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R Pichlmayr

Publications and source records attributed to R Pichlmayr.

At least 55 records · Page 3Linked to original sources
PubMed1997

What constitutes long-term survival after surgery for hilar cholangiocarcinoma?

BACKGROUND: Hilar cholangiocarcinomas are rarely considered to be resectable and specific data regarding long-term survival are not available. METHODS: A retrospective single center experience from 1971 and 1995 details long-term survival among 339 patients who underwent surgery for adenocarcinoma of the hepatic duct bifurcation. Tumor removal was accomplished by resection of the bile duct bifurcation either alone (33 patients), in combination with hepatic resection (77 patients), or combined with hepatic and vascular resection (41 patients). Thirty-two patients underwent total hepatectomy and liver transplantation. In 188 patients the tumor was unresectable and palliative internal or external biliary drainage was established. The resectability rate was 49.2% and rose to 54% after inclusion of liver transplantation. The clinicopathologic features of 32 5-year survivors were compared with patients whose survival was less than 5 years. RESULTS: Thirty-two patients survived longer than 5 years after surgical treatment of hilar cholangiocarcinoma; 22 of these patients (69%) were still alive at last follow-up. Twenty-six long-term survivors had primarily undergone resection; 4 received liver transplants. There was 1 long-term survivor beyond 5 years after both exploratory laparotomy and subsequent percutaneous transhepatic drainage, and palliative hepatojejunostomy. Long-term survival after resection was significantly associated with less advanced tumor stages. Lymph node involvement and residual tumor were the primary prognostic factors both in a multivariate analysis after resection and in the cohort of long-term survivors. Nevertheless, long-term survivors were still at a significant risk to die from tumor recurrence. CONCLUSIONS: Radical resection offers the best possibility of prolonged survival with a good quality of life for patients with hilar cholangiocarcinoma.

Bile Duct Neoplasms↗
PubMed1997

Long-term outcome of hepatitis C virus infection after liver transplantation.

We analyzed the long-term clinical course of 71 patients with RNA-positive hepatitis C virus (HCV) infection after liver transplantation. Patients with reinfection after transplantation for HCV-related liver disease, or de novo infection at transplantation were followed for up to 12 years. Cumulative survival for patients with HCV infection at 2, 5, and 10 years after transplantation was 67%, 62%, and 62%, respectively. It was not significantly different from that in patients transplanted for other nonmalignant diseases without HCV infection. The main factor determining long-term survival was the presence or absence of hepatocellular carcinoma (HCC) at transplantation. The 5-year survival rate for HCV patients with or without HCC was 35% versus 73%, respectively (P < .05). No deaths because of viral hepatitis of the graft were observed. Deaths in the first year after transplantation were caused by infectious complications, cardiovascular problems, or rejection; deaths after more than 12 months were exclusively because of recurrence of HCC. Biochemical and histological evidence of hepatitis was found in the majority of the patients, only 16% had normal alanine aminotransferase (ALT) values throughout. Twenty-two percent of patients complained of symptoms, with hepatitis C being the cause in 82% of these. Two patients lost their HCV-RNA for prolonged, ongoing periods of time. The severity of the posttransplantation hepatitis was unrelated to age, sex, severity of liver disease before transplantation, cold ischemic time of the graft, duration of the operation, transfusions, the number of rejection episodes, or the long-term immunosuppressive regime. Only initial short-term therapy with interleukin 2 (IL2) receptor antibodies adversely influenced inflammatory activity. Viral genotype did not influence the course of the graft hepatitis in our series. Histology showed inflammation in 88% of the biopsies and signs of fibrosis in 24%. Mean ALT values correlated with inflammation but not with fibrosis in the biopsies. Porto-portal bridging was observed in six patients, one patient developed cirrhosis within 2 years after orthotopic liver transplantation (OLT). We conclude that chronic hepatitis develops in the majority of patients with HCV infection after liver transplantation. Carrier states without significant laboratory abnormalities are observed in approximately 16%, biochemical abnormalities without symptoms are seen in 60%, and symptomatic disease develops in a quarter of the patients. The disease course closely resembles that seen in nontransplanted hepatitis C patients. It is generally mild but little over 10% of patients develop signs of fibrosis of the graft during the first decade.

Adolescent↗
PubMed1997

Identification of high- and low-risk patients before liver transplantation: a prospective cohort study of nutritional and metabolic parameters in 150 patients.

