Right adrenal metastases of hepatocarcinoma after liver transplantation: case report and literature review.

BACKGROUND: Hepatocellular carcinoma (HCC) represents one of the most common malignancies globally, accounting for nearly one million new cases per year. Although the treatment of extrahepatic metastases from primary liver tumors is essentially palliative, a solitary metastasis from such tumors offers a possibility of cure by surgical resection. The adrenal gland is an uncommon site for metastasis from primary liver tumors. METHODS: We report a liver transplantation case of HCC and hepatitis B virus in a 23-year-old man with an excellent postoperative result. However, because an increased alpha-fetoprotein was evident and complete radiologic and blood tests were performed, all of which were normal. Three years posttransplantation, a right adrenal mass was identified by CT. PAAF was performed as well as adrenalectomy for a solitary adrenal metastasis from hepatocellular carcinoma. RESULTS: The patient underwent adrenalectomy for the right adrenal metastasis at 3 years following liver transplantation for HCC. He is presently alive and disease-free 24 months after adrenalectomy. CONCLUSION: Carefully selected patients with solitary metastasis from HCC may be considered for resection.

Effectiveness of pegylated interferon and ribavirin in patients with liver HCV cirrhosis.

Clearance of HCV before transplantation could avoid recurrence of hepatitis C in the liver allograft, thereby improving graft and patient survival. We report our experience with combined therapy for patients with HCV cirrhosis, including 12 patients with biopsy-proven liver cirrhosis (n = 7) or previous cirrhotic complications (n = 5). The Child-Pugh score was A in eight patients and B in four. Two patients had hepatocellular carcinoma. Genotype distribution was 1a (n = 2), 1b (n = 8) or 3 (n = 1). Patients received peginterferon alpha2b (1.5 microg/kg once weekly) and ribavirin (10.6 g/kg per day) for 48 weeks (genotype 1) or 24 weeks (genotype 3). Twenty-one months after beginning therapy all the patients remained alive; three have undergone liver transplantation. In one patient treatment was discontinued after 2 months due to cachexia. End-of-treatment virologic response was achieved in five patients (41.7%) and sustained virologic response in three patients (25%). Patients who cleared the virus had negative PCR 4 weeks after beginning therapy. All patients had adverse events. The most common clinical events were asthenia, weight loss, fever, and anorexia. Infectious complications resolved in three patients (25%). Hematologic events were common. Seven of 11 patients (63.6%) who completed therapy required dose reduction. We conclude that therapy with peginterferon and ribavirin in patients with HCV cirrhosis has a similar effectiveness to previous treatments. A virologic response 1 month after the beginning of therapy could be a main predictor of a sustained response.

Prevalence of hepatitis C virus genotypes in a Spanish liver transplant unit.

INTRODUCTION: Among the at least six major identified genotypes of HCV, genotype 1b, the one associated with a poorer prognosis, is the most prevalent in Spain. We aimed to compare the distribution of hepatitis C virus genotypes in our liver transplant unit with that of the other HCV patients at our institution (n = 413) in order to assess whether genotype 1b is more prevalent among patients with more severe liver disease. PATIENTS AND METHODS: One hundred eight patients of mean age 56 years included 81 (75%) OLT recipients and 27 (25%) with HCV cirrhosis. Determination of HCV genotypes was made with the Inno-LiPA HCV III. RESULTS: The overall distribution of genotypes was: 1b, 93 patients (86.1%); 1a; eight patients (7.4%); 3, four patients (3.7%); 4; two patients (1.9%), and 2; one patient (0.9%). The distribution was similar among patients with cirrhosis and OLT. Genotype 1b patients were older. Eleven (78.6%) of 14 patients with hepatocellular carcinoma had genotype 1b. In the control group the distribution was: 1b, 287 patients (69.5%); 1a, 54 patients (12.1%); 3, 41 patients (9.9%); 4, 20 patients (4.8%), and genotype 2, 11 patients (2.7%). This differences in the distribution of genotypes between our population and the control group was statistically significant (P < .001). CONCLUSIONS: Genotype 1b, the most prevalent genotype in our liver transplant unit, included older patients in whom hepatocellular carcinoma was common, perhaps due to their higher prevalence of cirrhosis.

