{"title":"Organ transplantation update, part I: liver, intestine, and pancreas.","authors":"Sander Florman, Leona Kim-Schluger","doi":"10.1002/msj.21308","DOIUrl":"https://doi.org/10.1002/msj.21308","url":null,"abstract":"On March 1, 1963, an iconoclastic surgeon named Dr Thomas Starzl performed the first human liver transplants in Colorado. The first 3 patients were a child with biliary atresia, a 48-year-old man with alcoholic cirrhosis and hepatocellular carcinoma, and a 67-year-old man with advanced cholangiocarcinoma. These 3 patients all died within a month of the procedure. Four more patients then received liver transplants in Denver, Boston, and Paris with equally poor results. For the next 3 years, there was a self-imposed moratorium on liver transplantation. During this period, surgical and medical techniques were refined, with improved preservation techniques and the addition of antithymocyte globulin to the immunosuppressant regimen of prednisone and azathioprine. In July 1967, the liver program at Colorado under Dr Starzl was reopened and the first successful liver transplant was performed, in a patient who survived for approximately 1 year before dying from recurrent hepatocellular carcinoma. Despite the early success in the late 1960s and early 1970s, the mortality rate after liver transplant remained high due to the procedure’s technical complexities as well as the lack of medications to adequately counteract rejection of the transplanted organ. The four decades since the pioneering work of Dr Starzl have realized tremendous advancements in the field of liver transplantation. Thousands of lives have been saved after walking through the initial","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"167-8"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21308","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30570974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Recurrent hepatitis C after liver transplantation.","authors":"Patricia Sheiner, Caroline Rochon","doi":"10.1002/msj.21300","DOIUrl":"https://doi.org/10.1002/msj.21300","url":null,"abstract":"<p><p>Infection with hepatitis C virus is the most common indication for liver transplantation in the United States. Although recurrence of hepatitis C virus infection is universal following transplantation, the natural history of posttransplantation hepatitis C varies. In general, however, posttransplant hepatitis C virus infection progresses relatively quickly, with 10%-20% of patients developing cirrhosis within 5 years. Risk factors for severe recurrent hepatitis C include donor age, female sex, treatment of rejection, preservation injury, and high viral load pretransplant or early posttransplant. Type of allograft, infection with cytomegalovirus, or type of calcineurin inhibitor used may not play a role. Treatment with interferon + ribavirin in recurrent hepatitis C virus shows mixed results. Sustained virologic response has been observed in only 8%-30% of patients, and side effects of these medications are considerable. Protease inhibitors are not yet approved for the posttransplant population, but clinical trials are under way.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"190-8"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21300","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30572455","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Intestinal rehabilitation and transplantation for intestinal failure.","authors":"Jang Moon, Kishore Iyer","doi":"10.1002/msj.21306","DOIUrl":"https://doi.org/10.1002/msj.21306","url":null,"abstract":"<p><p>The management of intestinal failure has evolved dramatically in the last decade. This evolution has been in equal part due to continued improvements in outcomes of intestinal transplantation and to recognition of the need for multidisciplinary management of the patient with intestinal failure. This has led to establishment of intestinal rehabilitation programs, centered only in some instances at institutions with established intestinal transplant programs. Alongside this, improved management of parenteral nutrition-associated liver disease is creating a paradigm shift in both intestinal-failure management and in the evolving indications for intestinal transplantation. Unsolved challenges remain: A persistent mortality on the waiting list, especially for patients awaiting combined liver-intestine transplant; late graft loss to chronic rejection, especially in isolated intestine transplant; the role of antibody-mediated rejection; and transplantation in the highly sensitized patient continue to defy satisfactory solution. Notwithstanding these challenges, overall outcomes for patients with intestinal failure are vastly improved today and are approaching those for patients with end-stage renal and liver disease. This review will focus on a comprehensive approach to the patient with intestinal failure, including an overview of intestinal rehabilitation and transplantation. Transplantation outcomes and transplantation of the patient with liver disease are covered elsewhere.