Michael Bartels

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.

Valganciclovir prophylaxis versus preemptive therapy in cytomegalovirus-positive renal allograft recipients: 1-year results of a randomized clinical trial.

Background. Cytomegalovirus (CMV) prevention can be achieved by prophylaxis or preemptive therapy. We performed a prospective randomized trial to determine whether renal transplant recipients with a positive CMV serostatus (R+) had a higher rate of CMV infection and disease after transplantation when treated preemptively for CMV infection, compared with primary valganciclovir prophylaxis. Methods. Prophylaxis was 2×450 mg oral valganciclovir/day for 100 days; preemptive patients were monitored by CMV-polymerase chain reaction (PCR), and after a positive PCR test received 2×900 mg valganciclovir/day for at least 14 days followed by secondary prophylaxis. Valganciclovir dosage was adjusted according to renal function. Patients are followed up for 5 years and initial 12-month data are presented. Two hundred and ninety-six recipients were analyzed (168 donor/recipient seropositive [D+/R+], 128 donor seronegative/recipient seropositive [D−/R+]; 146 receiving prophylaxis and 150 preemptive therapy). Results. Overall, CMV infection (asymptomatic CMV viral load ≥400 CMV DNA copies/mL proven by CMV-PCR) was significantly higher in recipients under preemptive therapy (38.7% vs. 11.0%, P<0.0001), with the highest incidence in D+/R+ preemptive patients (53.8% vs. 15.6%, P<0.0001). D+/R+ recipients with preemptive therapy also had the highest rate of CMV disease (CMV syndrome and tissue-invasive disease that was clinically diagnosed and biopsy proven) (19.2% vs. 4.4%, P=0.003). Renal function assessed by creatinine clearance was similar for both groups. Graft loss occurred in 7 vs. 4 patients on preemptive versus prophylactic therapy (P>0.05). Tolerability was similar for both treatment groups. Conclusions. Oral valganciclovir prophylaxis significantly reduces CMV infection and disease, particularly for D+/R+ patients. Hence, our study supports routine prophylaxis for all D+/R+ recipients.

Navigation in surgery

Introduction“Navigation in surgery” spans a broad area, which, depending on the clinical challenge, can have different meanings. Over the past decade, navigation in surgery has evolved beyond imaging modalities and bulky systems into the rich networking of the cloud or devices that are pocket-sized.DiscussionThis article will review various aspects of navigation in the operating room and beyond. This includes a short history of navigation, the evolution of surgical navigation, as well as technical aspects and clinical benefits with examples from neurosurgery, spinal surgery, and orthopedics.ConclusionWith improved computer technology and a trend towards advanced information processing within hospitals, navigation is quickly becoming an integral part in the surgical routine of clinicians.

Impact of the MELD allocation after its implementation in liver transplantation

Abstract Objective . On 16 December 2006, most Eurotransplant countries changed waiting time oriented liver allocation policy to the urgency oriented Model for End-stage Liver Disease (MELD) system. There are limited data on the effects of this policy change within the Eurotransplant community. Patients and methods. A total of 154 patients who had undergone deceased donor liver transplantation (LT) were retrospectively analyzed in three time periods: period A (1-year pre-MELD, n = 42) versus period B (1-year post-MELD, n = 52) versus period C (2 years after MELD implementation, n = 60). Results. The median MELD score at the time of LT increased from 16.3 points in period A to 22.4 and 20.4 in periods B and C, respectively (p = 0.007). Waitlist mortality decreased from 18.4% in period A to 10.4% and 9.4% in periods B and C, respectively (p = 0.015). Three-month mortality did not change significantly (10% each for periods A, B and C). One-year survival was 84% for the MELD 6–19 group compared with 81% in the MELD 20–29 group and 74% in the MELD ≥30 group (p = 0.823). Analyzing MELD score and previously described prognostic scores [i.e. survival after liver transplantation (SALT) score and donor-MELD (D-MELD) score] with regard to 1-year survival, only a high risk SALT score was predictive (p = 0.038). In our center, 2 years after implementation of the MELD system, waitlist mortality decreased, while 90-day mortality did not change significantly. Conclusion. Up to now, only the SALT score proved to be of prognostic relevance post-transplant.

