[Management of late onset septic complications after IPOM implantation: case series from a hernia center]

BACKGROUND

The intraperitoneal onlay mesh (IPOM) is for many surgeons a pragmatic solution for the operative treatment of extensive and complex abdominal wall hernias. A few years after mesh implantation we are now faced with a number of late complications of the IPOM procedure. Chronic septic complications, such as mesh infections and fistula formation have an outstanding position.

OBJECTIVE

With this case series we would like to share our experiences with the operative treatment of severe late onset septic complications after abdominal wall augmentation with IPOM. Furthermore, the current indications for the IPOM procedure are discussed.

MATERIAL AND METHODS

For the period February 2016-July 2019 a total of 10 patients with late septic complications after IPOM implantation were treated in our clinic. The index interventions took place between 2010 and 2017. The clinical picture varied from mesh infections with only minor symptoms to formation of multiple intestinal fistulas.

RESULTS

Multiple stage procedures were required in 9 out of the 10 patients in order to achieve sufficient decontamination of the surgical field. Due to enterocutaneous fistulas, bowel resection was performed in 5 patients. The mesh could be preserved in situ in only one patient. For the reconstruction of the abdominal wall, both plastic surgical methods and implantation of absorbable and non-absorbable meshes were used.

CONCLUSION

A consistent treatment with great effort is required for septic complications of the IPOM procedure. The interventions are often associated with extensive adhesiolysis and intestinal resection. Therefore, the indications for intraperitoneal mesh implantation should be handled with caution and an alternative surgical procedure should be considered. There are still special cases, such as hernias with very large abdominal wall defects in which the IPOM method is a suitable treatment option for tension-free reconstruction.

Solid Organ Transplantation After Retrieval From Deceased Donors With Abdominal Aortic Grafts

INTRODUCTION

Organ procurement from deceased donors has been steadily augmented over the last 20 years. With a more aged donor population, a higher incidence of intraabdominal pathologies, including abdominal aortic aneurysms and atherosclerotic aortic disease, is commonly being encountered. The objective of our study was to report our institutional experience with abdominal aortic grafts during solid organ harvesting.

PATIENTS AND METHODS

Data concerning the presence of aortic grafts in deceased solid organ donors during a 36-month period were retrospectively reviewed.

RESULTS

During the study period, the organ retrieval team of our institution performed 246 multiorgan retrievals from deceased donors. More specifically, we harvested 6 livers and 12 kidneys from 6 donors with abdominal aortic grafts, which were not known/diagnosed to the organ retrieving team prior to the harvesting procedure. Severe atherosclerosis was present in all these donors. All 18 harvested organs were successfully transplanted. Apart of the absence of the aortic patch in 5 kidney grafts, no further special technical difficulties have been reported by the transplant teams. Data analysis of the recipient and graft outcome was performed through the Eurotransplant database.

CONCLUSION

There are so far no literature data on the outcome of recipients and grafts from deceased donors with abdominal aortic grafts. Although retrieval of such organs is very challenging and requires a very experienced team, the transplantation of the corresponding organs can be performed without special technical problems.

Surgery for colorectal cancer in elderly patients: is there such a thing as being too old?

INTRODUCTION

The overall increase in life expectancy causes a rapid increase in number of elderly patients needing colorectal surgery. It remains unclear if there is a significant risk factor in patients over 80 years of age for postoperative morbidity and mortality. For this reason we investigated the perioperative, outcome and long-term survival after surgery for colorectal cancer in our hospital.

MATERIALS AND METHODS

We retrospectively analysed a database containing information about patients who underwent surgery for colorectal cancer from January 2010 to December 2015 at the St. Bernhard Hospital in Kamp-Lintfort, Germany. The last follow-up date was 31th of December 2017.

RESULTS

A total of 232 patients were enrolled and analysed in this study. All patients were separated in tow groups depending in age. The first group was ≥80 years old (n=49). The second group was <80 years old (n=183). High ASA-Scores (≥3) were detectable more often in elderly patients (p<0,05). Elderly and young patients had a similar risk for postoperative anastomosic leakages (p=0,047). Likewise there were no significant differences regarding the Dindo-Clavien-Classification (p=0,13). The mortality within the first 30 days after surgery was significant elevated for elderly patients compared to younger patients (p=0,04). Also the overall 1-year survival was 90% for the younger and 73,5% for the older study group (p<0,05) Conclusion. Both the short-term outcome and long-term survival rate after colorectal surgery for cancer are worse for patients older than 80 years of age. After interpretation of all data it remains unclear if the age itself is still the biggest risk factor. When old patients have a good ASA-Score and no severe comorbidities, colorectal surgery remains safe even for patients older than 80 years.

[Klatskin tumor: long-term survival following surgery]

BACKGROUND

Perihilar cholangiocarcinoma (Klatskin tumor) is a rare tumor entity with an unfavorable prognosis despite optimal treatment.

OBJECTIVES

The aim of the study is to investigate beneficial histopathological features and recommendations for surgery in perihilar cholangiocarcinoma to improve patients' long term survival.