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"256-66"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21306","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30572461","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Long-term outcome after liver transplantation.","authors":"Kieron B L Lim, Thomas D Schiano","doi":"10.1002/msj.21302","DOIUrl":"https://doi.org/10.1002/msj.21302","url":null,"abstract":"<p><p>Liver transplantation is a life-saving therapy for patients with end-stage liver disease, acute liver failure, and liver tumors. Over the past 4 decades, improvements in surgical techniques, peritransplant intensive care, and immunosuppressive regimens have resulted in significant improvements in short-term survival. Focus has now shifted to addressing long-term complications and improving quality of life in liver recipients. These include adverse effects of immunosuppression; recurrence of the primary liver disease; and management of diabetes, hypertension, dyslipidemia, obesity, metabolic syndrome, cardiovascular disease, renal dysfunction, osteoporosis, and de novo malignancy. Issues such as posttransplant depression, employment, sexual function, fertility, and pregnancy must not be overlooked, as they have a direct impact on the liver recipient's quality of life. This review summarizes the latest data in long-term outcome after liver transplantation.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"169-89"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21302","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30570975","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Intestinal transplantation outcomes.","authors":"Gabriel E Gondolesi, Héctor M Almau","doi":"10.1002/msj.21301","DOIUrl":"https://doi.org/10.1002/msj.21301","url":null,"abstract":"<p><p>Intestinal transplantation has evolved from being considered an experimental procedure into a clinically accepted therapy for patients with intestinal failure and parenteral nutrition life-threatening complications. Early referral, advances in immunosuppression therapy, standardization of surgical techniques, prophylactic therapy of infections, early diagnosis of rejection, and better posttransplant patient management are some of the changes that have allowed more patients to receive transplants, thus recovering intestinal sufficiency, and at the same time allowing the procedure to spread worldwide. Over the last 2 decades, transplant centers have focused on improving short-term patient survival, which has consequently increased by >20%. It is now clear that even though isolated intestinal-transplant recipients have lower mortality risk on the waiting list, they are at higher risk for long-term graft loss. Mortality is higher on the waiting list and early posttransplant in recipients whose intestinal transplants are associated with liver grafts; however, they have better long-term patient and graft survival. Nevertheless, 3-year actuarial patient survival has not changed over the same period of time, and therefore this is our challenge for the next decade.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"246-55"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21301","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30572460","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Geriatric vision loss due to cataracts, macular degeneration, and glaucoma.","authors":"Joseph W Eichenbaum","doi":"10.1002/msj.21303","DOIUrl":"https://doi.org/10.1002/msj.21303","url":null,"abstract":"<p><p>The major causes of impaired vision in the elderly population of the United States are cataracts, macular degeneration, and open-angle glaucoma. Cataracts and macular degeneration usually reduce central vision, especially reading and near activities, whereas chronic glaucoma characteristically attacks peripheral vision in a silent way, impacting balance, walking, and driving. Untreated, these visual problems lead to issues with regard to taking medications, keeping track of finances and personal information, walking, watching television, and attending the theater, and often create social isolation. Thus, visually impaired individuals enter nursing homes 3 years earlier, have twice the risk of falling, and have 4× the risk of hip fracture. Consequently, many elderly with low vision exercise greater demands on community services. With the prospect of little improvement and sustained visual loss, in the face of poor tolerance of low-vision services and not accepting magnification as the only way to read, clinical depression is common. In many instances, however, early and accurate diagnosis can result in timely treatment and can preserve quality of life. This review will look at current diagnostic and therapeutic considerations. Currently, about 20.5 million people in the United States have cataracts. The number will reach 30 million by 2020. About 1.75 million Americans currently have some form of macular degeneration, and the number is estimated to increase to 2.95 million in 2020. Approximately 2.2 million Americans have glaucoma, and by 2020 that number is estimated to be close to 3.4 million people. It is projected that by 2030 there will be 72.1 million seniors. With some overlap of the above 3 groups conservatively estimated (if you add the 2030 cataract group to the macular degeneration and glaucoma groups), then about 1 in 2 senior individuals by 2030 may have some significant ocular disease, which could account for about 50% of the healthcare budget for the elderly.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"276-94"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21303","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30573428","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Automated analysis of coronary artery disease by computed tomography.","authors":"Juan Gaztanaga, Mario J Garcia","doi":"10.1002/msj.21297","DOIUrl":"https://doi.org/10.1002/msj.21297","url":null,"abstract":"<p><p>Computer-assisted detection systems are widely used in many areas of radiology. Coronary computed tomography angiography is a growing area of clinical cardiology and computer-assisted detection systems play an integral part in analysis. Truly automated systems are still in clinical-trial stages, but manually assisted programs are in clinical use today for calcium scoring as well as plaque burden, composition, and stenosis analysis. They are being used as a tool for confirmation more than for diagnosis. Accurate plaque-composition analysis would be a critical tool for better understanding the mechanisms and effectiveness of novel therapies for coronary atherosclerosis. A need for a complete quick, safe, noninvasive plaque analysis is the goal of automated coronary stenosis detection systems; however, their potential clinical benefit remains unknown.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"295-301"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21297","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30573430","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sukru Emre, Veysel Umman, Bayindir Cimsit, Richard Rosencrantz
