Actuarial Patient Survival Rates Research Articles

Long-term prognosis of renal transplantation after preemptive treatment of cytomegalovirus infection.

A role for cytomegalovirus (CMV) infection in the etiologies of acute and chronic rejection in renal allograft recipients has been suggested. We previously reported that preemptive treatment of CMV infection with ganciclovir in kidney transplant patients was safe and effective. We now present a retrospective analysis of 169 consecutive renal transplant patients, of whom 87 (51.5%) received preemptive treatment with ganciclovir (CMV(+) group). No patient died of CMV infection. Actuarial graft and patient survival rates were not different between the CMV(+) and the CMV(-) groups (graft survival: 68% and 69%; patient survival: 89% and 88%, respectively). At the end of the study, the mean plasma creatinine levels were not statistically different between the two groups (185+/-13 and 166+/-12 micromol/L for the CMV(+) group and the CMV(-) group, respectively). These results suggest that preemptive treatment of CMV infection with ganciclovir may prevent the CMV-induced renal injury and graft loss.

Adult liver transplantation and abnormalities of splanchnic veins: experience in 53 patients.

The aim of this study was to analyze the influence of technical problems resulting from splanchnic venous anomalies on the outcome of orthotopic liver transplantation. From February 1984 until December 1995, 53 (16.3%) of 326 adults underwent consecutive transplantations whilst having acquired anomalies of the splanchnic veins. These consisted of portal vein thrombosis (n = 32, 9.8%), thrombosis with inflammatory venous changes (phlebitis; n = 6, 1.8%) and alterations related to portal hypertension surgery (n = 15, 4.6%). Because of major changes in surgical technique, i.e., eversion instead of blind venous thrombectomy, immediate superior mesenteric vein approach in cases of extended thrombosis, and piggyback implantation with preservation instead of removal of the inferior vena cava, patients were divided into two groups: those who underwent transplantation during the period February 1984 to December 1990 (group 1) and those transplanted between January 1991 and December 1995 (group 2). Surgical procedures to overcome the anomalies consisted of venous thrombectomy (n = 26), implantation of the donor portal vein at the splenomesenteric confluence (n = 5) or onto a splenic (n = 1) or ileal varix (n = 1), interposition of a free iliac venous graft between recipient superior mesenteric vein and donor portal vein (n = 9), and interruption of surgical portosystemic shunt (n = 13). All patients had a complete follow-up. The 1- and 5-year actuarial patient survival rates were similar in patients with (n = 53) and without (n = 273) splanchnic venous abnormalities (75.5% vs 78.1% and 64.3% vs 66.9%, respectively). Early (< 3 months) post-transplant mortality was 24.5% (13/53 patients). Mortality was highest in the portal vein thrombophlebitis group (5/6, 83.3%), followed by the portal hypertension surgery group (5/15, 33.3%) and the portal vein thrombosis group (3/32, 9.4%). Technical modifications significantly reduced mortality in group 2 (10.3%, 3/29 vs 41.7%, 10/24 patients in group 1; P < 0.05) as well as the need for re-exploration for bleeding (13.8%, 4/29 patients in group 2 vs 15/24, 62.5% in group 1; P < 0.01). Mortality directly related to bleeding was also significantly lowered (1/29, 3.4% in group 2 vs 9/ 24, 37.5% in group 1; P < 0.01). We conclude that liver transplantation can be safely performed in the presence of splanchnic vein thrombosis and previous portal hypertension surgery.

Tacrolimus in pediatric renal transplantation.

