FK506 has been proven effective for prevention and treatment of liver allograft rejection. Herein, we compare FK506-based immunosuppression with an effective quadruple immunosuppressive regimen, ...including cyclosporine and antithymocyte globulin. The results of a single center participating in the European multicenter FK506 study are reported, including immunosuppressive efficacy as well as toxicity. One-year patient and graft survival was 96.7% and 90.0% for the CsA group and 90.2% and 88.5% for the FK506 group, which is not statistically different. The incidence and severity of acute rejection episodes during the first postoperative year was similar in both treatment groups with 34.4% and 33.3% for the FK506 and CsA treatment group, respectively. Immunosuppressive potency was better for the FK506 group compared with the CsA group according to the incidence of chronic rejection. Furthermore, 5 patients (8.3%) required conversion to FK506 for immunological reasons, i.e., refractory acute or chronic rejection. The incidence of moderate and severe neurotoxicity during the early postoperative period was higher in the FK506 group (21.3%) compared with the CsA group (11.7%), while the incidence of renal insufficiency and acute renal failure was similar (18.0% and 18.3% for the FK506 and CsA treatment groups, respectively). The incidence of CMV infection was significantly higher under treatment with CsA (25.0%) than with FK506 (6.6%) (P < or = 0.05), while the incidence of pneumonia (13.1% and 13.3%), cholangitis (29.5% and 26.7%), and urinary tract infection (39.3% and 28.3% for the FK506 and CsA treatment groups, respectively) was similar in both treatment groups. However, infection was more serious in some cases treated with FK506, and evolved as the main cause of death in the FK506 treatment group. Therefore, caution should be paid to over immunosuppression and toxicity in FK506-treated patients. Regarding the monitoring of FK506, FK506 plasma level failed to be a reliable indicator, and therefore we recommend measurement of whole blood FK506 levels. Our data indicate that immunosuppressive potency of FK506 is greater than that of CsA, especially concerning the incidence of chronic rejection.
Posterior choanal atresia (PCA) is an uncommon congenital anomaly which consists of an anatomical malformation and a bony and/or membraneous diaphragm that separates the nasal cavity from the ...nasopharynx. Therefore nasal breathing as well as mucus discharge are impeded. If present bilaterally it has life threatening consequences. The goal of treatment in neonates and infants is to safely open and maintain the patency of the nasal choana without damaging surrounding normal anatomical structures or affecting future growth patterns of the palate and the posterior nasal cavity – paranasal sinuses complex. In every case an unimpeded nasal breathing and mucus drainage towards the deeper aero-digestive tract must be achieved.
The therapeutical strategy is strictly surgical. Traditional surgical approaches are the transnasal, the transseptal, the transpalatine and – but seldom – the transvestibular-transmaxillary route. All these surgical approaches have one in common: There is either a quite large and tissue compromising access with rather good exposition of PCA and a high risk for intra- and postoperative complications, or a bad access and visibility of the PCA due to a very limited tissue sparing route. Neither intraoperative microscopy nor endoscopy could completely help out of this dilemma. We present with this paper
the new transoral retropalatine approach for endoscopic laser surgery of PCA
. We report on our first five patients with an age of 0 to 9 years all treated from 1998 to 2001 by this approach with fiber guided diode laser surgery (wavelength: 940 nm) and an endoscopic laser application sheath which derives from our concept of Functional Endoscopic Endonasal Laser Surgery (FEELS). Stenting of the re-opened choana with an individually customized U-shaped nasopharyngeally open silicone tube, which was transseptally fixed and hidden in the nasal cavity, was performed for 6 weeks. The outcome and follow up showed excellent results concerning wound healing; no complications, no re-stenosis and no evidence for growth changes in the surrounding choanal and palatal anatomy were encoutered.
From September 1988 to May 1991, 160 orthotopic liver transplantations were performed in our hospital. Twenty-four patients had end-stage cirrhosis caused by chronic non-A, non-B hepatitis. ...Antibodies against hepatitis C virus were documented before and after orthotopic liver transplantation in 13 patients. Studies using the polymerase chain reaction demonstrated hepatitis C virus RNA in the serum and liver tissue of 17 patients (10 of whom tested positive for hepatitis C virus antibodies) before orthotopic liver transplantation. Tissue samples taken from liver grafts during the operation were hepatitis C virus RNA negative in every case. Ten of these 17 patients had positive hepatitis C virus RNA findings in serum and liver biopsy specimens within the first month after surgery. One patient died of Mucor sepsis 2 mo after orthotopic liver transplantation. Another patient died of multi-organ failure 3 mo after a retransplantation. Two patients underwent retransplantation for graft rejection at 2 and 3 mo, respectively. One year after orthotopic liver transplantation, hepatitis C virus RNA was demonstrated in allograft biopsy specimens in 13 of 15 patients. Two patients remained hepatitis C virus RNA negative in repeated biopsies up to 12 mo. Mild portal and lobular hepatitis developed within 6 months of orthotopic liver transplantation in four patients and within 1 yr in five additional patients. The data suggest that persistent hepatitis C virus reinfects the allograft in most cases, but the risk of acute organ damage caused by hepatitis C virus reinfection is low.
