T. Kraus

Arterial steal: an unusual cause for hepatic hypoperfusion after liver transplantation

Case reports of two patients with an unusual cause for a rapid increase in transaminases following liver transplantation are described. In the postoperative course, angiography revealed an arterial, hypoperfusion of the liver due to a steal phenomenon with blood shunting from the hepatic to the splenic artery. In one case, the underlying pathophysiology was a pre-existing filiform stenosis of the celiac trunk with insufficient recruitment of arterial blood from the superior mesenteric artery via the pancreatic arcade. Adequate liver perfusion was restored by simple ligation of the common hepatic artery. In the other case, angiography showed an arteriovenous fistula formation of the splenic vessels and minimal blood flow through the hepatic vessels. This was successfully corrected by angiographic embolization of the splenic artery with metal coils. After therapeutic intervention, both patients rapidly recovered with excellent liver function.

First clinical realization of continuous monitoring of liver microcirculation after transplantation by thermodiffusion

Abstract  To date, no method is available for the continuous long‐term monitoring of liver microcirculation in patients. Experimentally, thermodiffusion has been validated in the quantification of hepatic per‐fusion. In an attempt to investigate the practicability of thermodiffusion technology in patients after liver transplantation thermodiffusion probes were inserted into the graft in seven patients during liver transplantation. Continous monitoring started intraoperatively and was performed until day 7, when the probes were extracted transcutane‐ously. No probe‐related complications (i. e., hemorrhage, infection) were observed. In four patients with normal graft function, liver perfu‐sion recovered within 12 h from the intraoperative reduction to a range between 85 and 93 ml/100 g per min. In contrast, primary graft failure (n= 1) was characterized by a constant decrease of hepatic perfusion (< 50 ml/100 g per min). In prolonged reperfusion injury (n= 1), a second peak of transaminases was paralled by an impairment of liver microcirculation. In one patient, rejection on day 7 was preceded by a drop in hepatic perfusion 48 h earlier. Thus, thermodiffusion is a safe and reliable method for the continuous quantification of liver micro‐circulation after transplantation in patients. Measurements are reproducible for at least 7 days. Changes in hepatic perfusion during postoperative complications can be detected. The characteristics of micro‐circulatory disorders will have to be defined in a larger number of patients.

Chirurgische Leistungsdokumentation – Hilft viel wirklich viel? Vergleich der Auswirkung von maximaler und geringer Dokumentationstiefe klinischer Patientendaten auf das theoretische Ertragsvolumen einer chirurgischen Klinik nach Einführung des DRG-basierten Entgeltsystems

