Computer-gestützte Operationsplanung bei Leberlebendspenden

INTRODUCTION

The appropriate recipient/donor match is a prerequisite for successful living donor liver transplantation (LDLT). A precise knowledge of the liver anatomy and the functional liver volume plays a key role in allocating live liver donor candidates. With the new software HepaVision, we obtained information on liver mapping by means of virtual 3-dimensional non-invasive imaging reconstructions and were able to perform a virtual simulation of the liver transsection. Aim of our study was to investigate, whether this new computer technology is advantageous in surgery planning for LDLT.

METHODS

From January 2002 until December 2004 355 liver transplantations were performed in our department, of which 36 were LDLT. According to our evaluation protocol 135 potential donors (63 male, 72 female) between 18 to 59 years received preoperatively an all-in-one CT. The acquired data sets were further analysed with the software HepaVision (MeVis, Germany).

RESULTS

Of the 135 evaluated donors, we excluded 99 (73 %) from donation based on the HepaVision-data. Reason for exclusion was an inadequate liver volume (70.8 %) or a risk related anatomical anomaly (2.2 %). In the remaining 36 cases a successful graft donation was possible. There were no postoperative complications in the donors and recipients, directly related to a misjudgment of the anatomy or miscalculation of the liver volume.

CONCLUSION

The systematic use of HepaVision for surgery planning proved to be indispensable for proper donor selection. A virtual simulation of the liver transsection on 3D-model additionally increased the safety of the operation, consequently decreasing the risk for the donor.

Indications for Liver Transplantation

Candidates for OLT must have irreversible acute or chronic end stage liver disease (table 41b.1). Virus or alcohol-induced liver cirrhosis constitute the most common disease indications in adults [1] (fig. 41b.1). In our department 28% of cirrhotic liver transplant recipients are transplanted for hepatitis C virus (HCV)-related liver disease and 26% undergo OLT for alcohol-related liver disease. Other indications include cholestatic liver disorders [primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), biliary atresia], hepatitis B virus (HBV) infection, autoimmune hepatitis, cystic fibrosis, inherited metabolic diseases (Wilson’s disease, hemochromatosis, alpha-1-antitrypsin deficiency), nonalcoholic steatohepatitis, nonmetastatic hepatocellular carcinoma, and acute virally-, toxin-, or drug-induced hepatic failure. The most common indications in children comprise biliary atresia and metabolic liver diseases

Disease course after liver transplantation for hepatocellular carcinoma in patients with complete tumor necrosis in liver explants after performance of bridging treatments

AIM

To study the disease course of patients with hepatocellular carcinoma (HCC) showing complete tumor necrosis in their liver explants after undergoing bridging treatments followed by liver transplantation (LTx).

PATIENTS AND METHODS

We evaluated data corresponding to 10 patients with liver cirrhosis undergoing bridging treatments for HCC prior to LTx. In all cases there was complete tumor necrosis in the explanted livers.

RESULTS

There were 8 men and 2 women. Percutaneous radiofrequency ablation (RFA) was performed under computed tomographic guidance in 4 patients. The remaining 6 patients underwent transarterial chemoembolization (TACE). Five of them received one session of TACE, while the remaining one received a series of 4 sessions prior to LTx. Six patients had solitary nodules with a median diameter of 3.5 cm (range 2.5-4.2 cm). Four of them underwent RFA. Segmental tumor chemoembolization was performed in 2 patients. The remaining 4 patients had 2 tumors each with a median total diameter of 4.4cm (range 4.2-6.0 cm) prior to TACE. They underwent bilobar hepatic chemoembolization, which under staged the tumors prior to live donor liver transplantation (LDLTx). Six patients underwent deceased donor orthotopic liver transplantation. LDLTx was performed in 4 patients. Median waiting time to LTx was 53 days. All patients are alive without recurrence after a median follow-up of 19 months.

CONCLUSION

Achievement of 100% tumor necrosis by means of bridging treatments followed by LTx for HCC is characterized by a very low recurrence rate and should receive further consideration and study.

