Outcome of living donor liver transplantation for Egyptian patients with hepatitis C (genotype 4)-related cirrhosis.

BACKGROUND: Hepatitis C virus (HCV) recurrence after living donor liver transplantation (LDLT) represents a challenging issue due to universal viral recurrence and invasion into the graft, although the incidence of histological recurrence, risk factors, and survival rates are still controversial. PATIENTS AND METHODS: Recurrence of HCV was studied in 38 of 53 adult patients who underwent LDLT. RESULTS: Recipient and graft survivals were 86.6% at the end of the follow-up which was comparable to literature reports for deceased donor liver transplantation (DDLT). Clinical HCV recurrence was observed in 10/38 patients (26.3%). Four patients developed mild fibrosis with a mean fibrosis score of 0.6 and mean grade of histological activity index (HAI) of 7.1. None of the recipients developed allograft cirrhosis during the mean follow-up period of 16 +/- 8.18 months (range, 4-35 months). Estimated and actual graft volumes were negatively correlated with the incidence and early clinical HCV recurrence. None of the other risk factors were significantly correlated with clinical HCV recurrence: gender, donor and recipient ages, pretransplantation Child-Pugh or model for end-stage liver disease (MELD) scores, pre- and postoperative viremia, immunosuppressive drugs, pulse steroid therapy, and preoperative anti-HBc status. CONCLUSIONS: Postoperative patient and graft survival rates for HCV (genotype 4)-related cirrhosis were more or less comparable to DDLT reported in the literature. Clinical HCV recurrence after LDLT in our study was low. Small graft volume was a significant risk factor for HCV recurrence. A longer follow-up and a larger number of patients are required to clarify these issues.

Reconstruction after resection of tumors around the knee: role of the free vascularized fibular graft.

We present our experience with reconstruction after resection of tumors around the knee, using free vascularized fibular grafting. The study included 23 patients. The lower femur was involved in 17 cases, the upper tibia in 6. The cases included giant cell tumor of the lower femur (2 patients), giant cell tumor of the upper tibia (1 patient), malignant fibrous histiocytoma of the lower femur (1 patient), parosteal osteosarcoma (1 patient), and periosteal osteosarcoma (1 patient). The remaining patients suffered from conventional osteogenic sarcomas. The size of the defect ranged from 12 to 16 cm in length. Skin flap necrosis after tumor resection was the most common complication encountered. Other complications included peroneal nerve involvement in one case and rupture of the arterial anastomosis in another. All transferred fibulas progressed to union within 7-9 months. Union time of both upper and lower ends of the fibula and time of appearance of periosteal reaction were identical. In evaluating periosteal hypertrophy of the fibula, the hypertrophy (de Boer) index (de Boer HD, Wood MB, J Bone Joint Surg 1989;71B:374-378) proved unreliable. False positive results are obtained, when callus formation around the lower end of the femur is far more abundant than at the upper end of the fibula. For this reason, we introduced the graft index. The latter is the ratio between the diameter of the graft at its thinnest portion at latest follow-up to its diameter on the day of operation, as calculated on plain radiographs. Two of the viable fibulas developed stress fractures after plate removal. Functional and quality-of -life results were satisfactory. It is concluded that the free vascularized fibular graft remains a valuable reconstruction option after the resection of tumors around the knee, provided certain precautions are followed. First, before closure of the wound, the skin flaps should be assessed for their viability. Necrotic parts should be excised. Stable fixation is a necessary prerequisite at the time of operation. Removal of the fixation device should not be guided by union or periosteal hypertrophy, but by true widening of the medullary canal.

Surgical and chemotherapeutic treatment of hepatic metastases from carcinoma of the breast.

To date, no five year survival rates have been reported for patients with hepatic metastases (HM) from breast origin treated by chemotherapy or hormone therapy. This study was done to evaluate whether or not surgical excision of such metastatic disease associated with chemotherapy has any effect on such a poor prognosis. Between May 1985 and September 1988, 22 patients with a diagnosis of isolated (solitary or multiple) HM have been surgically treated. The therapeutic approach also included systemic preoperative and postoperative chemotherapy. Laparotomy findings for those 22 patients are presented. There were benign hepatic lesions in four patients (four different histologic types) and hepatectomy was done in two patients. Diffuse metastatic disease contraindicated any attempt at hepatic resection in six patients. Hepatectomy was possible in 12 patients. There was no postoperative mortality and minimal morbidity. One-half of the patients with metastases had one or more positive lymph nodes at the hepatic pedicule. Median survival time for 12 patients treated by hepatectomy was 37 +/- 9 months after hepatectomy and 42 +/- 3 months after the discovery of HM. Eleven patients had other metastases after an average period of 11.8 months after hepatectomy, and the liver was the first site of recurrence in eight. One patient underwent a hepatectomy twice. Two patients were free of disease 29 to 46 months postoperatively in spite of poor prognostic features on the excised specimen. Although the median survival time was two times better than with usual treatment, we believe this procedure is of doubtful benefit. In this situation, hepatectomy acts as cytoreductive surgical treatment, with the main limiting factor being the relatively low effectiveness of chemotherapy. This type of therapy can be applied only to a restricted number of patients, and if we decide to proceed with this study, we will have to modify the protocol of chemotherapy radically.

[Synchronous cancers of the esophagus and of the ORL area: results of combined treatments with esophagectomy (28 cases)]. / Cancers synchrones de l'oesophage et de la sphère ORL: résultats des traitements combinés avec oesophagectomie (28 cas).

Twenty-eight patients with synchronous esophageal and head and neck epidermoid cancers have been treated by a combined protocol including esophagectomy. Seventy-nine percent received pre-operative chemotherapy, 50% had resection of the head and neck lesion at the same time as the esophagectomy and 79% received post-operative irradiation. Two patients died during the post-operative period (7%), and 1, 2 and 3-yr survival rate (Kaplan-Meier) was respectively 64, 32 and 27%. Contrary to our initial assumption, there was no significant decrease in survival compared to patients operated on for an isolated esophageal cancer. The patients were divided into 4 very simple prognostic groups based on the T and N stages of the clinical pre-therapeutic TNM classification: T1 or T2 for esophageal lesions and different T or N stages according to the prognosis for head and neck lesions. A study of each group tended to show that esophagectomy was beneficial except in cases of synchronous T2 esophageal cancer and locally advanced head and neck cancer (there was 2-yr survival in this group). The 28 patients studied represent a particular population which presented 91 cancerous localisations during the duration of the study (mean: 3.25 localisations per patient).