Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study.

BACKGROUND: Given the susceptibility of organs to ischaemic injury, alternative preservation methods to static cold storage (SCS), such as normothermic machine perfusion (NMP) are emerging. The aim of this study was to perform a comparison between NMP and SCS in liver transplantation with particular attention to bile duct lesions. METHODS: The outcomes of 59 consecutive NMP-preserved donor livers were compared in a 1 : 1 propensity score-matched fashion to SCS control livers. Postoperative complications, patient survival, graft survival and bile duct lesions were analysed. RESULTS: While patients were matched for cold ischaemia time, the total preservation time was significantly longer in the NMP group (21 h versus 7 h, P < 0.001). Patient and graft survival rates at 1 year were 81 versus 82 per cent (P = 0.347) and 81 versus 79 per cent (P = 0.784) in the NMP and SCS groups, respectively. The postoperative complication rate was comparable (P = 0.086); 37 per cent NMP versus 34 per cent SCS patients had a Clavien-Dindo grade IIIb or above complication. There was no difference in early (30 days or less) (NMP 22 versus SCS 19 per cent, P = 0.647) and late (more than 30 days) (NMP 27 versus SCS 36 per cent, P = 0.321) biliary complications. However, NMP-preserved livers developed significantly fewer ischaemic-type bile duct lesions (NMP 3 versus SCS 14 per cent, P = 0.047). CONCLUSION: The use of NMP allowed for a significantly prolonged organ preservation with a lower rate of observed ischaemic-type bile duct lesions.

[Grip strength measurement : Significance and boundaries]. / Die Messung der Griffkraft : Wertigkeit und Grenzen.

BACKGROUND: Grip strength measurement is a widely used method for clinical as well as scientific purposes. In hand surgery, it is an essential component in the diagnosis of disease, treatment sequences and assessment. In epidemiological studies, it is a good predictor of healthy ageing or disease progression. PROBLEM: Measurement results and their interpretation can be influenced by many factors. The historical development of dynamometry, measurement technology and the standard values in various population groups are presented. Comparisons with standard values should only be made using current tables because the grip strength has changed in recent decades. Assessment of the voluntarily submaximal grip strength remains problematic. Proposals are made for how to assess grip strength during the evaluation.

[Arthroscopy of the distal radioulnar joint]. / Die Arthroskopie des distalen Radioulnargelenks.

OBJECTIVE: The aim of the procedure is to visualize the proximal pouch of the DRUJ, the joint surfaces of the sigmoid notch and the ulnar head, the convexity of the ulnar head and the proximal ulnar side surface of the triangular fibrocartilage complex (TFCC). INDICATIONS: Arthroscopy of the distal radioulnar joint is applied for the evaluation of joint pathologies in ulnar-sided wrist pain, especially in cases without diagnostic findings in standard X­rays and MRIs and arthroscopically assisted procedures. SURGICAL TECHNIQUE: In vertical extension, two portals of the wrist are created on the dorsal side of the DRUJ between the extensor digiti minimi and extensor carpi ulnaris tendons. By insertion of a small joint arthroscope via these portals visualization of the ulnar head, the sigmoid notch, the proximal pouch of the DRUJ and the proximal surface of the TFCC is accomplished. CONCLUSIONS: Arthroscopy of the DRUJ is a rarely and not routinely performed procedure for the diagnosis and therapy of ulnar-sided wrist pain. It is technical demanding with a flat learning curve and anatomy-related obstacles. A complete view of the joint is not always accessible. Rare complications are injuries of the extensor digiti minimi tendon, as well as contusion or sectioning of the transverse branch of the dorsal branch of the ulnar nerve. In distinct cases, this procedure offers important additional information about the distal radioulnar joint. The procedure is especially valuable for the detection of proximal TFCC injuries that are missed otherwise.

[Carpus and distal radioulnar joint : Clinical and radiological examination]. / Carpus und distales Radioulnargelenk : Klinische und röntgenologische Untersuchung.

