ALPPS Procedure in Insufficient Hypertrophy After Portal Vein Embolization (PVE).

BACKGROUND: The main limiting factor for major liver resections is the volume and function of the future remnant liver (FLR). Portal vein embolization (PVE) is now standard in most centers for preoperative hypertrophy of FLR. However, it has a failure rate of about 20-30 %. In these cases, the "Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy" (ALPPS) may represent a suitable and possibly the only alternative. METHODS: We performed a retrospective analysis of nine patients who had ALPPS following an insufficient hypertrophy after PVE. Computed tomography volumetry were performed before and after PVE as well as the first step of ALPPS. Furthermore, complications, 30-day mortality and outcome were analyzed. RESULTS: The FLR volume rose significantly by 77.7 ± 40.7 % (FLR/TLV: 34.9 ± 9.7 %) as early as 9 days after the first stage despite insufficient hypertrophy after preoperative portal vein embolization. Major complications (Grade > IIIb) occurred in 33 % of the patients, and 30-day mortality was 11.1 %. The OS at 1 and 2 years was 78 and 44 %. Four patients are presently still alive at a median of 33.4 (range 15-48) months (survival rate 44.4 %). CONCLUSION: The ALPPS procedure could be a suitable alternative for patients following insufficient PVE or indeed the last chance of a potentially curative treatment in this situation. Nevertheless, the high morbidity and mortality rates and the lack of data on the long-term oncological outcome must also be taken into account.

[Preoperative imaging/operation planning for liver surgery]. / Präoperative Bildgebung/Operationsplanung für die Leberchirurgie.

The currently established standard for planning liver surgery is multistage contrast media-enhanced multidetector computed tomography (CM-CT), which as a rule enables an appropriate resection planning, e.g. a precise identification and localization of primary and secondary liver tumors as well as the anatomical relation to extrahepatic and/or intrahepatic vascular and biliary structures. Furthermore, CM-CT enables the measurement of tumor volume, total liver volume and residual liver volume after resection. Under the condition of normal liver function a residual liver volume of 25 % is nowadays considered sufficient and safe. Recent studies in patients with liver metastases of colorectal cancer showed a clear staging advantage of contrast media-enhanced magnetic resonance imaging (CM-MRI) versus CM-CT. In addition, most recent data showed that the use of liver-specific MRI contrast media further increases the sensitivity and specificity of detection of liver metastases. This imaging technology seems to lead closer to the ideal "one stop shopping" diagnostic tool in preoperative planning of liver resection.

Twenty-year longitudinal follow-up after orthotopic liver transplantation: a single-center experience of 313 consecutive cases.

With excellent short-term survival in liver transplantation (LT), we now focus on long-term outcome and report the first European single-center 20-year survival data. Three hundred thirty-seven LT were performed in 313 patients (09/88-12/92). Impact on long-term outcome was studied and a comparison to life expectancy of matched normal population was performed. A detailed analysis of 20-years follow-up concerning overweight (HBMI), hypertension (HTN), diabetes (HGL), hyperlipidemia (HLIP) and moderately or severely impaired renal function (MIRF, SIRF) is presented. Patient and graft survival at 1, 10, 20 years were 88.4%, 72.7%, 52.5% and 83.7%, 64.7% and 46.6%, respectively. Excluding 1-year mortality, survival in the elderly LT recipients was similar to normal population. Primary indication (p < 0.001), age (p < 0.001), gender (p = 0.017), impaired renal function at 6 months (p < 0.001) and retransplantation (p = 0.034) had significant impact on patient survival. Recurrent disease (21.3%), infection (20.6%) and de novo malignancy (19.9%) were the most common causes of death. Prevalence of HTN (57.3-85.2%, p < 0.001), MIRF (41.8-55.2%, p = 0.01) and HBMI (33.2-45%, p = 0.014) increased throughout follow-up, while prevalence of HLIP (78.0-47.6%, p < 0.001) declined. LT has conquered many barriers to achieve these outstanding long-term results. However, much work is needed to combat recurrent disease and side effects of immunosuppression (IS).

Assessment of the relationship between age and continuous intracranial compliance.

