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ObjectivesPreoperative hypoalbuminaemia is associated with adverse outcome, including increased postoperative mortality in cardiovascular surgery, neurosurgery, trauma and orthopaedic surgery. However, much less is known about the association between preoperative serum albumin and clinical outcomes after liver surgery. In this study, we sought to determine whether hypoalbuminaemia before partial hepatectomy is associated with a worse postoperative outcome.DesignObservational study.SettingUniversity Medical Centre in Germany.ParticipantsWe analysed 154 patients enrolled in the perioperative PHYsostigmine prophylaxis for liver resection patients at risk for DELIrium and postOperative cognitive dysfunction (PHYDELIO) trial with a preoperative serum albumin assessment. Hypoalbuminaemia was defined as serum albumin Outcome measuresThe outcome parameters of interest were postoperative complications according to Clavien (moderate: I, II; major: ≥III), length of intensive care unit (ICU) stay, length of hospital stay and survival rates 1 year after surgery.ResultsPreoperative hypoalbuminaemia was associated with the occurrence of major postoperative complications (OR 3.051 (95% CI 1.197 to 7.775); p=0.019) after adjusting for age, sex, randomisation, American Society of Anesthesiologists physical status, preoperative diagnosis and Child-Pugh class. Both ICU and hospital lengths of stay were significantly prolonged in patients with preoperative hypoalbuminaemia (OR 2.573 (95% CI 1.015 to 6.524); p=0.047 and OR 1.296 (95% CI 0.254 to 3.009); p=0.012, respectively). One-year survival was comparable between patients with and without hypoalbuminaemia.ConclusionsWe found that low serum albumin before surgery was associated with a worse short-term outcome after partial hepatectomy, which strengthens the prognostic value of serum albumin in the setting of liver surgery.Trial registration numbersISRCTN18978802and EudraCT 2008-007237-47.

Background Gastric cancer with peritoneal metastases is associated with an extremely poor prognosis. Developed multimodal treatment concepts, which include a combination of perioperative systemic treatment and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), show promising results with respect to improvement of the long-term survival. Methods This article contains a review of the literature of published studies on the topic of gastric cancer and peritoneal metastasis. Results The prognosis of patients with gastric cancer peritoneal carcinomatosis shows an extremely limited median survival of 7 months under palliative second-line systemic treatment. The median survival time increased to 12 months with cytoreductive surgery and in combination with HIPEC showed a positive effect on survival in individual studies. Expert opinion Treatment recommendations for patients with peritoneal metastases of gastric cancer should be carried out by experts in surgical reference centers.

Das peritoneal metastasierte Magenkarzinom hat eine sehr schlechte Prognose. Das mediane Uberleben liegt bei 7 Monaten mit palliativer Zweitlinienchemotherapie. Das Ziel dieses Artikels ist die zusammenfassende Darstellung der Diagnostik und Therapieoptionen des peritoneal metastasierten Magenkarzinoms unter Einbeziehung aktueller Studien. Zusatzlich zur Darstellung der eigenen Erfahrung als Referenzzentrum fur Peritonealkarzinose wurde eine Literaturrecherche zu aktuellen klinischen Studien uber die Datenbank PubMed durchgefuhrt. Eine Staging-Laparoskopie sollte beim lokal fortgeschrittenen Magenkarzinom in die Diagnostik vor Therapiebeginn integriert werden. Hierdurch ergibt sich die Moglichkeit, auch das Ansprechen der peritonealen Metastasen auf die praoperative Chemotherapie mit zu beurteilen. Die chirurgische Therapie eines peritoneal metastasierten Magenkarzinoms im Sinne einer Gastrektomie und Zytoreduktion sollte nur in selektionierten Fallen in einem ausgewiesenen Zentrum angeboten werden. Inwiefern eine hypertherme intraperitoneale Chemotherapie (HIPEC) oder auch die druckinduzierte intraperitoneale Aerosol-Chemotherapie (PIPAC) zusatzliche sinnvolle Verfahren sind, wird derzeit in Studien geklart. Durch eine Staging-Laparoskopie kann mit hoher Sicherheit eine peritoneale Metastasierung ausgeschlossen werden, was eine kurative Therapie ermoglicht. Bei peritonealer Metastasierung kann bei geringer Tumorlast in selektionierten Fallen die chirurgische Therapie mit Gastrektomie und Zytoreduktion in einem ausgewiesenen Zentrum erfolgen.

