The impact of liver preservation in HTK and UW solution on microcirculation after liver transplantation

Severe microcirculatory disturbances due to endothelial cell damage and leukocyte adherence during reperfusion of transplanted livers are considered to contribute to early graft failure. Since the degree of reperfusion injury after liver transplantation depends on the length of preservation time and the solution used for preservation, the aim of our study was to assess three solutions with respect to microvascular perfusion and leukocyte adhesion. Therefore, rat livers were stored up to 24 h in Euro-Collins (EC), University of Wisconsin (UW), or histidin-tryphtophan-ketoglutarate (HTK) solutions prior to orthotopic transplantation. The livers were studied in situ 60 min postoperatively using intravital fluorescence video microscopy. Using simple syringe flushing (10 ml), sinusoidal perfusion decreased below 50% in EC preserved livers after 8 h preservation, in HTK preserved livers after 16 h preservation, and remained higher than 70% in livers preserved in UW up to 24 h. Permanent adhesion of leukocytes was increased more rapidly in organs after 1, 8, 16, and 24 h preservation in HTK (16%, 15%, 34%, and 49.7% +/- 4.7%) compared to those preserved in UW (15%, 18%, 17%; and 32.7% +/- 3.3%; P<0.05). Using a 10-fold volumn of the organ weight of HTK solution during the harvesting procedure, with an 8 min equilibration period, sinusoidal perfusion (39.6 +/- 4.7%) and leukocyte adhesion (42.7 +/- 3.1%) were not improved after 24 h. In contrast, equilibration with a volumn of approximately 40-times the liver weight improved sinusoidal perfusion (70.8% +/- 2.7%; P < 0.01) and leukocyte adhesion (24.9% +/- 3.1%; P < 0.01) significantly. Thus, using HTK solution, simple flushing prior to long-term cold storage resulted in microcirculatory disturbances when compared to UW solution. Larger volumns of HTK solution with an additional equilibration period of 8 min, however, reduced leukocyte adhesion and improved sinusoidal perfusion to a similar degree as UW solution.

Hepatic microcirculatory disturbances due to portal vein clamping in the orthotopic rat liver transplantation model

Most modifications and applications of the orthotopic rat liver transplantation (ORLT) model require clamping of the portal vein, thus leading to ischemia of the gut. The purpose of this study was to evaluate the effect of portal vein clamping during ORLT on hepatic microcirculation and leukocyte--endothelial interaction by intravital fluorescence microscopy. ORLT were performed following 1 hr of cold storage in EuroCollins solution without (standard group) and with insertion of a portojugular shunt (shunt group) to minimize intestinal ischemia. ORLT induced reduction of perfused sinusoids (83%) and velocity of leukocytes (311 +/- 4.5 microns/sec; mean +/- SEM) compared with nontransplanted controls (99% and 417 +/- 4.9 microns/sec). Portojugular shunt during ORLT improved hepatic microvascular perfusion (89% and 355 +/- 3.4 microns/sec; P less than 0.05). Furthermore, percentage of permanent and temporary adherent leukocytes decreased significantly when a portosystemic shunt was applied (from 33.5 +/- 1% to 22.1 +/- 1% and 19.7 +/- 1.2% to 14.0 +/- 0.9%; P less than 0.05). The results of the study reveal that intestinal congestion and reperfusion results in a rise in leukocyte adhesion to the sinusoidal wall and in disturbances of the hepatic microcirculation. It seems likely that increased endotoxin concentrations in the portal vein induce an activation of hepatic macrophages that subsequently cause release of chemoattractant mediators. In conclusion, side effects of intestinal ischemia during experimental liver transplantation surgery on liver function due to release of chemoattractant mediators should be considered when experimental data are transferred to clinical settings.

[Experiences with continuous nerve block of the wrist]

Continuous nerve blocks are effective analgesics for physiotherapy following operative procedures on gliding tissues. In the upper extremity, continuous axillary blocks are regularly used, leading to weak muscular action and even paralysis, although active muscle action is wanted. With continuous wrist blocks, extrinsic motor function of the hand remains undisturbed. Placement of a polyethylene catheter near the nerves with instillation of a local anesthetic (carbostesine 0.5, 3-4 ml per nerve) provides complete anesthesia of the hand without loss of extrinsic motor function. After 124 nerve blocks in 60 patients, no complications (infections, nerve irritations or lesions) have been observed. Continuous wrist blocks are indicated for postoperative treatment after tenolysis, joint mobilisation or arthrolysis, open reduction and internal fixation and in certain cases of chronic pain care.

[Rupture of the tendon of the m. flexor pollicis longus--a rare complication after surgery on the scaphoid bone]

Tendon ruptures in the hand without previous direct trauma are rare. Two cases are reported on with attrition of the flexor pollicis longus tendon. The first tendon rupture was along a dislocated cortico-cancellous bone graft following a Matti-Russe procedure; the second was by attrition over the screw of an AO-plate following internal fixation in scaphoid nonunion. Immediate tendon repair by interposition of a short tendon graft or by transposition of the superficialis flexor tendon of the ring finger is the treatment of choice. Further tendon ruptures can arise if surgical intervention is delayed.

