Thomas W. Kraus

Stapler Hepatectomy is a Safe Dissection Technique: Analysis of 300 Patients

BackgroundIn many surgical procedures, stapling devices have been introduced for safety and to reduce the overall operative time. Their use for transection of hepatic parenchyma is not well established. Thus, the feasibility of stapler hepatectomy and a risk analysis of surgical morbidity based on intraoperative data have been prospectively assessed on a routine clinical basis.Materials and MethodsFrom October 1, 2001, to January 31, 2005, a total of 416 patients underwent liver resection in our department. During this period endo GIA vascular staplers were used for parenchymal transection in 300 cases of primary (22%) and metastatic (57%) liver cancer, benign diseases (adenoma, focal nodular hyperplasia [FNH], cysts) (14%), gallbladder carcinoma (2%), and other tumors (5%). There were 193 (64%) major resections (i.e., removal of three segments or more) and 107 minor hepatic resections. Additional extrahepatic resections were performed in 44 (15%) patients.ResultsMedian values for operative time and intraoperative hemorrhage were 210 minutes and 700 ml, respectively. Further, transfusion of RBC and FFP was needed in 17% and 11% of patients, respectively. A postoperative ICU stay for >2 days was required in 18% of patients. The median postoperative hospital stay was 10 days (IQR 8–14 days). The most frequent surgical complications were bile leak (8%), wound infection (3%), and pneumothorax (2%). In 7% of cases after stapler hepatectomy a relaparotomy was necessary. Treated medical complications were pleural effusion (7%), renal insufficiency (5%), and cardiac insufficiency (3%). Risk assessment revealed that both operative time and indication for resection had significant impact on surgical morbidity. Mortality (4%) and morbidity (33%) were comparable to other high-volume centers performing conventional liver resection techniques.ConclusionIn conclusion, stapler hepatectomy can be used in a routine clinical setting with a low incidence of surgical complications.

Surgical strategies for liver transplantation in the case of portal vein thrombosis – current role of cavoportal hemitransposition and renoportal anastomosis

Abstract:  Portal vein thrombosis (PVT), a common complication of end stage liver disease, is no longer considered a definite contraindication for liver transplantation (LTx). The clinical decision to perform an LTx in the case of PVT depends on the degree of PVT and the experience of the surgeon. Eversion thromboendovenectomy was suggested by most authors as the surgical technique of choice for PVT grade 1, 2, and 3. If PVT obstructs more extended parts of the porto‐mesenteric venous circulation, surgical options would include different types of venous jump graft reconstructions or arterialization of the portal vein. Combined liver and small bowel transplantation is another possible alternative. Cavoportal hemitransposition (CPHT) and renoportal anastomosis (RPA) were recently particularly advocated as creative surgical strategies in case of diffuse PVT. In this work, we focus on CPHT and RPA surgical techniques during LTx, which attempts to secure the portal flow to the liver graft in case of pre‐existent diffuse PVT. We provide a review of all reported clinical experience at international clinical centers using these techniques. According to our meta‐analysis a total of 15 studies were published on this topic between 1996 and 2005. In summary, a total of 56 orthotopic LTx have been performed in 53 patients (28 men, 25 women) combined with either CPHT or RPA, for the purpose of providing the donor graft with adequate inflow. Mean age was 44 yr including two patients who were infants, with the youngest recipient being two yr old. Main indications for LTx were liver cirrhosis caused by viral hepatitis, alcoholic cirrhosis and cryptogenic cirrhosis. CPHT was performed in 46 cases, and RPA in 10 cases. Thirty‐five of 53 patients (66%) had surgery previous to LTx. Of these, 13 (37%) patients presented with a history of other previous surgical procedures for decompression of portal hypertension or treatment of associated complications (portocaval shunts, splenectomy, etc). Ascites, renal dysfunction, lower extremity and torso edema and variceal bleeding were dominant post‐operative complications after CPHT or RPA noted in 22 cases (41.5%), 18 cases (34%), 17 cases (32%) and 13 cases (24.5%) respectively. Patients’ follow‐up ranged from two to 48 months. Patients survived [39 (74%)] and patients died [14 (26%)] during the course of observation. Based on the literature, we conclude that the ideal technique to overcome PVT during LTx is still controversial. Short‐term follow‐up results of both methods are promising, however, long‐term results are unknown at present. Furthermore, clinical follow‐up and basic experimental work is required to evaluate the influence of systemic venous inflow to the liver graft with respect to long‐term liver function and liver regeneration.

