Objective. In 2006, inhouse coordinators were introduced in all hospitals with intensive care units in Baden-Wurttemberg to improve organ donation. At our university hospital with a neurosurgery and a transplantation unit, we analyzed whether brain death certification and donation requests were always initiated (if possible).Materials and Methods. We retrospectively reviewed all 1312 hospital deaths from 2006-2007 by studying medical records and consulting with physicians. The possibility of organ donation was questioned.Results. Donation was requested among 68/702 deaths due to cerebral complications. A request was impossible in 8 cases. Consent for donation was obtained in 29 cases, and it was realized in 24 cases. In 14 cases of resuscitation from shock or cardiac failure, therapy was not continued because of questionable hemodynamic stability. In 17 cases admitted to peripheral wards and 19 to intensive care units death due to cerebral complications occurred within 48 hours, but medical records were not relevant for exclusion criteria for organ donation.Conclusions. The detection of donors was not acceptable. In patients without a prognosis after resuscitation, further hemodynamic stabilization was frequently omitted, because organ donation had not been considered. In cases of donation requests the refusal rate was high. We initiated specific training.

Die Organtransplantation wird als wirksame Therapie für die Behandlung der meisten Formen des Organversagens angesehen. Meilensteine prägten ihre Geschichte. Ständig weiterentwickelte Immunsuppressiva aber auch die verbesserte Organkonservierung, chirurgische Techniken sowie das peri- und postoperative Management konnten die Ergebnisse der klinischen Organtransplantation bis Ende des 20. Jahrhunderts in allen Bereichen deutlich verbessern. Bis dahin waren weltweit mehr als eine halbe Millionen Menschen transplantiert worden. Dabei überwiegen zahlenmäßig die Transplantationen im Bereich der abdominellen Organe, insbesondere von Niere, Leber und Pankreas. An thorakalen Organen sind international mehr als 50000 Herzen und mehr als 10000 Lungen transplantiert worden. Die Ergebnisse vereinzelt durchgeführter xenogener Organtransplantationen in der letzten Hälfte des vergangenen Jahrhunderts waren hingegen ernüchternd. So wird sich die Zukunft der klinischen Xenotransplantation an den Verbesserungen der genetischen Modifikation der Transplantate entscheiden. Allerdings können weder die zunehmende Lebendorganspende von Niere und Leber noch die Weiterentwicklung technischer Möglichkeiten bzw. extrakorporaler Organersatzverfahren dem steigenden Bedarf an Transplantaten und Geweben gerecht werden. Deshalb sind vermehrte Anstrengungen vor allem in der Organspende notwendig, um das Defizit an transplantierbaren Organen langfristig besser ausgleichen zu können.

ZusammenfassungOrganspende ist eine Gemeinschaftsaufgabe der Krankenhäuser und der Transplantationszentren. Die Deutsche Stiftung Organtransplantation (DSO) wurde mit der bundesweiten Koordinierung des Organspendeprozesses betraut (Koordinierungsstelle). Aufgabe der DSO ist u.a. durch Entnahme und Bereitstellung geeigneter Spenderorgane die gesundheitlichen Risiken der Organempfänger so gering wie möglich zu halten („Empfängerschutz“) und die dazu notwendigen Untersuchungen sicher zu stellen. Diese umfassen Organfunktionsprüfungen, Immunologie, Virologie, Bakteriologie, Blutgruppenbestimmung und Pathologie. Unabdingbar sind außerdem eine sorgfältige Anamneseerhebung und die daraus folgende Abklärung aller Anhaltspunkte für ein erhöhtes Übertragungsrisiko durch Vorerkrankungen des Spenders.

