Donor BMI >30 Is Not a Contraindication for Live Liver Donation.

The increased prevalence of obesity worldwide threatens the pool of living liver donors. Although the negative effects of graft steatosis on liver donation and transplantation are well known, the impact of obesity in the absence of hepatic steatosis on outcome of living donor liver transplantation (LDLT) is unknown. Consequently, we compared the outcome of LDLT using donors with BMI <30 versus donors with BMI ≥30. Between April 2000 and May 2014, 105 patients received a right-lobe liver graft from donors with BMI ≥30, whereas 364 recipients were transplanted with grafts from donors with BMI <30. Liver steatosis >10% was excluded in all donors with BMI >30 by imaging and liver biopsies. None of the donors had any other comorbidity. Donors with BMI <30 versus ≥30 had similar postoperative complication rates (Dindo-Clavien ≥3b: 2% vs. 3%; p = 0.71) and lengths of hospital stay (6 vs. 6 days; p = 0.13). Recipient graft function, assessed by posttransplant peak serum bilirubin and international normalized ratio was identical. Furthermore, no difference was observed in recipient complication rates (Dindo-Clavien ≥3b: 25% vs. 20%; p = 0.3) or lengths of hospital stay between groups. We concluded that donors with BMI ≥30, in the absence of graft steatosis, are not contraindicated for LDLT.

First-Degree Living-Related Donor Liver Transplantation in Autoimmune Liver Diseases.

Liver transplantation (LT) is the treatment of choice for end-stage autoimmune liver diseases. However, the underlying disease may recur in the graft in some 20% of cases. The aim of this study is to determine whether LT using living donor grafts from first-degree relatives results in higher rates of recurrence than grafts from more distant/unrelated donors. Two hundred sixty-three patients, who underwent a first LT in the Toronto liver transplant program between January 2000 and March 2015 for autoimmune liver diseases, and had at least 6 months of post-LT follow-up, were included in this study. Of these, 72 (27%) received a graft from a first-degree living-related donor, 56 (21%) from a distant/unrelated living donor, and 135 (51%) from a deceased donor for primary sclerosing cholangitis (PSC) (n = 138, 52%), primary biliary cholangitis (PBC) (n = 69, 26%), autoimmune hepatitis (AIH) (n = 44, 17%), and overlap syndromes (n = 12, 5%). Recurrence occurred in 52 (20%) patients. Recurrence rates for each autoimmune liver disease were not significantly different after first-degree living-related, living-unrelated, or deceased-donor LT. Similarly, time to recurrence, recurrence-related graft failure, graft survival, and patient survival were not significantly different between groups. In conclusion, first-degree living-related donor LT for PSC, PBC, or AIH is not associated with an increased risk of disease recurrence.

Universal prophylaxis or preemptive strategy for cytomegalovirus disease after liver transplantation: a systematic review and meta-analysis.

We systematically reviewed and meta-analyze the efficacy of universal prophylaxis (UP) and preemptive (PE) strategies (using ganciclovir or valganciclovir) in preventing cytomegalovirus (CMV) disease (CMD) among liver transplant recipients (LTRs). We performed an electronic search of MEDLINE, EMBASE and the Cochrane Database till December 2013. Studies that assessed UP or PE for preventing CMD in LTRs were included. The risk of bias was assessed using the Newcastle-Ottawa scale. The primary outcome was CMD, secondary outcomes being acute cellular rejection (ACR), graft loss (GL) and mortality. Due to the heterogeneity of comparative studies, an indirect comparison was performed. Pooled incidence rates with 95% confidence interval (CI) are calculated for each outcome using a random-effects model. Thirty-two studies involving 2456 LTRs were included. The majority of the studies were of low risk of bias. Irrespective of donor/recipient CMV sero-status, CMD was 10% with UP (95% CI: 6-14; I(2) = 87%; 16 studies, n = 1581) and 7% with PE (95% CI: 3-10; I(2) = 84%; 16 studies, n = 875) (mean difference 2.6; 95% CI: -3.25 to 8.45, p = 0.34). Likewise, ACR and mortality were similar with the two strategies. However, GL was significantly lower in the UP group, regardless of donor/recipient sero-status. In indirect comparison, the incidence of CMD, ACR and mortality in LTRs were similar with two strategies. Trials comparing the two strategies directly are needed.