Highly conserved pattern of recognition of influenza A wild-type and variant CD8+ CTL epitopes in HLA-A2+ humans and transgenic HLA-A2+/H2 class I-deficient mice

As an in vivo model for studying human MHC (HLA) class I-restricted CTL responses to viral infection, we established a series of HLA Tg mice expressing HLA-A2, -B7 or -B27 human/mouse hybrid genes on a background deficient for H2 class I (Tg HLA(hyb)/H2 class I DKO). To determine whether CTL recognition of influenza A (flu) infection in Tg HLA-A2(hyb)/H2 DKO mice is similar to HLA-A2+ humans, we compared the HLA-A2-restricted Tg mouse and human CD8+ T-cell responses to an immunodominant flu epitope (wild-type [WT] M1 58-66), as well as a variant of this peptide (var. M1 58-66). Similar to HLA-A2+ humans, our results show WT M1 58-66 is likely the dominant CTL epitope recognized in infected Tg HLA-A2(hyb)/H2 DKO mice. Var. M1 58-66 was also recognized by WT peptide-reactive T cells from both HLA-A2+ humans and Tg mice, although slightly less efficiently than WT M1 58-66 in both cases. Reduced variant recognition was shown to be associated with reduced peptide/A2 binding, as well as a more limited repertoire of utilized TCR Vbeta chains. The similar pattern of recognition and cross reaction observed here for the WT and variant M1 58-66 epitopes with HLA-A2 by human and Tg HLA mouse CTLs indicates that A2-dependent events of Ag processing, presentation and recognition are well-conserved between species. These findings demonstrate that this Tg HLA-A2/H2 DKO model will aid identification and development of epitopes as vaccines for numerous viral and tumor antigens for the HLA-A2 supertype.

A novel tool for B-cell tolerance research: characterization of mouse alloantibody development using a simple and reliable cellular ELISA technique

In animal-based transplantation research, the measurement of anti-donor antibodies in transplant recipients is limited by lack of an appropriate technique. We have developed a novel immunoassay capable of quantifying antibody bound to cell-surface major histo- compatability complex (MHC) and non-MHC antigens, using splenocytes from wild-type and MHC-deficient mice as antigen-bearing target cells. We utilized our "cellular ELISA" (CELISA) technique to study the development of tolerance versus immunity in the B-cell compartment in response to neonatal exposure to allogeneic fetal liver cells (FLC). This neonatal tolerance protocol typically induces permanent acceptance of donor-type and third-party cardiac allografts, but rejection of both donor-type and third-party skin grafts occurs. C3H/He (C3H; H-2(k)) mice were injected as neonates with BALB/c (BALB; H-2(d)) FLC and transplanted as adults with C57BL/6 (B6; H-2(b)) cardiac grafts. Despite long-term acceptance of third-party B6 cardiac grafts, serum contained increased anti-B6 IgG and IgM levels as measured by CELISA; IgM production was elevated by 2 weeks posttransplant and remained stable, while IgG production increased rapidly between 2 and 5 weeks posttransplant. In another experimental setting, CELISA assays were able to detect that neonatal injection of C3H mice with FLC from wild-type B6 mice or from MHC class II-deficient or class I/II-deficient (B6 background) mice (CI(+)CII(+), CI(+)CII(-), CI(-)CII(-), respectively) prevented sensitization to B6 antigens by subsequent skin transplants but did not induce graft acceptance, whereas FLC from MHC class I-deficient-only (CI(-)CII(+)) did not prevent B6 sensitization. The CELISA technique is a simple and sensitive means for quantifying alloantibodies in mice and will assist in further delineating the role of the B-cell compartment in neonatally induced cardiac allograft acceptance.

[Surgery during pregnancy]

The decision for surgical intervention during pregnancy should be interdisciplinary and include all aspects of prenatal care. The risk of surgery to mother and fetus must be calculated and weighed against the disadvantages of other, nonradical methods. If there is no danger to the mother, the highest priority in all therapeutic considerations is the fetus and its development. The greatest threat to the fetus exists during the first trimester. In case surgery cannot be postponed till after birth, they should be done if possible during the 4th to 6th months of pregnancy, not the first trimester. In case of danger to the mother, necessary surgery must be performed any time during the pregnancy. Once extrauterine fetal survival is possible (the 24th or 25th week of pregnancy), danger to the mother and the child's mortality and morbidity of the various options must be carefully weighed for both premature delivery and continued pregnancy. Due to the problems of prematurity, any surgery during pregnancy should be carried out only in perinatal clinics outfitted with neonatologic intensive care units.

