diffuse or nodular). MATERIALS AND METHODS: In 85 HDP, we evaluated the following US parameters of all and of the largest PTGs: number, maximum longitudinal diameter (MLD), structural (hypoechoic, heterogeneous, nodular) and vascular (nonhypovascular, intermediate, hypervascular) echo-pattern scores. Sixty-nine HDP underwent medical therapy (vitamin D, 39; vitamin D/cinacalcet, 30) and 16 underwent parathyroidectomy. The 69 HDP were classified as responders [median intact parathyroid hormone (iPTH) ≤300 pg/ml during follow-up) or nonresponders (iPTH >300 pg/ml). RESULTS: Number, MLD and structural and vascular echo patterns of PTGs were significantly correlated with iPTH and calcium concentrations. In the 41 (59%) responders, number (0-1), MLD (<10 mm) and structural and vascular scores (1-2) of the largest PTG were significantly lower than in nonresponders. Receiver operating curve (ROC) curve analysis showed high sensitivity and specificity (90% and 73%, respectively) of the MLD (<10mm) of the largest PTG in the predicting therapeutic outcome. US and histological MLD are significantly correlated and predict the type of hyperplasia. CONCLUSIONS: US parameters of PTGs are correlated to the degree of SHPT and type of hyperplasia and predict responsiveness to medical therapy.

Low values of left ventricular ejection time in the post-anhepatic phase may be associated with occurrence of primary graft dysfunction after orthotopic liver transplantation: results of a single-centre case-control study.

BACKGROUND: Previous investigations on risk factors for orthotopic liver transplantation (OLT) surgery have not analyzed hemodynamic aberrations in great detail. Moreover, the usefulness of esophageal Doppler monitoring has not been extensively studied in this clinical setting. The aim of this study was to evaluate if the occurrence of primary graft dysfunction (PGD) may be anticipated by hemodynamic indexes measured by esophageal Doppler (ED) monitoring system as well as by pulmonary artery catheter (PAC) in patients undergoing OLT. MATERIALS AND METHODS: 38 OLT recipients were studied. Patients with acute liver failure or having non treated esophageal varices and those transplanted with marginal donors were excluded from the study. The haemodynamic data - measured by ED monitoring system (HemosonicTM 100, Arrow, OK, USA) and PAC - collected at the following 3 time points were considered for statistical analysis: 30 minutes after the induction of anesthesia but before skin incision, T0; 20 minutes after liver dissection, T1; at the beginning of biliary reconstruction, T2. On the basis of early outcome (72 hours after OLT), patients were distinguished into two groups: those with PGD (grade III-IV of Toronto classification) and those without PGD (grade I-II). RESULTS: LVETc (left ventricular ejection time) values, registered at the beginning of biliary reconstruction (T2), were lower in patients with PGD compared to those without PGD (p < 0.000), while there were no differences in hemodynamic parameters derived from PAC between the two groups. CONCLUSIONS: Since LVETc is related to preload, the results of this study would suggest that normovolemia could be the end point of a fluid replacement strategy in OLT setting.

Intra-abdominal vacuum-assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience.

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by 'open' or 'close' abdomen management. We recently introduced the use of intra-abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Quantification of degree of steatosis in extended criteria donor grafts with standardized histologic techniques: implications for graft survival.

The gap between the availability of livers from organ donors and the increased demand has led many centers to apply strategies to reduce this deficit. Splitting of cadaveric organs for use in 2 recipients; domino transplantation; and organs from living donors, non-heart-beating donors, and extended-criteria donors (ECDs) are all currently used in orthotopic liver transplantation (OLT). Fatty changes in the donor liver are a risk factor for poor function after OLT; however, the presence of steatosis, frequently present in livers from ECDs, does not exclude the use of these organs. Since January 2000 at our institution, we observed 39 steatotic grafts that were stratified istologically as follows: low steatosis, 5% to 15%; mild steatosis, 16% to 30%; moderate steatosis, 31% to 60%; and severe steatosis (>60%). Histologic techniques can enable identification of the type of fatty change as macrovesicular and microvesicular. These alterations have different effects on primary nonfunction and primary dysfunction. Fifteen grafts, all with severe or moderate, macrovesicular changes were discarded. Twenty-four fatty grafts with low to moderate steatosis were utilized for transplant. Sections from 2 liver biopsies (1 wedge in the left lobe and 1 needle in the right lobe) were stained with hematoxylin-eosin, Masson trichrome, Gomori reticulin, and oil red O. The OLT was performed only in patients with a MELD (Model for End-Stage Liver Disease) score lower than 27. The rate of primary dysfunction was 12.5%, and of primary nonfunction 8.4%. The 6-month graft survival for all fatty livers was 80%. We encourage the careful use of grafts with low to moderate steatosis in recipients without additional risks.

Enteric-coated mycophenolate sodium: one-way conversion from mycophenolate mofetil and de novo use in stable liver transplant recipients.

