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  • 1
    ISSN: 1435-2451
    Keywords: Hilar carcinoma ; Liver resection ; Hiluscarcinom ; Leberresektion
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Zusammenfassung Neben verbesserten Möglichkeiten der Drainagebehandlung von Hiluscarcinomen haben Fortschritte der Leberchirurgie auch zu einer höheren Rate der Resektabilität dieser Tumoren geführt. Möglicherweise ist die Infiltrationstiefe mancher dieser Tumoren begrenzter als bei anderen Malignomen, so daß Resektion geeignet ist. Bei 65 zentralen Hilustumoren konnte 31mal ein resezierendes Verfahren, davon 17mal mit Teilleberresektion angewandt werden. Die 1-Jahres-Überlebenshöhe nach Resektion liegt bei 65%. Die Operation erfordert ein sehr sorgfältiges, häufig zeitaufwendiges präparatives Vorgehen.
    Notes: Summary Palliative treatment of hilar carcinoma has been improved by transhepatic and endoscopic techniques. Moreover, advances in liver surgery have allowed the resection of a higher percentage of these tumors, which sometimes do not infiltrate deeply into the hepatic parenchyma. Resection may thus be worthwhile. Of 65 central hilar tumors, 31 have been resected, in 17 of which resection was combined with partial hepatectomy. The 1 year survival of patients after resection is about 65%. Resection of these tumors requires skilful and mostly time consuming preparative surgical technique.
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  • 2
    ISSN: 1435-2451
    Keywords: Spenderkriterien ; Postischämieschaden ; Transplantatversagen
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Description / Table of Contents: Abstract The early outcome of 201 liver grafts transplanted consecutively between September 1988 and November 1991 was investigated retrospectively. Donors were categorized according to their hospitalization periods in an intensive care unit (ICU) prior to harvesting, their causes of death, and the variables generally believed to be critical in liver donation, such as arterial hypotension (n = 69; 34.3 %), cardiopulmonary resuscitation (n = 20; 9.9%), elevated serum-aminotransferases (s-AT) (n = 11; 5.5%), or an age over 50 years (n = 16; 8.0 %). Ninety-one donors (45.3 %) spent less than 24 h in an ICU; 29 donors (14.4%) and 14 donors (7.0%) had hospitalization periods generally considered critical of 4–6 days and more than 6 days, respectively. The most common causes of death were subarachnoidal bleeding (n = 70; 34.8%), isolated head injuries (n = 68; 33.8%), and polytraumata (n = 33; 16.4%).The postischemic hepatocellular damage was evaluated comparing peak post-transplant s-AT, which did not differ significantly between groups; nor did donor and recipient ages or cold ischemia times. Fourteen grafts (7.0%) showed a reversible preservation injury presenting with post-transplant s-AT elevated above 2000 IU/I. Five cases (2.5%) of a primary non-functioning graft (PNF) underwent early retransplantation successfully. Serum-aminotransferases (AST: 4944 ± 2280 IU/I; ALT: 3186 ± 1918 IU/ I) were significantly (P 〈 0.01) elevated as compared to primary functioning grafts (AST: 699 ± 935 IU/I; ALT: 620 ± 701 IU/I). The donor structure of both groups reflected the distribution of variables in the entire collective. No significant overrepresentations were observed. These results indicate that in the past criteria for donor selection have probably been applied too stringently. To determine true limits the pool of liver donors should carefully be extended.