Results of liver transplantation in patients with previous portosystemic shunts.

INTRODUCTION: Although liver transplantation is performed successfully in some patients with previous portosystemic shunts (PSS), these surgical procedures have been considered a relative contraindication for orthotopic liver transplantation (OLT). We aimed to determine whether a previous PSS worsens the prognosis of patients who undergo OLT. PATIENTS AND METHODS: Between March 1986 and October 2003, 520 liver transplants were performed in 467 patients in our center. Thirteen patients had undergone a PSS before OLT. The types of PSS were: portocaval (n = 8), splenorenal (n = 3), mesocaval (n = 1), and portoatrial (n = 1). We compared patients with previous PSS (cases) and the three patients with an OLT immediately before each case (controls). We analyzed the following variables: age, Child-Pugh stage, pretransplant liver disease, surgical times, transfusion requirements, infections, intensive care unit (ICU) stay, postoperative evolution, and survival. RESULTS: Age, Child-Pugh stage, and pretransplant liver disease were similar in both groups. There were no statistical differences in age, surgical times, ischemia time, anhepatic phase, transfusion requirements, ICU stay, infections, or hospital stay. The postoperative course was similar in both groups. Long-term survival was 84.62% in cases versus 78.5% in controls. CONCLUSIONS: Previous PSS should not be considered a contraindication for liver transplantation, even though this group of patients involves a special surgical challenge.

Mediastinitis necrotizante descendente de origen incierto

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[Techniques for determining case mix and their application to Allergology. 2]. / Técnicas de medición del "Case-Mix" y su aplicación a la Alergología (2a parte).

In this second part, we review the Generic Algorithms, the RUGs and the Ambulatory Visits Groups, remarking their possible application in our specialty. In an Allergology Service, most resources are spent on outpatients attendance. This fact allows us to propose that a production unit of that Service (GFH) could develop its activities, in its health area, ambulatorily. Its objectives and responsibilities, together with its human and material resources, could be clearly defined. An allergy outpatients clinic basic technological requirements are scarce, its costs being mainly determined by those of the staff. This makes possible the application of algorithms, to obtain the AVGs in Allergology, and to calculate the "cost by process", with the use of an indirect cost imputation system. The systematic use of evaluation technics in our specialty case-mix is a necessity in the present, because it permits: 1) a correct planning, fixing and ordering the objectives; 2) a better user of resources; 3) an adequate request of budgets, according to production; 4) obtaining a clinical and epidemiological data base; 5) billing the services; 6) information to the customer (patient) about the expenses his attention has generated.

[Techniques for determining case mix and their application to Allergology. 1]. / Técnicas de medición del "Case-Mix" y su aplicación a la Alergología (1a parte).

The use of adequate technics, in the Allergology case-mix evaluation, is a necessity in the present, and an aim to the future. Doing so, we shall be able to guarantee the quality of medical assistance. This article's objective is to introduce the reader, with a clear language, in the diverse procedures employed, in the actuality, to evaluate the diverse Health Services productive processes. We point out their advantages and disadvantages, and make a final proposal about the use of some of them in Allergology. Firstly, we analyze and describe the International Disease Classification (IDC-9-CM), the Diagnosis Related Groups (DRGs), the AS-SCORE, the Patients Severity Illness, the Staging Disease, the APACHE, and the Patients Management Categories. In the second part, we review the Generic Algorithms, the RUGs and the Ambulatory Visits Groups (AVGs). Finally, we propose some methods to improve activities in our specialty, to increase our knowledge, and to educate our colleagues under training in the basic concepts they need, to carry out their activities. In this way, we'll be able to guarantee a good assistance for the allergic patients, and to present objective data to the society, about the efficacy and efficiency with which public funds are used.