The clinical relevance of malnutrition and hypermetabolism in end-stage liver disease, as well as their effects on survival after liver transplantation (LTx), are largely unknown. This study investigates the prognostic value of nutritional and metabolic parameters obtained before LTx for survival after LTx. One hundred fifty patients with end-stage liver disease undergoing LTx were assessed prospectively and followed for a mean period of 46 +/- 16 months after LTx. All patients were randomized into a study group and a validation group, each comprising 75 patients. Body composition analysis (24-hour urinary creatinine excretion, anthropometry, bioelectrical impedance analysis), deviation of measured from predicted resting energy expenditure (deltaREE), year of transplantation, and several variables known to be of prognostic relevance in patients with liver disease undergoing conservative treatment were analyzed. Kaplan-Meier and log rank analysis showed that hypermetabolic patients (deltaREE > +20%) and patients with a body cell mass (BCM) < 35% of body weight tended to have reduced survival after LTx. A risk profile on the basis of deltaREE and BCM identified patients with high risk (5-year survival rate, 54%) and low risk (5-year survival rate, 88%; P < .01). The predictive power of this risk profile was independent of the presence of ascites and clinical edema, and its validity was confirmed in the validation group (P < .01). The Child-Pugh score was not of prognostic value. We conclude that a poor nutritional state, as well as hypermetabolism, adversely affects survival after LTx. These potentially treatable presurgical factors deserve close attention in interventional studies.

Adult↗
PubMed1997

Differential display in primary and metastatic medullary thyroid carcinoma.

Despite recent advances in the understanding of the role of the RET proto-oncogene in the development of familial and approximately 30% of sporadic medullary thyroid carcinomas (MTC), little is known about other genetic events that modify the course and outcome of the disease. We compared the expression of genes in intrathyroidal MTCs to autologous local lymph node metastases by means of mRNA differential display (DDRT-PCR). This is the first report of differential display using surgical specimens of a primary cancer and its metastases. Total RNA was extracted from tumor tissue of two patients with MTC associated with multiple endocrine neoplasia (MEN 2B) and sporadic MTC, respectively. Following reverse transcription (RT), the products were PCR-amplified and separated on a denaturating polyacrylamide gel. RT-PCR products demonstrating differential expression were reamplified and used as probes for Northern blot analysis. Six fragments for which differential expression was confirmed were cloned and sequenced. Resultant sequences were tested for homology to sequences in public data bases, and two novel MTC-derived fragments (MDF-1, MDF-2) were identified. Sensitivity of the method was confirmed by identification of a sequence encoding the calcitonin precursor flanking peptide which is expressed almost exclusively in MTC and normal thyroid C cells. Overexpression of the ribosomal genes S3a and P0 was found in the metastases. Recent reports suggest that components of the translational apparatus act as regulatory mediators of growth, proliferation, and neoplastic change. The altered expression of ribosomal proteins and gene products encoded by MDF-1 or MDF-2 may play an important role in the progression and metastatic spread of MTC.

Blotting, Northern↗
PubMed1997

[Therapy of persistent bleeding esophageal varices using intrahepatic portosystemic stent shunt and immediate liver transplantation].

A 41-year-old patient with liver cirrhosis due to autoimmune hepatitis received an emergency transjugular portosystemic stent shunt for uncontrolled acute variceal hemorrhage. Because of markedly impaired liver function, liver transplantation was considered to be indicated and was performed on the following day. Intraoperatively, one of the intrahepatic metal stents migrated unnoticed into the pulmonary artery. The postoperative course was uncomplicated and the displaced stent was left in situ. Eighteen months after the transplantation the patient is well with normal liver function and no pulmonary problems.

Adult↗
PubMed1997

[Prolonged intensive care stay after abdominal surgery interventions with special reference to quality of life, occupational rehabilitation and economics].

Owing to increasing limitations on resources in health care, there is an urgent need to investigate effectiveness and efficiency of medical procedures. Therefore, we retrospectively studied the courses of 62 surgical patients who required at least 30 days of intensive care regarding mortality, long-term prognosis and quality of life. Additionally, a cost analysis was made using quality-adjusted life years (QALYs). The hospital mortality was 40.3%. The overall median survival time of discharged patients (n = 37) was 3.7 years and the calculated 3-year survival was 56.4%. The most frequent causes of death were septic complications or multiple organ failure in hospitalized patients and tumor relapses in discharged patients. In most of the surviving patients quality of life (median Gastrointestinal Quality of Life Index: 104 points) was good. About 20% of the discharged patients were able to return to work. Although extended intensive care therapy is extremely expensive (DM 68,250 per QALY), these costs are comparable with other accepted procedures in medicine (i.e. hemodialysis). Therefore, economical aspects should not be a generalized reason for withdrawing or withholding intensive care therapy.

