Biomedical subjects

R L Jenkins

Publications and source records attributed to R L Jenkins.

At least 37 records · Page 2Linked to original sources

PubMed1998

Combined liver-kidney transplantation in patients with cirrhosis and renal failure: effect of a positive cross-match and benefits of combined transplantation.

Patients with renal failure after liver transplantation have a particularly poor prognosis. Therefore, in the setting of end-stage renal disease requiring dialysis or severe renal insufficiency that will not improve after liver replacement, combined liver-kidney transplantation (LKT) is the preferred approach. We have adopted a policy of LKT in patients with end-stage liver disease and renal insufficiency undergoing dialysis or with a creatinine clearance less than 35 mL/min and evidence of chronic renal dysfunction. Since 1991, we have performed 208 orthotopic liver transplantations. Fourteen patients (8%) have undergone combined LKT, including 6 patients undergoing hemodialysis. Cytotoxic cross-matches (modified Amos technique and antihuman globulin method) were performed on 13 of 14 patients and were positive in 3 patients. Two patients died less than 4 months after LKT and 12 patients are alive and well. Graft survival censored for patient death was 100% for liver allografts and 93% for renal allografts, with a mean follow-up of 39 +/- 24 months. The most recent serum creatinine level in the patients with the 11 functioning grafts was 1.1 +/- 0.6 mg/dL. Biopsy-proven acute rejection occurred in 50% of simultaneous liver allografts. By contrast, only a single episode (6%) of renal allograft dysfunction was attributable to acute rejection. All rejection episodes occurred in the first 90 days after transplantation and were steroid sensitive. Three of 14 combined procedures were performed in the setting of a positive cytotoxic cross-match. In 2 recent patients, the results were confirmed by positive cross-matches to the donor's T and B cells by flow cytometry. Flow cytometric cross-matches reverted to negative 1 hour after liver transplantation and several hours before the administration of antithymocyte globulin. The cross-matches remained negative on postoperative days 1 and 7. Presently, all 3 patients with a positive cross-match enjoy normal hepatic and renal function at 631, 706, and 2275 days follow-up. Renal scans were performed in 4 LKT recipients not previously undergoing hemodialysis and indicated varying and unpredictable degrees of function in the native and transplanted kidneys. In conclusion, combined LKT can be performed safely and is associated with a low rate of acute rejection, even in the setting of a positive cross-match. Predicting which patients with renal insufficiency will benefit from LKT remains challenging; however, these results suggest that LKT should be encouraged in patients with evidence of irreversible renal insufficiency who require liver transplantation.

Adult↗

PubMed1998

Surgical margin in hepatic resection for colorectal metastasis: a critical and improvable determinant of outcome.

OBJECTIVE: To update the analysis of technical and biologic factors related to hepatic resection for colorectal metastasis in a large single-institution series to identify important prognostic indicators and patterns of failure. SUMMARY BACKGROUND DATA: Surgical therapy for colorectal carcinoma metastatic to the liver is the only potentially curable treatment. Careful patient selection of those with resectable liver-only metastatic disease is crucial to the success of surgical therapy. METHODS: Two hundred forty-four consecutive patients undergoing curative hepatic resection for metastatic colorectal carcinoma were analyzed retrospectively. Variables examined included sex, stage of primary lesion, size of liver lesion(s), number of lesions, disease-free interval, ploidy, differentiation, preoperative carcinoembryonic antigen level, and operative factors such as resection margin, use of cryotherapy, intraoperative ultrasound, and blood loss. RESULTS: Surgical margin, number of lesions, and carcinoembryonic antigen (CEA) levels significantly control prognosis. Patients with only one or two liver lesions, a 1-cm surgical margin, and low CEA levels have a 5-year disease-free survival rate of more than 30%. Disease-free interval, original stage, bilobar involvement, size of metastasis, differentiation, and ploidy were not significant predictors of recurrence. The pattern of failure correlates with surgical margin. Routine use of intraoperative ultrasound resulted in an increased incidence of negative surgical margin during the period examined. CONCLUSIONS: Surgical resection or cryotherapy of hepatic metastasis from colorectal cancer is safe and curable in appropriately selected patients. Biologic factors, such as number of lesions and carcinoembryonic antigen levels, determine potential curability, and surgical margin governs the patterns of failure and outcome in potentially curable patients. Optimization of selection criteria and surgical resection margins will improve outcome.