Tacrolimus was used as the primary immunosuppressive agent in 69 pediatric renal transplantations between December 17, 1989, and June 30, 1995. Children undergoing concomitant or prior liver and/or intestinal transplantation were excluded from analysis. The mean recipient age was 10.3+/-5.0 years (range, 0.7-17.5 years). Seventeen (24.6%) children were undergoing retransplantation, and six (8.7%) had a panel reactive antibody level of 40% or higher. Thirty-nine (57%) cases were with cadaveric kidneys, and 30 (43%) were with living donors. The mean donor age was 28.0+/-14.7 years (range, 1.0-50.0 years), and the mean cold ischemia time for the cadaveric kidneys was 27.0+/-9.4 hr. The antigen match was 2.7+/-1.2, and the mismatch was 3.1+/-1.2. All patients received tacrolimus and steroids, without antibody induction, and 26% received azathioprine as well. The mean follow-up was 32+/-20 months. One- and 4-year actuarial patient survival rates were 100% and 95%. One- and 4-year actuarial graft survival rates were 99% and 85%. The mean serum creatinine level was 1.2+/-0.8 mg/dl, and the calculated creatinine clearance was 82+/-26 ml/min/1.73 m2. The mean tacrolimus dose was 0.22+/-0.14 mg/ kg/day, and the level was 9.5+/-4.8 ng/ml. The mean prednisone dose was 2.1+/-4.9 mg/day (0.07+/-0.17 mg/kg/day), and 73% of successfully transplanted children were off prednisone. Seventy-nine percent were not taking any antihypertensive medications. The mean serum cholesterol level was 158+/-54 mg/dl. The incidence of delayed graft function was 4.3%. The incidence of rejection was 49%, and the incidence of steroid-resistant rejection was 6%. The incidence of rejection decreased to 27% in the most recent 26 cases (January 1994 through June 1995). The incidence of new-onset diabetes was 10.1%; six of the seven affected children were able to be weaned off insulin. The incidence of cytomegalovirus disease was 13%, and that of posttransplant lymphoproliferative disorder was 10%; the incidence of posttransplant lymphoproliferative disorder in the last 40 transplants was 5% (two cases). All of the children who developed posttransplant lymphoproliferative disorder are alive and have functioning allografts. Based on this data, we believe that tacrolimus is a superior immunosuppressive agent in pediatric renal transplant patients, with excellent short- and medium-term patient and graft survival, an ability to withdraw steroids in the majority of patients, and, with more experience, a decreasing rate of rejection and viral complications.

Composite Graft Replacement of the Aortic Root in Patients with Marfan's Syndrome

Between October, 1979 and September 1994, 18 consecutive patients with Marfan's syndrome underwent replacement of the ascending aorta and aortic valve with a composite graft. There were 11 men and seven women; the mean age was 38.7 years. All patients had annuloaortic ectasia with significant aortic regurgitation. Ten of the 18 patients had aortic dissection. Concomitant procedures were performed in three patients. The hospital mortality rate was 17%, and two patients with concomitant procedures died early after surgery. There were three late deaths, two of which were related to late aortic complications. The actuarial 8-year survival rates in patients with and without aortic dissection were 58.3% and 77.8%, respectively. Since aortic dilatation and its complications are progressive in patients with Marfan's syndrome, improved surgical results can be obtained early in the course of the disease before cardiac disturbances and aortic dissections emerge.

Composite graft replacement of the aortic root in patients with Marfan's syndrome

Between October, 1979 and September 1994, 18 consecutive patients with Marfan's syndrome underwent replacement of the ascending aorta and aortic valve with a composite graft. There were 11 men and seven women; the mean age was 38.7 years. All patients had annuloaortic ectasia with significant aortic regurgitation. Ten of the 18 patients had aortic dissection. Concomitant procedures were performed in three patients. The hospital mortality rate was 17%, and two patients with concomitant procedures died early after surgery. There were three late deaths, two of which were related to late aortic complications. The actuarial 8-year survival rates in patients with and without aortic dissection were 58.3% and 77.8%, respectively. Since aortic dilatation and its complications are progressive in patients with Marfan's syndrome, improved surgical results can be obtained early in the course of the disease before cardiac disturbances and aortic dissections emerge. Copyright © 1996 The International Society for Cardiovascular Surgery.

Paediatric liver transplantation: A 10 year experience in Taiwan

AbstractBetween March 1984 and August 1994, 13 orthotopic liver transplantations were performed in 13 patients ≦ 25 years of age. The indications included Wilson's disease (n= 7), biliary atresia (n= 4), choledochal cyst (n=1) and hepatitis C cirrhosis (n=1). Technical variants included full‐size (n=11), reduced‐size (n=1) and living‐related (n=1) liver transplantation. These recent technical innovations have offered an expanded donor pool for earlier transplantation, shorter waiting times and excellent quality grafts. Surgical complications occurred in six patients; all required additional surgery. Biliary complications were encountered more commonly in our earlier patients. Our actuarial patient and graft survival rate is 92% at 2 years. The long‐term follow‐up of our liver‐transplanted Wilson's disease patients provides confirmatory evidence that orthotopic liver transplantation cures the underlying metabolic defect with complete normalization of biochemical abnormalities of copper metabolism, reversal of neurological impairments and the disappearance of Kayser‐Fleischer corneal rings. The high rate of patient survival and excellent rehabilitation indicate that with prudent clinical judgement, liver transplantation can be achieved with an acceptable rate of morbidity, mortality and cost in a setting where manpower and donor organs are very limited.

