Liver transplantation (OLT) has become a successful surgical therapy for terminal liver failure. We here report about long-term results of OLT in a single center over a period of 15 years. Between 1988 and 2002, 1365 adult OLTs were performed. Mean follow-up was 103 +/- 56 months. Main indications for OLT were viral-induced cirrhosis (27.1%), alcoholic liver disease (21%), tumors (15.7%) and cholestatic liver disease (14.6%). Retransplantation was necessary in 120 (9.6%) patients because of initial nonfunction (26.9%), recurrence of underlying disease (20.2%), acute and chronic rejection (16.8%) or thrombosis of the hepatic artery (16.8%). 275 patients (22.1%) died. Causes of death included recurrence of disease (32.1%), infections (21.8%), de novo malignancies (13.5%) and cardiovascular disease (11.6%). Patient survival after OLT was 91.4%, 82.5%, 74.7% and 68.2% after 1, 5, 10 and 15 years, and graft survival was 85.8%, 75.3%, 67.3% and 61.7% after 1, 5, 10 and 15 years, respectively. Patient survival after retransplantation was 81.6%, 68.8% and 57.1% and 48.0% after 1, 5, 10 and 15 years. This analysis reveals excellent long-term results after OLT achieved in a single center.

Background: Hepatic epitheloid hemangioendothelioma (HEHE) is a rare low-grade vascular tumor. Its treatment algorithm is still unclear mainly due to a lack of larger clinical experiences with detailed long-term follow-up.Material and Methods: Fifty-nine patients, reported to the European Liver Transplant Registry, were analyzed to define the role of liver transplantation (LT) in the treatment of this disease. Eleven (19%) patients were asymptomatic. Eighteen (30.5%) patients had pre-LT surgical [hepatic (7 patients) and extrahepatic (3 patients)] and/or systemic or locoregional (10 patients) medical therapy. Ten (16.9%) patients had extrahepatic disease localization before or at the time of LT. Follow-up was complete for all patients with a median of 92.5 (range; 7-369) from moment of diagnosis and a median of 78.5 (range, 1-245) from the moment of LT.Results: HEHE was bilobar in 96% of patients; 86% of patients had more than 15 nodules in the liver specimen. Early (<3 months) and late (>3 months) post-LT mortality was 1.7% (1 patient) and 22% (14 patients). Fourteen (23.7%) patients developed disease recurrence after a median time of 49 months (range, 6-98). Nine (15.3%) patients died of recurrent disease and 5 are surviving with recurrent disease. One-, 5-, and 10-year patient survival rates from moment of transplantation for the whole series are 93%, 83%, 72%. Pre-LT tumor treatment (n = 18) (89%, 89%, and 68% 1-, 5-, and 10-year survival rates from moment of LT vs. 95%, 80%, and 73% in case of absence of pre-LT treatment), lymph node (LN) invasion (n = 18) (96%, 81%, and 71% 1-, 5-, and 10-year survival rates vs. 83%, 78%, and 67% in node negative patients) and extrahepatic disease localization (n = 10) (90%, 80%, and 80% 1-, 5-, and 10-year survival rates vs. 94%, 83%, and 70% in case of absence of extrahepatic disease) did not significantly influence patient survival whereas microvascular (n = 24) (96%, 75%, 52% 1-, 5-, and 10-year survival vs. 96%, 92%, 85% in case of absence of microvascular invasion) and combined micro- and macrovascular invasion (n = 28) (90%, 72%, and 54% 1-,5-, and 10-year survival vs. 96%, 92%, and 85% in case of absence of vascular invasion, P = 0.03) did. Disease-free survival rates at 1, 5, and 10 years post-LT are 90%, 82%, and 64%. Disease-free survival is not significantly influenced by pre-LT treatment, LN status, extrahepatic disease localization, and vascular invasion.Conclusions: The results of the largest reported transplant series in the treatment of HEHE are excellent. Preexisting extrahepatic disease localization as well as LN involvement are not contraindications to LT. Microvascular or combined macro-microvascular invasion significantly influence survival after LT. LT therefore should be offered as a valid therapy earlier in the disease course of these, frequently young, patients. Recurrent (allograft) disease should be treated aggressively as good long-term survivals can be obtained. Long-term prospective follow-up multicenter studies as well as the evaluation of antiangiogenic drugs are necessary to further optimize the treatment of this rare vascular hepatic disorder.

