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K Rolles

Publications and source records attributed to K Rolles.

At least 55 records · Page 3Linked to original sources
PubMed1998

Multidisciplinary approach to biliary complications of laparoscopic cholecystectomy.

BACKGROUND: Bile leaks and bile duct strictures are major complications of cholecystectomy which increased in incidence after the introduction of laparoscopic surgery. The management and outcome of these complications following the introduction of laparoscopic cholecystectomy was reviewed. METHODS: Eighteen patients of median age 45 (range 22-70) years were treated between January 1992 and December 1995. Six patients had a common hepatic duct (CHD) stricture, four following a failed previous repair. Nine patients had bile leaks from bile duct transection (four), cystic stump (four) or segment V duct (one). Two patients had partial bile duct damage with primary sutured repair at time of cholecystectomy. One patient had recurrent haemobilia from a hepatic artery pseudoaneurysm. RESULTS: Cystic stump or segment V leaks were treated successfully by endoscopic stenting (median follow-up 42 months). Roux loop biliary reconstruction was carried out in nine patients: two CHD strictures, three of the four failed primary CHD repairs and four bile duct transections. All had normal liver function test results at median follow-up of 30 months. The two patients with partial duct injuries repaired at initial surgery required no further intervention. The right hepatic artery aneurysm was successfully embolized. There have been no deaths or major complications of endoscopic, radiological or surgical intervention. CONCLUSION: Endoscopic stenting successfully treats cystic stump and segment V duct leaks. Duct strictures, including failed initial repairs and transections, have a good outcome with Roux-en-Y loop reconstruction.

Adult↗
PubMed1998

Multimodality treatment for gastric carcinoid tumor with liver metastases.

Carcinoid tumors are the most common neuroendocrine tumors in the gastrointestinal tract, and between 10% and 30% of these tumors are gastric in origin. Three types of gastric carcinoid tumors are recognized: type I, associated with chronic atrophic gastritis type A; type II, associated with multiple endocrine neoplasia; and type III, sporadic and the most malignant. We present a patient with an aggressive, sporadic-type gastric carcinoid that metastasized to the liver. Her symptomatic treatment included the somatostatin analog octreotide. Octreotide scintigraphy demonstrated that this tumor avidly bound the peptide. The patient's gastric carcinoid (assessed by endoscopy and endoscopic ultrasound) regressed and she underwent hepatic artery embolization for her liver metastases. After initial partial CT resolution the tumor grew, compressing the inferior vena cava. The patient underwent orthotopic liver transplant with excellent recovery, although she was subsequently found to have two small lung metastases. She has responded well to adjuvant Indium-111 octreotide receptor targeted therapy. This case highlights the therapeutic options for metastatic neuroendocrine tumors, including liver transplantation and adjuvant receptor targeted therapy.

Adult↗
PubMed1998

In vivo and in vitro hepatic phosphorus-31 magnetic resonance spectroscopy and electron microscopy in chronic ductopenic rejection of human liver allografts.

BACKGROUND: In vivo hepatic phosphorus-31 magnetic resonance spectroscopy (MRS) provides non-invasive information about phospholipid metabolism. AIMS: To delineate MRS abnormalities in patients with chronic ductopenic rejection (CDR) and to characterise spectral changes by in vitro MRS and electron microscopy. PATIENTS AND METHODS: Sixteen liver transplant recipients (four with CDR; 12 with good graft function) and 29 controls (23 healthy volunteers; six patients with biliary duct strictures) were studied with in vivo 31P MRS. Peak area ratios of phosphomonoesters (PME) and phosphodiesters (PDE), relative to nucleotide triphosphates (NTP) were measured. In vitro MRS and electron microscopy were performed on biopsy specimens from five patients with CDR, freeze clamped at retransplantation. Phosphoethanolamine (PE), phosphocholine (PC), glycerophosphorylethanolamine (GPE), and glycerophosphorylcholine (GPC) concentrations were measured. RESULTS: The 12 patients with good graft function displayed no spectral abnormalities in vivo; the four patients with CDR showed significantly elevated PME:NTP (p < 0.01) and PDE:NTP ratios (p < 0.005). Patients with biliary strictures had significant differences in PME:NTP (p < 0.01) from patients with CDR, but not in mean PDE:NTP. In vitro spectra from CDR patients showed elevated PE and PC, mirroring the in vivo changes in PME, but reduced GPE and GPC concentrations were observed, at variance with the in vivo PDE findings. On electron microscopy, there was no proliferation in hepatocyte endoplasmic reticulum. CONCLUSIONS: The increase in PME:NTP reflects altered phospholipid metabolism in patients with CDR, while the increase in PDE:NTP may represent a significant contribution from bile phospholipid.

