1
|
Thölking G, Siats L, Fortmann C, Koch R, Hüsing A, Cicinnati VR, Gerth HU, Wolters HH, Anthoni C, Pavenstädt H, Suwelack B, Schmidt HH, Kabar I. Tacrolimus Concentration/Dose Ratio is Associated with Renal Function After Liver Transplantation. Ann Transplant 2016; 21:167-79. [PMID: 27003330 DOI: 10.12659/aot.895898] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The calcineurin inhibitor (CNI) tacrolimus (Tac) is an effective immunosuppressant used after liver transplantation (LTx), but is often associated with CNI nephrotoxicity. Currently, there is no simple clinical predictor for CNI nephrotoxicity after LTx. We hypothesized that the Tac metabolism rate - defined as the blood concentration normalized by its daily dose (the C/D ratio) - is associated with post-LTx renal impairment. MATERIAL AND METHODS We analyzed the relationship between the C/D ratio and post-transplant renal function in 179 patients who underwent LTx between 2000 and 2012 and were initially immunosuppressed with Tac, mycophenolate mofetil, and prednisolone. Six months after LTx, 115 patients were categorized into 1 of 2 groups based on their Tac C/D ratio (<1.09 or ≥1.09): fast (n=58) or slow (n=57) metabolizers. The renal function was determined 36 months after LTx using the estimated glomerular filtration rate (eGFR) as described by Cockcroft and Gault. RESULTS At the time of LTx there was no statistically significant difference between the eGFR of fast and slow metabolizers. Six months (P=0.016), 12 months (P=0.001), and 36 months (P=0.018) after LTx, fast Tac metabolizers had significantly more impaired renal function than slow metabolizers. Because of a presumption of CNI nephrotoxicity, 32.8% of fast metabolizers and 14.0% of slow metabolizers were switched from Tac to other immunosuppressants (P=0.027). CONCLUSIONS In this study, the Tac metabolism rate appears to influence renal function after LTx, suggesting that a C/D ratio of <1.09 is associated with increased CNI nephrotoxicity in LTx recipients.
Collapse
Affiliation(s)
- Gerold Thölking
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Lea Siats
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Christian Fortmann
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Raphael Koch
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Anna Hüsing
- Department of Transplant Medicine, University Hospital of Münster, Münster, Germany
| | - Vito R Cicinnati
- Department of Transplant Medicine, University Hospital of Münster, Münster, Germany
| | - Hans Ulrich Gerth
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Heiner H Wolters
- Department of General Surgery, University Hospital of Münster, Münster, Germany
| | - Christoph Anthoni
- Department of General Surgery, University Hospital of Münster, Münster, Germany
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital of Münster, Münster, Germany
| | - Hartmut H Schmidt
- Department of Transplant Medicine, University Hospital of Münster, Münster, Germany
| | - Iyad Kabar
- Department of Transplant Medicine, University Hospital of Münster, Münster, Germany
| |
Collapse
|
2
|
Assfalg V, Hüser N, van Meel M, Haller B, Rahmel A, de Boer J, Matevossian E, Novotny A, Knops N, Weekers L, Friess H, Pratschke J, Függer R, Janko O, Rasoul-Rockenschaub S, Bosmans JL, Broeders N, Peeters P, Mourad M, Kuypers D, Slaviček J, Muehlfeld A, Sommer F, Viebahn R, Pascher A, van der Giet M, Zantvoort F, Woitas RP, Putz J, Grabitz K, Kribben A, Hauser I, Pisarski P, Weimer R, Lorf T, Fornara P, Morath C, Nashan B, Lehner F, Kliem V, Sester U, Grimm MO, Feldkamp T, Kleinert R, Arns W, Mönch C, Schoenberg MB, Nitschke M, Krüger B, Thorban S, Arbogast HP, Wolters HH, Maier T, Lutz J, Heller K, Banas B, Hakenberg O, Kalus M, Nadalin S, Keller F, Lopau K, Bemelman FJ, Nurmohamed S, Sanders JS, de Fijter JW, Christiaans M, Hilbrands L, Betjes M, van Zuilen A, Heemann U. High-urgency kidney transplantation in the Eurotransplant Kidney Allocation System: success or waste of organs? The Eurotransplant 15-year all-centre survey. Nephrol Dial Transplant 2016; 31:1515-22. [DOI: 10.1093/ndt/gfv446] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 12/15/2015] [Indexed: 11/14/2022] Open
|
3
|
Lehner F, Budde K, Zeier M, Wüthrich RP, Reinke P, Eisenberger U, Mühlfeld A, Arns W, Stahl R, Heller K, Witzke O, Wolters HH, Suwelack B, Klehr HU, Stangl M, Hauser IA, Nadalin S, Porstner M, May C, Paulus EM, Sommerer C. Efficacy and safety of conversion from cyclosporine to everolimus in living-donor kidney transplant recipients: an analysis from the ZEUS study. Transpl Int 2014; 27:1192-204. [PMID: 25070687 DOI: 10.1111/tri.12411] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 06/08/2014] [Accepted: 07/20/2014] [Indexed: 01/05/2023]
Abstract
Conversion of living-donor kidney transplant patients from calcineurin inhibitor therapy to an mTOR inhibitor is poorly documented. In the prospective, multicentre ZEUS study, 300 kidney transplant recipients without prior rejection (Banff grade >1) and serum creatinine ≤265 μmol/l were randomized to continue cyclosporine or convert to everolimus at 4.5 months post-transplant. In a post hoc analysis of 80 living-donor recipients, adjusted estimated GFR (Nankivell) at month 12 (the primary endpoint) was 74.3 (95% CI [70.7, 77.9]) ml/min/1.73 m(2) with everolimus versus 63.8 (95% CI [60.0, 67.7]) ml/min/1.73 m(2) ) with cyclosporine, a difference of 10.5 ml/min/1.73 m(2) in favour of everolimus (P < 0.001). From randomization to month 12, adjusted estimated GFR increased by a mean of 9.8 (95% CI [6.2, 13.4]) ml/min/1.73 m(2) with everolimus versus -0.7 (95% CI [-4.6, 3.1]) ml/min/1.73 m(2) ) (P < 0.001) with cyclosporine. There were six biopsy-proven acute rejection episodes in everolimus-treated patients (five Banff grade I) and one episode in cyclosporine-treated patients (Banff grade 1). Overall safety profile was similar between groups. Discontinuation due to adverse events occurred in three everolimus patients (7.1%) and five cyclosporine patients (13.2%) between randomization and month 12. Initiation of everolimus with early elimination of calcineurin therapy is associated with a significant renal benefit at 12 months post-transplant that is observed in both living and deceased-donor recipients. (clinicaltrials.gov NCT00154310).
