Impact of model for end-stage liver disease score on long-term survival following liver transplantation for hepatocellular carcinoma.

BACKGROUND AND AIMS: Survival rates after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) have significantly increased after Milan criteria and Model for End-Stage Liver Disease (MELD) score implementation. However, few studies have reported this survival in countries with organ donor shortages over a period of 10 years and long waiting lists. METHODS: This retrospective analysis of clinical data from 93 consecutive HCC patients who underwent OLT from June 2001 to September 2011 excluded 22 who underwent living donor liver transplantation (LDLT). Seventy-one deceased donor liver transplantations (DDLT) were evaluated before and after the MELD era. Kaplan-Meier analysis was used to plot survival rates. The follow-up was 2 months to 10 years. RESULTS: The overall survival and recurrence rates at 10 years were 67% and 12.2%, respectively. After MELD, patient survival at 5 years decreased from 70% to 64% and the recurrence rate decreased from 15.3% to 12.5%. The most frequent recurrence sites were lung and liver. CONCLUSION: In our center MELD score implementation had a small impact on long-term survival post OLT for HCC.

Vascular complications after living donor liver transplantation: a Brazilian, single-center experience.

BACKGROUND: In living donor liver transplantation (LDLT), vascular complications are more frequently seen than in deceased donor transplantation. Early arterial, portal vein, or hepatic vein thromboses are complications that can lead to graft loss and patient death. The aim of this study was to assess the incidence, treatment, and outcome of vascular complications after LDLT in a single Brazilian center. METHODS: Between December 2001 and December 2010, we performed 130 LDLT. Sixty-four recipients were children (27 weighing <10 kg). RESULTS: Nine recipients had vascular complications. Hepatic artery thrombosis (HAT) occurred in 4 (3.1%), portal vein thrombosis (PVT) in 3 (2.3%), and hepatic vein thrombosis (HVT) and hepatic arterial stenosis (HAS) in 1 (0.8%) patient each. Complications were identified by Doppler and confirmed by angiography or angiotomography. Patients with HAT were listed for retransplantation. One died before retransplant. Two children were submitted to retransplantation; one is still alive, with neurologic sequelae. One adult with HAT was retransplanted with a deceased donor graft and is doing well 58 months after surgery. Two patients with PVT died as a consequence of graft malfunction. In the other case, portal vein arterialization was performed, but patient died 11 months posttransplant. HVT was detected after cardiac reanimation and was treated with an endovascular stent. This patient died 3 months after LDLT. HAS was diagnosed after liver abscess development and was successfully treated by endovascular angioplasty. No recurrence was observed after 22 months. Follow-up ranged from 9 to 117 months. CONCLUSION: Pediatric patients are more prone to develop vascular complications after LDLT. Long-term survival was statistically lower for recipients with vascular complications (33.3% vs 77.7%; P = .008).

Surgical complications in 100 donor hepatectomies for living donor liver transplantation in a single Brazilian center.

The rising demand for liver transplantation has continued to outspace the availability of deceased donor organs, leading to the need for other treatment options including living donor liver transplantation (LDLT). A precise evaluation of surgical complications is the most important issue in this setting. There are controversies about donor morbidity with reports ranging from 13%-75%. The aim of this study was to retrospectively analyze 100 LDLTs performed in a single Brazilian center from December 2002 to August 2008, stratifying the complications according to Clavien's scoring system. None of the donors experienced life-threatening complications or died. The majority of donors (n = 74) did not suffer any complication. Twenty-eight complications were observed in 26 patients. Fifty-seven hepatectomies were performed for adult and 43 for pediatric transplantations. According to the Brisbane classifications, we performed 49 right and 2 left hepatectomies as well as 49 left lateral segmentectomies. According to Clavien, the complications were as follows: grade I (n = 11; 39.2%); grade II (n = 8; 28.5%); and grade III (n = 9; 32.3%). No patient presented with grade IV or V. The most common problem a biliary tract injury, similar to other series. In this Brazilian series, hepatectomy for LDLT was a safe procedure with low morbidity, regardless of the type of liver resection. This practice will probably continue to grow to alleviate the pressure of growing waiting lists.

