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Liver transplantation (LT) using allografts from hepatitis C virus (HCV)-viremic/nucleic acid testing-positive donors' (DNAT+) organs into HCV-aviremic recipients (rHCV-) has been limited owing to nearly universal HCV transmission and concerns regarding availability, safety, and efficacy post-LT with direct-acting antiviral (DAA) therapy. We report our experience of LT using DNAT+ organs into rHCV- as a routine standard of care. Following verification of DAA access, absence of critical drug-drug interactions (DDIs) with DAAs, and informed consent, allocated DNAT+ organs were offered to patients on the waiting list for LT irrespective of recipient HCV status. Between June 2018 and December 2019, 292/339 rHCV- received an LT. Forty-seven patients were excluded from analysis because of recipient HCV viremia, refusal to receive DNAT+ organs, or inability to receive DAA therapy post-LT. Of these 292 patients, 61 rHCV- received DNAT+ livers (study group), and 231 rHCV- received DNAT- (aviremic donors [nuclear acid test-negative donors]) livers (control group). Recipient and donor characteristics as well as 1-year post-LT patient and graft survival were similar between groups. In the study group, 4 patients died, and 1 patient required retransplantation within the first year post-LT (all unrelated to HCV); 56 patients received DAA therapy, with a median time from LT to the start of DAA treatment of 66.9 days (interquartile range [IQR], 36-68.5), and 51 patients completed DAA treatment, all achieving sustained virologic response for 12 or more weeks (SVR-12) (1 patient required retreatment owing to relapse following initial DAA therapy). No patients had evidence of fibrosing cholestatic hepatitis or extrahepatic manifestations of HCV. This report indicates that transplantation of DNAT+ livers into rHCV- and subsequent DAA therapy is associated with clinical outcomes comparable to those achieved with DNAT- allografts.

Background With continued increase in the use of mechanical circulatory support, the incidence of device thrombus remains a challenge. This study is a retrospective analysis of data at a single center to assess the safety and efficacy of thrombolytic use in durable mechanical assist devices. Methods Data was analyzed retrospectively from 154 patients who underwent left ventricular assist device (LVAD) implantation from 1/1/2005 to 6/30/2014. The HMII device was implanted in 131 patients while 23 received the HVAD. LVAD thrombus was diagnosed when lactate dehydrogenase levels exceeded 1000 units/l accompanied by clinical signs of hemolysis and heart failure, echocardiographic data and surges in pump power. TPA (tissue plasminogen activator) protocol consisted of a 5 mg intravenous bolus followed by 3 mg/h infusion in normal saline for 10 h. If symptoms persisted another cycle of TPA at 1 mg/h was continued up to 48 h. Results The TPA group had a 70% success rate. Success was defined as complete resolution of hemolysis and clinical symptoms with no requirement for LVAD exchange at 30 days. 95% survival was noted at 30 days and 90% were free of a hemorrhagic stroke in the TPA group. The rates of hemorrhagic strokes in the TPA group and the control group were not different (OR = 0.92). Conclusion The TPA protocol described here was successful consistently. Though this study is limited by its size and retrospective nature it leads the way for larger studies to generate more robust comparisons between different types of mechanical assist devices as well as the tailored use of thrombolytics in this patient population., Graphical abstract Image 1

