Prague's IKEM and Berlin's Virchow Clinic: three years of bilateral cooperation between two European liver transplant centers.

With sweeping political changes in Europe since 1989, cooperation across former borders has become possible. This article reports an experience of cooperation between an established center in Western Europe (Berlin's Virchow Clinic) and a developing center in Central Europe (Prague's Institute for Clinical and Experimental Medicine, or IKEM). The relationship began with common organ procurement and has resulted in a high-quality transplant program in the Czech Republic. The Virchow Clinic functioned as counselor, adviser, and mentor to the developing center. The cooperation was supported by Eurotransplant, and training was provided to IKEM to enhance skills for an improved national program for liver transplantation. Standards for IKEM's full membership in the northwestern European network have been met. The number of liver transplantations per million population in the Czech Republic has markedly increased since the onset of this cooperative effort.

Incidence and outcome of arterial complications after orthotopic liver transplantation.

Arterial complications can be a major factor in morbidity and mortality after orthotopic liver transplantation (OLT), as they may cause graft failure, sepsis and complications of the biliary tract. From September 1988 to December 1994, 571 OLT were performed in 529 patients. The follow-up period ranged from 8 to 83 months. Actuarial 1-, 3- and 5-year survival figures were 91%, 87% and 85%, respectively. In 12 cases (2.1%) complications of the arterial anastomoses were observed. Early arterial complications occurred in eight cases from various causes, while late arterial complications were exclusively thromboses and developed in four patients 8, 12, 26 and 37 months after surgery, respectively. The main clinical course in patients with arterial thromboses was septic cholangitis with destruction of the biliary tree. Although 70% of the grafts with arterial thrombosis were lost, 30% could, at least temporarily, be salvaged by other treatment options. Provided adequate treatment is carried out, arterial complications do not affect overall patient survival.

[Effect of minimally invasive technique on the educational curriculum of future surgeons]. / Einfluss der minimal-invasiven Technik auf das Ausbildungscurriculum angehender Chirurgen.

The retrospective evaluation of 1219 operations for appendicitis (n = 602) or cholecystolithiasis and/or cholecystitis (n = 617) in the advent of minimal invasive techniques reveals a shift from educational interventions to mere care-taking interventions. In our investigation, we observed a decrease in appendectomies and an increase in cholecystectomies which nevertheless hazards surgical education because of the marked decrease in "teaching operations" in the advent of minimal invasive techniques. This development has to be taken into consideration in order to guarantee a qualified education for future generations of surgeons, and specific measures have to be taken to face this problem effectively.

Incidence and clinical relevance of recurrent hepatitis C infection after orthotopic liver transplantation.

From September 1988 to November 1992 318 liver transplants were performed at our hospital. Of these patients 68 had end-stage cirrhosis due to non-A, non-B, hepatitis, 44 of whom (64.7%) had hepatitis C virus RNA in the serum. Of this subgroup 35 patients (79.5%) were also anti-HCV positive. Postoperatively most recipients remained anti-HCV positive and after 1 year more than 90% had HCV RNA in the serum. About 40% developed a mild, chronic hepatitis and 50% were carriers of HCV without histopathological signs. Two patients suffered from a temporary severe acute hepatitis and one patient had a fulminant liver failure due to reinfection. In general, in liver recipients transplanted for end-stage HCV hepatitis there was a high incidence of reinfection with HCV. The clinical course, however, was less severe than in hepatitis B recurrence.

Does concommitant splenectomy raise the mortality of liver transplant recipients?

Within a 17-month period, 130 orthotopic liver transplantations were performed in our hospital. Nine of these were retransplantations and were not included in our analysis. In the remaining 121 patients, splenectomy was performed in 34 patients, either synchronously with the transplant procedure (27 patients) or in the postoperative period (7 patients). Indications for splenectomy were lienalis-steal syndrome in 15 patients and hypersplenism in 15 cases. The number of rejection episodes was fairly equal in both groups (splenectomized vs. non-splenectomized, 61.7% vs. 63.9%, respectively). There was a marked difference in the frequency of infectious episodes (61.7% vs. 25.3%) that resulted in a decreased survival rate (77.5% vs. 95.4%) for splenectomized patients. Therefore, we recommend splenectomy only for very selected patients and investigate the banding of the splenic artery as an alternative.

[Liver transplantation as a routine procedure? Indications and results in 270 patients]. / Lebertransplantation als Routineverfahren? Indikationen und Ergebnisse bei 270 Patienten.

AIM: To represent the current state of the art of orthotopic liver transplantation (OLT). The constantly expanding spectrum of indications are discussed in detail, and the specific risks of the individual indications considered. Major points discussed: On the basis of the authors' own results obtained at the Rudolf Virchow Hospital, University of Berlin, the current survival rates following orthotopic liver transplantation are shown. In addition to established indications for liver transplantation (primary biliary cirrhosis, primary sclerosing cholangitis, acute hepatic failure, various metabolic diseases, small hepatocellular carcinomas and a number of posthepatic cirrhoses) the indication and results of liver transplantation in HbsAg-positive and alcoholic cirrhosis are presented in detail. In contrast to reports in the Anglo-American literature, the incidence and severity of graft re-infections with the hepatitis virus was appreciably reduced through the use of anti-HBs hyperimmunoglobulin preparations in HBsAg-positive cirrhotics. The results obtained were comparable with those achieved for other indications.

Hepatitis C virus reinfection in allografts after orthotopic liver transplantation.

From September 1988 to May 1991, 160 orthotopic liver transplantations were performed in our hospital. Twenty-four patients had end-stage cirrhosis caused by chronic non-A, non-B hepatitis. Antibodies against hepatitis C virus were documented before and after orthotopic liver transplantation in 13 patients. Studies using the polymerase chain reaction demonstrated hepatitis C virus RNA in the serum and liver tissue of 17 patients (10 of whom tested positive for hepatitis C virus antibodies) before orthotopic liver transplantation. Tissue samples taken from liver grafts during the operation were hepatitis C virus RNA negative in every case. Ten of these 17 patients had positive hepatitis C virus RNA findings in serum and liver biopsy specimens within the first month after surgery. One patient died of Mucor sepsis 2 mo after orthotopic liver transplantation. Another patient died of multi-organ failure 3 mo after a retransplantation. Two patients underwent retransplantation for graft rejection at 2 and 3 mo, respectively. One year after orthotopic liver transplantation, hepatitis C virus RNA was demonstrated in allograft biopsy specimens in 13 of 15 patients. Two patients remained hepatitis C virus RNA negative in repeated biopsies up to 12 mo. Mild portal and lobular hepatitis developed within 6 months of orthotopic liver transplantation in four patients and within 1 yr in five additional patients. The data suggest that persistent hepatitis C virus reinfects the allograft in most cases, but the risk of acute organ damage caused by hepatitis C virus reinfection is low.

[Surgical ligation of patent ductus arteriosus on the intensive care unit in small premature infants]. / Ductusligatur auf der Intensivstation bei kleinen Frühgeborenen.

This paper summarizes the experience with ligation of persistent ductus arteriosus in prematures performed in the intensive care unit during the years 1986 to 1988. Records of 35 operated prematures on artificial ventilation were analyzed retrospectively. Management and organization of the operation are described. For comparison, records were analysed of 47 prematures, also artificially ventilated, who during the years 1978 to 1986 had to be transported to an operating theatre over a distance of 3 or 10 km for the ligation.