Background: The knowledge of the relationship between oxygen delivery (DO2) and oxygen consumption (VO2) of the liver is of major importance to understand liver dysfunction in postaggression metabolism. Using the freely diffusible tracers [O-15] H2O and [O-15]O-2 in combination with the Positron Emission Tomography (PET), it is possible to quantify the arterial (f(a)) and portal venous (f(p)) hepatic blood flow as well as the VO2 on a regional basis. [O-15] CO binds to hemoglobin with high affinity and, therefore, labels red blood cells. In combination with PET, [O-15]CO allows the localization of larger vessels, especially the portal vein, within the field of view. This study was performed to explore the potential of [O-15] H2O, [O-15] O-2 and [O-15] CO PET in the measurement of the hepatic oxygen consumption. Methods: Liver blood now and oxygen uptake was investigated in 6 anaesthetized pigs. The hepatic DO2 was calculated as the product of the regional f(a) and f(p) (measured by [O-15] H2O PET) and the O-2-content of the arterial and portal venous blood. To investigate the reliability of this PET method over a wide flow range, segmental arterial flow reductions were induced by occlusions of several branches of the hepatic artery of varying size and localization yielding different degrees of arterial flow impairment. The portal venous blood flow was not mechanically impaired. Before and after arterial occlusion, the liver tissue's oxygenation (TPO2) was measured directly using a needle electrode system (Eppendorf pO(2)-Histograph) to allow comparisons with the regional DO2 and VO2. After bolus injection of approx. 2.2 GBq [O-15] H2O, f(a) and f(p) were measured by a 10-min dynamic PET scan. The oxygen uptake was determined after inhalation of 3 GBq [O-15] O-2. After inhaltation of 3 GBq [O-15] CO, a 10-min PET scan followed to localize the portal vein. Kinetic parameters for f(a), f(p) and oxygen uptake were estimated from tissue, arterial and portal venous blood activity curves using an extended one tissue compartment model to account for the dual blood supply. The resulting flow estimates were then compared with microspheres reference blood flow measurements obtained from multiple liver tissue samples (post mortem). Results: The regional VO2 of the liver was determined as 0.048 +/- 0.03 und in occluded and 0.08 +/- 0.021 in normally perfused regions [ml O-2/(min . cm(3))] (mean +/- SD). A highly significant hyperbolic relationship was found between DO2 and VO2 (r(2) = 0.65; p < 0.001), reflecting the well known relation of these parameters for the liver as a whole. In hypoxic arterially occluded regions (TPO2 6.4 +/- 3.9 mm Hg), the mean oxygen extraction increased to 79%, while in normally perfused regions (TPO2 23.8 +/- 6.7 mm Hg), the O-2-extraction was found to be 40%. Conclusion: Combining [O-15] H2O, [O-15] O-2 and [O-15] CO PET allows the estimation of the hepatic VO2 on a regional basis. For the first time, it is possible to investigate pathophysiological aspects of the oxygen consumption during liver failure (i.e. shock, sepsis, cirrhosis, transplant dysfunction) including possible pharmacological influences.

Die Lokalisation und Quantifizierung einer Leberhypoxie ist bislang mit klinischen Methoden nicht möglich, könnte jedoch für die Beurteilung chronischer Lebererkrankungen, für das „Follow-up“ nicht resezierender Therapieverfahren bei primären und sekundären Lebertumoren sowie für die diagnostische Evaluation von Lebertransplantatfunktionstörungen von Bedeutung sein. Herkömmliche Verfahren wie die Leberfunktionsszintigraphie, die Doppler-Flowmetrie und die selektive Leberarterienangiographie erlauben lediglich semiquantitative Aussagen zu regionalen Perfusionsverhältnissen. Mit [18F]Fluormisonidazol (18FMISO) steht ein geeigneter PET-Tracer zur Visualisierung einer Gewebe- [1, 2] und Tumorhypoxie [3, 4] zur Verfügung. Misonidazol unterliegt als Nitroimidazolverbindung einer intrazellulären Radikalbildung. Unter aeroben Bedingungen ist diese Radikalbildung durch Reoxidierung zu einem diffusiblen Molekül reversibel, da Sauerstoff als Elektronenakzeptor zur Verfügung steht. Unter hypoxischen Bedingungen kommt es hingegen zu einer intrazellulären Anreicherung von Misonidazol, da es zu einer kovalenten Bindung an intrazelluläre Makromoleküle kommt. Aufgrund der physiologischen Metabolisierung von Misonidazol in der Leber wurde die Anwendung von 18FMISO als Hypoxie-tracer bei Lebererkrankungen eher zurückhaltend beurteilt. Jedoch verändert sich der hepatische Metabolismus von 18FMISO sobald hypoxische Verhältnisse herrschen [5].

In 1982 Weinstein coined the term HELLP syndrome to describe a special form of pre-eclampsia where haemolysis, elevated liver enzymes and low platelets are observed. HELLP syndrome is associated with high fetal and maternal lethality. Spontaneous hepatic rupture is a rare but always severe complication and requires immediate surgical intervention. Two case reports illustrate the severity of this complication and present therapeutical options.

In 1982 Weinstein coined the term HELLP syndrome to describe a special form of pre-eclampsia where haemolysis, elevated liver enzymes and low platelets are observed. HELLP syndrome is associated with high fetal and maternal lethality. Spontaneous hepatic rupture is a rare but always severe complication and requires immediate surgical intervention. Two case reports illustrate the severity of this complication and present therapeutical options.

Alkoholmiβbrauch ist die häufigste Ursache einer Leberzirrhose. In vielen Transplantationszentren werden Alkoholiker nicht akzeptiert, weil zum einen ein Alkoholrezidiv nach Transplantation gefürchtet und zum anderen eine fehlende Einsichtsfähigkeit angenommen wird. Zudem könnten extrahepatische alkoholinduzierte Organkomplikationen die Ergebnisse belasten. In einigen Zentren wurden jedoch gleiche Überlebensraten nach Lebertransplantation bei alkoholischer Leberzirrhose und bei nicht alkoholbedingten Lebererkrankungen beobachtet. Die Ergebnisse waren sogar noch besser bei den Patienten, die nach psychologischer Einschätzung nicht rückfallge-fährdet erschienen. Im Endstadium einer alkoholbedingten Lebererkrankung kann die Indikation zur Lebertransplantation gestellt werden, wenn die Patienten hochmotiviert sind, abstinent bleiben wollen und ihr soziales Umfeld in dieser Hinsicht unterstützend wirkt. Es gibt keine ethischen oder medizinischen Begründungen, so ausgewählten Patienten eine Lebertransplantation vorzuenthalten, auch bei derzeit begrenztem Organangebot.

