[Biliary fistulas and biliary congestion after hepatopancreaticobiliary surgery]. / Gallefisteln und biliäre Stauung nach hepatopankreatobiliären Eingriffen.

Biliary complications after hepatopancreaticobiliary surgery can have severe consequences for the long-term quality of life of patients. Adequate and timely diagnosis of the underlying problem by an experienced surgeon is essential. Ultrasonography, computed tomography, contrast-enhanced fluoroscopy of drains and endoscopic retrograde cholangiopancreatography (ERCP) are helpful examinations that can be employed in a step-wise approach. Early re-do surgery is indicated in the initial postoperative course. Interventional methods, such as ERCP and percutaneous transhepatic cholangiodrainage ( PTCD, plus stents and drains) offer a variety of additional therapeutic options that should be used by the experienced interventionalist in a patient-tailored interdisciplinary fashion.

High levels of procalcitonin in the early phase after pediatric liver transplantation indicate poor postoperative outcome.

BACKGROUND/AIMS: To date, no data is available about procalcitonin (PCT) levels and its relevance to morbidity and graft function in the early phase after pediatric liver transplantation (pLTx). The aim of this study was to analyse the prognostic relevance of early postoperative PCT elevations in pediatric liver recipients. METHODOLOGY: Thirty pediatric patients who underwent 32 liver transplantations were included into this observational single-center study. RESULTS: Patients with high PCT levels on postoperative day (POD) 2 had higher International Normalized Ratio values on POD 5 (p<0.05) and suffered more often from primary graft non-function (p<0.05). They also had a longer stay in the pediatric intensive care unit (p<0.01) and on mechanical ventilation (p=0.001). There was no correlation between PCT elevation and systemic infection. However, PCT levels were correlated with peak serum lactate levels immediately after graft reperfusion and elevation of serum aminotransferases on POD 1 (r2=0.61, p<0.001). CONCLUSIONS: High levels of PCT after pLTx are an early indicator of poor postoperative outcome and may reflect ischemia induced liver cell injury within the context of an ischemia- reperfusion injury.

Percutaneous treatment of biliary complications in pediatric patients after liver transplantation.

PURPOSE: Evaluation of the efficiency and safety of the percutaneous treatment of biliary complications in pediatric liver transplant recipients. METHODS: We conducted a retrospective analysis of children who underwent biliary percutaneous interventions after pediatric liver transplantation (PLT) over a 4-year period. Kind of biliary complication, interval between liver transplantation and intervention, status of the vessels, procedural interventional management, technical and clinical success, course of cholestasis, PTBD-related complications and patient survival were analyzed. RESULTS: 23 percutaneous transhepatic biliary drainages (PTBD) were placed in 16 children due to 18 biliary complications. The drains were customized individually by shortening and cutting additional holes. PTBD placement was performed with technical and clinical success in all children. 4 children received PTBD to bridge the time to retransplantation and surgical revision. One child received PTBD for successful treatment of anastomotic leakage. Long-term dilation of biliary stenoses was performed in 13 children using PTBD. One of these 13 patients showed recurrent stenosis during a median follow-up of 295 days. Bilirubin values decreased significantly after PTBD placement for biliary stenosis. One patient suffered from bacteremia after PTBD replacement. CONCLUSION: PTBD treatment for biliary complications after PLT is effective and safe.

Assessing liver function by liver enhancement during the hepatobiliary phase with Gd-EOB-DTPA-enhanced MRI at 3 Tesla.

OBJECTIVES: The purpose of this study was to evaluate the usefulness of Gd-EOB-DTPA-enhanced 3-T MRI to determine the hepatic functional reserve expressed by the model for end-stage liver disease (MELD) score. METHODS: A total of 121 patients with normal liver function (NLF; MELD score ≤ 10) and 29 patients with impaired liver function (ILF; MELD score > 10) underwent contrast-enhanced MRI with a hepatocyte-specific contrast agent at 3T. T1-weighted volume interpolated breath-hold examination (VIBE) sequences with fat suppression were acquired before and 20 min after contrast injection. Relative enhancement (RE) between plain signal intensity and contrast-enhanced signal intensity was calculated and was used to determine Gd-EOB-DTPA uptake into the liver parenchyma for patients with different MELD scores. RESULTS: RE differed significantly (p ≤ 0.001) between patients with NLF (87.2 ± 29.5 %) and patients with ILF (45.4 ± 26.5 %). The optimal cut-off value for RE to differentiate NLF from ILF was 47.7 % (AUC 0.87). This cut-off value showed a sensitivity of 82.8 % and a specificity of 92.7 % for the differentiation of the analysed groups. CONCLUSION: Gd-EOB-DTPA uptake in hepatocytes is strongly affected by liver function. Gd-EOB-DTPA-enhanced MRI and assessment of RE during the hepatobiliary phase (HBP) may serve as a useful image-based test in liver imaging for determining regional and global liver function. KEY POINTS: Hepatic uptake of Gd-EOB-DTPA is strongly affected by liver function. Relative enhancement during HBP in GD-EOB-DTPA MRI correlates with the MELD score. Assessment of relative enhancement may help improve treatment in routine clinical practice.

