Gas Chromatography-Mass Spectrometry Detection of Thymoquinone in Oil and Serum for Clinical Pharmacokinetic Studies.

Thymoquinone (TQ) is the primary component of Nigella sativa L. (NS) oil, which is renowned for its potent hepatoprotective effects attributed to its antioxidant, anti-fibrotic, anti-inflammatory, anti-carcinogenic, and both anti- and pro-apoptotic properties. The aim of this work was to establish a method of measuring TQ in serum in order to investigate the pharmacokinetics of TQ prior to a targeted therapeutic application. In the first step, a gas chromatography-mass spectrometry method for the detection and quantification of TQ in an oily matrix was established and validated according to European Medicines Agency (EMA) criteria. For the assessment of the clinical application, TQ concentrations in 19 oil preparations were determined. Second, two serum samples were spiked with TQ to determine the TQ concentration after deproteinization using toluene. Third, one healthy volunteer ingested 1 g and another one 3 g of a highly concentrated NS oil 30 and 60 min prior to blood sampling for the determination of serum TQ level. After the successful establishment and validation of the measurement method, the highest concentration of TQ (36.56 g/L) was found for a bottled NS oil product (No. 1). Since a capsule is more suitable for oral administration, the product with the third highest TQ concentration (No. 3: 24.39 g/L) was used for all further tests. In the serum samples spiked with TQ, the TQ concentration was reliably detectable in a range between 5 and 10 µg/mL. After oral intake of NS oil (No. 3), however, TQ and/or its derivatives were not detectable in human serum. This discrepancy in detecting TQ after spiking serum or following oral ingestion may be attributed to the instability of TQ in biomatrices as well as its strong protein binding properties. A pharmacokinetics study was therefore not viable. Studies on isotopically labeled TQ in an animal model are necessary to study the pharmacokinetics of TQ using alternative modalities.

Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure.

PURPOSE: Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy. METHODS: In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses. RESULTS: Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown. CONCLUSION: This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.

[Liver Transplantation as Treatment for Rare Diseases in Adults]. / Lebertransplantation als Therapie von seltenen Erkrankungen beim Erwachsenen.

In addition to the main indications pertaining to 95 % of all patients receiving liver transplantation in Germany, there are numerous other diseases that may become clinically evident in the adult age and may lead to the decision for liver transplantation. These may be metabolic diseases with their main defect located in the liver, malformations of liver cells, hepatic vascular diseases and rare tumours of the liver. Standard exceptions for the listing are in place only for a limited number of diseases. Exact diagnostics and the point in time for transplantation are crucial for the prognosis.

Effects of methylene-blue staining on the extent of pilonidal sinus excision.

OBJECTIVE: We aimed to examine the effects of methylene-blue staining (MBS) on the volume of specimens after excision of pilonidal sinuses. METHOD: This was a retrospective analysis of 135 excised specimens after pilonidal sinus (PS) surgery. All patients underwent procedures at the Department of Surgery of University Hospital Jena between 2000 and 2010. All specimens were measured in three dimensions. To calculate the volumes of excised specimens, we used a model of a hemi-ellipsoid. Demographic information (age, height, weight, body mass index, smoking status) were also obtained for all patients. RESULTS: Excised specimens with MBS had significantly larger volumes (p<0.001) as reflected in length (p=0.001), width (p=0.001), and depth (p=0.017) of the excised specimen compared with specimens that were not stained with methylene blue (MB). In addition, the volume was larger in subjects with a recurrent PS (p=0.021), which was predominantly the case in female subjects (p=0.025). CONCLUSION: These data suggest that excised specimens with MBS had significantly larger volumes of the excised specimen compared with specimens that were not stained with MB. MBS of a fistula system could enable such a system to be marked sufficiently, thereby facilitating complete resection of a PS.

[Vascular Problem Constellations and the Operational Tactical Approaches in Post-Mortem Liver Transplantations]. / Vaskuläre Problemkonstellationen und ihre operationstaktischen Lösungsansätze im Rahmen der postmortalen Lebertransplantation.

