Ex-situ in-vivo liver surgery

1616

be supportive of systems already in place and understood within the country, blending to meet shortfalls within an established usepattern rather than introducing a new system whose rules are unfamiliar. An example of a new syringe technology successfully introduced is that of WHO/UNICEF in the Expanded Programme on Immunusation (EPI), including use in immunisation programmes in Romania. It relies on cheap, portable, multi-fuel autoclaves, and re-sterilisable plastic syringes. These were new, both in terms of technique and technology, to the areas for which they were intended and so had to be accompanied by continuous training and monitoring of good practice and by supplies in sufficient quantity and long term. Only by such a committment has EPI remained unaffected by HIV transmission fears. Division of Hospital Infection, Central Public Health Laboratory, London NW9 5HT, UK

P. N. HOFFMAN

Expanded Programme on Immunisation, World Health Organisation,

P. EVANS

Geneva, Switzerland

Radiosensitivity in AIDS patients SIR,-Dr Vallis suggests (April 13, p 918) that glutathione depletion might explain the striking radiation sensitivity seen in patients with AIDS. A testable prediction of this hypothesis is that these patients become more radiosensitive as their disease progresses. We have examined this proposal after reviewing the notes of 690 AIDS patients seen at our hospital since 1986. Nineteen evaluable treatment episodes were identified among 15 patients who had received irradiation to the oropharynx for Kaposi sarcoma (doses ranging from 120 Gy in three fractions to 30 Gy in ten). A mucositis score was assigned after a review of the notes (1= erythema only; 2 ulceration of mucosa; 3 severe mucositis with difficulty swallowing semisolids). =

=

Uttley et al first described plasmid-mediated vancomycin resistance in E faecium infecting a cluster of patients in a nearby hospitalWe report here our preliminary findings of another serious challenge to treatment of infections with Efaecium-namely, a sudden increase in high-level gentamicin resistance (minimum inhibitory concentration [MIC] > 2000 mg/1). Although first reported in the USA in 1988,3 high-level gentamicin resistance in E faecium was detected in only two inpatients at King’s College Hospital until December, 1990, when, within 30 days, we isolated these strains from seven patients in a liver ward. None had received gentamicin within the past six weeks but three had been treated with cephalosporins and two with ciprofloxacin, which are known to encourage enterococcal colonisation and superinfection.4 The MICs of gentamicin and ampicillin were greater than 2048 and 64 mg/1, respectively. In broth mating experiments we have now transferred this high-level gentamicin resistance from a vancomycin-sensitive E faecium to a vancomycin-resistant clinical isolate of E faecium. The donor was distinguishable from the recipient by its resistance to chloramphenicol and rifampicin, sucrose and rhamnose fermentation, and a vancomycin MIC of 1 mg/l. Transfer occurred with a frequency of 10-6 per recipient. Further studies are in progress to characterise the transferable genetic elements. It seems probable that this genetic event will occur sooner or later in strains of Efaecium that infect patients, and our results reiterate the need, as suggested by others,5 for diagnostic microbiology laboratories to screen all enterococcal isolates for high-level gentamicin resistance by a 120 ug disc.6 Clinical infection by vancomycin-resistant strains that are also resistant to high levels of gentamicin will be almost beyond the bounds of antimicrobial chemotherapy, although some may be susceptible to the new lipopeptide, daptomycin.7 The survival of E faeciu11l on hands,8 and our recovery of one high-level gentamicin-resistant strain from ward dust, indicate the potential for epidemic spread and another challenge for hospital infection control. Dr Anne Uttley, Public Health Laboratory, Dulwich Hospital, kmdly provided vancomycin-resistant isolate of Efaecium.