Evaluation of living donor liver transplantation: causes for exclusion.

The decision to perform organ donation surgery involves a series of risks for the live donor including death. The aim of this study was to evaluate exclusion criteria for living donor liver transplantation, as well as to identify the rate of exclusion in each of the 3 process phases according to the Live Donor Evaluation Protocol for adult and child recipients. From December 2001 to December 2007, we evaluated 223 donors among whom 142 were excluded in various phases. The data were statistically evaluated. Among the 142 excluded donors, 113 (79.6%) had an adult recipient. The elimination rates for adult recipients were as follows: 68 cases in phase I, 41 cases in phase II, and 4 cases in phase III. Concerning child recipients, 29 (20.4%) donors were excluded: 17 in phase I, and 12 in phase II. Concerning adult recipients, sons and daughters were the largest part of the excluded donors, with withdrawal as the principal reason for exclusion followed by recipient death. Regarding child recipients the parents represented the largest number of excluded donors due to withdrawal followed by abnormal blood test results. Thus, 36.5% of potential donors were effective donors.

Ectopic placement of Sengstaken-Blakemore device to correct outflow obstruction in liver transplantation: case reports.

Liver transplantation is a complex procedure that has become the treatment for some end-stage liver diseases. Some technical features are important for the success of the transplantation, including the patency of the vascular anastomoses. In cadaveric whole organ liver transplantation, a large right subphrenic space may contribute to a twist of the inferior vena cava, leading to outflow obstruction, simulating an acute Budd-Chiari syndrome. Some devices can be used to correct this drainage problem. Herein, we have described 2 cases in which the Sengstaken-Blakemore balloon was safely used, in an ectopic position, to fix drainage complications in whole liver orthotopic transplantation.

[Value of sonography to monitor the course of Achilles tendon rupture after treatment--comparison of conservative therapy, percutaneous tendon adaptation, and open suture]. / Wertigkeit der sonographischen Verlaufskontrolle nach Achillessehnenrupturbehandlung--Vergleich konservative Therapie, perkutane und offene Naht.

In this prospective study,73 patients (with an average age of 36 years) were examined by ultrasound to compare the results of open Achilles tendon surgery, percutaneous tendon adaptation, and conservative treatment. Once the accident reports had been collected, all of the patients presented themselves at the Sportklinik Stuttgart at intervals of 4, 8, 12, 26 weeks, and approx. 2.5 years after the accident. During the course of these examinations, the thickness and structure of the tendon was quantified via ultrasound and the quality by clinical examination. The results of the ultrasonic quantification of the healing process appeared to be similar in all patients. On the day of the accident the thickness of the tendon was 9.3 mm. Four weeks later a remarkable regeneration could be seen in all patients (12.0 mm), which reached a maximum (16.7 mm) after 26 weeks. By the end of the study, however, the result was a scarred and thickened tendon of 11.5 mm. The comparison of the ultrasound results and the clinical examination after 26 weeks and 2.5 years showed no correlation between the value of the echo structure and functionality of the tendon, and the comparison between the different therapy groups showed no significant difference in the healing process either. In conclusion, ultrasound examination is able to provide information concerning the stage of the healing process. The quality of the healing and healed Achilles tendon and the relationship to their function cannot be studied with ultrasound, and this is not influenced by the choice of therapy.

[Achilles tendon ruptures: 25 year's experience in sport-orthopedic treatment]. / Die Achillessehnenruptur -- Erfahrungen aus 25 Jahren sportorthopädischer Behandlung.

