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Biomedical subjects

R M Goldstein

Publications and source records attributed to R M Goldstein.

At least 55 records · Page 3Linked to original sources
PubMed1995

A comparison of treatment with transjugular intrahepatic portosystemic shunt or distal splenorenal shunt in the management of variceal bleeding prior to liver transplantation.

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Adult↗
PubMed1993

Neoadjuvant chemotherapy and liver transplantation for hepatocellular carcinoma: a pilot study in 20 patients.

BACKGROUND: Liver transplantation for unresectable hepatocellular carcinoma yields disappointing results. Most cases recur within 2 years, often in the transplanted liver. METHODS: A combination of neoadjuvant doxorubicin and orthotopic liver transplantation was used in 20 patients with unresectable hepatocellular carcinoma confined to the liver. Seventeen patients had tumors > 5 cm in greatest diameter, and 11 cases were stage IVA by the TNM classification. Doxorubicin was administered preoperatively, intraoperatively, and postoperatively at a dose of 10 mg/m2 weekly, totaling 200 mg/m2. RESULTS: Chemotherapy was well tolerated although leukopenia was observed in 70% of patients. Eight patients died, five of recurrent tumor and three of hepatitis B. Three others remain alive 8-22 months after tumor recurrence. One patient had initial tumor recurrence in the allograft. Actuarial survival is 59% and tumor-free survival is 54% at 3 years. For the 17 patients with tumors > 5 cm, overall survival is 63% and tumor-free survival is 49% at 3 years. CONCLUSION: The results of this pilot study suggest that neoadjuvant doxorubicin chemotherapy favorably alters the post-transplant survival of patients with hepatocellular carcinoma.

Adult↗
PubMed1993

Is liver transplantation indicated for cholangiocarcinoma?

Liver transplantation for unresectable primary liver cancer has met with skepticism due to early aggressive recurrences occurring in early series from many centers. The primary tumors for which transplantation has been performed have been hepatocellular carcinoma and cholangiocarcinoma. In an attempt to improve these poor results, we instituted a protocol with adjuvant chemotherapy and radiotherapy after liver transplantation for cholangiocarcinoma. Between December 1984 and December 1992, 701 patients underwent 795 liver transplants. Seventeen patients had a diagnosis of cholangiocarcinoma and form the basis of this review. Three patients were excluded from the study, two because of early postoperative deaths, and one because of an unknown bony metastasis present at the time of transplant. Eleven patients have experienced a recurrence, and 7 of these died secondary to their recurrence. Three patients are alive with no evidence of disease 44 months, 31 months, and 28 months, respectively, after transplant. The 1-year survival rate in these patients is 53%, and the disease-free survival rate is 40%. Patients were able to tolerate the adjuvant chemotherapy and radiotherapy without apparent morbidity or mortality. Unfortunately, this protocol does not appear to provide significant benefit. Until a better adjuvant therapy protocol is developed, it is questionable whether unresectable cholangiocarcinoma should be considered an indication for liver transplantation.

Chemotherapy, Adjuvant↗
PubMed1993

OKT3 rescue for steroid-resistant rejection in adult liver transplantation.

The results of OKT3 use for steroid-resistant rejection rescue in adult liver transplantation were analyzed retrospectively from a single transplant center. Comparison was made with concurrent patients who had no rejection (NR) or steroid-responsive rejections (SR). The records of 290 patients who underwent 323 liver transplants from April 1985 to December 1989 were examined. The first technically successful grafts were used for this analysis (265 grafts). Follow-up was a minimum of 1 year, or until death or loss of graft. All patients received triple-drug induction immunosuppression (CsA, Aza, steroids). Initial rejection was treated with 1 g methylprednisolone bolus i.v., followed by a 5-day taper of steroids from 200 mg to 20 mg. No rejection occurred in 108 (40.8%) and SR in 86 (32.4%), and OKT3 was given for persistent rejection in 71 (26.8%). The age, sex distribution, mean follow-up, and preoperative status were similar in all three groups. The preoperative diagnoses were similar, except for fulminant liver failure, in which 19 of 20 patients experienced rejection (P < 0.0001). The median hospitalization stay was 37 days for OKT3, 27 days for SR, and 21 days for NR (P < 0.0001). The median ICU stay was similar in the three groups (OKT3, 4; SR, 4; NR, 3). Infections in the first 6 weeks, and in the period of 6 weeks to 1 year posttransplant, were of similar frequency for all three groups. By the Kaplan-Meier estimation, the graft and patient actuarial survival rates were comparable. At 1 year, the graft survival rate was 79.6% for NR, 79.8% for SR, and 67.6% for OKT3. The 1-year patient survival rate was 85.2% for NR, 83.7% for SR, and 84.5% for OKT3. Following treatment by OKT3, rejection was permanently reversed in 42 patients. A temporary response occurred in 12 patients, 16 patients failed to respond to OKT3, 2 patients died during therapy, and 6 of the nonresponders died within 12 months. Additional OKT3 treatment was attempted in 6 patients for persistent rejection within a 1-month interval from the previous OKT3 course. Of these 6, 4 developed lymphoproliferative disorder, and only 1 survived in response to drastic reduction of immunosuppression. In conclusion, OKT3 was effective as rescue therapy for adult liver transplant steroid-resistant rejection. Because of the associated morbidity and expense, OKT3 should be used in a selective fashion. Failure to respond to OKT3 is a serious complication, and should not be managed by prolonged or repeated courses, but rather by alternative means.