APACHE↗
PubMed1997

[Surgery in immunosuppressed patients with emergency or elective indications].

Immunosuppressive therapy and its influence on perioperative pathophysiology present special challenges in the event of surgical intervention. Immunosuppressive agents alter the patient's response to surgical stress and infectious complications. The often masked signs, even in the case of severe infection, require a high index of suspicion to establish the diagnosis. This may result in a fatal delay of therapy. In addition, the immunosuppressed state increases the patient's susceptibility to infection and leads to an impairment of wound healing. Therefore, careful perioperative clinical monitoring of the patient and complete control of the immunosuppressive therapy are mandatory. Elective operations in immunosuppressed patients should be performed with special caution regarding the potential perioperative risks for the patient and the graft. On the other hand, if there is evidence of, for example, an acute abdominal event, a more aggressive approach is required to rapidly establish the diagnosis and institute appropriate therapy. From the surgical point of view, special emphasis should be placed on wound closure and on anastomotic sutures when operating on a patient receiving immunosuppressive therapy.

Elective Surgical Procedures↗
PubMed1997

[Liver transplantation in familial amyloid polyneuropathy. Case report and review of the literature].

A 59-year old male of German origin noticed exercise-independent cardiac arrhythmia two years before admission. An alanine 47 transthyretin variant of Familial Amyloid Polyneuropathy with hypertrophic cardiomyopathy, peripheral sensory-motor polyneuropathy, I, degree AV heart block was diagnosed. To diminish production and deposition of mutant transthyretin and to prevent disease progression orthotopic liver transplantation was performed. Prior to transplant the patient complained of inappetence. Postoperatively, he received a chemically defined enteral nutrition regime that was discontinued after 30 months until return of appetite and weight gain indicated marked improvement. However, a duodenal biopsy still demonstrated amyloid deposits 24 months after transplantation. Echocardiographic findings remained unchanged. Neurologic examination showed an improvement of sensory-motor polyneuropathy with regression of electromyographic changes. Only traces of variant transthyretin were detectable in plasma samples taken 12 months after the operation. During the 3 year follow-up, no additional symptoms have occurred and progression of amyloidosis was prevented. Currently, orthotopic liver transplantation is the only specific treatment to prevent progression of familial amyloid polyneuropathy.

Amyloid↗
PubMed1997

Tacrolimus-based immunosuppression after liver transplantation: a randomised study comparing dual versus triple low-dose oral regimens.

To evaluate the efficacy and safety of oral tacrolimus-based immunosuppressive induction therapy, 130 primary orthotopic liver transplant (OLT) recipients were randomised to treatment in an open, parallel-group, European multicentre trial. Following OLT, patients were immediately administered either tacrolimus (0.10 mg/kg) and prednisolone (dual therapy group) or tacrolimus (0.06 mg/kg) in conjunction with prednisolone and azathioprine (triple therapy group) both orally. Patient survival at 1 year was 79.4% for the dual therapy group and 88.7% for the triple therapy group (P = 0.194); 1-year graft survival rates were 76.5% in the dual therapy group and 80.6% in the group receiving triple therapy (P = 0.615). The frequencies of rejection (dual therapy 42.6%, triple therapy 50.0%; P = 0.482), infection, and other complications (renal, neurological and glucose metabolic disorders) were similar in both groups. Tacrolimus whole blood trough concentrations were detectable on days 1 and 2, respectively, in the dual and triple therapy treatment groups whilst median tacrolimus blood concentrations in the triple therapy group reached levels similar to those in the dual therapy group on postoperative day 11 following a steady increase in dose. After 1 year, 54.4% of the patients randomised to dual therapy were receiving tacrolimus monotherapy and only 56.4% of the patients randomised to triple therapy continued to receive azathioprine. In conclusion, oral tacrolimus-based immunosuppression is both potent and safe when administered as induction therapy after OLT. Treatment may commence at either 0.06 or 0.10 mg/ kg per day, but doses may need to be increased to the latter value within the first 10 days to maintain effective immunosuppression.

Administration, Oral↗
PubMed1997

Human hepatic preneoplasia: phenotypes and proliferation kinetics of foci and nodules of altered hepatocytes and their relationship to liver cell dysplasia.