Carcinoembryonic Antigen↗

PubMed1997

The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt.

Hepatic hydrothorax is a rare complication of portal hypertension. Conservative therapy may be successful but refractory hepatic hydrothorax is not uncommon. Management of refractory hydrothorax is usually ineffective and can result in a worsened clinical status. Transjugular intrahepatic portosystemic shunts (TIPS) lower portal pressure and have been used in the treatment of refractory ascites. The aim of this study was to determine the efficacy of TIPS in the treatment of symptomatic refractory hepatic hydrothorax. A TIPS was placed in 24 consecutive cirrhotic patients with symptomatic refractory hepatic hydrothorax. Five patients (20.8%) were Child's/Pugh class B and 19 (79.2%) were class C. All had undergone multiple thoracenteses and were hypoalbuminemic. Mean follow-up was 7.2 months (range, 0.25-49 months). Fourteen (58.3%) of 24 patients had complete relief of symptoms after shunt placement and did not require further thoracentesis. Five (20.8%) additional patients required fewer thoracenteses. Five (20.8%) patients developed worsening liver function and died within 45 days. In eight (66.7%) of 12 patients with > or = 60 days of follow-up, the serum albumin increased by a mean of 1.2 g/dL (range, 0.1-2.2 g/dL). The Child's-Pugh score improved in 7 (58.3%) of these 12 patients and two patients improved from class C to class A. These two patients no longer require liver transplantation. This study shows that TIPS can be effective in the management of symptomatic, refractory hepatic hydrothorax. Clinical and laboratory improvement may be seen and liver transplantation may become unnecessary.

Female↗

PubMed1997

L-[1-(13)C] Phenylalanine oxidation as a measure of hepatocyte functional capacity in end-stage liver disease.

BACKGROUND: Liver disease is associated with impaired metabolism of these amino acids phenylalanine and tyrosine. Decreased metabolism of these amino acids leads to abnormal plasma elevations and impaired clearance rates. We have developed a noninvasive breath test that measures hepatic cytosolic enzyme activity. METHODS: The rate of hepatic phenylalanine metabolism was quantitatively calculated from the appearance of 13CO2 in the breath using the nonradioactive tracer L-[1-(13)C]phenylalanine. RESULTS: Normal controls (n = 47) oxidized phenylalanine more than twice that of end-stage liver disease patients (n = 117). Significant differences in the percent of phenylalanine oxidized per hour (mean +/- SEM) were found between controls (7.08% +/- 0.33%, 95% CI: 6.42%-7.74%) and Child Pugh classification patients, class A (4.96% +/- 0.69%, 95% CI: 3.50%-6.42%), class B (2.88% +/- 0.13, 95% CI: 2.39%-3.38%) and class C (1.75% +/- 0.13, 95% CI: 1.50%-2.01%). The phenylalanine breath test score significantly correlated with albumin levels, prothrombin time and total bilirubin. CONCLUSION: We have demonstrated that phenylalanine oxidation is significantly decreased with end-stage liver disease and is correlated with the best clinical measures of liver disease.

Adult↗

PubMed1997

Nifedipine interaction with tacrolimus in liver transplant recipients.