Background Despite good long-term results of primary total knee arthroplasty, it is a commonly accepted aim to stave off joint replacement as long as possible, particularly in younger patients. In this situation the surgeon has to make a careful decision whether an arthroscopic procedure will be promising, a corrective osteotomy may be sensible or a joint replacement due to the patient's age is acceptable. High tibial osteotomy had become increasingly popular by use of the opened wedge technique combined with locking compression plates fixation in the past decades while it has been replaced step by step by total knee arthroplasty. In spite of this fact the German national agency of quality management (BQS) showed that the number of total knee replacements in Germany increased from 90 000 in 2003 to 146 000 in 2008. The share of unicompartmental knee replacements in this period doubled from 5.3 % to almost 10 %. The aim of the present study was to inquire current data regarding particular surgical treatment concepts of unicompartmental knee arthritis in Germany. Material and methods In a nationwide anonymous survey in May 2009 220 departments of orthopaedics and 230 departments of trauma surgery were asked about their treatment strategies in unicompartmental knee arthritis in middle-aged patients (30 to 60 years) with unilateral Outerbridge grade III-IV lesions. Overall 46 questions in 6 subject areas (structure of the department, number of treated patients, surgical methods, anaesthesiological procedures, perioperative management, postoperative treatment) were posed. With regard to the item "operative treatment" we asked for the importance of arthroscopic procedures, corrective osteotomies and different procedures of joint replacement. The interpretation was done with invariant data analysis by indication of numerical frequency and percentage distribution of selected options. Results Questionnaires were returned by 51.1 % of the surveyed departments. This represents a total number of 76,028 procedures in unicompartmental knee arthritis in middle-aged patients. First of all, arthroscopic procedures were applied (50.4 %), followed by knee replacements (43.4 %, of which 87.3 % were total knee replacements, 12.3 % unicompartmental knee replacements and 0.4 % tibial hemiarthroplasties) and corrective osteotomies (6.1 %). In 59.8 % of the 38,376 arthroscopic procedures a microfracturing and in 28.2 % an abrasion arthroplasty was done. Most of the corrective osteotomies were performed at the proximal tibia (90.9 %) using an open wedge technique (73 %) and internal fixation with locking compression plates (72 %). 75.2 % of the responders performed cemented unicompartmental arthroplasties (97.8 %) with an average number of 23.2 per year. 43.4 % believe that bicompartmental arthroplasty in case of additional affection of the femoropatellar joint is an option and 22.6 % believe in the expected advantages of patient-specific unicompartmental implants. Total knee arthroplasties are performed with an average of 197.4 per year, most frequently using the free-hand technique (85.5 %) and medial-parapatellar approach (82 %). Interpositional knee devices were only used in 9.1 % of responding departments with an average number of 6.6 per year. Only procedures with low difficulty level such as arthroscopies were done by residents in a higher number (16.9 %). Procedures with higher difficulty level were mainly done by consultants, senior or chief surgeons. Conclusion In total, arthroscopic procedures still play an essential role in the treatment of unicompartmental knee arthritis prior to joint replacement. Total knee arthroplasty was preferred even though the number of unicompartmental knee replacements was only slightly increasing. Periarticular corrective osteotomies have gained in importance since the introduction of locking compression plates. Interpositional knee devices play a minor role in the treatment of unilateral knee arthritis in Germany.

One hundred and one patients below 45 years and showing objective signs of cerebral ischemia were studied retrospectively for pathogenetic factors. Twelve were below 15 years; the male to female ratio was 1:1. Factors known as predisposing (heart disease, hypertension, hyperlipemia, diabetes mellitus or infectious diseases) and other possible factors (e.g. trauma, abuse) were found in 41 patients. Among women using contraceptive pills there might be an increased risk of development of cerebral thrombosis, but the material was not large enough to warrant statistical analysis. In 64 patients one or more abnormal coagulation values were found, the most frequent being a deficient vessel wall fibrinolysis, which was noted in 38 %. We therefore consider it worthwhile to investigate the fibrinolytic defence mechanism of the vessel wall in patients with cerebral thrombosis, since it is possible to treat this condition with specific fibrinolytic stimulating agents.

Mit der ABBA („axillobilateral breast approach“) -Technik steht erstmalig ein Verfahren zur Schilddrusenresektion ohne Narbe am Hals zur Verfugung. In einer ersten Serie wurden von uns 26 Patientinnen operiert. Uber Inzisionen axillar und am Mamillenrand werden subkutan Trokare bis unter das Platysma vorgebrachte. Die Praparation erfolgt unter Videoskopie stumpf und mit Ultraschallskalpell. Die Schritte entsprechen denen des konventionellen Vorgehens, die Praparatebergung erfolgt uber die Axilla. Bei den 26 in ABBA-Technik operierten Patientinnen erfolgte in 24 Fallen eine subtotale Schilddrusenresektion. Die Op-Dauer betrug durchschnittlich 111 min (einseitig) bzw. 187 min (beidseitig). Es musste nicht konvertiert werden. Postoperativ bestanden passager eine Rekurrensparese und eine Armplexusparese. Bei einem selektionierten Krankengut ist die ABBA-Methode mit der notwendigen Radikalitat und Patientensicherheit durchfuhrbar. Es kann damit ein wesentlicher kosmetischer Vorteil erzielt werden.

