[Case volume and complications after thyroid gland surgery in Germany: an analysis of routine data from 48,387 AOK patients]

BACKGROUND

Many studies showed that hospital and surgeon volume have a significant influence on the complication rates of thyroid surgery. The present study investigates whether this relationship applies in subtotal as well as total lobe resections. Furthermore, it is still unclear which threshold for the hospital-related case volume can be determined, above which the risk of complications lies below the current national average.

MATERIAL AND METHODS

The study was based on nationwide routine data for persons insured with the Local General Sickness Fund (AOK) who had undergone thyroid surgery in 2014-2016. Permanent vocal cord palsy, bleeding and wound infection needing revision were recorded using indicators. The effect of the case volume on the indicators and the case number threshold was determined using logistic regression.

RESULTS

Permanent vocal cord palsy was observed in 1.3% and bleeding or wound infections needing revision in 1.6% and 0.3% of the cases. Compared to hospitals with >450 surgeries per year, the risk of permanent vocal cord palsy in hospitals with fewer than 201, 101 and 51 surgeries was significantly increased (OR [95% CI]: 1.5 [1.1-2.1]; 1.5 [1.1-2.1]; 1.8 [1.3-2.5]). The threshold needed to achieve a risk for permanent vocal cord palsy below the national average (1.3%) was 265 thyroid surgeries per year (95% CI: 110-420). For bleeding or wound infection in need of revision, no association between volume and outcome was found.

CONCLUSION

The present study showed that the risk of postoperative permanent vocal cord palsy decreased with increasing case volume. The broad confidence interval of the threshold makes clear case volume recommendation difficult. In order that the risk for a postoperative permanent vocal cord palsy is not likely above the national average, the annual case volume should reach 110 thyroid interventions.

No influence of immunosuppression on insulin sensitivity and beta-cell function in living donor liver transplantation

In liver transplantation alterations of glucose metabolism are common but not well understood. Influence of immunosuppression is widely presumed but has not proven until now. Using a frequently sampled intravenous glucose tolerance test with a minimal modeling technique of glucose disappearance we analyzed insulin sensitivity (SI) and beta-cell function (first and second phase of pancreatic beta-cell secretion, Phi 1 and Phi 2) in living donor liver transplantation of the right lobe. Initial immunosuppression in recipients was done with tacrolimus, prednisolone, and basiliximab induction. Donors and recipients were investigated before and 10 days, 6 months, and 1 year after operation. Normal SI of controls (donors before operation) decreased markedly 10 days after right lobectomy to SI 2.22 +/- 0.35 x 10(-4) min(-1) x microU/mL (P < .001); Phi 2 was compensatory increased. All parameters normalized within 1 year. Recipients were insulin-resistant with hyperinsulinemia before transplantation. After transplantation no parameter was significantly different from donors; all normalized equally to donors over 1-year follow-up. Thus, immunosuppression in recipients has no influence on glucose metabolism because liver function itself seems to play a more pronounced role than known until now.

Charakterisierung von Lebertumoren durch kontrastverstärkte Sonographie und digitale Graustufenbestimmung

PURPOSE

The characterization of different liver tumors is of therapeutic and prognostic relevance and has been the purpose of several studies. Although ultrasound offers the opportunity to detect hepatic tumors without ionizing radiation, its previous techniques did not lead toward a definitive differentiation of different tumor entities. The purpose of this study was the clinical evaluation of contrast enhanced ultrasound followed by quantitative digital analysis in patients with focal hepatic tumors.

MATERIALS AND METHODS

In a prospective study, 50 patients (18 females, 32 males, age 28 to 83 years, mean age 59.4 years) with liver tumors previously detected by CT (n = 47) or MRI (n = 3) were examined by ultrasound of the upper abdomen using conventional technique and phase inversion technique after intravenous application of sulfur-based contrast enhancer SonoVue. At scheduled intervals after application of the contrast enhancer, a digital image was stored and the characteristic signal course of each lesion determined semiquantitatively. The gold standard was either resection (n = 17), percutaneous needle biopsy (n = 19) or the clinical course (n = 14).

RESULTS

While the percentage of tumors correctly characterized by CT/MRI amounted to 78 %, the percentage increased from 60 % using conventional ultrasound to 86 % using contrast enhanced ultrasound including grey-scale analysis. Typical graphs were achieved for different tumor entities on digital grey-scale analysis. The optimal intervals for the differentiation of particular entities were 20 and 100 seconds after injection.

CONCLUSION

Quantification of contrast enhanced ultrasound is an addition to the previous diagnostic procedure in hepatic tumors. It offers the possibility of an investigator-independent characterization of lesions and should be evaluated in further studies.

Role of F18-FDG PET for Monitoring of Radiochemotherapy – Estimation of Detectable Number of Tumour Cells

BACKGROUND

FDG-PET has been proven to be useful for the diagnosis of pancreatic cancer. However, no quantitative data exist concerning its sensitivity for treatment monitoring or early diagnosis.

