Donor information based prediction of early allograft dysfunction and outcome in liver transplantation.

BACKGROUND & AIMS: Poor initial graft function was recently newly defined as early allograft dysfunction (EAD) [Olthoff KM, Kulik L, Samstein B, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl 2010; 16: 943]. Aim of this analysis was to evaluate predictive donor information for development of EAD. METHODS: Six hundred and seventy-eight consecutive adult patients (mean age 51.6 years; 60.3% men) who received a primary liver transplantation (LT) (09/2003-12/2011) were included. Standard donor data were correlated with EAD and outcome by univariable/multivariable logistic regression and Cox proportional hazards to identify prognostic donor factors after adjustment for recipient confounders. Estimates of relevant factors were utilized for construction of a new continuous risk index to develop EAD. RESULTS: 38.7% patients developed EAD. 30-day survival of grafts with and without EAD was 59.8% and 89.7% (P < 0.0001). 30-day survival of patients with and without EAD was 68.5% and 93.1% (P < 0.0001) respectively. Donor body mass index (P = 0.0112), gGT (P = 0.0471), macrosteatosis (P = 0.0006) and cold ischaemia time (CIT) (P = 0.0031) were predictors of EAD. Internal cross validation showed a high predictive value (c-index = 0.622). CONCLUSIONS: Early allograft dysfunction correlates with early results of LT and can be predicted by donor data only. The newly introduced risk index potentially optimizes individual decisions to accept/decline high risk organs. Outcome of these organs might be improved by shortening CIT.

Successful Management of an Infected Aortic Stent Graft in a Liver Transplanted Patient.

We report on a 57-year-old female liver transplanted patient who underwent endovascular aneurysm repair because of an infrarenal abdominal aortic aneurysm. Two months later, she developed an infection, and positron emission tomography computed tomography detected a paraprosthetic abscess. Explantation of the endoprosthesis and aortic reconstruction with a Y-shaped silver graft was made. The patient was discharged on the 12th postoperative day and shows up regularly in our outpatients department in a good clinical condition. After meticulous research of the current literature, this is the first published case of the successful management of an infected endovascular aortic stent in a liver transplanted patient.

Ten-year survival of esophageal cancer after an en-bloc esophagectomy.

BACKGROUND: Esophagectomy with gastric pull-up is the optimal treatment for patients with resectable esophageal cancer. Although the morbidity and mortality of an esophagectomy is reduced, the long-term outcome remains poor. The aim of this study was to evaluate the 10-year survival of a standardized multidisciplinary therapy concept for esophageal cancer. METHODS: Between 1989 and 1999, 114 patients were treated for esophageal cancer at the University of Essen. All patients underwent an en-bloc esophagectomy with systematic lymphadenectomy. Patients with locally advanced disease (stage III) received neoadjuvant therapy. All patients were followed-up for 10 years or more or until death. RESULTS: The 3-year survival was 35%, the 5-year survival 25%, and the 10-year survival was 18%. The recurrence rate was 44% with a median time of 13 months. There was no significant difference in survival between patients with locally advanced disease who received neoadjuvant therapy and patients with early disease (stadium I + II) who underwent surgery alone. Of the patients who achieved 10-year survival, 60% had locally advanced disease and received neoadjuvant therapy. CONCLUSION: Patients with locally advanced disease, managed by a multidisciplinary treatment strategy, achieved a similar long-term survival to patients with early disease (stadium I + II).

Towards real-time cardiovascular magnetic resonance guided transarterial CoreValve implantation: in vivo evaluation in swine.

BACKGROUND: Real-time cardiovascular magnetic resonance (rtCMR) is considered attractive for guiding TAVI. Owing to an unlimited scan plane orientation and an unsurpassed soft-tissue contrast with simultaneous device visualization, rtCMR is presumed to allow safe device navigation and to offer optimal orientation for precise axial positioning. We sought to evaluate the preclinical feasibility of rtCMR-guided transarterial aortic valve implatation (TAVI) using the nitinol-based Medtronic CoreValve bioprosthesis. METHODS: rtCMR-guided transfemoral (n = 2) and transsubclavian (n = 6) TAVI was performed in 8 swine using the original CoreValve prosthesis and a modified, CMR-compatible delivery catheter without ferromagnetic components. RESULTS: rtCMR using TrueFISP sequences provided reliable imaging guidance during TAVI, which was successful in 6 swine. One transfemoral attempt failed due to unsuccessful aortic arch passage and one pericardial tamponade with subsequent death occurred as a result of ventricular perforation by the device tip due to an operating error, this complication being detected without delay by rtCMR. rtCMR allowed for a detailed, simultaneous visualization of the delivery system with the mounted stent-valve and the surrounding anatomy, resulting in improved visualization during navigation through the vasculature, passage of the aortic valve, and during placement and deployment of the stent-valve. Post-interventional success could be confirmed using ECG-triggered time-resolved cine-TrueFISP and flow-sensitive phase-contrast sequences. Intended valve position was confirmed by ex-vivo histology. CONCLUSIONS: Our study shows that rtCMR-guided TAVI using the commercial CoreValve prosthesis in conjunction with a modified delivery system is feasible in swine, allowing improved procedural guidance including immediate detection of complications and direct functional assessment with reduction of radiation and omission of contrast media.