A precise medical history and specific symptom-oriented clinical tests of the wrist joint should always precede any radiological, computed tomography (CT) or magnetic resonance imaging (MRI) diagnostics. In many cases, specific clinical tests of the wrist joint allow at least a preliminary diagnosis, which can be supported by standard radiography using correct projections. A systematic approach is recommended covering the radiocarpal, midcarpal, ulnocarpal and distal radioulnar joints. Exact identification of the palpable anatomic landmarks is mandatory for correct application and interpretation of the various clinical tests. The results of the clinical tests in combination with radiological imaging can often detect precisely ruptures of distinct wrist joint ligaments and localized arthritis.

[Hand injuries in mountain sports]. / Handverletzungen beim Bergsport.

BACKGROUND: Apart from clean cut finger amputations, every kind of hand injury can be seen in mountain and winter sports but only skier's thumb and injuries of the pulley system in sport climbers are seen in a greater number of cases. Nevertheless, these two common injuries as well as the rare frostbite of the fingers are often underdiagnosed or overdiagnosed as well as undertreated or overtreated. PURPOSE: This paper describes the diagnostics and treatment of skier's thumb, injuries of the pulley system in sport climbers and frostbite of the fingers. RESULTS: Before checking the metacarpophalangeal (MP) joint of the thumb for stability, radiographs should be taken to exclude a bony avulsion of the ulnar collateral ligament in skier's thumb. If there is no bony ligament avulsion further diagnostic procedures, e.g. ultrasound, are recommended to prove or exclude a Stener lesion, which is an absolute indication for operative treatment together with a dislocated bony ligament avulsion. To quantify the severity of a lesion of the pulley system ultrasound and magnetic resonance imaging (MRI) are needed. Most lesions of the pulley system can be treated conservatively. Only multiple pulley ruptures or isolated ruptures associated with a lesion of the lumbrical muscles or collateral ligaments require operative treatment. As long as there is no infection amputation should be done as late as possible in frostbite of the fingers because the extent of the frostbite can rarely be correctly estimated. CONCLUSION: Most cases of skier's thumb as well as lesions of the pulley system can be treated non-operatively but precise diagnostics are needed.

[Scapholunate lesions]. / Die skapholunäre Bandverletzung.

Injuries to the scapholunate ligament are the most frequent cause of carpal instability. Therefore, if a scapholunate lesion is not diagnosed, it may result in a severe dysfunction of the wrist. This review describes the anatomy, and the kinematics of the wrist with an intact as well as a disrupted scapholunate ligament. The diagnostic of an isolated ligament lesion and a ligament injury associated with a fracture of the distal radius is presented. Finally, an algorithm for treatment based on the stage of injury is proposed.

[Injuries of the proximal interphalangeal joint]. / Verletzungen der Mittelgelenke.

BACKGROUND: Injuries of the proximal interphalangeal joint (PIP joint) are common. They are frequently underestimated by patients and initial treating physicians, leading to unfavorable outcomes. Basic treatment includes meticulous clinical and radiological diagnosis as well as anatomical and biomechanical knowledge of the PIP joint. TREATMENT: In avulsions of the collateral ligaments and the palmar plate with or without involvement of bone, nonoperative treatment is preferred. Operative stabilization is reserved for large displaced bony fragments or complex instabilities. In central slip avulsion or rupture, osseous refixation, suture, or reconstruction is common and nonoperative treatment is limited to special situations like minimally displaced avulsions. In basal fractures of the middle phalanx, elimination of joint subluxation and restoration of joint stability are priority. If the fragments are too small for fixation with standard implants, therapeutic alternatives include refixation of the palmar plate, dynamic distraction fixation, percutaneous stuffing, or replacement by a hemihamate autograft. Early motion is initiated regardless of the treatment regime. Undertreatment leads to persistent swelling, instability, and limited range of motion, which are difficult to treat. Contributing factors are unnecessary immobilization, immobilization in more than 20° flexion or transfixation by K-wires. For residual limitations, nonoperative treatment with physiotherapists and splinting is first choice. Operative treatment is reserved for persistent flexion/extension contractures persisting for more than 6 months, as well as reconstructions in boutonniere and swan neck deformity and salvage procedures for destroyed joints.