Postoperative chylothorax after injury of the thoracic duct during esophagectomy is a rare but severe complication which may lead to serious problems such as loss of fat and proteins, and immunodeficiency. Without treatment mortality can rise to over 50%. From 1988 to 2005, we treated 10 patients with postoperative chylothorax after 409 resections of the esophagus (2.4%). Of these 10 patients nine underwent transthoracic esophagectomy with gastric pull-up to enable an intrathoracic (n = 7) or cervical (n = 2) anastomosis and one patient received a transhiatal esophagectomy with gastric pull-up and cervical anastomosis. The average amount of postoperative chylus was 2205 mL (200-4500 mL) per day. After a median postoperative interval of 10 days, relaparotomy and transhiatal double ligation of the thoracic duct was performed in nine out of 10 patients. One patient could be managed conservatively. The average amount of chylus was reduced to 151 mL per day (90.5%). Seven patients had no complications, and three suffered from postoperative pneumonia. Two of the patients with pneumonia recovered, and one died. Discharge from hospital, after ligation of the thoracic duct, was possible after a median time of 18 days (11-52). Ligation of the thoracic duct via relaparotomy appeared to be a simple and safe method to treat postoperative chylothorax.

Background and Aim:  Chemoresistance often leads to loss of the last treatment option for cancer. 2‐Methoxyestradiol (2‐ME2) has been shown to inhibit tumor growth. The aim was to examine the efficacy of 2‐ME2 on multidrug‐resistant human cells from pancreatic and gastric cancer.

Facile conversion from mechanical to bioprosthetic composite aortic root replacement