Invasive Surgery Impairs the Regulatory Function of Human CD56 bright Natural Killer Cells in Response to Staphylococcus aureus. Suppression of Interferon-γ Synthesis.

Major surgery increases the risk for infectious complications due to the development of immunosuppression. CD56 bright NK cells play a key role in the defense against bacterial infections through the release of Interferon (IFN) γ upon stimulation with monocyte-derived Interleukin (IL) 12. We investigated whether invasive visceral surgery interferes with the IFN-γ synthesis of human NK cells in response to Staphylococcus aureus. In a prospective pilot study, peripheral blood mononuclear cells (PBMC) were isolated from 53 patients before and 1 to 7 d after elective visceral surgery. The release of IL-12 and IFN-γ from PBMC upon exposure to S. aureus in vitro was quantified. The expression of the IL-12 receptor ß1 chain on the surface, the phosphorylation of signal transducer and activator of transcription (STAT) 4, and the synthesis of IFN-γ on/in individual CD56 bright NK cells were investigated using flow cytometry. The modulatory effect of IL-12 on the S. aureus-induced IFN-γ production in CD56 bright NK cells was analyzed. The IFN-γ secretion from purified CD56 bright NK cells was quantified after stimulation with IL-12 and IL-18. After surgery, CD56 bright NK cells among total PBMC were impaired in the release of IFN-γ for at least 5 d. Likewise, the IL-12-induced release of IFN-γ from purified CD56 bright NK cells was abolished. Upon stimulation with S. aureus, PBMC secreted less IL-12 but supplementation with recombinant IL-12 did not restore the capacity of CD56 bright NK cells to produce IFN-γ. CD56 bright NK cells displayed reduced levels of the IL-12Rß1 chain whereas the phosphorylation of STAT4, the key transcription factor for the Ifng gene was not diminished. In summary, after invasive visceral surgery, CD56 bright NK cells are impaired in S. aureus-induced IFN-γ production and might contribute to the enhanced susceptibility to opportunistic infections.

Progression to adenocarcinoma in Barrett's esophagus after liver transplantation.

BACKGROUND: The risk for development of certain malignancies after transplantation is well known. Especially in premalignant lesions of the skin and colon, rapid progression is described. The aim of this study is to evaluate the progress of Barrett's mucosa to adenocarcinoma of the esophagus after liver transplantation. METHODS: Between 2000 and 2009, 895 patients underwent a liver transplantation in our department. All patients had an upper endoscopy as part of the evaluation before transplantation. Patients who had Barrett's mucosa described in their endoscopy report were identified. The records of these patients were retrospectively reviewed. RESULTS: There were seven patients who had Barrett's mucosa in the preoperative endoscopy. Five of these patients (71%) developed an esophageal adenocarcinoma in a median time of 66 months after liver transplantation. One had stage II disease and four had stage III disease. Three of them underwent neoadjuvant therapy. All patients underwent an en bloc esophagectomy. One patient developed recurrent disease after 12 months and died 37 months after esophagectomy. The other four patients are still alive without recurrence and have a median survival of 16 months. CONCLUSION: Esophageal cancer after liver transplantation is rare, whereas the risk for progression of Barrett's esophagus to adenocarcinoma is extremely high. Surveillance endoscopy with aggressive endoscopic treatment of the Barrett's is essential for these patients to prevent them from cancer death. Furthermore, immunosuppression therapy based on immunosuppressants with antitumoral effects should be preferred. The esophagectomy with neoadjuvant therapy is also in immunosuppressant patients feasible without increased risk for complications.