{"title":"Current concepts in pediatric liver transplantation.","authors":"Sukru Emre, Veysel Umman, Bayindir Cimsit, Richard Rosencrantz","doi":"10.1002/msj.21305","DOIUrl":"https://doi.org/10.1002/msj.21305","url":null,"abstract":"<p><p>Liver transplantation is the definitive treatment for end-stage liver disease in both children and adults. Advances over the last 2 decades have resulted in excellent patient and graft survival rates in what were previously cases of fatal disorders. These developments have been due to innovations in surgical technique, increased surgical experience, refinements in immunosuppressive regimens, quality improvements in intraoperative anesthetic management, better understanding of the pathophysiology of the liver diseases, and better preoperative and postoperative care. Remarkably, the use of split-liver and living-related liver transplantation surgical techniques has helped mitigate the well-recognized national organ shortage. This review will discuss the major aspects of pediatric liver transplantation as it pertains to indication for transplantation, recipient selection and listing for orthotopic liver transplantation, pre-orthotopic liver transplantation care of children, optimal timing of orthotopic liver transplantation, surgical technical considerations, postoperative care and complications, and patient and graft survival outcomes.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"199-213"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21305","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30572456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Surgical management of hepatocellular carcinoma.","authors":"Parissa Tabrizian, Myron E Schwartz","doi":"10.1002/msj.21307","DOIUrl":"https://doi.org/10.1002/msj.21307","url":null,"abstract":"<p><p>Hepatocellular carcinoma is the sixth most common cancer worldwide and its incidence is rising in Western countries. Liver resection is the treatment of choice in noncirrhotic patients and in cirrhotic patients with well-preserved liver function. Postresection survival rates are in the range of 41-74% at 5 years. Predictors of recurrence include tumor grade, vascular invasion, tumor size, number of tumors, presence of satellites, alpha-fetoprotein level, transfusion, and positive surgical margin. Second hepatic resection for recurrent hepatocellular carcinoma is applicable in about 15% of patients with recurrence. Liver transplantation has become an important element of the therapeutic strategy for hepatocellular carcinoma. Liver transplantation provides excellent outcomes applying the Milan criteria with 5-year survival rates of 70% and low recurrence rates. Intention-to-treat analysis has shown that wide extended indications lead to 25% 5-year survival rates. Expansion of indications beyond the Milan Criteria and use of bridging/downstaging procedures, to convert intermediate advanced stages of hepatocellular cancer within the Milan criteria limits, are counterbalanced by graft shortage and increasing use of marginal donors. Living donor transplantation is an alternative that can eliminate the waiting time and the attendant risk of drop-out.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"223-31"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21307","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30572458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Current management of cholangiocarcinoma.","authors":"Manoj K Singh, Marcelo E Facciuto","doi":"10.1002/msj.21298","DOIUrl":"https://doi.org/10.1002/msj.21298","url":null,"abstract":"<p><p>Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma and remains among the most difficult management problems faced by surgeons. Curative surgery is achieved in only 25% to 30% of patients. Local tumor extent, such as portal vein invasion and hepatic lobar atrophy, does not preclude resection. Long-term survival has been seen only in patients who underwent extensive liver resections, suggesting that bile-duct excision alone is less effective. The majority of patients have unresectable disease, with 20% to 30% incidence of distant metastasis at presentation. Unresectable patients should be referred for nonsurgical biliary decompression, and in potential curative resection candidates the use of biliary stents should be reduced. Liver transplantation provides the option of wide resection margins, expanding the indication of surgical intervention for selected patients who otherwise are not surgical candidates due to lack of functional hepatic reserve.</p>","PeriodicalId":51137,"journal":{"name":"Mount Sinai Journal of Medicine","volume":"79 2","pages":"232-45"},"PeriodicalIF":0.0,"publicationDate":"2012-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1002/msj.21298","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30572459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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