OBJECTIVE: To examine the possible drug interaction between nifedipine and tacrolimus in liver transplant recipients. STUDY DESIGN: A retrospective study was done comparing two groups of liver transplant recipients. The starting time for comparison was the same after transplant. One group (n = 22) consisted of hypertensive patients who were treated with nifedipine; the other group (n = 28) did not receive nifedipine. The two groups were compared over 1 year. The effect of nifedipine on tacrolimus was measured in terms of tacrolimus whole blood trough concentrations, daily tacrolimus dosages, and cumulative tacrolimus dosages at 1, 3, 6, and 12 months. All patient charts were reviewed with regard to concurrent medication that could affect the metabolism of tacrolimus and eventually affect tacrolimus concentrations and dosages. DATA COLLECTION: All required information was retrieved from medical records. RESULTS: There was a statistically significant difference between daily dosage requirements of tacrolimus at 90 (p = 0.03), 180 (p = 0.004), and 365 (p = 0.0004) days between the nifedipine and no-nifedipine groups. The tacrolimus daily dosage in the nifedipine group was decreased by 26%, 29%, and 38% at 3, 6, and 12 months, respectively, compared with the dosage of the no-nifedipine group. Statistically significant differences in cumulative dosages of tacrolimus were observed at 180 (p = 0.02) and 365 (p = 0.003) days between the nifedipine and no-nifedipine groups, with cumulative dosage reduction of 25% and 31% by 6 and 12 months, respectively, in the nifedipine group compared with the no-nifedipine group. CONCLUSIONS: Nifedipine decreased the daily and cumulative dosage requirement of tacrolimus. The interaction observed between nifedipine and tacrolimus is the first reported in humans and is clinically important. As a result of this drug interaction, it is recommended that blood concentrations of tacrolimus be monitored during coadministration of these drugs and that the tacrolimus dosage be adjusted accordingly.

Adult↗

PubMed1996

Hepatocellular carcinoma in the United States. Prognostic features, treatment outcome, and survival.

BACKGROUND: The purpose of this study was to investigate prognostic factors at presentation and the survival of North American patients with hepatocellular carcinoma (HCC). METHODS: A retrospective analysis of medical records was performed for 314 patients identified through the Tumor Registry as having been evaluated for hepatocellular carcinoma at the Deaconess Hospital, Boston, Massachusetts, from 1986 through 1995. Clinical characteristics were noted, including age, sex, TNM staging, serum biochemistries, serum alpha-fetoprotein (AFP), patency of portal vasculature, cirrhosis, history of alcohol abuse, hepatitis-B or C positivity, hemochromatosis, treatment received, and ultimate survival from the date of diagnosis. RESULTS: Overall median survival was 10 months. The presence of cirrhosis, a history of alcohol abuse, low albumin, high bilirubin, abnormal AFP, and portal vein obstruction (PVO) were each associated with significantly shorter survival, as was advanced stage. Only albumin, AFP, and PVO were independent risk factors by multiple regression analysis. Patients undergoing surgery had the longest median survival (45 months), followed by those receiving chemoembolization (14 months). Those patients who were untreated or received systemic chemotherapy alone had significantly shorter survivals (2-4 months). CONCLUSIONS: Despite the difference in the underlying etiology of HCC in this population compared with Asian patients, poor prognostic indicators are similar. In this large series of patients at a single Northeastern hospital, analysis of presenting clinical characteristics was found to offer useful prognostic information.

Actuarial Analysis↗

PubMed1996

Graft function and outcome of older (> or = 60 years) donor livers.