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.

Gelfoam for closure of large percutaneous transhepatic and transsplenic puncture tracts in pediatric patients.

PURPOSE: Evaluation of the efficacy and safety of Gelfoam for the closure of transhepatic or transsplenic parenchymal puncture tracts with large-bore sheaths in pediatric patients. MATERIALS AND METHODS: Between January 2012 and May 2013, 8 percutaneous transhepatic accesses and 3 percutaneous transsplenic accesses were closed using percutaneous Gelfoam in pediatric patients. The primary study endpoints to determine treatment efficacy and safety were patient survival, technical success defined as successful closure of the puncture tract without signs of bleeding, and complication rates. The secondary study endpoints were the occurrence of local and systemic inflammation. RESULTS: Overall survival was 100 % with a median follow-up of 256 days. The procedure was technically successful in 10 of 11 procedures. One patient suffered from bleeding, which was successfully managed by a single blood transfusion. No re-bleeding was detected during follow-up and no surgical interventions were necessary. No signs of local or systemic infections related to the Gelfoam application occurred. CONCLUSION: Percutaneous Gelfoam application is an effective and safe technique for the closure of transhepatic or transsplenic accesses in pediatric patients. KEY POINTS: Interventional closure of large transhepatic and transsplenic parenchymal accesses in children after interventional treatment is recommended to avoid bleeding. Gelfoam application does not cause artifacts in magnetic resonance imaging and does not increase the risk of local or systemic inflammation in comparison to permanent embolic agents. Thus, especially children under immunosuppressive therapy can benefit from the application of Gelfoam.

["In-situ split" (ISS) liver resection: new aspects of technique and indication]. / "In-situ-Split"- (ISS) Leberresektion: Neue Aspekte zu Technik und Indikation.

The combination of right portal vein ligation with complete parenchyma dissection ("in-situ split", ISS) for rapid hypertrophy induction of the left-lateral liver lobe is a novel strategy to convert primarily irresectable liver tumours into a resectable stage. Available data so far show a 60-80 % growth induction of the remnant liver within 7(- 9) days. Certainly, a novel concept that comprises two operations within a very short time period raises questions. Based on the very few literature reports that have been published so far, as well as our own experience, we here discuss technical issues such as the use of a plastic sheet on the resection margin, the possibility of laparoscopic dissection and the timing of the second operation. Moreover, aspects of the preoperative diagnostic work-up that is necessary are assessed. Finally, open questions, e.g., concerning the influence of preoperative chemotherapy and the use of ISS in patients with cirrhosis are evaluated. In summary, the assessment of chances and risks of this novel concept with regard to indication and technical issues helps to provide the potentially curative option of the "in-situ split" procedure to more patients with marginal or even irresectable liver tumours.

Monitoring during hepatic radiofrequency ablation (RFA): comparison of real-time ultrasound elastography (RTE) and contrast-enhanced ultrasound (CEUS): first clinical results of 25 patients.

PURPOSE: To evaluate the reliability of ultrasound elastography for delineating thermal ablation defects post-radiofrequency ablation (RFA) by comparing lesion dimensions determined by real-time elastography (RTE) with the findings of contrast-enhanced ultrasound (CEUS). MATERIALS AND METHODS: A total of 21 malignant liver tumors were percutaneously ablated using RFA. Color-coded elastography and CEUS were performed by one experienced examiner, using a 1 - 5 MHz multi-frequency convex transducer (LOGIQ E9, GE). Lesions were examined using CEUS and real-time elastography (RTE) to assess ablation defects. Measurements of lesions (long axis, short axis, and area) representing the same image plane used for elastography were taken during CEUS examination and compared to the measurements obtained from the elastograms. All measurements were performed by two independent observers. RESULTS: A statistically significant correlation in vivo between RTE and CEUS measurements with respect to the lesion's principal axis and area (r = 0.876 long axis, r = 0.842 short axis and r = 0.889 area) was found. Inter-rater reliability assessed with the concordance correlation coefficient was substantial for all measurements (ρc ≥ 0.96) Overall, elastography slightly underestimated the lesion size, as judged by the CEUS images. CONCLUSION: These results support that RTE could potentially be used for the routine assessment of thermal ablation therapies.

