Odocha, O

Starzl, TE

Stieber, AC

Tzakis, AG

Van Thiel, DH

English

Name not available

Portal vein thrombosis and liver transplantation (Letter)

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,."IC:, .... -. '" :KK:r~~"-KDKKK:K L l' , , c r s '() t II e E d i t () r PORTAL VEIN THROMBOSIS AND LIVER TRANSPLANTATION Our attention has been drawn to the June 1992 issue of HOSPITAL PHYSICIAN, particularly the section on Board Review in Internal Medicine.1 reconstruction for various associated occlusive and hypoplastic abnormalities in patients undergoing OLTX. Despite these successes, refinement in technique continues as demonstrated by Tzakis et al5 using the venous jump grafts in PVT in 1989. Fur-thermore, just recently, Stieber et al6 in 1991, expanded the work on the spectrum of PVr in liver transplantation replete with graphic details on the sev-eral techniques currently used to ensure successful revascularization in patients with PVT undergoing OLTX. On the issue of portal vein thrombosis (PVT) in orthotopic liver transplantation (OLTX), we wish to bring to your attention, the response to question 15: "Of the following, which represents the most impor-tant contraindication to liver transplantation?" The answer was Portal Vein Thrombosis (D); and the sub-sequent explanation, "Portal vein thrombosis tech-nically precludes successful liver transplantation." In 1992, PVf by itself, is not a contraindication to OLTX. Rapid advances in liver transplantation over the years, particularly the last decade, have led to the identification and successful resolution of several problems that had previously contraindicated or made liver transplantation a hazardous enterprise.2 Without question, the problem of PVT was a difficult one in OLTX. However, by 1985, Shaw et al3 had reported on the successful reconstruction of the portal vein in two patients with PVT undergoing OLTX. Later in 1986, Lerut et al 4 published the University of Pittsburgh experience (from 1980 to 1984) at not only portal vein but also vena cava As these developments unfolded, Maddrey and Van Thiel7 as far back as 1988 indicated that several problems (PVT being one of them) that had originally been listed as contraindications to liver transplantation were no longer so. INDlCAlIC*I AND U8AOI R_ 1. D1IIfI Topico Rfil Boot 1m. MOI'IMtI. NJ: Medical ECCIftCIIIIiet DItI; IIIZ. BRIEF SUMMARY UNASYN II Indicated for the treatment of infection' due to luaceptibte.r.inl of the dllignated microorg.niam. in thl condttiona lilted below. SIdII ____ .. utodby __ ltcttm_ ~t~Ku:~:z=I1~~~:! fK~:~::::~~u::uuI:::IuIK~;I::~h~::~: ml,.bill •• • S.ar.roio. fr.,m •• -/'nt,roNe,., app.,· and .---lnlnl \Itdorn ...... nfeotIotI8 .cluHd by betl·llctam.ae pro-ducing ItTlina of ElCIterichi, coli. Klebaielhl app. (including IC. __I. ___ • Uncludlng B. (ragi/MI •• nd E_IPP.· O, ••• IDI'''' ............ cauMd by bet.·lactaml" produc--in" .tr.ina of E.chlrichl. cOli,· .nd B.ct.roid ••• pp .• (InCluding .. (ragi/.-'. ·Efftcecy for thi. o".ni.m in lllhi erg ... __ ttUdied In_lII.n'Oln_ . While UNASYN fl indicltld only for the condition.liltld :~~:==bDi:rt~r:t::::D!Tt:u=~ ~:= ampicillin contlnt. Therefore. mixed Infectiona caulid by Imptcillin".u.clptlble oro.nilml .net b.t .... ct.m ••• ~o::~: :d:::;:~aa=~~=kApvk Ihould not CONTIIAINIIICAlIC*I The .... 