The dual blood supply of the liver allows embolization therapy of malignant liver tumors nearly complete supplied by arterial vessels. The last three years we treated 25 patients with hepatocellular carcinoma by transcatheter arterial chemotherapy using iodized oil and anticancer agents suspension. The survival rate of untreated patients ranges between 1.6 and 2.5 months. Five patients died within two weeks to 9.7 months following embolization. Twenty of these patients are alive with survival rates of 1 to 22.9 months following the procedure. Because of the low procedural morbidity, transcatheter embolization is superior to surgical dearterialization or systemic chemotherapy.

The dual blood supply of the liver allows embolization therapy of malignant liver tumors nearly complete supplied by arterial vessels. The last three years we treated 25 patients with hepatocellular carcinoma by transcatheter arterial chemotherapy using iodized oil and anticancer agents suspension. The survival rate of untreated patients ranges between 1.6 and 2.5 months. Five patients died within two weeks to 9.7 months following embolization. Twenty of these patients are alive with survival rates of 1 to 22.9 months following the procedure. Because of the low procedural morbidity, transcatheter embolization is superior to surgical dearterialization or systemic chemotherapy.

The double supply of the liver allows one to perform specific embolisation of liver carcinomas since these are mostly supplied arterially. According to their occlusion characteristics--central, peripheral, capillary--different embolising materials are suitable for tumour embolisation under varying conditions. Oily substances cause capillary occlusion and can be used in conjunction with chemotherapeutic agents. This study deals with the results from lipiodol-epirubicin embolisation in 25 patients with hepatocarcinomas and cholangiocarcinomas. In a three-and-a-half year follow-up period 16 of these 25 patients died, maximum survival time being 28.4 months. Survival varied from 9.2 to 28.4 months compared with a survival time of 2-8 months in untreated patients. In this case hypervascular tumours have a better prognosis than the rarer hypovascular tumours because of improved deposition and activity of the chemotherapeutic agent.

In 48 pigs the duodenogastric reflux of bile acids and lysolecithin is studied after different types of gastroduodenostomy, jejunal interposition and Roux-Y-gastroenterostomy. The intragastric concentrations of bile acids and lysolecithin were found to be pathologically elevated after gastroduodenostomy. There was no difference between end-to-end, end-to-side or supraduodenal end-to-side anastomoses. An effective reflux prevention was possible by interposition of 25 cm of isoperistaltic jejunum or by Roux-Y. A shorter (15 cm) interposition with or without an isoperistaltic invagination valve was not sufficient in normalizing reflux amounts.

In 30 pigs the prevention of duodenogastric reflux following distal gastrectomy through different types of jejunal transposition or Roux-en-Y-gastroenterostomy was studied. The reflux was measured by determination of the intragastric amounts of bile acids and lysolecithin, and by the total number of glycerophosphatids. After distal gastrectomy and proximal selective vagotomy, isoperistaltic jejunal segments of different lengths were transposed between gastric remnant and duodenum. The reflux was normalized by 25-cm segments. Shorter segments led to no significant decrease of the reflux. The jejunal invagination of additional isoperistaltic valve did not have a significant effect. The same protection as from 25-cm segments was obtained by Roux-en-Y-gastrojejunostomy. The role of the duodenogastric reflux following gastrectomy for the gastric mucosa is disucssed. The necessity of the reparation of the pyloric function is shown.

Summary In 36 pigs the intragastric C14 bile acid reflux and the concentration of lysolecithin is measured following different types of hemigastrectomy and gastroduodenostomy. Termino-terminal, termino-lateral and supraduodenal termino-lateral anastomosisses were as well studied as an isoperistaltic jejunal transposition of 15 cm resp. 25 cm length.-After all types of direct gastroduodenostomy the amounts of intragastral C14 bile acids and lysolecithin were significantly elevated. An additional jejunal transposition decrease the reflux in relation to the length of the transposed jejunal segment. The importance of the duodenogastric reflex of bile acids and lysolecithin for the development of alkaline reflux gastritis and carcinoma of the gastric stump is discussed. For clinical purpose a replacement of the pyloric reflux barrier by a primary jejunal transposition in case of pylorectomy has to be discussed.

In 36 pigs the intragastric C14 bile acid reflux and the concentration of lysolecithin is measured following different types of hemigastrectomy and gastroduodenostomy. Termino-terminal, termino-lateral and supraduodenal termino-lateral anastomosisses were as well studied as an isoperistaltic jejunal transposition of 15 cm resp. 25 cm length.-After all types of direct gastroduodenostomy the amounts of intragastral C14 bile acids and lysolecithin were significantly elevated. An additional jejunal transposition decrease the reflux in relation to the length of the transposed jejunal segment. The importance of the duodenogastric reflex of bile acids and lysolecithin for the development of alkaline reflux gastritis and carcinoma of the gastric stump is discussed. For clinical purpose a replacement of the pyloric reflux barrier by a primary jejunal transposition in case of pylorectomy has to be discussed.