Live donor liver transplantation: a valid alternative for critically ill patients suffering from acute liver failure.

We report the outcome of live donor liver transplantation (LDLT) for patients suffering from acute liver failure (ALF). From 2006 to 2013, all patients with ALF who received a LDLT (n = 7) at our institution were compared to all ALF patients receiving a deceased donor liver transplantation (DDLT = 26). Groups were comparable regarding pretransplant ICU stay (DDLT: 1 [0-7] vs. LDLT: 1 days [0-10]; p = 0.38), mechanical ventilation support (DDLT: 69% vs. LDLT: 57%; p = 0.66), inotropic drug requirement (DDLT: 27% vs. LDLT: 43%; p = 0.64) and dialysis (DDLT: 2 vs. LDLT: 0 patients; p = 1). Median evaluation time for live donors was 24 h (18-72 h). LDLT versus DDLT had similar incidence of overall postoperative complications (31% vs. 43%; p = 0.66). No difference was detected between LDLT and DDLT patients regarding 1- (DDLT: 92% vs. LDLT: 86%), 3- (DDLT: 92% vs. LDLT: 86%), and 5- (DDLT: 92% vs. LDLT: 86%) year graft and patient survival (p = 0.63). No severe donor complication (Dindo-Clavien ≥3 b) occurred after live liver donation. ALF is a severe disease with high mortality on liver transplant waiting lists worldwide. Therefore, LDLT is an attractive option since live donor work-up can be expedited and liver transplantation can be performed within 24 h with excellent short- and long-term outcomes.

Living vs. deceased donor liver transplantation provides comparable recovery of renal function in patients with hepatorenal syndrome: a matched case-control study.

Outcomes of living versus deceased donor liver transplantation in patients with chronic liver disease and hepatorenal syndrome (HRS) was compared using a matched pair study design. Thirty patients with HRS receiving a live donor liver transplantation (LDLT) and 90 HRS patients receiving a full graft deceased donor liver transplantation (DDLT) were compared. LDLT versus DDLT of patients with HRS was associated with decreased peak aspartate aminotransferase levels (339 ± 214 vs. 935 ± 1253 U/L; p = 0.0001), and similar 7-day bilirubin (8.42 ± 7.89 vs. 6.95 ± 7.13 mg/dL; p = 0.35), and international normalized ratio levels (1.93 ± 0.62 vs. 1.78 ± 0.78; p = 0.314). LDLT vs. DDLT had a decreased intensive care unit (2 [1-39] vs. 4 [0-93] days; p = 0.004), and hospital stay (17 [4-313] vs. 26 [0-126] days; p = 0.016) and a similar incidence of overall postoperative complications (20% vs. 27%; p = 0.62). No difference was detected between LDLT and DDLT patients regarding graft survival at 1 (80% vs. 82%), at 3 (69% vs. 76%) and 5 years (65% vs. 76%) (p = 0.63), as well as patient survival at 1 (83% vs. 82%), 3 (72% vs. 77%) and 5 years (72% vs. 77%) (p = 0.93). The incidence of chronic kidney disease post-LT (10% vs. 6%; p = 0.4) was similar between both groups. LDLT results in identical long-term outcome when compared with DDLT in patients with HRS.

Scintillation characteristics of the EJ-299-02H scintillator.

A study of the dead layer thickness and quenching factor of a plastic scintillator for use in ultracold neutron (UCN) experiments is described. Alpha spectroscopy was used to determine the thickness of a thin surface dead layer to be 630 ± 110 nm. The relative light outputs from the decay of 241Am and Compton scattering of electrons were used to extract Birks' law coefficient, yielding a kB value of 0.087 ± 0.003 mm/MeV, consistent with some previous reports for other polystyrene-based scintillators. The results from these measurements are incorporated into the simulation to show that an energy threshold of (∼9 keV) can be achieved for the UCNProBe experiment. This low threshold enables high beta particle detection efficiency and the indirect measurement of UCN. The ability to make the scintillator deuterated, accompanied by its relatively thin dead layer, gives rise to unique applications in a wide range of UCN experiments, where it can be used to trap UCN and detect charged particles in situ.

Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience.

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.

Adult right-lobe living liver donors: quality of life, attitudes and predictors of donor outcomes.

To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre- and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research.

Host- rather than virus-related factors reduce health-related quality of life in hepatitis C virus infection.

BACKGROUND: Hepatitis C virus (HCV) infection is associated with decreased health-related quality of life (HRQOL). Although HCV has been suggested to directly impair neuropsychiatric functions, other factors may also play a role. PATIENTS AND METHODS: In this cross-sectional study, we assessed the impact of various host-, disease- and virus-related factors on HRQOL in a large, unselected population of anti-HCV-positive subjects. All individuals (n = 1736) enrolled in the Swiss Hepatitis C Cohort Study (SCCS) were asked to complete the Short Form 36 (SF-36) and the Hospital Anxiety Depression Scale (HADS). RESULTS: 833 patients (48%) returned the questionnaires. Survey participants had significantly worse scores in both assessment instruments when compared to a general population. By multivariable analysis, reduced HRQOL (mental and physical summary scores of SF-36) was independently associated with income. In addition, a low physical summary score was associated with age and diabetes, whereas a low mental summary score was associated with intravenous drug use. HADS anxiety and depression scores were independently associated with income and intravenous drug use. In addition, HADS depression score was associated with diabetes. None of the SF-36 or HADS scores correlated with either the presence or the level of serum HCV RNA. In particular, SF-36 and HADS scores were comparable in 555 HCV RNA-positive and 262 HCV RNA-negative individuals. CONCLUSIONS: Anti-HCV-positive subjects have decreased HRQOL compared to controls. The magnitude of this decrease was clinically important for the SF-36 vitality score. Host and environmental, rather than viral factors, seem to impact on HRQOL level.

Rat hepatocytes exhibit basolateral Na+/HCO3- cotransport.

Primary cultures and plasma membrane vesicles were used to characterize Na+ and HCO3- transport by rat hepatocytes. Na+ uptake into hepatocytes was stimulated approximately 10-fold by 25 mM extracellular HCO3-.HCO3--stimulated Na+ uptake was saturable, abolished by 4-acetamido-4'-isothiocyano-2,2'-disulfonic acid stilbene (SITS), and unaffected by amiloride or Cl- removal. Neither propionate nor acetate reproduced this effect of HCO3-. 22Na efflux from preloaded hepatocytes was similarly increased approximately 10-fold by an in greater than out HCO3- concentration gradient. 22Na efflux was also increased by valinomycin and an in greater than out K+ concentration gradient in the presence but not absence of HCO3-. Intracellular pH (pHi) measured with the pH-sensitive fluorochrome 2',7'-bis-(2-carboxyethyl)-5-(and 6-)carboxyfluorescein (BCECF) decreased at a rate of 0.227 (+/- 0.074 SEM) pH units/min when extracellular HCO3- concentration was lowered from 25 to 5 mM at constant PCO2. This intracellular acidification rate was decreased 50-60% in the absence of Na+ or presence of SITS, and was unaffected by amiloride or Cl- removal. Membrane hyperpolarization produced by valinomycin and an in greater than out K+ concentration gradient caused pHi to fall; the rate of fall was decreased 50-70% by Na+ removal or SITS, but not amiloride. An inside positive K+ diffusion potential and a simultaneous out greater than in HCO3- gradient produced a transient 4,4'-diisothiocyano-2,2' disulfonic acid stilbene (DIDS) sensitive, amiloride-insensitive 22Na accumulation in basolateral but not canalicular membrane vesicles. Rat hepatocytes thus exhibit electrogenic basolateral Na+/HCO3- cotransport.

Amiloride and amiloride analogs inhibit Na+/K+-transporting ATPase and Na+-coupled alanine transport in rat hepatocytes.

