Role of liver augmentation prior to hepatic resection - a survey on standards, procedures, and indications in Germany, Switzerland, and Austria.

PURPOSE: For primary and secondary liver tumors oncological resection remains a chance of cure. Augmentation of functional liver tissue may be necessary to preserve sufficient future liver remnant (FLR). Clinical decision-making on liver augmentation techniques and indications may differ internationally. Thus, this study aims to identify standards of liver augmentation in hepato-pancreatico-biliary (HPB) centers in Germany, Switzerland, and Austria. METHODS: Using a web-based survey, 48 hospitals in Germany, Switzerland, and Austria were invited to report their surgical indication, standard procedures, and results of liver augmentation. RESULTS: Forty (83.3%) of the hospitals invited participated. Most of the hospitals were certified liver centers (55%), performing complex surgeries such as liver transplantation (57.5%) and ALPPS (80%). The standard liver augmentation technique in all countries was portal vein embolization (PVE; 56%), followed by ALPPS (32.1%) in Germany or PVE with hepatic vein embolization (33.3%) in Switzerland and Austria. Standard procedure for liver augmentation did not correlate with certification as liver center, performance of liver transplantation or ALPPS. Surgical indication for PVE varied depending on tumor entity. Most hospitals rated the importance of PVE before resection of cholangiocarcinoma or colorectal metastases as high, while PVE for hepatocellular carcinoma was rated as low. CONCLUSION: The survey gives an overview of the clinical routine in HPB centers in Germany, Austria, and Switzerland. PVE seems to dominate as standard technique to increase the FLR. However, there is a variety in the main indication for liver augmentation. Further studies are necessary evaluating the differing PVE techniques for liver augmentation.

MRI analysis of the physiological patellofemoral joint morphology of adult knees.

OBJECTIVE: The aim of the present study was to determine physiological reference values for the morphology of the patella and to analyse these parameters according to patella position in healthy knee joints. MATERIAL AND METHODS: Healthy knee joints of 409 patients (mean age, 52.3 years [± 16.8]) were analysed retrospectively on MRI images for Insall-Salvati index (ISI), sagittal patella thickness (PTS) and patella length (PLS) as well as axial patella thickness (PTA) and patella width (PWA). Differences between patellar diameters were analysed depending on ISI, side, age and gender. RESULTS: Mean PTS was 20.1 mm (± 2.4), PLS 44.0 mm (± 4.4), PTA 21.8 mm (± 2.4) and PWA 44.5 mm (± 4.7). Depending on the vertical patellar position (ISI), all patellar parameters (p < 0.01) showed significant differences between patients with a patella alta, norma and baja. In general, a smaller ISI showed higher measured values for the patellar parameters. There were no significant differences for the laterality. Only PTS showed a significant age difference (p = 0.031). All parameters were significantly larger in male compared to female knees (p < 0.001). CONCLUSION: Reference parameters for the patella morphology are reported. Concluding from the results, a relationship between vertical patellar position and patellar morphology seems to exist. This finding should be taken into account in diagnostics and therapy of patella disorders.

Sagittal magnetic resonance imaging-scan orientation significantly influences accuracy of femoral posterior condylar offset measurement.

BACKGROUND: In total knee arthroplasty the femoral posterior condylar offset (PCO) may serve as a potential branch for correct femoral component positioning. The technique of adjusting the sagittal magnetic resonance imaging (MRI)-scan on which it is measured has not been investigated in previous literature, but may be subject to variances due to knee joint positioning or axial localizer scan angulation. The purpose of this study was to investigate the effect of simulated femur rotation on the accuracy of PCO measurement. MATERIALS AND METHODS: Ten asymptomatic knee joints underwent MRI investigations. A sagittal plane perpendicular to the transepicondylar axis was defined as the true-sagittal plane (tsP). Sagittal images were reformatted in the tsP and angulated by 5° and - 5° in medial and lateral direction. In total each knee received three scans in 0°, 5° and - 5° axial localizer scan angulation. Medial and lateral PCO measurement was performed in each MRI-scan angulation. RESULTS: Simulated external rotation decreased medial PCO size by 1.7 mm (95% CI 0.5994-3.127) (p = 0.012), and simulated internal rotation increased medial PCO size by 2.1 mm (95% CI 1.142-2.994) (p = 0.001). Lateral PCO size increased by 1.9 mm (95% CI 0.5660-3.412) and decreased by 2.1 mm (95% CI 1.142-2.994) with simulated external and internal rotation, respectively (p = 0.011; p = 0.0007). CONCLUSION: This study shows the high sensitivity of medial and lateral PCO measurements to small changes of MRI axial localizer scan angulations simulating minor degrees of internal or external femur rotation. Thus, absolute PCO values should be interpreted with caution if the sagittal image acquisition is not standardized.

