Abstract Background Adult liver transplantation (OLT) recipients occasionally show serious acute cardiopulmonary dysfunction, requiring intensive care. We assessed the role of extracorporeal membrane ...oxygenation (ECMO) support in adult recipients facing acute pulmonary failure and refractory to conventional mechanical ventilation and concurrent nitric oxide gas inhalation. Methods From January 2008 to March 2011, 18 adult OLT recipients at our institution required ECMO support: 12 due to pneumonia and 6 to adult respiratory distress syndrome. Their mean age was 55.7 ± 6.9 years and mean Model for End-stage Liver Disease score, 24.8 ± 8.5. Twelve patients had undergone living donor and six deceased donor OLT. Results A venovenous access mode and concurrent continuous venovenous hemodiafiltration were used in all patients. There were no procedure-related complications. Eight patients (44.4%) were successfully weaned from ECMO upon the first attempt after a mean support of 11.9 ± 6.1 days, but the other 10 died due to overwhelming infection. Univariate analysis revealed no significant pre-ECMO risk factor for treatment failure but C-reactive protein concentration at the time of ECMO differed significantly among patients who did versus did not survive after ECMO. Conclusions ECMO as rescue therapy may be a final therapeutic option for OLT recipients with refractory pulmonary dysfunction who would otherwise die due to hypoxemia from severe pneumonia or adult respiratory distress syndrome.
Abstract Purpose Combined hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCC) is a rare pair of intrahepatic malignancies. Differential diagnosis among combined HCC-CCC, HCC, or CCC ...can be difficult; thus malignancies other than ordinary HCC are occasionally encountered unexpectedly in explanted liver specimens. The present study analyzed the long-term outcomes of liver transplantation (OLT) among patients with HCC-CCC. Methods Between January 1999 and December 2009, we performed 2137 adult OLT at our institution including 15 cases of pathologically confirmed HCC-CCC, who all underwent OLT with a pretransplant diagnosis of HCC. We reviewed retrospectively the medical records of these 15 patients. Results Their mean age was 58.9 ± 7.2 years. The median preoperative alpha-fetoprotein level was 32.6 ng/mL. Fourteen patients underwent living donor and one deceased donor OLT. The Milan criteria were met in 12 cases. A single tumor was identified in 8 and multiple lesions in 7 patients. The maximal tumor diameter was 2.9 ± 1.7 cm. Seven patients experienced tumor recurrences: including 6 within the first 12 months. All of the patients who experienced recurrences died at a median 4 months after that diagnosis. The overall patient survival rates were 66.7% at 1 year and 60.0% at 3 and 5 years. Disease-free patient survival rates were 60.0% at 1 year and 53.3% at 3 and 5 years. Conclusions Patients with combined HCC-CCC showed a high rate of early recurrences, particularly within the first year.
Abstract Background We previously showed that ringed polytetrafluoroethylene (PTFE) grafts combined with small allograft patches showed high patency rates similar to those of iliac vein grafts and ...therefore that they can be used for middle hepatic vein (MHV) reconstruction. Although such use of PTFE graft showed high patency rates, its long-term safety regarding infection and other types of complications were not presented. In this study, we investigated the actual risk of complications directly associated with PTFE graft interposition for MHV reconstruction. Methods During the study period of 30 months, we performed 215 cases of adult living-donor liver transplantation with modified right lobe graft and PTFE grafts. We classified the potential complications directly associated with PTFE graft interposition as infectious and surgical complications. The medical records of study patients were retrospectively reviewed. Results MHV graft patency rate was 76.3% at 6 months and 36.7% at 12 months. Their 1-year graft and patient survival rates were 92.6% and 93.5%, respectively. The 1-year actual incidences of infectious complication and surgical complication were near zero and 1 case (0.5%), respectively. In 1 recipient, the PTFE graft penetrated into the stomach wall 6 months after transplantation, but the patient did not complain of any specific symptoms. The PTFE graft was removed with the use of laparotomy, and the patient recovered uneventfully. Conclusions Although the incidence of PTFE graft–associated complication rate is very low, we suggest that it is necessary to closely monitor the PTFE graft, because unexpected complications can happen during long-term follow-up.