Squamous Cell Carcinoma of the Liver Originating from a Solitary Non-Parasitic Cyst: Case Report and Review of the Literature

Squamous cell carcinoma of the liver arising from a non-parasitic cyst is a rare entity of a primary liver tumor with an unfavourable prognosis. We report a case of a patient with a cyst in the right lobe leading to upper abdominal symptoms and respiratory discomfort. Malignancy was not suspected from the clinical findings or repeated cytological examination of the cyst fluid. However, the blood stained brown color of the cyst fluid was unusual. Cyst recurrence after six attempts of conservative treatment with sonography guided drainage over a period for more than one year led to laparotomy with cyst unroofing. Because frozen section from the cyst wall revealed the unexpected finding of squamous cell carcinoma right hemihepatectomy was performed during the same operation. The patient is alive more than four years after surgery without cyst or tumor recurrence. The difficulties in establishing diagnosis are confirmed by the review ofother reports. In the diagnosis and treatment ofsymptomatic non-parasitic liver cysts possible malignancy has to be considered. In case of proven carcinoma radical surgery with partial hepatectomy should be performed.

Is perioperative low molecular weight hydroxyethyl starch infusion a risk factor for delayed graft function in renal transplant recipients

BACKGROUND Crystalloid or colloid fluids may be utilized during kidney transplantation. Histopathological and clinical data indicate that hydroxyethyl starch (HES) may have nephrotoxic potential. METHODS This retrospective single-centre cohort study screened 192 and included 113 patients who underwent renal transplantation between 2003 and 2007 at University of Leipzig Medical Faculty, Germany. The primary outcome parameter was delayed graft function (DGF). Patients were divided into two groups. Patients in group CRYS (N = 73) received crystalloid solution (acetated Ringers or normal saline) only. Patients in the group HES (N = 40) received a minimum of 500 mL 6% HES 130/0.4 and additional crystalloid solution by discretion of the transplant team. RESULTS Patients in both groups did not differ with respect to demographic data and American Society of Anesthesiologists Physical Status Classification System scores, except for the donor age, which was significantly lower in the group HES. The rate of DGF was not found to be different in group CRYS (31.5%) when compared to group HES (32.5%) (P = 1.00, n.s.). CONCLUSION In this single-centre retrospective cohort study, infusion of low molecular weight 6% HES 130/0.4 during and after renal transplantation was found to have no significant negative effect upon the rate of DGF.

CD44 and CXCL9 serum protein levels predict the risk of clinically significant allograft rejection after liver transplantation

The diagnosis of acute cellular rejection (ACR) after liver transplantation is based on histological analysis of biopsies because noninvasive biomarkers for allograft rejection are not yet established for clinical routines. CD31, CD44, and chemokine (C‐X‐C motif) ligand (CXCL) 9 have previously been described as biomarkers for cross‐organ allograft rejection. Here, we assessed the predictive and diagnostic value of these proteins as serum biomarkers for clinically significant ACR in the first 6 months after liver transplantation in a prospective study. The protein levels were measured in 94 patients immediately before transplantation, at postoperative days (PODs) 1, 3, 7, and 14 and when biopsies were performed during episodes of biochemical graft dysfunction. The CD44 serum protein levels were significantly lower at POD 1 in patients who experienced histologically proven ACR in the follow‐up compared with patients without ACR (P < 0.001). CXCL9 was significantly higher before transplantation (P = 0.049) and at POD 1 (P < 0.001) in these patients. Low CD44 values (cutoff, <200.5 ng/mL) or high CXCL9 values (cutoff, >2.7 ng/mL) at POD 1 differentiated between rejection and no rejection with a sensitivity of 88% or 60% and a specificity of 61% or 79%, respectively. The combination of both biomarker cutoffs at POD 1 had a positive predictive value of 91% and a negative predictive value of 67% for clinically significant ACR. Moreover, CD44 was significantly lower at the time of ACR (P < 0.001) and differentiated the rejection group from patients with graft dysfunction due to other reasons. Our results suggest that CD44 and CXCL9 may serve as predictive biomarkers to identify liver allograft recipients at risk for clinically significant ACR. Liver Transpl 21:1195–1207, 2015.

Lessons learned from excess mortality associated with Klebsiella pneumoniae carbapenemase 2–producing k. pneumoniae in liver transplant recipients