Epistaxis is a widespread, though usually bland, symptom of highly varying etiopathogenesis. ENT specialists face the challenge of selecting the best individual treatment modality when it recurs in ...connection with prominent vascular convolutions and angiectases in Kiesselbach's area (Little's spot), pyogenic granulomas of the nasal mucosa, intranasal hemangiomas or disseminated manifestations of Osler-Weber-Rendu's disease in the nasal cavity. Precise dosing and excellent visualization of the entire operating area render videoendoscopy-guided laser surgery an effective approach for sealing these hemorrhage-prone areas. In our clinically controlled prospective study, we examined the suitability of the fiber-guided diode laser for managing the most frequent causes of recurrent epistaxis, as mentioned above. Despite a still limited patient population, a close follow-up ranging up to 24 months has demonstrated the high therapeutic efficiency of this novel laser system (940 nm diode laser), which is already applied with great success for turbinate hyperplasia treatment, septal crest and spur vaporization and concha bullosa resection in functional endoscopic endonasal laser surgery (FEELS) (12a). Diode laser surgery of epistaxis-generating mucosa was usually performed using a bare-fiber-guided noncontact technique with the use of special glass-spatulas for compression and coagulation of vessels in outpatients under local anesthesia; using the chopped mode, moderate, individually adjusted powers were applied over short laser exposure times and relatively long exposure pauses.The diode laser did not differ in its therapeutic efficiency from the Argon or Nd:YAG laser, the two systems we preferred to use for this treatment during the last decade. But rega
rds to its lower optical penetration and coagulation depth in combination with the use of different glass-spatulas, the diode laser appeared to involve a somewhat lower potential risk of wound-healing impairment.
This is particularily significant compared to the “free hand-held treatment” without the compression and coagulation method and compared to the use of the Nd:YAG laser, especially at the nasal septum.
The outcome after OLT was studied in 53 patients with chronic hepatitis B virus (HBV)* infection, 15 of whom had, in addition, evidence of hepatitis delta virus (HDV) superinfection. Nine of 53 ...patients received short-term immunoprophylaxis with anti-hepatitis B surface (HBs) hyperimmunoglobulin up to 1 week after OLT and 44 of 53 patients received long-term unlimited immunoprophylaxis. Eight of 9 (89%) patients with short-term immunoprophylaxis showed reactivation of replication with HBV DNA in serum > 10 pg/ml independently of the preoperative HBV DNA level and HBsAg reappeared in all cases. Four (44%) patients in this group lost their graft because of fulminant hepatitis or cirrhosis and required retransplantation, and 2 patients (22%) died after reinfection in the second graft. Nineteen of 44 (43%) patients with long-term immunoprophylaxis developed HBV values > 10 pg/ml after transplant and 12 of 44 (27%) became HBsAg+ again. Most of them had quantifiable HBV DNA levels before OLT. Retransplantation was required in 5 of 44 (11%) patients and 4 of them died after HBV recurrence. The frequency of HBV reactivation and the development of viral hepatitis after OLT were associated with the preoperative presence of HBV, as determined by the molecular hybridization assay. With nested polymerase chain reaction, all 53 patients were HBV-DNA+ in the serum before and after OLT. with just one exception, none of the patients with HDV superinfection died, in spite of increased HDV replication after OLT. The data indicate that long-term immunoprophylaxis with anti-HBs hyperimmunoglobulin after OLT improves the prognosis in HBV-infected patients. The preoperative detection of HBV DNA in serum by molecular hybridization assay is correlated with graft infection and represents a prognostic parameter. The presence of HDV may have a protective effect after OLT.
Ursodeoxycholic acid treatment of patients with primary biliary cirrhosis may lead to relief of pruritus and improvement of biochemical liver tests. The changes in serum and urinary bile acids ...induced by ursodeoxycholic acid treatment were studied. After 29 patients with primary biliary cirrhosis were treated with ursodeoxycholic acid (750 to 1,000 mg/day) for 6 to 12 mo because of an increase in ursodeoxycholic acid, total plasma bile acids increased from 30.5 +/- 6 mumol/L (mean +/- S.E.M.) to 52.7 +/- 11.7 mumol/L (p less than 0.01). The increase in total plasma bile acids correlated significantly with concentrations of plasma bile acid before treatment (p less than 0.01). The concentrations of endogenous bile acids decreased, mainly because of a decrease of cholic acid. During treatment, glycine conjugation increased and taurine conjugation decreased, whereas sulfation and glucuronidation of bile acids were unchanged. In 10 patients with primary biliary cirrhosis in stages III and IV, urinary excretion of bile acids was also studied. After treatment, ursodeoxycholic acid and its 3-beta isomer and C-1-hydroxylated and C-6-hydroxylated derivatives were also excreted. During treatment, urinary excretion of endogenous bile acids decreased. The increase of ursodeoxycholic acid and the decrease of endogenous bile acids may both be related to the improvement of biochemical liver tests in precirrhotic stages of the disease. In cirrhosis, endogenous bile acids in plasma remained high and changes in liver tests were small.
