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Biomedical subjects

G Ercolani

Publications and source records attributed to G Ercolani.

48 records · Page 3Linked to original sources
PubMedDate not supplied

Results of intestinal and multivisceral transplantation in adult patients: Italian experience.

PURPOSE: We report our experience with intestinal and multivisceral transplantation in Italy. METHODS: We performed 23 adult isolated intestinal transplants and seven multivisceral ones, three with liver, between December 2000 and June 2005. Indications for transplantation were loss of venous access (n = 14), recurrent sepsis (n = 10), and electrolyte-fluid imbalance (n = 6), 14 of whom also presented with total parenteral nutrition (TPN)-related liver dysfunction. Immunosuppression was based on induction agents like daclizumab (followed by tacrolimus and steroids) in the first period; alemtuzumab or thymoglobulin (with tacrolimus) in a second period after 2002. RESULTS: The mean follow-up was 742 +/- 550 days. Three-year patient actuarial survival rate was 88% for intestinal transplants and 42% for multivisceral (P = .015). Three-year graft actuarial survival rate was 73% for intestinal patients and 42.8% for multivisceral (P = .1). Graft loss was mainly due to rejection (57%). Complications were mainly represented by bacterial infections (92% of patients), relaparotomies (82%), and rejections (72%). Full bowel function without any parenteral nutrition or intravenous fluid support was achieved in 60% of recipients with functioning bowel including 95% on a regular diet. One patient underwent abdominal wall transplantation as well. DISCUSSION AND CONCLUSION: Intestinal transplantation has achieved high rates of patient and graft survival with even longer follow-up. Early referral of patients, especially in cases of TPN-liver disease, is mandatory to obtain good outcomes and avoid high mortality rates on the transplant waiting list. Immunosuppressive management remains the key factor to increase the success rate.

Adult↗
PubMedDate not supplied

Incidence, clinical significance, and outcome of vascular alterations in intestinal biopsies after isolated small bowel transplantation: a single-center experience.

BACKGROUND: Mild and moderate vascular alterations in intestinal biopsies after isolated small bowel transplantation (SBT) have uncertain clinical significance. METHODS: We retrospectively investigated the incidence, association with acute cellular rejection (ACR), treatment, and outcome of mild and moderate vascular changes in 15 adult SBTs performed between December 2000 and October 2003. The semiquantitative Ruiz score for vascular changes in intestinal mucosa was used. RESULTS: A total of 332 biopsies were analyzed. All patients had at least one sample showing mild or moderate vascular injury, which was globally found in 117 biopsies (35% of the total; 29% mild and 6% moderate). No cases of severe vascular injury were observed. First appearance of vascular alterations occurred 2 to 36 days after SBT (median: 6). Patients with vascular injury had a higher incidence of associated ACR than patients without this feature (16% vs 5%, P = .001). Patients with moderate vascular injury were also more likely to have moderate-to-severe ACR than patients showing no or mild vascular changes (14% vs 2%; P = .015). Treatment of rejection was more frequently administered with simultaneous diagnosis of ACR than in cases of isolated vascular alterations (84% vs 26%; P < .0001). Only one graft (7%) was lost due to severe ACR. DISCUSSION: Mild and moderate vascular changes are common findings in early post-SBT biopsies. They are frequently associated with ACR and parallel its severity. The clinical impact of mild or moderate vascular injury appears to be of little relevance.

Biopsy↗
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Advanced adenosquamous carcinoma of the gallbladder with bilio-biliary fistula: an uncommon case treated by hepatopancreatoduodenectomy.

A 70 year-old female, who presented with jaundice and abdominal pain, was found to have an advanced gallbladder cancer involving the liver parenchyma, duodenum, and transverse colon. This was complicated by a bilio-biliary fistula between the gallbladder and both the right and left hepatic ducts. After obtaining an accurate pre-operative diagnosis, the patient underwent hepatopancreatoduodenectomy (HPD) with lymph node dissection around the hepatic pedicle, celiac trunk, aorta, and inferior vena cava. Histologic examination revealed adenosquamous carcinoma. This rare variant accounts for 3.5% of gallbladder cancers, and is associated with a worse prognosis than adenocarcinoma. The patient is in good condition without any signs of recurrence 42 months after the HPD. In this case report, we discuss the histological type and internal biliary fistula with regard to the literature, and the usefulness of an aggressive surgical procedure such as HPD with extended lymph node dissection which can improve survival and quality of life in selected patients.

Aged↗
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Successful liver transplantation using an 87 year-old donor.

The increasing number of patients listed for liver transplantation and the persistent low number of potential donors have led, in recent years, to the expansion of organ availability, as is the case of liver procurement from elderly donors. So far, results reported in the literature are controversial and only a few reports described satisfactory outcomes of transplantation using donors older than 60 years. In the case presented herein, we report the successful elective liver transplantation of a 65 year-old patient, who received a graft from an 87 year-old donor, whose well-preserved hemodynamic conditions, normal hepatic function, absence of parenchymal alterations, as well as short ischemia time, were the key points for this good outcome. Even very old donors can be suitable for liver transplantation. A careful evaluation of all the possible donor-related risk factors, mostly the presence of steatotic changes at liver biopsy, is always mandatory.

Aged↗
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[Liver transplantation from elderly donors].