01 UNASYN I. contr.lndlctttd In Indlvidu.l. wkh • hlltOty oIliyporNntItivity _to .ny 011110 panlcilli ... w_ SERIOUS AND OCCASIONALLY FATAL HYPERSENSmvnv (ANAPHYLACTIC I REACTIONS HAVE BEEN REPORTED IN PATIENTS ON PENICILLIN THERAPY. THESE REACTIONS ARE MORE APT TO OCCUR IN INDIVIDUALS WITH A HISTORY OF PENICIWN HYPERSENSITMTY AND/OR HYPERSENSmVl· TV REACTIONS TO MUL nPLE ALLERGENS. THERE HAVE BEEN REPORTS OF INDMDUALS WITH A HISTORY OF PENI. CILLIN HYPERSENSITIVITY WHO HAVE EXPERIENCED S REACTIONS WHEN TREATED WITH CEPHA· S. BEFORE THERAPY WITH A PENICILLIN. CARE· IRY SHOULD BE MA ERNING PREVIOUS SITIVlTY REACTIO LLiNS. CEPHA. S. ANO OTHER AL N ALLERGIC OCCURS. UNASYN $CONTINUED ANDTHEAPPROI'RIATETHE SERIOUS ANAPHYLACTOID ATE EMERGENCY TREATM db~kqoAsbklrp STER ~iiblr~~~oDtC~UA h ............................. ;v;r::wtttt ...... ... =.:::-.. ~-=~no:KK::=rKD=-KKK::K ::KK~D==-neK=:==rK::"D~ Taken together, therefore, we are of the opinion that from our experience and from a review of the literature, PVT by itself no longer constitutes a contraindication to liver transplantation. REFERENCES 1. Babyatsky MW. Board review in internal medicine: liver diseases. Hospital PhysicilJn. 199O;OU:S~PUK 2. Stanl TE, Demetris AJ. Liver transplantation: a 31-year perspective. Curr Prohl Surg. 1990;27:49-240. 3. Shaw BW, Jr, lwatsuki S, Bron K, Stanl TE. Portal vein grafts in hepatic transplantation. Surg Gyne Obstet. Treatment with Intibllcterielegentl: lite,. the normal flofll of the colon and m~v permit overgrowth of clo.tridil. Studiea indicate that toxIn produc.d bV C/o.tridium difficll. il one primary ...... 01 ·.ntiblotlc_ colnl." Mild cae. of pMUdomemtnnoua colitil uauaUy ,..pond to drug dilContinu.tion alonl. In modlfllt. to 'Ivlre C ..... conaidlration Ihould be given to ma,nlg.ment with fluida Ind etectrotvtw. protein lupplementlltlon Ind treatment wfth In .ntib.cteri., drug clinically effective Ig.in" C. diffif:il. colm .. PIIECAUI10NI O.......t: .. high ~rcent-oK of patiente with mononucleoaia who receivelmplcilfin dav.lop. akin ra.h. Thua .• mpicdlin cl ... __ IIIavl<l not ... tdminitlered to ~_ . m_In ........ __ rkApvkthe~ of ou .... i1,'*"I0 .. _ -"' or _ pttIioo .... ""avid be ..,.In mind during __ .11 ou .... _. occur lfKut~ ~===:=K=~n:=K9fhlrldbe DrullllterMtlofte: Probenecid d.c ....... the renll tubuli' aecretlon of ampicillin Ind lulbectlm. Concurrent u.e of pro_n.cld with UNASYN mey mutt In increned .nd pro· lonpd blood _hi oI.mpicill,n _ .ul-.... The _,. rent acIminiwt'ation of .1I0purino' and ampiCillin incr .... aubltlntilily the Incid • .,. of rea""l in patienu receiving both druga a. comp.red to p.ti • .,.. rec.iving.mpicillin alone. It ta not known whether thil DOtenttation of ampicillin ra ..... i •. due to .1I0purinol or the h~peruricemia prnern: in ~o===r!:-D:==~ls:gD::::: :;Dfn~~cw r~==tdofnc:m~:~ed~~=pC:11~:= ofUNASVN. U~~~·= r:~fgl:~~:I .. !=:~nK::~K:K:::rKli:~ High urine concentrationl of ampicllnn m.y re.ult in fl ... rnl~~: ~:1=~nrn~~~g~T:~~~;D!:~~Dr:"c~ro::~w:K~~ Solution. ft II recommended th.t glueol. t •• t. b.lld on enzymatic: gluCOM oxide .. fUCtk)M •• uch •• Clini8tix11II or T._1M, be..-. FoII ..... ng tdmi_on 01 ampicillin to pregnant women .• traMtent dec,.... in pf • .",. concantr.