Traumatic rib and sternal fractures mostly occur in association with seat belts in car crashes without airbag deployment.1Knobloch K. Wagner S. Haasper C. Probst C. Krettek C. Otte D. et al.Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims.Ann Thorac Surg. 2006; 82: 444-450Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Lung herniation and pericardial rupture are rare concomitant injuries.2Arslanian A. Oliaro A. Donati G. Filosso P.L. Posttraumatic pulmonary hernia.J Thorac Cardiovasc Surg. 2001; 122: 619-621Abstract Full Text PDF PubMed Scopus (20) Google Scholar, 3Dato G.M. Arslanian A. Filosso P.L. Aidala E. Adduci M. Bardi G. et al.Heart herniation after blunt chest trauma.J Thorac Cardiovasc Surg. 2002; 123: 367-368Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar We report a case of traumatic extrathoracic herniation of the lung and pericardial rupture as a consequence of multiple rib fractures and sternal dislocation in a seat belted passenger in a high-velocity car crash. A 79-year-old woman was involved in a severe car crash while sitting in the back seat. Clinical examination in the emergency department showed a left flail chest with subcutaneous emphysema and a massive hematoma left lateral to the sternum. Conventional chest radiography revealed that both lungs were expanded, with bilateral areas of hyperlucency (Figure 1, A). Multislice computed tomography revealed pneumomediastinum (Figure 1, B), bilateral lung contusion, hemothorax, and a herniation of segment 3 of the left lung through a large anterior apical chest wall defect (Figure 1, C), caused by segmented fractures of ribs 1 to 5 and a sternal body fracture. The endotracheal tube was switched to a double-lumen tube, and the patient was moved to the operating room, where left posterolateral thoracotomy was performed. The left lung was deflated for adequate exploration. At inspection, the lung had spontaneously retracted to the pleural cavity, and ribs 1 through 5 were fractured multiply at the chondrosternal junctions and along the anterior axillary line. A pericardial rupture was seen at the apical portion as a result of sternal dislocation without luxation of the heart. The pericardium was left open to reduce the risk of constrictive cardiogenic shock by pericardial effusion. The ruptured internal thoracic artery was ligated. A polytetrafluoroethylene mesh (Dualmesh; W. L. Gore & Associates, Inc, Flagstaff, Ariz) was fixed to the pleura between the intact parts of the ribs lateral to the anterior axillary line and the sternum medially with interrupted 1-0 polypropylene sutures. Chest computed tomography performed on postoperative day (POD) 2 showed reintegration of the herniated lung and the mesh fitting to the anterior apical thoracic wall (Figure 2). The patient was extubated on POD 2. The further postoperative course was complicated by pneumonia; however, reintubation was not necessary. The chest tubes were removed on POD 20. Finally, the patient was discharged with no pain medication on POD 28.Figure 2Multislice computed tomographic image showing reintegration of herniated lung and mesh fitting (arrows) to anterior apical thoracic wall.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Seat belt use is recommended mainly to prevent head injuries in severe car crashes. It may, however, cause typical injuries to the lumbar or cervical spine, abdominal contents, or all three, known as seat belt syndrome. Airbag use is recommended to prevent rib, clavicle, or sternal fractures. In this case the use of the seat belt without airbag deployment led to an unstable left thoracic wall with sternal fracture, pericardial rupture, and lung herniation. Among 267 sternal fractures reported,1Knobloch K. Wagner S. Haasper C. Probst C. Krettek C. Otte D. et al.Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims.Ann Thorac Surg. 2006; 82: 444-450Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar most were located in the corpus sterni of seat-belted drivers injured in car crashes in old cars without airbags. Multiple rib fractures, lung contusions, and spinal injuries are the most frequent concomitant injuries.1Knobloch K. Wagner S. Haasper C. Probst C. Krettek C. Otte D. et al.Sternal fractures occur most often in old cars to seat-belted drivers without any airbag often with concomitant spinal injuries: clinical findings and technical collision variables among 42,055 crash victims.Ann Thorac Surg. 2006; 82: 444-450Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Pericardial rupture and lung herniation occur rarely. In future they may be diagnosed more often as a consequence of the more liberal use of multislice computed tomography.2Arslanian A. Oliaro A. Donati G. Filosso P.L. Posttraumatic pulmonary hernia.J Thorac Cardiovasc Surg. 2001; 122: 619-621Abstract Full Text PDF PubMed Scopus (20) Google Scholar As reported in this case, clinical symptoms and conventional radiography may not reveal lung herniation. Multislice computed tomography showed lung herniation but failed to demonstrate the pericardial rupture, although the pneumomediastinum served as an indicator. Pericardial ruptures may be left open if heart luxation seems unlikely, as in this case, or the pericardial sac may be partly covered with loose stitches to prevent existing or impending luxation of the heart.3Dato G.M. Arslanian A. Filosso P.L. Aidala E. Adduci M. Bardi G. et al.Heart herniation after blunt chest trauma.J Thorac Cardiovasc Surg. 2002; 123: 367-368Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Lung herniations are well described and occur mostly at the anterior part of the chest wall, presumably because a lack of muscular support. Although small herniations have been managed conservatively, most lung hernias require surgery, because they do not resolve spontaneously and complications such as incarceration should be prevented. Small defects may be closed by transcostal rib fixation, but there is a great risk of hernia recurrence.4Szentkereszty Z. Boros M. Sapy P. Kiss S.S. Surgical treatment of intercostal hernia with implantation of polypropylene mesh.Hernia. 2006; 10: 354-356Crossref PubMed Scopus (24) Google Scholar Larger defects require either complex meshing by muscular flaps or a prosthetic mesh. Because of the large thoracic wall hematoma and extended thoracic wall emphysema in this case, a muscular flap did not seem appropriate, and the mesh was applied rapidly through a posterolateral thoracotomy, reducing the risk of thoracic wall infection. As an alternative approach to open thoracotomy, hernia repair with video-assisted thoracoscopic techniques may be performed.5Reardon M.J. Fabre J. Reardon P.R. Baldwin J.C. Video-assisted repair of a traumatic intercostal pulmonary hernia.Ann Thorac Surg. 1998; 65: 1155-1157Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar For traumatic transthoracic lung herniation, open or thoracoscopic implantation of surgical mesh is suggested, because it is rapidly applicable and shows favorable perioperative and late results.

The relevance of sobriety for outcome after orthotopic liver transplantation (OLT) for alcoholic liver disease (ALD) is still discussed controversially. We conducted a retrospective analysis of 300 patients transplanted for ALD with regard to recurrent alcohol consumption, risk factors for drinking after OLT, and long-term survival. The 300 patients underwent OLT for ALD between 1989 and 2002. Median follow-up was 89 months. Incidence and severity of drinking, survival rates, and causes of death were assessed. Age, gender, duration of pretransplant sobriety, social support, presence of children, and the results of psychosomatic evaluation were analyzed for their impact on recurrent alcohol consumption after OLT. Drinking of various degrees was observed in 19% of ALD patients after OLT. Pretransplant sobriety of less than 6 months, absence of companion in life, presence of young children, and a predicted poor psychosomatic prognosis were associated with an increased risk of recurrent alcohol consumption, whereas age and gender were not independent risk factors. Survival rates of patients who resumed abusive drinking were significantly lower than survival rates of abstinent patients or patients with minor lapses. Recurrent alcoholic liver disease accounted for the vast majority of deaths among patients who resumed abusive drinking after OLT, whereas malignant tumors, infections, and cardiovascular disease were the most common causes of death among abstinent patients. In conclusion, abusive drinking after OLT is associated with poor long-term survival. Analysis of risk factors may help to identify patients with a high risk for recurrent alcohol abuse after OLT.