This retrospective, case-controlled study compared the outcome of 17 OLTs (group A) using livers donated by subjects over 70 years of age with 17 OLTs (group B) with livers from donors under 40. Clinical data were used form the period 1996-1998. The following variables were considered in the analysis: donor clinical and laboratory parameters, cold ischemic periods, intra-operative blood and plasma replacement, 30-day mortality rate, incidence of primary graft dysfunction, acute rejection and arterial complication and long term survival. The main post-operative parameters were also included. Liver biopsy, performed in 9/17 of group A, revealed minimal steatosis. There were 2 post-operative deaths in group A and 1 in group B (p = NS). Two arterial complications were observed in group A (p = NS) and only one patient required retransplantation (p = NS). The only other difference found among clinical variables was the amount of total bilirubin at post-operative days 8 and 10, aPTT at days 6 and 13 and albumin at days 5 and 6. A two-year follow-up showed survival rates to be 88.2% and 94.1% for groups A and B, respectively (p = NS). Candidates over 70 years of age should be excluded as liver donors. In such cases, greater care needs to be placed on pathological vascular conditions related to advanced stage atherosclerosis such as calcified plaques on the hepatic artery, a possible factor in severe postoperative complications.

Adult↗
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Highly aggressive policy of hepatic resections for neuroendocrine liver metastases.

BACKGROUND/AIMS: Neuroendocrine tumors are usually slow growing and carry a prolonged prognosis. The presence of liver metastases significantly impairs long-term survival. The clinical experience with 28 patients admitted since 1981 for liver metastases from neuroendocrine tumors was retrospectively reviewed to analyze the clinical and surgical management and to evaluate their outcome. METHODOLOGY: Surgery was indicated in 25 (89.2%) patients. Three had metachronous metastases. A correct diagnosis of these liver metastases was achieved before laparotomy in 15 (68.1%) of the remaining 22. The primary tumor site, unknown in 14/22 patients, was located during surgery only in 8 (57.1%). RESULTS: Due to tumoral spread, surgery was limited to exploration in 3 cases. Liver resections were performed in 19/22 patients (3 for palliation): 11/19 (57.9%) were major hepatectomies and in 8/19 (42.1%) cases they were accomplished by procedures for removing the primary tumor. Overall, curative procedures were carried out in 16/28 (57.1%). Resections were performed in 6 cases without the knowledge of the primary site. There was no operative mortality. Overall recurrence rate was 50.0%. Four-year actuarial survival was 92.6% after resection and 18.5% for patients that did not receive surgery (P < 0.001). CONCLUSIONS: Our experience confirms that the small number of patients makes the management of liver metastases from neuroendocrine tumors difficult to plan. In consideration of the satisfactory results achieved with an aggressive policy of resection, we advise referral of these patients to specialized liver units where major hepatic procedures, even if extended, can be safely performed.

Adult↗
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Splenoadrenal shunt. An original portosystemic decompressive technique.

Management of gastrointestinal hemorrhage from rupture of esophageal and gastric varices due to portal hypertension remains a debated question. In patients with sclerotherapy-resistant esophagogastric varices, and preserved hepatic function, a surgical shunt is considered the treatment of choice. A 63-year-old male was admitted in our Department with a diagnosis of idiopathic fibrosis of the liver, portal hypertension, esophageal and gastric varices and previous history of variceal bleeding. A distal splenorenal shunt was planned. During the isolation, a large diameter left adrenal vein was identified. An end-to-end anastomosis utilizing the distal splenic vein and the proximal adrenal stump was performed. The procedure was uneventful. An ultrasound color-Doppler on the 3rd postoperative day, showed normal intrasplenic resistance index, demonstrating the efficacy of the shunt. A splenic angiography carried out on the 8th postoperative day showed the complete patency of the splenoadrenal shunt. At the 15th postoperative day, the patient was discharged. In patients with portal hypertension, sclerotherapy-resistant esophagogastric varices and preserved hepatic function, a surgical portosystemic shunt is mandatory. Splenoadrenal shunt, utilizing a left adrenal vein represent an excellent option in selected cases.

Adrenal Glands↗
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Diagnostic dilemmas in biliary strictures mimicking cholangiocarcinoma.

BACKGROUND/AIMS: Bile duct strictures may be malignant or benign. In the absence of previous biliary surgery a precise preoperative diagnosis is often difficult, in particular when a tumor mass is absent in the preoperative radiologic findings. METHODOLOGY: A review of 179 patients observed between 1982 and 2001 by the same surgical team with a preoperative diagnosis of malignant stricture of the biliary tree. A surgical procedure was performed in 153 of these cases. RESULTS: The presence of a malignant stricture was confirmed by final pathologic examination in 32 of 38 cases (96%) in which a curative resection was performed. A final diagnosis of inflammatory stricture secondary to choledocholithiasis was made in 3 of the remaining 6 cases (4%), along with one case each of sclerosing cholangitis, granular cell tumor and Mirizzi's syndrome, respectively. CONCLUSIONS: Precise preoperative evaluation of biliary structures can be very difficult when a tumor mass is absent. Despite the use of invasive procedures and new techniques such as magnetic resonance cholangiopancreatography, a false-positive rate of 4% may be expected. However, whenever a malignancy is not definitely excluded, biliary strictures should be treated as a cholangiocarcinoma.

Adult↗
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Hepatic resective surgery in cirrhotic patients. Techniques and results of anatomical segmentectomies.

The paper describes the technique of anatomical liver segmentectomies based on the extraparenchymal clamping, at the hepatic hilum, of the afferent vascular pedicles. The resection is started on the liver surface along the demarcation line caused by the ischemia. During parenchymal transection the technique of hemihepatic vascular occlusion has been undertaken. The results obtained with 125 segmentary hepatic resections performed for hepatocellular carcinoma arised on cirrhosis are also reported. The overall operative mortality has been 6.4%. The actuarial 1 and 3 year survivals were 93.3% and 70.4% respectively. Hepatic segmentary resections are recommended for limited hepatic lesions, mainly in well compensated cirrhotic patients.

Hepatectomy↗