Structured diabetes self-management education and its association with perceived diabetes knowledge, information, and disease distress: Results of a nationwide population-based study

OBJECTIVE

To evaluate, how participation in structured diabetes self-management education (DSME) programs is associated with perceived level of knowledge about diabetes, information needs, information sources and disease distress.

METHODS

We included 796 ever- and 277 never-DSME participants of the population-based survey "Disease knowledge and information needs - Diabetes mellitus (2017)" from Germany. Data on perceived level of diabetes knowledge (12 items), information needs (11 items), information sources (13 items) and disease distress (2 indices) were collected. Multiple logistic regression analyses were used to examine the association of DSME-participation with these outcomes.

RESULTS

DSME-participants showed a higher level of diabetes knowledge compared to never-DSME participants, particularly in aspects concerning diabetes in general (odds ratio 2.53; 95% confidence intervals 1.48-4.33), treatment (2.41; 1.36-4.26), acute complications (1.91; 1.07-3.41) and diabetes in everyday life (1.83; 1.04-3.22). DSME-participants showed higher information needs regarding late complications (1.51; 1.04-2.18) and acute complications (1.71; 1.71-2.48) than DSME never participants. DSME-participants more frequently consulted diabetologists (5.54; 3.56-8.60) and diabetes care specialists (5.62; 3.61-8.75) as information sources. DSME participation was not associated with disease distress.

CONCLUSION

DSME is a valuable tool for improving individual knowledge about diabetes. However, DSME should focus more on psychosocial aspects to reduce the disease burden.

New 2D layered structures with direct fluorine–metal bonds: MF(CH3COO) (M: Sr, Ba, Pb)

New coordination polymers with 2D network structures with fluorine directly coordinated to the metal ion were prepared both via mechanochemical synthesis and fluorolytic sol–gel synthesis.

Seroepidemiological Studies of Arboviruses in Africa

The literature on sero-epidemiological studies of flaviviral infections in the African continent is quite scarce. Much of the viral epidemiology studies have been focussing on diseases such as HIV/AIDS because of their sheer magnitude and impact on the lives of people in the various affected countries. Increasingly disease outbreaks caused by arboviruses such as the recent cases of chikungunya virus, dengue virus and yellow fever virus have prompted renewed interest in studying these viruses. International agencies from the US, several EU nations and China are starting to build collaborations to build capacity in many African countries together with established institutions to conduct these studies. The Tofo Advanced Study Week (TASW) was established to bring the best scientists from the world to the tiny seaside town of Praia do Tofo to rub shoulders with African virologists and discuss cutting-edge science and listen to the work of researchers in the field. In 2015 the 1st TASW focussed on Ebola virus. The collections of abstracts from participants at the 2nd TASW which focused on Dengue and Zika virus as well as presentations on other arboviruses are collated in this chapter.

Lebens- und Versorgungssituation von Schlaganfallpatienten

Trotz einer gut etablierten Dokumentation in der Qualitätssicherung der Akutbehandlung beim Krankheitsbild Schlaganfall sind Daten zur Lebensund Versorgungssituation betroffener Patienten im weiteren Verlauf nach Entlassung aus der Akuttherapie nur spärlich vorhanden. Im Qualitätssicherungsprojekt Schlaganfall Nordwestdeutschland wurde eine fragebogenbasierte Erhebung drei Monate nach Entlassung aus dem akut behandelnden Krankenhaus durchgeführt. Ziel der Studie war die Erhebung der Lebensund Versorgungssituation einschließlich der Re-Insulthäufigkeit, der Mortalität und der funktionellen Leistungsfähigkeit. 3 632 Patienten nahmen an der Follow-up-Untersuchung teil, davon hatten etwa zwei Drittel die Diagnose eines ischämischen Insultes und etwa 20% eine TIA. Die Mortalität im Zeitraum zwischen Entlassung und Follow-up lag bei 5,0% und die Re-Insulthäufigkeit bei 3,5%. Standardisierte Nachbefragung von Schlaganfallpatienten liefern wichtige Informationen zum weiteren Krankheitsverlauf, die auch für die akut behandelnde Klinik wertvolle Hinweise enthalten.