CASE REPORT

We report on a 61-year-old patient with locally advanced cancer of the pancreas head who received sequential radiochemotherapy including gemcitabine and 5-FU/FA. Under this regimen, MR and CT showed a partial remission with a residual mass which seemed to allow surgical treatment for this patient. A pre-operative FDG-PETScan displayed a count rate close to the detection limit of vital residual tumour. An R0 resection was performed successfully. However, histopathology revealed residual tumour at the core of the resected mass that had gone undetected by all imaging modalities.

CONCLUSION

The number of vital tumour cells within this specimen was estimated to be 10(6)-10(7). The detection threshold for FDG-PET in pancreatic carcinoma appears to be within this range.

Diagnosis of neuroendocrine tumours by retrospective image fusion: is there a benefit?

This study evaluated the use of image fusion in the preoperative staging of neuroendocrine tumors (NET) of the pancreas and the gastrointestinal tract (GIT). Thirty-eight patients suffering from a metastasized NET with location of the primary in the pancreas ( n=15) or the GIT ( n=23) were examined by somatostatin receptor scintigraphy (SRS) and computed tomography (CT). Consecutive image registration and fusion were performed using custom-built software integrated in AVS/Express (Advanced Visual Systems, Waltham, MA, USA). Registration was performed by a voxel-based algorithm based on normalized mutual information. Image fusion was feasible in 36/38 patients. A total of 87 foci were assigned to anatomical regions (e.g. gut, pancreas, liver, lymph node or others) by two independent observers in both SRS and SRS/CT fusion images. The assignments used a binary ranking system (1="definite", 0="not definite"). These results were then retrospectively compared to the classification of the foci, based on postoperative histology or clinical follow-up. Imaging by SRS allowed a definite anatomical assignment in 57% (50/87) and 61% (53/87) of all lesions in the case of observers A and B, respectively. Image fusion improved the topographic assignment to 91% (79/87) and to 93% (81/87). The number classified as "definite" by both observers increased from 54% (47/87) to 86% (77/87). The increase in definite assignments was highly significant for both observers ( P<0.0001 for each). In the case of foci classified as liver metastases, image fusion allowed improved assignment to the corresponding liver segment from 45% (18/40) to 98% (39/40) and from 58% (23/40) to 100% (40/40) by observers A and B, respectively. Furthermore, the improved assignment of foci classified as lesions by image fusion was relevant for therapy in 7/36 patients (19%). Therefore, the image fusion technique presented herein appears to be a very useful method for clinical routine.

[Accuracy of the CT-estimated weight of the right hepatic lobe prior to living related liver donation (LRLD) for predicting the intraoperatively measured weight of the graft]

PURPOSE

Due to the shortage of cadaver donors, living related liver donation (LRLD) has emerged as an alternative to cadaver donation. The expected graft weight is one of the main determinants for donor selection. This study investigates the accuracy of preoperatively performed CT-volumetry to predict the actual weight of the right liver lobe graft.

MATERIALS AND METHODS

In a prospective study the weight of the right hepatic lobe was calculated by volumetric analysis based on CT in 33 patients (21 females, 12 males, mean age 42.1 years, median age 41 years) prior to living related liver donation. Graft weight was calculated as the product of CT-based graft volume and 1.00 g/ml (the approximated density of healthy liver parenchyma). The calculated weight was compared with the intraoperatively measured weight of the harvested right hepatic lobe. The difference was used to determine a correction factor for estimating the actual graft weight.

RESULTS

Based on the assumption of a parenchymal density of 1.00 g/ml, the preoperatively estimated graft weight (mean 980 g +/- 168 g) deviated +33 % from the intraoperatively measured right hepatic lobe weight (mean 749 g +/- 170 g). By reducing the preoperatively predicted weight of the right hepatic lobe with a correction factor of 0.75, the actual graft weight can be calculated.

CONCLUSION

Preoperative estimation of the weight of the right hepatic lobe based on CT of living related liver donors predicts the weight of the right lobe graft with sufficient accuracy by applying a single correction factor. Intraoperative fluid loss (i.e., blood, bile) from the harvested liver as well as variations in parenchymal density may contribute to the observed preoperative overestimation of the actual graft volume by CT-based volumetry.

Clinical extracorporeal hybrid liver support--phase I study with primary porcine liver cells

The objective of this study was to evaluate the feasibility and safety of a hybrid liver support system with extracorporeal plasma separation and bioreactor perfusion in patients with acute liver failure (ALF) who had already fulfilled the criteria for high urgency liver transplantation (LTx). Eight patients (one male, seven female) were treated in terms of bridging to transplantation. The mean age was 36.5 yr (range 20 to 58). Etiology of liver failure was drug-related in two patients, hepatitis B infection in three patients, and unknown for three patients. The bioreactors were charged with primary liver cells from specific pathogen-free pigs. Cell viability varied between 91 and 98%. Continuous liver support treatment over a period of 8 to 46 h (mean 27.3 h) was safely performed and well-tolerated by all patients. No complications associated with the therapy were observed during the follow-up period. Thrombocytopenia was considered to be an effect of the plasma separation. Subsequently, all patients were transplanted successfully and were observed over at least 3 yr with an organ and patient survival rate of 100%. Screening of patient's sera for antibodies specific for porcine endogenous retroviruses (PERVs) showed no reactivity--either prior to application of the system, or after extracorporeal treatment. The results encourage us to continue the development of the technology, and further studies appear to be justified. The bioreactor technology has been integrated into a modular extracorporeal liver support (MELS) system, combining biologic liver support with artificial detoxification technology.