Amiloride, a commonly used inhibitor of Na+-H+ exchange, has been shown to exhibit a variety of nonspecific effects. Recently, the more potent amiloride analogs, 5-(N,N-dimethyl)amiloride hydrochloride (DMA) and 5-(N-ethyl-N-isopropyl)amiloride (EIA), have been used to control for the nonspecific effects of the parent compound. In the present study, we have explored the effects of these analogs on Na+/K+-transporting ATPase (Na+/K+-ATPase) and Na+-coupled alanine transport in primary rat hepatocyte cultures and rat liver plasma membranes, and we have compared the effects of these analogs with the effects of amiloride and ouabain. Amiloride, DMA, and EIA increased steady-state Na+ content and inhibited ouabain-sensitive 86Rb+ uptake in a reversible, concentration-dependent, ouabain-like manner, with estimated 50% inhibitory concentrations (IC50) of 3.0.10(-3) M, 5.2.10(-4) M, and 1.2.10(-4) M, respectively. Amiloride, DMA and EIA also inhibited ouabain-sensitive ATP hydrolysis in rat liver plasma membranes with similar potency (IC50 values of 2.2.10(-3) M, 2.2.10(-3) M, and 1.7.10(-4) M, respectively). In separate experiments, amiloride (5.10(-3) M), DMA (10(-3) M), and EIA (2.5.10(-4) M) decreased the uptake into hepatocytes of alanine by 20%, 61%, and 59%, respectively, and further studies with DMA (10(-3) M) demonstrated that this inhibition was largely due to a decrease in the Na+-dependent fraction of alanine uptake. These findings indicate that amiloride, DMA, and EIA inhibit hepatic Na+/K+-ATPase directly, reversibly, and with a relative rank order potency of EIA greater than DMA greater than amiloride. All three compounds also inhibit the hepatic uptake of alanine, and presumably could indirectly inhibit other Na+-coupled transport processes as well.

A pragmatic and cost-effective strategy of a combination therapy of interferon alpha-2b and ribavirin for the treatment of chronic hepatitis C.

BACKGROUND: Combination of interferon (IFN) alpha and ribavirin is considered the standard treatment for patients with chronic hepatitis C. While combination therapy is more effective than IFN alone, the optimal management of combination treatment remains uncertain. OBJECTIVE: To assess a pragmatic and cost-effective strategy for the therapy of treatment-naive patients with chronic hepatitis C. DESIGN: Markov model on original data of two randomized trials. METHODS: A validated computer simulation model was applied to non-cirrhotic hepatitis C virus (HCV)-infected patients. Patient characteristics and efficacy of treatment were extracted from two randomized trials reporting on 1,445 non-cirrhotic patients. Different strategies were compared separately for genotype 1 and genotype non-1 (mostly genotype 2/3) infections: (1) no treatment; (2) IFN for 48 weeks (if at 12 weeks HCV RNA undetectable); (3) IFN and ribavirin for 24 weeks; (4) IFN and ribavirin for 48 weeks; (5) IFN and ribavirin for 48 weeks (if at 24 weeks HCV RNA undetectable). All strategies were tested for different combinations of known response factors. RESULTS: In genotype non-1 infection, 24 weeks of combination therapy dominates all other strategies. In genotype 1 infection, 48 weeks of combination therapy for week-24 responders only prolongs life expectancy at a favourable cost-effectiveness ratio (CE) of 7,135 euros per quality-adjusted life year (QALY). Taking response factors other than genotype into account does not add to the effectiveness or cost effectiveness. CONCLUSION: Treating non-cirrhotic patients with chronic hepatitis C according to genotype only is most cost effective independent of the number of other known response factors.

[Drug therapy of chronic hepatitis B]. / Medikamentöse Therapie der chronischen Hepatitis B.

Medical therapy of chronic hepatitis B aims at halting progression towards cirrhosis/hepatocellular carcinoma by inhibiting replication of hepatitis B virus in a sustained fashion (viral elimination). The sole therapy of proven efficacy is interferon-alpha (5-10 Mio IU sc TIW) which leads within 4 months to viral elimination (seroconversion from HBeAg to anti-HBe-antibody; serum HBV-DNA negative by hybridisation) in approximatively 40% of patients. Interferon-alpha therapy has been shown to decrease hepatitis B associated morbidity/mortality and to be cost-effective. Certain nucleoside analoga such as lamivudine or famciclovir are able to stop hepatitis B virus replication in a large proportion of patients; replication promptly resumes however after cessation of treatment and resistance develops in approximatively 15% of patients treated for one year. The clinical value, in particular for interferon-alpha non-responders, of a combination of interferon-alpha and/or nucleoside analoga remains to be seen.

