[Preconditioning of the liver]. / Präkonditionierung der Leber.

Posthepatectomy liver failure (PHLF) still represents a severe complication after major liver resection associated with a high mortality. In addition to an insufficient residual liver volume various factors play an important role in the pathophysiology of PHLF. These include the quality of the parenchyma, liver function, perfusion, i.e. maintenance of adequate inflow and outflow, as well as the condition of the patient and comorbidities. While the liver volume is relatively easy to evaluate using modern imaging techniques, the evaluation of liver function and liver quality require a differentiated approach. Both factors can be influenced by the constitutional status of the patient, medical history and previous treatment and must be given sufficient consideration in the risk evaluation. An adequate perfusion, e.g. portal and arterial circulation and adequate outflow by at least one hepatic vein as well an adequate biliary drainage should be always guaranteed in order to allow regeneration of the residual liver tissue. Only the understanding of all these aspects will support the surgeon in a correct and safe evaluation of the resectability. Additionally, the liver surgeon should be aware of all available perioperative and postoperative options to treat and to prevent PHLF. In this review article the most important questions regarding the risk factors related to PHLF are presented and the potential therapeutic and prophylactic management is described. The main goal is to ensure functional operability of the patient if oncological resectability is possible. In other words: in the case of correct oncological indication, the liver surgeon should be able to resect what is resectable or, alternatively, make resectable what primarily was not resectable.

Kidney Graft Salvage Strategies for Vascular Complications During Kidney Transplantation: A Single-center Experience.

BACKGROUND: Kidney-related unknown vascular injuries are rare and usually diagnosed only after reperfusion. Hemorrhage that makes in situ reconstruction impossible can lead to graft loss. In an era of organ shortage and an increasing number of patients on the waiting list for transplantation, a kidney graft salvage procedure consisting of graft nephrectomy, reperfusion, reconstruction, and reimplantation should be undertaken whenever possible as a contribution to extending the organs available for transplantation. METHODS AND PATIENTS: From January 2010 to December 2015, in total five patients suffered from intraoperative or immediate postoperative vascular complication and were included for this retrospective analysis. Age, sex, etiology of kidney failure, delayed graft function, kind of vascular complications and therapy, presence of aortoiliac calcification, cold and warm ischemia time, and length of hospital stay were analyzed. RESULTS: By applying this "one-step-back" procedure in three consecutive patients and a structured in situ repair in two patients, all grafts were saved. Two of five patients developed delayed graft function requiring hemodialysis. At discharge, graft function was excellent in all five patients. Reconstructed vasculature showed 100% patency. CONCLUSION: These graft salvage strategies are safe with excellent outcome and should be considered in the event of an acute vascular complication during kidney transplantation.

Liver fluke-infested graft used for living-donor liver transplantation: case report and review of the literature.

Clonorchiasis is a cholangiopathy caused by foodborne trematode parasites, also known as liver flukes. Clonorchiasis is endemic in a wide geographical area extending from Eastern Europe to Southeast Asia. Infested hosts may remain asymptomatic for decades and consequently their liver can become available as a graft. To date, 20 liver transplantations with liver fluke-infested grafts have been reported in the literature. All of them occurred in Asian countries. We, here, report the first case to our knowledge in the Western world of living-donor liver transplantation (LDLT) with an Opisthorchis felineus-infested graft, and present a review of the literature. A 6-month-old girl with decompensated secondary biliary cirrhosis underwent an LDLT with a left lateral graft infested with O. felineus. After prompt diagnosis and adequate therapy, both donor and recipient had an uneventful postoperative course and long-term follow-up. Liver grafts infested with liver flukes do not pose a contraindication to liver donation from deceased or living donors, provided that a correct diagnosis and treatment are performed in a timely fashion.

[Living liver donor: indications and technical aspects]. / Leberlebendspende - Indikation und Technik.

Living donor liver transplantation (LDLT) nowadays represents an important and safe alternative to conventional deceased donor liver transplantation (DDLT). A major concern related to the LDLT procedure is still represented by donor safety because a serious operation not without risks must be carried out on a healthy individual. In the present review of the indications for LDLT the technical concepts of donor surgery, criteria for donor selection and evaluation and morbidity and mortality results related to the procedure are presented. In general, the indications for LDLT are almost the same as for DDLT. The donor hepatectomy (right, left or left lateral) is presented in five main phases. The reported morbidity rates vary between 10 % and 60 % and are strongly related to the experience of the transplant center. The currently reported postoperative mortality rates for left and right hepatectomy are 0.1 % and 0.5 %, respectively. The results of LDLT are similar if not even better than those for DDLT depending on the specific indications.

[Vascular management in anatomical liver resection]. / Vaskuläres Management bei anatomischen Leberresektionen.