Surgical Treatment of Patients with Wandering Spleen: Report of Six Cases with a review of the literature

Wandering spleen, which is defined as a spleen without peritoneal attachments, is a rare disease and a delay in the clinical and/or radiological diagnosis may lead to splenic torsion, infarction, and necrosis. Owing to the physiologic importance of the spleen, especially in children, and the risk of postsplenectomy sepsis, early diagnosis and splenopexy are recommended. In the present article, we describe the results of our management of this rare problem on six patients, and we review all available literature from 1895 to 2005. Briefly, our technique includes flap creation from parietal peritoneum and settlement of spleen in the fossa splenica. Free edges of this flap are stitched to the stomach and the left end of transverse colon and the beginning of the descending colon. The body of the stomach was stitched to the abdominal wall to prevent gastric volvulus, while the fundus region was fixed to the diaphragm to support the spleen. Finally, an omental patch was stitched to the intact abdominal wall above the flap. In conclusion, the procedure of splenopexy without using mesh is considered to be a safe and curative modality for wandering spleen without imposing any undue risk of infection or foreign material reaction.

Emergency Carotid Endarterectomy

Objective: Evaluation of the therapeutical efficacy of emergency carotid endarterectomy (CEA) in neurologically unstable patients. Patients and Methods: Three groups of a consecutive series of 71 emergency CEAs performed from 1980 to July 1998 were classified: (1) acute onset of severe stroke (n = 16), (2) progressive stroke/stroke in evolution (n = 34), and (3) crescendo transient ischemic attacks (n = 21). Cerebral coma, cerebral haemorrhage, and major ischemic stroke established in cranial computed tomography scans were contraindications for surgery. The neurological outcome was assessed by the modified Rankin scale. Long-term survival and long-term stroke recurrences were analyzed. Results: The recovery/minor stroke rates (Rankin 0–3) in acute stroke, progressive stroke, and crescendo transient ischemic attacks were 56.3, 76.4 and 80.9%, respectively; the combined major stroke/mortality rates (Rankin 4–6) were 43.7, 23.6 and 19.1%, respectively. Intraoperative angiography in 39 patients detected early carotid reocclusions in 2 and intracranial embolism in 7 patients. Local application of thrombolytic agents (n = 5) may contribute to a better neurological outcome in emergency CEA. Life table probabilities of major strokefree survival were 74.5, 71.6, and 53.7% after 1, 2, and 5 years, respectively (including perioperative strokes). Life table probabilities to suffer no stroke recurrence during follow-up were 96.7, 96.7 and 85.3%, respectively (perioperative strokes excluded). Conclusions: Emergency CEA may be worthwhile in selected patients. Completion angiography is mandatory. Emergency CEA should be included in therapeutic strategies for ischemic stroke.

Assessment of hepatic perfusion in pigs by pharmacokinetic analysis of dynamic MR images

The purpose of this study was to evaluate a new method based on magnetic resonance imaging for the characterization of hepatic perfusion. In nine pigs dynamic MRI was performed before and after partial occlusion of the portal vein. The pharmacokinetic analysis of the contrast enhancement resulted in a set of parameters (amplitude, A; perfusion rate, kp; elimination rate, kel; lag time, tlag) of which kp was expected to correlate with hepatic perfusion. Reference measurements were done with ultrasound flowmeters and with a thermal diffusion probe (TDP). MR perfusion rate kp significantly dropped under partial portal vein occlusion from an average of 11.3 to 4.9 min−1 (P < 0.001), while the difference in amplitude A was not significant. The correlation between kp and the TDP measurement was r = 0.89 (P < 0.001). Pharmacokinetic analysis of MRI contrast enhancement provides a non‐invasive assessment of hepatic perfusion.J. Magn. Reson. Imaging 1999;9:568–572.

Surgical treatment of primary hepatic epithelioid hemangioendothelioma.