The aim of this open, descriptive and prospective study was to determine if the new monitoring parameter "continuous intracranial compliance (cICC)" decreases with age in patients with traumatic brain injury (TBI). 30 patients with severe and moderate TBI (Glasgow Coma Scale score < or = 10) contributing to a European multicenter study, organized by the Brain-IT group, underwent computerized monitoring of blood pressure, intracranial pressure (ICP), cerebral perfusion pressure and cICC. Regression analyses of individual median ICP and median cICC versus patients' age revealed no significant dependency. Median cICC declined significantly with increasing ICP (when median ICP = 10, 20 and 30 mmHg, cICC = 0.64, 0.56 and 0.42 ml/mmHg respectively, p < 0.05). These three ICP groups were then subdivided according to age (0-20, 21-40, 41-60 and 61-80 years). Median cICC declined with age in both high ICP groups (median ICP = 20,30 mmHg). Percentage cICC values below a set pathological threshold of lower than 0.05 ml/mmHg across the four age groups were 28% (0-20 yrs), 59% (21-40 yrs), 60% (41-60 yrs) and 70% (61-80 yrs) respectively. The observed phenomenon of decreased intracranial volume challenge compensation with advancing age may contribute to the well-known fact of a worse outcome in elderly patients after TBI.

Continuous monitoring of intracranial compliance after severe head injury: relation to data quality, intracranial pressure and brain tissue PO2.

The objective of the present study was to test the new continuous intracranial compliance (cICC) device in terms of data quality, relationship to intracranial pressure (ICP) and brain tissue oxygenation (PtiO2). A total of 10 adult patients with severe traumatic brain injury underwent computerized monitoring of arterial blood pressure, ICP, cerebral perfusion pressure, end-tidal CO2, cICC and PtiO2 providing a total of 1726 h of data. (1) The data quality assessed by calculating the 'time of good data quality' (TGDQ, %), i.e. the median duration of artefact-free time as a percentage of total monitoring time reached 98 and 99% for ICP and PtiO2, while cICC measurements were free of artefacts in only 81%. (2) Individual regression analysis showed broad scattered correlation between cICC and ICP ranging from low (r = 0.05) to high (r = 0.52) correlation coefficients. (3) From 225 episodes of increased ICP (ICP > 20 mmHg > 10 min), only 37 were correctly predicted by a preceding decline in cICC to pathological values (< 0.5 ml/mmHg). (4) In all episodes of cerebral hypoxia (PtiO2 < 10 mmHg > 10 min), cICC was not pathologically altered. Based on the present results, we conclude that the current hardware and software version of the cICC monitoring system is unsatisfactory concerning data quality, prediction of increased ICP and revelance of cerebral hypoxic episodes.

Intracranial compliance as a bed-side monitoring technique in severely head-injured patients.

A recently developed monitoring technology makes an on-line assessment of intracranial compliance (ICC) possible. Aims of our research: 1. Course and values of ICC (critical threshold: < 0.5 ml/mmHg) in episodes of pathological intracranial pressure (ICP) (> 20 mmHg) and reduced cerebral oxygenation (brain tissue PO2 (PtiO2) < 10 mmHg). 2. Mean ICC in different ages. 3. Relationship between ICC and outcome. 4. Evaluation of ICC as routine monitoring parameter by calculation of s.c. time-of-good-data-quality (TGDQ). Computer data assessment of 7 patients with severe closed head-injury was performed providing 830 hours of data. TGDQ resulted from the formula: TGDQ (%) = artifact free time (min) x 100 (%)/total monitoring time (min). Outcome was assessed 6 months posttrauma (Glasgow Outcome Score (GOS). 1. Analysis revealed 43 episodes of pathologically elevated ICP and 39 of critical ICC. In 17 cases overlapping periods were found. In 9 of these ICC preceded ICP. Reduced cerebral oxygenation was neither related with high ICP nor low ICC. 2. ICC was found to be age-related. At a cut-off-point of 20 mmHg in ICP, ICC in children (< or = 16 years) was 0.9, in adults (17-60 years) 0.7 and in elderly (> 60 years) 0.6 ml/mmHg. 3. Adverse outcome was indicated best by high ICP (up to 45% of monitoring time) followed by low ICC (up to 41% of monitoring time). 4. TGDQ in ICC was 72% compared to 95% in ICP and 98% in PtiO2. In predicting adverse outcome, ICP was equal to ICC. The different ICC in each age class points to the need of age-adjusted thresholds. Further refinements of ICC technology are needed to improve ICC data quality and therefore become a useful tool in neuromonitoring.