Collapse
Affiliation(s)
- Frank Lehner
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Bahde R, Vowinkel T, Unser J, Anthoni C, Hölzen JP, Suwelack B, Senninger N, Wolters HH. Prognostic factors for kidney allograft survival in the Eurotransplant Senior Program. Ann Transplant 2014; 19:201-9. [PMID: 24784838 DOI: 10.12659/aot.890125] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The shortage of organ donors has led to the introduction of the Eurotransplant Senior Program (ESP) to optimize the allocation of kidneys from elderly donors by age-matching. In the face of a rapidly aging population, identification of prognostic factors for kidney allograft survival within the ESP population will be of enormous significance. MATERIAL AND METHODS Donor and recipient data from 89 patients transplanted under the ESP protocol between 1999 and 2007 were retrospectively analyzed. Data were correlated with initial graft function, graft survival, acute rejection episodes, serum creatinine levels, glomerular filtration rates, and patient survival using univariate and multivariate analysis. Maximum follow-up was 5 years. RESULTS Cold ischemia time (CIT) >16 hours, body mass index (BMI) ≥25 kg/m(2), and kidney re-transplantation were significant risk factors for delayed graft function (DGF). Odds ratio for primary non-function was significantly increased with prolonged CIT, BMI ≥25 kg/m(2), and duration of renal replacement therapy >69 months. CIT >15 h, DGF, and kidney re-transplantation were associated with poor graft survival (P<0.05). CONCLUSIONS Risk reduction (e.g., aiming at CIT <15 h) and close surveillance of patients at risk appear to be crucial for allograft survival in the ESP.
Collapse
Affiliation(s)
- Ralf Bahde
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Thorsten Vowinkel
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Julia Unser
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Christoph Anthoni
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Jens Peter Hölzen
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Barbara Suwelack
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, Muenster University Hospital, Muenster, Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Heiner H Wolters
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| |
Collapse
|
5
|
Wolters HH, Köhler S, Brockmann JG. Confidence and skills for transplant surgery can be trained with hands-on courses. Transpl Int 2014; 27:e36-7. [PMID: 24386922 DOI: 10.1111/tri.12263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Heiner H Wolters
- Department of General and Visceral surgery, University Clinic Muenster, Münster, Germany.
| | | | | | | |
Collapse
|
6
|
Abstract
Modern oncological liver surgery continues to push the limits of resectability by incorporating an array of new developments in the fields of surgery, anaesthesia and intensive care, oncology, radiology and transplantation medicine. New criteria for determining the resectability of primary and secondary liver tumours have been developed and introduced into national consensus guidelines. Modern tools for improving oncological outcome include the rapid induction of liver hypertrophy prior to major liver resection, downstaging of tumours with advanced chemotherapy protocols, minimally invasive local therapies like radiofrequency ablation and chemo- or radioembolisation, and liver transplantation for non-resectable hepatocellular carcinoma.
Collapse
Affiliation(s)
- F Schmidt
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Münster, Deutschland
| | - N Senninger
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Münster, Deutschland
| | - H H Wolters
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Münster, Deutschland
| | - S T Mees
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Münster, Deutschland
| |
Collapse
|
7
|
Heinzow HS, Brockmann JG, Köhler M, Wolters HH, Senninger N, Schmidt H, Meister T. Liver transplantation versus supraselective transarterial chemoembolization in palliative patients with hepatocellular carcinoma exceeding the Milan Criteria - is it time for a more individual approach? Ann Transplant 2013; 18:515-24. [PMID: 24081430 DOI: 10.12659/aot.884018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND This study evaluated the effect of liver transplantation (LTX) and STACE on overall survival in palliative patients with HCC exceeding Milan criteria. MATERIAL AND METHODS At a single center 63 HCC patients exceeding Milan criteria were retrospectively analyzed. Forty patients underwent STACE as palliative therapy modality and 23 palliative patients were scheduled for LTX. The primary endpoint was overall patient survival. Statistical analysis included Kaplan-Meier method, log rank, chi squared tests and Cox regression model for the identification of prognostic factors. RESULTS There was no significant difference when comparing the 2 groups (LTX vs. no LTX) in terms of Child classification, co-morbidities, underlying disease, and sex. Overall survival was significantly prolonged after LTX was performed (p=0.012). In the Cox regression model, LTX (p=0.021), LTX <3Mo (p=0.047), CHILD stage (p=0.007), AFP (p=0.020), and tumor size of largest HCC nodule <40 mm (p=0.028) were independent prognostic factors for survival. CONCLUSIONS Palliative patients beyond Milan have a significant survival benefit after they received early liver transplantation in comparison with STACE. The current approach to waiting list candidacy based on Milan criteria should be modified with a more individualized approach that considers age, AFP level, and tumor size.