Thoracic duct injuries and chylous fistula are well-known complications of neck dissection, occurring in 1-2% of cases. Management of these injuries can be conservative or operative. Conservative treatment consists of fat restricted diet or total parenteral nutrition reducing the volume of chyle production. Operative management includes exploration of the neck or if necessary open thoracotomy to ligate the thoracic duct. Following cervical thoracic duct ligation only few complications like chylothorax or chylous ascites are described in the literature. To the best authors knowledge, this is the first report in the english literature describing lower-extremity lymphedema following cervical thoracic duct ligation.

Compared to primary liver transplantation (LT), the inferior results in the outcome of liver retransplantation (re-LT) continue to be a major challenge. The purpose of this study was to analyze changes in and outcomes of re-LT over a period of 15 years at the Charite Virchow Clinic. Between 1989 and 2003, we performed 1,619 LTs and 157 re-LTs (9.7%) in 1,462 patients. A total of 119 retransplants (50 females, 69 males) were analyzed after consideration of exclusion criteria: recipient age <16 years, second re-LT, primary LT as split-liver or living-related LT, or combination with renal transplantation or Whipple operation. All patients received a whole-size organ. Mean follow-up was 62 months (6 days to 187 months). The main indications for re-LT were initial nonfunction (26.9%), recurrence of viral-induced hepatitis (20.2%), or acute and chronic rejection or thrombosis of the hepatic artery (both 16.8%). The main causes of death were bacterial infections (26.0%) as well as bleeding complications or recurrence of disease (both 16.0%) within the first postoperative month. Overall, 50 out of 119 patients (42%) died after re-LT, 26 patients within the first 3 months and 38 within 1 year. Overall patient survival was 89.9% after 1 month, 78.2% after 1 year, and 67.1% after 5 years. In conclusion, our study showed good clinical results after re-LT. Apart from the changing indications for re-LT with an increasing amount of initial organ failure and hepatic artery thrombosis, the analysis also showed a decreasing amount of complications such as rejection, ischemic type biliary lesions, and recurrence of the disease with unchanged outcome over a period of 15 years.

Pulmonale Verkalkungen zeigen sich häufig in der CT der Lunge und stellen meistens Residuen bereits abgeheilter Prozesse dar. Anhand ihrer Anordnung und Morphologie kann oft Rückschluss auf ihre Genese gezogen werden. Dabei sind noduläre Verkalkungen, wie zum Beispiel bei postspezifischen Residuen, häufiger anzutreffen als flächige. Neben den durch Infektionskrankheiten ausgelösten Kalkablagerungen sind solche Phänomene jedoch auch bei anderen benignen Erkrankungen, wie zum Beispiel bei Kalziumstoffwechselstörungen, aber auch bei malignen Prozessen, wie zum Beispiel bei Bronchialkarzinomen oder bei verschiedenen pulmonal metastasierten Tumoren nachweisbar (Henk et al., Radiologe 1996; 36; 534 - 542).

BACKGROUND:The addition of mycophenolate mofetil (MMF) to the induction protocol resulted in a lower incidence of rejection episodes. However, the question whether MMF should be administered in combination with tacrolimus or cyclosporine has not been answered yet. In our study, we report on the long-term results of triple induction therapy after orthotopic liver transplantation (OLT), consisting of MMF and low-dose corticosteroids, in combination with either tacrolimus or cyclosporine.METHODS:Between March 1996 and April 1997, 120 consecutive patients, who underwent OLT at our institution, were enrolled in this study. Of these patients, 80 received triple induction therapy consisting of cyclosporine and MMF (40) or tacrolimus and MMF (40), in combination with low-dose corticosteroids, whereas the remaining 40 patients served as 'MMF-free' control group receiving dual induction therapy with tacrolimus and corticosteroids. Besides the eight-yr follow-up of patient and graft survival, clinical data were also reviewed for episodes of rejection and infection. Additionally, the early post-operative pharmacokinetics of mycophenolic acid (MPA, immunological active metabolite of MMF) were evaluated.RESULTS:Long-term results provided higher patient and graft survival after tacrolimus/MMF-based induction therapy than after cyclosporine/MMF-based induction therapy. However, the tacrolimus-based control protocol yielded similar results and, therefore, no significantly superior effect was observed when MMF was added. The same observation was made for incidence of rejection and infection episodes. AUC and C(max) of MPA increased in combination with tacrolimus compared with cyclosporine.CONCLUSIONS:Although pharmacological synergy between tacrolimus and MMF was observed, MMF showed no significant beneficial effects in the immunosuppressive induction protocol, neither in combination with tacrolimus nor with cyclosporine.

