Thomas Reck

Surgical treatment of HELLP syndrome-associated liver rupture — an update

In some 2% of the cases of the HELLP syndrome, severe spontaneous bleeding into the liver accompanied by haemorrhagic liver cell necrosis and rupture of the organ occurs and represents one of the main cause of death. On the basis of our own experience with four cases, a review of the literature is presented with particular focus on a therapeutic concept based on appropriate surgery. Within a MEDLINE search covering the period 1990-1999, the case reports of this kind of liver complication in the literature were analysed in terms of clinical course and outcome.In addition to our own four patients, a total of 49 cases with rupture of the liver were found in the literature. Despite surgical interventions, HELLP syndrome-associated liver rupture carried a mortality of 39%. Most patients died of haemorrhagic shock and organ failure. In order to improve survival, patients with ruptured liver or hepatic failure should be transferred to a centre with the necessary experience in liver surgery including liver transplantation. An interdisciplinary approach is required, including the use of temporary packing of the liver to control the bleeding, and during the further course of the condition, possibly even liver transplantation, as in one of our own cases.

Contrast-enhanced ultrasound improves hepatic vessel visualization after orthotopic liver transplantation

AbstractBackground: We investigated whether color-coded Doppler sonography combined with an ultrasound contrast medium would improve the assessment of liver-supplying vessels after orthotopic liver transplantation. Methods: Forty-seven patients after orthotopic liver transplantation participated. Examinations were done without and then with the ultrasound contrast medium Levovist. Visualization of the liver-supplying vessels was assessed with a scoring system. Results: Visualization of the portal vein was similar without and with contrast medium. Hepatic arteries were visualized in 39 patients without contrast medium and 46 patients with contrast medium. The remaining patient showed hepatic artery thrombosis, which was confirmed angiographically. With the use of Levovist, the examination took 3.7 min rather than the usual 6.4 min. Conclusion: Imaging of hepatic arteries after liver transplantation improved significantly with the use of ultrasound contrast medium. These findings are important because the early detection of blood flow through the liver after transplantation affects prognosis.

Clinical value of MRC in the follow-up of liver transplant patients with a choledochojejunostomy.

AbstractBackground: We investigated the clinical value of magnetic resonance cholangiography (MRC) in liver transplant patients receiving choledochojejunostomy (CDJ). Methods: Twenty-five MRCs were performed in 23 initially asymptomatic patients 19 months (mean) after liver transplantation with biliary reconstruction via CDJ. The images were evaluated by consensus (two investigators) for bile duct strictures and dilatations. As a standard of reference, clinical follow-up (including laboratory analysis) was used in 20 cases and direct cholangiography or surgery in three cases. Results: Fourteen pathologic findings were observed in 11 patients (anastomotic strictures in four, left or right bile duct strictures in three, and peripheral segmental dilatations with or without strictures in seven). Patients with pathologic MRC findings had significantly higher levels of alkaline phosphatase (p < 0.05) and more frequently had histories of cholangitis than did patients with normal MRC. Four of six patients with stenoses of the central bile ducts subsequently developed biliary complications requiring treatment (three confirmed by direct cholangiography). In patients with unremarkable bile ducts or only peripherally located changes on MRC, no bile duct complications or relevant changes in the cholestasis parameters occurred during follow-up (mean = 30 months). Conclusion: MRC can noninvasively detect pathologic biliary tract changes in liver transplant patients in the asymptomatic stage and provide information for planning invasive therapeutic procedures.

Portal vein arterialisation as a technical option in liver transplantation: impact on function, regeneration, and morphology of the liver following hemihepatectomy in pigs