[Liver transplantation in a small center: feasibility, efficacy and prospects]. / Die Lebertransplantation am kleinen Zentrum: Machbarkeit, Effizienz und Perspektive.

Today, orthotopic liver transplantation is the treatment of choice for the end-stage of various liver diseases, and a 1-year survival rate of 80% and a 5-year survival rate of 70% in elective patients without tumor are reported in international surveys. The liver transplant programme of the Inselspital in Bern is small compared with international centres, which may raise questions about the results and the justification for such a programme. Over a period of 66 months, 62 liver transplantations were performed in 60 patients at the Inselspital. The hospital mortality was 3.3%, and the 2.5-year overall survival rate was 92% for elective cases without tumor. After a median follow-up of 30 months, 68% of all patients were re-integrated in housework or full- or part-time in their profession, and 83% were independent from the help of others. We conclude that a small liver transplant programme based only on routine resources can achieve results comparable to the international standards.

[Autoimmune chronic active hepatitis]. / Autoimmune chronisch-aktive Hepatitis.

Autoimmune chronic active hepatitis is a rare type of chronic active hepatitis which occurs with a bimodal age distribution (10 to 30 or > or = 50 years) most frequently in women. It is characterized by negative markers for other possible (e.g. viral) etiologies, hypergammaglobulinemia and a number of circulating autoantibodies. According to the latter, several subgroups can be discriminated today. Histology shows chronic active hepatitis with chronic, sometimes plasma-cell-rich infiltration of portal tracts and piece-meal necroses. Symptoms and signs are classically non-specific and include general malaise, lethargy and fatigue. Accompanying autoimmune diseases may be present. The disease is today, however, also frequently diagnosed in an early, asymptomatic stage. Cause(s) and pathogenetic mechanism(s) of the increasingly heterogeneous appearing disease remain unknown. Recent observations seem to indicate that as yet undetermined (exogenous) substance(s) and the hepatitis C virus may, at least in certain subgroups, trigger autoimmune reactions, which may then perpetuate on the basis of a permissive (immuno)genetic background. Untreated, the disease is, in general, progressive, leads to cirrhosis and shows a mortality of up to > or = 50% in 2 to 4 years. Signs potentially indicating a nonfavorable prognosis include high inflammatory activity and the presence of cirrhosis at diagnosis. Typically, immunosuppressive therapy with corticosteroids (with or without azathioprine) results in remission of inflammatory, but usually not fibro-genetic activity with its potential for cirrhosis. Exacerbations after cessation of treatment are not infrequent (> or = 50%), and indefinite therapy is required in a number of patients, despite its potential for unwanted effects (e.g. osteopenia). Such therapy may increase the 5-year survival rate to > 80%. Liver transplantation remains the sole therapeutic option in end stage disease.

[Does the primary disease recur following liver transplantation?]. / Rekurriert die Grundkrankheit nach Lebertransplantation?

A number of underlying diseases may recur after orthotopic liver transplantation. While the recurrence of cholestatic diseases such as primary biliary cirrhosis and primary sclerosing cholangitis is still debated, and occurs, if at all, rarely and late after transplantation, the chronic viral hepatitides and the liver tumors recur frequently and in general early after grafting. Except for hepatitis B and tumor recurrence, recurrent diseases have rarely an impact on survival and/or quality of life in medium terms. The frequency of the often fatal hepatitis-B reinfection can be minimized by passive immunoprophylaxis and appropriate patient selection, that of tumor recurrence by thorough patient selection. Relapses occur only rarely after transplantation for post-alcoholic cirrhosis, provided stringent selection criteria, including a period of documented sobriety > or = 6 month prior to transplantation, are applied. Thus, except for chronic hepatitis B with ongoing viral replication and most liver cancers, the possibility of recurrent disease is not a contraindication to liver transplantation.

[Esophageal varices]. / Osophagusvarizen.

