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  • 1
    ISSN: 1435-2451
    Keywords: Key words Hepatoma ; Liver resection ; Liver transplantation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract  Introduction: Despite recent advances with techniques of in situ tumor ablation, surgical therapy remains at present the mainstay in the treatment of primary hepatic malignancies. Discussion: After an initial endeavor to establish liver transplantation as a treatment option, especially for unresectable liver tumors, only a few indications, for example early hepatocellular carcinoma in cirrhosis, are currently agreed upon. Other indications, such as peripheral cholangiocarcinoma and hepatocellular carcinoma in non-cirrhotics, have largely been abandoned or are still under debate, as with fibrolamellar carcinoma. Selection of patients suffering from hepatocellular carcinoma in cirrhosis for liver transplantation is still based on tumor size and node number, because the current state of diagnostic imaging fails to reliably predict the most important prognostic parameter: vascular infiltration. Other selection criteria are under investigation. Studies on multimodal therapy are also underway but have not yet demonstrated a benefit.
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  • 2
    ISSN: 1432-2277
    Keywords: Key words Mycophenolate ; mofetil ; Liver transplantation ; Immunosuppressive agents
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Mycophenolate mofetil (MMF) has been used successfully as an immunosuppressive agent after kidney and heart transplantation, but experience with MMF after liver transplantation is still limited. Between August 1995 and January 1996, we treated 20 patients with MMF after orthotopic liver transplantation in an open, prospective study. Five out of eight patients with acute rejection and one patient with early chronic rejection showed a complete response after MMF was added to the immunosuppression. Three patients with chronic rejection did not improve, one died, and two have stable graft function at present. In eight patients who suffered from toxicity, a reduction in the dosage of tacrolimus was attempted with simultaneous MMF therapy. One patient died due to multiple organ failure. Liver function improved completely in one other patient, and partially in three patients after adding MMF. In the remaining three patients, a reduced dosage of tacrolimus or cyclosporin, together with MMF, reduced toxicity, not significantly. In conclusion, MMF appears to be a safe and potentially useful adjuvant immunosuppressive agent for rescue and maintenance therapy.
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  • 3
    ISSN: 1432-2277
    Keywords: Key words Hepatitis B ; Liver transplantation ; Lamivudine ; Interferon ; Resistance ; Combination therapy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Development of resistance is a major issue in antiviral treatment of hepatitis B reinfection after liver transplantation. Antiviral combination therapy is discussed for therapy or prevention of this breakthrough of viral replication. Eight patients were enrolled into this retrospective analysis after liver transplantation for chronic hepatitis B infection. All had reinfection of the graft and breakthrough of HBV during consecutive famciclovir and lamivudine monotherapy. Subsequently a combination therapy with lamivudine and interferon-α 2 a (group I, n = 4) or lamivudine and famciclovir (group II, n = 4) was initiated. Combination therapy was started 61 months (group I) and 25 months (group II) after liver transplantation. It markedly reduced the viral replication rate in all patients despite lamivudine resistance. In group I three of four patients and in group II two of four patients became HBV-DNA negative. Two long-term responders were observed in group I, and none in group II. No patient became HBsAg negative or lost HbeAg. Pretreatment elevated ALT and AST levels were significantly reduced. No severe complications, and especially no rejection episodes, occurred. Lamivudine in combination with other antiviral agents, especially interferon-α, might be a therapeutic option for hepatitis B reinfection after liver transplantation. Suppression of virus replication to the point of undetectable values is possible even in patients with lamivudine-resistant virus mutations.
