Hans-Michael Hau

Liver resection for hepatocellular carcinoma in patients with cirrhosis.

Data on liver resection for hepatocellular carcinoma (HCC) without cirrhosis are sparse. The present study was conducted to evaluate the indications and results of liver resection for HCC with regard to safety and efficacy.

Combined heterotopic liver-pancreas transplantation as a curative treatment for liver cirrhosis and diabetes mellitus in cystic fibrosis.

Cystic fibrosis (CF) is an inherited disease with a defect in epithelial chloride transport that results in a multisystem disease. Although pulmonary disease remains the primary cause of morbidity and mortality, focal biliary cirrhosis and portal hypertension may develop in up to 8% of these patients. Liver transplantation (TX) is an accepted therapy and shows good results. We report on a patient with cystic fibrosis homozygous for the most common CFTR mutation delta F 508 who received a combined heterotopic liver and pancreas transplantation at the age of 18 yr. He suffered from CFRD, which untypically required high doses of insulin. In addition, the patient had pulmonary complications, was chronically colonized with multiresistant Pseudomonas aeruginosa (MBL) and had an allergic bronchopulmonary aspergillosis (ABPA). The patient remained in stable health for 54 months post‐TX and was able to live a nearly normal life. With a follow‐up of five yr, the function of the liver and pancreas allografts was excellent. However, and sadly, his pulmonary function continued to deteriorate from progression of his CF, and he died of respiratory failure due to a severe pneumonia and septicemia at the age of 23 yr and five months.

Horseshoe kidney for transplantation: Technical considerations

Abstract Owing to the ongoing shortage of cadaver organs, kidneys with an atypical anatomy such as horseshoe kidneys must be considered for transplantation. Owing to its low prevalence, experience with the transplantation of a horseshoe kidney is very limited. This article reports on the transplantation of a horseshoe kidney to a 58-year-old man with renal failure from chronic glomerulonephritis. Because of a relatively thick isthmus, which indicated a complex urinary collecting and intrarenal vessel system, the kidney was transplanted en bloc. Together with optimal placement of the kidney, only adequate length and positioning of the vessels, especially the venous drainage, could prevent postoperative complications such as kinking of the vessels and thrombosis. These problems could be solved by cutting the renal veins without using a vena cava patch. Careful positioning of the kidney within the intraperitoneal cavity is also necessary. The decision to transplant the kidney en bloc or after separation depends on many factors and should be made individually.

Alternative treatment of symptomatic pancreatic fistula

BACKGROUND The management of symptomatic pancreatic fistula after pancreaticoduodenectomy is complex and associated with increased morbidity and mortality. We here report continuous irrigation and drainage of the pancreatic remnant to be a feasible and safe alternative to total pancreatectomy. MATERIALS AND METHODS Between 2005 and 2011, patients were analyzed, in which pancreaticojejunal anastomosis was disconnected because of grade C fistula, and catheters for continuous irrigation and drainage were placed close to the pancreatic remnant. Clinical data were monitored and quality of life was evaluated. RESULTS A total of 13 of 202 patients undergoing pancreaticoduodenectomy required reoperation due to symptomatic pancreatic fistula. Ninety-day mortality of these patients was 15.3%. Median length of stay on the intensive care unit and total length of stay was 18 d (range 3-45) and 46 d (range 33-96), respectively. Patients with early reoperation (<10 d) had significantly decreased length of stay on the intensive care unit and operation time (P < 0.05). Global health status after a median time of 22 mo (range 6-66) was nearly identical, when compared with that of a healthy control group. Mean follow-up was 44.4 mo (±27.2). Four patients (36.6 %) died during the follow-up period; two patients from tumor recurrence, one patient from pneumonia, and one patient for unknown reasons. CONCLUSIONS Treatment of pancreatic fistula by continuous irrigation and drainage of the preserved pancreatic remnant is a simple and feasible alternative to total pancreatectomy. This technique maintains a sufficient endocrine function and is associated with low mortality and reasonable quality of life.

Impact of different immunosuppressive regimens on the health‐related quality of life following orthotopic liver transplantation

The influence of immunosuppression on the recipients’ quality of life (QoL) is of major importance after OLT and has not yet been evaluated.

Antibody-Mediated Rejection of Arterialised Venous Allografts Is Inhibited by Immunosuppression in Rats

Objectives and Design We determined in a rat model (1) the presence and dynamics of alloantibodies recognizing MHC complexes on quiescent Brown-Norway (BN) splenic cells in the sera of Lewis (LEW) recipients of Brown-Norway iliolumbar vein grafts under tacrolimus immunosuppression; and (2) the presence of immunoglobulins in the wall of acute rejected vein allografts. Materials and Methods Flow cytometry was used for the analysis of day 0, 14 and 30 sera obtained from Lewis recipients of isogeneic iliolumbar vein grafts (group A) or Brown-Norway grafts (group B, C) for the presence of donor specific anti-MHC class I and II antibodies. Tacrolimus 0.2 mg/kg daily was administered from day 1 to day 30 (group C). Histology was performed on day 30. Results Sera obtained preoperatively and on day 30 were compared in all groups. The statistically significant decrease of anti MHC class I and II antibody binding was observed only in allogenic non-immunosuppressed group B (splenocytes: MHC class I - day 0 (93%±7% ) vs day 30 (66%±7%), p = 0.02, MHC class II - day 0 (105%±3% ) vs day 30 (83%±5%), p = 0.003; B-cells: MHC class I - day 0 (83%±5%) vs day 30 (55%±6%), p = 0.003, MHC class II - day 0 (101%±1%) vs day 30 (79%±6%), p = 0.006; T-cells: MHC class I - day 0 (71%±7%) vs day 30 (49%±5%), p = 0.04). No free clusters of immunoglobulin G deposition were detected in any experimental group. Conclusion Arterialized venous allografts induce strong donor-specific anti-MHC class I and anti-MHC class II antibody production with subsequent immune-mediated destruction of these allografts with no evidence of immunoglobulin G deposition. Low-dose tacrolimus suppress the donor-specific antibody production.