Epithelioid hemangioendothelioma is a very rare tumor of vascular origin. It can develop in different tissues such as soft tissue, lung, or liver. Hepatic epithelioid hemangioendothelioma (HEH) mostly affects females. The malignant potential of HEH often remains unclear in the individual patient. It can range from benign hemangioma to malignant hemangioendotheliosarcoma. Here we present our experience with five patients with primary HEH, who were treated with curative intention in our department. All patients in our series with confirmed histological HEH did not show extrahepatic extension and consequently underwent surgical treatment. In three patients, liver transplantation (LTx) was performed (two cadaveric and one living related). In one patient, a right-sided hemihepatectomy with partial resection of the diaphragm was performed. One patient died while she was on the waiting list for LTx due to rapid tumor progression. Postoperative follow-up ranged from 1 to 13 years. No adjuvant chemotherapy was applied. Until now, no recurrence of local tumor or distant metastases could be observed during follow-up in our series. Early detection and surgical intervention in case of HEH can potentially offer curative treatment. The treatment of first choice appears to be radical liver resection. In our view, LTx represents a potentially important option for patients with a nonresectable tumor. Despite the long waiting time, its often unclear dignity, and a proven progressive growth pattern, living related LTx also plays a potentially important role. The 5-year overall survival rate of patients with HEH in the literature varies from 43% to 55%. Long-term survival of patients with HEH is significantly higher compared to other hepatic malignancies. The role of adjuvant therapy currently remains unclear.

Relationships between Volume, Efficiency, and Quality in Surgery — A Delicate Balance from Managerial Perspectives

Volume, efficiency, and quality in hospital care are often mixed in debate. We analyze how these dimensions are interrelated in surgical hospital management, with particular focus on volume effects: under financial constraints, efficiency is the best form of cost control. External perception of quality is important to attract patients and gain volumes. There are numerous explicit and implicit notions of surgical quality. The relevance of implicit criteria (functionality, reliability, consistency, customaziability, convenience) can change in the time course of hospital competition. Outcome data theoretically are optimal measures of quality, but surgical quality is multifactorially influenced by case mix, surgical technique, indication, process designs, organizational structures, and volume. As quality of surgery is hard to grade, implicit criteria such as customizability currently often overrule functionality (outcome) as the dominant market driver. Activities and volumes are inputs to produce quality. Capability does not translate to ability in a linear function. Adequate process design is important to realize efficiency and quality. Volumes of activities, degree of standardization, specialization, and customer involvement are relevant estimates for process design in services. Flow-orientated management focuses primarily on resource utilization and efficiency, not on surgical quality. The relationship between volume and outcome in surgery is imperfectly understood. Factors involve learning effects both on process efficiency and quality, increased standardization and task specialization, process flow homogeneity, and potential for process integration. Volume is a structural component to develop efficiency and quality. The specific capabilities and process characteristics that contribute to surgical outcome improvement should be defined and exported. Adequate focus should allow even small institutions to benefit from volume-associated effects. All volumes-based learning within standardized processes will finally lead to a plateauing of quality. Only innovations will then further improve quality. Possessing volume can set the optimal ground for continuous process research, subsequent change, innovation, and optimization, while volume itself appears not to be a quality prerequisite.

HEGPOL: Randomized, placebo controlled, multicenter, double-blind clinical trial to investigate hepatoprotective effects of glycine in the postoperative phase of liver transplantation [ISRCTN69350312]

BackgroundKupffer cell-dependent ischemia / reperfusion (I/R) injury after liver transplantation is still of high clinical relevance, as it is strongly associated with primary dysfunction and primary nonfunction of the graft. Glycine, a non-toxic, non-essential amino acid has been conclusively shown in various experiments to prevent both activation of Kupffer cells and reperfusion injury. Based on both experimental and preliminary clinical data this study protocol was designed to further evaluate the early effect of glycine after liver transplantation.Methods / designA prospective double-blinded randomized placebo-controlled multicenter study with two parallel groups in a total of 130 liver transplant recipients was designed to assess the effect of multiple intravenous doses of glycine after transplantation. Primary endpoints in hierarchical order are: peak levels of both aspartat-amino-transaminase (AST) and alanine-amino-transaminase (ALT) as surrogates for the progression of liver related injury, as well as both graft and patient survival up to 2 years after transplantation. Furthermore, the effect of glycine on cyclosporine A-induced nephrotoxicity is evaluated.DiscussionThe ongoing clinical trial represents an advanced element of the research chain, along which a scientific hypothesis has to go by, in order to reach the highest level of evidence; a randomized, prospective, controlled double-blinded clinical trial. If the data of this ongoing research project confirm prior findings, glycine would improve the general outcome after liver transplantation.