Foci of altered hepatocytes (FAH) represent preneoplastic lesions, as shown in various animal models of hepatocarcinogenesis, but their significance in the human liver has not been established. The cellular composition, size distribution and proliferation kinetics of FAH in 163 explanted and resected human livers with or without hepatocellular carcinoma (HCC) and their possible association with small-cell change of hepatocytes (SCC) were therefore studied. FAH, including glycogen-storing foci, were found in 84 of 111 cirrhotic livers, demonstrating higher incidences in cases with (29/32) than in those without HCC (55/79). FAH were observed more frequently in HCC-free cirrhosis associated with hepatitis B or C virus or chronic alcoholic abuse (high-risk group) (37/47) than in that due to other causes (low-risk group) (12/21). MCF, predominant in cirrhotic livers of the high-risk group, were more proliferative, larger and more often involved in formation of nodules of altered hepatocytes (39.3%) than were GSF (8.5%). The results suggest that the FAH are preneoplastic lesions, MCF being more advanced than GSF. Oncocytic and amphophilic cell foci were also observed, but their significance remains to be clarified. Two types of SCC, namely diffuse and intrafocal SCC, were identified, but only intrafocal SCC was found to be related to increased proliferative activity and more frequent nodular transformation of the FAH involved, suggesting a close association with progression from FAH to HCC.

Adolescent↗
PubMed1997

Long-term results after surgery for acute mesenteric ischemia.

BACKGROUND: Acute mesenteric ischemia is associated with high mortality rates, and little is known about the long-term prognosis of patients after initially successful surgical intervention. METHODS: Ninety patients were treated by vascular reconstruction or bowel resection, or both, between 1972 and 1993. The overall mortality was 66%. The outcomes and rehabilitational statuses of those 31 patients who were discharged from the hospital were analyzed retrospectively. Anticoagulation consisted of vitamin K antagonists in patients with venous thrombosis and arterial embolism or inhibition of thrombocyte aggregation in patients with arterial thrombosis and nonocclusive mesenteric ischemia. RESULTS: In 31 patients discharged from the hospital venous thrombosis, arterial embolism, arterial thrombosis, and nonocclusive disease occurred in 19, 5, 5, and 2 patients, respectively. The 2- and 5-year survival rates were 70% and 50% and mainly related to cardiovascular comorbidity and malignant disease. Only one patient died after a recurrent attack of arterial mesenteric thrombosis. Twenty percent of the patients suffered from chronic short bowel syndrome after extensive bowel resection, but none required permanent parenteral nutrition. CONCLUSIONS: Under appropriate anticoagulation there is a remarkably low risk of recurrent mesenteric ischemia. The impaired life expectancy of long-surviving patients is mainly due to cardiovascular comorbidity and malignancies.

Acute Disease↗
PubMed1997

Hepatic preservation with histidine-tryptophan-ketoglutarate solution in living-related and cadaveric liver transplantation.

1. Living-related liver transplantation has some advantages in the evaluation of novel clinical protocols, since many complicated factors affecting initial graft function are almost uniform in grafts obtained from healthy donors. 2. To compare histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW) solution in terms of tissue oxygenation in living-related liver transplantation, oxygen saturation of haemoglobin (SO2) in hepatic tissue and its heterogeneity (CV, coefficient of variation) were measured by near-infrared spectroscopy. The HTK and UW groups consisted of 15 and 49 successful transplants respectively, in which no statistical differences in background were observed. 3. In the HTK group, hepatic SO2 after portal vein reflow was higher (P < 0.01) than that in the UW group, as was that after hepatic artery reflow (P < 0.05). In the UW group, hepatic SO2 remained at the lower level at the end of the operation. 4. Furthermore, the increase in CV after portal vein reflow was normalized after hepatic artery reflow in the HTK group. However, the CV remained at a high level at the end of the operation in the UW group. 5. Postoperative peak aspartate aminotransferase level in the HTK group was lower than that in the UW group (P < 0.05). 6. In cadaveric liver transplantation, higher hepatic SO2 and lower CV of hepatic SO2 in the early phase after reperfusion compared with the UW group (n = 18) were also observed in the HTK group (n = 30) (P < 0.05). 7. In conclusion, recovery of tissue oxygenation and its heterogeneity after reperfusion in HTK-preserved livers were more rapid and homogeneous than in UW-preserved livers in living-related liver transplantation. Accordingly, HTK solution may be a potential alternative to UW solution.

Adenosine↗