AIM Although the outcome of surgical treatment of rotator cuff tears is well documented in the literature, less is known about the efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. METHODS A series of 30 patients (38 shoulders) with rotator cuff tears seen by ultrasonography were included in this prospective study. Rotator cuff tears were divided into partial defects (group A), full thickness tears of the supraspinatus tendon (group B), and massive rotator cuff defects (group C). Treatment consisted of a home program of stretching and strengthening exercises that were performed by the patients daily for a period of 12 weeks and controlled by a physician every 2 weeks. Range of motion, a modified constant score, and impingement signs at initial examination and after 12 weeks were compared. RESULTS All groups experienced improvement in range of motion. The Constant scores improved significantly (p < 0.05) in all groups (A: 13.0 [+/- 7.9 SD], B: 13.2 [+/- 11.4 SD], and C: 17.5 [+/- 6.6 SD]). Impingement signs showed a downward trend in all groups. DISCUSSION The results of this study show that patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect.

Some elderly persons develop high-grade decubitus ulcers, whereas others with comparable risk factors do not. In Germany, forensic pathologists are increasingly confronted by situations that necessitate an expert opinion on whether prevention of decubitus ulcers has been neglected in cases of suspected malpractice. This investigation was carried out in an attempt to identify risk factors for decubitus ulcers. We performed a postmortem case-control study in elderly persons who developed high-grade decubitus ulcers from 6 months to 14 days before death. Deceased with decubitus ulcers graded 3 or higher and controls at comparable risk were examined before cremation. After written informed consent had been obtained from the nearest living relatives, all available nursing and medical records of the deceased were thoroughly evaluated. Decubitus ulcer cases and controls were matched according to age, gender, immobility, and cachexia. One-hundred cases of decubitus ulcers with 71 grade 3 decubitus ulcers and 29 grade 4 decubitus ulcers were compared with 100 controls with 27 decubitus ulcers graded 2 or lower and the maximal risk as assessed by the Norton scale. The mean age was 86 years, 80% were females, 86% were bedridden, and cachexia was found in 66%. The individuals with decubitus ulcers were more often severely disabled, had more immobility of joints, and were more often under treatment with antidepressive and/or sedative drugs (e.g., opioid analgesies, neurolepties, benzodiazepines). Patients' impaired ability or unwillingness to comply or cooperate with preventive and therapeutic measures was more often recorded in cases of decubitus than in the control group. There was no evidence that supplementary nutrition or use of preventive pressure relief and protective devices differed between the decubitus cases and the controls.

Obwohl die allgemein bekannten Vorteile der laparoskopischen Technik auch fur die kolorektalen Eingriffe nachgewiesen werden konnten, wird die laparoskopische Resektion beim Rektumkarzinom kontrovers diskutiert. Das liegt unter anderem daran, dass in den meisten bisherigen Publikationen nur kleinere Patientenkollektive untersucht und ausgewertet werden konnten - mit letztlich offenem onkologischen Ergebnis. In dieser Arbeit soll anhand unserer eigenen Erfahrungen und einer Literaturanalyse der Stellenwert der laparoskopischen Resektion des Rektumkarzinoms erortert werden. Zwischen November 1992 und Juli 2003 erhielten in unserer Klinik insgesamt 194 Patienten eine laparoskopische Rektumresektion wegen Karzinom. Alle Patienten wurden prospektiv erfasst. Die Uberlebensberechnungen erfolgten mit Hilfe der Kaplan-Meier-Methode. Die Literaturrecherche wurde mit MEDLINE als Suchmaschine durchgefuhrt. Kasuistiken und Abstracts wurden ausgeschlossen. Am haufigsten kam die tiefe anteriore Resektion mit totaler Mesorektumexzision (TME) zum Einsatz (65,5%). Die mittlere Operationsdauer betrug 174 min. Durchschnittlich wurden 25,4 (Bereich 11-84) Lymphknoten entfernt. Die mittlere Lange des resezierten Praparats betrug 27,6 (11-68) cm. Die UICC-Tumorstadien verteilten sich wie folgt: Stadium I 49 (25,2%), Stadium II 53 (27,3%), Stadium III 59 (30,4%) und Stadium IV 33 Patienten (17%). Eine Konversion zum offenen Verfahren war in 2 Fallen (1%) erforderlich. Die haufigste postoperative Komplikation war die Anastomoseninsuffizienz (11,8%). Es gab keine postoperative Mortalitat. Das Follow-up betrug 12-128 Monate (Mittelwert 46,1 Monate). Die haufigste Spatkomplikation war die Narbenhernie (3,6%). Eine «Port site»-Metastase bildete sich bei 1 Patienten (0,5%). Die Lokalrezidivrate lag bei 4,1% nach kurativer Resektion. Die Gesamt-5-Jahres-Uberlebensrate war 76,9% nach kurativer Resektion und 31,8% nach palliativer Resektion. Die tumorbezogene 5-Jahres-Uberlebensrate betrug 87,7% nach kurativer Resektion und 48,5% nach palliativer Resektion. Nach 5 Jahren betrug die Uberlebensrate 100% fur Stadium I, 94,4% fur Stadium II, 66,6% fur Stadium III und 44,6% fur Stadium IV. Unsere Ergebnisse und die Literaturdaten zeigen, dass die laparoskopische Rektumresektion, insbesondere auch die TME keine erhohte Morbiditat und Mortalitat im Vergleich zur konventionellen Rektumresektion aufweist. Onkochirurgische Radikalitatskriterien werden erfullt. Die Langzeitergebnisse sind mit denen nach offener Rektumresektion vergleichbar.