The vascular management in anatomical liver resection plays a pivotal role in maintaining an adequately functional residual liver volume. In this respect it is essential to guarantee an adequate portal and arterial inflow as well venous outflow for the whole residual liver (lobe or segments). To achieve this, the liver surgeon should have excellent perioperative imaging, surgical expertise based on knowledge of vascular anatomy, physiology and hemodynamics of the liver and a well-designed and cautious operative strategy. The use of intraoperative ultrasonography (with or without contrast enhancement) and modern parenchymal dissectors (e.g. ultrasound or water jet dissectors) are strongly recommended.

Long-term effects of fundoplication in children with chronic airway diseases.

BACKGROUND: Association between chronic airway diseases (CAD) and gastroesophageal reflux disease (GERD) is well described, but causality has not yet been conclusively established. This study evaluates the therapeutic significance of laparoscopic Thal fundoplication in children with CAD and diagnosed GERD. METHODS: We performed a retrospective analysis of 182 neurologically nonimpaired children, all with medically refractory CAD and GERD undergoing laparoscopic Thal fundoplication. The clinical response, ability to wean oral and inhaled medication and satisfaction with postoperative results were evaluated. RESULTS: Main symptoms disappeared completely in 68.7% of patients and were markedly improved in a further 22% of patients following surgery. Complete discontinuation of medication was achieved in 70.1-96.4% of cases and reduced in a further 1.8-23.5%. One intraoperative complication occurred (gastric perforation), however no conversion to laparotomy was necessary. Postoperative Dumping Syndrome occurred in 1% of cases and was managed dietetically. Prolonged postoperative dysphagia occurred in 4.3% of patients, but disappeared within 8 weeks in all but one case. CONCLUSIONS: Our study suggests that Thal fundoplication in neurologically nonimpaired children with CAD and documented GERD is effective and safe. Children unresponsive to preoperative medical management showed significant improvement in airway symptoms together with a marked reduction in the need for medication. We conclude that laparoscopic Thal fundoplication represents a significant treatment worthy of consideration in this group of patients.

Indications and limits for associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). Lessons Learned from 15 cases at a single centre.

INTRODUCTION: The ALPSS procedure has been recently introduced as an alternative to PVE for liver volume augmentation in cases of planned right trisectionectomy with small future RLV and high risk of PHLF. We retrospectively analysed our single centre experience with 15 ALPPS procedures in order to better assess the limits and indications of the procedure. PATIENTS AND METHODS: The following volumetric parameters were evaluated: total liver volume (TLV), remnant liver volume (RLV), remnant liver volume to total liver volume ratio (RLV/TLV), remnant liver volume to body weight ratio (RLV/BWR) and median volume gain. The ALPPS procedure was usually considered when RLV/TLV < 25 % or RLV/BWR < 0.5. The ALPPS procedure consisted of phase 1 (in situ splitting of the liver), interphase (waiting for liver regeneration) and phase 2 (completion of right trisectionectomy). Postoperative complications were reported according to the Dindo-Clavien classification. Patient survival, late complications and tumour recurrence were analysed. RESULTS: Between November 2010 and September 2013, we performed 15 ALPPS procedures in 10 patients with primary liver tumours (5 h-CCA, 4 i-CCA and 1 HCC) and in 5 with CRLM. The preoperative RLV/TLV ratio was 22.6 % (15.7 - 29.2) and the RLV/BWR 0.46 (0.22 - 0.66). After 10 days (range 8 - 16) the RLV/TLV ratio and RLV/BWR increased up to 36.3 % (30 - 59.2 %) and 0.67 (0.5 - 1.2) respectively, with a median volume gain of 87.2 % (23.8 - 161 %). The time interval between phases 1 and 2 was 13 days (9 - 18). An R0 status was reached in 13 patients and R1 in 2. The overall postoperative morbidity was 66.7 %. After phase 1, 8 patients experienced 19 complications and 7 none. After phase 2, 11 patients experienced 36 complications and 4 none. Four patients died postoperatively after 22 days (9 - 36 days) resulting in a postoperative mortality of 28.7 %. After a median follow-up of 17 months (1 - 33), 10 out of 15 patients are still alive (survival rate 66.6 %). Four patients (2 i-CCA, 1 CRLM, 1 HCC) developed tumour recurrences (2 intrahepatic and 2 extrahepatic). One patient with i-CCA died at POM 4 secondary to peritoneal carcinosis. DISCUSSION: The actual high morbidity and mortality rates related to the ALPPS procedure should lead us to a more cautious selection of the candidates for this operation and restriction of the indications through an accurate work-up based on interdisciplinary cooperation among hepatologists, oncologists, radiologists and surgeons.