Livers from donors > or = 60 years of age are often considered inadequate for transplantation by many centers. With waiting times exceeding 1 year in our region, we have aggressively used livers from this donor age group. Between 1990 and 1994, 209 patients received 223 liver grafts at our institution. Of these, 29 (13%) were from donors > or = 60 years of age (group A) and 194 (87%) were from donors < 60 years of age (group B). The two groups were matched for recipient diagnosis and severity of disease. Group A and B donors had similar liver, renal, and hematologic studies prior to donation. Weight, sex, race and vasopressor requirement were also similar. Postoperative alanine aminotransferase, aspartate aminotransferase,and prothrombin time were not significantly different over the first 10 postoperative days. Group A grafts were significantly more cholestatic than group B grafts on postoperative days 6-10. The retransplantation rate for primary graft nonfunction was not significantly different from group A (6.7%) and group B (3.4%; P=0.04). Patient and graft survival rates at 1 year were 58.6 % and 44.8% for group A and 79.2% and 74.5% for group B (P<0.001 for both). Four of 12 deaths in the first year in group A were completely unrelated to graft function. If these are excluded, patient and graft survival rates were 68% and 52%, which are better but still significantly less than in group B. Initial graft function of older donor livers are similar to that of the matched younger group. However, patient and graft survival rates were significantly worse for the older donors, even when corrected for unrelated deaths. Livers should not be discarded based on age alone without inspection and/or biopsy to rule out significant steatosis. Prompt retransplantation for primary graft nonfunction of older donors are generally more cholestatic than those from the younger donor age group; however, many of them function quite well. At the present time, given the inability to identify donor variables associated with decreased recipient survival, we recommend cautious use of older liver grafts in healthier recipients.

Adult↗

PubMed1996

A regional experience with emergency liver transplantation.

Liver transplantation for patients requiring life-support results in the lowest survival and highest costs. A ten year (1983-1993) regional experience with liver transplantation for critically ill patients was undertaken to ascertain the fate of several subgroups of patients. Of the 828 liver transplants performed at six transplant centers within the region over this period, 168 (20%) were done in patients who met today's criteria for a United Network of Organ Sharing (UNOS) status 1 (emergency) liver transplant candidate. Recipients were classified according to chronicity of disease and transplant number (primary-acute, primary-chronic, reTx-acute, reTx-chronic). Overall one-year survival was 50% for all status 1 recipients. The primary-acute subgroup (n = 63) experienced a 57% one-year survival compared with 50% for the primary-chronic (n = 51) subgroup (P = 0.07). Of the reTx-acute recipients (n = 43), 44% were alive at one year in comparison with 20% for the reTx-chronic (n = 11) group (P = 0.18). There was no significant difference in survival for the following: transplant center, blood group compatibility with donors, age, preservation solution, or graft size. For patients retransplanted for acute reasons (primary graft nonfunction (PGNF) or hepatic artery thrombosis [HAT]), survival was significantly better if a second donor was found within 3 days of relisting (52% vs. 20%; P = 0.012). Over the study period progressively fewer donor organs came from outside the region. No strong survival-based argument can be made for separating, in allocation priority, acute and chronic disease patients facing the first transplant as a status 1 recipient. Clearly patients suffering from PGNF or HAT do far better if retransplanted within 3 days. Establishing an even higher status for recipients with PGNF, perhaps drawing from a supraregional donor pool, would allow surgeons to accept more marginal donors, thus potentially expanding the pool, without significantly compromising patient survival. Retransplantation of the recipient with a chronically failing graft who deteriorates to the point of needing life-support is nearly futile, and in today's health care climate, not an optimal use of scarce donor livers.

Acute Disease↗

PubMed1996

Hepatitis C viral infection in liver transplantation.