Adult↗
PubMed1998

Ulcerative colitis has an aggressive course after orthotopic liver transplantation for primary sclerosing cholangitis.

BACKGROUND: The course of inflammatory bowel disease after liver transplantation has been reported as variable with usually no change or improvement, but there may be an increased risk of early colorectal neoplasms. In many centres steroids are often withdrawn early after transplantation and this may affect inflammatory bowel disease activity. AIMS: To evaluate the course of inflammatory bowel disease in primary sclerosing cholangitis transplant patients who were treated without long term steroids. METHODS: Between 1989 and 1996, there were 30 patients transplanted for primary sclerosing cholangitis who survived more than 12 months. Ulcerative colitis was diagnosed in 18 (60%) patients before transplantation; two had previous colectomy. All patients underwent colonoscopy before and after transplantation and were followed for 38 (12-92) months. All received cyclosporin or tacrolimus with or without azathioprine as maintenance immunosuppression. RESULTS: Ulcerative colitis course after transplantation compared with that up to five years before transplantation was the same in eight (50%) and worse in eight (50%) patients. It remained quiescent in eight and worsened in four of the 12 patients with pretransplant quiescent course, whereas it worsened in all four patients with pretransplant active course (p=0.08). New onset ulcerative colitis developed in three (25%) of the 12 patients without inflammatory bowel disease before transplantation. No colorectal cancer has been diagnosed to date. CONCLUSIONS: Preexisting ulcerative colitis often has an aggressive course, while de novo ulcerative colitis may develop in patients transplanted for primary sclerosing cholangitis and treated without long term steroids.

Adolescent↗
PubMed1997

Small hepatocellular carcinomas in cirrhotic explant livers: identification by macroscopic examination and lipiodol localization.

Small hepatocellular carcinomas (HCCs) in cirrhotic livers are difficult to detect. This study aimed to assess if small HCCs can be better identified using specific macroscopic sampling criteria and Lipiodol (iodized oil) localization on radiographs, and to evaluate thereby their incidence and morphology. Prospective cirrhotic recipients of orthotopic liver transplantation (OLT) were administered hepatic arterial Lipiodol at angiography. Posttransplantation, the explant livers were sliced and inspected as per routine for unusual nodules. If unusual nodules were found or HCC clinically suspected, the slices underwent soft-tissue radiography. Tissue samples were then taken as per protocol from all nodules with diameter > or =1 cm/unusual appearance/exophytic bulge, and from foci of radiographic Lipiodol uptake or high soft-tissue density. One hundred three lesions were assessed and classified histologically as HCC (n = 55) or regenerative nodule (n = 39) or borderline (n = 9). Sampling according to predetermined macroscopic criteria proved an effective method for identifying small HCCs: 44 cancers were detected, most <5 mm in diameter, additional to those picked up on routine assessment. Green nodules were more likely to be HCC (P < .0001). The cancers were all multifocal, and had characteristic histological features of HCC except for 12 unusual fibrotic cancers in livers with alcoholic cirrhosis. Lipiodolization alone identified one additional HCC. Lipiodol retention on x-ray is fairly specific for HCC (83%), and can even identify lesions 2 mm in diameter. But its sensitivity is poor (45%), and its routine use to identify HCCs in explant livers is not recommended.

Carcinoma, Hepatocellular↗
PubMed1997

Interrelationships among quantity of human cytomegalovirus (HCMV) DNA in blood, donor-recipient serostatus, and administration of methylprednisolone as risk factors for HCMV disease following liver transplantation.

Longitudinal analysis of 162 liver transplant recipients identified 51 patients who were viremic. Virus load was determined in 47 of these patients using quantitative-competitive polymerase chain reaction. Peak virus load was significantly higher in 20 symptomatic patients than 27 asymptomatic patients (P < .0001). Elevated virus load, donor seropositivity, and total methylprednisolone dosage were risk factors for human cytomegalovirus (HCMV) disease (odds ratio [OR], 2.22/0.25 log10 increase in virus load, P = .001; OR, 4.11, P = .05; OR, 1.30/1-g increment in methylprednisolone, P = .01). Methylprednisolone and virus load were independent risk factors in a multivariate analysis (OR, 2.70/1-g increase, P = .003; OR, 1.61/0.25 log10 increase, P = .03, respectively). Virus loads of 10(4.75)-10(5.25) genomes/mL of blood were associated with an increased disease probability; the latter was shifted to lower virus loads with increasing quantities of methylprednisolone. These data illustrate the central role of virus load in HCMV pathogenesis.