From 1972 - 1996 570 Achilles tendon ruptures in 565 patients were treated in the Sportklinik Stuttgart. The 499 men and 66 women had an average age of 38 years. For the diagnosis of a Achilles tendon rupture Ultrasound and MRI are important procedures, but clinical history and examination are still the best methods to find an Achilles tendon rupture (100%). However,the Actiology of the Achilles tendon rupture is still controversial and cannot be answered by these methods. Opposed to the degenerative theory, biomechanical experiments show that any Achilles tendon can tear when the calf muscle is tensed before the tendon is quickly stretched. We found that 69.8% of the patients with Achilles tendon rupture had a real trauma. Regardless of that, the treatment of the ruptured Achilles tendon has considerably changed over the last ten years. Responsible for this development are the positive experiences at the field of sports medicine with minimally invasive methods and the early functional treatment after knee surgery. Since we use an early functional rehabilitation concept instead of plaster immobilisation, all methods to treat a ruptured Achilles tendon have been improved. 43.5% of the patients after plaster immobilisation and 28.8% of the patients after early functional rehabilitation had a subjectively felt force reduction. Other important selecting criteria are the risk factors related to treatment method. Minimal invasive percutaneous Achilles tendon repair is considerably better than conservative therapy with a high rate of re-rupture (9.8%) and better than the open surgical repair, which carries a higher risk of infection (2.2%)

[Achilles tendon rupture. A prospective study assessing various treatment possibilities]. / Die frische Achillessehnenruptur. Eine prospektive Untersuchung zur Beurteilung verschiedener Therapiemöglichkeiten.

The object of this study was to compare treatment of ruptured Achilles tendon by operative "end to end" surgery, percutaneous repair, or conservative therapy clinically; a subject of considerable controversy in the literature. These three methods were compared in 73 patients in a randomized trial between 1994 and 1996. After 2.5 years (11-41 months), the actual activities were assigned to the Hannover Achilles tendon score and the ability of doing work or sport activities was assessed. After this period, 59.3% of the patients showed good and excellent results on the Achilles tendon score, with over 79 points (open surgery 59.1%, percutaneous 60%, conservative treatment 58.3%). None of the patients reached the maximum score of 100 points. During the isometric strength tests, the patients with percutaneous repair had a lower weakening of the treated leg (8.9%) compared to the open-operated (12.7%) and non-operated patients (17.8%). Of the patients who had percutaneous surgery, 88% rated their treatment as good or excellent; those who had open surgery 77.3%, and those with conservative treatment 75%. The percutaneous group were able to resume work and sport much sooner than the other two groups. Bearing in mind the literature and these results, we have developed an algorithm for treating Achilles tendon rupture to assist decision making in daily routine. In this way, the use of percutaneous Achilles tendon repair can be carried out in most of cases.

[Epidemiology of sports injuries--25-year-analysis of sports orthopedic-traumatologic ambulatory care]. / Epidemiologie von Sportverletzungen--25-Jahres-Analyse einer sportorthopädisch-traumatologischen Ambulanz.

In a 25-years period (1972-1997) 30,603 sportsmen, having a total of 34,742 sports related injuries, were treated in our outpatient-department specialized in sports orthopaedics and traumatology. All cases were systematically recorded and analysed right from the beginning. This is the most extensive clinical statistics currently known. The absolutely highest incidence rate of sports-related injuries is seen in common disciplines like soccer with 10,493 (34.3%), skiing with 3632 (11.9%), handball 2307 (7.5%), tennis 1643 (5.4%) and volleyball 1550 (5.1%). 3/4 were male. The distribution of age shows a significant peak between 20 and 29 years of age, whereas in women we found a wide plateau between 10 and 39 years. Compared to earlier investigations we have an increase of injuries in higher age. In 72.4% the lower extremities are mainly effected, followed by the upper extremities (21.8%) and the spine with 3.0%. With increasing tendency knee injuries take main part (36.6%--12,708 cases) followed by injuries of the ankle (19.9%--6920 cases), shoulder (7.7%), lower leg (7.0%) and fingers (5.8%). Main diagnosis were: distortion (32.6%); ruptures of ligaments and menisci (21.5%); fractures (10.5%) and lesions of muscles and tendons (8.8%). Comparing our 15- and 25-years studies we found an interesting significant increase of injuries in skiing, tennis and physical exercising by 25%, in cycling four times. New disciplines like squash, snowboarding, mountainbiking and inlineskating have been added. All together the number of injuries is distributed to 87 different disciplines. In 1998 26.7 million sportsmen (one third of the German population) were member of the German Sports Association (DSB). The number of annual accidents in sports and sporting spare time activities is estimated at about 1.5-2 million, that's 25-30% of all accidents. The analysis of almost 35,000 treated sports injuries and further evaluation of more than 5000 orthopaedic examinations of top athletes are useful for analysis comparing single disciplines.