Complete bile duct sequestration after liver transplantation, caused by ischemic-type biliary lesions

Ischemic-type biliary lesions (ITBLs) are the most frequent cause of nonanastomotic biliary strictures in liver grafts, affecting about 2-19 % of patients after liver transplantation. ITBL is characterized by bile duct destruction, subsequent stricture formation, and sequestration. We report here the case of a patient affected by extremely severe ITBL, with sequestration and disintegration of the entire bile duct system, in which it was possible to extract the complete biliary tree endoscopically in a single piece. Histological examination revealed that all cells of the bile duct wall had been destroyed within 3 months after liver transplantation and replaced by connective tissue. Subsequently, biliary stricture formation occurred at the hepatic hilum, as well as the adjacent large bile ducts. It may be hypothesized that cellular rejection of small bile ducts leads to the vanishing bile duct syndrome, whereas cellular rejection of large bile ducts results in ITBL. The strictures were repeatedly dilated by endoscopic means, allowing successful control of stricture formation, as well as maintenance of liver function. At the time of writing, the grafted organ and the patient had survived for more than 3 years in good health. This is the first detailed report on a sequestration of the entire bile duct system caused by ITBL, successfully treated for several years by endoscopic means.

Review article: liver transplantation for hepatocellular carcinoma

Despite recent advances in techniques of in situ tumour ablation, surgical therapy remains at present the mainstay treatment for primary hepatic malignancies. After an initial endeavour in the establishment of liver transplantation as a treatment option, in particular for unresectable liver tumours, only a few indications, for example early hepatocellular carcinoma in cirrhosis, are currently agreed upon. Other indications, such as peripheral cholangiocarcinoma and hepatocellular carcinoma in noncirrhotics have largely been abandoned or are still under debate, as is the case with fibrolamellar carcinoma. The selection of patients suffering from hepatocellular carcinoma in cirrhosis for liver transplantation is still based on tumour size and node number, because the current state of diagnostic imaging fails to reliably predict the most important prognostic parameter: vascular infiltration. Other selection criteria are under investigation. Studies on multimodal therapy are also underway but have not yet demonstrated a clear benefit.

[Orthotopic liver transplantation in case of TIPS stent dislocation]

Transjugular intrahepatic portosystemic shunts (TIPS) are indicated in patients with liver cirrhosis and portal hypertension for treatment of variceal bleeding or refractory ascites. Additionally implantation of stents may lead to stent dislocation or thrombosis in up to 20 % of cases. Detailed information about stent dislocation and its impact on subsequent orthotopic liver transplantation (OLT) is rare regarding the literature. We report on a patient suffering from ethyltoxic liver cirrhosis in which OLT was technically complicated by a thrombosed TIPS stent, dislocated in the portal vein. This stent was implanted prior to OLT due to refractory ascites and partial portal vein thrombosis. We conclude that TIPS stent insertion, especially in liver transplant candidates, should only be performed by radiologists in centers with expertise and experience.

Combination prophylaxis with Hepatitis B immunoglobulin and lamivudine after liver transplantation minimizes HBV recurrence rates unless evolution of pretransplant lamivudine resistance

BACKGROUND

Survival rates of hepatitis B patients after liver transplantation improved significantly by introduction of passive immunoprophylaxis. Due to viral escape mutations recurrence still occurs, but recently a combination prophylaxis with hepatitis B immunoglobuline plus lamivudine is evaluated in transplant centers in terms of a further reduction of recurrence rates.

PATIENTS AND METHODS

Between 1996 and 2000 a postoperative combination prophylaxis with HBIg and lamivudine was initiated in 44 HBsAg positive liver transplant recipients. In total 14 patients were HBV-DNA negative and 30 were HBV-DNA positive at the time of evaluation. In 22 HBV-DNA positive patients a pre-operative lamivudine treatment (150 mg/die) was started. Five of them developed pre-transplant lamivudine resistance with high viral replication (mean HBV-DNA prior to transplantation 728 +/- 219 pg/ml). In all patients passive immunoprophylaxis was started in the anhepatic phase with application of 10.000 units hepatitis B immunoglobuline. It was continued after seroconversion to HBsAg negativity with an aimed titer of more than 100 U/l and only stopped in case of HBV recurrence. Lamivudine was also continued indefinitely after liver transplantation.

