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ABSTRACT: Following resection of colorectal liver metastases (CLMs) up to 75 per cent of patients develop recurrent liver metastases. Although repeat resection remains the only curative therapy, data evaluating the outcome are deficient. This study analysed postoperative morbidity, mortality and independent predictors of survival following repeat resection of CLMs.
Data on surgical treatment of primary and recurrent CLMs between 1994 and 2010 were collected retrospectively, and compared with those for single hepatic resections carried out during the same period. Independent predictors of survival were evaluated by means of univariable and multivariable Cox regression models.
In this interval 1026 primary resections of CLMs were performed and 94 patients underwent repeat CLM excision. Overall postoperative morbidity and mortality rates were low (15·8 and 1·3 per cent respectively), with no statistical difference in patients undergoing repeat surgery (P = 0·072). Compared with single liver resections, overall survival was improved in repeat resections (P = 0·003). Multivariable analysis revealed that size of primary CLM over 50 mm was an independent predictor of survival (hazard ratio (HR) 2·61; P = 0·008). Only major hepatic resection was associated with poorer outcome following repeat surgery (HR 2·62; P = 0·009). International Union Against Cancer stage, number of CLMs, age at surgery and need for intraoperative transfusion had no impact on survival after repeat resection.
Recurrent CLM surgery is feasible with similar morbidity and mortality rates to those of initial or single CLM resections.
British Journal of Surgery 06/2013; 100(7):926-32. · 4.61 Impact Factor
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ABSTRACT: Background and study aim: Placement of covered self-expanding metal or plastic stents (SEMS or SEPS) is an established method for managing intrathoracic leaks. Recently, endoscopic vacuum-assisted closure (EVAC) has been described as a new effective treatment option. Our aim was to compare stent placement with EVAC for nonsurgical closure of intrathoracic anastomotic leaks.Patients and methods: In a retrospective analysis we were able to identify 39 patients who were treated with SEMS or SEPS and 32 patients who were treated with EVAC for intrathoracic leakage. In addition to successful fistula closure, we analyzed hospital mortality, number of endoscopic interventions, incidence of stenoses, and duration of hospitalization. Results: In a multivariate analysis, successful wound closure was independently associated with EVAC therapy (hazard ratio 2.997, 95 % confidence interval [95 %CI] 1.568 - 5.729; P = 0.001). The overall closure rate was significantly higher in the EVAC group (84.4 %) compared with the SEMS/SEPS group (53.8 %). No difference was found for hospitalization and hospital mortality. We found significantly more strictures in the stent group (28.2 % vs. 9.4 % with EVAC, P < 0,05). Conclusions: EVAC is an effective endoscopic treatment option for intrathoracic leaks and showed higher effectiveness than stent placement in our cohort.
Endoscopy 06/2013; 45(6):433-8. · 5.21 Impact Factor
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ABSTRACT: Background: Survival of critically ill patients is significantly affected by prolonged ventilation. The goal of this study was the development of a Respiratory Risk Score (RRS) for the prediction of 3-month mortality and prolonged ventilation following liver transplantation. Methods: 254 consecutive liver transplant patients from a single center were retrospectively randomized into a training group for model design and a validation group. ROC-curve analysis was used to test sensitivity and specificity. Accuracy of prediction was assessed with the Brier-score and model calibration with the Hosmer-Lemeshow-test. Cut-off values were determined with the best Youden-Index. Results: The RRS was calculated in the first 24 hours as follows: (lab-MELD-score>30 = 2.36 points) + (fresh frozen plasma units>13 = 2.70 points) + (PaO2/FiO2 ratio <200mmHg = 2.23 points) + (packed red blood cells>10 = 3.50 points) + (pre-operative mechanical ventilation = 3.87 points) + (pre-operative dialysis = 2.83 points) + (donor steatosis hepatis>40% = 2.95 points). The RSS demonstrated high accuracy of prediction, good model calibration and c-statistics >0.7 in the training group and validation group. The RSS is able to predict 3-month mortality (cut-off 6.64; area under the ROC-curve (AUROC) 0.794) and prolonged ventilation (cut-off 3.69; AUROC 0.798) with a sensitivity of 69% and 81%, a specificity of 83% and 73% and an overall model correctness of 76% and 77%, respectively. Conclusions: This study provides the first prognostic model for the prediction of 3-month mortality and prolonged ventilation after liver transplantation with high sensitivity, specificity, and good model accuracy. Application of the RRS on an external cohort would be desirable for its further validation and introduction as a clinical tool for intensive care resource planning and prognostic decision making. Liver Transpl, 2013. © 2013 AASLD.