Percutaneous management of postoperative bile leaks with an ethylene vinyl alcohol copolymer (Onyx).

PURPOSE: The management of postoperative bile leakage is challenging especially if the leak rises from the cut surface of the liver and endoscopic treatment fails. Percutaneous transhepatic treatment of bile leaks with biliary drainage is accepted but often requires long-term placement of the drains and is associated with treatment failures. This series evaluates selective embolization of bile ducts with an ethylene vinyl alcohol copolymer (Onyx) in patients with postoperative bile leaks as an alternative treatment option. MATERIALS AND METHODS: Between January and September 2012, five consecutive patients with persistent postoperative bile leaks underwent percutaneous transhepatic Onyx application and were analyzed regarding procedural management, complications and success rates. RESULTS: The persistent bile leaks were situated at the cystic stump (after cholecystectomy, n = 2), at the cut surface of the liver (after extended liver resection, n = 2) and at the surface of the liver after surgical exploration and perihepatic abscess (n = 1). Bile drainage alone (endoscopic or percutaneous) failed in all patients and open redo-surgery was deemed potentially harmful. Bilomas were externally drained in all patients before Onyx application. For the closure of bile leaks, Onyx was injected through a microcatheter in a previously built coil nest to keep Onyx in place. All bile leaks were initially closed immediately. In the 2nd week after Onyx embolization, 2 patients showed recurrent small bile leaks without clinical symptoms. In the 4th week after Onyx application, all leaks were closed. No complications occurred. CONCLUSION: All leaking bile ducts were initially closed immediately after Onyx application. In the 2nd week after Onyx application, 2 patients showed small bile leaks without clinical symptoms. All leaks were closed in the 4th week after Onyx application.

[Surgical quality of organ retrieval in Bavaria]. / Chirurgische Qualität der Organentnahme in Bayern.

Surgical problems during organ procurement may propagate complications in the transplant recipient. Ultimately, these problems may result in the complete loss of already scarce donor organs.Donor reports (Eurotransplant donor report) of 1,492 donor organs from January 2010 to August 2012 in the German Foundation of Organ Transplantation (DSO) region of Bavaria and corresponding organ quality forms were analyzed. Surgical problems were classified into 3 categories: (I) surgical problems recognized and reported by the donor surgeon, (II) surgical problems observed by the recipient surgeon but not reported by the donor surgeon and (III) surgical problems leading to organ loss. Surgical problems during this 20-month time period were reported for 17.6 % of organs; category I in 5.5 %, category II in 11.1 % and category III in 1 %. Damage of graft vasculature in 9.1 % was the most frequently reported problem. The mean error index for individual surgeons was 16 % and one out of the five Bavarian organ procurement centers had significantly more problems in all categories (30 %). Interestingly, surgeons who performed rapid retrieval procedures had more problems with quality than surgeons who took more time. Organ retrieval is prone to surgical problems. Especially in a system of organ transport, consistent reporting of surgical problems and quality assurance is needed to maintain and to improve surgical quality.

[Abdominal organ retrieval: strategies to improve quality]. / Viszerale Organexplantation: Maßnahmen zur Verbesserung der Qualität.

The blatant problem of organ shortage leads to an increasing acceptance of organs from extended criteria donors. This increases the importance of the process of organ donation and retrieval. A working group of representatives of Bavarian retrieval surgeons and the procurement organization German Foundation of Organ Transplantation (DSO) was initiated to develop consensus-based recommendations for quality improvements in the field of organ retrieval on the basis of regional data. The main aim was to professionalize retrieval teams by specified training standards and to define objective qualifications for retrieval surgeons. Initial measures of the working group included agreement on standardized retrieval techniques and improvement of documentation in terms of quality forms and the return rate of the forms. Quality data are being analyzed prospectively with a new categorization of complications. Communication among centers and teams and complication reporting has already been improved and initial structural changes have been set up.

[Percutaneous thrombus aspiration and thrombolysis for the treatment of acute portal vein thrombosis in a 5-year-old child]. / Akute Pfortaderthrombose bei einem 5-jährigen Kind: Rekanalisierung mittels perkutaner Thrombenaspiration und Thrombolyse.