RESULTS

Overall recurrence rate in the 44 patients, including retransplantations and patients with pretransplant lamivudine resistance, was 11.5 % under combination prophylaxis. Recurrence was seen only in one of 39 patients (2.6 %) without preoperative lamivudine resistance, in contrast 4 out of 5 patients (80 %) with pre-existing lamivudine resistance suffered from early hepatitis B recurrence. The single patient without preoperative lamivudine resistance, who developed recurrence was pre-transplant HBV-DNA negative without lamivudine treatment, but a postoperative seroconversion to negative HBsAg could not be achieved. The overall 3 year patient survival rate was 91 % in the study population. One patient, who was retransplanted with preoperative lamivudine resistance, died 4.5 months after retransplantation due to hepatitis B recurrence and sepsis, three other patients died for reasons not related to hepatitis B recurrence. Combination prophylaxis was well tolerated in all patients and no severe side effects were observed.

CONCLUSION

Combination prophylaxis with hepatitis B immunoglobulin and lamivudine is safe and highly effective in prevention of HBV recurrence after liver transplantation, even in case of positive viral replication. In accordance with the results of other centers it should therefore be the standard regimen. However it fails in the majority of patients with preoperative evolution of YMDD mutations, in which the optimal management has to be determined yet. To minimize preoperative resistance formation universal preoperative antiviral treatment of HBV-DNA positive patients should be replaced by individualized indication for preoperative treatment.

[Multiorgan failure due to chronic granulomatous disease]

A 21-year-old male patient developed an acute septic clinical picture with intra-abdominal abscesses and multiorgan failure. The underlying disease was chronic granulomatous disease, an inherited disorder of granulocyte function caused by failure of intracellular superoxide production. In spite of surgical procedures and a calculated antibiotic and antimycotic therapy, the patient died within a few days from septic shock. This case report describes the typical problems of patients with a congenital immunodeficiency who grow out of the care of highly specialised pediatric-immunological departments.

Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases

BACKGROUND

Bile duct injuries in combination with major vascular injuries may cause serious morbidity and may even require liver resection in some cases. We present two case studies of patients requiring right hepatic lobectomy after bile duct and right hepatic artery injury during laparoscopic cholecystectomy.

PATIENTS

Two patients sustained combined major bile duct and hepatic artery injury during laparoscopic cholecystectomy. Surgical management consisted of immediate hepaticojejunostomy with reconstruction of the artery in one patient and hepaticojejunostomy alone in the other patient. In both cases the initial postoperative course was uncomplicated.

RESULTS

After 4 and 6 months both patients suffered recurrent cholangitis due to anastomotic stricture. Both developed secondary biliary cirrhosis and required right hepatic lobectomy with left hepaticojejunostomy. The patients remain well 31 months and 4.5 years after surgery.

CONCLUSIONS

The outcome of bile duct reconstruction may be worse in the presence of combined biliary and vascular injuries than in patients with an intact blood supply of the bile ducts. We recommend arterial reconstruction when possible in early recognized injuries to prevent late strictures. Short-term follow-up is most important for early recognition of postoperative strictures and to avoid further complications such as secondary biliary cirrhosis.

[Living donor liver transplantation of the right liver lobe between adults]

BACKGROUND AND OBJECTIVE

Adult living donor liver transplantation has been established in an increasing number of transplant centres during the last few years. Donor safety and risks are important criteria influencing the further development. We report our experience with 43 adult-to-adult right lobe living donor liver transplantations.

METHODS

43 patients (mean age: 49,8 +/- 16,0 years; f:m = 14:29) with end-stage liver disease received a right lobe liver graft from an adult living donor (mean age: 42,4 +/- 13,4 years; f:m = 27:16) between December 1999 and December 2001. An approval by the local ethics committee was obtained prior to the start of the programme and each donation.

RESULTS

None of the donors experienced fatal or long-term complications. The rate of surgical complications in donors (biliary leakage, bleeding) was 9 %. Actuarial recipient survival was 93 % after three months and 88 % after one year. Five patients had to be re-transplanted. Thus the actuarial 1-year graft survival was 79 %. Biliary complications occurred in 14 % of all recipients.

CONCLUSION

According to our experience, living donor liver transplantation of the right hepatic lobe is a safe and effective procedure. Especially for patients in acute and chronic liver failure, who otherwise would have died on the waiting list, this approach offers a life-saving option.

[Arterial port-catheter dislocation into the duodenum]

Arterial port-catheter dislocations into the duodenum are rare complications. We report on a 64-year-old male with sigmoid-resection for carcinoma, left hemihepatectomy and arterial port-catheter implantation into the common hepatic artery for liver metastases in both lobes and partial dislocation of the port system into the duodenum. Therefore, the port-catheter system had to be explanted after 8 cycles of cytostatic therapy and the duodenum had to be closed by a suture. Six months after surgery the patient felt well, a new singular metastasis in the right liver lobe could be treated successfully by laserinduced thermotherapy. At present the patient has no evidence for another metastasis.

Liver transplantation for recurrent hepatocellular carcinoma in Europe

BACKGROUND

Patient death after liver resection for hepatocellular carcinoma in cirrhosis is caused by tumor recurrence as well as by complications of cirrhosis. Liver transplantation represents the only simultaneous treatment of tumor and primary liver disease. Certain criteria regarding the number (up to three) and size (up to 5 cm) of tumor nodules have to be observed in order to ensure a low risk of extrahepatic spread or vascular infiltration. Liver transplantation, as treatment for recurrent hepatocellular carcinoma, has to observe the same rules. Only few patients have undergone liver transplantation for recurrent hepatocellular carcinoma in cirrhosis. The reason for this restraint is not fully evident. Poor survival rates after liver transplantation as therapy for advanced hepatocellular carcinoma in the 1980s and an increasing shortage of donor grafts are certainly two factors.