Department of Medical Microbiology, King’s College School of Medicine and Dentistry,

The risk of mucositis seemed to increase with the interval from the first cutaneous Kaposi lesions (figure) to the start of radiotherapy treatment, implying that patients with long-standing disease become more radiosensitive. This would be consistent with a quantitative decline in glutathione over time. This timedependency of AIDS radiosensitivity has not, to our knowledge, been noted. Meyerstein

Institute of Clinical

Middlesex Hospital, London W1 N 8AA, UK

Oncology,

LUKE HUGHES-DAVIES TERESA YOUNG MARGARET SPITTLE

Resistance of Enterococcus faecium to vancomycin and gentamicin S!R,—Optimum antimicrobial treatment of serious infections with enterococci requires the combination of an agent with activity against the bacterial cell wall (eg, penicillin or vancomycin) and one of the aminoglycosides. Against Enterococcus faecium, only gentamicin gives useful synergy in such a combination.! In 1988,

London SE5 9PJ, UK

JIM WADE

Institute of Liver Studies, King’s College School of Medicine and Dentistry

NANCY ROLANDO

Department of Medical Microbiology, King’s College School of Medicine and Dentistry

MARK CASEWELL

1. Chen HY. Resistance of enterococci to antibiotic combinations. J Antimicrob Chemother 1986; 18: 1-8. 2. Uttley AHC, George RC, Naidoo J, et al. High-level vancomycin-resistant enterococci causing hospital infections. Epidem Infect 1989; 103: 173-81. 3. Eliopoulos GM, Wennersten C, Zighelboim-Daum S, Reiszner E, Goldmann D, Moellering RC. High-level resistance to gentamicin in clinical isolates of Streptococcus (Enterococcus) faecium Antimicrob Agents Chemother 1988; 32: 1528-32. 4 Zervos MJ, Bacon AE, Patterson JE, Schaberg DR, Kauffmann CA. Enterococcal superinfection in patients treated with ciprofloxacin. J Antimicrob Chemother 1988; 21: 113-15 5 Hoffmann SA, Moellenng RC. The enterococcus "putting the bug in our ears". Ann Intern Med 1987; 106: 757-61. 6. Sahm DF, Torres C. High-content aminoglycoside disks for determining aminoglycoside-penicillin synergy against Enterococcus faecalis. J Clin Microbiol

1988; 26: 257-60. 7.

8

Eliopoulos GM, Willey S, Reiszner E, Spitzer PG, Caputo G, Moellering RC. In vitro and in vivo activity of LY 146032, a new cyclic lipopeptide antibiotic. Antimicrob Agents Chemother 1986, 30: 532-35. Wade JJ, Desai N, Casewell MW. Hygienic hand disenfection for the removal of epidemic vancomycin-resistant Enterococcus faecium and gentamicin-resistant Enterobacter cloacae. J Hosp Infect (in press).

Ex-situ in-vivo liver surgery SIR,-Progress in liver transplantation has allowed the development of new surgical techniques for hepatic resection. We now describe a procedure that enables the duration of hepatic ischaemia to be extended up to 4-5 h. Coventional liver surgery that involves total vascular exclusion permits normothermic liver ischaemia for up to 90 min.’ However, in some cases resection is not