Anatomical and physiological classification of hepatic vein dominance applied to liver transplantation

BACKGROUND

Proper outflow reconstruction is essential in LDLT. Preoperative planning requires meticulous attention to hepatic vein dominance patterns. The purpose of our study was to provide a combined anatomical-physiological classification of hepatic vein dominance useful for surgical decision-making in both donors and recipients.

METHODOLOGY

We analyzed 3-dimensional CT-imaging reconstructions of 55 potential live liver donors evaluated at our Institution between January 2003 and May 2004.

RESULTS

Our data revealed that: 1) The middle hepatic vein (MHV) and left hepatic vein (LHV) show a relative lack of anatomical diversity, whereas the right hepatic vein (RHV) exhibits multiple variants, 2) 45% donors had inferior hepatic veins (IHV) with anatomically and physiologically relevant venous drainage territories, 3) The RHV is usually dominant when present as a single vein without anatomical IHV (type 1A), or when considered as a complex with IHV (type 1Bx) (80% vs. 88%), 4) Only 55% of dominant type 1Bx RHV/IHV-complex automatically included a dominant type 1By RHV by itself, 5) A single RHV out of anatomical complex with IHV (type 1By) was dominant in only 48% of our donor candidates, 6) The MHV types 2A and 2By are strongly dominant accounting for up to 57% of total liver volume (TLV).

CONCLUSIONS

We propose a new classification based on both anatomical and physiological hepatic venous configurations. Our model also provides a new nomenclature that can be universally applied to preoperative planning in LDLT.

Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis

BACKGROUND

Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented.

METHODS

Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival.

RESULTS

Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine.

CONCLUSION

These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.

Ouabain induces apoptotic cell death in type I spiral ganglion neurons, but not type II neurons

Application of ouabain to the intact round-window (RW) membrane of the gerbil cochlea induces apoptosis in most spiral ganglion neurons (SGNs), leaving a few neurons intact (Schmiedt et al. 2002). Here, physiological measures and immunostaining were used to examine the process of SGN degeneration at 3, 6, 12, and 24 h, 4 days, and 1 and 5 months after ouabain treatment. The few remaining neurons surviving up to 5 months after ouabain treatment were immunoreactive for peripherin, a type II neuron marker. Peripherin-positive cell counts indicate that about 7% of the SGNs in the gerbil cochlea are type II neurons, and these neurons survive intact after ouabain treatment. Ouabain exposure had little effect on the outer hair cell and lateral wall systems, even after a 5 month loss of auditory-nerve function. The cellular locations of cytochrome c, poly (ADP-ribose) polymerase (PARP), and activated caspase 3 were examined in control and ouabain-treated cochleas. A redistribution of cytochrome c in peripherin-negative (type I) neurons was observed at 3 h after ouabain exposure. Degraded PARP and activated caspase 3 were also detected in peripherin-negative SGNs at 6 and 24 h after treatment, respectively. These results suggest that the redistribution of cytochrome c is an early event during apoptosis in type I SGNs and that activation of PARP and caspase 3 are associated with apoptosis in these cells. Calcineurin and NF-kappaB are two important signaling pathways that may modulate cell survival in the central nervous system. Here, we found that calcineurin and NF-kappaB selectively labeled type II neurons. It is speculated that the high levels of calcineurin and NF-kappaB in type II SGNs, as compared with type I SGNs, may play protective roles in enhancing the survival of type II neurons exposed to ouabain.

Staging laparoscopy in gastric cancer

BACKGROUND

As patients with gastric cancer are offered choices between surgical resection, neoadjuvant or palliative chemotherapy, or symptomatic relief alone, the need for accurate preoperative staging becomes apparent. Laparoscopy has been suggested as an appropriate staging modality in a variety of upper gastrointestinal malignancies.

METHODOLOGY

Staging laparoscopy was performed in 45 patients with potentially resectable gastric cancer as determined by physical examination, gastroscopy, endosonography, transcutaneous ultrasonography and current generation computed tomography. Conventional clinic staging and laparoscopic staging according to the Tumor-Node-Metastases classification of the International Union against Cancer were registered separately on a database. Results were then compared to evaluate the agreement of both staging procedures.