MATERIAL AND METHODS

192 patients suffering from perihilar cholangiocarcinoma underwent attempted tumor resection between 1998 and 2008 at our clinic. 50 patients survived more than 2 years. The follow-up ended in December 2013. The resection type, the UICC stage and histopathological features were compared between three groups (2-3-year, 3-5-year and > 5-year survival groups).

RESULTS

The overall 5‑year survival rate of the study groups was 32 %, and even 16 % survived more than 10 years after surgery. Patients with lymph node positive tumors (p = 0.0126) and distant metastasis (p = 0.0376) had the poorest survival rate. Perineural invasion had no significant impact on the overall survival, but patients surviving more than 5 years had the lowest incidence of perineural invasion with 18.75 %. Caudate lobectomy was significantly (p = 0.011) associated with a survival of more than 5 years in our study.

CONCLUSIONS

Complete tumor resection with additional caudate lobe resection is associated with long-term survival. Perineural invasion seems to be a negative prognostic factor for long-term survival.

Organ donation: new hope through the expected amendment in Germany?

INTRODUCTION

The current organ donor shortage in Germany results in the death of 1000 patients on the transplant waiting list every year. In response, a recent amendment to the German Transplant Act aiming to increase donor rates was passed. Among a number of other measures, Germans are asked to decide whether they choose to donate organs or not in the event of a brain death or whether they would like to designate someone who should decide for them in this situation. The objective of this study was to collect and evaluate data on the public's attitude toward organ donation before the expected amendment.

METHODS

A survey on the subject of organ donation was conducted in 2011 among clients of a public pharmacy in a major city in the federal state North Rhine-Westphalia, Germany. Data regarding sex, age, health behavior, and attitude toward the amendment were collected and association organ donor card possession was analyzed.

RESULTS

A total of 1485 questionnaires were evaluated. Of those surveyed, only 14.1% had an organ donor card. No statistically significant associations between sex (P value .3045), age (P value .1453) and the possession of a donor card were observed. We found that 72.5% of respondents stated that they appreciated the expected amendment, and in the case of implementation, the majority would obtain an organ donor card.

DISCUSSION

The future success of transplantation medicine relies on an increase in the public's overall willingness to donate organs. Educating the public and ensuring transparency in transplantation medicine are vital to achieving higher donation rates. The new German transplantation act may be an important step to increase society's awareness and participation in organ donation.

In-house coordination for organ donation--single-center experience in a pilot project in Germany (2006 to 2013)

A challenge for solid organ transplantation in Germany is the shortage of organs. In an effort to increase donation rates, some federal states mandated hospitals to install transplantation officers to coordinate, evaluate, and enhance the donation and transplantation processes. In 2009 the German Foundation for Organ Transplantation (DSO) implemented the In-House Coordination Project, which includes retrospective, quarterly, information technology-based case analyses of all deceased patients with primary or secondary brain injury in regard to the organ donation process in maximum care hospitals. From 2006 to 2008 an analysis of potential organ donors was performed in our hospital using a time-consuming, complex method using questionnaires, hand-written patient files, and the hospital IT documentation system (standard method). Analyses in the In-House Coordination Project are instead carried out by a proprietary semiautomated IT tool called Transplant Check, which uses easily accessible standard data records of the hospital controlling and accounting unit. The aim of our study was to compare the results of the standard method and Transplant Check in detecting and evaluating potential donors. To do so, the same period of time (2006 to 2008) was re-evaluated using the IT tool. Transplant Check was able to record significantly more patients who fulfilled the criteria for inclusion than the standard method (641 vs 424). The methods displayed a wide overlap, apart from 22 patients who were only recorded by the standard method. In these cases, the accompanying brain injury diagnosis was not recorded in the controlling and accounting unit data records due to little relative clinical significance. None of the 22 patients fulfilled the criteria for brain death. In summary, Transplant Check is an easy-to-use, reliable, and valid tool for evaluating donor potential in a maximum care hospital. Therefore from 2010 on, analyses were performed exclusively with Transplant Check at our university hospital.

Improve intra-uterine insemination in rabbits using ultra-high temperature skim milk as extender to keep semen at room temperature

Two experiments were carried out to examine in vitro quality and in vivo fertility of rabbit semen diluted in ultra-high temperature (UHT) skim milk. In the first experiment, pooled ejaculates of 10 adult rabbits were divided in three aliquots. Each aliquot was diluted in saline solution, TrisC or UHTm extender and kept at room temperature for 24 h. Sperm quality assessment was performed during all the incubation periods. In the second experiment, 27 adult rabbit does were inseminated with semen incubated for 5 h. Embryo recovery was performed 96 h after insemination. Results showed that treatments diluted in UHTm registered the highest values of spermatozoon with total motility, intact and functional plasma membrane and greater number of embryos recovered in rabbit does. We conclude that UHT skim milk would be a good extender for improved intra-uterine insemination in rabbits and to keep sperm cells for several hours at room temperature.

Single-center experience of transplantation for polycystic liver disease

BACKGROUND

Polycystic liver disease (PLD) may lead to massive hepatomegaly, abdominal distension, pain, and various degrees of dyspnea. The surgical treatment of this entity remains controversial.

METHODS

We report our experience from a retrospective analysis of 23 patients suffering from PLD who were treated with liver transplantation (LT) in our institution.