Adult↗
PubMed1993

Baylor update: outcome analysis in liver transplantation.

An analysis of the first 740 liver transplants performed at Baylor is presented, including all cases to the end of calendar 1992. Kaplan-Meier curves are extended to nine years posttransplant. Our focus on outcome analysis has led us to review our experience with diabetics, with elderly patients, causes and patterns of late graft loss, long-term renal function. Quality of life data tracked for 2 years posttransplant is outlined. Clinical correlates to whole blood and plasma assays of FK506 are reviewed. Concerns remain over the disappointing results of liver transplantation for cholangiocarcinoma and those of patients with hepatitis-B antigenemia under current protocols.

Academic Medical Centers↗
PubMed1993

Liver transplant in complete situs inversus: a case report.

BACKGROUND: Several technical solutions have been proposed for patients with situs inversus (SI) needing liver transplantation. This report describes the hepatic replacement in a patient with complete SI with dextrocardia. In the only other reported patient with complete SI the donor right lobe was placed over the vertebral column and the stomach to align the donor cava with that of the recipient. METHODS: A 45-year-old woman with complete SI, suffering from Laënnec's cirrhosis with frequent upper gastrointestinal hemorrhages, underwent transplantation in June 1991. The recipient weighed 48.2 kilograms and was 155 centimeters tall. The donor weighed 77.3 kilograms and was 188 centimeters tall. The weight of the native liver was 1934 grams, and the donor liver weighed 1595 grams. RESULTS: At hepatectomy of the native liver an intact vena cava was left behind. Donor liver was rotated 90 degrees to the left, making the donor left lobe point into the left iliac fossa and the donor right lobe fall into the recipient hepatic fossa. Donor infrahepatic vena cava was sewn end-to-side to the recipient vena cava. Suprahepatic vena cava was oversewn. Donor and recipient hila were well aligned, allowing a standard arterial reconstruction and a choledocholedochostomy. Patient's recovery was uneventful with no problems during the following 6 months. CONCLUSIONS: The proposed technique for a patient with complete SI and dextrocardia offers several advantages: no need to downsize the donor in comparison with the recipient; no need for cutdown of the liver; no risk of kinking of the venous outflow; hepatic hila are aligned; and it allows for a standard arterial and biliary reconstruction. We recommend this technique as a procedure of choice for patients with SI and an intact vena cava.

Dextrocardia↗
PubMed1993

The impact of operative bleeding on outcome in transplantation of the liver.

Excessive operative blood transfusion has been correlated with an increased rate of infectious complications and lower survival rate after transplantation of the liver. Two hundred and five consecutive transplants of the liver, performed between January 1988 and December 1989, were studied retrospectively to determine preoperative risk factors associated with an increased operative blood loss and to evaluate the impact of operative transfusion on the outcome of transplantation. Preoperative clinical and laboratory parameters in patients who required 10 units or more of banked erythrocytes were compared with those in patients who received less than ten units of erythrocytes. In evaluating the outcome, the two groups were compared for infection, rejection and graft and patient survival rates. The median operative blood loss for 205 patients was 5 units of banked erythrocytes (range of zero to 52, mean of 6.9 units). Only 41 patients (20 percent) required 10 units or more of erythrocytes. The significant factors on univariate analysis that were associated with an increased operative blood loss were hospitalized patients (United Network for Organ Sharing Status > or = 3), fulminant hepatic failure, previous portosystemic shunt and complete ABO mismatch. Patients who required more blood had higher incidence of coagulation abnormalities, renal dysfunction and high bilirubin levels. A stepwise logistic regression analysis model using all these parameters identified an elevated serum creatinine, decreased platelets and a prolonged partial thromboplastin time as being the strongest risk factors. Using these variables, operative bleeding of more than 10 units could be predicted accurately only 60 percent of the time (sensitivity 60.0 percent with a specificity of 69.1 percent). Septic episodes occurred more frequently in patients with an excessive operative blood loss (p < 0.05), and these patients also tended to have a higher rate of severe cytomegalovirus infections and a lower incidence of acute rejection. Patients who required more blood also had significantly prolonged stays in the intensive care units postoperatively (18.3 versus 6.3 days, p < 0.002) and lower graft and patient survival rates (p < 0.001 and p < 0.05, respectively). We conclude that intraoperative bleeding has remained a significant problem affecting the immediate outcome after transplantation of the liver. Preoperative parameters cannot predict operative bleeding accurately and the mainstay to prevent bleeding is a meticulous surgical technique during the hepatectomy and correction of coagulation abnormalities throughout the procedure.