From August 2004 to July 2005, 210 clinical methicillin-resistant Staphylococcus aureus (MRSA) isolates were collected prospectively from 173 children admitted to Chang Gung Children's Hospital in ...Taiwan. A comparative molecular analysis of the 111 community-associated (CA) isolates from 102 children and the 99 healthcare-associated (HA) isolates from 71 children was conducted. In comparison to the HA isolates (31%), the CA isolates (90%) were more likely to have been isolated from pus (p <5 × 10–8). For each patient with MRSA infection, only the first isolate was selected for molecular analysis. The molecular characteristics differed significantly between the CA and the HA isolates (p <5 × 10–8). The clone characterized as sequence type (ST)59/pulsotype D (similar to USA1000)/staphylococcal chromosomal cassette (SCC)mec VT/Panton–Valentine leukocidin (PVL)-positive accounted for 69% of the CA isolates, and another clone, characterized as ST239/pulsotype A (Hungary clone)/SCCmec III/PVL-negative, accounted for 45% of the 71 HA isolates. The CA clone of ST59 also accounted for 20% of the HA isolates, including 47% of the 17 community-onset isolates. It was concluded that the molecular characteristics of clinical MRSA isolates from children differed significantly between the CA and the HA isolates in northern Taiwan. However, the CA clone of ST59 was also identified in a substantial proportion of HA isolates.
We aimed to determine the role of palliative resection in metastatic colorectal cancer (mCRC) and ascertain which patient populations would benefit most from this treatment.
A total of 1015 patients ...diagnosed with mCRC at Seoul National University Hospital between 2000 and 2009 were retrospectively studied.
Of the 1015 patients, 168 patients with only liver and/or lung metastasis received curative resection. The remaining 847 patients were treated with palliative chemotherapy and/or palliative resection combined with best supportive care. Palliative resection was performed in 527 (62.2%) cases (complete resection with negative margin (R0) in 93, R1/2 in 434). Resected patients had a more prolonged median overall survival (OS) than unresected patients (21.3 vs 14.1 months; P<0.001). In multivariate analysis, R0 resection was found to be associated with a superior OS compared with R1/2 resection (51.3 vs 19.1 months; P<0.001) and no resection (51.3 vs 14.1 months; P<0.001). When we performed propensity score matching, palliative resection was found to be related to prolonged OS (hazard ratio=0.72, 95% confidence interval=0.59-0.89; P=0.003).
Palliative resection without residual disease and chemotherapy confers a longer-term survival outcome than palliative chemotherapy alone in mCRC patient subset.
Abstract Background This study sought to establish an actual risk-based long-term screening protocol for hepatocellular carcinoma (HCC) recurrence after liver transplantation (OLT). Methods The study ...was a retrospective review of medical records from 334 HCC patients who underwent primary living donor OLT and followed up for at least 5 years. Results Overall 10-year patient survival rate was 67.5%, with a 4.8% perioperative mortality. HCC recurred in 68/318 (21.4%) surviving patients over a mean follow-up of 77 months. HCC recurrence was 20.7% at 5 and 22.2% at 10 years. Annual recurrence rates were 11.4%, 6.6%, and 2.0% during the first, second, and third years, respectively. Among patients within Milan criteria, the annual incidence of HCC recurrence was highest during the first 3 years; thereafter only 6 sporadic recurrences were observed during next 8 years. Among subjects beyond Milan criteria, recurrence was common during, but not after 3 years. In 43 patients (63.2%) increased alpha-fetoprotein (AFP) was an initial indication to perform further imaging studies to diagnosis recurrence, whereas they were detected incidentally on protocol screening imaging among another 25 patients (36.8%) in the absence of an AFP rise. There was a close correlation between pretransplant AFP level and AFP increase after HCC recurrence. Conclusions Patients beyond the Milan criteria require frequent tumor marker tests and imaging studies over the first 3 years; and those within Milan criteria require 10-years to follow-up primarily with tumor marker tests.