Taurine improves graft survival after experimental liver transplantation

Relevant mechanisms of reperfusion injury after liver transplantation are most likely mediated by activated Kupffer cells. Recently, it has been demonstrated that taurine prevents Kupffer cell‐activation in vitro. Thus, this study was designed to assess the effects of taurine after liver transplantation. Female Sprague‐Dawley rats (210‐240 g) were infused with taurine dissolved in normal saline, before organ harvest. Controls were infused with the same volume of normal saline without taurine. Following 4 hours of cold ischemia, liver transplantation was performed. Graft and animal survival, serum transaminases, liver histology, perfusion data of intravital microscopy, blood distribution at reperfusion, and both phagocytosis of Kupffer cells and expression of tumor necrosis factor α (TNF‐α) to index cellular activation were investigated. For comparison, both, analysis of variance (ANOVA) and Fishers exact test were used as appropriate. Results are presented as mean ± SEM. Controls survived in 60% of cases. Taurine improved survival in a dose‐dependent manner to 100% (P < 0.05). In controls, mean aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactic dehydrogenase (LDH) serum levels increased to 3,260 ± 814; 1,703 ± 432; and 14,071 ± 3,177 U/L, respectively, after transplantation. In contrast, these values were between 20 and 45% of control values after taurine (P < 0.05). Histology taken after transplantation confirmed the significant protective effects of taurine, including the reduction of TNF‐α expression. Time until homogeneous reperfusion of the graft improved to 50% of control values (P < 0.05). Further, taurine significantly decreased both phagocytosis of latex beads by Kupffer cells and leukocyte–endothelial cell interaction. In parallel, flow velocity of red blood cells as well as acinar and sinusoidal perfusion improved (P < 0.05). In conclusion, these data show for the first time in vivo that taurine minimizes reperfusion injury after liver transplantation. Decreased leukocyte–endothelial cell interaction and improved microcirculation are the proposed mechanisms, which are most likely Kupffer cell–dependent. (Liver Transpl 2005;11:950–959.)

Recurrent herpes simplex virus hepatitis after liver retransplantation despite acyclovir therapy

Herpes virus hepatitis (HSV) represents a form of acute necrotizing hepatitis, which most frequently develops in immunocompromised patients. Therapeutic options include high‐dose intravenous acyclovir and liver transplantation. We report the first case of recurrent HSV hepatitis after liver retransplantation, which occurred despite continuous administration of high‐dose intravenous antiviral therapy. Because explant histology pointed to initial therapy response, we thought that the reason for recurrence might be due to acyclovir resistance. Most acyclovir resistance is caused by inactivating mutations in the herpes virus thymidine kinase gene. HSV infection was detected by histology and proofed by immunohistochemistry. PCR amplification of the herpes virus thymidine kinase gene was performed on histology specimens to demonstrate the course of viral infection in liver tissue. Genotypic resistance testing of the herpes virus was performed by sequencing the thymidine kinase amplicon. In serial biopsy, HSV‐DNA sequences were only detectable when histology revealed herpes hepatitis. Whereas the primary explant exhibited the wild‐type thymidine kinase gene, a biopsy of the second graft one month after retransplantation, which showed recurrent herpes virus hepatitis, had a single base insertion within a homopolymeric cytosine stretch. This mutation causes a frame shift leading to a premature stop codon and results in a known acyclovir‐resistant herpes strain. In conclusion, we believe that testing for acyclovir‐resistant herpes strains should be considered in high‐risk patients in whom viral clearance is not achieved serologically to prevent fatal recurrence of disease by using antiviral drugs such as inhibitors of HSV‐DNA polymerase or viral helicase primase inhibitors. (Liver Transpl 2005;11:1289–1294.)