Conservative treatment versus elective repair of umbilical hernia in patients with liver cirrhosis and ascites: results of a randomized controlled trial (CRUCIAL trial).

PURPOSE: To establish optimal management of patients with an umbilical hernia complicated by liver cirrhosis and ascites. METHODS: Patients with an umbilical hernia and liver cirrhosis and ascites were randomly assigned to receive either elective repair or conservative treatment. The primary endpoint was overall morbidity related to the umbilical hernia or its treatment after 24 months of follow-up. Secondary endpoints included the severity of these hernia-related complications, quality of life, and cumulative hernia recurrence rate. RESULTS: Thirty-four patients were included in the study. Sixteen patients were randomly assigned to elective repair and 18 to conservative treatment. After 24 months, 8 patients (50%) assigned to elective repair compared to 14 patients (77.8%) assigned to conservative treatment had a complication related to the umbilical hernia or its repair. A recurrent hernia was reported in 16.7% of patients who underwent repair. For the secondary endpoint, quality of life through the physical (PCS) and mental component score (MCS) showed no significant differences between groups at 12 months of follow-up (mean difference PCS 11.95, 95% CI - 0.87 to 24.77; MCS 10.04, 95% CI - 2.78 to 22.86). CONCLUSION: This trial could not show a relevant difference in overall morbidity after 24 months of follow-up in favor of elective umbilical hernia repair, because of the limited number of patients included. However, elective repair of umbilical hernia in patients with liver cirrhosis and ascites appears feasible, nudging its implementation into daily practice further, particularly for patients experiencing complaints. TRIAL REGISTRATION: Clinicaltrials.gov , NCT01421550, on 23 August 2011.

Liver transplantation using grafts from donors after circulatory death - the first Czech Republic experience.

INTRODUCTION: Liver transplantation is established as a lifesaving procedure for patients with acute and chronic liver failure, as well as certain selected malignancies. Due to a continuing organ shortage and ever-growing patient waiting lists, donation after cardiac death (DCD) is becoming more frequently utilized in order to close the gap between “supply and demand”. METHODS: A retrospective analysis of DCD and subsequent liver transplantations was performed. RESULTS: From May 2016 to September 2019, a total of 9 DCD liver transplantations were performed in our institution. All cases except one were primary liver transplantations. The recipients comprised 5 (56%) males and 4 (44%) females. The mean DCD donor age was 41±12 (22-57) years, with ventilation duration of 7±1 days and warm ischemia time 19±3 minutes. The average recipient age was 51±22 (4-73) years, with an average cold ischemia 3h:59m±27m and manipulation time of 23±5 minutes. Periprocedural mortality was 1 (11%). Hepatitis C recurrence was documented in 1 (11%) patient. The mean follow-up time was 19±13 (7-37) months. Until now, we have not observed any signs of ischemic cholangiopathy. CONCLUSION: DCD liver transplantation allows us to enlarge the pool of potential liver grafts, thus decreasing the time spent on the liver recipient waiting list. This paper documents the first series of DCD liver transplantations in the Czech Republic.

Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding.

BACKGROUND/AIMS: 1) To compare the effect of 2-day application of 0.2 mg terlipressin i.v. every 4 hours (group I) with that of 5-day application of 1 mg i.v. every 4 hours (group II) in the treatment of bleeding esophageal varices and portal gastropathy. 2) To assess the incidence of adverse events. METHODOLOGY: Eighty-six patients with liver cirrhosis (54 men and 32 women, average age 51 years) were randomized over a period of 2 years into 2 groups. Acute bleeding was diagnosed endoscopically within 24 hours of its onset. The two groups fully comparable; treatment failure rated according to "Baveno II". RESULTS: Success rate in group I was 78% at day 2 and 75% at day 5; in group II 89% and 79%, respectively (no statistical significance). Rebleeding had occurred by day 5 in 15% in group I, and in 16.3% in group II. Transfusion needs by day 2 were significantly lower in group II (2.4 units compare to 3.4 units in I). The 30-day mortality was 17.1% in group I and 20% in group II. No statistical difference between I and II in the occurrence of adverse events. CONCLUSIONS: At a dosage of 1 mg i.v. every 4 hours, the success rate at day 2 was as much as 90% while blood consumption was significantly lower compared with the lower dosage. Rebleeding during first 48 hours occurred almost exclusively at lower dosage. There was no increase in the rate of adverse events relative to the higher dosage.

