BACKGROUND: Tumor recurrence in liver transplant recipients greatly affects prognosis of liver transplantation with hepatocellular carcinoma (HCC). How to prevent tumor recurrence has aroused increasing attention. Arsenious acid chemotherapy is considered effective on treating moderate or advanced liver cancer, but its utilization following liver transplantation remains few. OBJECTIVE: To explore the role of arsenious acid on tumor recurrence in liver transplant patients with primary HCC extending Milan criteria. RESULTS AND CONCLUSION: All patients were routinely followed up for 3-32 months. Thirty recipients were presented with tumor recurrence, 16 in the chemotherapy group and 14 in the non-chemotherapy group. Tumor recurred in lung, liver graft and bones in most cases. The total recurrence rate was similar in these two groups, but chemotherapy could delay recurrence after transplantation (P=0.026). There was no significance in 6-month, 1-year survival rate between two groups, but the 2-year survival in the chemotherapy group was higher (P=0.037); 6-month tumor-free survival rates in the two groups had no significance, 1-year and 2-year tumor-free in the chemotherapy group were significantly higher than those in the non-chemotherapy group (P=0.030, 0.023). Intravenous arsenious acid chemotherapy can delay tumor recurrence and prolong survival in liver transplant patients with HCC extending Milan criteria.

Objective To investigate the features of familiar facial palsy,ophthalmoplegia and dysphagia characterized by autosomal dominant inheritance in a family and to discuss the classification and pathogenesis of the disease.Methods Clinical,electrophysiological,pathological examinations were performed and blood samples were obtained from 5 patients and 26 family members.PCR protocol was used to identify a certain gene. Results In the 5 patients receiving physical examination,all had ptosis,external ophthalmoplegia,facial paralysis,dyphagia,hoarseness,decreased pharyngeal reflex;4 had amyotrophy of muscle of tongue,temporal nuscle,masseter and muscles of distal lower limbs;3 had proximal limb asthenia and distal limbs amyotrophy.Compared to those of oculopharyngeal muscular dystrophy(OPMD)with similar symptoms and signs,both electrophysiological manifestation and pathological findings of the family members supported the diagnosis of muscular dystrophy,but the(GCG)6(GCA)3GCG in the first exon of PABPN1 mutated neither in normal family members nor in patients.Conclusions This family presents clinical manifestations somewhat resembling to those of OPMD and distinctive to other disorders,but has a totally different genetic background from OPMD.It may be a new subtype of muscular dystrophy.

Objective To explore the causes and management of intra-abdominal hemorrhage after orthotopic liver transplantation (OLT). Methods Clinical data of 638 OLT patients were analyzed retrospectively from January 2004 to December 2008 in the First Affiliated Hospital of Sun Yat-Sen University. The diagnosis and treatment of postoperative intra-abdominal hemorrhage after OLT were reviewed. Results Among the 638 patients, 53 suffered from posttransplant intra-abdominal hemorrhage,the morbidity was 8. 3% (53/638). Thirty-one cases suffering from bleeding on raw surfaces or around the liver due to impairment of coagulation function were treated by non-surgery methods, 22 cases who suffered from active postoperative intra-abdominal hemorrhage due to surgical factors underwent laparotomy and bleeding control operation after failure of anti-shock treatments such as hemostatic drugs, blood reperfusion.Among the 53 patients who suffered from intra-abdominal hemorrhage, 12 patients died, and the main causes were serious infections and multiple organ dysfunction syndrome. The mortality associated with intraabdominal hemorrhage was 22. 6%. Conclusions Intra-abdominal hemorrhage at different locations were found after OLT, and the fatal rate is quite high. Timely and appropriate treatments especially laparotomy may improve the prosnosis of these patients.