Gastrointestinal tolerability of meloxicam compared to diclofenac in osteoarthritis patients. International MELISSA Study Group. Meloxicam Large-scale International Study Safety Assessment.

Although widely used, non-steroidal anti-inflammatory drugs (NSAIDs) are associated with a high incidence of gastrointestinal (GI) side-effects. Inhibition of the cyclooxygenase (COX) enzyme is the basis for both the efficacy and toxicity of NSAIDs. The discovery of two COX isoforms, constitutive COX-1 and inducible COX-2, has led to the hypothesis that selective inhibition of COX-2 will minimize the potential for GI toxicity without compromising efficacy. The Meloxicam Large-scale International Study Safety Assessment (MELISSA) trial reported here was therefore set up to investigate the tolerability of meloxicam, a preferential inhibitor of COX-2, compared to diclofenac. MELISSA was a large-scale, double-blind, randomized, international, prospective trial, conducted over 28 days in patients with symptomatic osteoarthritis. Patients received either meloxicam 7.5 mg or diclofenac 100 mg slow release, the recommended doses for the treatment of osteoarthritis. Evaluation of the profile of adverse events was the main aim of the trial, together with assessment of efficacy. A total of 9323 patients received treatment (4635 and 4688 in the meloxicam and diclofenac groups, respectively). Significantly fewer adverse events were reported by patients receiving meloxicam. This was attributable to fewer GI adverse events (13%) compared to diclofenac (19%; P < 0.001). Of the most common GI adverse events, there was significantly less dyspepsia (P < 0.001), nausea and vomiting (P < 0.05), abdominal pain (P < 0.001) and diarrhoea (P < 0.001) with meloxicam compared to diclofenac. Five patients on meloxicam experienced a perforation, ulcer or bleed vs seven on diclofenac (not significant). No endoscopically verified ulcer complication was detected in the meloxicam group compared to four with diclofenac. There were five patient days of hospitalization in patients on meloxicam compared to 121 with diclofenac. Adverse events caused withdrawal from the study in 254 patients receiving meloxicam (5.48%) compared to 373 (7.96%) on diclofenac (P < 0.001). These differences were attributable to differences in reported GI adverse events (3.02% on meloxicam vs 6.14% on diclofenac; P < 0.001). Differences in efficacy, as assessed by visual analogue scales, consistently favoured diclofenac. In all instances, 95% confidence intervals did not cross zero, suggesting a statistically significant effect. However, differences were small (4.5-9.01% difference) and did not reach pre-determined levels of clinical significance. Nevertheless, significantly more patients discontinued meloxicam because of lack of efficacy (80 out of 4635 vs 49 out of 4688; P < 0.01). The MELISSA trial confirms earlier studies suggesting that meloxicam has a significantly improved GI tolerability profile in comparison with other NSAIDs, including diclofenac. These results may in part reflect the preferential COX-2 selectivity of meloxicam, although the dose and other aspects of tolerability may be important. These results may provide support for the hypothesis that selective inhibition of COX-2 relative to COX-1 might be an effective approach towards improved NSAID therapy.

Improvement in gastrointestinal tolerability of the selective cyclooxygenase (COX)-2 inhibitor, meloxicam, compared with piroxicam: results of the Safety and Efficacy Large-scale Evaluation of COX-inhibiting Therapies (SELECT) trial in osteoarthritis.