Perioperative LiMAx Test Analysis: Impact of Portal Vein Embolisation, Chemotherapy and Major Liver Resection.

BACKGROUND: Postoperative liver failure (PLF) is a severe complication after major liver resection (MLR). To increase the safety of patients, clinical bedside tests are of great importance. However, limitations of their applicability and validity impair their value. METHODS: Preoperative measurements of the liver maximum capacity (LiMAx) were performed in n = 40 patients, who underwent MLR (≥3 segments). Matched postoperative LiMAx was measured in n = 21 patients. Liver function was compared between pretreated patients (n = 11 with portal vein embolisation (PVE) and n = 19 patients with preoperative chemotherapy) and therapy naïve patients. The LiMAx values were compared with liver-specific blood parameters and volumetric analysis. RESULTS: In total, n = 40 patients were enrolled in this study. The majority of patients (n = 33; 82.5%) had high preoperative LiMAx values (>315 µg/kg/h), while only seven patients (17.5%) had medium values (140-315 µg/kg/h), and none of the patients had low values (<140 µg/kg/h). A comparison of pretreated patients (with PVE and/or chemotherapy) and therapy naïve patients showed no significant difference in the preoperative LiMAx values (p > 0.05). The preoperative LiMAx values were significantly higher than the matched postoperative values on postoperative day 1 (p < 0.0001). A comparison between the expected and measured postoperative LiMAx showed a difference (≥10%) in 7 out of 13 patients (53.8%). After an initial postoperative decrease in the LiMAx, the patients without complications (n = 12) showed a continuous increase until 14 days after surgery. In the patients with postoperative complications, a decrease in the LiMAx was associated with a prolonged recovery. CONCLUSIONS: For patients undergoing MLR within the 0.5% rule, which is the clinical gold standard, the LiMAx values do not offer any additional information. Additionally, the LiMAx may have reflected liver function, but it did not deliver additional information regarding postoperative liver recovery. The clinical use of LiMAx might be relevant in selected patients beyond the 0.5% rule.

[Treatment recommendation and care in traumatic rupture of the spleen]. / Therapieempfehlung und Versorgung bei traumatischer Milzruptur.

The spleen is the most frequently affected organ in blunt abdominal trauma. Initial diagnostics include the physical examination, laboratory blood controls and ultrasound. Furthermore, a triphasic dynamic contrast-enhanced computed tomography (CT) scan is indicated. Apart from the imaging-based classification of the injury with consideration of vascular alterations and active bleeding, the hemodynamic condition of the patient is a crucial factor. For patients who are hemodynamically stable or can be stabilized, a nonoperative management with a minimum of 24 h of continuous monitoring, regular blood controls of the hemoglobin level as well as ultrasound follow-up should be given precedence. In cases of active bleeding or pathological vascular alterations, a radiological intervention in the sense of an embolization should be initiated. A hemodynamically unstable patient must immediately undergo surgical treatment, during which a spleen-preserving approach via splenorrhaphy should principally be favored over splenectomy. This also applies to patients where the intervention has failed. To prevent severe infections after splenectomy it is advised to vaccinate against Pneumococcus, Haemophilus influenzae type B and Meningococcus as well as the annual seasonal influenza vaccination according to the Standing Committee on Vaccination (STIKO) recommendations.

Morphological Parameters of the Hip Joint and Its Relation to Gender, Joint Side and Age-A CT-Based Study.