RESULTS

Liver transplantation for PLD patients with extensive hepatic involvement offers excellent symptoms relief. The actuarial 1-, 3-, and 5-year survival rate after transplantation was 86%.

CONCLUSIONS

Our experience demonstrates that PLD patients with extensive hepatic involvement and who are treated with LT have good long-term prognosis and excellent symptoms relief. LT might be considered in severe PLD cases where conventional surgery is not a curative option, and it must be balanced against the risks of LT and lifelong commitment to immunosuppression.

Research reactor fuel element corrosion under repository relevant conditions: separation, identification, and quantification of secondary alteration phases of UAl x -Al in MgCl2-rich brine

The corrosion of the UAl x -Al research reactor fuel type in synthetic MgCl2-rich brine (static batch-type experiments) was investigated with respect to the long-term safety of directly disposed research reactor fuel elements in salt formations. During corrosion, crystalline secondary phases were formed, which may serve as a barrier against radionuclide migration. For an optimized identification and quantification of the secondary phases using X-ray diffraction, a sample treatment to separate and enrich the secondary phases is necessary. A grain size fractionation was carried out in iso-propanol. A chemical composition and phase characterization of the secondary phases was accomplished. The results of the chemical investigations reveal that only traces of Al and U were dissolved. The separation and enrichment of secondary phases were carried out reproducible and successfully. Due to the phase characterization by scanning electron microscopy/energy dispersive X-ray spectroscopy and X-ray diffraction the following secondary phases were unambiguously identified: Mg-Al-Cl layered double hydroxide, lesukite, Fe layered double hydroxide (green rust), lawrencite, Fe (elemental), and traces of uncorroded fuel (UAl4). The quantitative analysis showed that LDH compounds and lesukite are the major crystalline phases. All other observed compounds were only present in trace amounts, i.e. constituting accessories. The Rietveld analysis also revealed the high content of amorphous phases of approximately 30%, which are expected to include the uranium as U(OH)4.

Everolimus and early calcineurin inhibitor withdrawal: 3-year results from a randomized trial in liver transplantation

The feasibility of de novo everolimus without calcineurin inhibitor (CNI) therapy following liver transplantation was assessed in a multicenter, prospective, open-label trial. Liver transplant patients were randomized at 4 weeks to start everolimus and discontinue CNI, or continue their current CNI-based regimen. The primary endpoint was adjusted estimated GFR (eGFR; Cockcroft-Gault) at month 11 post randomization. A 24-month extension phase followed 81/114 (71.1%) of eligible patients to month 35 post randomization. The adjusted mean eGFR benefit from randomization to month 35 was 10.1 mL/min (95% confidence interval [CI] -1.3, 21.5 mL/min, p = 0.082) in favor of CNI-free versus CNI using Cockcroft-Gault, 9.4 mL/min/1.73 m(2) (95% CI -0.4, 18.9, p = 0.053) with Modification of Diet in Renal Disease (four-variable) and 9.5 mL/min/1.73 m(2) (95% CI -1.1, 17.9, p = 0.028) using Nankivell. The difference in favor of the CNI-free regimen increased gradually over time due to a small progressive decline in eGFR in the CNI cohort despite a reduction in CNI exposure. Biopsy-proven acute rejection, graft loss and death were similar between groups. Adverse events led to study drug discontinuation in five CNI-free patients and five CNI patients (12.2% vs. 12.5%, p = 1.000) during the extension phase. Everolimus-based CNI-free immunosuppression is feasible following liver transplantation and patients benefit from sustained preservation of renal function versus patients on CNI for at least 3 years.

Estimated organ donor potential in German maximum care hospitals

BACKGROUND

The decreasing number of organ donors in Germany remains a major issue in transplantation medicine. The aim of this study was to estimate the organ donor potential at German maximum care hospitals.

METHODS

To critically review potential in comparison with organ donation rates in 2010. We separated Maximum care hospitals into university institutions (A-level) and centers with a neurosurgical unit (B-level) based upon the size of hospital as indicated by the total number of beds. To estimate the number of possible organ donors, we adopted the American model previously published by Sheehy et al: the potential was 0.015 organ donors/bed/year for hospitals with more than 350 beds.

RESULTS

In 2010 overall in Germany there were 1296 organ donations resulting in 4205 transplanted organs. University hospitals realized 397 organ donations namely 0.008 organ donors/bed/year (57% of calculated organ donor potential), whereas B-level hospitals accounted for 555 of organ donors with a rate of 0.007 organ donors/bed/year (48% of calculated organ donor potential). Large variations in realizing organ donations occurred among single hospitals.

CONCLUSION

Our results indicated a substantial potential to increase organ donation rates in German maximum care hospitals. These hospitals (n = 145) are responsible for 73% (non-maximum care hospital n = 1195) of the absolute organ donor pool. Further studies are needed to evaluate possibilities to address the organ shortage particularly with regard to donor detection in intensive care units and also the refusal rate by families.

[Orthotopic liver transplantation for polycystic liver disease with massive hepatomegaly]

HISTORY

A 51-year-old man (126 kg, 192 cm) with massive hepatomegaly causing cardiopulmonary symptoms was referred to our transplant center 14 years after initial diagnosis of polycystic liver disease.