METHODS

We report on two cases from our experience and review the European literature.

RESULTS

Outcome in a few selected patients has been rather favorable, despite varying approaches.

CONCLUSIONS

The only conclusion that can be drawn is that tumor control by liver transplantation is possible in individual patients suffering from recurrent hepatocellular carcinoma. Adult living donor liver transplantation is one way to overcome graft shortage. Other strategies, for example, salvage transplantation, are presented.

[Surgical procedures and risk factors in therapy of benign multinodular goiter. A statistical comparison of the incidence of complications]

BACKGROUND

The best surgical approach for bilateral resections in the therapy of benign multinodular goiter is still controversial.

METHODS

The purpose of this study was to compare different modes of resection concerning differences in complication rates and risk factors influencing the outcome. 2235 thyroid resections for multinodular goiter between 1985 and 1999 were analysed.

RESULTS

When compared to bilateral subtotal resection (n = 327; 14.6%), those patients who received lobectomy and contralateral subtotal resection (n = 952; 42.6%) showed a statistically significant higher incidence of temporary hypocalcaemia (22.6% versus 15.9%) only. The "nerve at risk"-analysis demonstrated no significant difference of laryngeal nerve paralysis between the side of lobectomy and subtotal resection, respectively. In comparison to the entire patient population operations for recurrent goiters had an equal operative risk, whereas patients with goiter WHO III or an intrathoracic location had significant higher rates of temporary laryngeal nerve paralysis and hypocalcaemia.

CONCLUSIONS

Lobectomy and contralateral subtotal resection offers numerous advantages concerning intraoperative variability and definitive resection of suspicious nodules. With an adequate standardized surgical technique and identification of the laryngeal nerve, the complication rate is comparable to bilateral subtotal resection.

Occurrence and clinical outcome of lamivudine-resistant hepatitis B infection after liver transplantation

Lamivudine treatment of hepatitis B after orthotopic liver transplantation (OLT) is often accompanied by fast viral-resistance formation. Although no clinical data are available, in vitro data indicate that lamivudine-resistant reinfection has a mild course because of defective viral replication. Between 1996 and 1999, a total of 34 patients were treated with lamivudine because of hepatitis B recurrence after OLT. All patients developed reinfection despite long-term passive immunoprophylaxis with hepatitis B immunoglobulin, diagnosed by positive hepatitis B surface antigen and positive hepatitis B virus (HBV) DNA. Before treatment with lamivudine, 21 of these patients underwent a course of famciclovir and developed resistance. Monthly laboratory tests and sequential liver biopsies were performed during the follow-up period. Nineteen of 34 patients (56%) developed lamivudine resistance during the follow-up period of 12 to 49 months. One- and 3-year graft survival rates after the diagnosis of lamivudine resistance were 89% and 66%, respectively. In most cases, lamivudine resistance was associated with high viral replication (3,012 +/- 574 pg/mL 1 month after the diagnosis of lamivudine resistance); however, liver enzyme levels were only moderately elevated (alanine aminotransferase [ALT], 45 +/- 16 U/L). Only 3 patients (15%) showed a rapid increase in ALT level to more than 500 U/L within 3 months after resistance developed. All other patients had mildly elevated liver enzyme levels during the first 6 to 8 months after lamivudine resistance. In the later course, liver enzyme levels increased in most patients. Fourteen patients with elevated transaminase levels were switched to lamivudine plus interferon alfa (n = 8) or lamivudine plus famciclovir therapy (n = 6). This combination was successful in most cases, decreasing HBV DNA and liver enzyme levels. Four patients with lamivudine resistance died during follow-up, only 1 patient because of HBV reinfection. In addition, 2 patients underwent retransplantation because of hepatitis B cirrhosis of the first graft. Compared with historic courses of wild-type recurrence, lamivudine-resistant reinfection is characterized by a milder clinical course. Fulminant cases were not observed; however, in three cases, chronic liver failure developed. The combination of different antivirals diminished viral replication after lamivudine resistance. In the future, new antiviral agents, such as adefovir, might further expand therapeutic options.

