Outcome of hepaticojejunostomy for biliary tract obstruction following liver transplantation.

BACKGROUND: Strictures and concrements are the most common biliary complications following liver transplantation. Endoscopic treatment might not lead to a definitive cure in all patients, especially in strictures involving the biliary bifurcation. The aim of this study was to determine the efficacy and the long-term outcome of hepaticojejunostomy (HJS) for post-transplant biliary tract obstruction. MATERIAL AND METHODS: Thirty-seven patients were retrospectively studied for resolving of cholestasis and the incidence of recurring biliary obstruction. RESULTS: Surgery was performed because of anastomotic strictures in 11, ischemic strictures at the donor common bile duct in seven, strictures involving the bile duct bifurcation in 10, hepatolithiasis without strictures in one and biliary cast formation diagnosed by endoscopic retrograde cholangiography or T-tube cholangiography in eight patients. Cholestasis instantly improved in 82% of the patients. After a long-term follow-up of median 33 months (range 3-149), 28 of the patients (76%) required no further intervention for recurring biliary obstruction following HJS. Anastomotic strictures were observed in six (16%), recurring biliary concrements in two patients (5%). CONCLUSION: HJS did prevent recurrent biliary obstruction in the majority of the patients. We therefore recommend early HJS for complicated post-transplant biliary tract obstruction not treatable by a limited number of endoscopic interventions.

Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial.

BACKGROUND: The aim of this prospective randomized multicenter trial was to evaluate the recurrence rates and complications of open versus laparoscopic repairs of inguinal hernias. METHODS: Patients with primary unilateral inguinal hernias were randomized to Shouldice repair, Bassini operation, tension-free hernioplasty (Lichtenstein repair), laparoscopic transabdominal extraperitoneal hernioplasty (TEP), or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). The primary outcome parameter was the rate of recurrence at 3 years. The secondary outcome was the rate of intraoperative, perioperative, and long-term complications. Follow-up comprised of clinical examination after 1, 2, and 3 years. RESULTS: Three hundred and sixty-five patients were randomly assigned to one of the five procedures. The intention-to-treat analysis showed that the cumulative 3-year recurrence rate was 3.4% in the Bassini group, 4.7% in the Shouldice group, 0% in the Lichtenstein group, 4.7% in the TAPP group, and 5.9% in the TEP group (p = 0.48). Comparing open (Bassini, Shouldice, Lichtenstein) versus laparoscopic (TAPP, TEP) techniques (p = 0.29) and comparing the use of mesh prostheses (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) (p = 0.74) showed no significance in the rate of recurrence. The rates of intraoperative (p = 0.15), perioperative (p = 0.09), and long-term complications (p = 0.13) were without significance between the five groups. Comparing mesh techniques (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) showed no significance in the rate of complications. The per-protocol analysis for the comparison of mesh (Lichtenstein, TAPP, TEP) versus suturing (Bassini, Shouldice) techniques revealed that recurrences (p = 0.74), intraoperative (p = 0.64), perioperative (p = 0.27), and long-term complications (p = 0.91) were evenly distributed. CONCLUSIONS: In this multicenter study, no significant difference in the recurrence rate and complications between laparoscopic and open methods of hernia repair was revealed.

Postoperative pain and quality of life after laparoscopic and open inguinal hernia repair: results of a prospective randomized trial.

BACKGROUND: As part of a large prospective randomized Austrian multicenter trial evaluating recurrence rates and complications of open and laparoscopic unilateral inguinal hernia repairs we assessed postoperative pain and quality of life. METHODS: Approximately 151 patients were randomized to Shouldice repair, Bassini operation, or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). Pain was recorded preoperatively and on the first four postoperative days. Quality of life was recorded preoperatively and 1 month postoperatively. RESULTS: Patients having Shouldice repairs had significantly higher visual analog-scale scores for pain on the fourth postoperative day (P=0.048) and significantly higher scores in McGill pain questionnaires on the first four postoperative days (P=0.046) compared with the other groups. Apart from a significantly lower score in postoperative bodily pain in the Shouldice group (P=0.039), no significant differences in quality of life were apparent among the three methods. CONCLUSIONS: The TAPP and Bassini repairs result in less short-term postoperative pain.

Influence of cumulative number of marginal donor criteria on primary organ dysfunction in liver recipients.

