Hot topics in liver transplantation: Organ allocation – extended criteria donor – living donor liver transplantation

Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future

Immunological HCV-Associated Thrombocytopenia: Short Review

Infection with Hepatitis C virus (HCV) is affecting about 3% of the world's population, leading to liver damage, end-stage liver disease, and development of hepatocellular carcinoma, being thus the first indication for liver transplantation in the USA. Apart from the cirrhotic-liver-derived clinical signs and symptoms several conditions with immunological origin can also arise, such as, glomerulonephritis, pulmonary fibrosis, and thrombocytopenia. HCV-related autoimmune thrombocytopenia shows specific pathogenetic characteristics as well as symptoms and signs that differ in severity and frequency from symptoms in patients that are not HCV infected. Aim of this short paper is to estimate the epidemiological characteristics of the disease, to investigate the pathogenesis and clinical manifestation, and to propose treatment strategies according to the pertinent literature

Carotid ultrasound findings as a predictor of long-term survival after abdominal aortic aneurysm repair: a 14-year prospective study

AbstractPurposeSeveral factors have been related to long-term survival after open abdominal aortic aneurysm (AAA) repair. The effect of carotid stenosis on outcome has not yet been examined. We performed an open prospective study to evaluate the prognostic significance of carotid stenosis on long-term survival of patients who had undergone elective operative repair of AAA.MethodsTwo hundred eight patients who underwent elective open AAA repair in our department between March 1987 and December 2001 were included in the study. All patients were evaluated preoperatively with color duplex ultrasound (US) scanning of the carotid arteries, and were followed up with clinical examination and carotid duplex US scanning 1 month after the operation and every 6 months thereafter. Median duration of follow-up was 50 months (range, 5-181 months). Cardiovascular morbidity and mortality, as well as all causes of mortality, were recorded and analyzed with regard to traditional risk factors and carotid US findings.ResultsTwenty-seven fatal and 46 nonfatal cardiovascular events were recorded. Both univariate and multivariate analysis showed that carotid stenosis 50% or greater and echolucent plaque were significantly associated with cardiovascular mortality and morbidity. Carotid stenosis was a stronger predictor of cardiovascular death than was ankle/brachial index. Age, hypercholesterolemia, coronary artery disease, and diabetes mellitus were also associated with higher mortality and morbidity from cardiovascular causes.ConclusionPatients electively operated on for AAA repair and with stenosis 50% or greater and echolucent plaque at duplex US scanning are at significantly increased risk for cardiovascular mortality and morbidity. Carotid US can therefore be used to select a subgroup of patients with AAA who might benefit from medical intervention, including antiplatelet and lipid-lowering agents

From proprotein convertase subtilisin/kexin type 9 to its inhibition: state-of-the-art and clinical implications

Statins are recommended as first-line therapy for patients with hypercholesterolaemia. A sizable proportion of patients, however, does not reach therapeutic goals, is statin intolerant, or, despite optimal statin therapy, is at high risk of ischaemic events. Proprotein convertase subtilisin/ kexin type 9 (PCSK9) plays a major role in lipid metabolism and several comorbidities. Monoclonal antibodies targeting PCSK9 are a new lipid-lowering approach with the potential to improve clinical outcomes in patients with dyslipidaemia. In this review, we discuss current experimental and clinical evidence of the role of PCSK9 and its inhibition on lipid metabolism and several pathologic conditions with a focus on clinical outcomes. A state-of-the-art analysis of current clinical evidence and future directions on PCSK9 and its inhibition is provided

Pancreatic Pseudocyst

Pancreatic pseudocysts frequently occur in the context of acute or chronic pancreatitis and seldom appear as a post-surgical outcome or trauma. Complicated pancreatic pseudocysts represent extremely rare entities but still life-threatening situations, including infection, hemorrhage, rupture, pseudoaneurysms, pancreatic fistulas, obstructions, and splenic complications. Premature diagnosis, based on transabdominal ultrasonography or computed tomography, is crucial for the early therapeutic approach. Conservative treatment, surgical and endoscopic intervention consist the therapeutic options. Thus, management of the complicated pseudocysts demands a multidisciplinary team eligible to cope with complications that might even occur due to the intervention. Pancreatic pseudocysts represent a challenge for clinical doctors

