Enhanced prehospital volume therapy does not lead to improved outcomes in severely injured patients with severe traumatic brain injury.

BACKGROUND: Whether enhanced prehospital volume therapy leads to outcome improvements in severely injured patients with severe traumatic brain injury (TBI) remains controversial. The aim of this study was to investigate the influence of prehospital volume therapy on the clinical course of severely injured patients with severe TBI. METHODS: Data for 122,672 patients from TraumaRegister DGU® (TR-DGU) was analyzed. Inclusion criteria were defined as follows: Injury Severety Score (ISS) ≥ 16, primary admission, age ≥ 16 years, Abbreviated Injury Scale (AIS) head ≥3, administration of at least one unit of packed red blood cells (pRBCs), and available volume and blood pressure data. Stratification based on the following matched-pair criteria was performed: group 1: prehospital volumes of 0-1000 ml; group 2: prehospital volumes of ≥1501 ml; AIS head (3, 4, 5 + 6 and higher than for other body regions); age (16-54, 55-69, ≥ 70 years); gender; prehospital intubation (yes/no); emergency treatment time +/- 30 min.; rescue resources (rescue helicopter, emergency ambulance); blood pressure (20-60, 61-90, ≥ 91 mmHg); year of accident (2002-2005, 2006-2009, 2010-2012); AIS thorax, abdomen, and extremities plus pelvis. RESULTS: A total of 169 patients per group fulfilled the inclusion criteria. Increasing volume administration was associated with reduced coagulation capability and reduced hemoglobin (Hb) levels (prothrombin ratio: group 1: 68%, group 2: 63.7%; p ≤ 0.04; Hb: group 1: 11.2 mg/dl, group 2: 10.2 mg/dl; p ≤ 0.001). It was not possible to show a significant reduction in the mortality rate with increasing volumes (group 1: 45.6, group 2: 45.6; p = 1). CONCLUSIONS: The data presented in this study demonstrates that prehospital volume administration of more than 1500 ml does not improve severely injured patients with severe traumatic brain injury (TBI).

Prehospital fluid management of abdominal organ trauma patients--a matched pair analysis.

PURPOSE: Severe bleeding after trauma frequently leads to a poor outcome. Prehospital fluid replacement therapy is considered an important primary treatment option. We conducted a retrospective matched pair analysis to assess the influence of prehospital fluid replacement volume on the clinical course of patients with solid abdominal organ trauma. METHODS: Data were analyzed from 51,425 patients in TraumaRegister DGU® of the German Trauma Society. Inclusion criteria were as follows: injury severity score ≥ 16 points, primary admission, age ≥ 16 years, no isolated brain injury, transfusion of at least one unit of packed red blood cells (pRBCs), and systolic blood pressure ≥ 20 mmHg at the accident site. The patients were divided into "low-volume" (0-1000 ml) and "high-volume" (≥ 1,500 ml) groups according to the matched pair criteria. In each group, 68 patients met the inclusion criteria. RESULTS: Higher volume in fluid replacement was associated with increased need for transfusion (pRBCs: low-volume: 7.71 units, high-volume: 9.16 units; p = 0.074) and with by trend reduced clotting ability (prothrombin time: low-volume: 71.47 %, high-volume: 66.47 %; p = 0.27). The percentage of patients in shock (systolic blood pressure <90 mmHg) upon admission was equal in the two groups (25.0 %; p = 1). The mortality rate was discretely higher in the high-volume group (low-volume: 11.8 %, high-volume: 19.1 %; p = 0.089). CONCLUSIONS: Excessive prehospital fluid replacement is able to lead in an increased mortality rate in patients with solid abdominal organ injury. Our results support the concept of restrained fluid replacement in the preclinical treatment of severe trauma patients.

Comparison of the sixth and the seventh editions of the UICC classification for perihilar cholangiocarcinoma.