[Gender-Specific Differences in Liver Transplantation]

Liver transplantation is the treatment of choice for acute hepatic failure or endstage liver disease. Long-time outcome following liver transplantation has been increased as a result of improvements in surgical technique, perioperative management, organ procurement and immunuosuppression. Differences in liver disease, access and allocation to liver transplantation as outcome due to gender have been reported. This review highlights the important differences in the field of liver transplantation.

Tacrolimus effects and side effects after liver transplantation: is there a difference between immediate and extended release?

BACKGROUND

Immunosuppressive therapy after orthotopic liver transplantation (OLT) requires a high degree of patient compliance to guarantee safety and avoid side effects. In 2007, prolonged-release tacrolimus was launched in Europe to improve compliance. In this prospective observational crossover single-center trial, we analyzed effects and side effects of prolonged-release tacrolimus in OLT patients.

METHODS

LT patients at our center were included if they were older than l8 years of age, had had the procedure at least 6 months prior, and were outpatients currently on twice-daily tacrolimus. Patients were observed for 6 months before switching to once-daily tacrolimus. Patient history, clinical examination, and laboratory examinations were recorded on inclusion as well as after 3, 6, 9, 12, and 18 months.

RESULTS

The rates of rejection, hypertension, hypercholesterolemia, and diabetes mellitus were compared during twice-daily and once-daily tacrolimus. Similarly, laboratory parameters were identical during both periods with the exception of glycated hemoglobin, which was significantly elevated under once-daily tacrolimus (P = .00l).

CONCLUSION

Converting patients to extended-release tacrolimus with was safe in terms of rejection, hypertension, and hypercholesterolemia as well as renal and liver functions. Further investigations concerning pharmacokinetics and glucose metabolism will be needed to evaluate prolonged-release tacrolimus.

[Hilar cholangiocarcinoma: right versus left hepatectomy]

INTRODUCTION

Right-sided hepatectomy including segment 1 and right trisectionectomy are typical approaches to surgical treatment of hilar cholangiocarcinoma. In this study we have compared the oncological capacity of this approach to left-sided hepatectomy. PATIENTS AND PROCEDURES: In 223 patients referred to our institution 150 hepatic resections were performed: 14 hilar resections, 68 right and 68 left hepatectomies.

RESULTS

Survival after curative (R0) and palliative surgery was significantly superior to that in patient with exploration or no surgery at all (p < 0.0001). 5- and 10-year survival after right versus left hepatectomy was 29 and 22 % versus 21 and 7 % (p = 0.204). If hospital mortality was eliminated, survival after right hepatectomy was marginally significantly superior to that after left-sided hepatectomy (p = 0.041). Hospital mortality was 13 % after right compared to 4 % after left hepatectomy (p = 0.069). The R situation was of prognostic importance following right and the N situation after left hepatectomy (p = 0.038 and 0.01, respectively). Vascular resection - in right-sided procedures performed as "hilar en bloc resection" - did not influence the outcome.

CONCLUSIONS

Low perioperative mortality after left-sided resection and, obviously, inferior oncological radicality are features of left hepatectomy. These features do not detract from the importance of left hepatectomy which is an indispensable approach to surgically treated patients with hilar cholangiocarcinoma.

Melatonin induces transcriptional regulation of Bim by FoxO3a in HepG2 cells

Background:

Melatonin induces apoptosis in many different cancer cell lines, including hepatocellular carcinoma cells. However, the responsible pathways have not been clearly elucidated. A member of the forkhead transcription factors' family, FoxO3a, has been implicated in the expression of the proapoptotic protein Bim (a Bcl-2-interacting mediator of cell death). In this study, we used human HepG2 liver cancer cells as an in vitro model to investigate whether melatonin treatment induces Bim through regulation by the transcription factor FoxO3a.

Methods:

Cytotoxicity of melatonin was compared in HepG2 hepatoblastoma cells and primary human hepatocytes. Proapoptotic Bim expression was analysed by reverse transcriptase–polymerase chain reaction and western blot. Reporter gene assays and chromatin immunoprecipitation assays were performed to analyse whether FoxO3a transactivates the Bim promoter. Small interfering RNA (siRNA) was used to study the role of FoxO3a in Bim expression. Immunofluorescence was performed to analyse FoxO3a localisation in HepG2 cells.

