Biomedical subjects

C E Broelsch

Publications and source records attributed to C E Broelsch.

At least 19 recordsLinked to original sources

PubMed2007

Tri-iodothyronine as a stimulator of liver regeneration after partial and subtotal hepatectomy.

BACKGROUND: Tri-iodothyronine (T3) has been shown to be a hepatic mitogen. We investigated whether exogenous application of T3 improves liver regeneration after 70% partial hepatectomy (PH) and confers a survival advantage after 90% subtotal hepatectomy (SH) in rats and whether this is associated with the stimulation of angiogenesis. METHODS: Rats were subjected to PH or SH 10 days after injection of a single dose of T3. Liver body weight ratio (LBR), hepatic proliferation (Ki-67), biochemical markers as well as vascular endothelial growth factor (VEGF) expression were assessed by immunohistochemistry. Gene expression of pathogenic relevant genes was determined by customized cDNA arrays and quantitative RT-PCR. RESULTS: T3-treated rats showed an increased LBR and Ki-67 index after PH and SH, which reached statistical significance compared to placebo-treated rats (p < 0.05). On the transcriptional level, T3-treated rats had an increased expression of VEGF as demonstrated by immunohistochemistry, which was associated with a higher expression of its receptor Flt-1. CONCLUSIONS: Exogenous administration of T3 ameliorates liver regeneration after 70% PH and 90% SH, possibly due to stimulation of angiogenesis. Therefore, its clinical use might be of interest due to its excellent general practicability.

Alanine Transaminase↗

PubMed2007

Preoperative volume prediction in adult living donor liver transplantation: how much can we rely on it?

Accurate preoperative prediction of functional donor and remnant hemiliver volumes in live donor liver transplantation is essential in preventing postoperative liver failure and optimizing safety. Our aim was (1) to evaluate volume variability associated with multiphasic CT imaging and (2) to determine over- or under-estimations of 3-D CT graft-volume assessments based on 'largest' versus 'smallest' CT phases with respect to intraoperative findings. Native, arterial and venous phase CT images from 83 potential live liver donors were subject to 3-D CT liver volume calculations and virtual 3-D liver partitioning. Estimates were compared to intraoperative volumes obtained in 43 cases. Calculated (preoperative) graft-volume-body-weight-ratios (GVBWR) versus measured (intraoperative) graft-weight-body-weight-ratios (GWBWR) were analyzed. Significant differences in total liver volume- and in graft-liver volume calculations were found among the largest (venous) and smallest (native) CT phases. High significant overestimations were observed in graft-volume determinations and in GVBWR-calculations based on the 'largest' CT phase when compared to intraoperatively obtained graft-weight and -GWBWR values. In contrast, differences among intraoperative measurements and preoperative calculations based on the 'smallest' CT phase yielded less significant overestimations. While 3-D CT volumetry based on the 'largest' (venous) CT phase is associated with considerable overestimation, 3-D volumetry based on the 'smallest' (native) CT phase accurately matches the intraoperative findings.

Donor Selection↗

PubMed2007

[Liver resection and transplantation for hepatic tumors].

Hepatic surgery has made substantial advances in the last two decades due to technical developments and improvements in perioperative management. This has reduced surgery dependent mortality to less than 5%, and provides the possibility of carrying out more substantial hepatic resections and to interpret the indications more liberally, also for tumours localized unfavorably. A widely standardized surgical technique as well as new possibilities for organ conservation and, in particular, immunosuppression mean that given suitable indications, liver transplantation is today regarded as a routine procedure for the treatment of hepatocellular carcinoma. This work provides an overview of the current status of surgical therapy for the most frequent, benign liver tumours, as well as for hepatocellular and cholangiocellular carcinoma.

Adenoma, Liver Cell↗

PubMed2007

Computer-assisted operative planning in adult living donor liver transplantation: a new way to resolve the dilemma of the middle hepatic vein.