BACKGROUND: The seventh edition of the TNM classification separates extrahepatic bile duct tumors into perihilar and distal tumors and further changes the definition of the TNM classification. The impact of the seventh edition on stage-based prognostic prediction for patients with perihilar cholangiocarcinoma was evaluated. METHODS: Between January 1998 and March 2010, 223 consecutive patients with perihilar cholangiocarcinoma underwent surgery at the West German Cancer Center. Median survival times were calculated for the 195 evaluable patients (excluding those with in-hospital mortality) after separate classification by both sixth and seventh editions. RESULTS: Median overall survival was increased in patients classified using the seventh compared with the sixth edition (UICC I: 56.5 vs 23.75 months; II: 45.9 vs 31.6 months; III: 21.3 vs. 8.76 months; IV: 7.03 vs 5.93 months). The T category of the seventh edition did not alter median survival times of T1 (54.07 months) and T4 (7.83 months) cases, but median survival was prolonged for T2 patients (29.4 vs 31.6 months), and shortened for T3 patients (19.43 vs 11.8 months) staged using the seventh edition. According to Cox proportional hazards regression analysis, patient survival was better predicted by the seventh edition UICC stage and pT categories (p=0.0014 and p=0.0396, respectively), than the corresponding sixth edition categories (p=0.4376 and p=0.0926, respectively). CONCLUSIONS: The UICC seventh edition TNM classification for perihilar cholangiocarcinoma improves separation of patients with intermediate stage tumors compared with the sixth edition. The prognostic value of the UICC staging system has been strengthened by the introduction of the seventh edition.

Feasibility of video-assisted bilateral neck exploration for patients with primary hyperparathyroidism and failed or discordant localization studies.

PURPOSE: Minimally invasive video-assisted parathyroidectomy (MIVAP) is generally adopted for patients affected by primary hyperparathyroidism (pHPT) with clear preoperative localization. Standard bilateral neck exploration (BNE) is considered the obligate surgery for patients with unlocalized glands. We reviewed our experience of minimally invasive video-assisted BNE in patients with pHPT and negative or discordant localization studies. METHODS: From a prospective series of 576 MIVAP for pHPT, 107 patients (19 males, 88 females; mean age 58 years) with failed localization studies underwent BNE using the video-assisted technique. Operative time, complications, conversions to standard cervical exploration, and cure rate were analyzed. RESULTS: MIVAP with BNE was successfully completed in 99 (93 %) patients with 8 conversions. Mean operative time was 57 ± 37 min (range 20-180 min). Permanent recurrent laryngeal nerve palsy occurred in one patient. Biochemical cure was achieved in 104 patients (97 %). Five patients required a reoperation in the immediate postoperative period, which achieved cure in four. Two patients remained with persistent disease; one developed recurrence disease 3 years after the first exploration. CONCLUSION: In experienced hands, video-assisted BNE for pHPT is feasible and safe and provides results equivalent to the conventional open technique.

Liver transplantation in nonalcoholic steatohepatitis is associated with high mortality and post-transplant complications: a single-center experience.

BACKGROUND/AIMS: Non-alcoholic fatty liver disease (NAFLD) with its progressive form nonalcoholic steatohepatitis (NASH) is the most common chronic liver disease in western countries which is associated with end-stage liver disease and hepatocellular carcinoma (HCC). This entity is a consistently increasing indication for transplantation. However, data about postsurgery outcome and complications are still limited. PATIENTS AND METHODS: Records of 432 consecutive transplanted patients between October 2007 and January 2011 were investigated retrospectively. Forty transplants were performed due to NASH-induced cirrhosis. Perioperative courses and short- and long-term outcomes were analyzed. RESULTS: The NAFLD population consisted of 16 women and 24 men with a mean age of 55 years. The median MELD score was 27 at the time of liver transplantion. BMI before surgery ranged from 21 to 45 (mean 31). Sixteen of the initial 40 patients are still alive. Patients with sustained obesity and features of the metabolic syndrome had a worse 1-year mortality rate of 42%. CONCLUSIONS: A significant number of liver transplantations in our center was performed due to NASH; transplantation in this cohort was associated with high mortality and postoperative complications, most likely due to associated obesity and diabetes. Weight reduction prior to surgery may lead to a better outcome.