Laparoscopic Resection of Rectal Carcinomas in the Elderly Several studies dealing with open surgery in malignant tumors have shown that the postoperative course does not depend so

Laparoscopic Incisional Hernia Repair – Is It Necessary that the Mesh Used in Intraperitoneal Onlay Mesh Technique Has Specific Characteristics Different trials showed advantages of

The goal of this study was to examine the effectiveness of endoscopic retrograde choledocho-pancreatography (ERCP) at the Unfallkrankenhaus Berlin in the setting of pre-operative suspicion of choledocholithiasis. The predictive value of various pathologic findings with regard to choledocholithiasis was to be determined in this patient population.All patients treated operatively for symptomatic cholecystolithiasis between August 2000 and August 2001 were evaluated retrospectively for the following variables: age, gender, operative strategy, intra-operative cholangiography, sonographic findings, occurrence of choledocholithiasis. In 21.4 % of 196 patients who underwent cholecystectomy (n = 42) a pre-operative ERCP was performed. In 19 of these 42 patients, no pathology was found on ERCP. The percentage of therapeutic pre-operative investigations was 47.6 % (n = 20). In 3 patients, a juxtapapillary diverticulum was seen.69.9 % of the operations (n = 137) were performed laparoscopically. 167 patients (85.2 %) underwent intra-operative cholangiography. In 4 patients, the ERCP was performed post-operatively. The indication for 3 of those 4 examinations was an abnormal intra-operative cholangiogram. Complications occurred in 4 of the 46 patients who underwent ERCP (8.7 %). Choledocholithiasis was found in 12.2 % (n = 24) of all 196 patients. The pathologic finding with the highest positive predictive value for the diagnosis of choledocholithiasis was the finding of a dilated common bile duct to more than 8 mm diameter (PPV 75 %). Among laboratory variables investigated in this study, the elevation of serum bilirubin level exhibited the highest positive predictive value (PPV 39.2 %).

We report about a 44-year-old woman who presented at our Orthopaedic Department suffering from persisting pain and a tumor of the right knee after open articulosynovectomy. MRI did not clarify the entity at all. The X-ray examination could identify an inlying compress after a synovectomy in 1999. The intra-articular foreign body could be removed by open revision surgery.

Laparoscopic Colorectal Surgery in Germany – Results of an Inquiry In a German survey concerning establishment and frequency of laparoscopic colorectal surgery, 71.5% of 1,230 hospitals replied. Accordingly, 47% of the clinics are dealing with this new technique and 10.4% of the colorectal interventions are performed laparoscopically. Indications for laparoscopic surgery are benigne diseases in 91% and carcinomas in 10%. Assuming a 100% reply, there was an increase of laparoscopic operations from 0.86% in 1997 to 7.3% in 2000. The number of involved hospitals increased from 6.6 to 33%.

