Abstract Postoperative biliary tract complications after liver transplantation (LT) still lead to early and late morbidity and mortality. Modern interventional endoscopic techniques can replace ...surgical repair as the first line of treatment. Nevertheless surgical intervention plays an important role in specific situations. We performed a retrospective analysis of patients with biliary complications after LT over a 12-year period. We compared treatment programs based on duration and success rate. The rate of biliary complications was 24.5% (60/245). The side-to-side choledocholedochostomy (CDC) technique showed the significantly lowest rate. The rate of complications after hepaticojejunostomy (HJS) was considerably lower, albeit not significantly. Eighty-one percent of complications after CDC were treated with interventional endoscopy. The duration of treatment of strictures, was 10 times greater than that of leakages. Surgical repair was necessary for 19% of complications occurring after CDC. The treatment options after HJS largely comprised surgical repairs. From a surgical standpoint, choosing the correct method for biliary reconstruction and ensuring normal arterial flow are the best preventive techniques to avoid biliary complications. Over the past 10 years, the primary treatment regimen has moved from surgical repair to interventional endoscopy. Only when endoscopy fails, should one consider surgical repair. The treatment after HJS is still primarily surgical. Percutaneous transhepatic approaches should be avoided. Creation of an inspection stoma to allow endoscopic access is an option.
Abstract Objective The aim of this study was to examine the efficacy of preoperative, perioperative, and long-term treatment in liver transplant (OLT) patients suffering hepatitis B (HBV)-induced ...liver disease, in terms of graft and survivals as well as disease recurrence. Materials and Methods We reviewed the medical records of 19 HBV-infected patients who underwent OLT between 2000 and 2010 using antiviral treatment with either lamivudine (LAM, n = 14) and/or adefovir/entecavir/tenofovir ( n = 8) before OLT. Fifteen subjects showed a HBV DNA-negative status prior to OLT. All patients were administered HBIG (antiHBs immunoglobulin) perioperatively: 10,000 international units (IU) in the anhepatic phase and 2.000 IU/d until day 7 after OLT. The preoperative antiviral regimen was continued as maintenance prophylaxis from day 1 after OLT. In cases of the YMMD mutation the antiviral treatment was switched to combination therapy with entecavir and tenofovir. Results Patient follow-up as of December 2011 or till time of death ranged from 6 to 129 months (median = 47). All patients were prescribed tacrolimus. None of them experienced HBV-related graft dysfunction or graft loss. All subjects were HBV DNA negative at 6 months after OLT. HBV recurrence in the post-OLT phase was discovered in 3 patients, 2 of whom had undergone OLT because of acute liver failure due to hepatitis B. They showed LAM-resistant mutations at the time of recurrence and underwent entecavir/tenofovir therapy to achieve HBV DNA negative status. Conclusions Our study demonstrated excellent long-term outcomes among patients after successful preoperative antiviral treatment for HBV. Patients should be given a high dosage of HBIG during the first week after OLT in combination with the preoperatively established antiviral treatment. In presence of a LAM-resistance mutation, antiviral treatment should be adapted individually to achieve HBV recurrence freedom and graft survival.
Abstract Background Hepatocellular carcinoma (HCC) is among the most frequent malignant diseases worldwide. In the vast majority of cases, it is associated with liver cirrhosis. Liver transplantation ...(OLT) is potentially the gold standard treatment for patients suffering HCC in cirrhosis, because of synchronous eradication of HCC and of the underlying hepatic disease. The aim of this study was to evaluate long-term outcomes of OLT in HCC patients. Material and Methods Between January 2000 and December 2011, 43 patients who were diagnosed with HCC in liver cirrhosis and underwent OLT in our department, were identified from a prospective database. All patients received their grafts from deceased donors. We analyzed demographic data, laboratory values, number and size of lesions, primary liver disease, diagnostic methods, bridging therapy modalities, and postoperative outcomes, including complications, recurrences, and their treatment. Results Patient follow-up as of January 2012 or to death ranged from 0 to 138 months (median, 59; mean, 63). None of the patients were lost to follow-up. The gender bias was 85%:15% (male:female) and the median age, 57.8 years (range, 44–69). The most common underlying diseases for cirrhosis and HCC were alcoholic ( n = 12) and hepatitis C ( n = 16). Thirty-one subjects underwent bridging therapy through transarterial chemoembolization (TACE), and/or radiofrequency ablation. All patients underwent OLT within the Milan criteria according to the preoperative evaluation and histopathologic examination of the explanted liver. Twenty-one of them suffered postoperative complications (48.8%). HCC recurrence, which occurred in 5 (10.4%), was treated by surgery ( n = 3), systemic chemotherapy with sorafenib ( n = 1), or TACE ( n = 1). Conclusions OLT for HCC in cirrhosis, displays a relatively high complication rate. It shows good survivals with and low recurrence.