Pancreatic injury in 284 patients with severe abdominal trauma: outcome, course, and treatment algorithm.

PURPOSE: The relevance of pancreatic trauma in severely injured patients within a large collective has not been thoroughly analyzed yet. This study aimed at assessing the prevalence of pancreatic trauma in relation to the outcome and the currently established algorithm of treatment. METHODS: Some 51,425 patients from the Trauma Register of the German Society of Trauma Surgery (TR DGU) (1993-2009) were retrospectively analyzed. All patients with an "injury severity score" ≥16, direct admission to a trauma center and subsequent treatment for at least 3 days, age ≥16, and an abdominal injury [abbreviated injury scale (AIS)(abdomen) ≥2] were included. Patients with abdominal trauma (AIS(abdomen) ≥2) were compared with patients with an additional pancreatic trauma (AIS(pancreas) 2-5). RESULTS: Of 51,425 patients, 9,268 (18%) had documented abdominal injuries. Two hundred eighty-four (3.1%) patients with abdominal injury additionally showed a pancreatic injury (AIS(abdomen) ≥2, AIS(pancreas) 2-5) and were analyzed in dependency of the classification of the American Association for the Surgery of Trauma (AAST) organ severity score. AAST-pancreas: II°, 1.9%; III°, 0.6%; IV°, 0.3%; and V°, 0.2%. Patients with leading pancreatic injury (grades IV and V) thereby showed a significant increase of mortality (IV°, 30.0% and V°, 33.3%) and an increase of the need for surgical intervention (IV°, 80.6% and V°: 81.8%). CONCLUSIONS: The results presented here show the prevalence and the outcome of pancreas injury in a large collective within the TR DGU for the first time. Based on the current literature and the findings, a treatment algorithm has been developed.

Klatskin-mimicking lesions: still a diagnostical and therapeutical dilemma?

BACKGROUND/AIMS: The preoperative as well as the intraoperative differentiation between Klatskin-mimicking lesions and malignant bile duct tumors at hilar bifurcation is still challenging. Our intention was to review the preoperative diagnostics including preoperative CA19-9 and bilirubin serum levels to compare benign and malignant tumors. METHODOLOGY: We analyzed our prospectively established bile duct tumor database. From 1999 to 2008, 238 patients suspicious for hilar cholangiocarcinoma underwent surgery. In 24 patients the postoperative histological diagnosis showed a Klatskin-mimicking lesion. The histological report from 20 out of the 24 patients showed a chronic inflammatory transformation of the bile ducts. The histology of two patients showed a primary sclerosing cholangitis and the histological examination of the two remaining patients diagnosed a sarcoidosis of the extrahepatic bile duct. RESULTS: Reassessment of preoperative diagnostics did not deliver any change of interpretation of the tumors' dignity compared to how it had been assessed preoperatively. Also, preoperative CA19-9 serum levels do not show a statistically reliable differentiation between benign or malignant dignity. CONCLUSION: Current diagnostics cannot differentiate malignant from benign tumor masses in the hepatic hilum with the necessitated reliability. Therefore surgical resection of suspect hilar tumors is still the only appropriate therapy.

Transplantation after blunt trauma to the liver: a valuable option or just a "waste of organs"?