High Resolution HLA Matching Associated With Decreased Mortality After Unrelated Bone Marrow Transplantation

As compared with related HLA-identical sibling donors, bone marrow transplantation (BMT) with phenotypically HLA ABDR-compatible unrelated donors is associated with increased mortality. This may be due to hidden HLA incompatibilities not detected by conventional typing. We have analyzed 44 unrelated patient-donor pairs who were matched for HLA-A, -B, and -DR by routine tissue typing. Our comprehensive HLA typing approach consisted of serology, cytotoxic T-cell precursor (CTLp) tests, T-cell cloning, oligotyping, and DNA sequencing. Using these techniques, we identified numerous HLA allele mismatches not detected by the previously applied routine typing. Twenty-four patient-donor pairs were highly matched and had a low CTLp frequency, whereas the remaining 20 pairs were allele-mismatched for HLA-A, -B, -C, -DR, -DQ antigens and/or had a positive result of the CTLp test. Patient and donor age, diagnosis, and treatment did not differ significantly between the matched and mismatched transplants. The probability for severe acute graft-versus-host disease grades III-IV was 21% in the matched and 47% in the mismatched patients (P = .0464). Transplant-related mortality was 21% and 57% (P = .0072) and actuarial patient survival rates at 3 years were 61% and 13% (P = .0005). We conclude that both HLA class I and class II allele mismatches between unrelated phenotypically ABDR-compatible patient-donor pairs are frequent and associated with increased incidence of posttransplant complications.

Paediatric liver transplantation: a 10 year experience in Taiwan.

Between March 1984 and August 1994, 13 orthotopic liver transplantations were performed in 13 patients < or = 25 years of age. The indications included Wilson's disease (n = 7), biliary atresia (n = 4), choledochal cyst (n = 1) and hepatitis C cirrhosis (n = 1). Technical variants included full-size (n = 11), reduced-size (n = 1) and living-related (n = 1) liver transplantation. These recent technical innovations have offered an expanded donor pool for earlier transplantation, shorter waiting times and excellent quality grafts. Surgical complications occurred in six patients; all required additional surgery. Biliary complications were encountered more commonly in our earlier patients. Our actuarial patient and graft survival rate is 92% at 2 years. The long-term follow-up of our liver-transplanted Wilson's disease patients provides confirmatory evidence that orthotopic liver transplantation cures the underlying metabolic defect with complete normalization of biochemical abnormalities of copper metabolism, reversal of neurological impairments and the disappearance of Kayser-Fleischer corneal rings. The high rate of patient survival and excellent rehabilitation indicate that with prudent clinical judgement, liver transplantation can be achieved with an acceptable rate of morbidity, mortality and cost in a setting where manpower and donor organs are very limited.

Diabetes mellitus after renal transplantation: characteristics, outcome, and risk factors.

The incidence and risk factors of posttransplant diabetes mellitus were evaluated in 1325 consecutive renal transplant recipients. Thirty-three (2.5%) patients developed diabetes mellitus requiring insulin therapy. Onset occurred a mean of 5.7 +/- 1.5 months following transplantation. The patients were compared with 33 paired-control kidney recipients. The patients were significantly older than the controls (46.8 +/- 1.9 vs. 40.6 +/- 2.1 years) (P<0.05), and chronic renal failure was more often related to interstitial nephritis (P<0.05). A family history of diabetes mellitus, the body mass index, ethnic origin, HLA phenotype, and the total doses of steroids and cyclosporine were similar in the two groups. The number of patients with at least one rejection episode was significantly higher among the diabetic patients (21 versus 9) but the number of episodes was similar. Diabetes occurred a mean of 1.1 +/- 0.3 months following rejection treatment. Intravenous pulsed prednisolone was always used for anti-rejection therapy. Insulin was withdrawn in 16 cases after a mean of 4 +/- 1 months, independently of steroid dosage reductions. Actuarial patient and graft survival rates were not significantly different, although 6-year outcome tended to be better in the controls (86% versus 93% for patient survival and 67% versus 93% for graft survival). This study suggests that pulsed steroid therapy might be the critical factor in the onset of posttransplant diabetes and that the risk is increased in older patients with chronic interstitial nephrititis.