Results:

Melatonin treatment induces apoptosis in HepG2 cells, but not in primary human hepatocytes. The proapoptotic effect was mediated by increased expression of the BH3-only protein Bim. During melatonin treatment, we observed increased transcriptional activity of the forkhead-responsive element and could demonstrate that FoxO3a binds to a specific sequence within the Bim promoter. Furthermore, melatonin reduced phosphorylation of FoxO3a at Thr³² and Ser²⁵³, and induced its increased nuclear localisation. Moreover, silencing experiments with FoxO3a siRNA prevented Bim upregulation.

Conclusion:

This study shows that melatonin can induce apoptosis in HepG2 hepatocarcinoma cells through the upregulation of proapoptotic Bim mediated by nuclear translocation and activation of the transcription factor FoxO3a.

Localized modulation of rotating waves in Taylor-Couette flow

We report the results of an experimental study on the multiplicity of states in Taylor-Couette flow as a result of axial localization of azimuthally rotating waves. Localized states have been found to appear hysteretically from time-dependent Taylor-Couette flow at Reynolds numbers significantly above the onset of wavy Taylor vortices. These localized states have the shape of a modulated rotating wave and differ significantly from global modulated wavy Taylor vortex states in their spatial characteristics. Axial localization of rotating waves is accompanied with a significant increase in size of the underlying pair of Taylor vortices. Our work reveals that localization provides a mechanism for the appearance of multiple time-dependent states in Taylor-Couette flow.

Implantation of the liver during reperfusion of the heart in combined heart-liver transplantation: own experience and review of the literature

BACKGROUND

There are only a few reports about combined heart-liver transplantations. The surgical techniques differ widely, ranging from sequential implantation of the organs to simultaneous transplantations. We report our experience with simultaneous, combined heart-liver transplantations without using a veno-venous bypass demonstrating that this is a feasible surgical technique.

METHODS

Since 2005, we performed 4 combined heart-liver transplantations by implanting the liver during the reperfusion period of the newly implanted heart. We retrospectively reviewed patient clinical data and outcomes.

RESULTS

The mean operative time was 534 ± 247 minutes and the ischemia times for heart and liver were 190 ± 72 minutes (cold ischemia time for the heart), 98 ± 96 minutes (warm ischemia time for the heart), 349 ± 101 minutes (cold ischemia time for the liver), and 36.25 ± 3.5 minutes (warm ischemia time for the liver). Three patients were discharged from the hospital after an uneventful clinical course. One patient died due to multi-organ failure during the intensive care unit stay on the 23rd postoperative day.

CONCLUSION

We suggest that combined, simultaneous heart-liver transplantation without veno-venous bypass is a feasible surgical technique.

Liver transplantation for hepatocellular carcinoma--is there a risk of recurrence caused by intraoperative blood salvage autotransfusion?

BACKGROUND/AIMS

The use of intraoperative blood salvage autotransfusion (IBSA) during surgical approaches may contribute to tumour cell dissemination. Therefore, IBSA should be avoided in cases of malignancy. However, the risks of IBSA might be acceptable in liver transplantation (LT) for selected small hepatocellular carcinoma (HCC).

METHODS

In total, 136 recipients of LT with histologically proven HCC in the explanted liver were included in this analysis. With regard to tumour recurrence, 40 patients receiving IBSA despite HCC (IBSA group) were compared to 96 patients without IBSA (non-IBSA group).

RESULTS

Milan criteria as assessed in the explanted liver were fulfilled in 24 of 40 IBSA patients and 58 of 96 non-IBSA patients (p = 0.85). Five of 40 patients in the IBSA group and 18 of 96 patients in the non-IBSA group experienced tumour recurrence (p = 0.29). In spite the theoretical risk of tumour cell dissemination, the recurrence rate was not increased in the IBSA group.

CONCLUSION

Our results indicate that IBSA does not modify the risk of HCC recurrence. Therefore, in highly selected HCC patients undergoing LT, the use of IBSA appears to be justified.