SELECT is a large-scale, prospective, international, multicentre, double-blind, double-dummy, randomized, parallel-group trial. Patients with exacerbation of osteoarthritis were treated with the recommended dose of meloxicam (7.5 mg) or piroxicam (20 mg) once daily for 28 days; 4320 patients were administered meloxicam and 4336 piroxicam. The incidence of adverse events was significantly lower in the meloxicam group (22.5%) compared with the piroxicam group (27.9%; P < 0.001), mainly due to the significantly lower incidence of gastrointestinal (GI) adverse events in the meloxicam than in the piroxicam group (10.3% vs 15.4%,; P < 0.001), while the efficacy of both drugs was equivalent. Individual GI events occurred significantly less often with meloxicam than piroxicam: dyspepsia (3.4% vs 5.8%; P < 0.001), nausea/vomiting (2.5% vs 3.4%; P < 0.05) and abdominal pain (2.1% vs 3.6%; P < 0.001). There were 16 patients with perforations, ulcerations or bleeding (PUBs) of the upper GI tract in the piroxicam group compared with seven in the meloxicam group (relative risk piroxicam:meloxicam = 1.4). Four PUBs were complicated (perforations or bleedings); none of these occurred in the meloxicam group (relative risk piroxicam:meloxicam = 1.9). The outcome of SELECT is consistent with that of the large-scale clinical trial of similar design and size which compared 7.5 mg meloxicam with 100 mg diclofenac in patients with osteoarthritis, and with a previous global analysis of the safety of meloxicam. It adds further data to the proposed relationship between selective inhibition of cyclooxygenase-2 and improved GI tolerability of non-steroidal anti-inflammatory drugs.

[Elbow dislocation in children and adolescents caused by sports]. / Ellenbogenluxationen bei Kindern und Jugendlichen im Sport.

In the Sportsclinic Stuttgart 11 young athletes were treated because of a dislocation of the elbow joint from 1988-1990. They were 7 girls and 4 boys with an average age of 12.5 years. Mechanism of the dislocation and its diagnosis and treatment are reported. Indication and ways for non-operative and operative treatment in the Sportsclinic Stuttgart are described. Operation should be performed on open injuries, concomitant vessel and nerve damages and dislocated bone fractures. Two typical case reports of young athletes are given.

[Dislocation of the peroneal tendon--clinical aspects and therapy]. / Die Peronealsehnenluxation--Klinik und Therapie.

During the past 3 years, 22 patients were operated on at the Stuttgart Sports Clinic for dislocation of peroneal tendons. 5 patients were operated on after an acute injury, while 17 were treated because of a chronic dislocation. Sports trauma was the reason in 13 cases (59%). Soft tissue operations were performed 7 times, and a modification of the Kelly-operation 15 times.

[Ultrasound and clinical findings of the patellar ligament after excision of the central third for cruciate ligament-plasty]. / Sonographische und klinische Befunde am Ligamentum patellae nach Entnahme des mittleren Drittels zur Kreuzbandersatzplastik.

The use of a central one-third patellar tendon as a substitute for a damaged cruciate ligament has grown in popularity in recent years. 15 patients undergoing physical check-ups were examined clinically and with the aid of ultrasound imaging on both knees 2 years after the operation. The purpose of this study was to demonstrate changes of the patellar tendon after removal of its central third. Pain is not reported in the removal area, the clinical examinations show identical findings on both patellar tendons, X-ray and ultrasound evaluations do not demonstrate any change in patellar position. Sonographically there is an increase of cross-sectional diameter over 10% without any obvious intratendinous structural change. Our clinical and sonographical results are compared with biomechanical and histological observations of animal studies.

[Patellar dislocation in athletes. Arthroscopic diagnosis and therapy]. / Die Patellaerstluxation beim Sportler. Arthroskopische Diagnostik und Therapie.