Adult↗
PubMed1992

The use of marginal donors for liver transplantation. A retrospective study of 365 liver donors.

A total of 365 donor hepatectomies performed between May 1985 and March 1990 were reviewed and analyzed retrospectively to identify risk factors associated with poor graft function and to study the outcome of grafts retrieved from "marginal" donors. The donor mean age was 27.1 years (8-69 years). Mean ICU donor stay was 2.7 days (range 0 to 18 days), and the mean ischemic time was 8.6 hr (range 3 to 22 hr). The pancreas was retrieved in 39 donors. Donor's weight above 100 kg was the only variable found to be associated with both significantly increased 3-month graft loss (P less than 0.01) and early hepatocellular damage--AST or ALT greater than 2000 U/ml, 1st day posttransplant (P less than 0.02). Prolonged stay in the ICU (greater than 3 days), although associated with a significantly increased rate of hepatocellular damage (P less than 0.05), did not affect early graft survival. A systolic blood pressure less than 90 mmHg despite the use of high-dose dopamine (greater than 15 micrograms/mg/min), but not each of these variables itself, was also associated with a significantly increase rate of hepatocellular damage (P less than 0.001). All other variables, including age greater than 50, ischemic time greater than 12 hr, combined liver-pancreas procurement, and liver function test abnormalities, did not affect the outcome. We conclude that extending our limits to accept donors of the higher age group and those who have moderately abnormal liver function tests or a prolonged ischemic time will not jeopardize our results. It is suggested to perform liver biopsy in overweight donors during the retrieval to prevent using grafts with severe fatty infiltration. It is hypothesized that hormonal changes, starvation, and increased risk to develop infection might jeopardize the outcome of grafts from donors with a prolonged ICU stay. Although 70% of the early hepatocellular injuries are reversible, the remaining 30% result in graft failure.

Adolescent↗
PubMed1992

Late-onset acute rejection in orthotopic liver transplantation--associated risk factors and outcome.

A retrospective review of 375 consecutive orthotopic liver transplants was performed to determine the incidence and outcome of late rejection episodes ([LR] rejection occurring more than 6 months following transplant). A total of 31 episodes in 26 patients were identified. Eighteen of these episodes were associated with subtherapeutic levels of cyclosporine. Of these, 7 were due to noncompliance, 2 were due to biliary strictures, and 1 was due to malabsorption in a cystic fibrosis patient. All 31 episodes were treated initially with steroids, and 22 had a complete response, although one progressed to chronic rejection over a year later. Of the remaining 9, 1 received FK506 with a complete response, and 8 received OKT3. Of the 8 patients who received OKT3, 5 had a complete response, 1 received RS61443 following OKT3 and progressed to chronic rejection, and the remaining 2 received further steroids. Of these 2, 1 had a complete response following the steroids while the second was converted to FK506 with a complete response. Compared with 315 acute rejection episodes ([AR] occurring less than 6 months posttransplant), patients with late rejection episodes had an equivalent response to steroids (63.2% AR reversed vs. 71% LR reversed) but a lower response rate to OKT3 (91.5% AR reversed vs. 62.5% LR reversed). There was, therefore, a higher rate of persistent rejection (61% AR episodes vs. 15.4% LR episodes) but no increase in the incidence of chronic rejection (7% AR episodes vs. 7.7% LR episodes). We conclude that LR is a relatively common occurrence following liver transplant, which is most often associated with low cyclosporine levels. Many of these episodes are due to noncompliance, but biliary problems must also be investigated. The incidence of resistant rejection is higher in this group of patients but is not associated with a concurrent increase in chronic rejection.

Adolescent↗
PubMed1992

Approaching families for organ donation: physicians are willing.

While current literature documents a critical disparity between the increasing demand for organs for transplantation and the relatively static supply, reasons for the shortage of donors are not well understood. Public opinion surveys describe a population willing to donate, but consent rates reported by organ procurement organizations suggest problems in the process of approaching families. This study of Texas physicians regarding their knowledge of laws related to brain death and to routine inquiry for organ donation and their attitudes toward the critical step of seeking consent from families indicates that physicians need more information about questions asked by families, would benefit from more structured hospital policies on routine inquiry, feel that physicians rather than nurses should approach families, and believe that the public is not well informed about donation.

Brain Death↗