Early portal vein thrombosis is a frequent and severe complication following pediatric liver transplantation. The clinical presentation is characterized by signs and symptoms of portal hypertension such as ascites and digestive hemorrhage. Primary treatment consists of heparin therapy. In the case of persistent or progressive thrombosis or symptoms, surgical thrombectomy or retransplantation should be considered. However, surgical intervention is associated with significant morbidity and mortality. We report on successful minimally invasive percutaneous thrombus aspiration and thrombolysis for the treatment of acute portal vein thrombosis in a 5-year-old child post liver transplantation.

Dynamic evaluation and quantification of microvascularization during degradable starch microspheres transarterial Chemoembolisation (DSM-TACE) of HCC lesions using contrast enhanced ultrasound (CEUS): a feasibility study.

PURPOSE: To evaluate the time dependent changes of microcirculation in hepatocellular carcinoma (HCC) lesions during degradable starch microsphere (DSM)-TACE using contrast enhanced ultrasound (CEUS). MATERIALS AND METHODS: A total of 48 CEUS examinations were performed (1-5 MHz, convex probe) in 6 selected patients who underwent DSM-TACE with EmboCept®S for the treatment of HCC lesions. I.v. application of ultrasound contrast media was performed before and 24 hours post embolization. In addition i.a. contrast application was performed via the angiographic catheter right before and after the embolization and during a follow up time of 2 hours every 30 minutes. The capillary circulation of the treated HCC lesions was analyzed and quantitative perfusion analysis was performed using a perfusion software by two experienced radiologists in consensus. RESULTS: A significantly reduced microvascularization was seen right after DSM-TACE in all cases using CEUS. The reduction of PEAK, RBV (regional blood volume) and RBF (regional blood flow) compared to preembolization values was highly significant. Mean PEAK was 34.3 ± 13.1 prior to embolization and 9.4 ± 9.1 post embolization (p < 0.001). Mean RBV was 446.5 ± 122.4 prior to embolization and 70.9 ± 23.8 post embolization (p < 0.001). The corresponding figures for RBF were 34.7 ± 13.4 prior- and 4.8 ± 3.4 post embolization (p < 0.001). During follow up a stepwise revascularization of the lesions was documented: 90 minutes post embolization perfusion parameters were not significantly different from prae-embolization values. CONCLUSION: In this feasibility study, capillary perfusion quantification of HCC lesions after DSM-TACE could be demonstrated using CEUS. Using quantitative perfusion analysis it was possible to quantify the transient embolizing effect of DSM-TACE.

[Current developments in liver transplantation in Germany: MELD-based organ allocation and incentives for transplant centres]. / Aktuelle Entwicklungen der Lebertransplantation in Deutschland: MELD-basierte Organallokation und "incentives" für Transplantationszentren.

Liver transplantation represents a successful and well-established therapeutic concept for patients with advanced liver diseases. Organ donor shortage continues to pose a significant problem. To ensure fair and transparent allocation of too few post-mortem grafts, the model of end-stage liver disease (MELD)-based allocation was implemented in December 2006. This has decreased waiting list mortality from 20 to 10 % but at the same time has reduced post OLT survival (1-year survival from almost 90% to below 80%), which is largely due to patients with a labMELD score > 30. Following MELD introduction the regular allocation threshold has increased from a matchMELD of initially 25 to meanwhile 34. At the same time the quality of donor organs has seen a continuous deterioration over the last 10 - 15 years: 63% of organs are "suboptimal" with a donor risk index of > 1.5. Moreover, the numbers of living-related liver transplantations have decreased. In Germany incentives for transplant centres are inappropriate: patients with decompensated cirrhosis, high MELD scores and high post-transplant mortality as well as marginal liver grafts are accepted for transplantation without the necessary consideration of outcomes, and against a background of the still absent publication and transparency of outcome results. The outlined development calls for measures for improvement: (i) the increase of donor grafts (e. g., living donation, opt-out solutions, non-heart beating donors), (ii) the elimination of inappropriate incentives for transplant centres, (iii) changes of allocation guidelines, that take the current situation and suboptimal donor grafts into account, and (iv) the systematic and complete collection of transplant-related data in order to allow for the development of improved prognostic scores.

Contrast-enhanced ultrasound improves real-time imaging of ablation region during radiofrequency ablation: preliminary results.