OBJECTIVE: To study the outcomes of patients who underwent liver transplantation for the primary diagnosis of chronic active hepatitis secondary to hepatitis C virus (HCV). DESIGN AND SETTING: Retrospective review within a university medical center. PATIENTS: Seventy-four adult recipients who received 78 orthotopic liver allografts for the primary diagnosis of chronic active hepatitis secondary to HCV between January 1990 and December 1994. Sixty-seven patients (91%) survived more than 2 months and were analyzed further for recurrent HCV infection. MAIN OUTCOME MEASURE: Recurrence of HCV infection, hepatitis, or cirrhosis and survival rates for patients who were undergoing orthotopic liver transplantation for chronic active hepatitis secondary to HCV. RESULTS: Actuarial survival rates for the entire group were 79.3%, 70.9%, and 64.5% at 1,2, and 3 years, respectively. Four patients (5% underwent retransplantation with an actuarial survival rate of 14.3% at 1 year (P<.05). Thirty-eight patients (57%) had evidence of posttransplant HCV infection, 31 patients (46%) showed histologic evidence of viral hepatitis, and 11 patients (16%) experienced portal fibrosis or cirrhosis. Seven (33%) of the deaths and all retransplantations were secondary to recurrent HCV infection. There were no significant differences in age, sex, United Network of Organ Sharing status, associated diagnoses, intraoperative packed red blood cell requirements, OKT3 use, or 1-, 2-, and 3-year survival rates in the recurrent vs nonrecurrent HCV infection groups. A higher incidence of posttransplant cirrhosis was observed in patients who were treated with tacrolimus (FK 506) (31.8% vs 8.9%, P<.05). Twenty-one patients (70%) received interferon alfa antiviral therapy with a significant benefit in the liver function test results during therapy (P<.01). CONCLUSIONS: Despite recurrence of HCV infection in most patients after transplantation, survival following primary orthotopic liver transplantation for chronic active hepatitis secondary to HCV infection remains favorable, and these patients should continue to be candidates for liver transplantation. In contrast, survival following retransplantation for HCV infection is poor and should be reconsidered. There is an apparent association between the intensity of immunosuppression and recurrent HCV infection and cirrhosis that warrants continued evaluation. Interferon therapy appears to afford benefit to patients in whom recurrent HCV hepatitis develops after transplantation.

Actuarial Analysis↗

PubMed1996

Multimodality treatment of hepatocellular carcinoma in a hepatobiliary specialty center.

OBJECTIVES: To review the experience of the treatment of hepatocellular carcinoma by a single multimodality team during a 6-year period, including all patients who were referred for possible surgical intervention, to evaluate prognostic factors at presentation, and to determine the results of the different modalities of treatment that were used. DESIGN: Retrospective study of 154 patients who were referred to our Hepatobiliary Surgical Unit with the diagnosis of hepatocellular carcinoma from January 1988 through August 1995. SETTING: Tertiary care center. RESULTS: Methods of treatment included surgical resection (n=49), transplantation (n=22), hepatic artery chemoembolization (n=30), systemic chemotherapy (n=25), and no treatment (n=22). Predictive prognostic factors included coexisting cirrhosis, symptoms at presentation, and abnormal liver function test results. Unfavorable tumor characteristics were size (diameter, >5 cm) and multicentricity. For patients who underwent surgical exploration, advanced staging according to the manual of the American Joint Committee on Cancer, vascular invasion, and a margin of less than 1 cm in the group for patients who underwent resection impacted negatively on the prognosis. The median survival (42.4 months) for the group of patients who underwent resection was significantly higher than that for the groups of patients who did not undergo resection. Chemoembolization was associated with significantly better survival results than was systemic chemotherapy. CONCLUSIONS: Hepatic resection offers the best chance at cure for patients with hepatocellular carcinoma. The high association between hepatocellular carcinoma and cirrhotic liver disease makes surgical resection, even in favorable tumor types, a difficult task based on low hepatic reserve whose tumors are considered unresectable can be considered for chemoembolization. Liver transplantation should be reserved for selected patients with cirrhotic liver disease who have tumors (diameter, <5 cm) in the contest of neoadjuvant protocols.

Adolescent↗

PubMed1996

Liver transplantation for adult polycystic liver disease.