Current evidence on laparoscopic vs. open resection for gastric stromal tumours

Although the use of laparoscopic surgery is increasing, controversy still surrounds its application for malignant conditions. Gastrointestinal stromal tumours (GISTs) are less demanding in terms of lymphadenectomy, meaning that laparoscopic resection might have a more defined benefit when compared with open resection. To the best of our knowledge, no randomized study exists that compares the laparoscopic and open resection of GISTs. The current study aimed to examine the relevant literature by means of a systematic review. A systematic literature search was performed individually by two authors, in which three independent databases were searched using specific search-terms. Titles, abstracts and full texts were screened, as well as references to relevant articles, in order to comprise a comprehensive list of studies. Data were extracted using a detailed pre-agreed spreadsheet. Studies were evaluated according to the modified MINORS criteria. A total of 10 studies were included in the present review, yielding a total of 14 entries. The majority of studies reported significantly improved perioperative outcomes for the laparoscopic approach, including improved duration of operation, blood loss and length of hospital stay. Only four studies reported long-term outcomes and findings that were controversial, with some studies detecting no statistically significant differences, one reporting improved and one reporting worse disease-free and overall survival for the laparoscopic group. Three studies were deemed to be good quality, two of which had not reported significantly different long-term outcomes, while the third had reported significantly improved outcomes in the open resection group. While there is a clear benefit for performing laparoscopic surgery in patients with GIST with regards to perioperative outcomes, when it comes to long-term oncological outcomes, uncertainty over its application remains. The lack of randomized trials, as well as the poor reporting of retrospective studies, limits the amount of evidence that is currently available. Laparoscopic surgery for GIST is certainly safe, feasible and likely cost-effective; however, further studies are required to inform on whether this technique is superior to open resection

Requirement of β1 integrin for endothelium-dependent vasodilation and collateral formation in hindlimb ischemia

An acute increase in blood flow triggers flow-mediated dilation (FMD), which is mainly mediated by endothelial nitric oxide synthase (eNOS). A long-term increase in blood flow chronically enlarges the arterial lumen, a process called arteriogenesis. In several common human diseases, these processes are disrupted for as yet unknown reasons. Here, we asked whether β1 integrin, a mechanosensory protein in endothelial cells, is required for FMD and arteriogenesis in the ischemic hindlimb. Permanent ligation of the femoral artery in C57BL/6J mice enlarged pre-existing collateral arteries and increased numbers of arterioles in the thigh. In the lower leg, the numbers of capillaries increased. Notably, injection of β1 integrin-blocking antibody or tamoxifen-induced endothelial cell-specific deletion of the gene for β1 integrin (Itgb1) inhibited both arteriogenesis and angiogenesis. Using high frequency ultrasound, we demonstrated that β1 integrin-blocking antibody or endothelial cell-specific depletion of β1 integrin attenuated FMD of the femoral artery, and blocking of β1 integrin function did not further decrease FMD in eNOS-deficient mice. Our data suggest that endothelial β1 integrin is required for both acute and chronic widening of the arterial lumen in response to hindlimb ischemia, potentially via functional interaction with eNOS

Giant pedunculated hepatocellular carcinoma with hemangioma mimicking intestinal obstruction

<p>Abstract</p> <p>Background</p> <p>Pedunculated hepatocellular carcinoma (P-HCC) has rarely been reported and is characteristically large and encapsulated. Only sporadic cases have been published, in which P-HCC was combined with other liver tumors (mostly benign), making the diagnosis difficult.</p> <p>Case presentation</p> <p>We report a patient who was admitted to our hospital with clinical features of intestinal obstruction and a palpable mass in the right iliac fossa. Ultrasound, computed tomography and magnetic resonance imaging demonstrated an encapsulated mass of unclear origin and characteristics of liver hemangioma. Laboratory tests revealed elevated α-fetoprotein (> 800 ng/ml) and cancer antigen 125 (> 51.2 U/ml). With a possible diagnosis of giant liver hemangioma, we proceeded to surgery. During surgery, a giant pedunculated tumor was discovered on the inferior surface of the right lobe of the liver, hanging free in the right abdominal cavity towards the right iliac fossa. The macroscopic appearance of the tumor was compatible with liver hemangioma. Tumor resection was performed at a safe distance, including the pedicle. The rest of the liver appeared normal. Histopathological examination revealed grade II and III HCC (according to Edmondson-Steiner's classification) with nodular configuration, central necrosis, and infiltration of the capsule. Underneath the tumor capsule, residual tissue of a cavernous hemangioma was recognized. The resection margins were free of neoplastic tissue.</p> <p>Conclusion</p> <p>This rare presentation of a giant P-HCC combined with a hemangioma with features of intestinal obstruction confirmed the diagnostic difficulties of similar cases, and required prompt surgical treatment. Therefore, patients benefit from surgical resection because both the capsule and the pedicle prevent vascular invasion, therefore improving prognosis.</p