J Klempnauer

Hannover Medical School, Hanover, Lower Saxony, Germany

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Publications (306)648.51 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Abdominal complications after thoracic transplantation (Tx) are potentially associated with an increased risk of mortality. We recently reported about the severe outcome after bowel perforation in patients following lung transplantation (LuTx). The aim of the present study was to likewise identify the risk factors with an impact on patient survival following heart transplantation (HTx). A retrospective analysis for the frequency and outcome of abdominal interventions following HTx was performed in 342 patients, and these data thereafter compared to a re-evaluated pool of 1,074 patients following LuTx. All patients were transplanted at Hanover Medical School, Germany, between January 2000 and October 2011. The incidence for abdominal surgery was comparable between patients following HTx (n = 33; 9.6 %) and LuTx (n = 90; 8.4 %). Elective operations were more frequently performed in patients after HTx (8.5 vs. 5.1 %). In contrast, the incidence of emergency interventions was higher after LuTx (5.3 %) than that following HTx (2.3 %). Herewith associated was the mortality observed in these transplant recipients (15.3 and 9.9 % for LuTx and HTx, respectively). Leading diagnosis for emergency surgery was bowel perforation (n = 18, regarding all cases). In 11 of these patients, perforation occurred within the first 6 months after Tx and eight of them died in the course of this complication (one patient after HTx and seven patients after LuTx). Abdominal complications after HTx are less frequently than after LuTx but equally correlate with a high mortality rate. In finding or even reasonable suspicion of an acute abdomen after thoracic Tx, a broad practice for extended diagnostics and a low barrier for an early explorative laparotomy thus are recommended.
    Langenbeck s Archives of Surgery 04/2014; · 1.89 Impact Factor
  • B Kettler, H Schrem, J Klempnauer, G Grannas
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    ABSTRACT: A common problem in patients with chronic liver diseases and liver cirrhosis is the development of ascites. First line therapy for ascites is the restriction of sodium intake and a diuretic treatment. Paracentesis is indicated in patients with large compromising volumes of ascites. In selected cases, permanent drainage of ascites over prolonged periods of time may be indicated. In the case presented here, a 66-year-old male patient, who was hospitalized with liver cirrhosis caused by alcoholic abuse, required permanent drainage of ascites. After three weeks of continuous ascites drainage, he developed bacterial peritonitis. Conventional attempts to remove the catheter by transcutaneous pulling failed and we thus decided to perform a median laparotomy to remove the catheter surgically. Intraoperatively an adhesion of the ascites drain (a so called 'basket catheter') to the mesentery very close to the small intestine was found, approximately 50 mm distal of the ligament suspensorium duodeni (ligament of Treitz). The basket catheter used for this patient was especially designed to drain infections, not fluids. We solved the adhesion, removed the basket catheter, placed a new surgical drain and finished the operation. The patient developed a rupture of his abdominal fascia suture 12 days later, which was caused by massive ascites and complicated by hepatorenal syndrome type I. The patient was taken to the operating theater again. After the second operation, the chronic liver failure decompensated and the patient died. Ascites caused by liver cirrhosis is still a medical challenge. The indication for the use of the correct percutaneous catheter for permanent paracentesis should be carefully considered. Some catheters are obviously not suited to drain ascites and may lead to fatal outcomes.
    Clinical medicine insights. Case reports. 01/2014; 7:3-5.
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    ABSTRACT: HCV RNA levels correlate with the long-term outcome of hepatitis C in liver transplant recipients. Nucleic acid testing (NAT) is usually used to confirm HCV reinfection and to examine viral loads after liver transplantation. HCV core antigen (HCVcoreAg) testing could be an alternative to NAT with some potential advantages including very low intra- and interassay variabilities and lower costs. The performance of HCVcoreAg testing in organ transplant recipients is unknown. We prospectively studied 1011 sera for HCV RNA and HCVcoreAg in a routine real-world setting including 222 samples obtained from patients after liver or kidney transplantation. HCV RNA and HCVcoreAg test results showed a consistency of 98% with a very good correlation in transplanted patients (r > 0.85). The correlation between HCV RNA and HCVcoreAg was higher in sera with high viral loads and in samples from patients with low biochemical disease. Patients treated with tacrolimus showed a better correlation between both parameters than individuals receiving cyclosporine A. HCV RNA/HCVcoreAg ratios did not differ between transplanted and nontransplanted patients, and HCV RNA and HCVcoreAg kinetics were almost identical during the first days after liver transplantation. HCVcoreAg testing can be used to monitor HCV viral loads in patients after organ transplantation. However, the assay is not recommended to monitor antiviral therapies.
    Journal of Viral Hepatitis 11/2013; · 3.08 Impact Factor
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    ABSTRACT: The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.
    Zeitschrift für Gastroenterologie 11/2013; 51(11):1269-326. · 1.41 Impact Factor