TREATMENT AND COURSE

Uneventful hepatectomy was followed by orthotopic liver transplantation using caval replacement. Donor liver came from a 73-year-old woman (extended criteria donor organ offer). A portocaval shunting was not established during transplantation although the explanted liver weighed 22 kg. 18 months after transplantation liver function is stable and the patient enjoys normal quality of life.

CONCLUSION

This case report demonstrates the value and success of transplantation for patients suffering from enormous hepatomegaly due to polycystic liver disease.

The influence of non-osteogenic factors on the expression of M-CSF and VEGF during fracture healing

INTRODUCTION

Macrophage colony stimulating factor (M-CSF) as well as vascular endothelial growth factor (VEGF) play an important role in bone homeostasis and in the process of fracture healing. To date, limited data regarding the influence of age, gender, diabetes, smoking, and alcohol consumption on the systemic expression of M-CSF and VEGF after long bone fracture exist.

METHODS

From a total of 113 patients with long bone fractures 51 patients met inclusion criteria and were finally enrolled in this study. Patient's serum was collected over a period of 6 months following a standardised time schedule. M-CSF and VEGF serum concentrations were measured. Patient's history with special focus on cigarette smoking, diabetes mellitus, and regular alcohol intake was recorded. All patients were followed up clinically and radiologically for at least 24 weeks after trauma. A total of 22 male and 29 female patients formed the study population.

RESULTS

The present results show significantly elevated mean overall M-CSF serum concentration in women, older patients as well as in non-smoking individuals. The mean overall VEGF serum concentration was significantly higher in women, older patients, and diabetic individuals as well as in non-smokers. Statistically significant differences were not observed at any time point regarding alcohol consumption.

CONCLUSION

These results suggest that age, gender, diabetes mellitus and cigarette smoking significantly influence the expression of M-CSF and VEGF after fracture of long bones in human. Of note, diabetic patients showed significantly elevated overall VEGF levels when compared to non-diabetic patients. Therefore, further studies with larger patient cohorts are needed to better understand the influence of these endogenous and exogenous factors on the expression of the osteogenic during human fracture healing.

Regulation of forkhead box O1 (FOXO1) by protein kinase B and glucocorticoids: different mechanisms of induction of beta cell death in vitro

AIMS/HYPOTHESIS

In steroid diabetes insulin secretion does not adequately compensate for enhanced hepatic gluconeogenesis and peripheral insulin resistance. Previous studies suggest that activation of the transcription factor forkhead box O1 (FOXO1) contributes to glucocorticoid-induced beta cell death. This study examines the role and regulation of FOXO1 in insulin-secreting cells.

METHODS

INS-1E cells and mouse islet cells were cultured in the presence of dexamethasone. Signalling pathways were modified pharmacologically or by small interfering (si)RNA-mediated inhibition of protein synthesis. Changes in protein abundance and phosphorylation were analysed by western blotting, and subcellular localisation was assessed using confocal microscopy. Transcript levels were examined by RT-PCR.

RESULTS

Surprisingly, downregulation of FOXO1 by siRNA did not affect dexamethasone-induced apoptosis or Bim expression, but it prevented the effects of the pan protein kinase B (AKT) inhibitor (Akti-1/2). Indeed, dexamethasone and Akti-1/2 synergistically increased beta cell death and Bim expression. Akti-1/2 triggered dephosphorylation and nuclear translocation of FOXO1. Glucocorticoid-receptor activation stimulated Foxo1 transcription, but FOXO1 phosphorylation was unchanged and the cytosolic concentration of FOXO1 remained high in relation to its nuclear concentration. However, subcellular fractionation revealed a significant increase in both cytosolic and nuclear FOXO1 compared with untreated cells. Dexamethasone diminished Pdx1 mRNA level, an effect which was not reversed by siRNA against Foxo1. Downregulation of AKT isoforms and serum/glucocorticoid-regulated kinase 1 (SGK1) suggests that only sustained suppression of all three AKT isoforms caused dephosphorylation and nuclear accumulation of FOXO1.

CONCLUSIONS/INTERPRETATION

This study reveals that FOXO1 is not the main mediator of glucocorticoid-receptor-induced beta cell apoptosis, but rather that it escalates beta cell death when AKT activity is inhibited by distinct pathways.

Incarcerated diaphragmatic hernia after right hepatectomy for living donor liver transplantation: case report of an extremely rare late donor complication

Living donor liver transplantation has evolved to an indispensable surgical strategy to minimize the mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal risk of donor morbidity and mortality. A 46-year-old woman underwent right hepatectomy for living donor liver transplantation. Two and a half years after liver donation, she presented with upper abdominal pain and fullness. Radiographic evaluation revealed an incarcerated diaphragmatic hernia of the right hemithorax. After emergency laparotomy and evaluation of the right hemithorax, a partial jejunal resection was performed due to ischemic findings. The diaphragmatic hernia was repaired. Diaphragmatic hernia is a rarely reported complication of right donor hepatectomy for transplantation and should be considered to be a potential late complication.