Preliminary Experience With Intestinal Transplantation in Infants and Children

Objective. This report discusses the preliminary experience with intestinal transplantation in children at the University of Nebraska Medical Center. Patients. During the past 4 years, 16 intestinal transplants have been performed in infants and children. Thirteen have been combined liver and bowel transplants, and the remainder were isolated intestinal transplants. Nearly half of the patients were younger than 1 year of age at the time of surgery, and the vast majority were younger than 5 years of age. All but one had short bowel syndrome. Results. The 1-year actuarial patient and graft survival rates for recipients of liver and small bowel transplants were 76% and 61%, respectively. Eight of 13 patients who received liver and small bowel transplants remain alive at the time of this writing, with a mean length of follow-up of 263 (range, 7 to 1223) days. Six patients are currently free of total parenteral nutrition. All three patients receiving isolated intestinal transplants are alive and free of parenteral nutrition. The mean length of follow-up is 384 (range, 330 to 450) days. Major complications have included severe infections and rejection. Lymphoproliferative disease, graft-versus-host disease, and chylous ascites have not been major problems. Conclusions. Although intestinal transplantation is in its infancy, these preliminary results suggest combined liver and bowel transplants and isolated intestinal transplantation may be viable options for some patients with intestinal failure caused by short bowel syndrome or other gastrointestinal disease in whom long-term total parenteral nutrition is not an attractive option.

Treatment of carcinomas of the uterine cervix which remain bulky after initial external beam radiotherapy: a pilot study using integrated cytotoxic chemotherapy prior to brachytherapy.

The use of cytotoxic chemotherapy (CT) between external beam radiotherapy (EBRT) and intracavitary brachytherapy (BT) in patients with bulky carcinomas of the uterine cervix which regress poorly after initial EBRT has been evaluated in a pilot study. The aim of CT was to limit tumour clonogen repopulation while awaiting further tumour regression in order to improve the BT dose distribution. Between 1989 and 1992, 22 patients with FIGO Stage IIA, IIB and IIIB cervical carcinomas were given two to three cycles of cisplatin-based CT between EBRT and intracavitary BT. Patients were selected for CT if there was bulky residual tumour extending beyond the range of point "A" after completion of EBRT. The median survival of patients with Stage IIA/B and Stage IIIB disease was 24 months and 13 months, respectively. The 5 year actuarial survival rate for patients with Stage IIA/B disease was 42%. There were no long-term survivors among patients with Stage IIIB disease. Survival difference between Stage IIA/B patients and Stage IIIB patients was statistically significant (p < 0.04). 5 year actuarial pelvic control rates were 38% and 0% for Stage IIA/B and Stage IIIB patients, respectively. There were no serious late radiation complications in the entire study group. Bulky carcinomas of the cervix which respond poorly to initial EBRT have a particularly poor prognosis. For Stage IB-IIB patients with persistent bulky disease after EBRT, published reports suggest that a 5 year actuarial survival rate of around 40% can be obtained using higher doses of radiation alone, but the risk of serious late morbidity is considerable. The results of our study suggest that in Stage IIA/B carcinomas of the cervix which remain bulky after initial EBRT, the use of integrated cytotoxic chemotherapy prior to intracavitary BT can give similar 5 year survival rates but with minimal treatment related morbidity.