In liver transplantation, vascular problems may occur in the donor as well as in the recipient and during the donor operation as well as during the transplantation. They have a major influence on the outcome of the transplantation. In addition to anatomic variants, arteriosclerotic vascular diseases, complications from portal hypertension, vascular lesions from mistakes during the donor operation, complications from interventions and bridging procedures need to be identified and treated. In addition to duplex sonography and contrast enhanced computed tomography, invasive vascular diagnostics (digital subtraction angiography) are established for diagnostic purposes. Problem constellations should be identified prior to transplantation and the technique of the donor operation and the transplantation should be adjusted accordingly. Problems that are diagnosed after transplantation may be treated interventionally or with open surgery. In a number of cases, vascular complications lead to loss of the transplant or death of the recipient from post-operative organ failure.

[Extended Pathohistological Criteria for Assessment of the Long-Term Prognosis of Gastric Cancer]. / Erweiterte pathohistologische Kriterien zur Bewertung der Langzeitprognose des Magenkarzinoms.

BACKGROUND: Gastric cancer is one of the most frequent tumour diseases worldwide. Despite numerous innovations in the diagnostic procedures and treatment the prognosis remains poor as the detection of the disease depends on tumour-associated symptoms which develop rather late in the majority of cases. The treatment outcomes may be improved by a more differentiated and individualised evaluation of the tumour biology. We present a detailed analysis of potentially relevant factors. MATERIAL AND METHODS: From 1995 to 2011, data from 923 patients with gastric cancer have been collected in a prospective tumour database. We performed monovariate and multivariate analyses of factors. For the statistical analyses, SPSS software version 19.0 was used. The literature research was performed with Medline. RESULTS: 748 patients underwent surgical exploration. The resection rate was 87 % with a morbidity and mortality of 27 and 9 % (2004 to 2001: 13 and 5 %), respectively. 36 and 29 % of patients survived 5 years or 10 years, respectively. The 5-year and 10-year survival after curative resection was 58 and 46 %, respectively. TNM-associated criteria, tumour size, histological growth pattern, intestinal metaplasia, location of the tumour and classification according to Lauren were of significant influence in the monovariate analyses. In the multivariate analysis, tumour size, curative resection and lymph node involvement were independent prognostic factors. 90 % of the tumour recurrences developed within five years. The median recurrence-free interval was 16 months. Depending on the type of tumour, different survival times were identified. The 228 patients with node-negative curatively resected gastric cancer had a markedly better long-term prognosis. Diffuse type according to Lauren, tumour size, non-tubular histological growth pattern, female sex and proof of serosa infiltration from the primary tumour were prognostic factors in the monovariate analysis. In the multivariate analysis, tumour size was an independent significant prognostic factor (p = 0.05). CONCLUSION: The data analyses showed that the evaluation of gastric cancer may be extended in a sensitive way by factors that have not been previously established. The benefit of an individualised structured treatment and follow-up on the basis of extended criteria should be investigated in future studies.

[Living Donor Liver Transplantation - Past and Present]. / Lebertransplantation mit Lebendspende ­ Historie und Gegenwart.

Since the first living donor liver transplantations at the end of the 1980s, this transplantation technique has developed as an established tool within the modern transplantation medicine. Especially in Asia, the majority of liver transplantation is performed through living donation, mainly for religious reasons. Liver grafts for adult recipients are mainly the right liver lobe of the donor, for paediatric recipients mainly the left lateral lobe. In some cases, the living donor liver transplantation is realised from two different donors for one recipient, the so-called "dual graft" transplantation. This article summarises the history of living donor liver transplantation up to the current status of this transplantation procedure worldwide.

[Classic Limberg Flap Procedure for Treatment of a Sacrococcygeal Pilonidal Sinus Disease - Explanation of the Surgical Technique]. / Klassische Rautenplastik nach Limberg zur Behandlung einer sakrokokzygealen Pilonidalsinuserkrankung - Erklärung der OP-Technik.