Cholecystectomy due to symptomatic gallbladder disease after orthotopic liver transplantation: report of three cases

Although biliary stones and sludge are relatively common after liver transplantation (OLT), symptomatic cholecystolithiasis or acute cholecystitis have rarely been reported. Until the early 1990s few transplant centers preserved the donor's gallbladder for transplantation with the liver graft. This technique allows one to perform procedures, such as cholecystojejunostomy or a donor gallbladder conduit for biliary tract reconstruction, to treat posttransplant biliary complications. Herein we have reported three cases of successful either laparoscopic or open cholecystectomy for symptomatic cholecystolithiasis or acute cholecystitis between 14 and 19 years after OLT, as well as a systematic literature review.

Avulsion fracture and complete rupture of the thumb radial collateral ligament

PURPOSE

Acute grade III tears of the radial collateral ligament (RCL) of the thumb as well as certain bony avulsion fractures receive early surgical repair at our institution. The aim of this study was to evaluate if patients would benefit from this treatment algorithm at long-term.

METHODS

47 patients with RCL bony avulsion fracture or grade III RCL tear were evaluated at a median follow-up of 4.5 years (range 1-17.3 years). Grade III RCL tears were treated operatively when presenting >30° angulation in stress X-ray together with palmar subluxation of ≥3 mm. Further, avulsed bony fragments with diastasis >2 mm or fragment rotation >30°-45° in conventional X-ray underwent surgery. 6 patients with grade III RCL tear as well as 9 patients with bony avulsion underwent surgical repair.

RESULTS

At follow-up, metacarpophalangeal joint stability and pain free ROM did not differ significantly between the groups. Subjective satisfaction based on the Catalano grading system revealed excellent results in operatively and conservatively treated patients.

CONCLUSIONS

This retrospective analysis indicates that early surgical repair in severe RCL injuries is associated with unrestricted ROM, persistent joint stability, and subjective patient satisfaction. This data suggest that surgical treatment in certain RCL injuries might be a feasible therapeutic option in order to avoid chronic instability.

[Inhouse coordination to promote organ donation: a pilot project in three full-service hospitals]

BACKGROUND

There is still a lack of organ donors in Germany to provide organs for everyone on the waiting list. Against this background, the project "inhouse coordination" was initiated in 112 German hospitals in order to promote organ donation. We report the first results and experiences with this project at three full-service university hospitals.

METHODS

From April 2010 to March 2011 data on all deceased patients with primary or secondary brain damage were collected retrospectively. The analysis of anonymised data was carried out by using the Software "Transplant-check" of the German Hospital Institute, as well as in-house databases.

RESULTS

In comparison to the year before, no increase in numbers of organ donation was achieved during the study period. A total of 544 patients were deceased with a primary or secondary brain damage as main or secondary diagnosis. In 40.3 % medical contraindications prevented organ donation. In 34.5 % treatment limitation was introduced. Brain death was diagnosed in 59 of 544 patients (10.8 %) and organ donation was possible in 5.5 %.

CONCLUSION

In our analysis, a potential donor gap was noted which could not be clarified. Above all, it remains unclear in how many deceased patients with a fatal brain damage, the final diagnosis of brain death would have been possible. Even if these analyses did not lead to reliable results or conclusive evidence of organ donor potential, structural qualities were achieved in all hospitals. Ensuring the identification of potential organ donors and the accompanying support of the process should be of priority for future collaborative efforts of hospitals, transplant centers and the organ procurement organisation.

[Disposition for organ donation: analysis of a survey and trial of 974 respondents]

BACKGROUND

Due to the lack of donor organs many patients cannot be helped in time with the necessary transplantation in Germany. At the same time, there is an organ donor potential that is not being exploited. A high refusal rate with a low rate of organ donor card holders remains problematic. The objective of this study was to collect the rate of holders of organ donor cards in a collective and to evaluate the collective according to other attributes in the context of a targeted trial.

METHODS

In 2009, a three-part questionnaire including an educational text regarding the topic of "organ donation" was sent out to the employees of the Sparkasse Essen (a savings bank).

RESULTS

Altogether, 974 out of 1480 (65.8 %) completely answered questionnaires were evaluated. 21.3 % of the respondents had an organ donor card at the time the survey was carried out. A statistically significant association between gender (p value, 0.0438), age (p value, 0.0267) and the possession of a donor card could be determined. 22.1 % of the respondents who participated in sports regularly or donated blood (p value, < 0.0049), were holding an organ donor card. 60 % of the respondents found the brief information to be sufficient, 22.6 % could imagine acquiring an organ donor card for them based on the presented information alone.

CONCLUSION

The spread of information and transparency in transplant medicine are essential for the facilitation of "willingness to donate organs". In the framework of this trial, besides data analysis, also fundamental information on "organ donation" could be conveyed. After all, 95.3 % of the respondents have read the information material and hence document the success of the study.