Enteric-coated mycophenolate sodium (EC-MPS) is a formulation of mycophenolic acid (MPA) that releases the active molecule in the intestine reducing drug-related gastrointestinal (GI) side effects. The aim of present work was to summarize the use of EC-MPS for one-way conversion from mycophenolate mofetil (MMF) due to GI side effects and for de novo administration in a stable liver transplant population. In 10 patients on MMF and low-dose calcineurin inhibitors (CNI), significant GI side effects suggested drug conversion to ameliorate subjective symptoms. In 5 patients, EC-MPS was initiated de novo together with reduction of CNI for prevention of long-term renal failure. Conversion was carried out at equivalent MMF/EC-MPS dosages. Reevaluation at 2 months after conversion showed that no episode of rejection or infection occurred, and white blood cell count, CNI levels and doses, and creatinine clearance did not vary significantly. In 70% of converted patients there was a reduction of GI symptoms, especially diarrhea. Eighty percent suspended proton pump inhibitors. The de novo-treated patients showed no significant GI side effects. In conclusion, conversion from MMF to EC-MPS demonstrated significant GI symptom relief and de novo drug administration was well tolerated.

Posttransplant lymphoproliferative disorders after liver transplantation: analysis of early and late cases in a 255 patient series.

We reviewed the incidence and the impact of posttransplant lymphoproliferative disorders (PTLDs) on patient survival among a consecutive series of 255 patients. Five cases of PTLD were observed in adults: two cases were early (less than 1 year) and three cases, late lymphomas. The EBV positivity and the degree of immunosuppression were the main risk factors. We labeled cases as early or late according to whether the time elapsed from the transplant to the first clinical evidence of PTLD was less than 12 months. The median time from transplant to diagnosis of PTLD was 8 (early) and 108 (late) months. All cases were treated by reduction in immunosuppressive therapy with conventional chemotherapy and rituximab. The early cases with lymphoma located at the hepatic hilum died due to local complications (biliary sepsis and hemobilia), after an initial partial response to chemotherapy. The three patients with late cases are in remission after a mean follow-up of 23 months.

Review article: botulinum toxin in the therapy of gastrointestinal motility disorders.

Since 1980, botulinum toxin has been employed for the treatment of various voluntary muscle spastic disorders in the fields of neurology and ophthalmology. More recently, botulinum toxin has been proved to be effective in the therapy of dyskinetic smooth muscle disorders of the gastrointestinal tract. Achalasia and anal fissure are the gastrointestinal disorders in which botulinum toxin therapy has been most extensively investigated. Botulinum toxin is the best treatment option for achalasia in patients whose condition makes them unfit for pneumatic dilation or surgery. In anal fissure, botulinum toxin is highly effective and may become the treatment of choice. In the future, botulinum toxin application in the gastrointestinal tract will be extended to many other gastrointestinal disorders, such as non-achalasic motor disorders of the oesophagus, dysfunction of Oddi's sphincter, achalasia of the internal anal sphincter and others. This article describes the mechanism of action, rationale of employment, indications and side-effects of botulinum toxin application in smooth muscle disorders of the gastrointestinal tract, and compares the results of different techniques of botulinum toxin therapeutic application.

Marginal donors for patients on regular waiting lists for liver transplantation.

The use of marginal donors is well accepted by most centers for emergency situations, but there is debate on their use for patients on regular waiting lists. We report our experience of the 1-year survival for patients on waiting lists (n = 147, 1-year survival = 32%), patients transplanted from good donors (n = 60, 1-year survival = 84%), and patients transplanted from marginal donors (n = 15, 1-year survival = 56%). We concluded that liver transplantation from marginal donors (a) is a safe procedure (b) has a 1-year survival that is significantly better than that on a waiting list (c) is ethically justified especially in countries with donor shortages, and (d) may allow transplantation of "special" high risk and poor long-term outcome patients.

[Primary carcinoid of the umbilicus. Description of the 1st case]. / Carcinoide primitivo dell'ombelico. Descrizione del primo caso.

A 78-year old male came to our observation presenting and enlargement of bilateral inguinal lymph nodes and a tumor of the mesogastric abdominal wall. Three years before the patient had been operated on for a primary tumor of the umbilicus with concomitant longstanding diarrhea. No histological examination was performed at that time. We performed a lymph node biopsy which demonstrated carcinoid metastasis. We went on to perform radical resection of the abdominal wall, regional lymphadenectomy and right hemicolectomy for malignant villous adenoma of the right colon. The abdominal defect was repaired by using Goretex mesh. Cyclic adjuvant alpha-interferon therapy was continued for more than 1 year, followed by long term therapy with longastatin. Twenty months after the operation the patient is in good clinical conditions and disease-free. On the basis of literature review our case appears to be the first primary carcinoid of the umbilicus.

Pulmonary gas exchange during orthotopic liver transplantation.

The aim of this study was to evaluate the efficiency of pulmonary gas exchange during the course of liver transplantation. We studied 25 adult cirrhotic patients undergoing transplantation, performed with venovenous bypass. A significant increase in PaO2, and a significant decrease in physiological shunt and alveolar-arterial partial pressure difference were observed just before the start of venovenous bypass. These changes were probably caused by modifications in respiratory mechanics, such as an increase in functional residual capacity. There were no other respiratory changes during the anhepatic and post-anhepatic phases.

Should retransplantation still be considered for primary non-function after liver transplantation?

Primary non-function (PNF) of a transplanted liver is a postoperative condition characterized by absence of hepatic recovery due to various insults during harvesting, preservation or revascularization. Until recently early retransplantation (RTx) has been considered the policy of choice. Results of RTx for PNF are unsatisfactory (1-year survival rates ranging from 0 to 34%). The management of PNF by medical care without RTx with a recovery rate of 80% and a 1-year actuarial survival rate of 50% is reported for a series of 33 consecutive liver transplants. The guidelines for the medical care management are given and the results are discussed.