Liver Transplantation 05/2013; · 3.39 Impact Factor
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01/2013; , ISBN: 978-953-51-1070-5
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R Taubert,
S Pischke,
J Schlue,
H Wedemeyer,
F Noyan,
A Heim,
F Lehner,
H Barg-Hock, J Klempnauer,
S Olek,
M P Manns,
M Hardtke-Wolenski,
E Jaeckel
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ABSTRACT: Acute cellular rejection (ACR) occurs frequently after liver transplantation and can usually be controlled. Triggering of allospecific immune responses and lack of immunoregulation are currently suggested as a cause of ACR, but there are no investigations of intrahepatic immune responses during ACR. Therefore we prospectively analyzed the intrahepatic T cell infiltration pattern in correlation to the severity of ACR in a cohort of patients with graft hepatitis (n = 151). While CD4(+) cells dominated the portal infiltrates in mild-moderate ACR, CD8(+) cells prevailed in severe ACR. Furthermore portal CD8(+) and not CD4(+) infiltration correlated with serum transaminases and with the likelihood of subsequent ACRs. Surprisingly, the rise of portal effector T cells density during ACR was surpassed by the increase in portal infiltration of regulatory T cells by a factor of two. Thus ACRs rather showed an increase and not a lack of regulation, as was suggested by analysis of peripheral blood mononuclear cells. Despite the pattern of enhanced immunoregulation, patients with severe ACR had a higher risk for subsequent rejections and showed a trend to a reduced survival. Thus, patients with severe rejections might need a modification of their immunosuppression to improve prognosis.
American Journal of Transplantation 09/2012; · 6.39 Impact Factor
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ABSTRACT: The course of viral hepatitis shows wide interindividual differences, ranging from asymptomatic disease to liver failure. Only limited data on gender differences in patients undergoing liver transplantation (OLT) exist. We studied the gender distribution in patients who underwent liver transplantation for viral hepatitis.
A retrospective analysis was performed on a cohort of 368 patients who underwent OLT for viral hepatitis-associated acute or chronic liver failure. In 96 of them, additional hepatocellular carcinoma (HCC) was present at transplantation. Gender ratios of the different hepatitis virus infections and in relation to HCC were evaluated.
Significantly more males than females underwent OLT for chronic HBV. In contrast, patients after OLT for fulminant HBV were more frequently females. In patients transplanted for chronic HCV or HDV, no significant gender differences were found. However, men presented more frequently with HCC in both groups of chronic liver disease.
There was a gender difference in HBV infection with more women developing fulminant hepatic failure in acute HBV while more men progressed to end-stage liver disease in chronic HBV. The role of gender in chronic HCV and HDV infection was less pronounced, except for a male predominance among patients with HCC.
Zeitschrift für Gastroenterologie 08/2012; 50(8):760-5. · 0.90 Impact Factor
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ABSTRACT: INTRODUCTION: Expansion of the donor pool by the use of grafts with extended donor criteria reduces waiting list mortality with an increased risk for graft and patient survival after liver transplantation. The ability of the number of fulfilled extended donor criteria as currently defined by the German Medical Association (BÄK-Score) to predict early outcome is unclear. PATIENTS: A total of 291 consecutive adult liver transplantations (01.01.2007-31.12.2010) in 257 adult recipients were analyzed. METHODS: Primary study endpoints were 30 day mortality, 3 month mortality, 3 month patient and graft survival and the necessity of acute retransplantation within 30 days. For primary study endpoints a ROC curve analysis was performed to calculate sensitivity, specificity and overall model correctness of the BÄK score as a predictive model. Further methods included Kaplan-Meier estimates, log-rank tests, Cox regression analysis, logistic regression analysis and χ(2)-tests. RESULTS: The number of extended donor criteria fulfilled had no statistically significant influence on the primary study endpoints (p > 0.05) or on patient survival (p > 0.05). ROC curve analysis revealed areas under the curve ≤ 0.561 for the prediction of primary study endpoints (overall model correctness < 58%, sensitivity < 52%). CONCLUSIONS: The number of fulfilled extended donor criteria as currently defined by the German Medical Association is unable to predict early outcome after liver transplantation.