Patients with adult polycystic liver disease and massive cystic replacement of the liver may present with severe debilitation and impairment of functional performance or, rarely, with signs of portal hypertension or hepatic dysfunction. In those patients incapacitated by severe hepatomegaly secondary to massive cystic replacement with predominantly small cysts (2 cm) without areas of parenchymal sparing, liver transplantation is a therapeutic option. Five patients with incapacitating symptoms from polycystic liver disease underwent liver transplantation as a final therapeutic procedure. Two patients had previous fenestration procedures without significant relief. All patients had radiographic evidence of concomitant polycystic kidney disease; two of these patients were dialysis-dependent at the time of liver transplantation. One patient underwent combined liver-kidney transplantation, whereas another received a six-antigen matched kidney transplant 64 months after liver transplantation. Four of five patients are alive 84, 39, 20, and 8 months after successful liver transplantation. All four have returned to normal functional status with complete resolution of symptoms. Liver transplantation is a suitable option for the patient with bilobar small cystic liver disease without areas of parenchymal sparing. However, only patients with severely compromised functional status should be offered this therapy. Concomitant renal evaluation is mandatory, and a knowledge of the natural history of this disease will aid in the decision of whether a combined liver-kidney transplantation is indicated.

Adult↗

PubMed1996

Severe ascites: efficacy of the transjugular intrahepatic portosystemic shunt in treatment.

PURPOSE: To evaluate the transjugular intrahepatic portosystemic shunt (TIPS) as primary treatment in patients with cirrhosis and severe ascites. MATERIALS AND METHODS: A TIPS placement was attempted in 54 consecutive patients with intractable ascites. Clinical assessment findings, shunt patency, complications, and survival were analyzed. RESULTS: A TIPS was successfully placed in 50 patients (93%). Follow-up for clinical effectiveness in 51 patients was a mean of 285 days (range, 1-981 days). Forty patients (78%) gained clinical benefit from the shunt. Of these, 29 (57%) had a complete response (required no further paracentesis) and 11 patients (22%) had a partial response (required less frequent but additional paracentesis for control of ascites). The absence of preprocedure renal insufficiency (creatinine < 1.5 mg/dL [< 130 mumol/L]) was the only characteristic identified as an indicator of clinical success (P < .05). Eleven patients (22%) required shunt revision during follow-up to gain or prolong control of symptoms. Cumulative survival in the population evaluated for clinical efficacy was 53% at 6 months and 48% at 1 year. A complete response was the only variable that indicated increased survival (P < .05; R2 = 12%) with a 6-month survival rate of 76% and a 1-year rate of 71%. CONCLUSION: TIPS placement appears to be effective as a primary treatment of patients with cirrhosis and severe ascites.

Adult↗

PubMed1996

Liver masses: replacement of conventional T2-weighted spin-echo MR imaging with breath-hold MR imaging.

PURPOSE: To evaluate breath-hold magnetic resonance (MR) imaging with single-shot and multishot T2-weighted fast spin-echo (SE) and inversion-recovery (IR) SE echo-planar (EP) SE (IR-SE-EP) sequences compared with conventional T2-weighted SE imaging for detection of liver masses. MATERIALS AND METHODS: Imaging with all sequences was performed in 32 patients on a 1.5-T whole-body system. Images were compared on the basis of lesion-to-liver contrast-to-noise ratio (C/N), lesion conspicuity, and image quality. Image analysis was performed by two experienced radiologists in consensus. RESULTS: Lesion-to-liver C/Ns were highest on fat-suppressed-half-Fourier-single-shot-fast-SE images. For solid lesions, the lesion-to-liver C/Ns were highest with IR-fast-SE, which was significantly better (P < .05) than IR-SE-EP and conventional SE techniques and also produced the best image quality. Sensitivity with IR-fast-SE was 96%; with fat-suppressed-half-Fourier-single-shot-fast-SE, 92%; with fat-suppressed-fast-SE, 89%; with IR-SE-EP, 83%; and with conventional SE, 78%. CONCLUSION: T2-weighted breath-hold imaging, particularly IR-fast-SE imaging, was more sensitive for hepatic masses than conventional SE imaging, with a substantial reduction in acquisition time. Half-Fourier-single-shot-fast-SE imaging was especially useful in patients who were unable to hold their breath.

Adult↗

PubMed1996

Cholangiocarcinoma.