ObjectiveTo investigate the effectiveness and tolerability of immunosuppressive regimen with daclizumab induction therapy. MethodsIn study group, 139 patients received immunosuppressive regimen with daclizumab induction therapy. In historical control group, 106 recipients received immunosuppressive regimen without daclizumab induction therapy. All patients were followed up at least for 1year. The acute rejection episodes, infectious and metabolic complications at one month and one year post-transplantation were compared between two groups.ResultsThe one-month incidence of acute rejection, new-onset diabetes mellitus, hypertension and infection was 7. 9 ％, 33. 8 ％, 21.6 ％ and 22. 3 ％, respectively in study group, as compared with 15. 1 ％, 72. 6 0％, 40. 6 ％ and 43. 4 ％, respectively in control group ( P ＜ 0. 05 ). The one-year incidence of acute rejection, new-onset diabetes mellitus, hypertension and hyperlipidemia was 10. 8 ％,5. 0 ％ ,4. 3 ％ and 7. 9 ％, respectively in study group, as compared with 19. 8 ％, 9. 4 ％, 8. 5 ％ and 14. 2 ％, respectively in control group (P＜0. 05). The one-year survival rate was comparable between two groups (P＞0. 05). ConclusionThe immunosuppressive regimen with daclizumab can enable early steroid withdrawal, significantly reduce acute rejection rate and various side effects mediated by longterm steroids use.

Objective To evaluate the impact of steatotic hepatic grafts on postoperative early liver function and prognosis.Methods Clinical data of 35 cases receiving steatotic liver grafts in our hospital were retrospectively analyzed.The donor liver grafts were divided into 3 groups based on the degree of fatty infiltration(＜20%group,20%～40%group,≥40%group).Results were compared with that from control normal grafts(41 cases).Liver function parameters including AST,ALT,TB,PT on the day of surgery and 1,2,3,7 days later were monitored among the 4 groups,as well as the incidence of delayed nonfunction (DNF),and 3 and 6 months patient survival rate.Analysis of the correlation between degree of donor steatosis and liver function after operation was carried out.Resuits There was significant difference in postoperative ALT、AST、TB、PT level between≥40%group and 20%～40%group,and between 20%～40%and group＜20%group.There was no significant difference among the groups in DNF occurrence rate and 3 month.6 month patient survival rate.Correlation analysis suggested that the degree of donor steatosis was positively correlated with the damage of liver function.Conclusions Grafts with≤20% steatosis was safe,whereas≥20% especially ≥40% steatosis carries a high risk of posttransplant liver dysfunction even delayed nonfunction.

Objective To investigate the diagnosis,and management of aspergillosis infection in orthotopic liver transplant recipients.Methods The clinical data of 776 cases of orthotopic liver transplantation patients from 2000 to 2006 were collected and analyzed retrospectively.Results Aspergillosis infection occurred in 13 patients(1.68%),among those there were pulmonary aspergillus infection in 7 cases,hepatic aspergillus infection in 2,cerebral aspergillosis in one and multi-organ aspergillosis in 3.Liposomal amphotericin B was the main therapy especially for cases at early stage.7 patients died of aspergillosis and the aspergillosis-related mortality was 53.8%.Conclusion Early diagnosis and management remain the key for the prevention and cure for aspergillus infection and decreasing mortality.The use of anti-fungal therapy should follow the principle of eliminating the local infection,adjusting immunosuppressive regimen and use of sensitive anti-fungal drugs.Anti-fungal drugs should be started early,with sufficient dosage and long-term.

Objective To compare the effects of combined ‘en bloc' liver-pancreas transplantation (LPT) with portal vein drainage and simultaneous combined kidney-pancreas transplantation (KPT) with systemic venous drainage on the pancreatic endocrine function and related metabolism.Methods Four LPT patients and 6 KPT ones with normal hepato-renal function, good quality of life and periodic follow-up received measurement of serum insulin, insulin provocation test, fasting glucose, oral glucose tolerance test, C-peptide, glycated hemoglobin, triglyceride and total cholesterol; and their laboratory test parameters were compared and analyzed.Results In KPT group, 2-h insulin level, C-peptide level and total cholesterol level were significantly higher at 6th month, 3rd and 6th month postoperation (all P<0.05). But there was no significant difference in other parameters between the two groups at 6th month after operation.Conclusion Either KPT or LPT can achieve excellent endocrine function, carbohydrate and lipid metabolism; and the results show that portal venous drainage does not offer major metabolic advantages within 6 months after operation.