Intraoperative measurement of intact parathyroid hormone in renal hyperparathyroidism by an inexpensive routine assay

Although the kinetics of intraoperative intact parathyroid hormone (iPTH) are well characterised in primary hyperparathyroidism, no data are available for patients with renal hyperparathyroidism and renal insufficiency, partially because of the high costs of intraoperative quick iPTH measurement. Therefore we evaluated an inexpensive laboratory test with a duration of 18 min for intraoperative use and measured iPTH intraoperatively in 34 patients with renal hyperparathyroidism. Samples were taken before and 5 min and 15 min after parathyroid resection. Blood samples were put on ice immediately and sent to the hospital central laboratory via a pneumatic tube system. The first 76 probes were measured in parallel using three assays: the Nichols Quick PTH, the Roche Elecsys and the Biermann Immulite assay. The subsequent samples were only measured using the Elecsys assay. Determination of iPTH from 76 samples showed a correlation coefficient of 0.997 between the Immulite and Elecsys assay and a correlation coefficient of 0.987 for the Nichols Quick PTH and the Elecsys test. In renal hyperparathyroidism the mean iPTH was 26+/-2% of the starting value 5 min after subtotal parathyroidectomy and 18+/-2% after 15 min. Renal function influenced absolute iPTH values in patients with renal hyperparathyroidism but not relative changes. In patients with terminal renal insufficiency iPTH decreased from 615+/-57 pg/m before preparation to 109+/-13 pg/ml 15 min after subtotal resection. In contrast in patients after kidney transplantation iPTH decreased from a lower starting value of 341+/-94 pg/ml to 58+/-9 pg/ml after 15 min. The iPTH kinetics showed a biphasic clearance of iPTH with an initial dominant half-life of 3.2 min and a terminal half-life of 29.2 min. Half-life did not correlate with renal function. All operations were successful as indicated by an adequate drop in PTH (from 709+/-92 pg/ml preoperatively to 22+/-6 pg/ml at discharge) and calcium (from 2.57+/-0.04 mmol/l to 2.32+/-0.04 mmol/l). In conclusion, intraoperative measurement of iPTH is also reliable in patients with renal hyperparathyroidism. Elimination kinetics are similar to that in patients with primary disease. However, the half-life was not influenced by renal function. The availability of a quick, inexpensive, routine iPTH test might expand its use to renal hyperparathyroidism, specifically for surgical decisions in problem cases.

Preoperative antiviral treatment and postoperative prophylaxis in HBV-DNA positive patients undergoing liver transplantation

BACKGROUND

Despite passive immunoprophylaxis a significant number of patients, especially if hepatitis B virus (HBV) DNA is positive prior to transplantation, develop HBV recurrence. This number might be reduced by lowering viral replication pretransplant with antiviral agents and by postoperative combination of antiviral agents and passive immunoprophylaxis.

PATIENTS AND METHODS

A total of 74 HBV-DNA positive patients who underwent liver transplantation between 9/88 and 4/00 were analyzed retrospectively. Before lamivudine or famciclovir were available, in total 40 patients did not receive any preoperative antiviral therapy. Since 11/93, 17 patients were treated with famciclovir 1500 mg daily, after 4/96 17 patients with lamivudine 150 mg daily prior liver transplantation. Posttransplant all patients received passive immunoprophylaxis aiming at a titer of more than 100 U/liter. In the 34 patients with preoperative antiviral therapy an additional prophylaxis with the respective antiviral agent was applied.

RESULTS

Under preoperative famciclovir and lamivudine 30 and 71% of patients became HBV-DNA negative, respectively. Actuarial reinfection rate 2 years after liver transplantation was 48% without antiviral prophylaxis, which was not statistically different from 55% under perioperative famciclovir therapy. In contrast only 18% developed HBV recurrence under perioperative lamivudine treatment. During both antiviral regimens neither pre nor posttransplant severe side effects were observed.

CONCLUSION

Perioperative application of famciclovir is not recommendable, whereas lamivudine seems to lower recurrence rates significantly. Whether the observed effect is due to pre- or postoperative application remains to be addressed in further studies. In addition the long-term course has to be awaited.

[Combined liver and kidney transplantation: indications and long-term follow-up]

INTRODUCTION

In patients suffering from chronic liver and kidney disease combined liver-kidney transplantation is the only therapeutic option. However, in these patients, it is mandatory to distinguish between chronic and acute renal failure prior to transplantation, because acute renal failure may recover after successful liver transplantation. In this study we investigated the indications and results of this combined procedure.

PATIENTS AND METHODS

We report on 27 patients who underwent liver and kidney transplantation. The underlying diseases were viral hepatitis (n = 12), polycystic liver and kidney disease (n = 9), primary hyperoxaluria (n = 4), and cryptogenic cirrhosis (n = 2) with end-stage renal disease due to glomerulonephritis, diabetic nephropathy or renal failure caused by nephrotoxicity of immunosuppressive therapy after liver transplantation. Nine patients had lymphocytotoxic antibodies and 5/27 patients had a positive crossmatch pretransplant.

RESULTS

One patient died due to bleeding complications, two patients lost the kidney graft due to initial non-function or technical problems. The incidence of acute and steroid-resistant rejections was 60% and 20% in patients with a positive cross-match compared to 32% and 14% in negative cross-match transplants. Only two patients experienced a rejection episode of the kidney (3.7%). No hyperacute rejection of the kidney graft occurred. Long-term patients and graft survival was not impaired in the presence of a positive cross-match. The 1- and 5-year survival rates of patients who underwent combined transplantation was 97% and 93% versus 91% and 83% in patients with liver transplantation alone.