[Hepatocellular carcinoma and cholangiocarcinoma]

Hepatocellular carcinoma and cholangiocarcinoma are relatively rare tumors of the gastrointestinal tract in western Europe but their incidence has been increased in recent years. Newly diagnosed intrahepatic lesions or intrahepatic cholestasis require extensive laboratory tests and imaging studies in order to confirm the diagnosis of hepatocellular carcinoma, intrahepatic or extrahepatic cholangiocarcinoma. The treatment options range from liver resection or liver transplantation to conservative measures (in cases of non-resectable lesions). This review article aims to provide an overview on the diagnostic options and the subsequent treatment.

Liver transplantation utilizing old donor organs: a German single-center experience

INTRODUCTION

Due to the current profound lack of suitable donor organs, transplant centers are increasingly forced to accept so-called marginal organs. One criterion for marginal donors is the donor age >65 years. We have presented herein the impact of higher donor age on graft and patient survival.

PATIENTS AND METHODS

Since 2004, 230 liver transplantations have been performed at our center, including 54 donor organs (23.5%) from individuals >65 years of age. We performed a retrospective analysis of recipient and graft survivals.

RESULTS

The overall 1-year mortality was 22.2% (12/54) among recipients of organs from older donors versus 19.5% among recipients whose donors were <65 years. When donor organs were grouped according to age, the 1-year mortality in patients receiving organs from donors aged 65-69 years was 30% (6/20); 70-74 years, 29.4% (5/17); and donors >75 years, 5.9% (1/17). There was no significant correlation between mortality rate and the number of additional criteria of a marginal donor organ.

DISCUSSION

The current lack of donor organs forces transplant centers to accept organs from older individuals; increasingly older patients are being recruited for the donor pool. Our results showed that older organs may be transplanted with acceptable outcomes. This observation was consistent with data from the current literature. It should be emphasized, however, that caution is advised when considering the acceptance of older organs for patients with hepatitis C-related cirrhosis.

End wall effects on the transitions between Taylor vortices and spiral vortices

We present numerical simulations as well as experimental results concerning transitions between Taylor vortices and spiral vortices in the Taylor-Couette system with rigid, nonrotating lids at the cylinder ends. These transitions are performed by wavy structures appearing via a secondary bifurcation out of Taylor vortices and spirals, respectively. In the presence of these axial end walls, pure spiral solutions do not occur as for axially periodic boundary conditions but are substituted by primary bifurcating, stable wavy spiral structures. Similarly to the periodic system, we found a transition from Taylor vortices to wavy spirals mediated by so-called wavy Taylor vortices and, on the other hand, a transition from wavy spirals to Taylor vortices triggered by a propagating defect. We furthermore observed and investigated the primary bifurcation of wavy spirals out of the basic circular Couette flow with Ekman vortices at the cylinder ends.

Nonlinear defects separating spiral waves in Taylor-Couette flow

Stable domain walls which are realized by a defect between oppositely traveling spiral waves in a pattern-forming hydrodynamic system, i.e., Taylor-Couette flow, are studied numerically as well as experimentally. A nonlinear mode coupling resulting from the nonlinearities in the underlying momentum balance is found to be essential for the stability of the defects. These nonlinearly driven defects separate spiral domains and act either as a phase generating or annihilating defect. Specific phase differences of either 0 or pi between the participating traveling waves are a characteristic feature of this defect. The influence of a symmetry breaking externally imposed flow on the spiral domains and the defects is studied. The numerical and experimental results are in excellent agreement.

Organ recipients suffering from undifferentiated neuroendocrine small-cell carcinoma of donor origin: a case report

BACKGROUND

Transmission of donor-derived cancer by organ transplantation is rare, but the risk has been increasing due to the aging donor pool. Undifferentiated neuroendocrine small-cell carcinoma is an aggressive tumor with the tendency to spread. Herein we have demonstrated different approaches to treat organ recipients with transmitted tumors.