· ~:~C:~:D~~~~=i~~:; ~=KI~ii~·i=u~:~ 0110 __ UNASYN. Carll.,,1 .................. ~ofcMtllty: Long· term ltudill in .nim ... have not been performed to wetulta carcinogenioor m___K~K "-D ~KI RopfOductlon tlUdiH h .... _n par-formed iii mice ....... nd _ tt_ up 10_ 4101·ti .... the hum.n daM .nd have reveated no evtdllnc. of impaired fertility or harm 10 1Iie fetut due to UNASYN. Th ....... _ ever, no adequ.te and Will controUed Itudle. In pregnant women. Becauu 1ftirn14 reproduction 1Nd_ .... not a'wayI rnD:II=I~u=~=;I:::rD4t:~:-ia=~ Tut_.1 ~o:=~c:KnK~~::e-K:K::::II= ine tOM. freque~ of contrwctionl. height of contractiona. and duration of contraction •. Howly.r. it il not known wh_the _ of UNASVN In hu_ during labor or dellv-ery h.1 immldllte or delaved Idven •• ffecta on the lItua. prolono' the duration of Ilbor. or incr ••••• the likelihood th.t forclpa deliYery or oth.r obat.tric.1 intervention or _oIthenewbomwili be_. ........ Motttera: Low conce:ntrationl of .mpicillin .nd lui· bICI8m are excreted in the milk; therefo,.. Clution ehautd be .xercilld wh.n UNASVN ia adminiatared to I nurlinG wom.n. _ U_ Tho officacy and .atetv at UNASYN h .... _ ...... _bliohtd in infontt .nd cliildntn undolrllie _of '2. ADVIIIIIE IIIACnONIJ UNASYN I. g.n .... 11y w.1I tolerated. Th. foll ....... _ ,._--_. '-----P.ln .IM lIi)ectlon tibi - 18% Pain. IV Infection tilt - 3% Thrombaplolobitla- 3% .,----;::KTn"::?~::~:t=::~:~::~:=:D ~g~f:; ~ Add_ ayattmlc reactlo .... potttd In __ , .. of 1Iie pat __ : i\dIlng ........ ....".,oting. ~ fooIIgue. m._. 110_. chut pa,n. tt __ •• __lion,glol.itia. urine retention. dyauril. ed.ml; faCial =~f~=~=D=f~~D in tnroat.',aubwtlrMl --~~ ~ ItbarMOrv ch._ wi'hout rog."'todnlg __ alilp __ rwpofItd dUring clinical_ _ H.,,-Inc_ AST (SOon. ALT (5OPTl •• 1_ p/Ioo. p_.tndLOH. H._'OfII.: Oecro ... d h.mOGlobln. liematocrll. RBC. wac. ne_hll •• lymphOCYltl. pltt __ lnerettod Iymphocytel. monocyte., b.lOphill, eolinophit •• and pl-U/~~""1ftty: o.e,..Md .. rum .Ibumift end totel pro-R __ BUN_crelltl_. Urirot/yM:_ 01 RIC •• nd liytli .. _In uri ... !~~~====c:~::IeK=~=r~~ Gwli4llt.. III III: Oaltrttil. Itometitia. blaCII: -h.'ry- tongue. .nd_1IIt. On .. of _uclomembninouecolilia_~ t!;::~crcur durinG or Itter antibiotio tr.atment e .. e f~ L21dultV ~ Urticaria. ItYth.m. mutttforme. .nd .. _I .... oI .. follativo dermttiti. h .... _ ,.,....-. T_ ..... _ m.y be controlltd with .nttliiett-m' __ ."_._ .... icco __ IUC" N.etlonl occur. the drug ahould ba di.contlnu.d. unl ••• thl opinion of the ~hvliciKn dictat.a otherwia •. =::K~K=K ~::KK::fl:K"KK=K~iFqg~ftvftctfcf H II 1 •• 11. In additkln to thl ..... 'aborMory cfIangeI 1I __ IorUNASYN •• gIKKKKK~"" __du~_panlcillinaKA1lof _  ... _ ~!DqK:1f¥KKKK;_::1~~M1-KI __ -Letters to the Editor .' pp.14 - 15 1985;161:67-68. 4. Lerut J, Tzakis AG, Bronk, et al. Complications of venous reconstruction in human orthotopic liver transplantation. Ann Surg. 1986;205:404414. 5. Tzakis A, Todo S, Stieber AC, Starzl TE. Venous jump grafts for liver transplantation in patients with portal vein thrombosis. Tmnsplantation. 1989;48:530-531. 6. Stieber AC, Zetti G, Todo S, Tzakis AG, et al. The spectrum of portal vein thrombosis in liver transplantation. Ann SU?g. 1991;213:199-206. 7. Maddrey WC, Van Thiel DH. Liver transplantation: an overview. Hepatology. 1988;8:94&-959. O. Odocha, MD A.C. Stieber, MD A.G. Tzakis, MD D.H. Van Thiel, MD T.E. Starzl, MD, PhD Department of Surgery Division of Transplantation University of Pittsburgh School of Medicine Pittsburgh, Pa. EDITOR'S NOTE: The author of the original article concurs with the condusions of Odocha et aL ICE WATER: NOT THE ANSWER TO HEAT STROKE I was intrigued to read the article in the September 1992 issue on heatstroke (Ukiwe J. Heat stroke. Hospital Physician. 