1617

possible because of the volume and location of the tumour and the need for complex vascular reconstruction. In these cases, results of orthotopic liver transplantation (OLT) have been disappointing.2 In-situ hypothermic liver perfusion3 and extracorporeal ex-vivo liver surgery’ improve the resectability rate of liver tumours. We report our preliminary results of a new ex-situ in-vivo procedure that avoids division of the hepatic pedicle, as in the ex-vivo procedure, but which allows complex liver resection and extended hypothermic liver ischaemia (up to 4 h). Hepatic veins are sectioned to permit the liver to be exteriorised (ex situ) while connected only by the hepatic pedicle (in vivo). A heat exchanger improves and prolongs liver hypothermic ischaemia. The surgical procedure involves a thoraco-abdominal approach, followed by complete mobilisation of the liver and inferior vena cara, venovenous bypass (portal and caval shunting), total vascular exclusion of the liver, and hypothermic (4°C) portal perfusion in the remnant liver with ’Belzer’ solution. The hepatic veins are then sectioned and the liver is placed on a heat exchanger (4°C). The liver remnant hepatic veins are reconstructed and and the liver is flushed (4°C Ringer’s lactate) and reimplanted, revascularised. Since April, 1990, we have operated on 3 patients: a 53-year-old man presented with a hepatocellular carcinoma in an otherwise normal liver; a 56-year-old woman had two colonic metastases; and a 58-year-old man had a haemangioma. Duration of ischaemia ranged from 205 to 230 min, and the packed red cell transfusion requirement ranged from 7 to 58 units. Their postoperative course was uneventful and patients were discharged 18 to 28 days after surgery. All subjects are alive 3 to 11 months later without any sign of recurrence, although we have noted a rise in carcinoembryonic antigen concentration in the second patient. This ex situ in vivo procedure allows 15-20% of normal liver to be conserved and revascularised after 4 h of cold ischaemia, with only temporary postoperative liver insufficiency. Such a procedure is indicated in only selected cases; nevertheless, it allows safe hepatic resection with complex vasclar reconstruction, and could be adopted for malignant or multifocal benign liver tumours involving all but two segments of liver parenchyma.

is

resected,

L. HANNOUN Y. PANIS

Centre for

Surgical Gastroenterology, Hôpital Saint-Antione,

75012 Paris, France

P. BALLADUR E. DELVA J. HONIGER E. LEVY R. PARC

E, Camus Y, Nordlinger B, et al. Vascular occlusions for liver resections: operative management and tolerance to hepatic ischaemia, 142 cases. Ann Surg

1. Delva

1989; 209: 211-18.

Ringe B, Wittekind C, Bechstein WO, Bunzendahl H, Pichlmayr R. The role of liver transplantation in hepatobiliary malignancy. Ann Surg 1989; 209: 88-98. 3. Former JG, Shiu MH, Kinne DW, et al. Major hepatic resection using vascular isolation and hypothermic perfusion. Ann Surg 1974; 180: 644-52. 4. Pichlmayr R, Grosse H, Hauss J, Gubernatis G, Lamesch P, Bretschneider HJ. Technique and preliminary results of extracorporeal liver surgery (bench procedure) and of surgery on the in situ perfused liver. Br JSurg 1990; 77: 21-26. 2.

wide range of different EBV isolates.3 This differential pattern of viral gene expression (LMP + , EBNA2 - ) is not only restricted to Hodgkin’s disease but has also been observed in other EBVassociated malignant diseases-namely, nasopharyngeal carcinoma (NPC),4 AIDS-related lymphoma/ CD30-positive anaplastic large cell lymphomas, and peripheral T cell lymphomas (unpublished observations). Although EBNA2 can regulate LMP expression in an activated B lymphocyte, such control is clearly not necessary in other cellular environments. A controversial aspect of Brousset and colleagues’ work is the transcriptional activity of the EBV BamHI-W fragment in Hodgkin’s disease. This highly repetitive region of the EBV genome is implicated in the transcription of the full repertoire of EBNA genes (ie, EBNAs 1,2,3a,3b,3c, and EBNA-LP), as seen in lymphoblastoid cell lines .6 However, in Burkitt’s lymphoma and in NPC, where EBNA gene expression is restricted to EBNA1 only, BamHI-W transcription is absentand a similar situation would probably exist in Hodgkin’s disease. Thus, in in situ hybridisation studies with 35S-labelled riboprobes we have been unable to detect BamHI-W transcription in 8 patients with Hodgkin’s disease who are positive for both LMP expression and EBER (EBV small RNAs) transcription. Although contradicting Brousset and colleagues’ findings,1 our data, obtained with an established and validated technique, are consistent with present knowledge of EBV gene expression in virally-associated malignant diseases. A thorough analysis of EBV gene transcription in Hodgkin’s disease will help to define the role of EBV in the pathogenesis of this tumour and how it relates to other EBV-associated lymphoid neoplasms. Department of Cancer Studies, University of Birmingham, Birmingham B15 2TJ, UK