Der Chirurg 07/2012; · 0.70 Impact Factor
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ABSTRACT: Cases with subcutaneous metastasis of differentiated hepatocellular carcinoma to the abdominal wall without prior seeding as a consequence of local interventions with a negative or normal alpha-fetoprotein level in the serum are extremely rare.
This is the first report of a case with AFP-negative, differentiated hepatocellular carcinoma metastasis to the abdominal wall within a pre-existing subcutaneous lipoma since childhood after antiandrogen therapy with leuprorelin and buserelin acetate for prostate cancer without seeding.
Clinical features including histology, immunohistochemistry, clinical course and surgical approach are presented.
Histological examination revealed a hepatocellular carcinoma with a trabecular and pseudoglandular growth pattern with moderately atypical hepatocytes with multifocal bile formation within a lipoma. The postoperative course of abdominal wall reconstruction with a monocryl-prolene mesh and a local flap after potentially curative resection was uncomplicated.
It may be that previous antiandrogen treatment for prostate carcinoma contributed to the fact that our patient developed alpha-fetoprotein-negative and androgen receptor-negative subcutaneous abdominal wall metastasis within a pre-existing lipoma since childhood.
World Journal of Surgical Oncology 05/2012; 10:98. · 1.12 Impact Factor
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ABSTRACT: Komplikationen der viralen Hepatitis stellen insgesamt die häufigste Indikation zur Lebertransplantation dar. Für den betroffenen
Patienten handelt es sich oft um die einzig lebensrettende Option. Die Reinfektion des Lebertransplantats ist heute ein zentrales
Problem. Bei der Hepatitis B führt eine Reinfektion häufig zur Transplantatcirrhose und zum Transplantatversagen. Die Prophylaxe
der HBV-Reinfektion durch polyklonale humane Antikörper gegen HBsAg allein oder in Kombination mit dem Nucleosidanalogon Lamivudine
ist effektiv, aber teuer. Eine Reinfektion bei Hepatitis C erfolgt regelmäßig bei allen Patienten und hat im Vergleich zur
HBV-Reinfektion eine günstigere Prognose. Eine effektive Reinfektionsprophylaxe bei Hepatitis C konnte noch nicht etabliert
werden und bedarf noch umfangreicher Studien. Bei der Hepatitis C ist nach Reinfektion die Prognose für das Transplantat ungünstiger,
während die 5-Jahresüberlebensrate mit anderen benignen nichtviralen Indikationen vergleichbar ist.
Chronic hepatic dysfunction and acute liver failure due to viral hepatitis represent the most frequent indications for liver
transplantation. Liver grafting is the only available life-saving intervention for most of these patients. Reinfection of
the graft is still a central problem. In hepatitis B, reinfection frequently leads to cirrhosis with subsequent dysfunction
of the graft. Prophylaxis of HBV reinfection with polyclonal human antibodies against HBsAg alone or in combination with the
nucleoside analogue lamivudine is effective but costly. Reinfection in hepatitis C is a regular event in all patients and
has a far better prognosis than HBV reinfection of the graft. Effective prophylaxis of HCV reinfection has still not been
established and requires further studies. After HCV reinfection the prognosis of allograft survival is negatively affected;
however, the 5-year survival rate in patients who have undergone liver transplantation for HCV-related liver disease is not
lower than for other non-viral benign indications.
Der Chirurg 04/2012; 71(4):404-409. · 0.70 Impact Factor
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ABSTRACT: Pancreatic endocrine tumours are often diagnosed at an advanced stage with hepatic metastasis. This study investigated whether extended resections for advanced malignant pancreatic endocrine tumours influenced disease-free and disease-specific survival.
Patients who had curative resection of pancreatic endocrine tumours were analysed retrospectively for disease-free and disease-specific survival, with a focus on the role of extended surgical resection.
Forty-one patients were included in the analysis, 13 of whom underwent extended surgical resection in addition to pancreatic resection. This included partial liver resection in nine patients, portal vein resection in three, partial gastric resection in five and liver transplantation in three patients. There were no deaths in hospital or within 30 days. Median follow-up was 40 (range 2-239) months. Thirty-five, 24 and 13 patients survived more than 1, 3 and 5 years respectively. Patients who underwent extended resection had similar disease-specific survival to those who had pancreatic resection alone (hazard ratio (HR) 1·50, 95 per cent confidence interval (c.i.) 0·35 to 6·35; P = 0·581) but with a higher frequency of complications (odds ratio (OR) 4·28, 95 per cent c.i. 1·04 to 17·62; P = 0·044). Among patients with liver metastases, the mortality rate was higher in those in whom liver resection was not possible than in patients who had liver resection (HR 9·24, 1·00 to 85·18; P = 0·049). Patients who had liver resection had similar disease-specific survival to those without liver metastases (HR 0·84, 0·09 to 7·57; P = 0·877).