An adequate venous outflow is essential for securing viability of both graft and remnant in adult living donor liver transplantation (ALDLT). Seventy-five potential live liver donors were evaluated for LDLT by means of an "all-in-one" CT, which defined the biliary tree, portal vein, hepatic artery, and hepatic vein anatomy. The acquired data sets were further analysed by means of the software HepaVision (MeVis, Germany). Only a minority (29%) of potential donors were found to have a vascular and biliary anatomy consistent with the classically described "normal" patterns. The vast majority (71%) had "anatomical variations". Thirty-nine (52%) donors underwent ALDLT hepatectomy. The right hepatic vein was dominant in 64 cases, representing 48 +/- 6% of the total liver volume (TLV). The middle hepatic vein was dominant in 11 cases, making up 40 +/- 8% of the TLV. The left hepatic vein was never dominant. The volume contribution of the middle hepatic vein (MHV) was 114-782 ml for the right and 87-419 ml for the left hemiliver. Computer-assisted planning allows for the 3D reconstruction of the vascular and biliary anatomy, automatic calculation of the total and territorial liver volumes, and risk analysis of hepatic vein dominance relationships. This comprehensive data acquisition supports preoperative evaluation and provides a high degree of safety for donors and improved outcomes for recipients.

Adolescent↗

PubMed2006

Liver transplantation for hepatocellular carcinoma in patients beyond the Milan but within the UCSF criteria.

AIM: Liver transplantation (LT) is the best therapy for early hepatocellular carcinoma (HCC) in cirrhosis. Whereas the Milan criteria are routinely applied, the University of California San Francisco (UCSF) criteria are occasionally considered in large-volume transplant centers. Poor information is available about the real "gain" in patients' outcome when extending the listing criteria from Milan to UCSF. PATIENTS AND METHODS: Out of 100 patients transplanted for HCC at our center, 4 patients exceeding the Milan but meeting the UCSF criteria were identified. Data of these patients were analysed for the purposes of this study. RESULTS: Three of them are currently alive after a median follow up of 57 months. One patient died 20 months post-transplant as a result of complications from hepatitis. Of the three who are alive, one underwent surgery for HCC recurrence 81 months post transplant. The remaining two have no evidence of tumor 56 and 57 months post transplant, respectively. CONCLUSION: Our results, as well as the reviewed literature, showed that only a small percentage of transplanted HCC patients can be classified as "beyond Milan-within UCSF". These patients seem to have acceptable overall, as well as recurrence free survivals. Large-volume patients' series, intention- to-treat analysis based on the radiological findings and multi-center prospective studies are required, in order to further explore the outcome of patients "beyond Milan-within UCSF" criteria and in order to better define the risk/benefit ratio of a potential expansion of the current listing criteria.

Adult↗

PubMed2006

Effects of positive end-expiratory pressure on systemic haemodynamics, with special interest to central venous and common iliac venous pressure in liver transplanted patients.

BACKGROUND AND OBJECTIVES: Positive end-expiratory pressure may alter cardiac function and systemic haemodynamics. As transplanted livers may be sensitive to liver congestion, the aim of our study was to evaluate the effect of positive end-expiratory pressure on the cardiovascular system and in particular on central venous and iliac venous pressure in liver transplanted patients. PATIENTS AND METHODS: Seventy-two liver transplant patients were enrolled in this prospective, interventional study. On admission to our Intensive Care Unit all patients were ventilated in a biphasic positive airway pressure mode. Haemodynamic effects of three randomly set levels of end-expiratory pressures (0, 5 and 10 mbar) were studied in the immediate postoperative period in all patients. Mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, central iliac venous pressure and cardiac index were recorded and analysed at each of the three end-expiratory pressure levels. RESULTS: The values of central- and wedge-pressure significantly increased with increased end-expiratory pressure. Central venous pressure increased by 24% and wedge pressure showed a 6% increase at 10 mbar in comparison to 0 mbar. The values for cardiac index and mean arterial pressure showed no statistically significant difference at 10 mbar as compared to 0 and 5 mbar. The mean pulmonary arterial and common iliac venous pressure were unaffected by different positive end-expiratory pressure levels. CONCLUSIONS: Short-term pressure controlled ventilation with end-expiratory pressure up to 10 mbar does not significantly impair systemic haemodynamics in liver-transplanted patients. Further studies are needed to determine whether these findings could be confirmed with higher pressure levels and/or over a longer period of ventilation time.

Aged↗

PubMed2006

Target range maximum of cyclosporine blood concentration two hours post dose in stable liver transplant patients.