Objective To assess the effects of epidural anesthesia (EA) on patients who underwent liver resection. Design Secondary analysis of a prospective randomized controlled trial. Setting This single-center study was conducted at an academic medical center. Methods A subset of 110 1:1 propensity score–matched patients who underwent liver resection with and without EA were analyzed. Outcome measures were pain intensity ≥5 on a numeric rating scale (NRS) at rest and during movement on postoperative days 1–5, analyzed with logistic mixed-effects models, and postoperative complications according to the Clavien-Dindo classification, length of hospital stay (LOS), and one-year survival. One-year survival in the matched cohorts was compared using a frailty model. Results EA patients were less likely to experience NRS ≥5 at rest (odds ratio = 0.06, 95% confidence interval [CI] = 0.01 to 0.28, P 0.999, and P = 0.467, respectively). Reduced mortality rates were seen in the EA group one year after surgery (9.1% vs 30.9%, hazard ratio = 0.32, 95% CI = 0.11 to 0.90, P = 0.031). No EA-related adverse events occurred. Earlier recovery of bowel function was seen in EA patients. Conclusions Patients with EA had better postoperative pain control and required fewer systemic opioids. Postoperative complications and LOS did not differ, although one-year survival was significantly improved in patients with EA. EA applied in liver surgery was effective and safe.

Background: Surgical site infections are among the most common healthcare-associated infections, especially in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this retrospective study was to examine postoperative infectious complications according to preoperative screening findings of nasal and rectal swabs. Methods: Two hundred four consecutive patients received nasal and rectal swab examination for multidrug-resistant (MDR) bacteria within 30 days before the operation in patients where CRS and HIPEC were planned. Inclusion criteria were as follows: confirmed peritoneal metastases (histologically and/or cytologically); age under 85 years; adequate renal, liver, and bone marrow function; no sign of infection preoperatively; resectable disease; and CRS and HIPEC procedure. If surgical site infection occurred, the microbial spectrum of the site was assessed. One hundred twenty-one patients (63 female [52.1%] and 58 male [47.9%]) met the criteria and were further analyzed retrospectively. Statistical correlations between postoperative complications and risk factors were investigated by univariate and multivariate analysis. Results: Postoperative complications in total were observed in 57 patients (47.1%) with major complications (Clavien-Dindo grades 3–4) in 15 patients (12.4%) and infectious complications in 37 (30.6%) patients. The overall prevalence of nasal MRSA carriage was 3.28%, and the overall prevalence of rectal MDR bacteria carriage was 10.7%. In propensity score analysis, colonized patients compared to noncolonized patients showed increased total complications (CD1–5, p = 0.025), infectious complications (p = 0.028), surgical site infections (p = 0.022) as well as pneumonia (p = 0.016). Multivariate analysis showed that in addition to preoperative rectal colonization, American Society of Anesthesiologists score was a risk factor for postoperative complications. Conclusions: Preoperative 3-MRGN and vancomycin-resistant enterococcus colonization were associated with increased complications and surgical site infections. Special antimicrobial treatment pathways are necessary for these patients to reduce postoperative complications due to colonization.

Expansions of donor pools have a controversial impact on healthcare expenditures. The aim of this study was to investigate the emerging costs of expanded criteria donor (ECD) kidney transplantations (KT) and to identify independent risk factors for increased transplant-related costs. We present a retrospective explorative analysis of hospital costs and reimbursements of KTs performed between 2012 and 2016 in a German university hospital. A total of 174 KTs were examined, including 92 (52.9%) ECD organ transplantations. The ECD group comprised 43 (24.7%) 'old-for-old' transplantations. Median healthcare costs were 19 570€ (IQR 18 735-27 405€) in the standard criteria donor (SCD) group versus 25 478€ (IQR 19 957-29 634€) in the ECD group (+30%; P = 0.076). 'Old-for-old' transplantations showed the highest healthcare expenditures [26 702€ (19 570-33 940€)]. Irrespective of the allocation group, transplant-related costs increased significantly in obese (+6221€; P = 0.009) and elderly recipients (+6717€; P = 0.019), in warm ischaemia time exceeding 30 min (+3212€; P = 0.009) and in kidneys with DGF or surgical complications (+8976€ and +10 624€; both P < 0.001). Transplantation of ECD organs is associated with incremental costs, especially in elderly and obese recipients. A critical patient selection, treatment of obesity before KT and keeping warm ischaemia times short seem to be crucial, in order to achieve a cost-effective KT regardless of the allocation group.