Extended surgical resection for locally advanced and metastatic pancreatic endocrine tumours is feasible with encouraging disease-specific survival.
British Journal of Surgery 01/2012; 99(1):88-94. · 4.61 Impact Factor
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ABSTRACT: The aim of this study was to evaluate the health-related quality of life of living liver donors after living-donor liver transplantation (LDLT).
Health-related quality of life (HRQOL) in 55 living liver donors operated on at our center between 2002 and 2009 was assessed using the German Version of the 36-Item Health Survey (SF-36).
Donors after full right-lobe hepatectomy (n=18) scored similarly to and without statistically significant difference from the German reference population, whereas donors after left lateral segmentectomy (n=37) revealed statistically significant higher average score values (P<.005) in the categories of physical functioning, bodily pain, and general health compared with the German reference population. In the analysis between donors after full right-lobe hepatectomy and donors after left lateral segmentectomy no statistically significant difference was observed in any of the SF-36 categories. Postoperative complications of the donors and postoperative recipient mortality were particularly revealing regarding HRQOL. Donors who developed postoperative complications presented a lower HRQOL, especially in the categories of role physical, bodily pain, and social functioning, where statistically significant differences (P<.005) were observed. Similarly, postoperative recipient mortality correlated with lower mean score values in all SF-36 categories, but a statistically significant difference (P<.005) was reached only in the categories of role emotional and mental health.
Donors did not regret their decision to donate, because HRQOL was not negatively affected by the donation procedure. Living liver donors scored as well as or even better than the German reference population, but it was clearly shown that the development of postoperative donor complications and the postoperative recipient mortality had a negative effect on the HRQOL of donors.
Transplantation Proceedings 12/2011; 43(10):3584-7. · 1.00 Impact Factor
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ABSTRACT: The percentage of elderly patients with colorectal liver metastases (CLM) has increased. Liver resection remains the only curative therapy; data evaluating the outcome in this age group is limited. Aim of the present study was to determine if postoperative morbidity, mortality, and other independent predictors influence survival in patients ≥ 70 years undergoing liver resection for CLM.
Clinical data on primary tumor and metastases of 939 patients after liver resection for CLM between 1994 and 2008 were retrospectively collected and subdivided in three age-groups (≥ 70, 40-69, <40). Independent predictors of survival were evaluated with overall and age-specific univariate and multivariate Cox regression models.
A total of 939 patients underwent liver resection for CLM, 20.3% aged ≥ 70 years. Overall postoperative mortality and morbidity were 1.08 and 14.82%, revealing no age-related differences. With 5-year survival of 31.8% in the elderly and 37.5% in the mid-age population, age ≥ 70 years was linked with decreased survival (Hazard Ratio [HR] = 1.305; P = 0.0186). Multivariate overall analyses showed size of CLM > 50 mm (HR = 1.376; P = 0.0060), a high amount of transfusion during surgery (HR = 1.676; P = 0.0110), duration of surgery >210 min (HR = 1.241; P = 0.0322), primary UICC (International Union Against Cancer) stage IV (HR = 2.297; P < 0.0001), and performance of repeat resections (HR = 0.652; P = 0.0107) as independent predictors of survival. In the elderly group, effects of UICC IV (HR = 3.260; P = 0.0148) and high numbers of transfusions (HR = 3.647; P = 0.0129) were confirmed; the others did not show statistical significance.
Resection of CLM at older age is feasible with morbidity and mortality rates similar to those in younger patients. Although age ≥ 70 was shown to be associated with poorer overall outcome, reasonable 5-year survival was observed.