METHODS AND RESULTS

Grafts were retrieved from a decreased donor without any history of previous diseases. Autopsy was not performed after donation. The recipient of the liver graft presented with suspected nodules on routine abdominal ultrasound. After computed tomography (CT) scan, biopsy confirmed the diagnosis of a small-cell carcinoma. Donor origin was unequivocally identified by DNA fingerprinting. Despite chemotherapy the patient died 7 months after orthotopic liver transplantation (OLT). All involved transplantation centers were informed immediately following diagnosis. The male kidney recipient underwent detailed diagnostic work-up to exclude tumor transmission. One year after transplantation, liver metastases caused by a histologically proven small-cell carcinoma from the same donor were apparent. Chemotherapy was immediately started and the graft was removed. Despite continued treatment the tumor progressed and the patient died after repeated intestinal complications. The pathological examination of the explanted second kidney graft did not show any tumor infiltration.

CONCLUSION

Therapeutic regimens in recipients suffering from donor-derived carcinoma differ depending on the transplanted organ. Graft removal of non-life-sustaining organs and discontinuation of immunosuppressive medication should result in complete tumor rejection. Minimizing the risk of tumor transmission, a CT scan might be advisable in donors of more advanced age.

Spirals vortices in Taylor-Couette flow with rotating endwalls

A Hopf bifurcation with translational invariance has been widely considered as an appropriate model for the appearance of spiral vortices in counter-rotating Taylor-Couette flow. Our experimental work demonstrates that flow conditions close to the axial boundaries are responsible for the type of bifurcation scenario, i.e., either asymmetric pure traveling waves or more complex behavior, such as defect states or symmetric mixed states appearing from a Hopf bifurcation. The measurements were performed in the first Taylor-Couette experiment with independently rotating endwalls confining the system in axial direction. The rotation rate of the (synchronous) endwalls is found to be an essential control parameter for the spatial amplitude distribution of the traveling waves and also reflects symmetry of the corresponding flow pattern appearing from the Hopf bifurcation.

[Indications and results of palliative gastric resection in advanced gastric carcinoma]

BACKGROUND

Gastric carcinoma is often diagnosed at UICC stage 3 b or 4. R0 resection can be achieved only in very few such cases. Even for these patients the 5-year survival rate is less than 5 %. Surgical palliation is traditionally reserved for the treatment of severe tumour complications not responding to other forms of treatment.

PATIENTS AND METHODS

We report on 21 patients who underwent palliative resection for gastric carcinoma at our institution between 2004 and 2007. Ten of these were assigned to palliative surgical treatment pre-operatively while this choice was made for 11 patients on the grounds of the intra-operative findings. We performed 17 gastrectomies, 3 proximal gastric resections and one distal gastric resection.

RESULTS

It has been shown that the patients have an improved overall survival time as compared to patients who received non-surgical treatment. The perioperative risk was reasonable when patients were carefully selected. Median survival for resected patients was 16 months. 80 % of patients were alive after 6 months and approximately 60 % of patients were alive after 12 months. The perioperative mortality was 0 % with a mean hospital stay of 12 days. All patients were discharged home with proper bowel passage and analgesia as individually required.

CONCLUSIONS

We are convinced that palliative gastric resection provides a pronounced survival benefit over any other palliative treatment options. Patients also have an improved quality of life.

Localized spirals in Taylor-Couette flow

We present a type of spiral vortex state that appears from a supercritical Hopf bifurcation below the linear instability of circular Couette flow in a Taylor-Couette system with rigid end plates. These spirals have been found experimentally as well as numerically as "pure" states but also coexist with "classical" spirals (or axially standing waves for smaller systems) which typically appear from linear instability in counterrotating Taylor-Couette flow. These spiral states have an axial distribution of the strongly localized amplitude in the vicinity of the rigid end plates that confine the system in the axial direction. Furthermore, they show significantly different oscillation frequencies compared to the critical spiral frequencies. Despite the localization of the amplitude near the ends, the states appear as global states with spirals that propagate either toward the middle from each end of the system or vice versa. In contrast to classical spirals, these states exhibit a spatial or a spatiotemporal reflection symmetry.

Stabilization of domain walls between traveling waves by nonlinear mode coupling in Taylor-Couette flow

We present a new mechanism that allows the stable existence of domain walls between oppositely traveling waves in pattern-forming systems far from onset. It involves a nonlinear mode coupling that results directly from the nonlinearities in the underlying momentum balance. Our work provides the first observation and explanation of such strongly nonlinearly driven domain walls that separate structured states by a phase generating or annihilating defect. Furthermore, the influence of a symmetry breaking externally imposed flow on the wave domains and the domain walls is studied. The results are obtained for vortex waves in the Taylor-Couette system by combining numerical simulations of the full Navier-Stokes equations and experimental measurements.