Dynamic liver function assessment by the [13C]methacetin maximal liver function capacity (LiMAx) test reflects the overall hepatic cytochrome P-450 (CYP) 1A2 activity. One proven strategy for preoperative risk assessment in liver surgery includes the combined assessment of the dynamic liver function by the LiMAx test, the volumetric analysis of the liver, and calculation of future liver remnant function. This so-called volume-function analysis assumes that the remaining CYP1A2 activity in any tumor lesion is zero. The here presented study aims to assess the remaining CYP1A2 activities in different hepatic tumor lesions and its consequences for the preoperative volume-function analysis in patients undergoing liver surgery. The CYP1A2 activity analysis of neoplastic lesions and adjacent nontumor liver tissue from resected tumor specimens revealed a significantly higher CYP1A2 activity (median, interquartile range) in nontumor tissues (35.5, 15.9–54.4 µU/mg) compared with hepatocellular adenomas (7.35, 1.2–32.5 µU/mg), hepatocellular carcinomas (0.18, 0.0–2.0 µU/mg), or colorectal liver metastasis (0.17, 0.0–2.1 µU/mg). In nontumor liver tissue, a gradual decline in CYP1A2 activity with exacerbating fibrosis was observed. The CYP1A2 activity differences were also reflected in CYP1A2 protein signals in the assessed hepatic tissues. Volume-function analysis showed a minimal deviation compared with the current standard calculation for hepatocellular carcinomas or colorectal liver metastasis ( NEW & NOTEWORTHY The cytochrome P-450 (CYP) 1A2-dependent maximal liver function capacity test reflects the overall functional capacity of the liver. To which extent hepatocellular tumors harbor CYP1A2 activity and thus contribute to the maximal liver function capacity test outcome is unknown. We here show that hepatocellular adenomas but not hepatocellular carcinomas or colorectal liver metastasis contain significant residual CYP1A2 activity. These findings are important for an improved preoperative volume-function analysis and an accurate surgical risk assessment in hepatocellular adenoma cases.

Gastric cancer with peritoneal metastases is associated with an extremely poor prognosis. Developed multimodal treatment concepts, which include a combination of perioperative systemic treatment and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), show promising results with respect to improvement of the long-term survival.This article contains a review of the literature of published studies on the topic of gastric cancer and peritoneal metastasis.The prognosis of patients with gastric cancer peritoneal carcinomatosis shows an extremely limited median survival of 7 months under palliative second-line systemic treatment. The median survival time increased to 12 months with cytoreductive surgery and in combination with HIPEC showed a positive effect on survival in individual studies.Treatment recommendations for patients with peritoneal metastases of gastric cancer should be carried out by experts in surgical reference centers.HINTERGRUND: Das peritoneal metastasierte Magenkarzinom ist mit einer äußerst schlechten Prognose assoziiert. Entwickelte multimodale therapeutische Konzepte, welche eine Kombination aus perioperativer Systemtherapie und zytoreduktiver Chirurgie mit hyperthermer intraperitonealer Chemotherapie (HIPEC) beinhalten, zeigen Erfolg versprechende Ergebnisse hinsichtlich der Verbesserung des Langzeitüberlebens.Diese Arbeit beinhaltet eine Literaturrecherche zu publizierten Studien zum Thema Magenkarzinom und peritoneale Metastasierung.Die Prognose des peritoneal metastasierten Magenkarzinoms ist mit einem medianen Überleben von nur 7 Monaten unter palliativer Zweitliniensystemtherapie äußerst limitiert. Eine zytoreduktive Chirurgie ermöglicht im Mittel ein medianes Überleben von 12 Monaten; eine zusätzliche HIPEC zeigte in einzelnen Studien gute Auswirkungen auf das Überleben.Behandlungsempfehlungen für Patienten mit peritoneal metastasiertem Magenkarzinom sollten durch Experten in chirurgischen Referenzzentren erfolgen.

Introduction: In pediatric liver transplantation (pLT), hepatic artery thrombosis (HAT) is associated with inferior transplant outcome. Hepatic artery reconstruction (HAR) using an operating microscope (OM) is considered to reduce the incidence of HAT. Methods: HAR using an OM was compared to a historic cohort using surgical loupes (SL) in pLT performed between 2009 and 2020. Primary endpoint was the occurrence of HAT. Secondary endpoints were 1-year patient and graft survival determined by Kaplan-Meier analysis and complications. Multivariate analysis was used to identify independent risk factors for HAT and adverse events. Results: A total of 79 pLTs were performed [30 (38.0%) living donations; 49 (62.0%) postmortem donations] divided into 23 (29.1%) segment 2/3, 32 (40.5%) left lobe, 4 (5.1%) extended right lobe, and 20 (25.3%) full-size grafts. One-year patient and graft survival were both 95.2% in the OM group versus 86.2% and 77.8% in the SL group (p = .276 and p = .077). HAT rate was 0% in the OM group versus 24.1% in the SL group (p = .013). One-year patient and graft survival were 64.3% and 35.7% in patient with HAT, compared to 93.9% and 92.8% in patients with no HAT (both p < .001). Multivariate analysis revealed HAR with SL (p = .022) and deceased donor liver transplantation (DDLT) (p = .014) as independent risk factors for HAT. The occurrence of HAT was independently associated with the need for retransplantation (p < .001) and biliary leakage (p = .045). Conclusion: In pLT, the use of an OM is significantly associated to reduce HAT rate, biliary complications, and graft loss and outweighs the disadvantages of delayed arterial perfusion and prolonged warm ischemia time (WIT).