INTRODUCTION: Sacrococcygeal pilonidal sinus disease is frequently encountered in surgical practice. Besides excision only, the current pilonidal sinus guideline of the Association of the Scientific Medical Societies in Germany (AWMF-S3) also recommends plastic surgical procedures such as the cleft-lift operation described by Bascom, the Karydakis flap procedure and, due to the low recurrence rates, the Limberg flap procedure, for the treatment of this disease. INDICATION: In our case we show the surgical procedure performed on a 23-year-old male patient, who was previously treated for an acute abscess-forming sacrococcygeal pilonidal sinus. METHOD: Our video shows the fasciocutaneous rhombic flap procedure described by Limberg step by step. CONCLUSION: The Limberg flap procedure is a simple operation for the treatment of sacrococcygeal pilonidal sinus disease.

[Assessment of bovine pericardium (tutomesh®) and coated polypropylene (proceed®) in the para-oesophageal position in a pig model]. / Untersuchung von bovinem Perikard (Tutomesh®) und beschichtetem Polypropylen (Proceed®) in paraösophagealer Position im Schweinemodell.

BACKGROUND: Hiatal hernias are nowadays increasingly treated with meshes. Often, biological implants are being used for this application. Oesophageal perforations have been reported as rare but serious complications from the application of synthetic meshes at the oesophageal hiatus. The role of the different mesh types has not been clearly established by experimental research so far. In the present large animal model, we investigated two implant types (Tutomesh® and Proceed®) with respect to their biocompatibility and mechanical stability. MATERIAL AND METHODS: We used 12 domestic pigs aged three months. Tutomesh® and Proceed® were implanted in 6 animals each for bridging at the oesophageal hiatus. After a follow-up of 3 months, the experiment was terminated. We performed endoscopy and intraoperative macroscopic evaluation of the situs. In representative histological sections, established histopathological and immunohistochemical parameters of biocompatibility were investigated and tensile strength testing was performed on standardised tissue samples. RESULTS: One animal of the Proceed® group had grade 2 oesophagitis. None of the animals had an oesophagus arrosion. The analysis of adhesions revealed slightly less adhesions in the Tutomesh® group. There was no significant difference with respect to the investigated inflammation response and immune response between both meshes. The most substantial finding of the mechanical analysis was a loss of tear strength of the Tutomesh®-tissue-complex of 30 % as compared to native tissue and more than 50 % compared to Tutomesh® prior to implantation, respectively. CONCLUSIONS: After 3 months, there was no significant difference between the two implant types with respect to the inflammatory response. The loss of tear strength of the Tutomesh®-tissue-complex at the oesophageal hiatus is probably clinically not relevant and may be explained by the so-called biological remodeling of biological materials. The remodeling depends on the extent of the cross-linking of the respective material. It is expected that biological hernia implants, such as Tutomesh®, may have a marked potential for avoiding complications at the oesophageal hiatus in the long run. This potential cannot be proven after 3 months from our data. Further experimental investigations are necessary to clarify this issue, in particular with respect to the long-term results.

[Preparation and in-vitro analysis of a polyethylenimine coating on hernia meshes]. / Herstellung und In-vitro-Analyse einer Polyethylenimin-Beschichtung auf Herniennetzen.