World Journal of Surgery 06/2011; 35(9):2063-72. · 2.36 Impact Factor
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Sven Pischke,
Pothakamuri V Suneetha,
Christine Baechlein,
Hannelore Barg-Hock,
Albert Heim,
Nassim Kamar,
Jerome Schlue,
Christian P Strassburg,
Frank Lehner,
Regina Raupach,
Birgit Bremer,
Peter Magerstedt,
Markus Cornberg,
Frauke Seehusen,
Wolfgang Baumgaertner, Juergen Klempnauer,
Jacques Izopet,
Michael P Manns,
B Grummer,
Heiner Wedemeyer
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ABSTRACT: Hepatitis E virus (HEV) infection induces self-limiting liver disease in immunocompetent individuals. Cases of chronic hepatitis E have recently been identified in organ transplant recipients. We questioned if chronic hepatitis E plays a role in graft hepatitis after liver transplantation in a low endemic area. Two hundred twenty-six liver transplant recipients, 129 nontransplanted patients with chronic liver disease, and 108 healthy controls were tested for HEV antibodies. HEV RNA was investigated in all sera from transplanted patients. HEV antibodies were detected in 1 healthy control (1%), 4 patients with chronic liver disease (3%), and 10 liver transplant recipients (4%). Three liver transplant patients also tested positive for HEV RNA. Two of them developed persistent viremia with HEV genotype 3. The patients were anti-HEV immunoglobulin G-negative and HEV RNA-negative before transplantation and had an episode of acute hepatitis 5 or 7 months after transplantation, which led to advanced liver fibrosis after 22 months in 1 patient. Seroconversion to anti-HEV occurred not before 4 months after the first detection of HEV RNA. The possibility of reverse zoonotic transmission was experimentally confirmed by the infection of 5 pigs with a patient's serum. The pigs showed histological inflammation in the liver, and HEV RNA was detectable in different organs, including muscle. In conclusion, the prevalence of HEV infection in Central European liver transplant recipients is low; however, chronic hepatitis E may occur and needs to be considered in the differential diagnosis of graft hepatitis. The diagnosis of HEV infection should be based on HEV RNA determination in immunosuppressed patients. We suggest that immunocompromised individuals should avoid eating uncooked meat and contact with possibly HEV-infected animals.
Liver Transplantation 10/2009; 16(1):74-82. · 3.39 Impact Factor
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ABSTRACT: The value of hepatic resection for non-colorectal, non-neuroendocrine liver metastases remains controversial and is still under debate. Although there are numerous reported cases, the results are inconsistent due to the heterogeneity of the enrolled patients. The aim of the present study was to determine the utility of liver resection in the long-term outcome of patients with non-colorectal, non-neuroendocrine liver metastases and to define prognostic factors predicting long-term survivors.
The records of patients undergoing liver resection for non-colorectal, non-neuroendocrine liver metastases between January 1994 and December 2008 were analysed. Patient demographics, tumour characteristics, type of resection, long-term outcome and prognostic factors were analysed.
Between 1994 and December 2008 273 liver resections were performed in 242 patients because of non-colorectal, non-neuroendocrine liver metastases. The morbidity rate was 20.9 % (n = 57), the mortality rate was 2.2 % (n = 6). Patient survival at 1, 3, 5 and 10 years was 76 %, 42 %, 28 % and 13 %, respectively. In multivariate analyses margin status (R0 vs. R2; p = 0.001) and time to metastases (synchronous vs. metachronous) were predictors of survival. Patient's age, type of resection, number and size of metastases did not achieve significance. According to the primary tumour site, patient survival differed. Patients with urological and gynaecological primary tumours fared better whereas patients with liver metastases from gastrointestinal primary tumours did worse without reaching statistical significance.
Liver resection for non-colorectal, non-neuroendocrine liver metastases is safe and effective. For individual patients with controlled systemic disease, liver resection can offer appropriate survival rates and should be a part of the onco-surgical treatment.
Zentralblatt für Chirurgie 09/2009; 134(5):430-6. · 1.02 Impact Factor
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R T Grundmann,
P Hermanek,
S Merkel,
C-T Germer,
J Hauss,
D Henne-Bruns,
K Herfarth,
U T Hopt,
T Junginger,
E Klar, [......],
A Reinacher-Schick,
J Ricke,
J Roder,
A-O Schäfer,
H J Schlitt,
M R Schön,
D Stippel,
A Tannapfel,
K Tatsch,
T J Vogl
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ABSTRACT: In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.