Transarterial Chemoembolization Before Liver Transplantation in 60 Patients With Hepatocellular Carcinoma

Tumor recurrence is a major problem after orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC). In 60 patients OLT was performed for HCC after pretreatment by repeated transarterial chemoembolization (TACE). Forty-four recipients exceeded the Milan criteria. Recurrence-free 5-year survival was 65.2% and 5-year freedom from recurrence was 73.2%. During the waiting time, 14 patients experienced minimal change, which did not fulfill the definition of tumor progression according to official oncological criteria. Five-year freedom from recurrence among patients with stable compared with progressive disease was 93.3% versus 28.1%, respectively (P = .0001). A strict TACE pretreatment protocol may select patients with obviously biologically less aggressive tumors, who are suitable for OLT even if the HCC exceeds the commonly accepted listing criteria.

Imperfect Hopf bifurcation in spiral Poiseuille flow

We present the results of an experimental study on the transition to spiral vortices in flow between concentric counter-rotating cylinders in the presence of an axial through-flow, i.e., in spiral Poiseuille flow. The experiments were performed in an apparatus having an aspect ratio Gamma=L/d=22.8 ( L axial length, d gap width between cylinders) and end plates enabling an in and outflow of mass. As a result of an applied axial through-flow the "classical" Hopf bifurcation to spiral vortices (SPI) splits up and a primary and secondary branch of down and upstream propagating SPI, respectively, as well as a transient quasiperiodic flow appear. Downstream propagating SPI resulting from the primary supercritical Hopf bifurcation are either convectively or absolutely unstable. The bifurcation structure observed in this open flow experiment is in qualitative agreement with predictions from theory of Hopf bifurcation with broken reflection symmetry [J. D. Crawford and E. Knobloch, Nonlinearity 1, 617 (1988)] and also in quantitative agreement with results from recent numerical calculations [A. Pinter, M. Lücke, and C. Hoffmann, Phys. Rev. E 67, 026318 (2003); C. Hoffmann, M. Lücke, and A. Pinter, Phys. Rev. E 69, 056309 (2004)].

PEG-hirudin/iloprost Coating of Small Diameter ePTFE Grafts Effectively Prevents Pseudointima and Intimal Hyperplasia Development

OBJECTIVES

Small diameter PTFE grafts are prone to thrombosis and intimal hyperplasia development. Heparin graft coating has beneficial effects but also potential drawbacks. The purpose of this study was to evaluate the experimental efficacy of PEG-hirudin/iloprost coated small caliber PTFE grafts.

METHODS

Thirty-six femoro-popliteal ePTFE grafts (expanded polytetrafluoroethylene, diameter 4 mm) were inserted into 18 pigs. Grafts were randomised individually for each leg and grouped for 3 groups. Group I consisted of native ePTFE grafts, group II were grafts coated with a polylactide polymer (PLA) without drugs and group III grafts were coated with PLA containing a polyethylene glycol (PEG)-hirudin/iloprost combination. The follow-up period was 6 weeks. Patency rates were calculated and development of pseudointima inside the grafts was noted. Thickness of intimal hyperplasia at the distal anastomoses was measured using light microscopy.

RESULTS

Patency rates for group I were 6/9 (67%), for group II 9/10 (90%) and 12/12 (100%) for group III. In groups I and II there was a significant reduction of blood flow proximal to the graft at graft harvest, to 29+/-12 and 28+/-20 ml/min respectively (both p<0.01 versus preoperative value), whilst in group III blood flow, 99+/-21 ml/min, remained at the preoperative level. Subtotal stenosis due to development of pseudointima was noted in each of the native and PLA coated grafts but not in group III grafts. Intimal hyperplasia at the distal anastomosis was lowest in group III.

CONCLUSIONS

The PEG-hirudin/iloprost coating of ePTFE prostheses effectively reduced pseudointima and intimal hyperplasia development and led to superior graft patency.