Abstract Purpose Pneumocystis carinii pneumonia (PCP) is an opportunistic infection associated with morbidity and mortality in solid-organ transplant recipients. We retrospectively assessed the ...characteristics and outcomes of liver transplant (OLT) recipients with PCP compared with those of patients with severe non- P carinii pneumonia (non-PCP) who required intensive care with mechanical ventilation. Methods During the 2-year period between January 2008 and December 2009, 43 adult OLT recipients had severe pneumonia requiring mechanical ventilation; of these, 8 (19%) had PCP. During this period, routine antibiotic prophylaxis was administered for the first 6 months after OLT. Results The median period from OLT to development of PCP was 9.5 months (range, 1–67); the 1-year incidence was 0.9%. The 6 and 6 to 12-month incidences of non-PCP were 4.2% and 0.3%, respectively, and those of PCP were 0.3% and 0.6%, respectively. Four of 8 patients (50%) in the PCP group had a recent history of a rejection episode. PCP was associated with a higher incidence of prior antirejection treatment. There were no significant differences between PCP and non-PCP groups in age, gender, preoperative Model for End-stage Liver Disease score, primary diagnosis, graft type, and total number of rejection episodes. Conclusions These results indicate that the risk of PCP in OLT recipients is closely related to strong immunosuppressive treatment for acute cellular rejection episodes, suggesting the importance of PCP prophylaxis in these patients. Because most patients developed PCP at around 1 year, it may be advisable to prolong routine post-OLT PCP prophylaxis for 12 months, especially among patients receiving antirejection treatment.
Version of the femoral stem is an important factor influencing the risk of dislocation after total hip replacement (THR) as well as the position of the acetabular component. However, there is no ...radiological method of measuring stem anteversion described in the literature. We propose a radiological method to measure stem version and have assessed its reliability and validity. In 36 patients who underwent THR, a hip radiograph and CT scan were taken to measure stem anteversion. The radiograph was a modified Budin view. This is taken as a posteroanterior radiograph in the sitting position with 90° hip flexion and 90° knee flexion and 30° hip abduction. The angle between the stem-neck axis and the posterior intercondylar line was measured by three independent examiners. The intra- and interobserver reliabilities of each measurement were examined. The radiological measurements were compared with the CT measurements to evaluate their validity. The mean radiological measurement was 13.36° (sd 6.46) and the mean CT measurement was 12.35° (sd 6.39) (p = 0.096). The intra- and interobserver reliabilities were excellent for both measurements. The radiological measurements correlated well with the CT measurements (p = 0.001, r = 0.877). The modified Budin method appears reliable and valid for the measurement of femoral stem anteversion.
Abstract ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) is a feasible therapeutic option for countries with a scarcity of deceased donors. This report presents our initial ...experiences in ABOi ALDLT in 10 patients between December 2008 and September 2009. The mean age of recipients was 48.5 ± 5.7 years (range, 40–54 years). The mean Model for End-stage Liver-Disease score was 13.9 ± 4.0 (range, 9–22). All patients were administered preoperative rituximab once and plasma exchanges according to the hemagglutinin titer. The spleen was preserved in all cases. For local infusion therapy, hepatic arterial infusion was performed in 9 patients and portal vein infusion in 1 subject. The 10 patients experienced no in-hospital mortality. At a mean follow-up period of 31.8 ± 2.9 months (range, 4.1–34.9 months), 1 patient has died (postoperative month 4 due to sepsis following a biliary stricture. The 3-month patient and graft survivals were 100%, and 1- and 2-year survivals, 90.0%. There was no episode of antibody-mediated rejection. The promising results of our initial experience may have been due to the use of preoperative rituximab and the good preoperative conditions of the patients.
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