    Notes: Zusammenfassung Nach 201 Lebertransplantationen von September 1988 bis November 1991 wurde retrospektiv der Postischämieschaden bei Vorliegen verschiedener Spenderkriterien untersucht. Als Kriterien galten die Hospitalisierungszeit auf Intensivstation vor Organentnahme, die Todesursache Bowie allgemein als kritisch eingeschätzte Parameter wie hypotensive Kreislaufphasen (n = 69; 34,4%), kardiopulmonale Reanimation (n = 20; 9,9%), erhöhte Serumtransaminasen (s-AT) (n = 11; 5,5%) oder ein Alter über 50 Jahre (n = 16; 8,0%). 91 Organspender lagen weniger als 24 h auf einer Intensivstation, hingegen 29 Spender (14,4%) 4–6 Tage und 14 Spender (7,0%) länger als 6 Tage. Häufigste Todesursachen waren Subarachnoidalblutungen (n = 70; 34,8%), isolierte Schädel-Hirn-Traumen (n = 68; 33,8%) und Polytraumen (n = 33; 16,4%). Der Postischamieschaden wurde anhand der maximalen postoperativen s-AT sowie der Inzidenz eines primären Transplantatversagens (PNF) oder einer schweren, reversiblen Transplantatschädigung (s-AT 〉 2000 IU/I) abgeschätzt. Maximale s-AT, Alter der Organspender und -empfänger sowie kalte Ischämiezeiten unterschieden sich zwischen den einzelnen Gruppen nicht signifikant. Schwere reversible Schäden zeigten 14 Transplantatlebern (7,0%); eine PNF trat in 5 Fallen (2,5%) auf, die erfolgreich einer frühen Retransplantation unterzogen wurden. Spenderkriterien waren in beiden Gruppen mit ähnlicher Häufigkeit wie im Gesamtkollektiv vertreten. Maximale s-AT bei Transplantatversagen (GOT: 4944 ± 2280 IU/I; GPT: 3186 ± 19181U/I) lagen signifikant (p 〉 0,01) höher als bei primärer Transplantatfunktion (GOT: 699 ± 935 IU/I; GPT: 620 ± 701 IU/I). Diese Ergebnisse sind trotz eines hohen Anteils bislang als kritisch angesehener Spender Ausdruck einer vermutlich zu strengen Selektion. Eine vorsichtige Lockerung der Selektionskriterien erscheint daher gerechtfertigt.
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  • 3
    ISSN: 1435-2451
    Keywords: Key words Liver transplantation ; Vasculature ; Blood flow ; Organ failure
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract  Background: From September 1988 through April 1998, 1000 liver transplantations were performed on 911 patients. The standard technique for liver re-vascularization to guarantee an optimal blood inflow during transplantation was modified in 19% of the cases on the arterial side and in 5.6% of the cases on the portal side as a result of unusual anatomical features and pathological changes in the vasculature of the organ recipient.In 113 transplantations, successful reconstruction of accessory vessels of the graft (12 left and 101 right hepatic arteries) was performed without complications. It is our opinion that preoperative diagnosis of the vasculature (stenoses of the celiac trunk etc.) of the organ recipient by duplexsonography and angiography is necessary. Even with the help of these tests, it is extremely difficult to diagnose a ”steal” syndrome in the splenic artery: for example, 31 of 40 patients with poor liver function received postoperative therapy for newly diagnosed ”steals”. Results and conclusions: There is no increase in complications (stenosis and thrombosis) with modifications of arterial reconstruction (4.9 vs 6.3%); however, with modification of portal reconstruction the increase is from 2.4% to 8.3%.
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  • 4
    ISSN: 1435-2451
    Keywords: Key words Hepatoma ; Liver resection ; Liver transplantation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract  Introduction: Despite recent advances with techniques of in situ tumor ablation, surgical therapy remains at present the mainstay in the treatment of primary hepatic malignancies. Discussion: After an initial endeavor to establish liver transplantation as a treatment option, especially for unresectable liver tumors, 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 non-cirrhotics, have largely been abandoned or are still under debate, as with fibrolamellar carcinoma. Selection of patients suffering from hepatocellular carcinoma in cirrhosis for liver transplantation is still based on tumor 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 benefit.