Microcirculatory disturbances and leucocyte adherence in transplanted livers after cold storage in Euro-Collins, UW and HTK solutions

Integrity of the hepatic microcirculation and maintenance of endothelial cell viability are critical components in preventing primary non-function after liver transplantation. Therefore, hepatic microcirculation and leucocyte-endothelial interaction were studied in rat livers stored for 1 h in Euro-Collins (EC), University of Wisconsin (UW), and histidine-tryptophan-ketoglutarate (HTK) solutions and subsequently transplanted. One hour after transplantation surgery, the livers were exposed under an intravital fluorescence microscope. After injection of the leucocyte marker acridine orange (1 mumol/kg), six pericentral fields were observed for 30 s and experiments were recorded continuously. The percentage of perfused sinusoids was reduced in the livers in the EC group (82.9%) in contrast to the UW (93.2%) and HTK groups (91.0%). Livers in the EC group showed a reduction in the diameters of pericentral sinusoids (7.3 +/- 0.2 microns; mean +/- SEM) compared with the UW group (9.5 +/- 0.2 microns; P less than 0.05) and HTK group (10.2 +/- 0.8 microns; P less than 0.05), indicating substantial cell swelling in livers stored in EC solution. Permanent adherence of leucocytes was most frequently observed in the EC group (33.5 +/- 1%), while this phenomenon was less pronounced in the UW group (14.5 +/- 1.1%; P less than 0.05) and HTK group (16.3 +/- 0.7%; P less than 0.05). Conversely, temporary adherence of leucocytes was reduced in the EC group (19.7 + 1.3%) compared with the UW group (30.5 + 2.1%) and the HTK group (34.4 + 0.8%).(ABSTRACT TRUNCATED AT 250 WORDS)

[A treatment concept using external transfixation in unstable defect trauma of the knee joint]

The main problems in the treatment of severe knee injuries with extensive soft tissue damage, ligamentary lesions and compound fractures consist in the high risk of infection and complex instability of the joint. 20 patients suffering such type of trauma were treated by a schedule comprising an extensive debridement and a combination of minimal internal osteosynthesis and external transfixation. Secondary operations were always performed as a second look in all patients and various surgical reconstructions of the soft tissue coverage under continuous protection of the external fixation. Most patients obtained satisfactory functional results, only 2 cases ended up with arthrodesis due to deep infection.

[Spontaneous and simultaneous bilateral quadriceps ruptures in hyperparathyroidism]

A report of a case of bilateral spontaneous and simultaneous quadriceps tendon ruptures and a review of the world literature is given. Chronic renal failure and its sequelae, hemodialysis and particularly hyperparathyroidism are associated with all such patients under the age of 50. Diagnosis should be made early since primary suture of the tendons is the treatment of choice.

[Intraluminal balloon occlusion of the aorta in traumatic massive hemorrhage]

Management of massive abdominal hemorrhage is a major challenge in trauma care. In this clinical setting high aortic blockade is known to be effective, as it stops arterial bleeding and restores the vital central circulation. Balloon occlusion of the descending aorta provides an alternative to thoracotomy with aortic cross-clamping, thereby avoiding this major surgical procedure. For introduction of the balloon the recommended technique is cut-down and insertion of the balloon to the femoral artery. More research and clinical experience are needed to define useful indications and to explore the long-term consequences of aortic balloon occlusion.

[The Graner capitate interposition arthroplasty in lunate malacia]

In capitate interpositional arthroplasty (Graner II) the necrotic lunate bone is removed and the congruity of the proximal carpal row is restored by interposition of the proximal half of the capitate. The carpal bones are fused except for the scaphotrapezial joint. In this fashion carpal instability can be safely treated. Good results are achieved for both grip strength and relief of pain. Motion is restricted but with a useful range of motion remaining. The arc of remaining motion can be shifted into extension through the use of an opening wedge osteotomy of the capitate. Capitate interpositional arthroplasty without an intercarpal arthrodesis has poor result because of remaining carpal instability.

[Principles of primary functional fracture treatment]

The main characteristic feature of primary functional treatment of fractures is that all parts of the affected segment of the locomotor apparatus are essentially functional again within a week after the trauma has been sustained, even without any internal splinting. Stable cancellous bone compression, fractures that are stabilized by a pronounced muscular sheath and certain fractures affecting the shafts of the long tubular bones are all indications for application of this method, providing there is no concomitant high-grade soft tissue damage. Adjuvant analgesia is an important basis of the therapy; others are exercises under the supervision of a physiotherapist and the adaptation of supporting splints and cuffs. The primary functional treatment regimen has few complications, and when it is applied only in situations where it is genuinely indicated and is competently supervised, the clinical results are excellent.

[Surgical treatment of tumor-induced destruction of the spine]

Surgery for treatment of destructions of the spine varies depending on localization and tumour status. If the body of the vertebra is affected, the ventral approach allows radical tumour resection as far as possible. The following stabilization is effected by filling the defect and carrying out osteosynthetical fusion. Of 38 patients, three had benign tumours, whereas ten patients had primary malignant and 25 had metastatic tumours. The results show that surgical treatment is justified also in palliative indications; although survival time is not prolonged, the quality of life can be improved.

[Results of the surgical treatment of distal femoral fractures]

In a follow-up of 97 operated distal femoral fractures good and satisfactory results were found in 64% of the cases. 22% unsatisfactory and 14% poor findings attribute mainly to the comminuted supracondylar fracture types. More than half of the patients were multiple injured. In 83% of the cases the internal fixation was obtained by the use of the condyle buttress plate.