Background: Physiological reference values for morphological parameters of the hip (MPH) are of clinical importance for the treatment of painful, degenerated or fractured hip joints, as well as to detect morphological deformities, which could result in early osteoarthritis of the hip. Currently, sufficient data for MPH are lacking. Therefore, it remains unclear if age-dependent alterations in adult hip morphology are physiological and if there are side- and gender-dependent differences. The aim of the study was to analyze MPH according to gender, side and age in a large-scaled cohort by CT scans. Methods: A total of 1576 hip joints from 788 patients (female: 257, male: 531; mean age: 58.3 years (±18.9; 18−92 years)) were analyzed by CT. For all hips, acetabular anteversion (AcetAV); lateral centrum edge angle (LCE); acetabular index (AI); femoral neck version (FNV); centrum-collum-diaphyseal angle (CCD); and anterior alpha angle (AαA) were measured. Results: The mean values in this cohort were: AcetAV 20.5° (±6.9); LCE 40.8° (±8.8); AI 0.3° (±5.3); FNV 11.0° (±9.8); CCD 129.9° (±7.4); and AαA 41.2° (±7.7). There was a detectable side-specific difference for AcetAV (p = 0.001); LCE (p < 0.001); CCD (p < 0.001); and AαA (p < 0.001). All the analyzed parameters showed a significant gender-specific difference, except for AI (p = 0.37). There was a significant correlation between age and AcetAV (r = 0.17; p < 0.001); LCE (r = 0.39; p < 0.001); AI (r = −0.25; p < 0.001); CCD (r = −0.15; p < 0.001); and AαA (r = 0.09; p < 0.001), except FNV (p = 0.79). Conclusions: There are side-, gender- and age-specific alterations in hip morphology, which have to be considered in treating hip joint pathologies.

Physiological Offset Parameters of the Adult Shoulder Joint-A MRI Study of 800 Patients.

Background: Humeral offset (HO) and glenoidal offset (GO) are important morphological parameters in diagnostics and therapy for shoulder pathologies. However, physiological reference values have not yet been sufficiently determined. The aim of the present study was to establish physiological reference values for shoulder offset parameters (SOPs). Methods: MRI images of the shoulder joints of 800 patients (mean age: 50.13 years [±16.01]) were analysed retrospectively. HO, GO, lateral glenoidal humeral offset (LGHO), humeral shaft axis offset (HAO) and cortical offset (CO) were measured. SOPs were examined for associations with age, gender, side and osteoarthritis. Results: The mean HO was 26.19 (±2.70), the mean GO was 61.79 (±5.67), the mean LGHO was 54.49 (±4.69), the mean HAO was 28.17 (±2.82) and the mean CO was 16.70 (±3.08). For all SOPs, significantly higher values were measured in male shoulders. There was a significantly (p < 0.001) higher mean value for HO, GO and LGHO in right shoulders. There was a significant correlation between age and LGHO, and HAO and CO, but not between age and HO or GO. Shoulders with osteoarthritis and non-osteoarthritis did not differ in the mean value of HO, GO, LGHO and HAO, except for CO (p = 0.049). Conclusion: Reference values for SOPs in the adult shoulder joint were determined for the first time. Significant gender-specific differences were found for all measured SOPs. In addition, it was seen that for some SOPs, the joint side and the patient's age has to be taken into account in shoulder diagnostics and surgery.

Assessment of esophagogastric junction morphology by dynamic real-time MRI: comparison of imaging features to high-resolution manometry.

PURPOSE: To assess the esophagogastric junction (EGJ) on real-time MRI and compare imaging parameters to EGJ morphology on high-resolution manometry (HRM). METHODS: A total of 105 of 117 eligible patients who underwent real-time MRI and high-resolution manometry for GERD-like symptoms between 2015 and 2018 at a single center were retrospectively evaluated (male n = 57; female n = 48; mean age 52.5 ± 15.4 years). Real-time MRI was performed at a median investigation time of 15 min (1 frame/40 ms). On HRM, EGJ morphology was assessed according to the Chicago classification of esophageal motility disorders. Real-time MRI was performed at 3 T using highly undersampled radial fast low-angle shot acquisitions with NLINV image reconstruction. A 10 mL pineapple juice bolus served as oral contrast agent at supine position. Real-time MRI films of the EGJ were acquired during swallowing events and during Valsalva maneuver. Anatomic and functional MRI parameters were compared to EGJ morphology on HRM. RESULTS: On HRM, n = 42 patients presented with EGJ type I (40.0%), n = 33 with EGJ type II (31.4%), and n = 30 with EGJ type III (28.6%). On real-time MRI, hiatal hernia was more common in patients with EGJ type III (66.7%) than in patients with EGJ type I (26.2%) and EGJ type II (30.3%; p < 0.001). Sliding hiatal hernia was more frequent in patients with EGJ type II (33.3%) than in patients with EGJ type III (16.7%) and EGJ type I (7.1%; p = 0.017). The mean esophagus-fundus angle of patients was 85 ± 31° at rest and increased to 101 ± 36° during Valsalva maneuver. CONCLUSION: Real-time MRI is a non-invasive imaging method for assessment of the esophagogastric junction. Real-time MRI can visualize dynamic changes of the EGJ during swallowing events.

Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis.

BACKGROUND: Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment. OBJECTIVE: To compare OTSC treatment to TAE in refractory peptic ulcer bleeding. PATIENTS AND METHODS: In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics. RESULTS: Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant. CONCLUSIONS: OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.

Comparison of Chest Ultrasound and Standard X-Ray Imaging in COVID-19 Patients.

PURPOSE: The COVID-19 pandemic poses new challenges for the medical community due to its large number of patients presenting with varying symptoms. Chest ultrasound (ChUS) may be particularly useful in the early clinical management in suspected COVID-19 patients due to its broad availability and rapid application. We aimed to investigate patterns of ChUS in COVID-19 patients and compare the findings with results from chest X-ray (CRX). MATERIALS AND METHODS: 24 patients (18 symptomatic, 6 asymptomatic) with confirmed SARS-CoV-2 by polymerase chain reaction underwent bedside ChUS in addition to CRX following admission. Subsequently, the results of ChUS and CRX were compared. RESULTS: 94% (n=17/18) of patients with respiratory symptoms demonstrated lung abnormalities on ChUS. ChUS was especially useful to detect interstitial syndrome compared to CXR in COVID-19 patients (17/18 vs. 11/18; p<0.02). Of note, ChUS also detected lung consolidations very effectively (14/18 for ChUS vs. 7/18 cases for CXR; p<0.02). Besides pathological B-lines and subpleural consolidations, pleural line abnormality (89%; n=16/18) was the third most common feature in patients with respiratory manifestations of COVID-19 detected by ChUS. CONCLUSION: Our findings support the high value of ChUS in the management of COVID-19 patients.

Assessment of esophageal motility disorders by real-time MRI.

PURPOSE: To investigate imaging findings of esophageal motility disorders on dynamic real-time. MATERIAL AND METHODS: 102 patients with GERD-like symptoms were included in this retrospective study between 2015-2018. Dynamic real-time MRI visualized the transit of a 10 mL pineapple juice bolus through the esophagus and EGJ with a temporal resolution of 40 ms. Dynamic and anatomic parameters were measured by consensus reading. Imaging findings were compared to HRM utilizing the Chicago classification of esophageal motility disorders, v3.0. RESULTS: All 102 patients completed real-time MRI in a median examination time of 15 min. On HRM, 14 patients presented with disorders with EGJ outlet obstruction (EGJOO) (13.7 %), 7 patients with major disorders of peristalsis (6.9 %), and 32 patients with minor disorders of peristalsis (31.4 %). HRM was normal in 49 patients (48.0 %). Incomplete bolus clearance was significantly more frequent in patients with esophageal motility disorders on HRM than in patients with normal HRM (p = 0.0002). In patients with motility disorders with EGJOO and major disorders of peristalsis, the esophageal diameter tended to be wider (23.6 ±â€¯8.0 vs. 21.2 ±â€¯3.5 mm, p = 0.089) and the sphincter length longer (19.7 ±â€¯7.3 vs. 16.7 ±â€¯3.0 mm, p = 0.091) compared to patients with normal HRM. 3/7 patients with achalasia type II were correctly identified by real-time MRI and one further achalasia type II patient was diagnosed with a motility disorder on MRI films. The other 3/7 patients presented no specific imaging features. CONCLUSION: Real-time MRI is an auxiliary diagnostic tool for the assessment of swallowing events. Imaging parameters may assist in the detection of esophageal motility disorders.