CONCLUSION

Combined liver-kidney transplantation is a safe treatment for endstage liver and kidney disease even in the face of a positive cross-match.

Prospective randomized trial to assess the value of preemptive oral therapy for CMV infection following liver transplantation

BACKGROUND

With the development of sensitive tests to detect cytomegalovirus (CMV) viremia, preemptive approaches become a reasonable alternative to general CMV prophylaxis. We performed a randomized trial comparing pp65-antigenemia guided preemptive therapy using oral ganciclovir with symptom-triggered intravenous ganciclovir treatment.

METHODS

Eighty-eight of 372 liver transplant recipients developed antigenemia early after orthotopic liver transplantation. Twenty-eight symptomatic patients with antigenemia were excluded from randomization and treated with intravenous ganciclovir. Sixty pp65-antigen-positive asymptomatic patients were randomized to receive either oral ganciclovir 3x1 g/day for 14 days (group 1) or no preemptive treatment (group 2). Patients that developed CMV disease were treated with intravenous ganciclovir 2x5 mg/kg body weight for 14 days. The high-risk (Donor+/Recipient-) patients were equally distributed in the two study groups.

RESULTS

Three of 30 (10%) patients on oral ganciclovir developed mild to moderate CMV disease compared with 6/30 (20%) patients in the control group. In the Donor+/Recipient- patients, the incidence of CMV disease was 1/6 and 3/7. All disease episodes resolved after intravenous treatment. The 1- and 3-year patient and organ survival was the same in the study groups and in the patients with or without CMV infection. No deaths related to CMV occurred.

CONCLUSIONS

The positive predictive value of pp65-antigenemia for the development of CMV disease was very low, and, in 28/88 patients (32%), antigenemia did not precede symptoms. Therefore, pp65-antigenemia is of limited value in deciding on the timing and need for ganciclovir therapy after liver transplantation.

Liver transplantation for treatment of intrahepatic Osler's disease: first experiences

BACKGROUND

Intrahepatic Osler's disease with multiple arteriovenous malformations and high intrahepatic shunting may lead to secondary pulmonary hypertension followed by right-heart stress and insufficiency. Until now, therapy with arterial embolization, banding, or ligation of the hepatic arteries is still limited and provides unsatisfactory long-term results. Liver transplantation offers another therapeutic option.

METHODS

We report on four patients with intrahepatic involvement of Osler's disease who were liver transplanted between 1995 and 1999. All patients suffered from restricted liver function and right-heart insufficiency with multiple cardiac decompensations. One patient received one course of embolization, and another received six courses of embolization and then banding of the main hepatic artery before transplantation. In both patients, the clinical symptoms improved for only a few months.

RESULTS

All patients had high degrees of intrahepatic arteriovenous shunting, and cardiac output measurements were between 8.0 to 13.3 L/min preoperatively. Preoperative mean pulmonary artery pressure was between 24 to 35 mmHg. After liver transplantation, cardiac output and right-heart diameter decreased or normalized and pulmonary pressure reached the normal range after 2 months. All patients received tacrolimus and steroids for primary immunosuppression. In one case, temporary hemodialysis was necessary for 2 weeks after transplantation, but renal function recovered completely. After follow-up time of 12 to 65 months, all patients had normal graft function and good cardiopulmonary condition.

CONCLUSIONS

Indication for liver transplantation should be considered in patients with intrahepatic Osler's disease, high arteriovenous shunting with right-heart stress, and restricted liver function before irreversible fixed pulmonary hypertension leads to severe right-heart insufficiency or failure. Our therapeutic regimen of early liver transplantation in the case of intrahepatic Osler's disease in four patients has promising results.

Simultaneous carotid artery reconstruction in patients undergoing other surgical interventions

Abstract. We performed 343 vascular reconstructions of the supraaortal arteries from April 1996 to April 2000. Of these patients, 30 underwent combined vascular reconstructions - 22 combined extrathoracal and 8 combined transthoracal reconstructions. In 15 patients, carotid endarterectomy was combined with other cervical surgical interventions. In 10 patients, the vascular operation was combined with surgical interventions in other regions. No permanent complications were observed 8-52 months postoperatively, with the exception of one hemiparesis in the complex vascular operations. Consequently, we recommend the simultaneous surgical approach after careful individual assessment.

[Surgical therapy of liver hilus tumors]

Hilar resections and hemihepatectomies as surgical strategies for hilar cholangiocarcinoma achieve only limited rates of resectability and radicality. Principles of surgical oncology have to be applied in order to increase the numbers of patients undergoing resection as well as their long-term survival. Due to the anatomical architecture of the hepatic hilum and side-specific variations within the biliary tree, right trisectorectomy and principal portal vein resection have the potential to comply with basic rules of surgical oncology, i.e. wide tumor-free margins and a no-touch dissection technique. In our experience, 5-year survival after formally curative right trisectorectomy and portal vein resection is 65% in spite of advanced tumor stages. Resection of the entire biliary tract without dissection of the tumor is possible by combining total hepatectomy, partial pancreatoduodenectomy and liver transplantation. However, even this procedure does still not fully prevent tumor cell dissemination. So far, a putative alteration of tumor cell kinetics due to posttransplant immunosuppressive treatment results in an increased rate of implantation metastases.