BACKGROUND: Certain coatings such as titanium may improve the biocompatibility of hernia meshes. The coating with biopolymers such as polyethylenimine (PEI) can also improve the material characteristics of implants. This approach has, however, not yet been explored. Thus, it was the aim of the present work to clarify if and how hernia meshes with their three-dimensional structure can be successfully coated with PEI and with which technique this coating can be best analysed. METHODS: Commercially available meshes made from polypropylene, polyester and ePTFE have been coated with PEI. The coating was analysed via cell proliferation test (mouse fibroblasts), electron microscopy, X-ray photoelectron spectroscopy (XPS) and fluorescence microscopy. Cell viability and cytotoxicity were tested by the MTT test. RESULTS: With the PEI surface modification, mouse fibroblasts grow faster and in greater numbers on the mesh surface. XPS as well as fluorescence microscopy show weaknesses in their applicability and meaningfulness because of the three-dimensional mesh structure while XPS showed overall better results. Optical proof in the electron microscope after cell fixation was not unambiguously accomplished with the techniques used here. In the MTT test, no cellular damage from the PEI coating was detected after 24 hours. CONCLUSION: The present results show for the first time that PEI coating of hernia meshes is possible and effective. The PEI coating can be achieved in a fast and cost-efficient way. Further investigations are necessary with respect to coating quality and cytotoxicity before such a coating may be used in the clinical routine. In conclusion, PEI is a promising polymer that warrants further research as a coating for medical implants.

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.

[Liver transplantation - current aspects of allocation, indication and donor pool expansion]. / Lebertransplantation - aktuelle Aspekte der Allokation, Indikation und Strategien zur Erweiterung des Spenderpools.

Liver transplantation is nowadays an established treatment option for end-stage liver disease and the associated complications. In this article, we summarise the actual aspects of allocation, indication for transplantation as well as approaches for donor pool expansion in the field of liver transplantation in Germany. Beside the maintenance of long-term survival and quality of life, the actual donor organ shortage is the most important issue worldwide. While trying to control this shortage, there is a lot of discussion about the transplantation for malignant liver disease. In our opinion, the focus in this topic should be the utilisation and expansion of the donor pool. There are many logistic and medical aspects which could be optimised. Furthermore, there are open questions in public and political discussions (up to the revision of the transplantation law) which should be improved for the purpose of the waiting list patients.

[Portal vein embolisation prior to extended liver resection - current and future aspects]. / Pfortaderembolisation zur Konditionierung erweiterter Leberresektionen - aktueller Stand und Ausblick.

Extended liver resections are associated with the risk of postoperative liver dysfunction up to liver failure. For this reason, prior to extended liver resections patients are conditioned in multi-modal therapy regimes. Portal vein embolisation is an essential part of such a multi-modal therapy. The aim of this intervention is an induction of hypertrophy of the future remnant liver volume. Thereby, the risk of postoperative liver failure is decreased. This article summarises the actual aspects of portal vein embolisation prior to extended liver resections.

A randomized, controlled study to assess the conversion from calcineurin-inhibitors to everolimus after liver transplantation--PROTECT.

Posttransplant immunosuppression with calcineurin inhibitors (CNIs) is associated with impaired renal function, while mTor inhibitors such as everolimus may provide a renal-sparing alternative. In this randomized 1-year study in patients with liver transplantation (LTx), we sought to assess the effects of everolimus on glomerular filtration rate (GFR) after conversion from CNIs compared to continued CNI treatment. Eligible study patients received basiliximab induction, CNI with/without corticosteroids for 4 weeks post-LTx, and were then randomized (if GFR > 50 mL/min) to continued CNIs (N = 102) or subsequent conversion to EVR (N = 101). Mean calculated GFR 11 months postrandomization (ITT population) revealed no significant difference between treatments using the Cockcroft-Gault formula (-2.9 mL/min in favor of EVR, 95%-CI: [-10.659; 4.814], p = 0.46), whereas use of the MDRD formula showed superiority for EVR (-7.8 mL/min, 95%-CI: [-14.366; -1.191], p = 0.021). Rates of mortality (EVR: 4.2% vs. CNI: 4.1%), biopsy-proven acute rejection (17.7% vs. 15.3%), and efficacy failure (20.8% vs. 20.4%) were similar. Infections, leukocytopenia, hyperlipidemia and treatment discontinuations occurred more frequently in the EVR group. No hepatic artery thrombosis and no excess of wound healing impairment were noted. Conversion from CNI-based to EVR-based immunosuppression proved to be a safe alternative post-LTx that deserves further investigation in terms of nephroprotection.

[Management of complications after liver resection]. / Management von Komplikationen nach Leberresektionen.