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    ABSTRACT: Abdominal seat belt marks can be an indication of abdominal wall rupture. The focused assessment with sonography for trauma (FAST) and computed tomography (CT) scanning are the diagnostic tools of choice in hemodynamically stable patients. The typical mechanism of trauma frequently leads to additional intra-abdominal injuries, spinal injuries and in some cases aortic rupture. Abdominal wall injuries of grade IV according to Dennis should be surgically treated. The increasing numbers of obese vehicle occupants and the resulting special risk of injury warrant optimization of technical restraint systems.
    Der Unfallchirurg 07/2013; · 0.64 Impact Factor
  • U Kulik, H Bektas, J Klempnauer, F Lehner
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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. · 4.84 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. · 5.74 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; · 3.94 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; · 3.94 Impact Factor
  • Annals of Surgery 05/2013; 257(5):807-815. · 6.33 Impact Factor
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    ABSTRACT: Objective: The purpose of this study was to assess outcomes and indications in a large cohort of patients who underwent liver transplantation (LT) for liver metastases (LM) from neuroendocrine tumors (NET) over a 27-year period. Background: LT for NET remains controversial due to the absence of clear selection criteria and the scarcity and heterogeneity of reported cases. Methods: This retrospective multicentric study included 213 patients who underwent LT for NET performed in 35 centers in 11 European countries be-tween 1982 and 2009. One hundred seven patients underwent transplantation before 2000 and 106 after 2000. Mean age at the time of LT was 46 years. Half of the patients presented hormone secretion and 55% had hepatomegaly. Before LT, 83% of patients had undergone surgical treatment of the primary tumor and/or LM and 76% had received chemotherapy. The median interval between diagnosis of LM and LT was 25 months (range, 1–149 months). In addition to LT, 24 patients underwent major resection procedures and 30 patients underwent minor resection procedures. Results: Three-month postoperative mortality was 10%. At 5 years after LT, overall survival (OS) was 52% and disease-free survival was 30%. At 5 years from diagnosis of LM, OS was 73%. Multivariate analysis identified 3 pre-From the
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    ABSTRACT: OBJECTIVE:: The purpose of thisstudy was to assess outcomes and indications in a large cohort of patients who underwent liver transplantation (LT) for liver metastases (LM) from neuroendocrine tumors (NET) over a 27-year period. BACKGROUND:: LT for NET remains controversial due to the absence of clear selection criteria and the scarcity and heterogeneity of reported cases. METHODS:: This retrospective multicentric study included 213 patients who underwent LT for NET performed in 35 centers in 11 European countries between 1982 and 2009. One hundred seven patients underwent transplantation before 2000 and 106 after 2000. Mean age at the time of LT was 46 years. Half of the patients presented hormone secretion and 55% had hepatomegaly. Before LT, 83% of patients had undergone surgical treatment of the primary tumor and/or LM and 76% had received chemotherapy. The median interval between diagnosis of LM and LT was 25 months (range, 1-149 months). In addition to LT, 24 patients underwent major resection procedures and 30 patients underwent minor resection procedures. RESULTS:: Three-month postoperative mortality was 10%. At 5 years after LT, overall survival (OS) was 52% and disease-free survival was 30%. At 5 years from diagnosis of LM, OS was 73%. Multivariate analysis identified 3 predictors of poor outcome, that is, major resection in addition to LT, poor tumor differentiation, and hepatomegaly. Since 2000, 5-year OS has increased to 59% in relation with fewer patients presenting poor prognostic factors. Multivariate analysis of the 106 cases treated since 2000 identified the following predictors of poor outcome: hepatomegaly, age more than 45 years, and any amount of resection concurrent with LT. CONCLUSIONS:: LT is an effective treatment of unresectable LM from NET. Patient selection based on the aforementioned predictors can achieve a 5-year OS between 60% and 80%. However, use of overly restrictive criteria may deny LT to some patients who could benefit. Optimal timing for LT in patients with stable versus progressive disease remains unclear.
    Annals of surgery 03/2013; · 7.90 Impact Factor
  • Transplant International 03/2013; · 3.16 Impact Factor
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    01/2013; , ISBN: 978-953-51-1070-5
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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; · 6.19 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. · 1.41 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; · 0.52 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. · 1.09 Impact Factor
  • J. Klempnauer, M. P. Manns
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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. · 0.52 Impact Factor

Publication Stats

3k Citations
648.51 Total Impact Points

Institutions

  • 1987–2013
    • Hannover Medical School
      • • Department of Gastroenterology, Hepatology and Endocrinology
      • • Clinic for General, Abdominal and Transplant Surgery
      Hanover, Lower Saxony, Germany
  • 2012
    • University Medical Center Hamburg - Eppendorf
      • Department of Hepatobiliary and Transplant Surgery
      Hamburg, Hamburg, Germany
  • 1994–2009
    • Hochschule Hannover
      Hanover, Lower Saxony, Germany
  • 2004
    • Heinrich-Heine-Universität Düsseldorf
      Düsseldorf, North Rhine-Westphalia, Germany
  • 2001
    • Goethe-Universität Frankfurt am Main
      • Orthopädische Universitätsklinik
      Frankfurt am Main, Hesse, Germany
  • 2000
    • German Primate Center
      Göttingen, Lower Saxony, Germany
  • 1998–1999
    • Ruhr-Universität Bochum
      Bochum, North Rhine-Westphalia, Germany
  • 1997
    • Städtisches Krankenhaus Kiel
      Kiel, Schleswig-Holstein, Germany