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  • 4
    ISSN: 1432-2277
    Keywords: Shipped donor livers ; Liver transplantation ; Graft function, liver
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Between September 1988 and November 1991, 201 donor hepatectomies and transplantations were performed. Fifty-four livers (26.9%) were harvested by other teams and shipped for transplantation; 147 livers (73.1%) were procured by teams from our transplant center. Comparing the maximal postoperative serum-aminotransferases (s-AT), we evaluated the postischemic damage of shipped organs (AST 951±931 IU/l; ALT 820±666 IU/l) and nonshipped organs (AST 753±1256 IU/l; ALT 636±896 IU/l); this did not differ significantly. Donor-related factors, such as critical parameters (i.e., cardiac arrest, arterial hypotension, age over 50 years, or elevated preoperative s-AT), length of stay in the intensive care unit before harvesting, and cause of death showed similar patterns in both groups. The mean cold ischemia time in the group of shipped livers (12 h 10 min±4 h 22 min) and in the nonshipped livers (10 h 6 min±3 h 53 min) did not differ significantly. Five cases (2.5%) of a primary nonfunctioning graft presenting with significantly (P〈0.001) elevated s-AT (AST 4944±2280 IU/l; ALT 3186±1918 IU/l) necessitated an early retransplantation. One organ was shipped and four organs were nonshipped, thus corresponding to their portion of all grafts. These data indicate that the transplantation of shipped livers is a safe procedure procedure, provided that procurement is done by experienced centers.
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  • 5
    ISSN: 1432-2277
    Keywords: Key words Hepatocellular carcinoma ; Liver transplantation ; Recurrence
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Recurrence-free survival (RFS) in patients with small hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT) was analyzed. From 1988 until 1996, 725 OLTs were performed in 669 patients. In 52 adults, HCC was confirmed histologically. OLT was limited to patients with small (〈 5 cm) HCC with a maximum number of three nodules. Actuarial survival for these 52 patients at 1 and 5 years is 88 % and 71 %. RFS was defined as time until death without recurrence, time until follow up with a diagnosis of recurrence, or, in patients without recurrence, time of last follow up. Overall, the 5-year RFS was 60 %. Five-year RFS was less for bilobar compared to unilobar tumors (36 % vs 70 %), less for stage IVa tumors (UICC) compared to stage I–III tumors (17 % vs 71 %), and less for multiple compared to solitary tumors (54 % vs 67 %). In conclusion, potential cure may be achieved in more than 50 % of all transplanted patients.
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  • 6
    ISSN: 1432-2277
    Keywords: Key words Hilar cholangiocarcinoma ; Extended bile duct resection ; Liver transplantation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Although the surgical treatment of hilar cholangiocarcinoma represents the only potentially curative option, survival figures remain low over the long term. After hilar and partial hepatic resections for hilar cholangiocarcinoma, locoregional tumor recurrence appears as the primary site of failure. From April 1992 to April 1996, 14 patients underwent extended bile duct resections. Extended bile duct resections combine total hepatectomy, partial pancreatoduodenectomy, and liver transplantation in an attempt to eradicate the entire biliary tract without dissecting the hepatoduodenal ligament. The postoperative 60-day mortality rate was 14% (n = 2).The rate of curative resections was 93% (13 of 14 extended bile duct resections). One- and 4-year survival rates after curative resections were 56% and 30%, respectively. The rate of curative resections increased by combining total hepatectomy, partial pancreatoduodenectomy, and liver transplantation, i. e., extended bile duct resection. However, survival figures have not improved accordingly. Therefore, this extended surgical procedure has to be implemented with caution and possibly not without modifications (e. g., multimodal treatment).
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  • 7
    ISSN: 1432-2277
    Keywords: Key words Liver transplantation ; Arterial complications
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract From September 1988 through April 1998, 1000 liver transplantations were performed on 911 patients. During the postoperative control examinations of 837 patients, we found 23 (2.74 %) with hepatic artery thromboses, 27 stenoses of the hepatic artery (3.22 %), and 6 aneurysms of the graft artery. Seventeen patients underwent retransplantation because of arterial complications. Depending on the clinical symptoms, we treated both the local situation as well as the resulting complications of inadequate arterial graft flow. The aneurysms were primarily treated surgically. The first choice of treatment of stenoses was balloon angioplasty. Early postoperative artery thromboses were also treated surgically by thrombectomy in selected cases. For the resulting biliary and local septic complications we preferred endoscopic and drainage procedures. Our clinical experiences have led us to find pretransplantation angiography recommendable, especially in the case of splanchnic artery stenoses, for bypassing from the aorta for arterial perfusion of the graft.
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