Recently, single blood level measurement 2 hours after cyclosporine administration (C2) is taken as a more sensitive indicator of drug exposure in de novo transplant recipients than trough levels (C0). However, few studies focused on the determination of the C2 target range maximum and its associated adverse events in stable liver recipients. This prospective study was designed to assess the relative risk of developing CsA related side effects in patients with high C2-levels. Adverse effects were determined clinically, and by using a specially designed questionnaire. Eventual adverse events as well as C2 levels were determined repeatedly up to 4 times in 3-months intervals (observation period 9 +/- 3 months) in 36 long-term liver recipients (1-13.5 years post-transplant), in addition to conventional C0 levels. Cyclosporine dose was adjusted according to a predefined C0 target level range and clinical status. Totally 103 questionnaires and the corresponding paired CsA blood level records were obtained. C0 levels and C2 levels ranged from 90 to 287 (143 +/- 31) ng/ml and from 212 to 1358 (672 +/- 203) ng/ml respectively. No patient experienced a rejection episode during the observation period, demonstrating the efficiency of the immunosuppressive therapy. However, 33/36 patients (91%) showed symptoms attributable to CsA therapy. C2 levels above 750 ng/ml, determined at least twice in an interval of 3 months, were identified as a relevant risk factor for the presence of multiple adverse effects, which were defined as the combination of hypertension, renal insufficiency and more than two neurological complaints (RR = 3.11, p<0.01). This risk population was not completely identified by determination of C0 level.

Adult↗

PubMed2006

The "territorial belonging" of the middle hepatic vein: a troublesome dilemma in adult live donor liver transplantation--anatomical evidence based on virtual 3-dimensional-computed tomography-imaging reconstructions.

BACKGROUND: The venous drainage of the liver plays an essential role in securing viability of both graft and remnant in live donor liver transplantation (LDLT). There is still controversy on whether the middle hepatic vein (MHV) should be routinely included as part of the graft or retained with the remnant liver. The purpose of this study was to analyze hepatic venous drainage patterns based on information obtained by 3-dimensional CT-imaging reconstructions. METHODOLOGY: Fifty five potential live liver donors were evaluated between January 2003 and May 2004 at our Institution. We analyzed two anatomical definitions of liver dominance: total liver dominance (TLD) and hemiliver dominance (HLD). The following concepts were addressed: 1) Hepatic vein territories, 2) Hepatic vein dominance relationship, 3) Territorial belonging- patterns of the MHV to the right and left hemilivers, additionally an analysis of venous outflow in the central liver sectors was performed. RESULTS: Our results showed that: 1) The definitions of dominance: TLD vs. HLD overlap, displaying the MHV belonging, by taking into account the individual right hepatic vein (RHV) variability; 2) A dominant RHV for the whole liver indicates that the RHV is also dominant in the right hemiliver; 3) The MHV belongs predominantly to the left hemiliver (LHL); 4) The left hepatic vein (LHV) is dominant in the LHL. CONCLUSION: Both dominance definitions provide independent mappings of the liver and offer helpful insight into venous dominance relationship.

Adult↗

PubMed2006

[Surgical therapy of intrahepatic cholangiocellular carcinoma].

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy. Tumor resection is the treatment of choice, but so far the value of hepatic resection has not been well defined. We report results with an aggressive surgical approach for the treatment of this tumor entity. PATIENTS AND METHODS: Between April 1998 and June 2004, 54 liver resections were performed in 120 patients with ICC. In 24 patients, 39 additional procedures were performed: resection of hilar bifurcation (n=18), partial resection of diaphragm (n=6), vascular resection and reconstruction (n=15). RESULTS: There were 30 R0, 21 R1, and three R2 resections. After R1/R2 resection and explorative laparotomy, the median survival times are 9 months and 6 months, respectively. Following R0 resection, the calculated median survival is 46 months, and the 1-, 3-, and 5-year survival rates are 83%, 58%, and 48%, respectively. CONCLUSION: The presented data show that R0 resection leads to a significant prolongation of survival in patients with ICC. In contrast, incomplete tumor removal does not provide a survival benefit. These results justify an aggressive surgical approach to achieve a R0 resection. The low resectability rate of less than 50% underlines the need for improved preoperative staging.

Bile Duct Neoplasms↗

PubMed2006

[Surgical therapy of hilar cholangiocarcinoma].

Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Due to the central anatomic localization within the liver hilum, established guidelines of oncologic surgery are difficult to apply. Resection of the hilar bifurcation alone or in combination with limited hepatic resection can be performed with low morbidity and low mortality but shows a high rate of local tumor recurrence. Usually, extended resection is required to achieve adequate safety margins. Right trisectionectomy complies best with the basic rules of oncologic surgery while allowing the maximum safety margin. The 5-year survival rates reported after right trisectionectomy range between 20% and 40% and reach 59% in selected patients. The increasing experience with living donor transplantation and recent advances in neoadjuvant tumor therapy may lead to renewed discussion of liver transplantation in hilar cholangiocarcinoma.