Noninvasive imaging of liver repopulation following hepatocyte transplantation.

Near infrared fluorescence (NIRF) optical imaging is a technique particularly powerful when studying in vivo processes at the molecular level in preclinical animal models. We recently demonstrated liver irradiation under the additional stimulus of partial hepatectomy as being an effective primer in the rat liver repopulation model based on hepatocyte transplantation. The purpose of this study was to assess optical imaging and the feasibility of donor cell expansion tracking in vivo using a fluorescent probe. Livers of dipeptidylpeptidase IV (DPPIV)-deficient rats were preconditioned with irradiation. Four days later, a partial hepatectomy was performed and wild-type (DPPIV+) hepatocytes were transplanted into recipient livers via the spleen. Repopulation by transplanted DPPIV+ hepatocytes was detected in vivo with Cy5.5-conjugated DPPIV antibody using the eXplore Optix System (GE HealthCare). Results were compared with nontransplanted control animals and transplanted animals receiving nonspecific antibody. Optical imaging detected Cy5.5-specific fluorescence in the liver region of the transplanted animals, increasing in intensity with time, representing extensive host liver repopulation within 16 weeks following transplantation. A general pattern of donor cell multiplication emerged, with an initially accelerating growth curve and later plateau phase. In contrast, no specific fluorescence was detected in the control groups. Comparison with ex vivo immunofluorescence staining of liver sections confirmed the optical imaging results. Optical imaging constitutes a potent method of assessing the longitudinal kinetics of liver repopulation in the rat transplantation model. Our results provide a basis for the future development of clinical protocols for suitable fluorescent dyes and imaging technologies.

Current perspective of multidetector computed tomography (MDCT) in patients after midface and craniofacial trauma.

PURPOSE: The purpose of the study was to determine the prevalence of fractures and incidental findings (IF) with emphasis on clinical significance. MATERIALS AND METHODS: A total of 784 patients were evaluated by computed tomography. Fractures and IF were registered and classified as significant if they were recommended for additional diagnostics or therapy. RESULTS: Four hundred seventy of 784 patients (60%) sustained a fracture. Significant fractures were found in 694/1213 fractures (57%); nonsignificant fractures were found in 519/1213 (43%) fractures. A total of 972 IF were observed in 464/784 (59%) patients. Significant findings were found in 358/972 findings (37%). There were 1.5 fractures and 1.2 IF per patient. CONCLUSION: There is a high prevalence of significant fractures (57%) and IF (37%).

Noninvasive Imaging of Liver Repopulation following Hepatocyte Transplantation.

Near infrared fluorescence (NIRF) optical imaging is a technique particularly powerful when studying in vivo processes at the molecular level in preclinical animal models. We recently demonstrated liver irradiation under the additional stimulus of partial hepatectomy as being an effective primer in the rat liver repopulation model based on hepatocyte transplantation. The purpose of this study was to assess optical imaging and the feasibility of donor cell expansion tracking in vivo using a fluorescent probe. Livers of dipeptidylpeptidase IV (DPPIV)-deficient rats were preconditioned with irradiation. Four days later, a partial hepatectomy was performed and wild-type (DPPIV+) hepatocytes were transplanted into recipient livers via the spleen. Repopulation by transplanted DPPIV+ hepatocytes was detected in vivo with Cy5.5-conjugated DPPIV antibody using the eXplore Optix™ System (GE HealthCare). Results were compared with nontransplanted control animals and transplanted animals receiving nonspecific antibody. Optical imaging detected Cy5.5-specific fluorescence in the liver region of the transplanted animals, increasing in intensity with time, representing extensive host liver repopulation within 16 weeks following transplantation. A general pattern of donor cell multiplication emerged, with an initially accelerating growth curve and later plateau phase. In contrast, no specific fluorescence was detected in the control groups. Comparison with ex vivo immunofluorescence staining of liver sections confirmed the optical imaging results. Optical imaging constitutes a potent method of assessing the longitudinal kinetics of liver repopulation in the rat transplantation model. Our results provide a basis for the future development of clinical protocols for suitable fluorescent dyes and imaging technologies.