18 TOTAL PARENTERAL NUTRITION DURING NEONATAL CARE OF THE FIRST BITRANSGENIC FEMALE BOVINE CLONE

This work describes the treatment with total parenteral nutrition (TPN) of a 37-day cloned calf after suffering ruminal acidosis by ingestion of milk. Cells for SCNT were obtained by using a bicistronic vector for human lysozyme and lactoferrin. We obtained 7 embryos and 2 pregnancies. Only one fetus was born alive weighing 47 kg and it was presented to the neonatal unit of INTA showing a deep depression, diarrhoea, dehydration (10%), hyperthermia and inability to stand (Table 1). A 20-cm-length 20-Ga-diameter catheter (Arrow) was placed in the jugular vein. Blood samples from catheter and brachial artery showed leukocytosis, hypoglycemia and metabolic acidosis (Table 1). Esophageal tube was placed to remove 5 L of ruminal content and for the administration of 2 L of a solution of sodium bicarbonate (40 g L–1 of water). Saline (NaCl, 9 g L–1), sodium bicarbonate (8.4 g/100 mL) and 10% dextrose were administered IV until dehydration; blood pH and glucose were corrected. Ceftriaxone 1 g IM/12 h (Acantex, Roche) to prevent bacterial translocation, 1.175 mg of flunixin meglumine (PharmaVet) as anti-endotoxic dose and 80 mg of ranitidine IV/12h (Vetanco) to prevent laminitis were also administered. Two litres of bovine plasma were administered during the first 2 days and, after this, we began with a TPN regimen due to lack of sucking reflex and animal anorexia. Kabiven (Fresenius Kabi AV) was administered at 1 g of lipids/kg/24 h by a regimen of 18 drops min–1 to prevent hyperlipidemia at the recommended dose for humans. For this reason, we also administered dextrose 25% 12.5 drops min–1 and amino acids 11.5% 504 mL (Rivero), to reach a dose of 10 g/kg/24 h and 2 g/kg/24 h, respectively. Saline (NaCl, 9 g L–1) and vitamin complex (Rivial Paediatrics, Rivero) was also administered to cover water and vitamin requirements. The TPN therapy lasted 24 days during which the animal regularized its metabolic functions, reversed signs of ruminal acidosis and learned to eat a balanced ration and hay. To our knowledge, no information is available on such a long period of TPN in bovine neonates. This work shows that TPN can increase the survival chances of high risk animals and thus the final efficiency of cloning and transgenesis. Table 1.Clinical and haematological responses to 24-day total parenteral nutrition in a 37-day cloned female calf The authors thank Fresenius Kavi and Rivero Laboratories for their support.

93 STRESS INDICATOR GENES EXPRESSION PATTERN IN BOVINE BLASTOCYSTS PRODUCED BY IN VITRO FERTILIZATION AND SOMATIC CELL NUCLEAR TRANSFER

Reproductive biotechnologies, such as IVF and somatic cell nuclear transfer (SCNT) enable improved reproductive efficiency of animals. However, the birth rate from in vitro derived embryos still lags behind their in vivo counterparts. It is critical to develop an accurate evaluation and prediction system of embryo competence, for commercial purposes and for scientific research. Previous works have demonstrated that in vitro culture systems induce alterations in the relative abundance (RA) of diverse transcripts compromising embryo quality. The aim of this work was to analyse the RA of a set of genes involved in cellular stress (HSP70), endoplasmic reticulum (ER) stress (BiP and PSMB5) and apoptosis (Bax and Caspase-3), in bovine blastocysts produced by IVF, SCNT and their in vivo counterparts. Poly(A) RNA was isolated from 3 pools of 10 blastocysts per treatment and analysed by real-time PCR (RT–PCR). The results were normalized to the expression of the endogenous control (GAPDH). Data of mRNA expression was analysed using the InfoStat software (Universidad Nacional de Córdoba, Córdoba, Argentina). ANOVA, followed by Tukey multiple comparison test, was used for the analysis of differences in mRNA expression assayed by quantitative RT–PCR. Differences of P < 0.05 were considered significant. The RA of 3 stress indicators shown to be significantly increased in SCNT embryos compared with in vivo-derived blastocysts: by 23.9-fold for Bax, 12.1-fold for PSMB5 and 7.9-fold for Bip. No significant differences in RA of HSP70 and Caspase-3 gene transcripts were found. The increased expression of PSMB5 and BiP suggest that the SCNT embryos were under conditions of ER stress. When ER stress conditions persist, initiation of apoptotic processes is promoted. Furthermore, the significantly elevated transcript level of Bax could imply an initial activation of the apoptotic mechanisms, but the low levels of Caspase-3 revealed that the apoptotic caspase-cascade signalling system was not activated, hence not eliciting apoptosis, so far. With regard to IVF-derived embryos, no significant differences were detected in the RA of investigated genes compared with in vivo-produced blastocysts. Even though the embryos were morphologically comparable, mRNA expression pattern was dissimilar. Differential mRNA expression in bovine blastocysts obtained by different reproductive techniques produces blastocysts of divergent quality. We propose a new set of stress-indicator genes that give a widespread idea of bovine blastocyst quality. This study could complement morphological analysis to help develop an effective and accurate technique to diagnose embryo quality, towards improving the efficiency of artificial reproductive techniques.