Variceal hemorrhage still carries a high mortality and a high risk of recurrence. Esophageal varices bleed rarely with a porto-systemic pressure gradient below 12 mmHg; pharmacotherapy, thus, aims at lowering the pressure gradient below this critical threshold. Conceptually, this can be achieved by decreasing portal-venous inflow (via lowering cardiac output and/or increasing splanchnic-arteriolar vasoconstriction) or by decreasing portal-venous resistence (via portal vasodilation). In acute variceal bleeding, easily applicable pharmacotherapy with terlipressin plus nitroglycerin, probably also with octreotide, can help to stabilize the patient and to buy time until diagnostic endoscopy and treatment by sclerotherapy or variceal band ligation. For pharmacotherapeutic secondary prophylaxes of variceal hemorrhage the combination of propranolol or nadolol with isosorbid-5-mononitrate is available. Future studies will tell, whether this drug combination is superior to the nowadays established endoscopic eradication of varices, especially by long-term variceal band ligation. For primary prophylaxis of variceal hemorrhage non-selective beta-anatagonists remain the therapy of choice in compliant patients with esophageal varices and endoscopic signs indicating a high risk of bleeding. Future studies must clarify the role of the beta-antagonist-nitrate combination, as well as that of prophylactic variceal band ligation, in this setting.

[Management of the liver transplant patient]. / Betreuung des lebertransplantierten Patienten.

The general practitioner plays a crucial role in the care for the liver transplant recipient. The number of liver transplant recipients increasing steadily by about 50 a year in Switzerland, the practitioner will increasingly be confronted with such patients. A close cooperation between general practitioner and transplant center is mandatory and the key to success. This paper aims at introducing the general practitioner to the care for the liver transplant recipient.

[Increased liver enzymes: what should be done?]. / Erhöhte Leberenzyme: was nun?

The transaminases, alkaline phosphatase (AP) and gamma-glutamyl transferase (G-GT) are most widely used as indicators of hepatobiliary disease. Elevated serum levels of transaminases (AST and ALT) usually indicate hepatocellular damage. ALT elevations, however, can also be of extrahepatic origin (muscle). The ratio of the transaminases in serum (AST/ALT) and the mitochondrial isoenzyme of AST are frequently higher in alcoholic than in non-alcoholic liver diseases. Serum activities of AP and G-GT are elevated in cholestasis: Both enzymes, however, are not liver-specific and G-GT activity is induced by alcohol and certain drugs. A hepatic enzyme pattern (predominant transaminase elevation) should be discriminated from a cholestatic pattern (predominant AP and G-GT elevation). The most frequent diagnoses in asymptomatic patients with accidentally detected, mostly mild to moderate transaminase elevations are: alcoholic liver disease, (mostly chronic) viral hepatitis, and already much less frequently, drug induced liver disease and non-alcoholic steatosis. Solely if the respective investigations are negative or/and the transaminases stay elevated for greater than or equal to 6 months despite strict alcohol abstinence, omission of any potentially hepatotoxic drug or weight reduction are further steps justified.

[Symptomatic cholecystolithiasis: 1992 therapy options]. / Symptomatische Cholezystolithiasis: Therapieoptionen 1992.

Modern treatment of symptomatic cholecystolithiasis requires a knowledge of several nonsurgical and surgical treatment options. Extracorporeal shock-wave lithotripsy and oral bile acid therapy offer the possibilities of noninvasive, outpatient treatment in approximately 20% of all symptomatic gallstone patients at a low complication rate. The percutaneous interventional techniques such as contact dissolution by means of ether or mechanical stone removal may in principle be used in a higher percentage of patients but are considerably more invasive. None of the nonsurgical techniques can exclude the relative risk of gallstone recurrence. Laparoscopic cholecystectomy constitutes a major progress in the surgical treatment of gallstone disease, since it is much less invasive than conventional cholecystectomy and requires a much shorter hospital stay and recovery time. The laparoscopic technique is primarily indicated in patients with symptomatic, uncomplicated cholecystolithiasis. Nevertheless, the range of indications is expanding as experience with this technique increases. Under certain circumstances, laparoscopic cholecystectomy is already being combined with endoscopic sphincterotomy in the presence of bile duct calculi. Conventional cholecystectomy remains the treatment of choice for complicated cases.