Bile Duct Neoplasms↗

PubMed2006

[Computer-assisted planning in living donor liver operation].

INTRODUCTION: The appropriate recipient/donor match is a prerequisite for successful living donor liver transplantation (LDLT). A precise knowledge of the liver anatomy and the functional liver volume plays a key role in allocating live liver donor candidates. With the new software HepaVision, we obtained information on liver mapping by means of virtual 3-dimensional non-invasive imaging reconstructions and were able to perform a virtual simulation of the liver transsection. Aim of our study was to investigate, whether this new computer technology is advantageous in surgery planning for LDLT. METHODS: From January 2002 until December 2004 355 liver transplantations were performed in our department, of which 36 were LDLT. According to our evaluation protocol 135 potential donors (63 male, 72 female) between 18 to 59 years received preoperatively an all-in-one CT. The acquired data sets were further analysed with the software HepaVision (MeVis, Germany). RESULTS: Of the 135 evaluated donors, we excluded 99 (73 %) from donation based on the HepaVision-data. Reason for exclusion was an inadequate liver volume (70.8 %) or a risk related anatomical anomaly (2.2 %). In the remaining 36 cases a successful graft donation was possible. There were no postoperative complications in the donors and recipients, directly related to a misjudgment of the anatomy or miscalculation of the liver volume. CONCLUSION: The systematic use of HepaVision for surgery planning proved to be indispensable for proper donor selection. A virtual simulation of the liver transsection on 3D-model additionally increased the safety of the operation, consequently decreasing the risk for the donor.

Adolescent↗

PubMed2005

Disease course after liver transplantation for hepatocellular carcinoma in patients with complete tumor necrosis in liver explants after performance of bridging treatments.

AIM: To study the disease course of patients with hepatocellular carcinoma (HCC) showing complete tumor necrosis in their liver explants after undergoing bridging treatments followed by liver transplantation (LTx). PATIENTS AND METHODS: We evaluated data corresponding to 10 patients with liver cirrhosis undergoing bridging treatments for HCC prior to LTx. In all cases there was complete tumor necrosis in the explanted livers. RESULTS: There were 8 men and 2 women. Percutaneous radiofrequency ablation (RFA) was performed under computed tomographic guidance in 4 patients. The remaining 6 patients underwent transarterial chemoembolization (TACE). Five of them received one session of TACE, while the remaining one received a series of 4 sessions prior to LTx. Six patients had solitary nodules with a median diameter of 3.5 cm (range 2.5-4.2 cm). Four of them underwent RFA. Segmental tumor chemoembolization was performed in 2 patients. The remaining 4 patients had 2 tumors each with a median total diameter of 4.4cm (range 4.2-6.0 cm) prior to TACE. They underwent bilobar hepatic chemoembolization, which under staged the tumors prior to live donor liver transplantation (LDLTx). Six patients underwent deceased donor orthotopic liver transplantation. LDLTx was performed in 4 patients. Median waiting time to LTx was 53 days. All patients are alive without recurrence after a median follow-up of 19 months. CONCLUSION: Achievement of 100% tumor necrosis by means of bridging treatments followed by LTx for HCC is characterized by a very low recurrence rate and should receive further consideration and study.

Adult↗

PubMed2005

[Cross-over kidney transplantation in Germany].

A donor kidney exchange or cross-over program with exchange of organs between two donor-recipient pairs offers a possibility to realise living donor renal transplantation in cases of ABO-blood group incompatibility. The German transplantation law demands, in contrast to other countries, a close personal relationship between living donor and recipient. In this paper, we propose a concept based on the generation of a close personal relationship between donor-recipient pairs that allows cross-over renal donor transplantation considering the statement of the responsible medical-ethical institutions and the German transplantation law.

ABO Blood-Group System↗

PubMed2005

Anatomical and physiological classification of hepatic vein dominance applied to liver transplantation.