Resection is indisputably associated with prolongation of survival in patients with cholangiocarcinoma and provides the only chance for cure. Equally as important is the ability to achieve microscopically clean margins at the time of resection. Liberal use of hepatic resection in conjunction with hilar vascular skeletonization may improve the ability to achieve disease-free margins and can be performed with little additional morbidity. Optimal treatment for the patient with unresectable disease is currently still debatable. Our experience, as well as others, suggests that patients who have unresectable disease by radiologic or laparoscopic evaluation are better served by nonsurgical internal biliary decompression. We currently favor nonoperative treatment with self-expandable wire mesh stents over operative biliary enteric bypass for nonresectional candidates. Patients who underwent resection who develop local recurrence with biliary obstruction also can be managed with metallic stents across the obstructed hepaticojejunostony to provide an additional period of symptomatic palliation.

Bile Duct Neoplasms↗

PubMed1995

Major infectious complications after orthotopic liver transplantation and comparison of outcomes in patients receiving cyclosporine or FK506 as primary immunosuppression.

A retrospective cohort study was conducted to determine the incidence of major infectious complications after orthotopic liver transplantation and to compare outcomes in patients receiving either cyclosporine (CsA) or FK506 (tacrolimus) as primary immunosuppression. Of 133 transplants performed in 118 patients, 124 transplant episodes were evaluated. Cytomegalovirus (CMV) infection (INF) and disease (DIS), deep fungal infection (DFI), and intraabdominal bacterial infections (IAI) were catalogued. The overall incidences of major infectious outcomes were: CMV INF = 33%; CMV DIS = 19%; DFI = 15%; and IAI = 25%. Cox proportional hazard analysis identified donor seropositivity, OKT3 as secondary immunosuppression and initial intensive care unit (ICU) duration as risk factors for CMV INF and DIS in the overall population. Fungal colonization was the dominant risk factor associated with deep fungal infection. A choledochojejunostomy anastomosis, the number of cellular blood products transfused at the time of transplantation surgery, and prior CMV INF were independent risk factors for both fungal colonization and deep infection. The single risk factor identified for intraabdominal bacterial infections was the number of cellular blood products transfused at the time of surgery. In the Cox proportional hazards model the relative risk (RR) for each category of infection was lower in the FK506 group (CMV: RR = .87, 95% confidence interval [C.I.] = [.32-2.4]; DFI: .58 [.13-2.6]; IAI: .51 [.15-1.7]), but the effect was not statistically significant. Survival was similar in patients receiving FK506 or CsA. CMV INF and DFI were independent predictors of death for all patients. Risk factors identified for CMV INF and DIS support the findings of others. Higher intraoperative blood product requirements and complicated intraoperative or postoperative courses increase the risk for IAI or DFI. The development of effective strategies to prevent CMV and fungal infections in liver transplant recipients remains a priority for future endeavors.

Bacterial Infections↗

PubMed1995

Aggressive surgical resection for cholangiocarcinoma.

OBJECTIVES: To review the spectrum of cholangiocarcinoma in patients treated by a single team of hepatobiliary surgeons over an 8-year period, to evaluate the predictors of survival, and to assess the results of an aggressive approach to surgical resection. DESIGN: Retrospective review of all clinical records of patients referred for treatment of cholangiocarcinoma, with univariate analysis of clinical and pathologic factors in relation to patient survival. SETTING: New England Deaconess Hospital, Boston, Mass. PATIENTS: Eighty-eight consecutive patients referred with the established diagnosis of cholangiocarcinoma, from December 31, 1985, to April 15, 1994. INTERVENTIONS: Seventy-five of 88 patients were treated surgically, with 59 undergoing major resection for cure. Of the 29 patients treated palliatively, 16 had operations and 13 had wire mesh stents placed nonoperatively. MAIN OUTCOME MEASURES: Morbidity, mortality, and patient survival. RESULTS: Survival correlates directly with the pathologic stage (TNM). Tumor location had no impact on survival. Patients undergoing resection survived significantly longer (median, 23.2 months) than palliated patients (median, 7.7 months; P = .0015). Nonoperative palliation resulted in better survival than surgical palliation (P = .045). Major hepatic resection was used alone in eight patients with predominating intrahepatic lesions, while 18 patients with hilar lesions underwent en bloc skeletonization in conjunction with major hepatic resection. Resection with microscopically free margins significantly improved survival. Only patients undergoing major resection enjoyed survival greater than 2 years. CONCLUSIONS: Patient survival can be significantly improved by aggressive surgical resection. Hepatic resection should be used aggressively to achieve disease-free margins to optimize survival. Hepatic resection can be performed with low morbidity and mortality. Liver transplantation should be avoided as a treatment for cholangiocarcinoma. The best palliation for unresectable disease remains debatable. We advocate nonoperative treatment with endobiliary expandable wire mesh stents for patients with unresectable disease.