Klebsiella pneumoniae is a major cause of nosocomial infections, primarily among immunocompromised patients. The emergence of carbapenem-resistant K. pneumoniae (CRKP) strains has limited treatment options and has resulted in a high infection-related mortality rate. However, only small case series are available on the effects of CRKP in organ transplant recipients. From July 2010 to April 2013, the Leipzig University Hospital experienced a large outbreak due to a K. pneumoniae carbapenemase 2–producing K. pneumoniae (KPC-2-KP) strain (sequence type ST258). The outbreak occurred after the transfer of a patient from Greece, where K. pneumoniae carbapenemase 2–producing organisms are endemic. One hundred three patients became either colonized (58%) or infected (42%), and they included 9 liver transplant recipients (LTRs). Successful containment of the outbreak was achieved through the implementation of efficient infection control measures (strict barrier precautions, improved hand hygiene, antibiotic stewardship, systematic CRKP screening, and cohorting of CRKP-positive patients). Eighty-nine percent (8/9) of the KPC-2-KP–positive LTRs progressed to infection (50% had radiologically and microbiologically confirmed pneumonia, 25% had surgical site infections, and 25% had recurrent secondary peritonitis). In 56% (5/9), a KPC-2-KP bloodstream infection was confirmed. With European Committee on Antimicrobial Susceptibility Testing breakpoints, broth microdilution tests revealed susceptible or intermediate results for tigecycline (minimum inhibitory concentration 5 0.5-2 mg/L), gentamicin (minimum inhibitory concentration 5 2 mg/L), and colistin (minimum inhibitory concentration 5 0.25-1 mg/L). For treatment, these antimicrobials were used in combination [intravenous tigecycline (50-100 mg every 12 hours), intravenous gentamicin (5-7 mg/kg every 24 hours), and intravenous colistin methanesulfonate (2,000,000-3,000,000 IU every 8 hours)]. Four of the 9 patients received tigecycline, gentamicin, and colistin; 2 received tigecycline and colistin; and 2 received tigecycline and gentamicin. Combination therapy with carbapenems was not considered because the corresponding minimum inhibitory concentrations were 16 mg/L for all KPC-2-KP isolates. We retrospectively compared the clinical outcomes of these 9 LTRs with KPC-2-KP and 34 LTRs with proof of invasive infections due to carbapenem-susceptible Klebsiella spp. [71% had K. pneumoniae, and 29% had Klebsiella oxytoca; extended-spectrum b-lactamase (ESBL)–producing strains were included (71%); Table 1]. This analysis revealed hospital mortality rates of 78% for LTRs with KPC-2-KP and 32% for LTRs with carbapenem-susceptible Klebsiella strains (P 5 0.02, Fisher’s exact test). The 6-month survival rate for LTRs with KPC-2-KP (22%) was significantly reduced in comparison with the rates for LTRs with sensitive Klebsiella strains (70%) and LTRs with ESBL-producing Klebsiella strains (67%; P<0.05; Fig. 1). The hospital mortality rate for all organ transplant recipients colonized or infected with KPC-2-KP (11 LTRs, including 2 patients who had already undergone transplantation more than 6 months before the outbreak; 3 kidney transplant recipients; 2 lung transplant recipients; and 3 stem cell transplant recipients) was 58% (11/19).

A single-center experience with liver transplantation for Wilson's disease.

Abstract:  Wilson’s disease is an inherited disorder of copper metabolism, presenting with prominent hepatic and neurologic manifestations. There is an established place for liver transplantation in the presence of liver disease, while the indication for neurologic manifestations is debated. Between 1993 and 2005, 11 patients were liver transplanted for Wilson’s disease at our institution. We retrospectively reviewed the medical records of the patients. The pathology of the explanted livers was analyzed. The patients were divided into three groups based on the evolution of the disease. Postoperative data gathered included patient and graft outcome, complications, neurologic status, and copper metabolism. Six males and five females were transplanted at a mean age of 29.7 yr (range 15–48 yr). Three patients had a fulminant presentation, two patients had decompensation of established disease, and six patients had chronic disease. Neurologic features were prominent in five patients. The pathologic analysis of the explanted graft showed cirrhosis in all patients. The five patients with fulminant and acute on chronic presentations also showed necrosis in the explant. The mean postoperative follow‐up was 56.8 months (range 10–129 months). Two patients were re‐transplanted. One patient died because of severe sepsis. Two patients with severe neurologic dysfunction showed significant remission of symptoms. Liver transplantation is a safe and effective treatment for both acute and chronic presentations of Wilson’s disease. Acute presentation correlates with the presence of necrosis in the explanted liver. In our series, there was a relevant improvement of the neurologic features after transplantation.

Prevention of lamivudine-resistant hepatitis B recurrence after liver transplantation with entecavir plus tenofovir combination therapy and perioperative hepatitis B immunoglobulin only.

T. Karlas, J. Hartmann, A. Weimann, M. Maier, M. Bartels, S. Jonas, J. Mössner, T. Berg, H.L. Tillmann, J. Wiegand. Prevention of lamivudine‐resistant hepatitis B recurrence after liver transplantation with entecavir plus tenofovir combination therapy and perioperative hepatitis B immunoglobulin only.
Transpl Infect Dis 2011: 13: 299–302. All rights reserved