BACKGROUND: The aim of this cohort study was to assess the cumulative effect of marginal donor criteria on initial graft function and patient survival after liver transplantation. METHODS: We included 734 consecutive patients who underwent orthotopic liver transplantation at the Vienna General Hospital between January 1993 and December 2003. We employed the local registry of the Department of Transplant Surgery, where variables of all patients are routinely and prospectively recorded. Primary outcome was initial graft function, secondary outcome was patient survival. RESULTS: Cumulative number of marginal donor criteria was significantly and linearly associated with an increased rate of primary dysfunction (PDF; p = 0.005). In patients with more than three cumulative marginal donor criteria the rate of PDF was 36%. Patient survival was not influenced by the cumulative number of donor criteria (log-rank test, p = 0.81). Independent marginal donor criteria to predict PDF were cold ischemia time >10 h [odds ratio (OR) 0.56; 95% CI 0.32-0.98] and donor peak serum sodium >155 mEq/L (OR 0.44; 95% CI 0.26-0.77), as assessed in a multivariate regression model. CONCLUSIONS: The use of marginal liver donors with more than three marginal donor criteria shows deleterious effects on initial graft function. Noteworthy, patient survival was not associated with marginal donor criteria, which may be explained by early and successful retransplantation of liver recipients with primary non-function.

Long-term follow-up of surgically treated gallbladder cancer patients.

AIMS: Palliative attempts have traditionally led treatment of gallbladder cancer but resection offers the only chance for long-term survival. This study investigates the impact of surgery with curative intent in gallbladder cancer treatment and evaluates prognostic factors for survival. METHODS: Two hundred and sixty-seven patients were admitted for surgical therapy. Sixty received resection with curative intent and form the basis of this analysis. RESULTS: R0 resection (n=45) was a highly significant independent survival predictor (P<0.001). All 5-year survivors (n=10) had tumour-free resection margins. Early T stage (P=0.017) and highly differentiated cancer (P=0.008) had a significant better outcome. Nodal spreading increased by local tumour extension and lymphatic involvement decreased patient survival (P=0.018). Patients' age (>75 years) was without influence on long-term survival. CONCLUSIONS: Long-term survival is possible both in elderly patients and in advanced cancer.

[Transhiatal laparoscopic approach in epiphrenic esophageal diverticulum]. / Transhiatale laparoskopische Divertikelresektion bei einem epiphrenischen Oesophagusdivertikel.

Epiphrenic diverticula are rare. The exact prevalence of this condition is unknown because asymptomatic patients are usually not discovered. Symptoms are more often the result of an esophageal motility disorder than the diverticulum itself and no correlation exists between the size of the diverticulum and the severity of symptoms. We present a patient suffering from dysphagia, chest pain, food retention and regurgitation because of an epiphrenic diverticulum. The current treatment of choice for symptomatic epiphrenic diverticula is diverticulectomy via a left thoracic approach. We performed a successful abdominal laparoscopic approach.

Multiorgan donation from a donor with unrecognized ornithine transcarbamylase deficiency.

Ornithine transcarbamylase (OTC) deficiency, the most common inherited urea cycle disorder, shows a spectrum of severity ranging from severe neonatal hyperammonemic coma to no symptoms among adults. We report on the multiorgan procurement from a donor who died of cerebral edema due to unrecognized late-onset OTC deficiency. The donor's OTC deficiency was diagnosed retrospectively since the liver graft recipient developed cerebral edema postoperatively due to hyperammonemia. Plasma ammonia was extremely elevated (3793 micromol/l), but was not accompanied by general liver dysfunction. Post mortem, the diagnosis of OTC deficiency was established by enzyme and molecular analysis in a biopsy of the transplanted liver. In contrast to the fatal course of the liver graft recipient, the kidney, lung, and heart transplantations were successful. Ten months after transplantation these recipients were alive and showed good graft function. This case demonstrates the importance of careful donor evaluation, particularly if the donor's cause of death is obscure.

Measurements in the raw gas of a full scale municipal waste incinerator using a wavelength resolved REMPI mass spectrometer.