Adult↗

PubMed1995

Biliary tract complications after liver transplantation.

OBJECTIVE: To assess the incidence, type, and treatment of biliary complications after orthotopic liver transplantation. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: One hundred ninety consecutive adults who underwent 220 orthotopic liver transplantations with biliary reconstruction between January 1, 1989, and December 31, 1993, with follow-up of all survivors to May 1994. MAIN OUTCOME MEASURES: Incidence, type, and treatment of biliary complications. RESULTS: Biliary complications were identified in 65 of the 190 patients who underwent biliary reconstruction (49 of 147 with choledochocholedochostomy and 16 of 43 with Roux-en-Y choledochojejunostomy). The group with complications who had choledochocholedochostomy had 32 biliary leaks (22 T-tube related), 11 strictures or obstructions, and six cases of choledocholithiasis. Twelve percent of choledochocholedochostomies were converted to choledochojejunostomies, while 26 of 49 biliary complications in patients who had choledochocholedochostomies were treated nonoperatively. Elective removal of T tubes resulted in biliary leak in 15 of 89 patients, treated nonoperatively in 12. Leaks (unrelated to scheduled removal of the tube) occurred earlier than strictures (choledochocholedochostomy, mean +/- SEM 25.6 +/- 5.8 vs 184.7 +/- 61.0 days; choledochojejunostomy, 13.4 +/- 4.4 vs 521.0 +/- 142.0 days) and were more often treated operatively (choledochocholedochostomy, 14 of 17 vs three of seven; choledochojejunostomy, four of five vs three of eight). Three deaths were associated with early biliary leaks, all in patients with preexisting multiorgan dysfunction. There was no significant difference in the incidence of biliary complications by type of reconstruction, year of transplantation, age, UNOS (United Network for Organ Sharing) status, preservation time, or indication for transplantation. CONCLUSIONS: Biliary complications are common after orthotopic liver transplantation but are rarely an isolated cause of death. Stenting of the choledochocholedochostomy or choledochojejunostomy anastomosis does not prevent strictures, and T tubes are associated with a high incidence of biliary leakage on removal. Nonoperative interventions have an increasing role in the treatment of biliary complications.

Adult↗

PubMed1995

Primary malignant melanoma of the biliary tract.

Primary malignant melanoma of the biliary tract is an obscure entity, with only four previously reported cases. We report two cases involving the common bile duct. A 43-year-old male who underwent a right hepatectomy and excision of the extrahepatic biliary tree for a lesion at the bifurcation of the common bile duct. He remains alive and well 11 months after resection. The second patient is a 45 year old male with obstructive jaundice due to an ampullary lesion. Pancreaticoduodenectomy was performed with no signs of metastatic disease. He is 6 years following resection without evidence of disease. This is an unusual cause of obstructive jaundice and a definitive search for a possible extra-biliary primary should be pursued. In appropriately selected patients without evidence of metastatic disease, resection can potentially afford long-term survival if these lesions are true primary lesions and not metastatic from an undefined primary. However, given the high metastatic potential of melanoma it is unclear whether resection of these lesions results in cure or just effective long-term palliation.

Adult↗