Collapse
|
8
|
Hummel R, Irmscher S, Schleicher C, Senninger N, Brockmann JG, Wolters HH. Aorto-hepatic bypass in liver transplantation in the MELD-era: outcomes after supraceliac and infrarenal bypasses. Surg Today 2013; 44:626-32. [DOI: 10.1007/s00595-013-0513-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
|
9
|
Budde K, Lehner F, Sommerer C, Arns W, Reinke P, Eisenberger U, Wüthrich RP, Scheidl S, May C, Paulus EM, Mühlfeld A, Wolters HH, Pressmar K, Stahl R, Witzke O. Conversion from cyclosporine to everolimus at 4.5 months posttransplant: 3-year results from the randomized ZEUS study. Am J Transplant 2012; 12:1528-40. [PMID: 22642473 DOI: 10.1111/j.1600-6143.2012.03994.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The long-term effect of conversion from calcineurin inhibitor (CNI) therapy to an mTOR inhibitor requires clarification. Following completion of the 12-month, open-label, multicenter ZEUS study, in which 300 kidney transplant recipients were randomized to continue cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant, outcomes were assessed at month 36 (n = 284; 94.7%). CNI therapy was reintroduced in 28.4% of everolimus patients by month 36. The primary efficacy endpoint, estimated glomerular filtration rate (Nankivell, ANCOVA) was significantly higher with everolimus versus the CsA group at month 24 (7.6 mL/min/1.73 m(2) , 95%CI 4.3, 11.0 mL/min/1.73 m(2) ; p < 0.001) and month 36 (7.5 mL/min/1.73 m(2) , 95%CI 3.6, 11.4 mL/min/1.73 m(2) ; p < 0.001). The incidence of biopsy-proven acute rejection from randomization to month 36 was 13.0% in the everolimus arm and 4.8% in the CsA arm (p = 0.015). Patient and graft survival, as well as incidences of malignancy, severe infections and hospitalization, were similar between groups. Kidney transplant patients who are converted from CsA to everolimus at month 4.5 and who remain on everolimus thereafter may achieve a significant improvement in renal function that is maintained to 3 years. There was a significantly higher rate of rejection in the everolimus arm but this did not exert a deleterious effect by 3 years posttransplant.
Collapse
Affiliation(s)
- K Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Wolters HH, Vowinkel T. Risks in life after living kidney donation. Nephrol Dial Transplant 2012; 27:3021-3. [PMID: 22619313 DOI: 10.1093/ndt/gfs150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Heiner H Wolters
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany.
| | | |
Collapse
|
11
|
Bonrath EM, Weber BK, Fritz M, Mees ST, Wolters HH, Senninger N, Rijcken E. Laparoscopic simulation training: Testing for skill acquisition and retention. Surgery 2012; 152:12-20. [PMID: 22341719 DOI: 10.1016/j.surg.2011.12.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 12/23/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND Simulation in laparoscopy leads to skill acquisition. Although many curricula for simulation training have been described, the nature of skill deterioration remains unclear. We evaluated skill acquisition and retention after laparoscopic simulation training. METHODS Thirty-six novices in surgery (medical students) underwent a 5-day curriculum consisting of 9 skills of increasing complexity. Each subject underwent baseline and post-training evaluation after completion of the course. Skill retention testing was measured after 6 weeks (group 1; n = 18) and after 11 weeks (group 2; n = 18). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance. RESULTS Comparison of the baseline and post-training values revealed a significant learning outcome for all exercises in both groups (P < .001). In group 1, skill retention testing found no significant decrease in skill level when compared to post-training values in all but 1 task (extracorporeal knot tying; P = .007). In group 2, differences between skill retention and post-training evaluation were observed for 5 of the 9 tasks (transfer task, positioning, loop tie, extracorporeal knot, and intracorporeal knot; P ≤ .05 for each). CONCLUSION Basic laparoscopic skills can be learned successfully by novices in surgery using a compact curriculum. These skills are retained for at least 6 weeks. Eleven weeks after initial training, skill deterioration is likely, and therefore an opportunity for practice and repetition is desirable.
Collapse
Affiliation(s)
- Esther M Bonrath
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany.
| | | | | | | | | | | | | |
Collapse
|
12
|
Kranz B, Kelsch R, Kuwertz-Bröking E, Bröcker V, Wolters HH, Konrad M. Acute antibody-mediated rejection in paediatric renal transplant recipients. Pediatr Nephrol 2011; 26:1149-56. [PMID: 21461632 DOI: 10.1007/s00467-011-1864-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/12/2011] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
Abstract
Acute antibody-mediated rejections (aAMR) after renal transplantation are defined by rapidly deteriorating graft function, detection of donor-specific antibodies (DSA) and characteristic histological features. In adults, anti-rejection strategies comprise intravenous immunoglobulin (IVIG), steroid pulses, plasmapheresis and rituximab. Data of children with aAMR are scarce. We report four episodes of aAMR in three children (aged 10, 10 and 11 years respectively) occurring early after renal transplantation. Pre-transplant complement-dependent cytotoxicity crossmatches were negative; in the case of re-transplantation repeated antigens were excluded. Basic immunosuppression comprised cyclosporine A, MMF and steroids. All four rejection episodes were histologically proven and associated with acute renal failure. De novo DSAs were detected in two aAMRs; one patient was additionally tested positive for AT1-receptor antibodies. All aAMRs were treated with steroid pulses, tacrolimus, MMF, IVIG, plasmapheresis and one single dose of rituximab. Despite therapy one graft was lost; in the remaining three cases kidney function re-established within 1-8 weeks. At follow-up, 14, 15 and 22 months' post-rejection their GFRs were 65, 88 and 105 ml/min/1.73 m(2) respectively. A combined therapy of steroid pulses, IVIG, plasmapheresis and rituximab is potentially effective in the treatment of aAMR in children.