[Traumatic aneurysm of the superior mesenteric artery associated with a burst- fracture of the second lumbar spine -- unforeseen sequelae of a fall from a ladder!]

Traumatic aneurysms of the superior mesenteric artery, although uncommon, are nevertheless life-threatening because of their high risk of rupture. In this case report the aneurysm was accompanied by a burst fracture of the second lumbar spine nearly at the same height. In a prolonged case the diagnosis of the injury was delayed. The clinical manifestation of repeated episodes of abdominal pain did not recur after resection of the aneurysm and interposition of a venous autograft.

[Resection and reconstruction of the retrohepatic vena cava in combination with liver resections]

Liver resection combined with the resection and reconstruction of the vena cava represents the only potential curative therapy for malignant hepatic tumors with invasion of the vena cava. We performed a liver resection with segmental replacement of the retrohepatic vena cava by synthetic grafts in 29 patients. In three cases, the additional presence of central involvement of all three hepatic veins required ex situ tumor resection. Four patients underwent a simultaneous exstirpation of the primary tumor (kidney or suprarenals). The remaining hepatic veins were reimplanted into the graft in three cases, and in two cases the renal veins were reimplanted. There was no perioperative mortality. A distal arteriovenous fistula was not applied. Five patients revealed postoperative transient liver insufficiency, requiring temporary dialysis in three cases. Two of these patients developed a transient multiorgan failure with the need of mechanical ventilation. 18 patients died during the course of follow-up, 17 of these cases due to recurrent metastases of the primary disease. Infection or thrombosis of the prosthetic vascular graft have not been observed. Beside tumor exstirpation, extended liver resection and concomitant vena cava replacement may prevent embolism as well as the obstruction of the vena cava with lower extremity swelling and the possibility of developing a Budd Chiari syndrome. We were able to achieve a long-term survival for surgically treated patients even in cases with advanced tumor stages.

Liver Transplantation for Hepatocellular Carcinoma in Cirrhosis: Prognostic Parameters

Selection of patients suffering from hepatocellular carcinoma (HCC) in cirrhosis for liver transplantation is based upon the number and diameter of tumor nodules but not with vascular invasion. From 1989 to 2003, 1619 liver transplantations were performed in 1471 patients, including 163 patients with an HCC in cirrhosis. Selection criteria were a maximal diameter of up to 5 cm when the tumor appeared to be uninodular, or up to 3 cm in the case of two or three nodules and no vascular invasion prior to transplantation. The postoperative mortality rate was 1.7%. One-, 5- and 10-year survivals were 88%, 62%, and 51%, respectively. Among 1307 transplantations without HCC, the rates were 90%, 84%, and 76%, respectively (P < .0001). Multivariate analysis identified histopathological grading and vascular invasion to predict survival. A subgroup analysis showed 5-year survivals of 67% and 57% for well versus moderately differentiated tumors with vascular invasion. Liver transplantation is a safe and effective long-term treatment for small HCC in cirrhosis. Exeptions from the morphometric rules may be justified for patients with HCC in cirrhosis who show well or moderately differentiated tumors with vascular invasion.

[Reconstruction of visceral arteries with homografts in excision of the pancreas]

BACKGROUND

At present, surgical treatment with R(0) resection offers the only chance of cure for patients suffering from pancreatic cancer. Carcinomas of the pancreas are frequently diagnosed at an inoperable stage because of local tumor progression by vessel wall infiltration. In a small series of patients, efforts have been made to increase curative resection rates for advanced pancreatic cancer by excision and reconstruction of the involved visceral arteries. Whether this provides clinical benefit remains uncertain.

METHODS

Since 2001 we have been employing "en bloc" tumor resection for advanced pancreatic carcinomas with extended infiltration of visceral vessels. Technical experience was gained previously by performing portal vein resection as well as arterial excision and reconstruction by direct anastomosis in the presence of malignant wall infiltration. A total of ten patients underwent vascular reconstruction by arterial homograft interposition. In six of ten cases, combined extended reconstructions of the hepatic and superior mesenteric arteries were performed. One patient died during the perioperative course due to fulminant bleeding. One patient developed severe diarrhea. During a 3- to 18-month follow-up, one case of liver metastasis and one case of local tumor recurrence were documented.