PURPOSE: To assess the added value of depicting tumour microvascularisation, using dynamic contrast enhanced (CEUS), during radiofrequency ablation, as a means of achieving a complete ablation (CA) of malignant liver lesions. MATERIAL AND METHODS: 18 consecutive patients (2 female, 16 male, age range 52-79 years, mean 64.1 ± 9.9 years) with 22 histologically confirmed hepatic malignancies (HCC: n = 10, liver metastases: n = 12) underwent RFA. Before RFA treatment, conventional US, CEUS and contrast enhanced CT (ceCT) of the liver were performed. During the CT-guided RFA procedure, CEUS was performed to asses the ablation defect. In case of partial ablation a subsequent ablation was performed with a corrected electrode position and evaluated again using CEUS. This procedure was repeated until a CA was achieved. The number of ablations per patient was recorded. Secondary efficacy parameters assessed were lesion detectability in the different imaging modalities and contrast phases. RESULTS: Overall intraprocedural CEUS led to a change in therapeutic management in 59% of cases, resulting in 17 additional ablation cycles. Lesion detectability during CT Fluoroscopy was the sole statistical significant predictor of incomplete ablations (p = 0.008). The mean number of ablations for detectable lesions was 1.27 vs. 2.27 ablations for not detectable lesions (p = 0.002). The combined CT and CEUS RFA procedure led to a CA for all treated lesions in follow up 3 month post intervention. CONCLUSION: CEUS does allow a reliable and immediate assessment of therapeutic efficacy of percutaneous RFA procedures of malignant liver lesions, through the continuous dynamic evaluation of tumour microcirculation.

Characterization of microvascularization of liver tumor lesions with high resolution linear ultrasound and contrast enhanced ultrasound (CEUS) during surgery: First results.

AIM: Evaluation of high resolution linear ultrasound and intra-operative linear contrast enhanced ultrasound (CEUS) and its benefit for the detection and characterization of tumor lesions. MATERIAL AND METHODS: Twenty patients were investigated preoperatively regarding tumor detection using CT (n = 8) or MRI (n = 12) and image fusion (VNav) (n = 3). All patients had surgery for their hepatic tumor (hepatocellular carcinoma (HCC), cholangiocellular carcinoma (CCC), metastasis, and adenoma). Ultrasound was performed intra-operatively first with B-scan using a convex probe. Than multifrequency linear transmitters (6-9 MHz, 6-15 MHz, LOGIQ E9, GE) were applied for B-scan, coulor coded Doppler sonography (CCDS) and Power Doppler followed by dynamic CEUS with Contrast Harmonic Imaging (CHI) after bolus injection of a maximum of 15 mL SonoVue®. RESULTS: In 9 cases with the use of intra-operative CEUS additional tumor lesions (diameter 4-15 mm) could be detected and were histologically confirmed after surgical resection (7 cases) or intra-operative biopsy (2 cases). Using intraoperative CEUS 64 tumor lesions could be detected compared to 51 tumor lesions detected by preoperative CT or MRI (p < 0.05). Using the 6-15 MHz multifrequency linear transducer with CHI, arterial perfusion of adenomas, neuroendocrine metastases and HCC lesions was detectable. In 3 cases a resection was not achievable. Two of these cases were treated with radio frequency ablation (RFA). The other case had no curable option due to multifocal tumor manifestation. CONCLUSION: The intra-operative use of high-resolution linear transducer techniques with CEUS offers new diagnostic perspectives for an effective liver surgery.

[Surgical treatment of liver metastases]. / Chirurgische Therapie von Lebermetastasen.

The treatment of liver metastases has become more and more complex in recent years. More individualized therapeutic concepts have become feasible by the increase in different treatment options (surgical, interventional and oncological). In the field of surgery the definition of resectability could be broadened. More extensive liver resections are being performed, which are partly carried out as staged resections after neoadjuvant chemotherapy in combination with portal vein embolization (PVE), radio frequency ablation (RFA) or other procedures in order to increase complete resection rates and patient survival. Consequently the overall 5 year survival rate of patients with resected colorectal liver metastases has doubled from 30% to nearly 60% in the past decade. Due to the complexity of the different treatment approaches an interdisciplinary assessment of the individual patient in experienced centers is necessary.

[Hepatic trauma. Interventional and conservative therapy]. / Lebertrauma. Interventionelle und konservative Therapie.

The non-operative management of hemodynamically stable patients with liver trauma has become the standard of care. Non-operative treatment has a success rate of >80%. In the majority of cases of hemodynamic instability or high grade liver injuries, however, a surgical approach is necessary. As for conservative treatment of liver trauma the surveillance of patients in the ICU is of utmost importance. Repeat CT scans are only necessary in patients with high grade injuries or in case of complications. Interventional procedures, such as the endoscopic retrograde cholangiopancreatography in cases of biliary complications or angiography for vascular complications, are increasingly being used in order to avoid surgery. The success rates of non-operative strategies have been improving continuously over the last decades.