A resonance enhanced multiphoton ionization (REMPI) mass spectrometer consisting of a tunable laser unit (Nd:YAG pump laser and OPO) and a reflectron mass spectrometer have been upgraded to cope with the difficult conditions such as vibrations, temperature fluctuations and dust, prevailing in an incinerator. On-line measurements of the raw gas have been carried out at the municipal waste incinerator in Stuttgart. Although this test series could not be completed the results are encouraging. They show that wavelength resolution can provide valuable information beyond the one obtainable by fixed frequency REMPI. Examples discussed include separation of interferants to the aniline signal and identification of phenantrene.

Late-onset ornithine transcarbamylase deficiency in two families with different mutations in the same codon.

We report on late-onset ornithine transcarbamylase (OTC) deficiency in two families with mutations in the same codon, but different base substitutions. Onset of symptoms showed great variation, and five hemizygotes finally died. Clinical diagnosis was late and difficult. In family A, 1 patient also developed the signs of Gilbert's disease. In family B, the index case came to attention as OTC deficiency, after the transplantation of his liver when the recipient died of cerebral edema and hyperammonemia. In family A, the hemizygote males died at the ages of 12 and 18 years; in family B, they died at the ages of 20, 26, and 30 years, respectively. Diagnosis was confirmed by reduced OTC activity in liver specimens. The residual activity in autopsy liver of the index patient in family A was less than the activity in the biopsy of the transplanted liver of the index patient in family B. The molecular investigations showed mutations in exon 2 at codon 40 in the OTC gene in both families. However, different bases were substituted. In family A, the single-base mutation was a cytosine-to-thymine transition (Arg 40 Cys); in family B, it was a guanine-to-adenine transition (Arg 40 His). Published data on in vitro expression studies of the recurrent OTC mutation Arg 40 His have shown little effect on the protein structure of the enzyme. These studies would fit well with our observation of higher OTC activity and later age of onset of symptoms in family B.

Use of absorbable mesh in the treatment of parenchymal liver injuries during orthotopic liver transplantation.

OBJECTIVE: To find out whether packing or wrapping with polyglactin 910 mesh was more effective in stopping bleeding in livers that had been damaged during transplantation. DESIGN: Retrospective study. SETTING: University hospital, Austria. SUBJECTS AND INTERVENTIONS: 15 of 27 livers that had been damaged during transplantation bled sufficiently to warrant either packing (n = 6) or wrapping (n = 9). MAIN OUTCOME MEASURES: Arrest of bleeding; other complications. RESULTS: Both packing and wrapping succeeded in stopping the bleeding, and neither caused infections. Packing may theoretically cause an increase in intra-abdominal pressure and impair organ function. CONCLUSION: It is preferable to wrap rather than pack a bleeding liver that has been damaged during transplantation.

Parenchymal liver injury in orthotopic liver transplantation.

BACKGROUND: A 35-year period of clinical development resulted in orthotopic liver transplantation (OLT) becoming a standardized surgical procedure. Despite this progress, the rate of technical complications is still high. Although the main problem in most analyses is vascular or bile duct failure, we observed a remarkable number of parenchymal liver injuries that led to intraoperative problems. Our aim, therefore, is to present an overall report on the incidence, treatment, and clinical course of parenchymal liver injuries in OLT. METHODS: Five hundred seventy-two consecutive OLT procedures performed between 1988 and 1998 were analyzed in a retrospective study. Parenchymal liver injury was diagnosed by means of examination of the surgical reports. Donor- and recipient-related data followed the medical report. The lesions were classified according to the Organ Injury Scale. RESULTS: Parenchymal liver injury was diagnosed in 23 patients (4%). The lesions were classified as grade Ia (13.1%), grade Ib (13.1%), grade IIb (52.1%), grade IIIa (17.1%), and grade IIIb (4.3%). In 19 patients (82.6%), the lesion was detected during OLT, and in four patients (17.4%), during relaparotomy. The latter group showed significantly higher-grade injuries. Treatment was suture or fibringlue alone, 17.4%; fibringlue and hemostyptics, 26.1%, mesh wrapping 30.4%, and mesh packing 26.1%. Seven patients (30.4%) underwent relaparotomy. Further active bleeding was not found in any of them. Statistical analysis found a correlation between injury grade and relaparotomy rate. No patients died as a result of parenchymal liver injury. CONCLUSIONS: Parenchymal liver injuries can be treated well, with no adverse effect on patient or graft survival. An early decision concerning the surgical procedure for controlling hemorrhage is required. A basically aggressive therapeutic approach might avoid further complications relating to reperfusion edema.