OBJECTIVE: Liver injury due to trauma is a rare indication for transplantation. The main indications in such cases were uncontrollable bleeding and insufficient hepatic function. Because of poor results, liver transplantation in these patients is occasionally described as "waste of organs", however based on insufficient data. This study aims to report our experience and to critically question the indication of transplantation in these patients. METHODS: All liver transplantations at our institution were reviewed retrospectively. This covered 1,529 liver transplants between September 1987 and December 2008. Of them, 6 transplants were performed due to motor-vehicle accidents which caused uncontrollable acute liver trauma in 4 patients. The patients' peri-operative course, short- and long-term outcomes were analyzed. RESULTS: Five deceased-donor liver transplantations (4 full size, 1 split) and 1 living donor (right) transplantation were performed. The median GCS score was 9/15; the median MELD score was 15. Postoperative complications were observed in 3 patients, requiring re-operation in 2. After a median (range) follow-up of 32.95 (10.3-55.6) months, 2 patients are alive and remain well on immunosuppression. CONCLUSION: Liver transplantation in patients with otherwise surgically uncontrollable acute liver injury can be indicated as a life saving procedure and can be performed successfully in highly selected cases.

Prehospital volume therapy as an independent risk factor after trauma.

BACKGROUND: Prehospital volume therapy remains widely used after trauma, while evidence regarding its disadvantages is growing. The primary objective of this study was to investigate the volume administered in a prehospital setting as an independent risk factor for mortality. MATERIAL AND METHODS: Patients who met the following criteria were analyzed retrospectively: Injury Severity Score=16, primary admission (between 2002 and 2010), and age=16 years. The following data had to be available: volume administered (including packed red cells), blood pressure, Glasgow Coma Scale, therapeutic measures, and laboratory results. Following a univariate analysis, independent risk factors for mortality after trauma were investigated using a multivariate regression analysis. RESULTS: A collective of 7,641 patients met the inclusion criteria, showing that increasing volumes administered in a prehospital setting were an independent risk factor for mortality (odds ratio: 1.34). This tendency was even more pronounced in patients without severe traumatic brain injury (TBI) (odds ratio: 2.71), while the opposite tendency was observed in patients with TBI. CONCLUSIONS: Prehospital volume therapy in patients without severe TBI represents an independent risk factor for mortality. In such cases, respiratory and circulatory conditions should be stabilized during permissive hypotension, and patient transfer should not be delayed.

Online intervention study--Willingness to donate organs among the employees of a German University.

BACKGROUND: Organ shortage remains a major challenge in transplantation medicine. The aim of this study was to analyze the public's willingness to donate organs and to observe whether increased knowledge about organ donation has an effect on the attitude toward organ donation. The study in particular tested the efficacy of using electronic communication as a means to distribute information. METHODS: In 2011, an Email invitation to participate in a survey was sent to the employees of the University Duisburg-Essen. The survey consisted of a two-piece questionnaire with an informational intervention on organ donation between the questionnaires. The technical design ensured that interviewees remained anonymous and could participate only once. RESULTS: In total, 1,818 interviewees completed the questionnaire. Of the respondents, 42% were organ-donor card holders (which was consistent among genders and age groups), whereas 87% of the interviewees would support an organ donation for themselves. Of the interviewees who did not possess an organ-donor card, 67% were positively inclined toward holding one in future after reading the interventional information. CONCLUSIONS: The considerable improvement in attitude toward carrying an organ-donor card after reading the information illustrates the effectiveness of distributing concise information on organ donation. To increase the willingness to donate organs, it is of great importance to inform the public and facilitate the documentation of a decision to donate. The present study has proven the use of Email communication to be an important asset to this process.

The effect of education on the attitude of medical students towards organ donation.

BACKGROUND: The persisting shortage of organs for transplantation could be reduced by increasing the willingness to donate organs. An appropriate education and a positive attitude of medical students and future physicians towards organ donation may have a positive impact on the attitudes of the general public. MATERIAL/METHODS: During the summer semester 2010 we conducted a voluntary educational intervention study concerning organ donation among medical students in the course of the main surgery lecture at the University of Essen, Germany. RESULTS: The survey comprised 94 questionnaires. At the beginning of the lecture there were 67% of organ donor card carriers among the students. An additional 20% imagined they might carry an organ donor card in the future. 37% needed more information regarding organ donation. After the lecture 13% were still not willing to carry an organ donor card in the future. 18% of the students required further information. 42% of the students rated their attitude towards organ donation to be influenced positively by the lecture, 57% of the students stated there was no influence. One student documented a negative influence by the lecture towards organ donation. CONCLUSIONS: Well-directed interventions are needed to sensitize young adults to the topic of organ donation. Better understanding of medical students and future physicians in the field of organ donation will help them to become disseminators for this important topic in our society.