The role of ERCP in management of biliary complications after liver transplantation.

Biliary complications remain to pose a serious problem in patients after liver transplantation. In the past, they occurred in as many as 50% of patients, and were associated with a height mortality. This has changed and at present the incidence of this complications is lower. The authors present their own series and discuss the role of ERCP in the management of complications.

Liver transplantation in Eastern Europe.

The aim of this report is to evaluate the development of liver transplantation in eastern Europe until mid-1998. Representatives of gastroenterological and hepatological societies of the respective countries answered a questionnaire about the most descriptive items of the issue of liver transplantation. The Baltic countries, together with 6 southern Balkan countries, Moldovia, and Belarus, have not developed a program of liver transplantation. In Ukraine, 7 transplantations were performed, with 3 early deaths. In Russia, 31 liver transplantations were performed, with 8 of the last 12 patients surviving short term. In Slovenia, 1 of 2 patients, and in Yugoslavia, 8 of 9 patients survived. In Croatia and Slovakia, 2 patients each died immediately after surgery. The number of liver transplantations is increasing in both Hungary and Poland. In Hungary, 63 transplantations were performed, with a 1-year survival rate reaching 85%; in Poland, 55 adults and 29 children underwent transplantation, with an actuarial 1-year survival rate of 70%. In former East Germany, 4 centers developed their programs since 1992. A total of 196 transplantations were performed, with 1-year survival rates varying from 80% to 89%. The total spectrum of indications for transplantation was standard, with a greater proportion of hepatocellular cancer compared with Eurotransplant statistics. In the Czech Republic, the first liver transplantation was performed in 1983, but it was not until 1994 that the number of procedures increased steeply. Until mid-1998, a total of 182 transplantations were performed. At the Prague Institute for Clinical and Experimental Medicine, we performed 94 transplantations, with a 1-year patient survival rate of 90.6%. There has been rapid development over the last 3 years in the 3 countries of Central Europe. The progress is influenced by the sweeping political and economic changes.

[Morphologic findings in liver tissue in chronic active hepatitis B after seroconversion from HBeAg to anti-HBe]. / Morfologické nálezy v jaterní tkáni u chronické aktivní hepatitidy B po sérokonverzi HBeAg na anti-HBe.

Replication of the virus is in the majority of patients with chronic hepatitis B associated with permanent activity and progression of the inflammatory process. The change of the virus to the latent stage expressed by seroconversion of HBeAg to anti-HBe leads to a significant repression of inflammatory changes and has a favourable impact on the course of the disease. The morphological changes in the hepatic tissue after spontaneous seroconversion or after interferon treatment were investigated in specimens of needle biopsy in 18 patients with active chronic hepatitis B. In 10 of them the diagnosis of chronic hepatitis was confirmed by biopsy in the stage of replication of the virus. During the subsequent time interval after seroconversion of HBeAg, incl. two instances where interferon was administered, in the tissue of 14 HBsAg positive patients regression of inflammatory changes was apparent, in particular a lower incidence of piecemeal necroses. The regular finding of periportal and septal fibrosis in these patients is probably associated with a longer course of chronic active hepatitis and late spontaneous or therapeutically induced seroconversion of HBeAg. In one man, treated with interferon, morphological examination revealed one month after seroconversion of HBeAg an acute exacerbation of the disease. In another three patients, who at the time of the bioptic examination were HBsAg negative, in the hepatic tissue minor silent periportal and septal fibrosis persisted.