Out of 270 arthroscopies performed in the Sports Clinic in Stuttgart-Bad Cannstatt in 1987 and 1988, 317 (11.5%) were done because of hemarthrosis of the knee after an acute trauma. Besides ruptures of the anterior cruciate ligament and synovial ruptures, in 53 cases (16.4%) acute patellar dislocation was found. These were only the first dislocations. Most, i.e., 44 (83%) occurred in sports, such as soccer (18) and skiing (9), which were the most frequent sports involved. Thirty-three (62.2%) were young men with an average age of 21.5 years. The clinical history, physical examination and plain X-rays failed in more than 50% to come up with a diagnosis. Arthroscopy showed the typical pattern of patellar dislocations with hemarthrosis, rupture and hematoma of the medial quadriceps retinaculum and a concomitant cartilage lesion, which was found in 39 cases (66%). During arthroscopy, operative treatment could also be performed, such as the extraction of splinter bone fragments and chondroplasties. Seven chondral and osteochondral fragments were refixated. Immobilization of the knee was guaranteed for 4 weeks by the application of a plaster splint. Only one recurrent dislocation was observed.

[Traumatic dislocation of the posterior tibial tendon]. / Traumatische Luxation der Tibialis-posterior-Sehne.

Luxation of tibialis posterior tendon is rarely to be seen. In our case luxation is caused by direct traumatisation. Surgical deepening of tibial groove and trans-osseous suture of retinaculum are sufficient for good results after three months.

[Rupture of the triceps tendon in the athlete]. / Ruptur der Trizepssehne beim Sportler.

Subcutaneous rupture of the triceps tendon is mostly preceded by previous damage. Local injections, systemic anabolics, metabolic disorders, damage due to overstrain in heavy athletes and body builders are risk factors. Surgical treatment is mandatory. If the rupture has occurred mainly at the point of insertion of the tendon, we can recommend transosseous refixation via V-bore channels with early functional follow-up treatment.

[Examination of the knee joint. The value of clinical findings in arthroscopic control]. / Untersuchung des Kniegelenks. Wertigkeit klinischer Befunde unter arthroskopischer Kontrolle.

Purely clinical examination of the knee joint can, at best, only be regarded as a "screening procedure". Diagnosis with the aid of apparatus (sonography, arthrography, CT, NMR) produces better results. However, arthroscopy performed by an experienced examiner confirms the diagnosis in cases of suspected meniscus injury or isolated lesions of the cruciate ligaments and leads to early and therefore optimal therapy. In a retrospective study 300 arthroscopies performed in 1985 were selected and evaluated. In 1986/87, a further 300 patients were clinically examined prospectively, according to the same criteria, and findings were compared with the arthroscopy performed the following day. Clinically, in 287 patients with multiple diagnoses, internal meniscus lesions were diagnosed in 162 cases (54%), external meniscus lesions in 38 (13%), chondropathia patellae in 54 (18%), and old ruptures of the cruciate ligaments in 46 (15%). In 13 patients no diagnosis could be established. Arthroscopically, pathology of the internal meniscus was found in 98 (33%) of the 300 patients, of the external meniscus in 40 (13%), cartilage damage in 103 (34%), old cruciate ligament ruptures in 51 (17%), and recent anterior cruciate ligament ruptures in 156 (52%); in 40 cases findings were normal. At 78%, the highest positive predictive value (proportion of tentative clinical diagnoses confirmed by arthroscopy) was found in cases of old ruptures of the anterior cruciate ligament, followed by external meniscus lesions (61%) and internal meniscus lesions (55%); i.e., only 55 out of 100 clinically suspected internal meniscus lesions are diagnosed by arthroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term roentgenologic studies in peak performance javelin throwers]. / Röntgenologische Langzeitbeobachtungen bei Speerwerfern der Spitzenklasse.

The example of the javelin thrower demonstrates that an unphysiological movement sequence at the elbow joint (valgus stress) leads to regular arthrotic alterations by summation of such strains: these are known as "javelin elbow". Since the new javelin introduced in 1986 requires a greater explosive force, a tendency to an increased incidence of these alterations must be reckoned with in the future. Further observations are necessary to clarify whether there will be an increase in degenerative alterations in the lumbar spine by abrupt hyperlordosis and trunk rotation in producing the bow tension of the javelin thrower; whether the above-average incidence of patients with spondylolysis amongst competitive javelin throwers is coincidental; whether the processes of remodelling in the interarticular portion of javelin throwers constitute zones of fatigue; and, finally, whether the unilateral trunk strain of the javelin thrower influences the scoliotic posture.