ZusammenfassungEinleitung. Die bevorstehende Einführung eines DRG-basierten Abrechnungssystems in Deutschland soll der Forderung nach höherer Transparenz und Wirtschaftlichkeit im stationären Versorgungssektor Rechnung tragen. Eine maximale Dokumentationsqualität unter Erfassung aller potenziell relevanten Diagnosen erscheint als optimaler Lösungsweg zur Erzielung maximaler Erträge. Ziel der vorliegenden Studie war, die Abrechungsrelevanz unterschiedlicher Dokumentationstiefen klinischer Patientendaten zu ermitteln und abzuschätzen, wie evtl. zu treffende Qualitätssteigerungen personell zu realisieren sind. Methodik. In einer prospektiven Querschnittserhebung wurden klinische Daten von 402 Patienten erhoben und die theoretischen Ertragsvolumina einer Minimal-, und Maximaldokumentation unter Verwendung des Australian-Refined DRG-Systems verglichen. Hierfür wurden verschiedene Dokumentationsqualitäten definiert. Zur Detektierung von Bereichen besonderer Relevanz wurden die betrachteten Fälle 23 Behandlungsgruppen zugeordnet. Ergebnisse. In 267 Fällen bestimmte nur eine Hauptdiagnose den Ertrag, in 137 Fällen (34%) wurde der Ertrag maßgeblich durch die Dokumentation weiterer Diagnosen erhöht. Die Hälfte dieses theoretischen dokumentationsbedingten Ertragsgewinnes konnte nur durch den Einsatz eines zusätzlichen, von der Patientenbehandlung unabhängigen ärztlichen Dokumentars erzielt werden. Dabei scheint es eine Effizienzobergrenze zu geben, da höchste Gewinne keine maximale Anzahl an dokumentierten Diagnosen erfordern. Besonders bei gravierenden Pathologien und komplexen Operationen erbrachte die maximale Dokumentation Ertragsgewinne. Schlussfolgerungen. Eine hohe Dokumentationstiefe hat einen bedeutenden Einfluss auf das Ertragsvolumen ärztlicher Leistung im Hinblick auf eine leistungsgerechte Vergütung in Zeiten der DRGs. Die Höhe der theoretischen Ertragsgewinne einer Maximaldokumentation unterstreicht die Notwendigkeit einer maximalen Dokumentationsqualität. Diese maximale Dokumentationsqualität und Effizienz scheint nicht durch alleinige Dokumentationsarbeit des behandelnden Stationsarztes in der klinischen Routine erreichbar.AbstractIntroduction. The forthcoming introduction of a DRG-based account system in Germany aims at higher transparency and economic efficiency, particularly in the sector of in-patient health care. The availability of documentation of the highest quality, taking into account all potentially relevant diagnoses, appears to be the best method for achieving maximum revenue in individual surgical units. The aim of the study was to determine the relevance of various degrees of documentation depth on calculated DRG-based revenue. Furthermore, we evaluated whether improvements in the quality of documentation can be realized in current hospital organization. Methods. In a prospective study, clinical data from 402 in-patients were collected and revenues were calculated based on the Australian-Refined DRG system. Various qualities of documentation were defined. In order to find the medical sectors most sensitive to “under-documentation”, homogenous cases were classified into 23 treating groups, according to diagnosis. Results. In 267 cases, maximum revenue was determined only by one main diagnosis, while better results could be achieved in 137 cases (34%) by extended documentation quality. Half of this gain could only be achieved by an independent medical documentation specialist. An upper limit of documentation intensity (number ofdiagnoses) could be defined. Maximum gain did not require maximum number ofdiagnoses. Conclusions. Documentation depth has an important influence on the calculated revenue of surgical therapy based on AR-DRG system. The quality and depth of the documentation is not, in itself, sufficient. In order to be really effective, it requires the highest degree of professionalism from hospital staff.

Impairment of hepatic microcirculation as an early manifestation of acute rejection after clinical liver transplantation

DURING REJECTION episodes after liver transplantation, T cell activation is partly the result of intracellular adhesion molecule–I (ICAM-I) expression on hepatocytes. As an adhesion molecule, ICAM-I generally induces leucocyte-endothelium interaction in the liver predominantly along postsinusoidal venules. An increase of endothelial leucocyte adherence is considered to be a mechanism of hepatic microcirculatory impairment after ischemia and reperfusion. However, clinical data on potential changes of hepatic microcirculation during rejection are missing. After experimental validation, thermodiffusion represents a tool to allow continuous monitoring of liver microcirculation during the first week postoperatively. It was the goal of this study to quantify hepatic microperfusion in patients with early rejection.

Der VCS-Clip – Experimentelle Erfahrungen mit einem neuen vasculären Klammernahtinstrument

Summary. Despite improvements in technique and suture material, vascular anastomosis is still associated with a significant rate of early (stenosis, thrombosis) and late (intimal hyperplasia) complications. Although automatic mechanical staplers were practical und comparatively safe to use, they did not play a major role in vascular surgery, probably due to the complexity and difficult handling. In an experimental study with the VCS clip system, we found a significant improvement in performing a hepatic artery anastomosis [9.2 ± 1.5 min (VCS) vs 20.6 ± 2.7 min (suture), P < 0.001], early patency and flow rate [150 ± 29.1 ml/min (1.0 h) → 79.9 ± 24.0 ml/min (24 h) (suture) vs 186 ± 45 ml/min (1.0 h) → 162 ± 48 ml/min (VCS), P < 0.005]. Besides easy handling, the VCS clip system allows for a fast, standardized vascular anastomosis without intimal penetration.Zusammenfassung. Die Anlage einer suffizienten Gefäßanastomose ist, trotz Verbesserung von Nahttechnik und Nahtmaterial, weiterhin mit erheblichen Früh- (Stenose, Thrombose) und Spätkomplikationen (Intimahyperplasie) behaftet. Trotz Praktikabilität und vergleichbarer Sicherheit haben mechanische Klammernahtinstrumente infolge der eingeschränkten Handhabung und Komplexität keine Rolle gespielt. Mit dem VCS-Clip-System steht für vasculäre Anastomosen ein weiteres Klammernahtgerät zur Verfügung. Im Rahmen einer experimentellen Untersuchung ergaben sich für kleine Gefäße ( < 4 mm) signifikant niedrigere Anastomosenzeiten [9,2 ± 1,5 min (VCS) vs. 20,6 ± 2,7 min (Naht), p < 0,001] sowie höhere Flußraten im Vergleich mit der konventionellen, fortlaufenden Nahttechnik [150 ± 29,1 ml/min (1,0 Std) → 79,9 ± 24,0 ml/min (24 Std) (Naht) vs. 186 ± 45 ml/min (1,0 Std) → 162 ± 48 ml/min (24 Std) (VCS), p < 0,005]. Das VCS-Clip-System erlaubt – neben einer leichten Handhabung – eine schnelle, standardisierte Anastomosenanlage ohne Penetration der Intima.