Immune cell dynamics deconvoluted by single-cell RNA sequencing in normothermic machine perfusion of the liver.

Normothermic machine perfusion (NMP) has emerged as an innovative organ preservation technique. Developing an understanding for the donor organ immune cell composition and its dynamic changes during NMP is essential. We aimed for a comprehensive characterization of immune cell (sub)populations, cell trafficking and cytokine release during liver NMP. Single-cell transcriptome profiling of human donor livers prior to, during NMP and after transplantation shows an abundance of CXC chemokine receptor 1+/2+ (CXCR1+/CXCR2+) neutrophils, which significantly decreased during NMP. This is paralleled by a large efflux of passenger leukocytes with neutrophil predominance in the perfusate. During NMP, neutrophils shift from a pro-inflammatory state towards an aged/chronically activated/exhausted phenotype, while anti-inflammatory/tolerogenic monocytes/macrophages are increased. We herein describe the dynamics of the immune cell repertoire, phenotypic immune cell shifts and a dominance of neutrophils during liver NMP, which potentially contribute to the inflammatory response. Our findings may serve as resource to initiate future immune-interventional studies.

[Long-term results following denervation of the wrist]. / Langzeitergebnisse nach Handgelenkdenervation.

BACKGROUND: This retrospective study examines long-term follow-up results after complete denervation of the wrist. PATIENTS AND METHODS: Between 1994 and 2000 a total of 61 complete wrist denervations of 59 patients (median age at operation 46 years) were performed. In 2009 29 patients with 30 complete wrist denervations took part in a follow-up examination after an average of 10 years. The mobility of the wrist and the grip force were examined. Pain and satisfaction with the operation were determined by means of a visual analogue scale (VAS) (0-100). The patients were asked about pain reduction and how long it lasted. Further the DASH and the Mayo Wrist Score were evaluated. Radiographs of the denervated wrist were performed and the degree of the degenerative osteoarthritis was determined according to Knirk and Jupiter. RESULTS: In 7 of the 36 patients examined, a partial or total wrist arthrodesis was performed. These patients were excluded from the study. Pain was improved in 28 of the 30 denervated wrists examined, in 22 the improvement lasted until the follow-up examination, whereas in 6 the pain increased after a median of 90 months. The median pain intensity was 10 at rest and 50 with activity; the satisfaction was 90. The median of the extension/flexion was 81% and the grip force 82% in comparison to the opposite hand. The DASH Score was 25 and the Mayo Wrist Score 73. CONCLUSION: Complete denervation of the wrist according to Wilhelm is a treatment option for the chronically painful wrist and can lead to good grip force, mobility, sufficient pain reduction and satisfaction in the long term.

The liver-resident immune cell repertoire - A boon or a bane during machine perfusion?

The liver has been proposed as an important "immune organ" of the body, as it is critically involved in a variety of specific and unique immune tasks. It contains a huge resident immune cell repertoire, which determines the balance between tolerance and inflammation in the hepatic microenvironment. Liver-resident immune cells, populating the sinusoids and the space of Disse, include professional antigen-presenting cells, myeloid cells, as well as innate and adaptive lymphoid cell populations. Machine perfusion (MP) has emerged as an innovative technology to preserve organs ex vivo while testing for organ quality and function prior to transplantation. As for the liver, hypothermic and normothermic MP techniques have successfully been implemented in clinically routine, especially for the use of marginal donor livers. Although there is evidence that ischemia reperfusion injury-associated inflammation is reduced in machine-perfused livers, little is known whether MP impacts the quantity, activation state and function of the hepatic immune-cell repertoire, and how this affects the inflammatory milieu during MP. At this point, it remains even speculative if liver-resident immune cells primarily exert a pro-inflammatory and hence destructive effect on machine-perfused organs, or in part may be essential to induce liver regeneration and counteract liver damage. This review discusses the role of hepatic immune cell subtypes during inflammatory conditions and ischemia reperfusion injury in the context of liver transplantation. We further highlight the possible impact of MP on the modification of the immune cell repertoire and its potential for future applications and immune modulation of the liver.

New trends in breast reconstruction.