Polytetrafluoroethylene bypasses to infrapopliteal arteries without cuffs or patches: A better option than amputation in patients without autologous vein

This study was undertaken to evaluate our results of polytetrafluoroethylene (PTFE) tibial and peroneal artery bypasses done for limb salvage. Within a group of patients undergoing infrainguinal limb salvage bypasses at our institution between January 1986 and May 1995, 63 patients faced an immediate amputation, had no autologous vein on duplex examination and operative exploration, and had only a tibial or peroneal artery as an outflow vessel for bypass. Most of these patients (82%) had two or more prior ipsilateral infrainguinal bypasses. These 63 patients underwent 66 PTFE bypasses to a tibial or peroneal artery without a distal anastomotic vein cuff or an adjunctive arteriovenous fistula. Our results were then compared with those reported from infrapopliteal (crural) bypasses performed with alternate autologous vein sources or PTFE in conjunction with various recommended adjuncts. The 3- and 5-year cumulative primary graft patency rates for our PTFE infrapopliteal bypasses were 39%+/-7% and 28%+/-9%, respectively. Secondary graft patency rates were 55%+/-8% and 43%+/-10% at 3 and 5 years, respectively. Limb salvage rates were 71%+/-7% at 3 years and 66%+/-8% at 5 years. Two-year actuarial patient survival rate was only 67%+/-7%. These results indicate that a PTFE bypass to an infrapopliteal artery remains a worthwhile option in patients without usable autologous vein. The secondary patency and limb salvage rates were acceptable in this setting and were not significantly different from the best results reported with prosthetic tibial/peroneal bypasses with distal vein cuffs or patches (74% at 1 year; 58% at 3 years), arteriovenous fistulas (71% at 1 year) or composite arm vein grafts (39% and 29% at 3 and 5 years, respectively).

Results of pediatric oncology group protocol 8104 for infants with stages D and DS neuroblastoma.

We determined the complete response and survival rates for infants with disseminated (stage D) neuroblastoma that followed therapy identical to that for regional disease. In those infants whose disease excluded cortical bone metastases (stage DS), we determined complete response rates achieved either spontaneously or with stage D therapy. Eighty-eight patients with metastatic disease received induction chemotherapy followed by a second operation, the results of which determined additional therapy. Twenty-five patients were observed after diagnosis, without chemotherapy, until a second operation. The complete response (CR) rates for patients with stage D disease after induction chemotherapy and postinduction surgery were 26% and 52%, respectively, and for immediately treated patients with stage DS disease 69% and 77%, respectively. Fifty-four percent of initially observed patients with stage DS disease achieved CR after a second operation; 44% were never treated beyond these two operations. Five-year actuarial survival rates for patients with stage D and for all those with stage DS disease were 60% (SE = 6%) and 90% (SE = 5%), respectively. Improved survival rates for patients with stage D disease were achieved on this protocol but remained considerably lower than those for infants with less extensive disease. Rates of survival for patients with stage DS disease were achieved with therapy less aggressive than in published series.

Cutaneous angiosarcoma of the head and neck. A therapeutic dilemma.

Because of a tendency for diffuse, clinically undetectable local spread, cutaneous angiosarcoma is difficult to treat with surgery alone. Radiation is a rational treatment modality for this disease, because a wide region of dermis can be treated, whereas the underlying normal tissues are spared. The authors retrospectively studied 14 patients with dermal angiosarcoma of the head and neck who were treated with electron-beam radiation from 1970 to 1989. Primary tumors were located in the scalp and forehead (11 patients) and in the upper face (3 patients). Eleven patients presented with multiple foci of disease. Three patients were treated with radiotherapy alone; the other 11 were treated with chemotherapy (10 patients) and/or surgery (7 patients). Surgical excisions were limited procedures for patients whose disease readily could be encompassed; total scalp resections were not performed. Patients were irradiated with a multiple-field electron-beam technique. Six patients presented postoperatively for radiotherapy with no macroscopic disease in the treatment field and were given a median dose of 60 Gy (range, 50-66 Gy) over a median of 40 days (range, 37-43 days). Eight patients were irradiated with clinically evident disease; doses ranged from 55 to 75 Gy over a median of 44 days (range, 33-66 days). Five of the six patients irradiated without clinically detectable disease were controlled in the treatment field, but only two are currently disease free. Of the eight patients irradiated with macroscopic tumor, initial disease recurrence occurred in the radiation field in two patients and at the radiation field margin in three patients. The actuarial 5-year control rates above the clavicles for patients irradiated with and without clinical disease were 24% and 40%, respectively (P = 0.03). The 5-year actuarial incidence of distant metastases for all patients was 63%. The 5-year actuarial survival rate for patients irradiated with and without clinical disease was 13% and 50%, respectively (P = .04). Radiation is an effective modality for treating local disease, especially when used after surgical resection of macroscopic tumor. Our current strategy is to resect clinically evident tumor in patients presenting with focal, limited disease, and to follow this resection with moderate dose, very wide-field radiation. The survival outcome for patients presenting with diffuse multifocal disease is bleak, but some patients can be controlled infield with radiation. There must be continued efforts to develop effective systemic therapy.