LAWRENCE S. YOUNG ELIZABETH M. DEACON MARTIN ROWE

Department of Histopathology, East Birmingham Hospital, Birmingham

JOHN CROCKER

Institute of Pathology, Klinikum Steglitz, Free University of Berlin,

Berlin, Germany

Laboratory of Immunohistology, University Institute of Pathology, Aarhus Kommunehospital, Aarhus, Denmark

7

SIR,-Dr Brousset and colleagues’ comments (May 4, p 1107) about the expression of Epstein-Barr virus (EBV) genes in the tumour cells of Hodgkin’s disease, together with their other findings,t are difficult to reconcile with our original observations (Feb 9, p 320) on the differential expression of EBV-encoded latent gene products in Reed-Sternberg and Hodgkin’s cells. The crux of the matter is expression of the EBV-encoded latent membrane protein (LMP) in the absence of EBV nuclear antigen 2 (EBNA2) in Hodgkin’s disease. Another group has confirmed this finding, using polyclonal rabbit antisera specific for either LMP or EBNA2.2Thus, the lack of EBNA2 expression does not result from the inability of our EBNA2-specific monoclonal antibody (PE2) to recognise a structurally different form of the EBNA2 protein. Indeed, the PE2 monoclonal antibody reacts with EBNA2 from a

STEPHEN J. HAMILTON-DUTOIT GORM PALLESEN

1. Brousset P, Chittal S, Schlaifer D, et al. Detection of Epstein-Barr virus messenger RNA in Reed-Stemberg cells of Hodgkin’s disease by in situ hybridisation with biotinylated probes on specially processed modified acetone methyl benzoate xylene (ModAMex) sections. Blood 1991; 77: 1781-86. 2. Herbst H, Dallenbach F, Hummel M, et al. Epstein-Barr virus latent membrane protein in Hodgkin and Reed-Stemberg cells. Proc Natl Acad Sci USA 1991; 88: 4766-70. 3. Young LS, Alfien C, Hennessy K, et al. Expression of Epstein-Barr virus transformation-associated genes in tissues of patients with EBV lymphoproliferative disease. N Engl J Med 1989; 321: 1080-85. 4. Young LS, Dawson CW, Clark D, et al. Epstein-Barr virus gene expression in nasopharyngeal carcinoma. J Gen Virol 1988; 69: 1051-65. 5. Pallesen G, Hamilton-Dutoit SJ, Rowe M, et al. Expression of Epstein-Barr virus replicative proteins in AIDS-related non-Hodgkin’s lymphoma cells. J Pathol (in 6.

Epstein-Barr virus latent genes in tumour cells of Hodgkin’s disease

HERMANN HERBST GERALD NIEDOBITEK

press). Rogers RP Woisetschlaeger M, Speck SH. Alternative splicing dictates translational start in Epstein-Barr virus transcripts EMBO J 1990; 9: 2273-77. Sample J, Brooks L, Sample C, et al. Restricted Epstein-Barr virus protein expression in Burkitt lymphoma is reflected in a novel EBNA1 mRNA and transcriptional initiation site. Proc Natl Acad Sci USA (in press).

Infusion of intravenous

immunoglobulin via

implantable subcutaneous catheter SIR,-Long-term intermittent therapy with intravenous gammaglobulin (IVIG) is well established. When peripheral infusion sites become unavailable permanent indwelling catheters may be necessary. These carry the risk of infection, which is especially dangerous for the immunocompromised patient, and thrombosis. Infection may be introduced during repeated reconnections for infusions, although catheters may be removed quite easily if infection does develop. To reduce the risk of infection we have treated two hypogammaglobulinaemic patients via an implantable catheter (’Portacath’), in which vascular access is by transcutaneous injection into a reservoir connected by a catheter in