Collapse
Affiliation(s)
- Birgitta Kranz
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Münster, Waldeyerstrasse 22, 48149 Münster, Germany.
| | | | | | | | | | | |
Collapse
|
13
|
Bonrath EM, Mees ST, Weber B, Wolters HH, Senninger N, Rijcken EM. Laparoscopic simulation training: When do we need a refresher? J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.06.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
14
|
Wolters HH, Heistermann HP, Stöppeler S, Hierlemann H, Spiegel HU, Palmes D. A New Technique for Ureteral Defect Lesion Reconstruction Using an Autologous Vein Graft and a Biodegradable Endoluminal Stent. J Urol 2010; 184:1197-203. [DOI: 10.1016/j.juro.2010.04.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Indexed: 12/22/2022]
Affiliation(s)
- Heiner H. Wolters
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | | | - Sandra Stöppeler
- Surgical Research, Muenster University Hospital, Muenster, Germany
| | - Helmut Hierlemann
- Institute of Textile Technology and Process Engineering, Denkendorf, Germany
| | | | - Daniel Palmes
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| |
Collapse
|
15
|
Bonrath EM, Mees ST, Weber B, Wolters HH, Senninger N, Rijcken EM. Intensive laparoscopic training: The impact of a simplified pelvitrainer curriculum on long-term learning in surgical novices. J Am Coll Surg 2009. [DOI: 10.1016/j.jamcollsurg.2009.06.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
16
|
Bölling T, Janke K, Wolters HH, Glashörster M, Ernst I, Willich N, Brockmann J, Könemann S. Kidney-autotransplantation before radiotherapy: a case report. Anticancer Res 2009; 29:3397-3400. [PMID: 19661363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND A 28-year-old man suffering from a Ewing tumour arising from the 9th-11th ribs with infiltration of neuroforamina without distant metastases was planned to receive radiotherapy following primary intralesional surgery and induction chemotherapy. Due to pleural infiltration and effusion, a hemithorax irradiation with a sequential boost to the primary tumour site had to be administered. Different treatment planning variants failed to provide sufficient radiotherapy planning in view of target volume coverage and avoidance of organs at risk, especially due to high calculated radiation doses potentially compromising the left kidney. MATERIALS AND METHODS To prevent left kidney organ exposure, an autotransplantation of the left kidney into the right fossa iliaca was performed. An infiltration of the kidney was initially excluded. RESULTS Postoperatively, a renal scintigraphy showed a normal function of both kidneys allowing sufficient radiotherapy treatment planning. Target volume coverage was easily obtained using a combination of hemithorax irradiation and a sequential boost by an intensity-modulated-radiotherapy technique. CONCLUSION In difficult individual treatment situations, surgical transpositions as well as organ autotransplantation might be useful in reducing radiotherapy organ dose levels.
Collapse
Affiliation(s)
- Tobias Bölling
- Department of Radiotherapy, University Hospital Münster, Albert-Schweitzer-Str.33, D-48129 Münster, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Mennigen R, Wolters HH, Schulte B, Pelster FW. Segmental resection of the duodenum for gastrointestinal stromal tumor (GIST). World J Surg Oncol 2008; 6:105. [PMID: 18826622 PMCID: PMC2567321 DOI: 10.1186/1477-7819-6-105] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 09/30/2008] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumors of the gastrointestinal tract. The biological appearance of these tumors reaches from small lesions with benign appearance to aggressive sarcomas. Only 3-5% of GISTs are localized in the duodenum. There is a controversy, if duodenal GISTs should be treated by a duodenopancreatectomy or by a limited resection of the duodenum. CASE PRESENTATION A 29-year-old man presented with an acute upper gastrointestinal bleeding from a submucosal tumor located in the proximal part III of the duodenum, 3 cm distal of the papilla of Vater. After an emergency laparotomy with ligation of tumor-feeding vessels in a primary hospital, definitive surgical therapy was performed by partial resection of the duodenum with a duodenojejunostomy. Histology revealed a GIST with a diameter of 2.5 cm and <5 mitoses/50 high power fields, indicating a low risk of malignancy. Therefore no adjuvant therapy with Imatinib was initiated. CONCLUSION GISTs of the duodenum are a rare cause of upper gastrointestinal bleeding. Partial resection of the duodenum is a warranted alternative to a duodenopancreatectomy, as this procedure has a lower operative morbidity, while providing comparable oncological results.
Collapse
Affiliation(s)
- Rudolf Mennigen
- Department of General and Visceral Surgery, Muenster University, Muenster, Germany.
| | | | | | | |
Collapse
|
18
|
Abstract
Simultaneous pancreas-kidney transplantation is the treatment of choice for patients suffering from type 1 diabetes mellitus and end-stage renal failure secondary to diabetic nephropathy. Until 1995, about 90% of pancreas transplantations were performed with exocrine drainage into the bladder. Since then the proportion of pancreas transplants with enteric drainage increased steadily because of frequency of complications and long-term disadvantages of bladder drainage. However, the use of enteric drainage removes the opportunity to monitor pancreatic allograft function either by measuring urinary amylase or by carrying out biopsy via cystoscopy. We report a new technique of exocrine pancreatic drainage into the recipient duodenum. This modification places the pancreas graft including the duodenal anastomosis in a retroperitoneal location and, importantly, allows easy graft monitoring via gastroscopy.
Collapse
Affiliation(s)
- Richard Hummel
- Klinik und Poliklinik für Allgemeine Chirurgie, Universitätsklinikum Münster, Münster, Germany
| | | | | | | | | |
Collapse
|
19
|
Abstract
BACKGROUND AND AIMS Living donor nephrectomy (LDN) has evolved a variety of different surgical techniques. Minimal invasive strategies were introduced to benefit the healthy donors. This paper attempts to identify the best possible practise in live kidney donation with special respect to donor safety. MATERIALS AND METHODS We present a single-centre experience of 173 live kidney donations and describe the surgical technique of open retroperitoneal donation in detail and by video sequences. Additionally, the evidence for donor safety (mortality and morbidity) and the integrity of the graft function are reviewed, comparing different surgical techniques for LDN. RESULTS Focussing on maximal donor safety, a retroperitoneal access seems mandatory. Very detailed informed consent, including the offer for different retrieval techniques, has led to a total of 163 open and 10 hand-assisted retroperitoneal live kidney donations at our institution. Published and own data reveal longer operating and warm ischaemic times for minimal invasive kidney removal when compared with open technique. Adequate perioperative analgesia (peridural catheter) provides comparable patient comfort, duration of hospital stay, complications and graft function although there are some procedure-associated risks for minimal invasive techniques. CONCLUSION The special ethical situation of live donation necessitates maximal donor safety. Although open antero-lateral incision and retroperitoneal access does provide some inconveniences for the surgeon, we are convinced that this and the hand-assisted retroperitoneal approach are the only two options for LDN.
