Can low volume liver transplant centers be successful? The Regional Transplant Center of Willis-Knighton & Louisiana State University Medical Center. The first 120 liver transplants.

The development of orthotopic liver transplantation represents this century's most significant advance in the management of liver disease. In the 1980s the vast majority of liver transplants were performed at several large centers; however, in this decade, improvements in techniques and success rates have allowed live transplantation to expand to regional centers across the country, particularly in the southeast. This proliferation of regional centers and the widening disparity between organ availability and numbers of recipients have created tremendous controversy at the national level regarding the allocation scheme used to distribute livers to recipients. The large programs today are advocating change to a national waiting list which would eliminate local priority and jeopardize the existence of smaller regional centers. Furthermore, the large programs favor establishing a limited number of megacenters where all liver transplants would take place, arguing that low volume centers cannot perform liver transplants with acceptable complication and survival rates. At the Regional Transplant Center of Willis-Knighton Hospital and Louisiana State University Medical Center in Shreveport (WK/LSUMC) we performed 122 liver transplants between July 1, 1991 and December 31, 1997. The purpose of this study was to examine our complication and survival rates and compare them to national averages. The actuarial graft survival at 1, 2, and 3 years in this series compared to the national average respectively was 76% and 70%, 66% and 66%, 62% and 62%. The actuarial patient survival (WK/LSUMC vs National) at 1, 2, and 3 years was 80% and 80%, 75% and 75%, 70% and 74%. The rate of retransplantation was 8% with a national average of 10% to 20%. Our rate of graft primary non-function was 5% with the national average being 2% to 10%. The rate of vascular thrombosis of the graft in this series was 2% with a national rate of 5%. The differences in these results were not statistically significant (P < .05). Low volume transplant centers can perform liver transplant successfully, allowing the regionalization of the treatment of choice for end-stage liver disease.

Spontaneous bacterial peritonitis in liver failure.

Cirrhosis of the liver results from a variety of mechanisms that cause progressive hepatic injury. It is the sixth leading cause of death in all patients between the ages of 35 and 55. This study attempts to correlate the morbidity and mortality of spontaneous bacterial peritonitis in liver failure patients to numerous etiologic and clinical variables. A retrospective review of 26 patients with spontaneous bacterial peritonitis associated with chronic liver disease was performed in a university hospital. Demographics (age and gender), clinical variables (etiology of liver failure, Child's classification, prior history of ascites, fever, abdominal pain, encephalopathy, and upper gastrointestinal hemorrhage), and laboratory variables (ascitic polymorphonuclearcyte count and cultures, serum albumin, bilirubin, creatinine, and prothrombin time) were studied. All of the patients had Child's C liver disease. Mortality rate was 46 per cent. Alcohol (46%) and hepatitis (30%) were the most common etiologies. Escherichia coli and Klebsiella pneumoniae were the most common culture isolates. All of the infections were monomicrobial. The only significant predictor of mortality (P < 0.05) in this study was the peritoneal fluid polymorphonuclear (PMN) cell count. PMN count >1000 PMN/mm3 was associated with a mortality of 88 per cent. Few patients with spontaneous bacterial peritonitis are ultimately transplanted.

Surgical and nonsurgical management of primary and metastatic liver tumors.

The medical records of 267 patients who had liver tumors, primary and metastatic, from 1988 to 1995 were retrospectively reviewed. Two hundred thirteen patients (80%) had metastatic disease, and 54 patients (20%) had primary liver disease. Their clinical manifestations and laboratory values were evaluated as factors predictive of diagnosis and survival. There was a significant increase in the occurrence of upper abdominal pain, weight loss, extrahepatic symptoms due to the metastatic origin, and hepatomegaly. Metastases from colorectal primary lesions were synchronous in 34 patients and metachronous in 31 patients. Stomach, lung, and pancreatic primaries were more commonly synchronous. Breast metastases were more commonly metachronous. Elevated serum glutamic-oxaloecetic transaminase and alkaline phosphatase and decreased albumin were the most common liver test abnormalities at diagnosis. Carcinoembryonic antigen values were elevated in the majority of colon cancer patients. Eighty-one percent of patients with primary liver cancer had elevated levels of alpha-fetoprotein, 40 per cent were seropositive for hepatitis B, and 23 per cent were seropositive for hepatitis C. Seventy-nine patients (30%) underwent surgery for their cancer, 37 (47%) had resections, 38 (48%) were unresectable, and 4 (5%) underwent liver transplantation. The patients who underwent surgery had a 32 per cent 5-year survival rate compared to a 0 per cent 5-year survival in the patients who did not have surgery (p = 0.0001). The patients who had resections had a better survival rate than those deemed unresectable at surgery (62% versus 0% at 5-years with p = 0.0008). The perioperative morbidity rate was 16 per cent, with lobectomies having the best rate and trisegmentectomies having the worst. Perioperative mortality rate was zero for all liver resections. Hepatic resection and, in selected patients, liver transplantation are the only two available therapeutic modalities that produce long-term survival with a possible cure in patients with primary and metastatic liver tumor.

Helicobacter pylori: current concepts.