RESULTS

Compared to conventional staging, laparoscopy resulted in up staging of 23 patients (51.1%). In 10 patients of them peritoneal seeding was first found during laparoscopy, whereas additional liver metastases were detected in 3 patients and Krukenberg's tumor in one. As a consequence, the therapy planning was changed and laparotomy was avoided in 14 of these patients as the first operative procedure. Sensitivity of clinical staging was especially poor for stage IV tumors (5.3%) and for the majority of stage IIIB tumors (42.9%). Cytologic examination of peritoneal fluid had no additional information in our series.

CONCLUSIONS

The value of laparoscopy in staging patients with gastric carcinoma could be demonstrated in this study. It is a safe and effective staging modality, helping to avoid unnecessary laparotomies and providing new means of directing appropriate treatment strategy.

Insulin detemir used in basal-bolus therapy in people with type 1 diabetes is associated with a lower risk of nocturnal hypoglycaemia and less weight gain over 12 months in comparison to NPH insulin

AIM

The aim of this study was to compare the long-term safety and efficacy of twice-daily insulin detemir or NPH insulin as the basal component of basal-bolus therapy in people with type 1 diabetes.

METHODS

A multicentre, open-label, parallel-group study was conducted over 12 months and completed by 308 people (from an original randomized cohort of 428). Patients were randomized in a 2:1 ratio to receive insulin detemir or NPH insulin before breakfast and dinner, with insulin aspart at mealtimes.

RESULTS

Glycaemic control improved in both groups with HbA(1c) decreasing by 0.64 and 0.56% point in the insulin detemir and NPH insulin groups, reaching baseline-adjusted final values of 7.53 +/- 0.10% and 7.59 +/- 0.13%, respectively. No significant difference was apparent between treatments in terms of HbA(1c), fasting plasma glucose or 9-point blood glucose profiles. Fewer hypoglycaemic events (major and minor) occurred in association with insulin detemir compared with NPH insulin, but the overall hypoglycaemic risk did not differ statistically significantly (RR for detemir, 0.78 [0.56-1.08]). However, the risk of nocturnal hypoglycaemia during the maintenance phase (month 2-12) was 32% lower in the detemir group (p = 0.02) and lower in every month. This risk reduction remained statistically significant after correction for HbA(1c). After 12 months, baseline-adjusted mean body weight was significantly lower in the insulin detemir group than in the NPH insulin group (p < 0.001).

CONCLUSIONS

In long-term basal-bolus therapy, insulin detemir with insulin aspart as mealtime insulin is well tolerated and reduces the risks of nocturnal hypoglycaemia and weight gain compared to NPH insulin.

π-Conjugated N-heterocyclic compounds: correlation of computational and electrochemical data

Electrochemical reduction potentials of a broad selection of nitrogen-containing molecules suitable as bridging (dipodal and tripodal) ligands in coordination and organometallic chemistry are reported and compared with results of semiempirical calculations. Trends of electrode potentials observed experimentally agree with respective calculated data, deviations can be explained by invoking peculiarities of the involved molecular orbitals and ligand-electrode surface interactions.

Organ protective management of the brain-dead donor

The adequate management of brain dead donors on an Intensive Care Unit (ICU) is one of the major key points for a successful transplantation of harvested organs. In addition to an invasive monitoring like in any other ICU patient these patients needs a meticulous attention to their hemodynamic. The early administration of desmopressin to treat diabetes insipidus, a differentiated use of fluid resuscitation and a distinct catecholamine support are special features of an appropriate basic treatment. The administration of corticoids has to be considered if a sufficient circulation can not be regained.

[Organ transplantation in human immunodeficiency virus-infected patients. Results of a survey in German transplantation centres]

BACKGROUND

Despite considerable advances following the introduction of highly active antiretroviral therapy, organ transplantation is usually denied categorically for human immunodeficiency virus (HIV) patients, and it is presented in German transplantation law as a contraindication. Today, this should be questioned critically.

METHOD

A survey at all 87 German transplant centres was done concerning (1) how many HIV-positive patients were transplanted before and after February 2000, (2) willingness of the centres to transplant HIV-infected patients in the future, and (3) course of transplanted HIV patients so far.

RESULTS

With a response rate of 78%, 39% of the questioned centres were accepting HIV patients in the future for transplantation, and 39% rejected this. Twenty percent voted for individual case decision. Three centres had practiced liver transplantation in 11 patients.

CONCLUSION

The decision to transplant HIV-positive patients in Germany is mostly based on individual cases and not refused in general. However, prospective studies on this issue are justified and needed.