Collapse
Affiliation(s)
- Jens G Brockmann
- Klinik und Poliklinik für Allgemeine Chirurgie, Universitätsklinikum Münster, Walderyerstrasse 1, 48149 Münster, Germany.
| | | | | |
Collapse
|
20
|
Wolters HH, Palmes D, Brockmann J, Suwelack B, Hertle L, Senninger N, Brinkmann O. Therapeutical options in ureteral necrosis following kidney transplantation. Transpl Int 2006; 19:516-8. [PMID: 16771875 DOI: 10.1111/j.1432-2277.2006.00310.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
21
|
Abstract
Colon perforation due to diverticulitis is a life-threatening complication in the postoperative course of kidney transplantation. In the immunocompromised patient a diagnosis of diverticulitis is difficult to make. We report a 53-year-old woman being kidney transplanted 14 years ago with known diverticulosis. She was admitted with acute severe pain in the lower left abdomen. Abdominal computed tomography (CT) scan indicated a diagnosis of intestinal abscess in the small pelvis. Laparotomy showed a covered sigma perforation with abscess located in the small pelvis (Hinchey-I). Because of the immunocompromised situation of the patient we performed a Hartmann procedure. Her postoperative course was uneventful. In a 6-month interval the intestinal continuity restoration was performed. Twelve days after discharge the patient was readmitted with reduced renal function and increased infection parameters. During physical examination the abdomen was tender. The patient complained of abdominal pain in the left upper abdomen and additional pain in the left shoulder. An antibiotic therapy using ciprofloxacin was already initiated owing to a urinary tract infection. An abdominal CT scan was performed and indicated an intestinal abscess in the left upper abdomen. Laparotomy showed an abscess involving transverse colon, distal jejunum, and proximal ileum (Hinchey-II). Segmental resection of the left colonic flexure, proximal jejunum, and ileum was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The present casuistry emphasizes that the immunocompromised patient can undergo diverticulitis twice, and that primary anastomosis is a feasible option for patients with localized peritonitis due to complicated diverticulitis.
Collapse
Affiliation(s)
- M Utech
- Department of General Surgery, University of Münster, Munster, Germany.
| | | | | | | | | | | |
Collapse
|
22
|
Wolters HH, Brockmann JG, Diller R, Suwelack B, Krieglstein CF, Senninger N. Kidney Transplantation Using Donors With History of Diabetes and Hypertension. Transplant Proc 2006; 38:664-5. [PMID: 16647437 DOI: 10.1016/j.transproceed.2006.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Due to the persistant organ shortage for kidney transplantation, donor selection has changed in the past years. Although hypertension and diabetes mellitus are known to be risk factors for renal insufficiency, kidneys from donors with these diagnoses in their history have been accepted for kidney transplantation even with an increased risk of poor graft function. Herein we have reported our experience with kidney transplantation using grafts from donors with both, a history of type II diabetes and hypertension. METHODS Between 2000 and 2005, ten patients were grafted using donors with history of type II diabetes mellitus and hypertension. Mean donor age was 58 +/- 7.5 years and recipient age, 52.2 +/- 15.7 years. Mean HLA mismatch was 0.8 (A); 1.2 (B) and 0.9 (DR). Cold ischemia time was 17.4 +/- 4.1 hours. Immunosuppression was based on CyA (n = 7), tacrolimus (n = 2) or sirolimus (n = 1). RESULTS Six patients (60%) showed good initial function, and four (40%) had delayed graft function (DGF). One patient died at ten weeks due to multiorgan failure. Two (20%) biopsy-proven rejections were diagnosed, one of which was resistant to therapy. Six months after kidney transplantation, 7 (77%, n = 9) showed good graft function (creatinine 1.3 to 2.4 mg/dL), but one patient displayed long-lasting DGF with poor function. CONCLUSION Grafts from donors with a history of diabetes mellitus and hypertension are suitable for kidney transplantation. Elevated rate of DGF (40%) would justify allocation of these organs to local transplant centers to shorten ischemia time and thereby reduce DGF and achieve better long-term results. Identification and detailed evaluation of these donors prior to allocation (eg, HbAlc, biopsy) may help transplant centers to accept these kidneys.
Collapse
Affiliation(s)
- H H Wolters
- Department of General Surgery, University of Münster, Münster, Germany.
| | | | | | | | | | | |
Collapse
|
23
|
Abstract
PURPOSE The organ shortage has led to increasing acceptance of living donation in all transplant centers. Although the risk of impaired long-term outcome seems to be greater using elderly donors, these organs are not generally refused for transplantation. We report our experience with 25 living donor kidney transplantations from donors older than 60 years. METHODS Between 1995 and 2004, 124 living donor procedures were performed in our center from 83 related and 41 unrelated donors. Twenty-five donors (19 female, 6 male) were 60 years or older (mean, 65.3 +/- 3.9 years). The recipient included (10 females and 15 males) showed a higher degree of variance in age (46.1 +/- 14.6 years). The immunosuppressive protocol was cyclosporine (CyA)-based regimen in related cases and tacrolimus-based in unrelated cases. RESULTS We transplanted 16 left and 9 right kidneys from older donors. The mean cold ischemia time was 171 +/- 64 minutes with a second warm ischemia time of 24 +/- 6 minutes. Severe arteriosclerosis made vascular reconstruction by graft interposition necessary in two recipients. The acute rejection rate was 20%. Two patients (8%) required dialysis in the early postoperative course, whereas initial function was excellent in 22 patients (88%). The mean serum creatinine concentration after 12 months was 1.6 +/- 0.3 mg/dL (n = 24) and 2.0 +/- 0.7 mg/dL (n = 16) at 4 years. In comparison, the mean creatinine concentration after 4 years in donors under 60 years was 1.6 +/- 0.9 mg/dL. Our analysis showed no significant difference in long-term graft function comparing young versus old donors in the setting of living donor transplants. CONCLUSION Using living donors older than 60 years for transplantation is a feasible and safe option. The difference in long-term creatinine between young and old donors was not significant.