Purpose: This single-center retrospective study addresses cost and net income for leading causes of readmissions for patients supported by continuous-flow left ventricular assist devices (LVADs). Methods: Leading causes of readmissions were identified, along with baseline characteristics of the patient population. Length of stay (LOS) and financial data were collected for direct costs, indirect costs, contribution margin and net income, per readmission (n= 153 events). LOS, cost and net income per type of readmission were characterized. ANOVA was used to test for significance between readmission types (p< 0.05). Results: Leading causes of readmissions were identified as GI bleeding, “other” (per INTERMACS definition), CVA/TIA symptoms, VT and/or AICD fire, other infection, and hemolysis. Combined causes accounted for 64.3% of readmissions. Payer mix was composed of 55.2% Medicare, 28.4% private insurance and 16.4% Medicaid. Patients in the hemolysis group had the largest average cost (average direct + indirect cost $141,791, LOS 8 days), which was significant in comparison to patients with CVA/TIA symptoms (average direct + indirect cost $15,690, LOS 4 days) (p= 0.043). The category “other” resulted in the highest contribution margin (average $6,195 per readmission). Surprisingly, categories of GI bleed, CVA/TIA symptoms, and hemolysis all had an average contribution margin of approximately +/$1,000. The average LOS for the combined causes of readmissions was 6 days, contribution margin was $2,425 and net income was -$13,744. Conclusion: This study offers for the first time an insight into the financial implications of the leading causes of readmissions for LVAD patients. Analysis shows a small contribution margin can be attained from treating LVAD patients for common types of readmissions. By identifying costs and net income associated with specific types of readmissions, financial and clinical strategies can be employed to improve screening and treatment efficiency.

We report the occurrence of spontaneous splenic hemorrhage in a patient with Wegener's granulomatosis. Pulmonary infiltrates, hemoptysis, and crescentic glomerulonephritis were accompanied by a progressive splenic enlargement with minimal abdominal symptoms. Magnetic resonance imaging was particularly helpful. The spleen was removed by minimally invasive endoscopic surgery. Subcapsular hemorrhage had occurred because of splenic vasculitis. Postoperatively, a remission was achieved by a combination of high-dose corticosteroids and cyclophosphamide.

There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes. Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed. The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were

Laparoscopic pancreatic resections are rare procedures. A particular position is held by the left resection. In animal trials and 37 operations performed to date, this laparoscopic procedure has been positively assessed. The diseases operated upon were nearly exclusively benign. From November 1998 to July 2001, we performed 5 laparoscopic distal pancreatic resections at our hospital. The indications were: 2 adenocarcinomas; 1 neuroendocrine carcinoma; 1 high malignant T-cell lymphoma, and 1 cystadenoma. Additional procedures in 3 patients were: gastrectomy and resection of the left liver in the case with T-cell lymphoma; resection of a distant metastasis in the liver in the case with advanced pancreatic carcinoma, and a partial adrenalectomy in the case with cystadenoma. We did not note any intra- or postoperative complications in our patients. First of all, benefit is to be found in the early postoperative course. All oncosurgical criteria could be fulfilled.

Hemophilia and von Willebrand's disease are the most common congenital coagulation and bleeding disorders. The situation for patients suffering from these conditions has changed drastically during the last 2 to 3 decades. It is the purpose of this article, first, to give data on demography and mortality in hemophilia and, then, to review basic problems of therapy, especially in connection with surgery in hemophilia and von Willebrand's disease with emphasis on the use of blood components.

Seventy-seven hemophilic patients of type A or type B were subjected to a total of 108 major surgical procedures mainly in the field of general surgery, orthopedic surgery, or neurosurgery. The principles for the substitution therapy in the different types of procedures and different types of hemophilic diseases are described, as well as the indications for surgery and the surgical technique. The importance of prolonged substitution therapy postoperatively to avoid late hematoma, particularly in patients with severe hemophilia undergoing major surgery, is stressed. With this type of management there has been no increased intraoperative hemorrhage, and very few cases of late hematoma formation. By combining the substitution therapy with immunosuppression, it has been possible to operate also on patients with inhibitors against factor VIII or IX. The rate of complications, particularly the incidence of hepatitis, has been low with the type of substitution given in this series of patients. It is concluded that major surgery can be carried out even in severe hemophilia without significantly increased risk. The handling of the substitution therapy, and the surgical judgment and technique, offers however, special problems, necessitating centralization of elective cases.

Philadelphia,Pa., March 21, 1899. To the Editor: —Referring to Dr. F. R. Sherwood's very meritorious article in theJournalof March 11, on the above subject, I am constrained to contribute this brief record of an observation, made en passant as it were, which may possess some interest for the doctor, and for some other readers. It was several months ago that, while riding in a trolley-car, I saw sitting upon its mother's lap near by, a child apparently about three years of age, having five distinct fingers on each hand—no thumbs. In place of the latter there were two prehensile fingers having each three phalanges, and quite closely resembling the apposed forefingers respectively, in size, shape, length, and mobility. The finger-thumbs seemed to serve the hands with as much freedom of motion, prehension and adaptability as ordinary thumbs, as I could unmistakably detect while in a sufficiently favorable