Quality of life of patients after intestinal transplantation.

BACKGROUND: Quality of life is an important consideration in evaluating new medical or surgical treatments. Intestinal transplantation is now available for patients with irreversible intestinal failure. We compared quality of life among patients with intestinal failure receiving home parenteral nutrition (HPN) to that among patients who underwent intestinal transplantation (ITx) at the University of Pittsburgh Medical Center. METHODS: The results of the Quality of Life Inventory, a self-administered questionnaire, were compared among 10 ITx recipients and 10 HPN patients. Change in quality of life was examined longitudinally over a 2-year period with repeat testing in four patients in each group. RESULTS: ITx recipients were evaluated at mean time of 2.7 years after transplantation and after a mean period of 5.3 years of intestinal failure. HPN patients were evaluated after a mean period of 5.1 years of intestinal failure and were similar to the transplant recipients in age, gender, race, social status, education, etiology, and duration of disease. Assessed quality of life was markedly similar between HPN-dependent patients and ITx recipients, with significant differences in only 2 of 25 domains, despite the difficult early postoperative course and complex management that accompany intestinal transplantation. In longitudinal follow-up (n=4), ITx recipients reported significant improvement in anxiety (P=0.02), sleep (P=0.03), and impulsiveness/control (P<0.001), reflecting a progressive adjustment to their posttransplant status. CONCLUSION: The quality of life in ITx recipients is similar to that in HPN-dependent patients. Quality of life among ITx recipients improves over time with decreased anxiety over physical functioning. Further research and efforts to improve quality of life in transplant recipients are needed.

Quality of life after small intestinal transplantation and among home parenteral nutrition patients.

BACKGROUND: The purpose of the study was to quantify changes in the quality of life of small bowel recipients before and after transplantation and of home parenteral nutrition (HPN)-dependent patients before and after therapy. We examined quality of life across multiple areas of function including physical, social, and emotional indices. METHODS: The Quality of Life Instrument in the form of a self-administered questionnaire was completed voluntarily by the recipients of small intestinal transplants and by a cohort of HPN-dependent patients. RESULTS: Small intestinal transplant recipients reported significant improvement in the quality of their life and function. They also rated their quality of life and function during the pretransplant, TPN-dependent period to be worse than before the development of chronic intestinal failure. Similarly, HPN recipients reported significant worsening across most areas of quality of life when they compared their premorbid period to the HPN-dependent state. CONCLUSIONS: TPN dependence causes significant impairment in the quality of life in most areas of functioning. In contrast, small intestinal transplantation restores the quality of life among recipients with functioning grafts.

Comparison of laparoscopic versus open repair of paraesophageal hernia.

BACKGROUND: Recent reports suggest that laparoscopic paraesophageal hernia repair (LPHR) is feasible, but no direct comparisons with the standard open paraesophageal hernia repair (OPHR) have been reported. The purpose of this study was to compare the short-term outcome of LPHR versus OPHR at a single institution. METHODS: The operative and postoperative courses of 95 consecutive patients undergoing open or laparoscopic repair of a paraesophageal hernia (PEH) were retrospectively reviewed, and outcomes of LPHR versus OPHR were compared. RESULTS: PEH was associated with advanced age and significant comorbidity. Although the operative time was increased for LPHR, there was a significant reduction in blood loss, intensive care unit stay, ileus, hospital stay, and overall morbidity associated with LPHR compared with OPHR. CONCLUSIONS: PEH is associated with significant comorbidity that increases the operative risk. Short-term outcomes for LPHR are superior to OPHR, suggesting that the laparoscopic approach is the preferred approach to paraesophageal hernia repair.

Comparative studies of esophageal function in systemic sclerosis.

Three modalities for assessing esophageal dysfunction in patients with systemic sclerosis were prospectively compared. Seventeen patients underwent (a) esophageal manometry with measurement of distal esophageal peak contraction pressure amplitude, percentage of peristaltic waves, and lower esophageal sphincter pressure; (b) cine-esophagography with scoring based on residual contrast and the character of visualized waves; and (c) esophageal transit scintigraphy with quantification of residual swallowed tracer. Highly significant correlations were found between scintigraphic residual and cine-esophagography score, between scintigraphic residual and manometric amplitude, and indeed between all pairs of measured esophageal function parameters except those involving lower esophageal sphincter pressure. In addition, scintigraphy and cine-esophagography showed comparable ability to discriminate between patients with abnormal and normal esophageal motor function. Symptoms did not significantly correlate with quantitative parameters, nor did they have diagnostic discriminating ability. Induction of Raynaud's phenomenon in a subgroup of patients had no detectable effect on esophageal function. It was concluded that these three diagnostic modalities are approximately equivalent in their ability to detect esophageal dysmotility in systemic sclerosis and measure its severity.

Ethanol, a Leydig cell toxin: evidence obtained in vivo and in vitro.

The available evidence which suggests that ethanol is a Leydig cell toxin is presented. Both in vivo and in vitro data are reviewed. The minor differences obtained in vitro as compared to those obtained in vivo are discussed. As a result of information obtained during the last decade, there can be little doubt that ethanol and possibly acetaldehyde are clinically important environmental Leydig cell toxins.

Fetal rat hepatic ultrastructural changes associated with organ culture and glucocorticoid treatment.

Fetal hepatic ultrastructure was examined from 18 days gestation to term. Such structure was compared to that of tissue obtained at 18 days gestation which had been maintained in organ culture for 24, 48, and 72 h. In addition, the effects of maternal glucocorticoid administration in vivo and in vitro organ culture glucocorticoid exposure upon fetal hepatic morphogenesis were examined. Enhanced fetal hepatocyte ultrastructural maturation, characterized by a reduction in hematopoietic percursors, an increased frequency of hepatocyte-hepatocyte contact, a complete compliment of intracellular organelles, and the development of bile canaliculi by either maternal in vivo or in vitro fetal organ culture glucocorticoid exposure, was demonstrated. These studies extend previous observations concerning bile salt synthesis and secretion by fetal hepatic tissue both in vivo and in vitro by providing an ultrastructural basis for the functional changes observed and reported to occur in response to steroid therapy

Synthesis of taurocholate by rat fetal liver in organ culture: effects of cortisol in vitro.

Taurocholate production by fetal hepatic organ cultures was measured by radioimmunoassay. Taurocholate production was maximal on day 1 of in vitro incubation, but was demonstrable in organ cultures maintained for periods up to 15 days. Explants obtained from fetuses of 18 gestational days of age produced only 82 pmol taurocholate per milligram dry weight of tissue during the first 24 h of incubation. Explants obtained from fetuses 21 gestational days of age produced 1,043 pmol taurocholate per milligram dry weight. The presence of cortisol (2.0 X 10(-6) M) in the incubation medium increased synthesis of taurocholate by rat fetal liver in which total taurocholate rose 50-fold above control after 120 h of incubation. In increasing concentrations from 2.0 X 10(-9) M to 2.0 X 10(-7) M, cortisol produced an incremental rise in taurocholate. However, additional increases in cortisol dose failed to provide further stimulation, and taurocholate production was inhibited by cortisol concentrations of 2.0 X 10(-5) M. The results provide further validation for the technique of fetal hepatic organ culture. They demonstrate that taurocholate synthesis is increasing rapidly during the final stages of gestation and show that cortisol augments taurocholate synthesis in a dose-response pattern.