Zentralblatt für Chirurgie 07/2008; 133(3):267-84. · 1.02 Impact Factor
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ABSTRACT: The success of transplantation with good long-term outcome is closely related to the possibilities of iatrogenic immunosuppression. Progress in immunosuppression combines basic scientific research of alloimmunity with practical clinical management of transplanted patients, their underlying diseases, and management of immunosuppressant side effects. Calcineurin inhibitors and steroids form the basis of immunosuppression in liver transplantation. To prevent steroid side effects and most importantly nephrotoxicity, the roles of antimetabolites such as mycophenolate and calcineurin inhibitor reduction have become more important. Developments in the 1990s provided specific antibodies and induction protocols renabling the delayed application of calcineurin inhibitors and a reduction in side effects. Against the background of a range of indications reaching from chronic viral infection to tumors, the progress of immunosuppression is characterized by the calculated combination of synergistic individual immunosuppressants. Novel drugs and strategies for the induction of tolerance are under development.
Der Chirurg 03/2008; 79(2):149-56. · 0.70 Impact Factor
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ABSTRACT: Liver transplantation has been reported to reach excellent results for selected indications. We analysed the results of liver transplantation in our centre over a period of 23 years, with a total of 2,114 consecutive liver transplants in 1,773 patients (eras I-III 5.5 years each, era IV 6.5 years). Overall 20-year survival after liver transplantation was 29.8%. The most frequent leading causes of death were infections of various origins (30%), tumour recurrence (14.2%), and pneumonia (8.4%). The most frequent leading causes for graft loss were infection of various origins (19.6%), initial nonfunction of the graft (14.6%), and tumour recurrence (9.6%). Both long-term patient and graft survival were significantly better after primary liver transplantation than after first retransplantation (P<0.001). Patient and graft long-term survival improved significantly across all four consecutive eras (P<0.001). In era IV, the most recent, 5-year patient survival reached 96% for PBC, 89.4% for PSC, 78.5% for biliary atresia, 70% for acute liver failure, 69.1% for HBV-related cirrhosis, 61.3% for hepatocellular carcinoma, and 56% for HCV-related cirrhosis.
Der Chirurg 03/2008; 79(2):121-9. · 0.70 Impact Factor
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ABSTRACT: Bei ausgewählten Indikationen wurden exzellente Ergebnisse nach Lebertransplantation berichtet. Die Ergebnisse in unserem
Zentrum wurden über 23Jahre mit 2114 konsekutiven Lebertransplantationen in 1773Patienten untersucht (Epochen I–III jeweils
5,5Jahre, EpocheIV 6,5Jahre). Nach 20Jahren erreichte das Gesamtüberleben 29,8%. Die häufigsten führenden Todesursachen
waren Infektionen unterschiedlicher Genese (30%), Tumorrezidive (14,2%) und Pneumonie (8,4%). Die häufigsten führenden Ursachen
für den Transplantatverlust waren Infektionen unterschiedlicher Genese (19,6%), initiale Nichtfunktion des Transplantates
(14,6%) und Tumorrezidive (9,6%). Das Patientenüberleben und das Transplantatüberleben waren beide signifikant besser nach
primärer Transplantation als nach erster Retransplantation (p<0,001). Das Patienten- und Transplantatüberleben haben sich
über die 4konsekutiven Epochen signifikant verbessert (p<0,001). In der jüngsten EpocheIV erreichte das 5-Jahres-Überleben
bei primärer biliärer Zirrhose (PBC) 96%, bei primärer sklerosierender Cholangitis (PSC) 89,4%, bei Gallengangsatresie 78,5%,
bei akutem Leberversagen 70%, bei Hepatitis-B (HBV)-assoziierter Leberzirrhose 69,1%, bei hepatozellulärem Karzinom 61,3%
und bei Hepatitis-C (HCV)-assoziierter Leberzirrhose 56%.
Liver transplantation has been reported to reach excellent results for selected indications. We analysed the results of liver
transplantation in our centre over a period of 23years, with a total of 2,114 consecutive liver transplants in 1,773 patients
(eras I–III 5.5years each, era IV 6.5years). Overall 20-year survival after liver transplantation was 29.8%. The most frequent
leading causes of death were infections of various origins (30%), tumour recurrence (14.2%), and pneumonia (8.4%). The most
frequent leading causes for graft loss were infection of various origins (19.6%), initial nonfunction of the graft (14.6%),
and tumour recurrence (9.6%). Both long-term patient and graft survival were significantly better after primary liver transplantation
than after first retransplantation (P<0.001). Patient and graft long-term survival improved significantly across all four
consecutive eras (P<0.001). In era IV, the most recent, 5-year patient survival reached 96% for PBC, 89.4% for PSC, 78.5%
for biliary atresia, 70% for acute liver failure, 69.1% for HBV-related cirrhosis, 61.3% for hepatocellular carcinoma, and
56% for HCV-related cirrhosis.