Tumor growth effects of rapamycin on human biliary tract cancer cells.

BACKGROUND: Liver transplantation is an important treatment option for patients with liver-originated tumors including biliary tract carcinomas (BTCs). Post-transplant tumor recurrence remains a limiting factor for long-term survival. The mammalian target of rapamycin-targeting immunosuppressive drug rapamycin could be helpful in lowering BTC recurrence rates. Therein, we investigated the antiproliferative effect of rapamycin on BTC cells and compared it with standard immunosuppressants. METHODS: We investigated two human BTC cell lines. We performed cell cycle and proliferation analyses after treatment with different doses of rapamycin and the standard immunosuppressants, cyclosporine A and tacrolimus. RESULTS: Rapamycin inhibited the growth of two BTC cell lines in vitro. By contrast, an increase in cell growth was observed among the cells treated with the standard immunosuppressants. CONCLUSIONS: These results support the hypothesis that rapamycin inhibits BTC cell proliferation and thus might be the preferred immunosuppressant for patients after a liver transplantation because of BTC.

Fulminant septic shock due to Clostridium perfringens skin and soft tissue infection eight years after liver transplantation.

BACKGROUND: Bacterial and fungal infections are the main cause of death within the first year after liver transplantation. Clostridium perfringens is the most common germ causing gas gangrene. Infections with Clostridium perfringens may present in a variety of clinical manifestations, reaching from asymptomatic infections to massive intravascular haemolysis and multiple organ failure due to septic shock. CASE REPORT: We here report on a 55-year old male liver transplant patient suffering from skin and soft tissue infection eight years after liver transplantation. The patient was referred to our department from a community hospital. Upon admission in our department the infection had been ongoing for at least three days. Laboratory analyses demonstrated severe infection and impaired liver function. Tomogram and computed tomography scan of his right limb showed typical images of gas gangrene. The patient was immediately scheduled for surgical debridement. During surgery the patient developed septic shock with severe coagulopathy and died six hours after the operation due to uncontrolled septic shock. The histopathological and microbiologic work-up of the resected skin and soft tissue showed necrotic areas infiltrated with Clostridium perfringens. CONCLUSIONS: Even long-term survivors of liver transplantation are at major risk for life-threatening infections. The reported clinical scenario of Clostridium perfringens infection indicates the narrow therapeutic window. Clostridium perfringens should always be considered as a cause of infection in liver transplant patients.

Surgical treatment of nonparasitic cysts of the liver: open versus laparoscopic treatment.

BACKGROUND: The aim of this study was to compare the immediately postoperative and follow-up results of open and laparoscopic surgery of hepatic cysts in a tertiary hepatobiliary referral center. MATERIALS AND METHODS: From March 1999 to February 2007, 59 patients underwent surgical treatment for nonparasitic liver cysts. Patients were assigned to the laparoscopic (n = 42) or open group (n = 17) for analysis. RESULTS: Three conversions to open procedures had to be performed in the laparoscopic group. One patient had to be reoperated because of a bile leakage in the laparoscopic group. Follow-up examination showed 2 recurrences in the laparoscopic and 3 in the open group. Three out of 17 patients in the open group had to be operated for incisional hernias. Time to previous activities was significantly shorter after laparoscopy. CONCLUSIONS: Laparoscopic treatment of symptomatic nonparasitic liver cysts is superior concerning short- and long-term results in a vast majority of cases.

Prognostic factors of liver injury in polytraumatic patients. Results from 895 severe abdominal trauma cases.