Controversial transplant issues

Background: Little information is available on the indications for, and the efficacy and timing of, liver transplantation in patients with primary sclerosing cholangitis (PSC). This issue is particularly relevant because prolonged survival has been reported in patients who do not undergo transplantation. Methods: Long-term results of therapeutic interventions including liver transplantation were assessed in a representative series of 51 patients. Patient survival was compared with that expected from prognostic models. Results: Actuarial symptom-free survival rate inpatients treated by nontransplantation biliary surgery (n = 23) was 35% at 10 years. Actuarial survival rate from onset of PSC (56% at 10 years) was identical to that expected from the prognostic model. Actuarial patient (n = 28) survival rate 5 years after transplantation was greater that expected from prognostic models (89% versus 31%; P < .05). Cumulative actuarial incidence of cancer 5 and 10 years after the onset of PSC was 13% and 31%, respectively. Conclusions: Liver transplantation improves the prognosis of patients with PSC. Failure to identify patients who will benefit from nontransplantation therapeutic interventions or in whom a cancer will develop, and the risk associated with previous abdominal surgery, suggest that liver transplantation should be indicated early after onset of symptoms. (Reproduced with permission from Mosby-Year Book, Inc.)

Sequential internal mammary artery grafting: a viable alternative in myocardial revascularization

The internal mammary artery has become the conduit of choice in myocardial revascularization. The expanded use of this ideal conduit for sequential grafting has enhanced its application. Between March 1985 and June 1993, 245 consecutive patients underwent revascularization of the myocardium with internal mammary artery bypass grafts with at least one sequential anastomosis. There were 186 men and 59 women, with a mean age of 65.1 (range 40–82) years. Unstable angina was present in 141 patients (57.6%) and 36 patients (14.7%) had left main coronary artery stenosis (>50%). Before surgery, five patients (2.0%) were in New York Heart Association (NYHA) class II, 113 (46.1%) in class III, and 127 (51.8%) in class IV. There were a total of 1041 coronary artery grafts, mean 4.2 (range 2–7) grafts per patient and 528 sequential left internal mammary artery anastomoses, mean 2.2 per patient. Hospital mortality rate was 2.4% (six patients). Almost two-thirds of the patients experienced no hospital complications. The most frequent complication included arrhythmia in 36 patients (14.7%), respiratory insufficiency in 15 (6.1)% and temporary left phrenic nerve palsy in ten (4.1%). Mean follow-up was 37.0 (range 1–94.2) months. The mean(s.e.m.) actuarial survival rate for patients discharged from hospital was 94.8(1.6)% at 36 months and 82.4(5.0)% at 72 months. At follow-up of 222 patients, 185 (83.3%) were symptom-free in NYHA class I and 27(12.2%) were in class II. Though technically demanding, multiple sequential internal mammary artery grafting is feasible and can be accomplished with low hospital mortality and morbidity. The added complexity, length of procedure and potential for inadequate volume flow through the application of sequential grafting did not adversely affect the clinical outcome in the series

Second primary lung cancer and relapse: treatment and follow-up.

During a 14-year period (1980-1993) second primary lung cancer or relapse was treated in 44 consecutive patients. Thirty-seven patients had synchronous (n = 18) or metachronous (n = 19) second primary lung cancer. Ten synchronous tumors were ipsilateral and treated contemporarily with five pneumonectomies, three lobectomies and two double wedge resections. The bilateral synchronous lesions (8 patients) were treated by staged bilateral thoracotomy (mean interval; 2 months). The first resection consisted of a lobectomy in six patients and wedge resection in two. The second one was a wedge resection in six patients and a lobectomy in two. In the metachronous presentation 15 patients (79%) were asymptomatic and detected by follow-up chest X-ray. In this group the first operation was a lobectomy in 12 patients, a wedge resection or segmentectomy in 6 and a pneumonectomy in 1. The second one was a wedge resection in nine patients, a lobectomy in six and completion pneumonectomy in four. Seven patients, all of them asymptomatic, had local recurrence from their primary lung cancer. The first lung resection was a lobectomy in five patients and a wedge resection in two. The second one was completion pneumonectomy in five patients and completion lobectomy in two. We had no operative death. The actuarial over-all 5-year survival rate after the second pulmonary resection for second primary lung cancer was 38.3% with a median survival time of 13.5 months. The synchronous presentation had a better survival than the metachronous one (46.2% and 25.9%), respectively). The actuarial overall 5-year survival rate for patients with relapse was 38.1% with a median survival time of 37 months. We may conclude that an aggressive surgical approach is safe, effective and warranted in patients with either a second primary lung cancer or relapse from their primary lung cancer. Moreover, for early detection of the second lesions, follow-up at a maximum of 6-monthly intervals should be continued for more than 5 years after the first resection.