Immunosuppressive protocol with delayed use of low-dose tacrolimus after aortic transplantation suppresses donor-specific anti-MHC class I and class II antibody production in rats.

BACKGROUND Arterial allografts are used as vascular conduits in the treatment of prosthetic graft infection. Immunosuppression decreases their rupture risk rate. However, immunosuppression can be unprofitable in florid infection. Previously, we confirmed inhibition of cell-mediated destruction of rat aortic grafts by delayed use of tacrolimus. In this work, we studied the influence of this protocol on the antibody-mediated rejection. MATERIAL AND METHODS Flow cytometry was used for the retrospective analysis of day 0, 14, and 30 sera obtained from Lewis rat recipients of isogeneic fresh infrarenal aortic grafts (group A) or Brown-Norway rat aortic grafts (group B,C,D) for the presence of donor-specific anti-MHC class I and II antibodies. Tacrolimus in daily dose of 0.2 mg/kg was administered from day 1 to day 30 (group C) or from day 7 to day 30 (group D). RESULTS Inhibition of fluorescence-labeled anti-BN MHC class I and MHC class II antibodies binding to BN-splenocytes was observed only by day 14 and day 30 sera of allogeneic non-immunosuppressed Lewis rats (group B). The day 30 sera significantly decreased anti-MHC I (42±3%) and anti-MHC II antibody binding (56±3%) compared to day 0 (76±9%, p=0.005 and 79±5%, p=0.003, respectively). Deposition of immunoglobulins G into the tunica media was observed only in non-immunosuppressed aortic allografts on day 30. CONCLUSIONS Fresh aortic allografts induce donor-specific anti-MHC class I and anti-MHC class II antibody production. Delayed administration of tacrolimus completely suppressed antibody production and antibody-mediated destruction of aortic allografts.

Outcome after open surgery repair in endovascular-suitable patients with ruptured abdominal aortic aneurysms.

BACKGROUND Endovascular aneurysm repair (EVAR) has been suggested in several studies to be superior to open surgery repair (OSR) for the treatment of ruptured abdominal aortic aneurysms (rAAAs), but this finding might be affected by selection bias based on aneurysm morphology and patient characteristics. We tested rAAA anatomy according to EVAR suitability in patients undergoing OSR to assess the impact on mortality. PATIENTS AND METHODS This retrospective analysis reports on 83 patients with rAAAs treated between November 2002 and July 2013. Pre-operative computed tomography (CT) scans were evaluated based on EVAR suitability and were determined by blinded independent reviewers. CT scans were lacking due to acquisition in an external institution with no availability (n = 9) or solely ultrasound evaluations (n = 8). In addition patient characteristics and outcomes were assessed. RESULTS All patients who underwent OSR and who had available preoperative CT scans were included in the study (n = 66). In summary, 42 % of the patients (28/66; 95 % confidence interval [CI], 30.5 - 54.4) were considered eligible for EVAR according to pre-operative CT scans and 58 % of the patients (38/66; 95 % CI, 45.6 - 69.5) were categorized as unsuitable for endovascular repair. Patients suitable for EVAR had a significantly lower prevalence of in-hospital deaths (25 % [7/28]; 95 % CI, 9 - 41) in contrast to patients unsuitable for EVAR (53 % [20/38]; 95 % CI, 36.8 - 68.5; p = 0.02). CONCLUSIONS EVAR-suitable patients had a highly significant mortality reduction undergoing OSR. Thus, the present study proposes that EVAR suitability is a positive predictor for survival after open repair of rAAA.

Pancreaticoduodenectomy in the Elderly Patient: Age-Adapted Risk Assessment

Background: Older patients are increasingly faced with pancreatic surgery because of shifting demographics. The differential effects of aging on surgical outcomes remain vague, while the elderly patient is often neglected in clinical trials. Methods: Medical records of 370 patients who underwent pancreaticoduodenectomy were analyzed. Patients were then subdivided into 3 groups according to age and comorbidities. Results: Overall mortality was 5% and did not significantly differ between age-matched groups. Increasing age was linked to a higher prevalence of diabetes mellitus (p < 0.001) and preoperative cardiovascular comorbidities (p < 0.001). Independent risk factors for major complications were age over 70 years (p = 0.018; OR 2.3), elevated body mass index (p = 0.004; OR 0.2) and cardiovascular comorbidities (p = 0.022; OR = 2.6). Patients who were older (>70 years), obese and had cardiovascular disease had an increased risk of major complications when compared with the younger study population (p = 0.010). Conclusions: Pancreatic surgery in elderly patients showed similar mortality rates as in younger patients. Nevertheless, a careful risk assessment is particularly important because older patients who are considered to be high risk suffer more frequently from major surgical complications compared with young patients that have similar risk profiles.

Prognostic significance of TIE2-expressing monocytes in hilar cholangiocarcinoma.

Angiopoietins (Angs) play a pivotal role in angiogenesis and inflammation, and are associated with prognosis in malignancies. Monocyte express Ang‐receptor TIE2 and correlate with prognosis in cancer. We aimed to investigate the prognostic value of Angs and TIE2‐expressing monocytes (TEMs) in cholangiocarcinoma.