Adolescent↗
PubMed1997

In vivo and in vitro hepatic 31P magnetic resonance spectroscopy and electron microscopy of the cirrhotic liver.

In vivo 31P magnetic resonance spectroscopy (MRS) provides direct biochemical information on hepatic metabolic processes. To assess in vivo changes in hepatic 31P MRS in liver transplant candidates, we studied 31 patients with cirrhosis of varying aetiology; 14 with compensated cirrhosis (Pugh's score < or = 7) and 17 with decompensated cirrhosis (Pugh's score > or = 8). Underlying cellular abnormalities were characterised using in vitro 31P MRS and electron microscopy. In vitro spectra were obtained from liver extracts, freeze-clamped at recipient hepatectomy, from all subjects. Electron microscopy of liver tissue was also performed in 17 cases. Relative to nucleotide triphosphates, elevations in phosphomonoesters and reductions in phosphodiesters were observed in vivo with worsening liver function. In vitro spectra showed elevated phosphoethanolamine and phosphocholine, and reduced glycerophosphorylethanolamine and glycerophosphorylcholine, mirroring the in vivo changes, but no distinction was noted between compensated and decompensated cirrhosis. With electron microscopy, functional decompensation was associated with reduced endoplasmic reticulum in parenchymal liver disease, but elevated levels in biliary cirrhosis. We conclude that in vivo spectral abnormalities in cirrhosis are consistent with alterations in phospholipid metabolism and quantity of endoplasmic reticulum. However, in individual patients the biopsy results do not always mirror in vivo findings.

Adult↗
PubMed1997

Detection of small hepatocellular carcinomas in cirrhotic livers using iodised oil computed tomography.

BACKGROUND: The detection of hepatocellular cancers (HCC) is a major role of preoperative imaging in patients with end stage liver disease being considered for orthotopic liver transplantation (OLT). AIMS: To assess the sensitivity of iodised oil computed tomography (IOCT). PATIENTS AND METHODS: A prospective evaluation in 50 consecutive patients undergoing OLT included ultrasound scan, contrast enhanced CT, angiography (with intra-arterial injection of iodised oil), and a second CT (IOCT) 10 days later. Following transplantation the explant liver was serially sectioned for pathological evaluation. Soft tissue radiographs of the liver slices were used to match histological lesions with CT findings. RESULTS: Eleven patients were excluded due to protocol violations. Of the remaining 39, histological evaluation revealed no cancers in 33 explant livers, in keeping with negative preoperative imaging. Six explant livers contained 55 HCCs, 84% of which were less than 1 cm in diameter. Pretransplant IOCT detected 3/6 patients with cancer (50%) but only 7% of cancerous lesions. Ultrasound, contrast CT, and angiography each detected 2/6 patients with cancer and 4% of cancerous lesions. CONCLUSION: IOCT is an insensitive method for the detection of small HCCs in livers with advanced cirrhosis but in this study was slightly superior to ultrasound, CT, and angiography.

Carcinoma, Hepatocellular↗
PubMed1997

Use of polymerase chain reaction to provide prognostic information on human cytomegalovirus disease after liver transplantation.

Sixty-four consecutive liver transplant patients receiving 76 organs have been monitored for human cytomegalovirus (HCMV) in blood and urine posttransplantation using a polymerase chain reaction (PCR) assay that amplifies a 149 base pair fragment of the glycoprotein B gene. Six hundred and twenty-six blood and 310 urine samples were analysed during surveillance. Thirty-two patients had CMV infection (50%), 12 of whim progressed to HCMV disease. Detection of HCMV in either blood or urine was significantly associated with the presence or development of HCMV disease (blood, P < 0.00001; urine, P = 0.0033). All cases of HCMV disease were detected as PCR-positive in blood, although due to sampling only 50% of these patients were PCR-positive prior to disease onset. HCMV infection and disease were more likely in patients who suffered rejection (P < 0.001). In addition, the median amounts of augmented prednisolone were higher in patients with HCMV infection and disease. In all cases, augmented prednisolone preceded HCMV infection/disease. There was no statistical association between CMV infection and death. Overall, the results show that routine use of PCR for HCMV in surveillance samples of blood and urine of liver transplant recipients can provide diagnostic and prognostic information. However, its ability to provide prognostic information is directly related to the availability of appropriate surveillance samples, emphasising the importance of the routine acquisition of such samples in patient management to allow preemptive anti-HCMV therapy.