Hepatic resections represent a standard procedure for both benign and malignant liver diseases. Nevertheless, typical complications arise follow-ing hepatic surgery. Besides common problems, such as bile leakage or impaired wound healing, rare complications, like progressive liver failure or portal vein thrombosis are observed. Mortality and morbidity after liver resection depend on the preoperative constitution of the patient, on the state of the liver parenchyma and on the re-main-ing liver volume. In particular, a marked steatosis increases both morbidity and mortality of hepatic resections. The advances of modern chemotherapy increases the number of surgical patients, who were previously not resectable. However, the chemotherapy induced hepatotoxicity implies additional problems, thus increasing the morbidity of liver resections. Therefore, before planning hepatic surgery, the individual situation of the patient has to be evaluated in order to maximise the security of the operative procedure.

[The war in my head : A psychotraumatological case report after a prolonged intensive care unit stay]. / Der Krieg in meinem Kopf : Ein psychotraumatologischer Fallbericht nach prolongiertem Intensivaufenthalt.

Intensive care treatment is proven to be associated with patients' mental symptoms. There is a correlation between acute stress and psychological sequelae, which has not yet been sufficiently theoretically substantiated. This case report illustrates the development of mental symptoms during and after intensive care treatment with reference to a psychotraumatological model. Above all, memories that are not related to reality but are associated with fear of death are potentially traumatic. A re-evaluation of these memories can help to prevent psychological sequelae. Psychoeducation, conversation with the staff of the intensive care unit (ICU) and the ICU diary are helpful instruments in this process. Continuous psychological care should be provided if acute psychological stress occurs during intensive care medical treatment.

[Living related liver transplantation]. / Lebertransplantation durch Lebendspende.

Liver transplantation has become established as a standard procedure in the treatment of end-stage liver diseases. Despite intense efforts by all parties involved up to the amendment of the German Transplantation Act, the lack of suitable donor organs was still one of the limiting factors of this therapeutic procedure. One way out of this problem is to make so-called marginal organs usable, e.g. with the help of machine perfusion or by utilizing living liver donation, which are used in some countries for more than 90% of organ donations. In general, there is no difference in the indications for liver transplantation between a (partial) organ obtained by post-mortem or living donation. Before any living donation, a thorough evaluation of the donor is carried out in order to minimize postoperative morbidity as far as possible. Technically the partial liver donation is based on the oncological liver resection, while the partial liver transplantation is a further development of split liver transplantation after post-mortem liver donation. In specialized centers comparable or even better results can nowadays be achieved using living liver donation instead of post-mortem donation.

Liver resection and transplantation in Caroli disease and syndrome.

INTRODUCTION: Caroli disease (CD) is a congenital dilatation of the intrahepatic bile ducts. In combination with liver fibrosis or cirrhosis, it is called Caroli syndrome (CS). Infectious complications and intrahepatic cholangiocarcinoma are secondary problems. The aim of this study was to analyse the clinical pattern and outcome in patients with CD/CS who underwent liver surgery. METHODS: Between January 2004 and December 2016, 21 patients with CD/CS were treated with liver resection or transplantation (LTX) and post-operative data of patients with CD/CS were retrospectively analysed in a database. RESULTS: Two patients underwent LTX, and 19 patients underwent liver resection due to CD/CS. During follow-up, one patient developed lung cancer nine years after LTX. Patients resected due to CD/CS were predominantly females (74%) with an overall low incidence of co-morbidities. The median post-operative Clavien-Dindo score was 1 (range: 0-3). There was no death during a median follow-up period of over five years. In four patients, cholangiocarcinoma was confirmed. Tumor recurrence was seen in three patients, and was treated with chemotherapy or repeated liver resection. CONCLUSIONS: LTX and liver resections due to CD/CS are rare and associated with an acceptable post-operative morbidity and low mortality. Surgical treatment should be performed as early as possible to avoid recurrent episodes of cholangitis or carcinogenesis.