CONCLUSIONS

In selective cases, operability and R(0) resection can be achieved in advanced pancreatic cancer by performing extended resection procedures with vascular reconstruction using arterial homografts. Vascular substitution of visceral arteries can be conducted without ischemic disturbances of the small bowel and liver. Only a few perioperative complications were observed.

Rosiglitazone improves insulin sensitivity, glucose tolerance and ambulatory blood pressure in subjects with impaired glucose tolerance

AIMS

To determine the effects of rosiglitazone on insulin sensitivity, glucose tolerance and ambulatory blood pressure when administered to subjects with persistent impaired glucose tolerance (IGT).

METHODS

Eighteen subjects with persistent IGT were randomized to receive rosiglitazone 4 mg twice daily or matching placebo for 12 weeks. Evaluation at baseline and at the end of treatment included measurement of whole body insulin sensitivity during a euglycaemic hyperinsulinaemic clamp and deriving an insulin sensitivity index. Changes in glucose and insulin concentration were determined after oral glucose tolerance test (OGTT) and mixed meal tolerance tests, and 24-h ambulatory blood pressure was monitored.

RESULTS

Rosiglitazone significantly improved the insulin sensitivity index by 2.26 micro g/kg per min per pmol/l relative to placebo (P = 0.0003). Four of nine subjects receiving rosiglitazone reverted to normal glucose tolerance and 5/9 remained IGT, although four of these had improved 2-h glucose values. In the placebo group, 1/9 subjects progressed to Type 2 diabetes and 8/9 remained IGT. Following OGTT and meal tolerance test, glucose and insulin area under curve were reduced over 3 and 4 h, respectively. Compared with placebo, ambulatory blood pressure decreased significantly in the rosiglitazone group by 10 mmHg systolic (P = 0.0066) and 8 mmHg diastolic (P = 0.0126).

CONCLUSIONS

Consistent with its effects in patients with Type 2 diabetes, rosiglitazone substantially improved whole body insulin sensitivity and the glycaemic and insulinaemic responses to an OGTT and meal tolerance test in subjects with persistent IGT. Furthermore, rosiglitazone reduced systolic and diastolic ambulatory blood pressure in these subjects.

[Management of bile duct injuries following laparoscopic cholecystectomy]

INTRODUCTION

The aim of the present study is to analyse our experience in the treatment of bile duct injury following laparoscopic cholecystectomy and to propose an algorithm for the management.

PATIENTS AND METHODS

From January 1990 to March 2002 175 patients with biliary tract injury sustained during laparoscopic cholecystectomy were treated at our institution. We divided the injuries into five basic types according to the mechanism, localisation and time of manifestation of the lesion. Risk factors affecting the outcome after operative repair were analysed by uni- and multivariate analysis.

RESULTS

There were 46 patients with peripheral bile leak (Type A). Endoscopic treatment was successful in 92 %. 8 patients presented with an occlusion of the common bile duct (CBD) (Type B). Five of 6 patients with an incomplete occlusion of the CBD could be treated by endoscopic options. Of 52 patients that presented a lateral lesion of the CBD (Type C), endoscopic treatment was successful in 35 patients (67 %), but surgical treatment was necessary in 17 (33 %). 27 patients with a complete transsection of the CBD required surgical reconstruction. Endoscopic treatment was successful in 34 of 42 patients with a late stenosis of the CBD. 11 of 55 patients (20 %) developed postoperative biliary complications. Univariate analysis identified three factors to be significant predictors of outcome: 1. attempts of repair before referral, 2. combined bile duct and hepatic artery injury, 3. Reconstruction in a situation of peritonitis. After a median follow-up of 44.6 months (2-109) a successful outcome was obtained in 51 of 55 (93 %) patients, including those requiring a secondary procedure for recurrent stricture.

CONCLUSIONS

Peripheral leakages, small lateral lesions and short stenosis usually can be treated endoscopically. Extended lateral injuries, complete CBD transsections and long stenoses require surgical therapy. For a successful therapy a specialized multidisciplinary team is crucial.