Hypothermic reconditioning by gaseous oxygen improves survival after liver transplantation in the pig

The quality of cold-stored livers declines with the extension of ischemic time and the risk of primary dys- or nonfunction increases. Here, we provide in vivo evidence for the efficacy of the previously developed end-ischemic gaseous oxygen persufflation technique to resuscitate liver grafts after extended storage times. Porcine livers were recovered according to standard multiorgan procurement protocol. Control livers were cold stored in histidine tryptophan ketoglutarate solution for 10 h (cold storage [CS]; n = 6) at 4°C. In the treatment group (n = 6), livers were additionally subjected to hypothermic reconditioning (HR) by gaseous oxygen persufflation via the caval vein for 2 h before transplantation. Viability was assessed by orthotopic liver transplantation and 1 week follow-up. HR significantly improved pretransplant energy charge and initial graft function after transplantation. One week survival after CS was 0% whereas five of six pigs (83%) survived in the HR group. At that time, coagulation parameters were in the normal range and histological analysis disclosed healthy liver tissue with normal trabecular architecture in the treated grafts. Molecular analyses identify the prevention of ischemia-induced decline of cellular autophagy and mitigation of innate immune machinery (high-mobility group protein B1, interferon-β) as operative mechanisms among the protective effects provided by HR.

Long-term outcomes of liver transplant patients with human immunodeficiency virus infection and end-stage-liver-disease: single center experience

Objective

Orthotopic-liver-transplantation (OLT) in patients with Human-Immunodeficiency-Virus infection (HIV) and end-stage-liver-disease (ESDL) is rarely reported. The purpose of this study is to describe our institutional experience on OLT for HIV positive patients.

Material and methods

This is a retrospective study of all HIV-infected patients who underwent OLT at the University Hospital of Essen, from January 1996 to December 2009. Age, sex, HIV transmission-way, CDC-stage, etiology of ESDL, concomitant liver disease, last CD4cell count and HIV-viral load prior to OLT were collected and analysed. Standard calcineurin-inhibitors-based immunosuppression was applied. All patients received anti-fungal and anti-pneumocystis carinii pneumonia prophylaxis post-OLT.

Results

Eight transplanted HIV-infected patients with a median age of 46 years (range 35-61 years) were included. OLT indications were HCV (n = 5), HBV (n = 2), HCV/HBV/HDV-related cirrhosis (n = 1) and acute liver-failure (n = 1). At OLT, CD4 cell-counts ranged from 113-621 cells/μl, and HIV viral-loads from < 50-175,000 copies/ml. Seven of eight patients were exposed to HAART before OLT. Patients were followed-up between 1-145 months. Five died 1, 3, 10, 31 and 34 months after OLT due to sepsis and graftfailure respectively. Graft-failure causes were recurrent hepatic-artery thrombosis, HCV-associated hepatitis, and chemotherapy-induced liver damage due to Hodgkin-disease. One survivor is relisted for OLT due to recurrent chronic HCV-disease but non-progredient HIV-infection 145 months post-OLT. Two other survivors show stable liver function and non-progredient HIV-disease under HAART 21 and 58 months post-OLT.

Conclusions

OLT in HIV-infected patients and ESLD is an acceptable therapeutic option in selected patients. Long-term survival can be achieved without HIV disease-progression under antiretroviral therapy and management of the viral hepatitis co-infection.

Neuromonitoring in a porcine model of acute hepatic failure

Cerebral oedema has been noted to occur frequently in patients dying of fulminant hepatic failure. Therefore, in the present study, multimodal neuromonitoring was evaluated in an animal model of hepatectomy. Acute liver failure was surgically induced in swine by complete hepatectomy (n = 8). Intracranial pressure monitoring via a ventricular drainage system, electroencephalogram and recording of visually evoked potentials were used to establish a continuous neuromonitoring system. Measurements of liquor and serum ammonia (NH(3)) levels were taken at later stages of the trial in an approach to widen monitoring. Serial monitoring of the electroencephalogram revealed progressive slowing of the frequency with decreasing amplitude. Monitoring of the intracranial pressure with a subdural pressure transducer demonstrated a progressive and reproducible elevation. Increase in blood NH(3) was observed. Anaesthesia was terminal. In all cases death was caused by cardiocirculatory insufficiency, confirmed by autopsy. At autopsy, brain tissue of the animals was found to be swollen showing flattened cortical gyri. In conclusion, the technique of extended neuromonitoring offers an advanced option for monitoring animal models of fulminant hepatic failure for further developments and investigations.

„Sms-the subjective mania scale“

Introduction

Non-adherence of medication still is a major problem among patients suffering from bipolar disorders.

Objectives

Previous studies focused mainly on possible side-effects, attitudes and subjective well-being. Most scales concerning this issue have been developed by psychiatric experts and based on their knowledge not on the patients points of view.

Aims

The purpose of this study was to find out what kind of drug effects the patients themselves want.

Methods

2 focus-groups with 13 patients and In-depth interviews with 15 mania patients were conducted to collect information about subjective burden and symptoms of the illness. Content analyses of the transcriptions were performed and the results were used to develop a first draft of the questionnaire.

Results

The final German test version consists of 32 items and is called “The Subjective Mania Scale”. The study of content-validity showed that all SMS items were considered to be important by more than 50% of the sample. Test-retest reliability and sensitivity to change were evaluated. All SMS-items showed a significant change between time-point 1 and 3.