Der Chirurg 01/2008; 79(2):121-129. · 0.70 Impact Factor
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[show abstract]
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ABSTRACT: Die Erfolge der Transplantationsmedizin mit gutem Langzeitüberleben sind eng mit der medikamentösen Möglichkeit einer iatrogenen
Immunsuppression verbunden. Fortschritte der Immunsuppression verbinden grundlagenwissenschaftliche Erkenntnisse der Alloimmunität
mit dem praktischen klinischen Management transplantierter Patienten, ihren Grunderkrankungen und den Nebenwirkungen der Immunsuppressiva.
Basis der gängigen Immunsuppression bei der Lebertransplantation ist der Einsatz von Kalzineurininhibitoren und Steroiden.
Zur Vermeidung von Steroidnebenwirkungen und vor allem der Nephrotoxizität hat die Rolle der Antimetaboliten, wie der Mycophenolsäure,
und der Kalzineurininhibitorreduktion zugenommen. Die Entwicklungen der 1990er Jahre haben überdies durch gezielte Antikörper
gegen den Interleukin-2-Rezeptor zur Entwicklung von Induktionsprotokollen geführt, die eine verzögerte Gabe von Kalzineurininhibitoren
ermöglichen und Nebenwirkungen vermeiden können. Vor dem Hintergrund eines Spektrums von Indikationen, das von chronischer
Virusinfektion bis hin zu Tumoren reicht, sind die Fortschritte der Immunsuppression durch die sinnvolle Kombination synergistischer
Einzelimmunsuppressiva gekennzeichnet. Neue Wirkprinzipien sowie Strategien zur Toleranzinduktion sind in Entwicklung.
The success of transplantation with good long-term outcome is closely related to the possibilities of iatrogenic immunosuppression.
Progress in immunosuppression combines basic scientific research of alloimmunity with practical clinical management of transplantated
patients, their underlying diseases, and management of immunosuppressant side effects. Calcineurin inhibitors and steroids
form the basis of immunosuppression in liver transplantation. To prevent steroid side effects and most importantly nephrotoxicity,
the roles of antimetabolites such as mycophenolate and calcineurin inhibitor reduction have become more important. Developments
in the 1990s provided specific antibodies and induction protocols renabling the delayed application of calcineurin inhibitors
and a reduction in side effects. Against the background of a range of indications reaching from chronic viral infection to
tumors, the progress of immunosuppression is characterized by the calculated combination of synergistic individual immunosuppressants.
Novel drugs and strategies for the induction of tolerance are under development.
Der Chirurg 01/2008; 79(2):149-156. · 0.70 Impact Factor
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ABSTRACT: Evaluation of the influence of arterial anastomoses on hepatic hemodynamics and overall survival in liver graft recipients using color Doppler ultrasound.
224 patients recruited retrospectively were divided into five groups according to arterial anastomoses: (1) common hepatic (CHA)/gastro duodenal, (2) CHA/CHA, (3) aorta/celiac trunc, (4) aorta/aorta, (5) more than one anastomosis. We compared maximum portal [(P)Vmax], systolic [(A)Vmax] and end diastolic [(A)Vmin] arterial velocities, resistance indexes(RI), spleen and liver size between the groups. We analyzed further in a multivariate analysis the influence of time elapsed since orthotopic liver transplantation, age of recipient and donor on significant parameters as well as the overall survival of the patients between the groups.
Significant differences were found for: (A) Vmax between groups 2/4 (p<0.007) and 2/5 (p<0.010), (A) Vmin between groups 1/3 (p<0.029) and 2/3 (p<0.015) and RI between the groups 1/3 (p<0.018) and 3/4 (p<0.006). (A)Vmax and RI were only dependent on the type of arterial anastomosis (p<0.008 and p<0.014). The overall survival of the patients between the groups was significantly different (p<0.047).
In this study we report the natural course of the mean values of portal and arterial velocities in different arterial reconstructions for the first time. (A) Vmax of the hepatic artery is identified as the most promising candidate prognostic parameter for the assessment of hemodynamic alterations after liver transplantation originating in the type of arterial anastomosis performed. The group of patients with more than one anastomosis had the lowest arterial (A) Vmax and simultaneously the lowest overall survival.
Ultraschall in der Medizin 01/2008; 28(6):587-92. · 2.40 Impact Factor