Comparison of Transjugular and Surgical Portosystemic Shunts on the Outcome of Liver Transplantation

To analyze the effect of previous transjugular intrahepatic portosystemic shunt (TIPS) vs surgical portosystemic shunt (SPS) on the outcome of orthotopic liver transplantation (OLT). A case series of 38 patients who underwent OLT: 25 with a previous TIPS and 13 with a previous SPS. A liver transplant center and interventional radiology service in a private, tertiary referral medical center. Eighteen men and seven women who had a TIPS before OLT were compared with nine men and four women who had an SPS before OLT. Operative transfusion requirements, operative time, length of hospital stay, postoperative liver chemistry studies, and graft and patient survival. Compared with patients who had an SPS, patients who had a TIPS had significantly less median transfusion requirements for packed red blood cells (5 vs 12 U), fresh-frozen plasma (0 vs 8 U), and thrombocytes (0 vs 1 U). The median operative time (9 vs 13 hours), length of intensive care unit stay (3 vs 5 days), and length of hospital stay (12 vs 24 days) were also significantly less in patients who had a TIPS. The 2-year actuarial patient survival rate was 92% in both groups. In patients undergoing OLT, TIPS is associated with reduced operative transfusion requirements, operative time, and length of intensive care unit and hospital stays compared with SPS. In the potential liver transplant candidate with refractory complications of portal hypertension, TIPS is preferred to SPS.

100 Consecutive liver transplants in infants and children: An 8-year experience

Orthotopic liver transplantation has become the treatment of choice for most children and infants with end-stage liver disease. The purpose of this retrospective study was to examine the results of 100 consecutive liver transplants performed in infants and children at a single institution. During an 8-year study period (July 1984 to December 1992), 100 pediatric liver transplants were performed in 76 patients. Thirty-four patients (44.7%) were infants (mean age, 7.0 months; mean weight, 6.1 kg), and 42 (55.3%) were children (mean age, 8.2 years; mean weight, 30.6 kg). There were 36 reduced-size liver transplants (RLT) and 64 whole-size transplants (WLT). Eight infants (23.5%) and 10 children (20.7%) required retransplantation. After transplantation, 71% of the patients had one or more rejection episodes, 66% had one or more infections, 17.1% had biliary complications, and 39.4% required one or more reoperations. There were 17 deaths. The actuarial 8-year survival rate for the patients with biliary atresia was 82.3%; for all infants in this series, it was 77.6%. No difference in patient survival was noted when RLT was compared with WLT. The overall 8-year actuarial patient survival rate for infants and children was 77.3%.

Gastric tube transposition for cancer of the hypopharynx and cervical oesophagus.

A study of 20 cases of gastric tube transposition following total laryngopharyngoesophagectomy during an eight-year period is presented. The site of the tumour was: hypopharynx in 13 cases (12 pyriform sinus, 1 post-cricoid); and cervical oesophagus in seven cases. There were nine (45 per cent) Stage III lesions and 11 (55 per cent) Stage IV lesions (UICC, 1987). Post-operative morbidity rate was 15 per cent. Hospital mortality rate was 10 per cent (cause of death was myocardial infarction). Anastomotic fistula rate was five per cent. Excluding hospital mortality, the three year actuarial survival rate was 35 per cent for the whole series and 53 percent for patients with hypopharyngeal cancer. The actuarial survival rate for patients with oesophageal cancer at one and two years was 41 and zero per cent respectively. The transposition of a tubed stomach provided successful swallowing in two-thirds of the patients for a period of more than a year and these patients developed good neoesophageal speech.