Vascular invasion and histopathologic grading determine outcome after liver transplantation for hepatocellular carcinoma in cirrhosis

Selection of patients suffering from hepatocellular carcinoma (HCC) in cirrhosis for liver transplantation follows limits of number and diameter of tumor nodules. It has not been investigated whether there is a correlation of these parameters with vascular invasion. From 1989 to 2000, 1,188 liver transplantations were performed in 1,087 patients, including 120 patients (11%) with an HCC in cirrhosis. Selection criteria were a maximal diameter of up to 5 cm if the tumor appeared to be uninodular or of up to 3 cm in the case of 2 or 3 nodules. The postoperative mortality rate was 1.7%. One-, 5-, and 10-year survival was 90%, 71%, and 60%, respectively. In 940 transplantation patients without an HCC, these rates were 93%, 87%, and 83% (P < .0001). Vascular invasion and histopathologic grading were identified as prognostic parameters by multivariate analysis. In a logistic regression analysis, histopathologic grading and maximal diameter showed a significant correlation with a vascular invasion. Analyzing tumors larger than 5 cm, i.e., tumors not fulfilling the selection criteria as a result of diagnostic inaccuracy or progression thereafter, the rates of vascular invasion were significantly (P < .01) lower in patients suffering from well-differentiated tumors (25%) when compared with moderately and poorly differentiated tumors (100%). Liver transplantation is a safe and effective long-term treatment for small HCC in cirrhosis. Tumor diameter and number of nodules in correlation with the histopathologic grading were predictive of a vascular invasion only in HCC larger than 5 cm.

Vascular invasion and histopathologic grading determine outcome after liver transplantation for hepatocellular carcinoma in cirrhosis

Selection of patients suffering from hepatocellular carcinoma (HCC) in cirrhosis for liver transplantation follows limits of number and diameter of tumor nodules. It has not been investigated whether there is a correlation of these parameters with vascular invasion. From 1989 to 2000, 1,188 liver transplantations were performed in 1,087 patients, including 120 patients (11%) with an HCC in cirrhosis. Selection criteria were a maximal diameter of up to 5 cm if the tumor appeared to be uninodular or of up to 3 cm in the case of 2 or 3 nodules. The postoperative mortality rate was 1.7%. One-, 5-, and 10-year survival was 90%, 71%, and 60%, respectively. In 940 transplantation patients without an HCC, these rates were 93%, 87%, and 83% (P < .0001). Vascular invasion and histopathologic grading were identified as prognostic parameters by multivariate analysis. In a logistic regression analysis, histopathologic grading and maximal diameter showed a significant correlation with a vascular invasion. Analyzing tumors larger than 5 cm, i.e., tumors not fulfilling the selection criteria as a result of diagnostic inaccuracy or progression thereafter, the rates of vascular invasion were significantly (P < .01) lower in patients suffering from well-differentiated tumors (25%) when compared with moderately and poorly differentiated tumors (100%). Liver transplantation is a safe and effective long-term treatment for small HCC in cirrhosis. Tumor diameter and number of nodules in correlation with the histopathologic grading were predictive of a vascular invasion only in HCC larger than 5 cm.

Arterial complications after liver transplantation

From September 1988 through April 1998, 1,000 liver transplantations were performed on 911 patients. During the postoperative control examinations of 837 patients, we found 23 (2.74 %) with hepatic artery thromboses, 27 stenoses of the hepatic artery (3.22 %), and 6 aneurysms of the graft artery. Seventeen patients underwent retransplantation because of arterial complications. Depending on the clinical symptoms, we treated both the local situation as well as the resulting complications of inadequate arterial graft flow. The aneurysms were primarily treated surgically. The first choice of treatment of stenoses was balloon angioplasty. Early postoperative artery thromboses were also treated surgically by thrombectomy in selected cases. For the resulting biliary and local septic complications we preferred endoscopic and drainage procedures. Our clinical experiences have led us to find pretransplantation angiography recommendable, especially in the case of splanchnic artery stenoses, for bypassing from the aorta for arterial perfusion of the graft.

Arterial complications after liver transplantation

From September 1988 through April 1998, 1,000 liver transplantations were performed on 911 patients. During the postoperative control examinations of 837 patients, we found 23 (2.74 %) with hepatic artery thromboses, 27 stenoses of the hepatic artery (3.22 %), and 6 aneurysms of the graft artery. Seventeen patients underwent retransplantation because of arterial complications. Depending on the clinical symptoms, we treated both the local situation as well as the resulting complications of inadequate arterial graft flow. The aneurysms were primarily treated surgically. The first choice of treatment of stenoses was balloon angioplasty. Early postoperative artery thromboses were also treated surgically by thrombectomy in selected cases. For the resulting biliary and local septic complications we preferred endoscopic and drainage procedures. Our clinical experiences have led us to find pretransplantation angiography recommendable, especially in the case of splanchnic artery stenoses, for bypassing from the aorta for arterial perfusion of the graft.