Although first described almost a century ago, only in the last 15 years has Helicobacter pylori been characterized and associations with disease states recognized. H pylori has been linked to both gastritis and peptic ulcer disease. There is also evidence for a relationship with non-Hodgkin's lymphoma, mucosa-associated lymphoid tissue lymphoma, and perhaps even adenocarcinoma of the stomach. There is currently insufficient evidence to link H pylori to nonulcer dyspepsia. Current recommendations are to treat all patients with gastric or duodenal ulcers who test positive for H pylori, as therapy will significantly reduce the recurrence rate of these conditions.

Kinetic interactions between 4-methylpyrazole and ethanol in healthy humans.

4-Methylpyrazole (4-MP), a potent inhibitor of alcohol dehydrogenase activity, is a candidate to replace ethanol as the antidote for methanol and ethylene glycol intoxications, because it has a longer duration of action and apparently fewer adverse effects. To study a probable mutual inhibitory effect between ethanol and 4-MP on their elimination, two studies were performed in healthy human volunteers using double-blind crossover designs. In study A1 4-MP in the presumed therapeutic dose range of 10 to 20 mg/kg caused a 40% reduction in the rate of elimination of ethanol in 12 subjects given 0.5 to 0.7 g/kg of ethanol. These data suggest that such doses of 4-MP inhibit alcohol dehydrogenase activity in humans in vivo and would be effective at blocking methanol or ethylene glycol metabolism. In study B, ethanol (0.6 g/kg followed by 0.2 g/kg twice) significantly decreased the rate of elimination of 4-MP (5 mg/kg, given intravenously to four subjects). These moderate doses of ethanol also inhibited the rate of urinary excretion of 4-carboxypyrazole, the primary metabolite of 4-MP in humans. Data suggest that ethanol inhibits 4-MP metabolism, thereby increasing the duration of therapeutic blood levels of 4-MP in the body. This mutual interaction may have clinical implications, because most self-poisoned patients have also ingested ethanol. Theoretically, methanol and ethylene glycol might also show such interactions with 4-MP.

Intravenous ketorolac tromethamine versus meperidine for adjunctive sedation in upper gastrointestinal endoscopy: a pilot study.

BACKGROUND: Meperidine is commonly used with a benzodiazepine to achieve conscious sedation but may potentiate respiratory depression. Ketorolac tromethamine has few sedative effects and no respiratory depression. The purpose of this study was to compare ketorolac to meperidine as adjuncts in conscious sedation for upper gastrointestinal endoscopy (EDG). METHODS: Patients undergoing diagnostic EGD (n = 47) were randomly assigned to receive normal saline solution or 50 mg meperidine or 30 mg ketorolac intravenously. Midazolam was subsequently administered (as needed, to achieve adequate conscious sedation) by endoscopists who were blinded to the test substance given before the procedure. RESULTS: For all treatment groups, there was no significant difference in extent or adequacy of sedation, incidence of oxygen desaturation, patient amnesia, time of procedure, or vital signs (except for a relative procedural tachycardia in the ketorolac and placebo groups as compared to baseline). The ketorolac group experienced more pain and anxiety. The meperidine group experienced less gagging, a shorter sedation time, less midazolam usage, and more discomfort at the intravenous site. Meperidine seemed to offer a "protective" effect against procedural tachycardia. CONCLUSION: There is no benefit to ketorolac as an adjunct in conscious sedation for EGD. Meperidine had several benefits; however, discomfort at the intravenous site was common.

Oral sodium phosphate versus sulfate-free polyethylene glycol electrolyte lavage solution in outpatient preparation for colonoscopy: a prospective comparison.

BACKGROUND: Biochemical abnormalities induced by oral sodium phosphate and the risk of cardiac arrhythmias as potential sequelae have yet to be investigated. METHODS: We studied 98 outpatients scheduled to undergo diagnostic colonoscopy and prospectively randomized them to receive oral sodium phosphate or sulfate-free polyethylene glycol electrolyte lavage solution (SF-PEG-ELS) as recommended by the manufacturers. RESULTS: Forty-nine patients received sodium phosphate and 49 received SF-PEG-ELS. There was no significant difference in tolerance or quality of preparation as judged by blinded endoscopists. Significant changes in serum sodium, potassium, chloride, calcium, ionized calcium, and inorganic phosphorus levels were noted following sodium phosphate preparation when compared to values before preparation. A significantly greater number of patients who received sodium phosphate preparation had serum potassium and ionized calcium levels that fell into the abnormal range. Ambulatory electrocardiogram monitors placed 24 hours before the preparation and removed after colonoscopy showed no increase in ventricular premature contractions or other serious arrhythmias in either group during preparation or colonoscopy. CONCLUSIONS: (1) Sodium phosphate and SF-PEG-ELS are equally well tolerated and effective in preparation for outpatient colonoscopy, and (2) sodium phosphate preparation at the recommended dose causes significant alterations in serum sodium, potassium, chloride, calcium, ionized calcium, and phosphorus levels.

Serologic diagnosis of hepatitis C infection. Review of available tests.

Several tests are currently available to assist in the diagnosis of the hepatitis C virus. These tests can be classified as antibody tests (ELISA, RIBA, and MATRIX-HCV) or tests that actually detect or quantify the hepatitis C virus (PCR techniques). These tests vary in cost, technical complexity, specimen handling requirements, and diagnostic information achieved. Those tests currently available to the clinician are reviewed along with their associated benefits and disadvantages.