Abstract Background Cytomegalovirus (CMV) infections are among the most common infections following liver transplantation. The main preventive methods for CMV infections are universal prophylaxis and ...pre-emptive therapy. In our study, we adopted a pre-emptive strategy in a higth-risk group of donor CMV-positive (D+)/recipient CMV-negative (R−) casses. We investigated whether this strategy was safe and effective to prevent CMV disease. Methods One hundred fifty-nine liver transplantation recipients who underwent over a 15-year period were retrospectively analyzed after follow-up for at least 6 months (mean, 63 months). Weekly quantitative polymerase chain reaction (PCR) measurements were performed to detect viral DNA. No CMV drug prophylaxis was given: antiviral CMV therapy was initiated when the PCR for CMV-DNA was >400 copies/mL. Results Fifty-one of 159 liver transplant recipients enrolled in the study received antiviral therapy. High-risk patients (D+/R−) developed CMV infections significantly more often than D−/R− serostatus ( P = .005). CMV disease was diagnosed in 12% of CMV-positive patients. Independent of serostatus in 14 cases (27.5%) virological recurrence of CMV infection occurred after primary treatment. Survival analysis showed no significant difference between patients with versus without CMV infection ( P = .950). No relationship could be found between transplant rejection and CMV infection ( P = .349). Conclusion Our results showed that a pre-emptive strategy to prevent CMV disease was possible, even among the serological high-risk group. Only 12% of cases with CMV infection went on to manifest CMV disease with organ involvement. Survival curves were similar among patients with versus without CMV infections.
Abstract Background Acute cellular and chronic graft rejection are major disorders in the postoperative setting after orthotopic liver transplantation (OLT). An immediate diagnosis and successful ...therapy are essential for graft survival. We sought to determine whether quantitative and qualitative analysis of Doppler sonography data was predictive and sensitive as noninvasive diagnostic tools for rejection episodes. Materials and methods We prospectively recorded and retrospectively analyzed the medical records of patients who underwent OLT between January 2000 and November 2011, identifying patients with acute cellular (ACR) and chronic rejection (CR) and the grade classified the activity index according to BANFF criteria. Analyzed parameters included resistive index (R/I), systolic acceleration time (SAT) in the hepatic artery, laboratory values, histopathologic grade and therapy as well as graft and patient survival. Results Patient follow-up as of December 2011 or to the time of death ranged from 2 to 132 months (median follow- up: 79 months, mean = 83 months). We registered 29 rejection episodes (ACR n = 20 and CR n = 9) in 20 subjects. The majority of patients received a tacrolimus-based immunsuppressive regimen ( n = 14, trough level: 7–12 ng/mL) in addition to high-dose corticosteroids, and sometimes a third drug. One patient displayed a corticosteroid-resistant ACR and 4 CR cases, graft loss followed by retransplantation. R/I was calculated for all patients and SA for those who underwent OLT since 2009. As a control group we used subjects with delayed SAT and high R/I without graft rejection. In all patients with a high R/I (>0.7, range: 0.71–0.91) and in all patients who suffered graft rejection since 2009 ( n = 14), we observed a delayed SAT (>0.08, range: 0.08–0.18). The sensitivity and specificity for R/I were 82%, and 54.9%; for SAT 100% and 78%, respectively. Conclusion Delayed SAT (>0.08) and high R/I (>0.7) were sensitive indices of graft rejection episode. The limitation of these diagnostic parameters is their specificity, especially in the immediate postoperative period, where early vascular disorders trigger similar sonographic results. Nevertheless SAT and R/I may be considered to be important diagnostic tools, in combination with elevated laboratory liver values they can provide an early diagnosis of graft rejection.