Abstract: Background: Arterialisation of the portal vein has been propagated as a technical variant in liver transplantation. However, the consequences of this unphysiological vascular supply are insufficiently known. Methods: Twenty‐seven healthy pigs were subjected to a left hemihepatectomy and divided into three groups. The first group received complete arterialisation of the portal vein (PVA). In the second group hepatic artery blood flow was also interrupted by dividing the artery (PVA/DHA). Nine animals served as controls (Group C). Results: Early mortality in the PVA/DHA group (6/9) was significantly increased in comparison with the PVA (2/9) and control (2/9) groups (P < 0.05). In the surviving animals, arterialisation (PVA and PVA/DHA) led to significantly faster hepatic regeneration in comparison with control animals, with comparable liver function and with liver size increasing to 278% and 293% vs 134% (P= 0.002) after 3 weeks, in liver … weeks. This was accompanied by enhanced hepatic expression of the proliferation markers MIB‐1(22.4% and 16.7% vs 5.9%, P = 0.002) and PCNA(86% and 68% vs 66%, P = 0.002) one week postoperation. At the same time, the number of apoptotic hepatocytes increased from 1.6% to 2.5% and 2.3% (P= 0.002). No significant difference was found in the collagen content of the liver after 3 weeks. Conclusions: Arterialisation of the portal vein promotes early and enhanced hepatic regeneration without impairing liver function. This technique may therefore be useful in split‐graft liver transplantation, where this aspect would be of particular importance.

Pseudoaneurysma der A. hepatica – eine seltene Komplikation nach orthotoper Lebertransplantation

Abstract.Introduction: Pseudoaneurysm of the hepatic artery is a rare complication of liver transplantation, the most common cause of which – apart from technical surgical problems – is an infection. The most common symptoms are rupture and hemorrhage. Method: The present case report describes an asymptomatic pseudoaneurysm of the hepatic artery following liver transplantation, and its treatment. Results: In this patient, an pseudoaneurysm involving an eroded branch of the hepatic artery was found. Surgical treatment consisted in the excision of the aneurysm and oversewing of the branch of the hepatic artery. Conclusion: The potential for rupture and hemorrhage makes surgical intervention mandatory even in asympotomatic patients with pseudoaneurysm of the hepatic artery. The surgical procedure depends on the local situation and the time elapsed since transplantation. Preservation or reconstruction of the arterial perfusion is essential.Zusammenfassung.Einleitung: Ein Pseudoaneurysma der A. hepatica nach Lebertransplantation ist eine seltene Komplikation, der am häufigsten – neben operationstechnischen Problemen – ein infektiöses Geschehen zu Grunde liegt. Die Symptomatik besteht meist in der Ruptur und akuten Blutung. Methode: Es wird der Fall eines asymptomatischen Pseudoaneurysmas an der A. hepatica nach Lebertransplantation und dessen Therapie beschrieben. Ergebnis: Im geschilderten Fall lag ein Pseudoaneurysma an einem arrodierten Seitenast der A. hepatica vor. Die chirurgische Therapie umfaßte die Excision des Aneurysmas und die Übernähung. Fazit: Auch bei asymptomatischen Patienten mit einem Pseudoaneurysma der A. hepatica ist auf Grund der hohen Rupturrate und Letalität eine Operation indiziert. Diese muß individuell und in Abhängigkeit vom zeitlichen Intervall zur Lebertransplantation erfolgen und ist vom Lokalbefund und der Gefäßsituation abhängig zu machen. Ein Erhalt oder die Rekonstruktion der arteriellen Strombahn ist vordringlich.

Changes in hepatic hemodynamics after orthotopic liver transplantation: color Doppler sonography

AbstractBackground: Liver perfusion has an influence on therapy results in patients undergoing orthotopic liver transplantation (OLT). The objective of the present study was to investigate changes in hepatic hemodynamics in patients after OLT with color-coded Doppler sonography (CCDS). Methods: Forty-five consecutive patients were included. The examinations were done before, on postoperative day 1, and then weekly until the patients were discharged. Mean velocity of the portal (PV-V) and splenic (SV-V) veins and the maximum velocity and resistance index of the hepatic artery were determined. Results: After OLT a significant increase in PV-V and SV-V was observed. Twenty-five patients had normal perfusion of the hepatic artery, whereas 16 patients had abnormal flow patterns. In these patients prostaglandin I2 was used until flow rates normalized. In four patients, CCDS could not detect perfusion of the hepatic artery. Conclusions: CCDS is a suitable method for evaluating hepatic hemodynamics before and after OLT. Changes in blood flow velocities in the liver-supplying vessels are detectable, but perfusion of the hepatic artery is seldom detectable. These observations are of special interest after OLT, where liver circulation has an influence on therapy results.