Purpose: To report the association between hepatocellular carcinoma (HCC) and hepatic focal nodular hyperplasia (FNH) and the possible impact on clinical decision-making with regard to resective approaches in patients with FNH.Material and Methods: We retrospectively analyzed the findings in 77 adult patients who underwent liver resections for FNH between October 1989 and September 2001 at our center. HCC within the confines of FNH was found in two patients. We demonstrate the magnetic resonance imaging (MRI) and macroscopic and microscopic findings.Results: Presurgical MRI demonstrated heterogeneous signal characteristics of moderately hyperintense FNH on T2-weighted images and, after IV administration of super-paramagnetic iron oxide particles, HCC in FNH was barely delineable. Both patients underwent successful right hemihepatectomy to remove the suspicious FNH with diameters of 12 and 14 cm; intralesional HCC diameters were 3 and 5 cm, respectively. Patients could be rapidly dismissed. However, one patient died after recurrence of HCC 1.5 years after surgery, whereas the other patient continues tumor-free 4 years after surgery. Alpha-feto-protein was normal in both patients.Conclusion: In FNH with rapid growth tendency and heterogenic MR appearance, surgical removal should be considered to overcome the risk of inadequate therapy in the very rare group of patients with HCC in association with FNH.

BACKGROUND:Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is a rare disease characterized by the presence of arteriovenous malformations. Hepatic involvement can lead to life-threatening conditions. MATERIAL AND METHODS:Forty patients, reported to the European Liver Transplant Registry, were analyzed to define the role of liver transplantation in the treatment of the hepatic disease form. Indications for transplantation were classified according to Garcia-Tsao: cardiac failure (14 patients), biliary necrosis causing hepatic failure (12 patients), severe portal hypertension (5 patients), cardiac failure and biliary necrosis (6 patients), cardiac failure and portal hypertension (2 patients), and cardiac failure associated with biliary necrosis and portal hypertension (1 patient). Eighteen (81%) of 22 patients had pulmonary artery hypertension. Twelve (30%) patients had pretransplant hepatic interventions. Follow-up was complete for all patients with a mean of 69 months (range, 0-230 months). RESULTS:One-, 5- and 10-year actuarial patient and graft survival rates are 82.5%. Six of the 7 pretransplant procedures performed on the hepatic artery were severely complicated. Cardiovascular function documented in 24 patients improved in 18 patients and remained stable in 5 patients; 1 patient died perioperatively of acute heart failure. Twenty-four (60%) patients had post-transplant complications, all but one occurring within the first 4 posttransplant months. Seven (17.5%) patients died perioperatively, 6 of them due to bleeding and 1 due to cardiac failure; 1 (2.5%) patient died late due to chronic rejection. There were 2 possible recurrences. Quality of life markedly improved in all 32 surviving patients. CONCLUSION:The results of the largest reported transplant series in the treatment of hepatic-based HHT are excellent. Elimination of hepatobiliary sepsis and reversal of cardiopulmonary changes dramatically improve quality of life of the recipients. LT should be proposed earlier in the course of symptomatic hepatic HHT presenting with life-threatening conditions. Palliative interventions, especially on the hepatic artery, should be avoided in view of their high (infectious) complication rate.

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominantly inherited disorder characterized by cutaneous and mucosal telangiectasias, epistaxis and arteriovenous malformations in lung, liver, central nervous system, and gastrointestinal tract. Mutations in the genes for endoglin (ENG) and for activin A receptor type II-like kinase 1 (ALK-1) have been identified to be associated with HHT. Intrahepatic manifestation in HHT might lead to the requirement of liver transplantation. We report here on 6 liver transplanted patients and 2 who were scheduled for liver transplantation due to intrahepatic HHT, in whom both genes were sequenced. Mutation analysis revealed in all patients the presence of mutations in ALK-1. In conclusion, these results are of possible prognostic value concerning the need of liver transplantation in HHT patients.

Mit dem Begriff malignes epitheloides Hämangioendotheliom wird ein seltener vaskulärer Tumor, der hauptsächlich im Weichgewebe, der Lunge und der Leber beschrieben worden ist, bezeichnet. Da die Verläufe mit und ohne Therapie sehr variabel sind, berichten wir hier unsere Erfahrungen mit der resektiven Therapie und der Lebertransplantation für diesen seltenen Lebertumor.