Collapse
Affiliation(s)
- H H Wolters
- Department for General Surgery, University of Munster, Munster, Germany
| | | | | | | | | | | | | |
Collapse
|
24
|
Wolters HH, Palmes D, Krieglstein CF, Suwelack B, Hertle L, Senninger N, Brinkmann O. Reconstruction of Ureteral Necrosis in Kidney Transplantation Using an Ileum Interposition. Transplant Proc 2006; 38:691-2. [PMID: 16647446 DOI: 10.1016/j.transproceed.2006.01.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Ureteral necrosis is a serious problem in kidney transplantation. Sometimes re-ureterocystostomy is possible, while other cases require an elaborate reconstruction to maintain kidney function. We report our experience with ileum interposition for ureteral reconstruction. METHODS After 9 years of dialysis treatment a 58-year-old patient was grafted using the left kidney of a 59-year-old donor with a cold ischemic time of 9.5 hours. The early postoperative course was uneventful apart from delayed graft function. Immunosuppression consisted of an IL-2-receptor antibody, calcineurin inhibitor, mycophenolate mofetil, and corticosteroids. Discharge serum creatinine was 2.3 mg/dL. In month 4 the patient showed a pararenal urinoma; cystoscopy revealed necrosis of the distal ureter. Operative revision showed urine leakage from the renal pelvis through the urinoma into the bladder. As the whole ureter was necrotic, a re-ureterocystostomy was not possible. The patient's own ureter had been extirpated, and the bladder was too small to do a direct anastomosis between it and the kidney. Consequently, an ileum interposition was performed. RESULTS The postoperative course was uneventful. Kidney function was stable with a nadir creatinine concentration of 2.0 mg/dL 18 months' posttransplantation, and 14 months' post ileal interposition the kidney function was still satisfactory, with a creatinine level of 2.0 mg/dL. CONCLUSION Ureteral necrosis is a serious complication following kidney transplantation. Whenever a re-ureterocystostomy or an uretero-ureterostomy is not possible, the interposition of the ileal segment represented a safe procedure to deal with this problem.
Collapse
Affiliation(s)
- H H Wolters
- Department of General Surgery, University of Münster, Münster, Germany.
| | | | | | | | | | | | | |
Collapse
|
25
|
Brockmann JG, August C, Wolters HH, Hömme R, Palmes D, Baba H, Spiegel HU, Dietl KH. Sequence of reperfusion influences ischemia/reperfusion injury and primary graft function following porcine liver transplantation. Liver Transpl 2005; 11:1214-22. [PMID: 16184569 DOI: 10.1002/lt.20480] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The impact of 3 different reperfusion sequences following orthotopic liver transplantation (OLT) in pigs were evaluated. The reperfusion technique commonly performed is primary portal in order to shorten warm ischemic times (WITs). Experimental and clinical data, usually comparing 2 out of 3 possible reperfusion sequences, provide controversial results. OLT was performed in 24 pigs randomized into 3 groups: primary arterial (A), simultaneous (SIM), and primary portal (P) reperfusion. Hemodynamics were continuously monitored and reperfusion injury and primary graft function were assessed by standard serum parameters, histopathological findings, immunohistochemistry for heme oxygenase 1 (HO-1), and heat shock protein 70 (HSP 70). Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and gamma-glutamyl transpeptidase (gammaGT) following reperfusion were significantly increased for group A when compared to groups SIM and P. Hemodynamics showed significant differences after reperfusion compared to physiological data; differences in group comparisons were not significant. The bile production/100 g liver/hr was significantly higher for group SIM (1.15 mL) compared to group P (0.66 mL) and group A (0.62 mL). Histology and immunohistochemistry significantly correlated with functional results and outcome. Histological score was best for group SIM and worst for group A. HSP 70, being visualized mainly in the hepatocytes, showed higher expression for groups SIM and P. Inversely, HO-1, found in perisinusoidal cells, showed highest expression after primary arterial reperfusion. In conclusion, although associated with a 10-minute longer warm ischemic time, simultaneous reperfusion causes the least reperfusion injury with superior primary transplant function. Primary arterial reperfusion showed the worst overall outcome and highest degree of HO-1 expression.
Collapse
Affiliation(s)
- Jens G Brockmann
- Department of Surgical Research-General Surgery, University Hospital Münster, Germany
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Wolters HH, Heidenreich S, Dame C, Brockmann JG, Senninger N, Krieglstein CF. Living donor kidney transplantation: impact of differentiated immunosuppressive regimen. Transplant Proc 2005; 37:1616-7. [PMID: 15866688 DOI: 10.1016/j.transproceed.2004.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Recipients of related (R) and unrelated (NR) living donor kidney transplantations (LDKTX) receive immunosuppressive (IS) therapy 5 days in advance in order to achieve low rates of acute rejection episodes. We herein report the different IS regimens for R and NR transplants as well as acute rejection and primary function rates. METHODS Ninety-five LDKTX (69% R, 31% NR) were performed with mean cold ischemia time (CIT) of 145 +/- 32 minutes. In R-LDKTX mean age of recipients was 31 +/- 12.5 years. This cohort included 41 men and 25 women whose mean age was 50 +/- 11.1 years. The therapeutic regimen for R-LDKTX included CyA/MMF/prednisone; for NR-LDKTX, FK/MMF/prednisone. Among the recipients of NR grafts the mean recipient age was 51 +/- 8.5 years. This cohort included 23 men and 6 women whose donor mean age was 50 +/- 8.8 years. The mean HLA mismatch among R-LDKTX (2.3) was significantly less than that in the NR-LDKTX cohort (3.51). RESULTS At a mean follow-up of 35 months, 94.7% of grafts were functioning. DGF was seen in only one recipient (1%). Three grafts were lost due to acute (R) or chronic (NR) rejection or to multiorgan failures. Two recipients died with functioning grafts. Biopsy-proven rejection episodes were observed in 17.2% of NR-LDKTX and 9% of R-LDKTX. In R-LDKTX 50% of rejection episodes were corticoid-sensitive, while 33% needed ATG, and 16% were treated by a switch to FK. In NR-LDKTX 20% of rejections were corticoid-sensitive, 40% needed ATG, and 40% were treated with rapamycin rescue therapy. CONCLUSION Although HLA mismatching is significantly different between R- and NR-LDKTX, no difference in outcome was observed, which may be due to the specific therapeutic regimen and short CIT.