BACKGROUND: Proper outflow reconstruction is essential in LDLT. Preoperative planning requires meticulous attention to hepatic vein dominance patterns. The purpose of our study was to provide a combined anatomical-physiological classification of hepatic vein dominance useful for surgical decision-making in both donors and recipients. METHODOLOGY: We analyzed 3-dimensional CT-imaging reconstructions of 55 potential live liver donors evaluated at our Institution between January 2003 and May 2004. RESULTS: Our data revealed that: 1) The middle hepatic vein (MHV) and left hepatic vein (LHV) show a relative lack of anatomical diversity, whereas the right hepatic vein (RHV) exhibits multiple variants, 2) 45% donors had inferior hepatic veins (IHV) with anatomically and physiologically relevant venous drainage territories, 3) The RHV is usually dominant when present as a single vein without anatomical IHV (type 1A), or when considered as a complex with IHV (type 1Bx) (80% vs. 88%), 4) Only 55% of dominant type 1Bx RHV/IHV-complex automatically included a dominant type 1By RHV by itself, 5) A single RHV out of anatomical complex with IHV (type 1By) was dominant in only 48% of our donor candidates, 6) The MHV types 2A and 2By are strongly dominant accounting for up to 57% of total liver volume (TLV). CONCLUSIONS: We propose a new classification based on both anatomical and physiological hepatic venous configurations. Our model also provides a new nomenclature that can be universally applied to preoperative planning in LDLT.

Adolescent↗

PubMed2005

[New techniques in liver transplantation].

Due to innovative surgical techniques, improved immunosuppressive regimens and better postoperative management, orthotopic liver transplantation achieved patient and allograft survival rates of 80 to 90% that have expanded both the indications for transplantation as well as the number of potential recipients awaiting liver transplantation. One of the major challenges facing organ transplantation is the current shortage of donors. Despite supportive legislation, media network systems and the attempt to raise public awareness, the actual donor numbers have remained relatively constant and do not meet the growing need for more organs. In 2002 the mortality among patients waiting for a liver organ reached 20%. Among the several measures that can be undertaken to expand the donor pool is the use of previously unused donors, such as marginal livers, domino-, split- or living related liver transplantation.

Adult↗

PubMed2005

Staging laparoscopy in gastric cancer.

BACKGROUND: As patients with gastric cancer are offered choices between surgical resection, neoadjuvant or palliative chemotherapy, or symptomatic relief alone, the need for accurate preoperative staging becomes apparent. Laparoscopy has been suggested as an appropriate staging modality in a variety of upper gastrointestinal malignancies. METHODOLOGY: Staging laparoscopy was performed in 45 patients with potentially resectable gastric cancer as determined by physical examination, gastroscopy, endosonography, transcutaneous ultrasonography and current generation computed tomography. Conventional clinic staging and laparoscopic staging according to the Tumor-Node-Metastases classification of the International Union against Cancer were registered separately on a database. Results were then compared to evaluate the agreement of both staging procedures. RESULTS: Compared to conventional staging, laparoscopy resulted in up staging of 23 patients (51.1%). In 10 patients of them peritoneal seeding was first found during laparoscopy, whereas additional liver metastases were detected in 3 patients and Krukenberg's tumor in one. As a consequence, the therapy planning was changed and laparotomy was avoided in 14 of these patients as the first operative procedure. Sensitivity of clinical staging was especially poor for stage IV tumors (5.3%) and for the majority of stage IIIB tumors (42.9%). Cytologic examination of peritoneal fluid had no additional information in our series. CONCLUSIONS: The value of laparoscopy in staging patients with gastric carcinoma could be demonstrated in this study. It is a safe and effective staging modality, helping to avoid unnecessary laparotomies and providing new means of directing appropriate treatment strategy.

Adult↗

PubMed2005

[Surgical and interventional treatment of liver metastases].

The liver is the most common target organ for metastatic disease. The majority of patients undergoing surgical treatment for liver metastases have colorectal primaries. Endocrine liver metastases, or metastases from other tumors such as mammary carcinoma, sarcomas, renal tumors or gastrointestinal stromal tumors (GIST) are appreciably less common for surgical treatment. The gold standard of treatment is resection of the metastatic lesions. In the meantime, advances in surgical techniques and improved perioperative patient management make it possible to perform extensive resections with acceptable morbidity and mortality rates. In the event of metastases that are not primarily resectable, various downstaging procedures are available, with the aid of which secondary resectability can be achieved. Among the interventional treatment options that should be applied only in palliative intent, radiofrequency ablation is in widespread use.

Antineoplastic Agents↗

PubMed2005

Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis.

BACKGROUND: Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented. METHODS: Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival. RESULTS: Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine. CONCLUSION: These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.

Adult↗