Conclusion

The SMS-rating scale is a feasible, reliable and valid instrument for clinical trials among mania patients.

Efficacy and safety of linezolid in liver transplant patients

Bacterial infections are the main cause of death within the first year after liver transplantation, and the increased incidence of multidrug-resistant gram-positive pathogens has created a major challenge in the treatment of these patients. Linezolid, the first US Food & Drug Administration-approved oxazolidinone, offers a valuable novel treatment option for serious gram-positive infections. Linezolid is relatively non-toxic but prolonged treatment with linezolid was associated with thrombocytopenia. Here we report on the experience of linezolid treatment in adult liver transplant patients, who are at an increased risk for thrombocytopenia because of hypersplenism. From November 2003 until December 2009, we evaluated the clinical course of 46 liver transplant patients (27 male/19 female) in our surgical intensive care unit. For proven or probable gram-positive infection, all patients received linezolid 600 mg intravenously every 12 h. On clinical improvement, treatment was changed to oral linezolid 600 mg twice daily. Treatment duration was 11 ± 7 days. Treatment indications were pneumonia (n = 8), blood stream infection (n = 30), and surgical site/abdominal infection (n = 3). Clinical cure was achieved in 43 out of 46 patients. During the course of treatment, no cases of severe thrombocytopenia occurred and a statistically significant platelet count increase was seen from day 1 (110 ± 73/nL) to day 7 (165 ± 116/nL) and day 14 (180 ± 140/nL). We did not observe any further adverse events, especially no severe neurological complications (e.g., serotonin syndrome) or signs of lactate acidosis. Two patients died from uncontrolled vancomycin-resistant Enterococcus faecium sepsis with septic shock and one due to uncontrolled methicillin-resistant Staphylococcus aureus pneumonia. These deaths were considered to be unrelated to linezolid treatment, and linezolid was regarded as the optimal treatment choice in these patients. A subgroup analysis of patients treated for >14 days revealed no statistically significant differences when compared with patients on shorter treatment. In particular, no cases of thrombocytopenia occurred during longer treatment. In conclusion, linezolid is a safe and effective treatment for adult liver transplant patients with gram-positive infections.

No further incidence of sepsis after splenectomy for severe trauma: a multi-institutional experience of The trauma registry of the DGU with 1,630 patients

Objective

Non-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure.

Methods

13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score > 16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)).

Results

From 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (> 10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%).

Conclusions

Non-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.

Tumor markers as a diagnostic key for hilar cholangiocarcinoma

OBJECTIVE

Hilar cholangiocarcinoma is the fourth most common gastrointestinal malignancy. CA19-9 and CEA are helpful devices in the management of gastrointestinal malignancies and belong to clinical routine in surgical oncology. But the validity of these parameters in terms of tumor extension and prognosis of bile duct malignancies still remains unclear.

METHODS

From 1998 to 2008, we obtained preoperative CA19-9 and CEA serum levels in 136 patients with hilar cholangiocarcinoma. We correlated tumor stage, resectability rate and survival with preoperative CA 19-9 and CEA serum levels.

RESULTS

CA19-9 (UICC I: 253 ± 561U/ml; UICC II: 742 ± 1572 U/ml; UICC III: 906 ± 1708 U/ml; UICC IV: 1707 ± 3053U/ml) and CEA levels (UICC I: 2.9 ± 3.8U/ml; UICC II: 4.6 ± 6.5 U/ml; UICC III: 18.1 ± 29.6 U/ml; UICC IV: 22.7 ± 53.9 U/ml) increase significantly with rising tumor stage. Patients with pre?operative serum levels of CA19-9 (>1000U/ml) and CEA (>14.4ng/ml) showed a significant poorer resectability rate and survival than patients with lower CA19-9 and CEA serum levels respectively.

CONCLUSION

CA19-9 and CEA serum levels are associated with the tumor stage. If preoperatively obtained CA19-9 and CEA serum levels are highly elevated patients have an even worse survival and the frequency of irresectability is significantly higher.

Transplantation after blunt trauma to the liver: a valuable option or just a "waste of organs"?

Objective

Liver injury due to trauma is a rare indication for transplantation. The main indications in such cases were uncontrollable bleeding and insufficient hepatic function. Because of poor results, liver transplantation in these patients is occasionally described as "waste of organs", however based on insufficient data. This study aims to report our experience and to critically question the indication of transplantation in these patients.

Methods

All liver transplantations at our institution were reviewed retrospectively. This covered 1,529 liver transplants between September 1987 and December 2008. Of them, 6 transplants were performed due to motor-vehicle accidents which caused uncontrollable acute liver trauma in 4 patients. The patients' peri-operative course, short- and long-term outcomes were analyzed.

Results

Five deceased-donor liver transplantations (4 full size, 1 split) and 1 living donor (right) transplantation were performed. The median GCS score was 9/15; the median MELD score was 15. Postoperative complications were observed in 3 patients, requiring re-operation in 2. After a median (range) follow-up of 32.95 (10.3-55.6) months, 2 patients are alive and remain well on immunosuppression.

Conclusion

Liver transplantation in patients with otherwise surgically uncontrollable acute liver injury can be indicated as a life saving procedure and can be performed successfully in highly selected cases.