BACKGROUND: Breast reconstruction (BR) after radical mastectomy is intended to recreate symmetrical natural-appearing breasts while preserving patient safety and quality of life. PURPOSE: To evaluate the esthetic results and the complications of various BR methods after radical mastectomy. PATIENTS AND METHOD: Between August 2006 and March 2010, 36 women underwent BR after mastectomy in our institution. Their charts were reviewed retrospectively to evaluate the results and complications. We used immediate BR for Stage I and IIa breast carcinoma, and delayed BR for stage IIb and III breast carcinoma. RESULTS: We performed a pedicled Transverse Rectus Abdominis Muscle flap in 13 cases, pedicled Latissimus Dorsi with silicone implant in 10 cases, free Deep Inferior Epigastric Perforator (DIEP) flap in 9 cases, and other procedures in four cases. The encountered complications were: total flap failure--one case, partial edge flap necrosis--three cases, donor area wound dehiscence--one case, seroma--one case, local infection--one case. DISCUSSION: Trends in BR in recent years focus more on free perforator flaps, with the DIEP flap being the leader. Internal mammary vessels are most often used as recipient vessels for anasthomoses. Immediate BR when indicated has better aesthetic results. In less well-developed countries, insurance companies do not cover implant expenses and the autologous procedures remain the best option.

Gastroduodenal artery pseudoaneurysm ruptured in the common bile duct.

A pseudoaneurysm of the gastroduodenal artery (GDA) is the rarest splanchnic artery aneurysm, comprising fewer than 10% of these lesions. Bleeding into the gastrointestinal tract is the most rapidly fatal complication of an arterial visceral pseudoaneurysm, affecting 4-10% of patients. We present an unusual case of a GDA pseudoaneurysm that ruptured in the common bile duct, and that was successfully treated by partial resection and hepatic artery reconstruction. The postoperative evolution was favourable and the CT performed six months later disclosed the absence of a vascular tumour.

Different models of training and certification in plastic surgery.

A varying period of training followed by examinations is the usual way to become a specialist in one of the many fields of Medicine. Plastic Surgery is one of the surgical fields that require good technical and cognitive skills. The best way to train and evaluate a candidate is hard to judge. The model of training and board examination varies, every country having its own method. This is a descriptive report presenting the ways of training residents in Plastic Surgery and then examining them in Romania, Israel, U.S.A., Germany and the Netherlands. Specific points regarding the structure and the format are addressed for all models and also for factors that might influence the objectivity of the examination. The authors bring their thoughts on these issues.

Hepatitis C virus presumably associated bilateral consecutive anterior ischemic optic neuropathy.

PURPOSE: To report a case of bilateral nonarteritic anterior ischemic optic neuropathy (NAION) in a hepatitis C (HCV) infected patient and demonstrate the relationship between HCV and the development of NAION. METHODS: Case report. RESULTS: A 43-year-old woman with chronic HCV infection and long-term euthyroid autoimmune thyroiditis suddenly lost vision in her right eye, and 6 months later in her left eye, due to NAION. Slightly elevated levels of aminotransferases suggested liver infection activity. Anti-HCV antibody was detected; the genotype of the virus was 1b and the viral RNA level was 1.8 x 106 IU/mL. Liver biopsy proved chronic active hepatitis (Ishak score grading: 7, staging: 2). Except for the elevated levels of antithyroid antibodies and a weak antinuclear factor, the detailed laboratory examinations (thrombophilia, cryoglobulin, anticardiolipin antibodies, co-infections) revealed no other abnormalities; a causative relationship between the underlying chronic hepatitis C and bilateral NAION therefore seems probable. The patient was treated with pegylated interferon and ribavirin for 1 year and a sustained viral remission could be achieved. Her vision has neither improved nor deteriorated further. CONCLUSIONS: This appears to be the first reported case of bilateral NAION presumably caused by HCV infection.

Simultaneous extra-anatomic bypass and abdominal "flag flap" for lower limb salvage in a patient with severe post-bypass anastomotic groin infection.