1992;28:4649.). The author recom-mended using icepacks rubbed on the body to get the temperature below 101°F. He is aware that ice water and similarly cold substances will induce vasocon-striction, thereby making the job of heat dissipation harder. Saudi Arabia, the site of the Annual HAlJ, is frequently faced with the problem of older and otherwise unacclimatized individuals descending en masse for weeks at a time. They have tried a variety of treatments for this condition and found that the most effective was placing the patient in a temperate room and exposing them to a strong ventilating system. I cannot cite you the appropriate references, but this was a topic discussed in our tropical medicine journal club about two years ago. Robert Wmsball, MD, MPH Richmond, Calif. TORADOL INfORMATION CLARIFIED In your September 1992 issue [Rx Update. Hospital Physician, 1992;28(9):52], information about Toradol (ketorolac tromethamine), the nonsteroidal anti-inflammatory drug (NSAID) marketed by Syntex Laboratories and Roche Laboratories, was discussed. We would like to clarify the information presented regarding the safety of using ketorolac for periods beyond 5 days. Although both intramuscular (1M) and oral ketorolac are indicated in the management of pain, the recommended duration of use is different for the two forms of ketorolac. ToradolIM is indicated for the short-term management of pain for up to 5 days. Safety studies of 1M ketorolac have not been conducted beyond 5 days. The use of ToradolORAL is, however, not restricted to 5 days. Oral ketorolac is indicated for limited duration use, as needed in the management of pain. Ketorolac shares the risks associated with other NSAIDs when taken chronically, including the potential to cause gastrointestinal (GI) bleeding, ulceration, and perforation. As with other NSAlDs, ketorolac should be used with caution in patients with a prior history of serious GI events, and patients with other risk factors known to be associated with peptic ulcer disease (particularly elderly patients); patients with impaired renal or hepatic function, or a history of kidney or liver disease; patients with coagulation disorders, and patients receiving drug therapy that interferes with hemostasis. It should also be noted that ketorolac is contraindicated in patients with previously demonstrated hypersensitivity to ketorolac, or in those with the complete or partial syndrome of nasal polyps, angioedema, and bronchospastic reactivity (eg, asthma) or other allergic manifestations to aspirin or other NSAIDs. The Toradol package insert should be consulted for full prescribing information. Ronald H. Lewis, MD Senior Associate Medical Director Medical Services Department Syntex Laboratories, Inc Palo Alto, Calif. Hospital Physician welcomes your comments on these and other important medical issues. Please send your comments to: Editor, HOSPITAL PHYSICIAN 125 Strafford Ave, Suite 220 Wayne, PA 19087·3391 HOB/Iital Physician: Feinuary 1993 : I 5 . 

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Portal vein thrombosis and liver transplantation (Letter)

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