Objective To summarize the experience with salvage liver transplantation for patients with recurrent hetaptocellular carcinoma(HCC)after primary liver resection.Methods From 2004 to 2008,376 patients with HCC received liver transplantation in our single center.Among these patients,36 (9.6 %)underwent salvage liver transplantation after primary liver curative resection due to intrahepatic recurrence.There were 29 males and 7 females with the mean age of 46 years old.Sixteen received right lobectomy,10 received left lobectomy and the others received sectionectomy or segmentectomy.As a control group for comparison,we used clinical data of the 147 patients who underwent primary OLT for HCC within Milan Criteria.Results The mean interval between initial liver resection and salvage transplantation was 34.9±16.2 months(1-63 months).Intraoperative bleeding volume,transfusion volume and operative time in the salvage group were significantly different from those in control group (P<0.05).There were no significant difference in post-operative complications,tumor recurrence rate,survival rate and tumor-free survival between these two groups(P>0.05).Conclusion In comparison with primary OLT,although salvage liver transplantation would increase the operation difficulties,it still remains a good option for patients with HCC recurrence after curative resection.

ObjectiveTo summarize the clinical experience of simultaneous pancreas and kidney transplantation (SPK) after liver transplantation for patients with diabetes and uremia.MethodsThe clinical data of two patients who received SPK after liver transplantation were retrospectively analyzed.The two male patients had type 2 diabetes mellitus before liver transplantation,and suffered from endstage uremia due to diabetic nephropathy and immunosuppressant-induced toxicity.Rapid technique for combined abdominal multiple viscera procurement was performed.Kidneys,pancreas,duodenum segment and spleen were procured.Renal allograft was placed in the left iliac fossa,whereas pancreas allograft in the right iliac fossa. The pancreatic allograft exocrine secretion was drained into the proximal jejunum via a side-to-side duodenojujunostomy. Quadruple immunosuppressive regime including IL2 receptor monoclonal antibody induction,tacrolimus (Tac),mycophenolate mofetil (MMF) and steroid were used in case 1,and ATG and methylprednisolone were used in case 2.ResultsSPK was successfully applied to these two patients without serious surgical complications such as pancreatitis,graft and pancreatic fistula. The immunosuppressive regimen was based on tacrolimus with ATG induction,MMF and steroids.In the second case,serum creatinine level was decreased to the normal range within 1 week after the operation and then elevated continuously even he received empirical anti rejection treatment,Tac was tampered and rapamycin was used when the renal graft biopsy indicated drug toxicity,and creatinine level was decreased 3 weeks after the operation and recovered to the normal range at 5th week post-transplant. Both of the two patients achieved euglycemia with insulin independence about 10 days after the operation.And now these two patients have been followed up for 36 and 9 months,and the grafts function of the liver,kidney and pancreas was normal. Conclusion Immunologic reaction in patients undergoing simultaneous pancreas and kidneytransplantationafterlivertransplantationseemsmorecomplex, andareasonable immunosuppressive regimen is important to improVe the outcome.

Objective To explore the outcome and treatment for recipients with steroid-resistant acute rejection (SRAR) after liver transplantation. Methods From Jan 2004 to Dec 2007, 596 adult patients received liver transplantation in the Organ Transplantation Center, the First Affiliated Hospital of Sun Yat-Sen University,96 recipients experienced 113 episodes of acute rejection (AR)after the operation, 11 recipients had no response to conventional steroid bolus treatment, the clinical data of this group of patients was analyzed retrospectively. Results Incidence rate of AR in our single center was 16.1% (96/596), among them 9.7% (11/113) were steroid-resistant. SRAR occurred averagely on 19 d (6-72 d)after liver transplantation, 3 were controlled by OKT3 treatment, 4 were reversed by IL-2 receptor inhibitors combined with MMF. Rejection could not be reversed in 4 patients and 2 finally received retransplantation. Mortality rate associated with SRAR was 36.4% (4/11) including, one from acute liver failure, 1 from chronic liver failure, 1 from renal failure after retransplantation and 1 from pulmonary infection after OKT3 treatment. Conclusion SRAR is a severe complication with high mortality after liver transplantation, OKT3 and IL-2 receptor inhibitors are effective in only a portion of these patients.