Collapse
Affiliation(s)
- H H Wolters
- Department of General Surgery, University of Münster, Münster, Germany.
| | | | | | | | | | | |
Collapse
|
27
|
Wolters HH, Palmes D, Heidenreich S, August C, Brockmann J, Senninger N, Dietl KH. Long-term follow-up of double kidney transplantation using a score for evaluation of marginal donors*. Transpl Int 2005; 18:453-7. [PMID: 15773966 DOI: 10.1111/j.1432-2277.2004.00068.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To face the problem of organ shortage, marginal grafts from 36 donors which had been refused for single transplantation were used for double-kidney transplantation (D-KTX). The residual kidney function was evaluated by the Muenster double kidney score. In a 5-year period kidneys from 57 marginal donors were transferred to our center. According to the Muenster double kidney score, the kidneys were distributed to single, double or refusal of transplantation. Sixteen male and 20 female donors were used for D-KTX (70+/-9.3 years, range 53-86). Thirty-six recipients (23 male, 13 female; 60.5+/-6.9 years) were double-grafted within a mean cold ischemic time of 19.3+/-3.4 h. Immunosuppression varied according to human leukocyte antigen (HLA)-mismatch. Graft and patient survival was observed up to 5 years. Initial graft function rate was 69%. Two recipients had a primary nonfunction (5.5%) and nine recipients suffered from delayed graft function (DGF; 25%). One-, 2-, 3-year creatinine values were 1.6 +/- 0.5, 1.9 +/- 0.6 and 2.2 +/- 0.7 mg/dl, respectively. One-, 2-, 3-, 4- and 5-year function rate was 93.7%, 93.5%, 81.8%, 76.4% and 55%, respectively (n = 32, 31, 22, 17 and 9). Acute rejection rate was 19%. 4 grafts were lost to chronic rejection (months 22, 25, 28, 48). Six (16%) died in long-term follow-up because of pneumonia (n = 2), carcinoma of the lung (n = 1), cardial complications (n = 2) and multiorgan failure (n = 1). D-KTX is a safe way to face the problem of organ shortage. However, a score for preoperative evaluation of marginal kidneys for single, dual or refusal of transplantation is essential.
Collapse
Affiliation(s)
- Heiner H Wolters
- Department of General Surgery, Muenster University Hospital, Germany.
| | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
BACKGROUND With living donation, in addition to the medical risk, the financial risk for the donor is essential, especially in case of complications that potentially can led to disability and loss of work. We report the experiences of those who have donated a kidney in our transplant center. METHODS We contacted 80 donors who donated a kidney at least 6 months prior to evaluation: 72% answered 33 questions. [mean age: 54 +/- 10 (33-75) years; 69% living related, 31% unrelated]. RESULTS Of the 80 donors contacted, 91% (53) reported to have no financial expenses due to donation; 9% (5) had expenses, but only few of them clarified exact amount. One donor had to borrow money to cover the lack when he was unable to perform his job. Another claimed the disparity between normal salary and payment from insurance company as a financial expense. Evaluation procedure prior to donation was organized variously: some donors were on holiday while evaluated, some officially were ill, others had to take off some days without payment. None of the donors lost his or her job due to donation. CONCLUSION The financial risk of living donation is theoretically well covered by different insurances. However, some of the donors had to cover some expenses by themselves. Fortunately, so far in our center no major complications occurred and all donors went home in good health after donation. If costs are covered when a healthy donor loses his or her ability to work due to donation remains unclear since no donor has experienced this problem.
Collapse
Affiliation(s)
- H H Wolters
- Department of General Surgery, Universitätsklinikum Münster, Münster, Germany.
| | | | | |
Collapse
|
29
|
Wolters HH, Vowinkel T, Heidenreich S, Brockmann J, August C, Krieglstein CF, Senninger N, Dietl KH. Expanding the donor pool using marginal organs: single-center experience with 36 double-kidney transplantations in 5 years. Transplant Proc 2003; 35:2099. [PMID: 14529853 DOI: 10.1016/s0041-1345(03)00678-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- H H Wolters
- Department of General Surgery, Universitätsklinikum Münster, Münster, Germany
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Wolters HH, Vowinkel T, Brockmann J, Palmes D, Heidenreich S, Dietl KH. Living donor renal transplantation--experience with 50 patients in 5 years. Transplant Proc 2002; 34:2216. [PMID: 12270370 DOI: 10.1016/s0041-1345(02)03208-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- H H Wolters
- Department of General Surgery and Transplantation, University Hospital Münster, Münster, Germany
| | | | | | | | | | | |
Collapse
|
31
|
Stähle D, Vogel T, Wolters HH, Brockmann J, Vowinkel T, Menzel J, Hermann M, Senninger N, Dietl KH. Screening for clostridiae and treatment of clostridiae contamination to prevent fatal infections after liver transplantation. Transplant Proc 2002; 34:2292-3. [PMID: 12270403 DOI: 10.1016/s0041-1345(02)03240-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D Stähle
- Department of General Surgery, University Hospital of Muenster, Muenster, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Vowinkel T, Wolters HH, Brockmann J, Vogel T, Stähle D, Heidenreich S, Menzel J, Senninger N, Dietl KH. End-stage liver and kidney disease: results of combined transplantation. Transplant Proc 2002; 34:2276-7. [PMID: 12270396 DOI: 10.1016/s0041-1345(02)03233-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- T Vowinkel
- Department of General Surgery, University Hospital Münster, Münster, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
The necessity of operative treatment of abdominal aortic aneurysm (AAA) is reported in an increasing number of patients after renal transplantation as a result of improved renal graft long-term survival. In these patients, aortic surgery however, places the allograft at risk for ischemic damage. We present a first case of AAA stenting in a kidney-grafted patient. This procedure helped us avoid ischemia of the graft, which showed excellent function pre- and postoperatively. The patient had an uneventful recovery with no evidence of renal dysfunction and was discharged in good condition 7 days after stenting. This case demonstrates a useful alternative for the repair of AAA in kidney-grafted patients.