Spatially selective deposition of electrically charged microparticles onto integrated circuits that generate electrical fields in programmable patterns using electrodes on their surface was ...previously limited to a pixel pitch of 100
μm. Now, we demonstrate spatially selective deposition onto pixels of 45
μm pitch in experiments on a test chip allowing arbitrary patterns, but being of limited size and of fixed characteristics, complemented by COMSOL simulations. Experiments on a prototype high voltage CMOS chip demonstrate the feasibility of miniaturisation in the first place, imply simulations of interest that cannot be tested experimentally and, conversely, complement the simplified simulation models by reality checks. Using COMSOL for the optimisation of the setup parameters, particles of decreasing average diameter in a number of aerosol and electrical field geometries are simulated with particular attention to minimising contamination (deposition of particles on undesirable locations). Combining these results, the average particle diameter is decreased from 10
μm to less than 3
μm and the deposition voltage is reduced from 100
V to 30
V, when using pixels with a pitch of 45
μm. Optimising these parameters allows for more than quadrupling the spot density compared to the previous chip, on which combinatorial particle deposition with minimal contamination is achieved. Peptide arrays, having been previously shown to be a major application for this method, benefit in particular, as the increase in density from 10,000
pixels/cm
2 to approximately 50,000
pixels/cm
2 promises a significant decrease in cost-per-peptide and amount of test specimens required.
Limited access to health care in rural areas is a challenge in Namibia. In 2007 a survey was conducted among employers of commercial farms to assess the feasibility of introducing private, affordable ...health insurance that including HIV/AIDS coverage for commercial farm workers in Namibia. Healthcare access and utilization by people living and working on commercial farms were evaluated to gain insight into the possibility to strengthen health service delivery in this sector.
Desmoid tumors, also known as aggressive fibromatosis, occur with an incidence of 10 to 15 percent in patients affected by familial adenomatous polyposis, an autosomal inherited disease caused by ...germline mutations in the APC gene. However, sporadic forms with no hereditary background exist. The aim of this study was to find out whether there are APC germline mutations in apparently sporadic desmoid tumor patients without clinical or familial signs of familial adenomatous polyposis but with a family history of colorectal carcinoma in at least one family member.
Genomic DNA and mRNA were isolated from peripheral blood leukocytes of index patients of eight nonrelated families. Mutation screening was performed using reverse transcriptase polymerase chain reaction-based protein truncation test for APC exons 1-14. The large APC exon 15 was scrutinized by the protein truncation test of four overlapping genomic fragments. Additionally, genomic DNA from five desmoid tumors was analyzed for loss of heterozygosity at D5S346 close to the APC locus.
No translational stop mutations typical for familial adenomatous polyposis could be found in the APC gene in any of the analyzed blood samples from the desmoid tumor patients. Additionally, no loss of heterozygosity at D5S346 was found in four of five desmoids; one tumor was not informative.
These results may suggest that patients with sporadic desmoids and no clinical signs of familial adenomatous polyposis detected on careful examination, esophagogastroduodenoscopy, and complete colonoscopy do not need to be tested routinely for germline mutations of the APC gene. However, as large studies dealing with this problem are absent, it might be more time and cost effective to perform an APC mutational analysis instead.
Limited access to health care in rural areas is a challenge in Namibia. In 2007 a survey was conducted among employers of commercial farms to assess the feasibility of introducing private, affordable ...health insurance that including HIV/AIDS coverage for commercial farm workers in Namibia. Healthcare access and utilization by people living and working on commercial farms were evaluated to gain insight into the possibility to strengthen health service delivery in this sector.
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