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  • 5
    Electronic Resource
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    Springer
    Der Internist 39 (1998), S. 1237-1245 
    ISSN: 1432-1289
    Keywords: Schlüsselwörter Lebertransplantation ; Leberversagen ; Lebertransplantation ; Hepatitis ; Therapie ; Leberzirrhose ; Therapie ; Transplantation ; Leber
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Zum Thema Die ultima ratio der Lebertherapie, die Lebertransplantation, hat hierzulande und in aller Welt eine zunehmende Bedeutung gewonnen. Die Prognose der Lebertransplantation ist auch langfristig sehr günstig und hat sich aufgrund vieler Voraussetzungen in den letzten Jahren immer weiter verbessert. Nur die mangelnde Bereitschaft zur Organspende limitiert die Anzahl weiterer wünschenswerter Transplantationen, worauf – wieder einmal – hingewiesen sei. Da hauptsächlich über Indikation und Prognose informierte Ärzte am überzeugendsten in ihrem Umfeld auf einen Wandel zugunsten einer positiven Einstellung zur Organtransplantation bewirken können, sei diese Übersicht auch den nicht auf die Behandlung von Lebererkrankungen spezialisierten Kolleginnen und Kollegen empfohlen. Im Mittelpunkt der vorliegenden Arbeit stehen die Indikationen zur Lebertransplantation und deren Prognose. Da sich diese mit der Progredienz des Leidens im Hinblick auf das Transplantationsergebnis verschlechert, sollte bei bestehender Indikation die Lebertransplantation möglichst bald durchgeführt werden. Große Fortschritte wurden auch mit der möglichst individuellen Immunsuppression und antiviralen Therapie erzielt. Die Ergebnisse in der Entwicklung therapeutischer Systeme, die z.B. im Falle eines aktuen Leberversagens bis zur Bereitstellung eines Spenderorgans vorübergehend die Leberfunktion überbrücken helfen, sind ermutigend. Auch darüber wird referiert.
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  • 6
    ISSN: 1432-2277
    Keywords: Key words Mycophenolate ; mofetil ; Liver transplantation ; Immunosuppressive agents
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Mycophenolate mofetil (MMF) has been used successfully as an immunosuppressive agent after kidney and heart transplantation, but experience with MMF after liver transplantation is still limited. Between August 1995 and January 1996, we treated 20 patients with MMF after orthotopic liver transplantation in an open, prospective study. Five out of eight patients with acute rejection and one patient with early chronic rejection showed a complete response after MMF was added to the immunosuppression. Three patients with chronic rejection did not improve, one died, and two have stable graft function at present. In eight patients who suffered from toxicity, a reduction in the dosage of tacrolimus was attempted with simultaneous MMF therapy. One patient died due to multiple organ failure. Liver function improved completely in one other patient, and partially in three patients after adding MMF. In the remaining three patients, a reduced dosage of tacrolimus or cyclosporin, together with MMF, reduced toxicity, not significantly. In conclusion, MMF appears to be a safe and potentially useful adjuvant immunosuppressive agent for rescue and maintenance therapy.
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  • 7
    ISSN: 1432-2277
    Keywords: Key words Liver transplantation ; Perioperative nutrition
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract The present clinical experience in perioperative nutrition for patients undergoing orthotopic liver transplantation was evaluated by a questionnaire, answered by 16/21 European transplant units (76.1 %). There is agreement, that malnutrition reflects per se the severity of chronic liver disease and should be not considered, in general, to exclude patients from the transplant waiting list. Most centers administer postoperative nutrition without difference to other patients after gastrointestinal major surgery. A combination of parenteral and enteral nutrition is preferred. Experience with preoperative nutritional support and use of new immunomodulating substances is rather limited.
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  • 8
    ISSN: 1432-2277
    Keywords: Key words Hepatitis B ; Liver transplantation ; Lamivudine ; Interferon ; Resistance ; Combination therapy
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Development of resistance is a major issue in antiviral treatment of hepatitis B reinfection after liver transplantation. Antiviral combination therapy is discussed for therapy or prevention of this breakthrough of viral replication. Eight patients were enrolled into this retrospective analysis after liver transplantation for chronic hepatitis B infection. All had reinfection of the graft and breakthrough of HBV during consecutive famciclovir and lamivudine monotherapy. Subsequently a combination therapy with lamivudine and interferon-α 2 a (group I, n = 4) or lamivudine and famciclovir (group II, n = 4) was initiated. Combination therapy was started 61 months (group I) and 25 months (group II) after liver transplantation. It markedly reduced the viral replication rate in all patients despite lamivudine resistance. In group I three of four patients and in group II two of four patients became HBV-DNA negative. Two long-term responders were observed in group I, and none in group II. No patient became HBsAg negative or lost HbeAg. Pretreatment elevated ALT and AST levels were significantly reduced. No severe complications, and especially no rejection episodes, occurred. Lamivudine in combination with other antiviral agents, especially interferon-α, might be a therapeutic option for hepatitis B reinfection after liver transplantation. Suppression of virus replication to the point of undetectable values is possible even in patients with lamivudine-resistant virus mutations.