Impact of biliary reconstruction on postoperative complications and reinterventions in 179 liver transplantations.

SURGICAL complications are found in around 50% of patients following liver transplantation. About 22% to 30% require surgical treatment. Complications associated with the biliary tree are encountered in 10% to 30% of patients following liver transplantation. The early and late postoperative outcome is highly dependent on intraoperatively induced surgical complications. Apart from vascular complications being most commonly associated with morbidity and mortality, biliary reconstruction, often described as the “achilles heel” in liver transplantation, accounts for a significant percentage of surgically induced postoperative complications. Our retrospective study investigated the impact of bile duct reconstruction on morbidity and mortality following liver transplantation. Various bile duct techniques were analyzed with respect to biliary complications and reinterventions.

Determination of plasma activities of purine nucleoside phosphorylase by high-performance liquid chromatography estimates of nonparenchymal cell injury after porcine liver transplantation

An assay is described for measurement of purine nucleoside phosphorylase (PNP) in plasma by high-performance liquid chromatography (HPLC). A plasma sample was incubated with hypoxanthine and ribose-1-phosphate in phosphate-free medium at pH 7.4 to catalyse the production of inosine by plasmatic PNP. The reaction was stopped by addition of perchloric acid to inactivate the enzyme and to precipitate plasma proteins. After centrifugation and neutralization of the supernatant with NaOH the increase in the substrate inosine was determined by HPLC. Plasma activities of PNP averaged 5.0 mU/ml before and 12.3 mU/ml (p < 0.001), 5 min after porcine liver transplantation. At the same time points, the plasma activities of the frequently used liver enzymes lactate dehydrogenase or alanine aminotransferase remained virtually unchanged. Thus, plasmatic activities of PNP may be a suitable and early indicator of ischemic alterations to the graft in vivo.

Stellenwert einer allgemeinen chirurgischen Hochschulambulanz für die medizinische Patientenversorgung

ZusammenfassungÜber den Zeitraum 2001 bis 2003 wurden alle in der allgemein-chirurgischen Hochschulambulanz der Universitätsklinik Heidelberg anfallenden Behandlungsfälle, Diagnosen und Prozeduren, sowie Daten zu Patientenherkunft und Zuweisercharakteristik, differenziert nach viszeral-, gefäßchirurgischen und traumatologischen Bereichen prospektiv aufgezeichnet. Weiterer Fokus wurde auf die Quantifizierung von zeitphasenabhängigen Variabilitäten der Leistungsvolumina und der resultierenden Belastungsschwankungen gesetzt. Zusätzlich wurde retrospektiv eine Aufwandsabschätzung in den Bereichen Forschung, Lehre und Krankenversorgung mittels strukturierten Fragebögen und Interviews durchgeführt. Die Daten verdeutlichen die dominierend medizinische Versorgungsfunktion einer allgemein-chirurgischen Hochschulambulanz mit Überlauffunktion für den ambulanten Sektor. Forschung und Lehre treten in der Bedeutung zurück und werden überwiegend in nachgeschalteten Spezialambulanzen realisiert. Allgemein-chirurgische Ambulanzen, können damit für integrierte medizinische Versorgungsmodelle eine gute Basis darstellen. Die Leistungsvergütung muss allerdings wegen der hohen Versorgungsvolumina und hohen Leistungsvorhaltungserfordernis durch immense Belastungsschwankungen zukünftig kostendeckender gestaltet werden.Abstract During the observation period between 2001 and 2003, all outpatient surgical therapy, including degrees of urgency, surgical care volume, regional provenance of patients, diagnoses, and referral channels were prospectively analysed at the Surgical Department of the University of Heidelberg, Germany. The data gathered do not merely describe the volume and characteristics of care encountered at this academic surgical institution but also provide further insight into the variability of resource utilisation and associated patient flow. Additionally, a retrospective evaluation using structured interviews and questionnaires was performed to differentiate and quantify patient care, teaching, and research activities. This study illustrates the high relevance of academic outpatient institutions to regional provision of general surgical care in Germany. There is a clear dominance of medical support functions, while research and teaching activities are of only minor relevance and realised particularly in subspecialty clinics. These data should give important stimuli for the future planning of health care in Germany. Outpatient clinics for general surgery appear to be an excellent basis for regional models of integrated health care delivery in the future.