Collapse
Affiliation(s)
- Heiner H Wolters
- Department of General Surgery, University Hospital Münster, Münster, Germany.
| | | | | | | | | |
Collapse
|
34
|
Wolters HH, Vowinkel T, Schult M, Heidenreich S, Senninger N, Dietl KH. Fibromuscular dysplasia in a living donor: early post-operative allograft artery stenosis with successful venous interposition. Nephrol Dial Transplant 2002; 17:153-5. [PMID: 11773483 DOI: 10.1093/ndt/17.1.153] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Heiner H Wolters
- Department of General Surgery, Universitätskliniküm Münster, Westf.-Wilhelms Universität, Waldeyerstrasse 1, D-48149 Münster, Germany.
| | | | | | | | | | | |
Collapse
|
35
|
Wolters HH, Schult M, Heidenreich S, Chariat M, Senninger N, Dietl KH. The anastomosis between renal polar arteries and arteria epigastrica inferior in kidney transplantation: an option to decrease the risk of ureter necrosis? Transpl Int 2001; 14:442-4. [PMID: 11793043 DOI: 10.1007/s001470100011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ureteral necrosis after renal transplantation is often the result of impaired perfusion due to loss of donor polar arteries. A way of preserving polar arteries is their anastomosis with the A. epigastrica inferior. In three cases (aged 49-, 58-, and 63 years), 9.3 % of 33 living donors, we detected donor polar arteries on both sides, and anastomosed the polar artery to the A. epigastrica inferior with microsurgical methods. Intraoperatively, the flow was measured by flowmeter, in the postoperative course duplexsonography and MR-angiography was performed. In all three cases we noted a bluish, ischemic parenchym mass of 10-25 % of the kidney and ureter. It recovered immediately, however, after the polar artery had been reconstructed. Intraoperative measurement showed a high flow on the polar- and the main renal artery. Duplexsonography and MR-angiography documented a good flow on the A. epigastrica anastomosis. There have been no signs of ureteral problems at all. After a mean follow-up time of 26 months, the mean creatinine level is 1.46 mg/ml. Ureteral necrosis after kidney transplantation is mostly the result of a lack of perfusion of the polar arteries of the lower kidney pole. If arteriosclerotic lesions inhibit an anastomosis with the renal artery, the anastomosis with the A. epigastrica inferior seems to be a useful alternative.
Collapse
Affiliation(s)
- H H Wolters
- Department of Surgery/General Surgery, University of Münster, Waldeyerstrasse 1, 48 129 Münster, Germany.
| | | | | | | | | | | |
Collapse
|
36
|
Affiliation(s)
- M N Chariat
- Surgery, University School of Medicine, Münster, Germany
| | | | | | | | | | | |
Collapse
|
37
|
Schult M, Wolters HH, Lellé RJ, Winde G, Senninger N. Outcome of surgical intervention for rectoneovaginal fistulas in Mayer-Rokitansky-Kuester-Hauser syndrome. World J Surg 2001; 25:438-40. [PMID: 11344394 DOI: 10.1007/s002680020151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Creation of a neovagina to treat vaginal atresia or aplasia in Mayer-Rokitansky-Kuester-Hauser syndrome must always be followed by long-term application of dilators to avoid shrinkage. However, rectoneovaginal fistulas are caused by chronic alteration and consecutive necrosis of the posterior neovaginal wall. We evaluated retrospectively the postoperative outcome of rectal wall and neovaginal reconstruction using a standardized surgical technique in an exclusive collection of women. Eight women with a mean age of 28 years (range 22-31 years) were treated for rectoneovaginal fistulas in our clinic. Preoperatively, proctoscopy, sphincter manometry, endoluminal rectal ultrasonography, and colonoscopy were performed; and regular postoperative follow-up by digital examination and rectoscopy were obligate. The standard surgical procedure via a perineal approach included fistulectomy and closure of the mucosa and rectal wall followed by a levatorplasty. All but one woman had a temporary colostomy. After 2 weeks the patients were allowed to wear vaginal dilators of a smaller size. Within the mean follow-up period of 20 months, reintervention was necessary twice because of late fistula relapse detected by proctoscopy, barium enema, and subjective symptoms. Morbidity was 25% (n = 2) due to secondary superficial wound healing or urinary tract infection. The average time of the hospital stay was 13 days (10-14 days). One patient complained of vaginal shrinkage and underwent local estrogen therapy with a good functional result 3 months later. Proper fistulectomy and surgical reconstruction with interpositioning of well perfused muscle layers achieved good functional outcome with an acceptable number of minor morbidities. Local estrogen treatment is helpful for avoiding scarification and decreasing the neovaginal size.
Collapse
Affiliation(s)
- M Schult
- Department of Surgery, University of Muenster, 48129 Muenster, Germany.
| | | | | | | | | |
Collapse
|
38
|
Dietl KH, Wolters HH, Marschall B, Kisters K, Heidenreich H, Senninger N. [Results of double kidney transplantation from elderly donors]. Langenbecks Arch Chir Suppl Kongressbd 1998; 115:165-7. [PMID: 14518234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
From July 1996 to November 1997 13 patients underwent "two-in-one"-kidney transplantation from marginal donors. Up to now all renal grafts show a stable function measuring an average creatinin of 1.73 mg/dl after an average follow up of 8.2 month. To take the decision between "one-in-one" or "two-in-two" transplantation in marginal donors we developed a specific score. This score needs more evaluation because of the still small amount of patients undergoing double-kidney-transplantation.
Collapse
Affiliation(s)
- K H Dietl
- Allg.-chirurgische Universitätsklinik Münster
| | | | | | | | | | | |
Collapse
|