Acyclovir↗
PubMed1997

Prospective study of hepatobiliary scintigraphy and endoscopic cholangiography for the detection of early biliary complications after orthotopic liver transplantation.

BACKGROUND: Biliary complications are a significant cause of morbidity and death after orthotopic liver transplantation (OLT). This study was a prospective evaluation of endoscopic retrograde cholangiography (ERC) and hepatobiliary scintigraphy (HBS), using 99mTc Mebrofenin, to detect early biliary complications following OLT. METHODS: One hundred consecutive patients who had OLT with a biliary duct-to-duct anastomosis were studied. Of these, 67 had both ERC and HBS performed within 30 days of OLT. Sensitivity, specificity and diagnostic accuracy of HBS in identifying biliary leak or stricture was calculated. RESULTS: Of the 67 cholangiographies performed 45 were normal. In 22 patients there was radiological evidence of a leak (n = 14) or stricture (n = 8) which required further intervention in nine and four patients respectively. The sensitivity and specificity of scintigraphy for the detection of biliary leak after transplantation was 50 and 79 per cent and for biliary stricture 62 and 64 per cent respectively. No patient with normal scintigraphy required biliary intervention. Only six of 14 patients with biliary leaks and two of 20 with strictures suggested by scintigraphy required intervention. If both ERC and HBS reported leak or stricture, the intervention rate was considerably higher at five of seven leaks and two of five strictures. CONCLUSION: This study suggests that scintigraphy is a useful screening test for biliary complications after OLT, ERC is only necessary if HBS is abnormal.

Adolescent↗
PubMed1997

Hepatic microcirculation during human orthotopic liver transplantation.

BACKGROUND: Laser Doppler flowmetry (LDF) can measure blood flow in the hepatic microcirculation. Adequate graft perfusion is essential to the outcome of organ transplantation and has not previously been measured during operation in liver transplant recipients. METHODS: LDF was carried out during operation in 22 human liver grafts after restoring portal vein and hepatic artery inflow. LDF readings were validated against liver blood flow with an electromagnetic flowmeter. Intraoperative haemodynamics and donor organ parameters known to influence graft function were correlated with LDF. RESULTS: There was a significant correlation (r = 0.96, P < 0.001) between hepatic perfusion determined with LDF and total liver blood flow measured by electromagnetic flowmetry. The perfusion measurements were reproducible with a coefficient of variation of 4 per cent. Mean(s.d.) hepatic perfusion increased significantly from baseline following venous reperfusion (17(6) versus 114(37) flux units, P < 0.001). Arterial revascularization resulted in a significant increase in mean(s.d.) perfusion (32(4)per cent, P = 0.02). There was a significant negative correlation between cold ischaemia time and graft perfusion (r = 0.48, P = 0.02; n = 22). CONCLUSION: LDF provides a reliable non-invasive method of monitoring liver graft blood flow perfusion during transplantation.

Constriction↗
PubMed1996

Lamivudine prophylaxis against reinfection in liver transplantation for hepatitis B cirrhosis.

BACKGROUND: Orthotopic liver transplantation in patients positive for hepatitis B virus (HBV) DNA is associated with a high reinfection rate, even with hepatitis B immunoglobulin (HBIG) prophylaxis. Nucleoside analogues that inhibit hepatitis B replication in patients with chronic hepatitis B could prevent reinfection after transplantation. The aim of this study was to analyse the efficacy and safety of prophylaxis both before and after transplantation with the nucleoside analogue lamivudine, without HBIG, in patients undergoing liver transplantation. METHODS: 17 HBsAg-positive patients with decompensated cirrhosis and previous evidence of viral replication were enrolled. 12 were HBV-DNA-positive by a signal amplification assay. Patients were treated with oral lamivudine (100 mg daily) for at least 4 weeks before transplantation and followed up for 18-90 weeks after transplantation. FINDINGS: HBV DNA became undetectable in serum before transplantation in all HBV-DNA-positive patients. Four died before transplantation from complications of cirrhosis; one patient was withdrawn from the study because of a cerebrovascular accident. The remaining 12 patients underwent transplantation. Two patients died after transplantation (one at 3 days and one [suicide] at 20 weeks). HBV DNA reappeared in one patient with histological evidence of recurrent hepatitis (72 weeks). By week 24 the nine remaining patients had lost HBsAg and remained negative for HBV DNA. INTERPRETATION: Lamivudine treatment may prove useful in preventing recurrence of hepatitis B after liver transplantation. The effect on survival of patients after transplantation remains to be assessed.

DNA, Viral↗