Resection of liver metastases – aim, timing and results

Eine Vielzahl von malignen Erkrankungen konnen im naturlichen Verlauf zum Auftreten von Lebermetastasen fuhren. Ohne Therapie betragt die Lebenserwartung weniger als acht Monate. Die chirurgische Resektion von Lebermetastasen ist beim kolorektalen Karzinom auch heute noch die einzige erwiesene Behandlungsmoglichkeit, bei der fur die betroffenen Patienten die Chance auf eine Heilung besteht. Abhangig vom Primartumor gilt dies auch zum Teil fur nicht-kolorektale Karzinome. Uber den Zeitpunkt der Resektion wird kontrovers diskutiert. Wahrend einige Autoren fur kolorektale Karzinome einen «test of time» von einigen Wochen bis sechs Monaten befurworten, fordern andere eine sofortige Resektion der Lebermetastasen nach deren Diagnose. Synchrone Lebermetastasen konnen zum Zeitpunkt der Primartumoroperation reserziert werden, wenn vor allem der Zugang mit der Operation des Primartumors problemlos moglich und das Komplikationsrisiko kalkulierbar ist. Die meisten Chirurgen pladieren fur eine zweizeitige Resektion. L...

148. Primäre und sekundäre Thoraxwandtumoren —Diagnostik, Therapie, Ergebnisse

Von 1969–1986 fuhrten wir bei 51 Patienten mit malignen Tumoren eine Thoraxwandresektion durch. Es waren 28 Manner und 23 Frauen zwischen 6 und 76 Jahren (Mittelwert 50 J.). Wir fanden 34 primare Tumoren bzw. Tumorinfiltrationen von Nachbarorganen und 17 Metastasen. Die Lokalisation war 6mal das Sternum, ansonsten der Rippenbereich. Die Rekonstruktion erfolgte 16mal mit prothetischem Material und 10mal mit plastischen Massnahmen. Gute Heilungschancen bestehen bei den primaren Tumoren. Nur ” dieser Patienten verstarb am Tumor. Patienten mit Mamma-Ca-Rezidiven oder Thoraxwandmetastasen wurden zwar selten tumorfrei, jedoch nach Beseitigung von Schmerzen und Hautulcera z. T. jahrelang symptomlos.SummaryIn a retrospective study 51 patients who underwent chest wall resection for malignant chest wall tumors were reviewed. There were 28 male and 23 female patients with ages ranging from 6 to 76 years (average 50). 34 patients had primary malignant neoplasms (including breast and lung) 17 had metastatic tumors. The tumor was located in the ribs in 45 patients and in the sternum in 6. Reconstruction was with prosthetic material in 16 patients and further plastic reconstruction in 10. Aggressive resection for malignant chest wall tumors and reliable reconstruction can be performed safely, and early wide resection proved to be a potentially curative treatment for primary neoplasms.ZusammenfassungVon 1969–1986 führten wir bei 51 Patienten mit malignen Tumoren eine Thoraxwandresektion durch. Es waren 28 Männer und 23 Frauen zwischen 6 und 76 Jahren (Mittelwert 50 J.). Wir fanden 34 primäre Tumoren bzw. Tumorinfiltrationen von Nachbarorganen und 17 Metastasen. Die Lokalisation war 6mal das Sternum, ansonsten der Rippenbereich. Die Rekonstruktion erfolgte 16mal mit prothetischem Material und 10mal mit plastischen Massnahmen. Gute Heilungschancen bestehen bei den primären Tumoren. Nur ” dieser Patienten verstarb am Tumor. Patienten mit Mamma-Ca-Rezidiven oder Thoraxwandmetastasen wurden zwar selten tumorfrei, jedoch nach Beseitigung von Schmerzen und Hautulcera z. T. jahrelang symptomlos.

Intraperitoneal Colonic Anastomosis with Laparoscopic Purse-String Suture Clamp and Valtrac Ring — An Experimental Study

In the literature numerous experimental [7, 14, 15, 17] and clinical studies [2, 3, 7, 13, 16, 20] have appeared dealing with resections in the region of the left hemicolon with intracorporeal anastomosis. In contrast to this approach, extracorporeal anastomosis on the right hemicolon [5, 6, 12, 13, 22] following laparoscopic mobilization and resection of the corresponding colon section is preferred. Apart from the higher technical expenditure and time required by intracorporeal anastomoses, the main reason for this preference appears to be the fact that the circular staplers introduced transanally with left-sided anastomoses can be used on the right colon only after additional enterotomy.