Relevance of surgical outpatient clinics in academic university centers to health care in Germany

ZusammenfassungÜber den Zeitraum 2001 bis 2003 wurden alle in der allgemein-chirurgischen Hochschulambulanz der Universitätsklinik Heidelberg anfallenden Behandlungsfälle, Diagnosen und Prozeduren, sowie Daten zu Patientenherkunft und Zuweisercharakteristik, differenziert nach viszeral-, gefäßchirurgischen und traumatologischen Bereichen prospektiv aufgezeichnet. Weiterer Fokus wurde auf die Quantifizierung von zeitphasenabhängigen Variabilitäten der Leistungsvolumina und der resultierenden Belastungsschwankungen gesetzt. Zusätzlich wurde retrospektiv eine Aufwandsabschätzung in den Bereichen Forschung, Lehre und Krankenversorgung mittels strukturierten Fragebögen und Interviews durchgeführt. Die Daten verdeutlichen die dominierend medizinische Versorgungsfunktion einer allgemein-chirurgischen Hochschulambulanz mit Überlauffunktion für den ambulanten Sektor. Forschung und Lehre treten in der Bedeutung zurück und werden überwiegend in nachgeschalteten Spezialambulanzen realisiert. Allgemein-chirurgische Ambulanzen, können damit für integrierte medizinische Versorgungsmodelle eine gute Basis darstellen. Die Leistungsvergütung muss allerdings wegen der hohen Versorgungsvolumina und hohen Leistungsvorhaltungserfordernis durch immense Belastungsschwankungen zukünftig kostendeckender gestaltet werden.Abstract During the observation period between 2001 and 2003, all outpatient surgical therapy, including degrees of urgency, surgical care volume, regional provenance of patients, diagnoses, and referral channels were prospectively analysed at the Surgical Department of the University of Heidelberg, Germany. The data gathered do not merely describe the volume and characteristics of care encountered at this academic surgical institution but also provide further insight into the variability of resource utilisation and associated patient flow. Additionally, a retrospective evaluation using structured interviews and questionnaires was performed to differentiate and quantify patient care, teaching, and research activities. This study illustrates the high relevance of academic outpatient institutions to regional provision of general surgical care in Germany. There is a clear dominance of medical support functions, while research and teaching activities are of only minor relevance and realised particularly in subspecialty clinics. These data should give important stimuli for the future planning of health care in Germany. Outpatient clinics for general surgery appear to be an excellent basis for regional models of integrated health care delivery in the future.

Intraoperative evaluation of big-endothelin plasma levels during liver transplantation in different vascular compartments

Abstract Endothelin‐1 (ET) is derived from its precursor big‐ET, secreted by endothelial cells of multiple origin. The role of ET peptides in the physiological responses after orthotopic liver transplantation (OLT) was investigated. Venous big‐ET plasma levels were analysed by RIA in 28 patients before and after OLT. Samples for analysis were taken intraoperatively from 12 patients from the caval, portal and hepatic veins and the radial artery at multiple time points. Highest caval levels were found during the an‐hepatic period and 60 min after reperfusion, followed by a drop and subsequent increase postoperatively. Highest levels in the hepatic and portal veins were detected during explanation and reperfusion. A different pattern was found in the radial artery. Values during rejection and infection were elevated compared with preoperative and postoperative levels. The heterogeneity of the kinetics points to different sites of ET generation, including liver and splanchnic circulation. It suggests a predominant paracrine secretion mode of ET peptides with various stimuli involved. Big‐ET levels could reflect endothelial cell damage, as big‐ET is generated intracellularly and biological activity is rather weak.