BACKGROUND AND AIMS: Prognosis of multiple injured patients is mainly limited by severe haemorrhage. Although mechanisms of altered immune response have been intensively investigated, little is known about the relevance of liver trauma as an independent predictive outcome factor in these patients. METHODS: 10,469 patients from the DGU Trauma Registry (1993-2005) were retrospectively analyzed. Primary admitted patients with an injury severity score > or = 16, without isolated head injury were included. Patients were analyzed according to the injury pattern as liver injury (Abbreviated Injury Scale--AIS abdomen < 3 and AIS liver 2-5; n = 321), non-liver abdominal trauma (AIS abdomen 2-5 or AIS liver < 3; n = 574) and control group without abdominal injuries (AIS abdomen or liver < 3; n = 9,574). RESULTS: Severe liver injury was associated with excessive demands for volume resuscitation and induced a significantly increased risk for sepsis and multi-organ failure (MOF) compared to both other groups (sepsis 19.9% vs. 11.0%; MOF 32.7% vs. 16.6%). Furthermore, deleterious outcome was more frequently associated with severe liver trauma (mortality 34.9%) compared to severe abdominal trauma (12.0%). CONCLUSION: Severe liver trauma is an independent predictor for severe haemorrhage with a substantially increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with liver trauma but no haemorrhage is effective, patients with hemodynamic instability seem to be from a subgroup where contemporary treatment modalities are not yet sufficient.

Paediatric acute liver failure and transplantation: the University of Essen experience.

To report our experience with 17 children who underwent a liver transplantation (LT) for acute liver failure (ALF). All LT procedures (deceased and living donor) were offered. Since 2003 Molecular Adsorbents Recycling System (MARS) was proposed as bridging procedure. We monitored the perioperative course and the short- and long-term outcomes. All children developed pretransplant hepatic encephalopathy (mostly grades II and III); six needed ventilator support and three haemodialysis. Median PELD/MELD score was 30. MARS was used in five children with poor pretransplant prognostic factors: all five survived the LT without sequelae. We performed 13 deceased donor LT (seven whole, five split and onr reduced) and four left lateral LDLT. Postoperative complications were observed in 10 children, requiring re-operation in seven. Two children developed irreversible neurological disorders. After a median follow up of 45 months, 16 children are still alive. About 1- and 5-year cumulative patient survival rates are 94% with a corresponding graft survival of 88% and 81%, respectively. The combination of experienced paediatric ICU management, the application of new liver support devices, and the capacity to offer both living and deceased donor transplant alternatives in a timely fashion represent the best formula to achieve optimal results in children with ALF.

General handling and anesthesia for experimental surgery in pigs.

The pig is a common large animal for experimental settings in many fields of surgery. In experimental surgery, there is a need for different narcotic procedures depending on the complexity of the surgical investigation. Narcotic procedures have to be safe, easy to handle, and should not influence the experimental results. We hereby present important aspects of handling and narcotic procedures for pigs. The aim of this publication is to supply an introduction for young surgical investigators who are planning or already have started investigations using pigs as an experimental animal. This publication is based on our institutional experience of narcotic and surgical procedures in more than 400 cases.

Successful salvage therapy with tigecycline after linezolid failure in a liver transplant recipient with MRSA pneumonia.

Pulmonary infections are a significant cause of morbidity and mortality after liver transplantation. Infections with methicillin-resistant Staphylococcus aureus (MRSA) have increased in the last 10 years. Mortality may exceed 80% in liver transplant recipients who develop MRSA pneumonia. A 57-year-old male following living-donor liver transplantation developed a right-sided MRSA pneumonia 6 weeks after transplantation, which required artificial ventilation for 14 weeks. Initially, pneumonia was treated with linezolid. However, after 12 days under current therapy, the infection spread out to both lungs. At that time. we initiated the treatment with tigecycline. Under this therapy, the patient could be cured from MRSA pneumonia and was extubated. We detected no tigecycline related hepatotoxic effect. In conclusion, this case suggests that tigecycline may be useful in the salvage therapy of pneumonia due to MRSA after linezolid failure.