The incidence of prosthetic graft infection after bypass surgery ranges from 0.2 to 5%, depending on location, co-morbid diseases and host defense mechanisms. In spite of surgical treatment, the amputation rate can be up to 67%. Herein, we present our treatment strategy for a patient with severe Methicillin Resistant Staphylococcus Aureus infection and pseudo-aneurysm after a femoropopliteal bypass with a prosthetic graft. An extra-anatomic bypass without touching the previously operated groin area (aseptic time) was done at the beginning. Radical debridement (septic time) and simultaneous abdominal "flag flap" were performed in the same surgical procedure to save the lower limb.

Integrating interventional oncology in the treatment of liver tumors.

BACKGROUND: Percutaneous ablation techniques offer a vast armamentarium for local, minimally invasive treatment of liver tumors, nowadays representing an established therapeutic option, which is integrated in treatment algorithms, especially for non-resectable liver tumors. The results of ablative treatment compare very well to surgical treatment in liver lesions, and confirm that these techniques are a valuable option for bridging for transplantation. Different techniques have been established to perform tumor ablation, and the feasibility varies according to the procedure and technical skills of the operator, depending on the size and location of the liver lesion. In recent years, stereotactic multi-needle techniques using 3D trajectory planning, general anesthesia, and tube disconnection during needle placement have had a strong impact on the application range of ablation for liver tumors. CONCLUSION: It is well known that creating a sufficient ablation margin and overlapping ablation zones is one key issue to enable ablation of large liver lesions with tumor-free margins (A0 ablation in analogy to R0 resection). Image fusion during treatment and follow-up assure highly accurate staging procedures and interventional planning. NOVEL ASPECTS: Review on the standards in ablation techniques for the treatment of liver tumors. Update on different ablation techniques, indications, and contraindications for percutaneous liver tumor treatment. Summary of recently published reports on liver tumor ablation.

Influence of intrauterine growth restriction on renal function in the adult rat.

Intrauterine growth restriction (IUGR) has been shown to influence renal development and lead to fewer nephrons. Data on long term renal function after IUGR are limited. We studied the effect on renal function of IUGR in aging rats. IUGR was induced using a model of bilateral uterine artery ligation in pregnant Wistar rats. Renal function was studied at the age of 18 months. In male IUGR rats, estimated glomerular filtration rate was significantly decreased compared to male control rats [1.1 (SD 0.3) 1.7 (SD 0.3) ml x min(-1), p<0.05]. Female IUGR rats showed an increased urinary protein excretion compared with female control rats [84 (SD 73) vs. 12 (SD 13) mg x 24h(-1), p<0.01]. All male rats showed heavy proteinuria (p<0.01 vs. female rats from same experimental group), with no significant differences between the groups. Tubular reabsorption of phosphorus was lower in females, but showed no differences between the experimental groups. In conclusion, IUGR impairs renal function in the rat. It is suggested that a low nephron endowment leads to proteinuria as a sign of glomerular damage, and ends with a decrease in glomerular filtration rate as a sign of glomerular loss.

Weekend versus working day: differences in telemetric blood pressure in male Wistar rats.

Blood pressure (BP) is a frequently monitored parameter in research. Various methods are used to obtain BP values in animal models, but telemetry is the method of choice because it allows for continuous monitoring in conscious and freely moving animals. However, factors due to the animal facility, like activities and sound, can still influence measurements. We, therefore, retrospectively compared BP values in adult male Wistar rats during working hours with values from non-working days. Telemetry devices were implanted according to standard protocol. Values were obtained at the age of 6 and 12 months during working hours (Friday 10:00-16:00 h, lights on 06:00-18:00 h) and compared with data from the average of Saturday 10:00-16:00 h and Sunday 10:00-16:00 h, representing non-working days. Data were available from 12 and 7 rats at 6 months and 12 months of age respectively. Relative differences in heart rate, spontaneous locomotor activity, systolic and diastolic BP were 2.2% (P<0.001), 32.9% (P<0.05), 3.2% (P<0.05) and 3.7% (P<0.05), respectively, with no differences between the age groups. We have shown a significant and important difference between BP values obtained during working hours and non-working days using telemetry in adult male Wistar rats. This phenomenon has implications for the interpretation of BP measurements in animals.