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  • 9
    ISSN: 1432-2277
    Keywords: Key words Liver transplantation ; Alcoholic cirrhosis ; Alcohol relapse ; Outcome
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract Because of the donor shortage, there are concerns for liver transplantation in patients with alcoholic cirrhosis. We therefore analyzed patients transplanted for alcoholic cirrhosis at our center with respect to patient and graft survival, recurrence of disease, and postoperative complications. Out of 1000 liver transplantations performed in 911 patients, 167 patients were transplanted for alcoholic cirrhosis; 91 patients received CsA- and 76 patients FK506-based immunosuppression. Recurrence was diagnosed by patient's or relative's declaration, blood alcohol determination, and delirium. Diagnosis and treatment of acute and chronic rejection was performed as previously described. One- (96.8 % versus 91.3 %) and 9-year patient survival (83.3 % versus 80 %) compared well with other indications. Five of 15 patients died due to disease recurrence. Recurrence of disease was significantly related to the duration of alcohol abstinence prior to transplantation. In patients who were abstinent for less than 6 months (17.1 %), recurrence rate was 65 %, including four of the five patients who died of recurrence. Recurrence rate decreased to 11.8 %, when abstinence time was 6–12 months and to 5.5 %, when the abstinence times was 〉 2 years. Next to duration of abstinence, alcohol relapse was significantly related to sex, social environment, and psychological stability. The incidence of acute rejection compared well with other indications (38.1 %); CsA: 40.1 % versus 33.3 % in FK506 patients. In all, 18.2 % of CsA patients experienced steroid-resistant rejection compared with 2.6 % of FK506 patients. Seven patients (7.6 %) in the CsA group and one patient (1.3 %) in the FK506 group developed chronic rejection. A total of 57.1 % developed infections; 5.7 % were life-threatening. CMV infections were observed in 14.3 % (versus 25 % for other indications). New onset of insulin-dependent diabetes was observed in 8.6 % and hypertension in 32.4 %. In conclusion, alcoholic cirrhosis is a good indication for liver transplantation with respect to graft and patient survival and development of postoperative complications. FK506 therapy was favourable to CsA treatment. Patient selection is a major issue and established criteria should be strictly adhered to. Patients with alcohol abstinence times shorter than 6 months should be excluded, since recurrence and death due to recurrence was markedly increased in this group of patients.
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  • 10
    ISSN: 1432-2277
    Keywords: Key words Liver transplantation ; Multiple organ dysfunction syndrome ; Patient outcome ; Donor recipient status
    Source: Springer Online Journal Archives 1860-2000
    Topics: Medicine
    Notes: Abstract We have previously shown that the development of multiple organ dysfunction syndrome (MODS) after liver transplantation significantly reduced patient survival. Therefore, the question arises of which are the most prominent perioperative donor and recipient factors leading to MODS after transplantation. In total, 634 patients with 700 liver transplants were analyzed. Donor factors included age, increase in transaminases, sex mismatch, requirement for catecholamines, intensive care time, histology, and macroscopic graft appearence. Recipient factors included Child classification, preoperative gastrointestinal (GI) bleeding, mechanical ventilation, hemodialysis, and requirement for catecholamines. MODS was defined by more than two severe organ dysfunctions. The cumulative 2 to 9-year patient survival was 90.9 % in patients developing less than 3 severe organ dysfunctions following transplantation. Survival decreased to 60.3 % in patients with MODS. Neither any of the donor factors nor the duration of cold ischemia (CIT) was associated with an increase in MODS or decrease in survival. On the other hand, duration of warm ischemia, amount of blood loss, requirement for red packed blood cells, and reoperation had an influence on the development of MODS (40 %–56 %) and decreased patient survival to 58 %–69 %. Preoperative therapy with catecholamines, GI bleeding, mechanical ventilation, and hemodialysis were associated with the development of MODS in 54 %–88 %. Patient survival following MODS decreased to 50 %–74 %. Initial graft function had a slight influence on the development of MODS, but no influence on the long-term patient survival. In conclusion, patient survival was significantly influenced by the development of postoperative MODS. The most prominent factors in this were recipient and intraoperative ones. No major influence was observed for donor factors, CIT, and initial graft function. Prevention of MODS will further improve the outcome after liver transplantation.
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