The new COVID-19 pandemic has an impact on routine thoracic surgery. Various concepts and recommendations are being pursued to protect patients and hospital staff. However, the implementation of these recommendations may depend on the existing infrastructure, local conditions and in-house procedural instructions.Between 11th May and 26th May 2020, an anonymous online survey on the topic of COVID-19 was conducted among thoracic surgeons in Germany. The survey consisted of 16 questions on the local COVID-19 case numbers, protective measures, procedural instructions and treatment concepts. The results were summarised, descriptively analysed and discussed.The response rate of 42.6% (n = 66), included replies from 23 (34.8%) specialised hospitals, 18 (27.3%) maximum care hospitals and 14 (21.2%) university clinics. COVID-19-positive patients were treated in 65 (99%) clinics and 37.9% of the clinics also performed surgery on COVID-19-positive patients. Nasopharyngeal swabs were the main instrument for COVID-19 patient testing (in 95.4% of the clinics). Test results influenced decisions on treatment in 71.2% of the clinics. In 59.1% of clinics, safety equipment was supplemented with FFP2 masks and eye protection during thoracic surgeries due to the COVID-19 pandemic.Almost all thoracic surgeons reported that they had treated patients with COVID-19 and half of them also had performed surgery on COVID-19-positive patients. The applied procedural instructions as well as the effects of COVID-19 on treatment decisions and patient-doctor contact differed between the reporting clinics.Die Thoraxchirurgie ist im Alltag durch die COVID-19-Pandemie mit neuen Herausforderungen konfrontiert. Gegenwärtig werden unterschiedliche Konzepte und Empfehlungen verfolgt, um unsere Patienten/-innen und uns selbst zu schützen. Wie diese im Einzelnen umgesetzt werden, kann jedoch aufgrund der bestehenden Infrastruktur, der lokalen Gegebenheiten sowie aufgrund hauseigener Verfahrensanweisungen unterschiedlich sein.Im Zeitraum von 11.05. bis 26.05.2020 wurde eine Onlineumfrage an deutschen thoraxchirurgischen Einrichtungen zum Thema COVID-19 durchgeführt. Der Fragenkatalog bestand aus 16 Fragen zu den lokalen Fallzahlen, den Schutzmaßnahmen, Verfahrensanweisungen und Behandlungskonzepten. Die Ergebnisse wurden zusammengefasst, deskriptiv analysiert und diskutiert.Unter den 66 Antworten (Antwortrate: 42,6%) kamen 23 (34,8%) aus Schwerpunktkrankenhäusern, 18 (27,3%) aus Krankenhäusern der Maximalversorgung und 14 (21,2%) aus Universitätskliniken. In 65 (99%) der Kliniken wurden COVID-19-positive Patienten behandelt und in 39,9% der Kliniken auch operiert. Die Untersuchung der Patienten auf COVID-19 erfolgte in 95,4% der Kliniken durch nasopharyngealen Abstrich. In 71,2% der Kliniken wurde die chirurgische Behandlung durch das Testergebnis beeinflusst. Eine generelle Erweiterung der Standardschutzausrüstung um FFP2-Masken und Augenschutz für thoraxchirurgische Operationen während der COVID-19-Pandemie wurde in 59,1% der Kliniken durchgeführt.In fast allen thoraxchirurgischen Einrichtungen wurden Patienten mit COVID-19 behandelt und in nahezu der Hälfte der Kliniken wurde mindestens ein COVID-19-positiver Patient operiert. Es zeigten sich teilweise deutliche Unterschiede zwischen den einzelnen Kliniken hinsichtlich der Verfahrensanweisungen, der Auswirkungen auf Behandlungsentscheidungen und des Patienten-Arzt-Kontaktes durch COVID-19.

Abdominal wall closure after pediatric liver transplantation (pLT) in infants may be hampered by graft-to-recipient size discrepancy. Herein, we describe the use of a porcine dermal collagen acellular graft (PDCG) as a biological mesh (BM) for abdominal wall closure in pLT recipients. Patients

MELD attempts to objectively predict the risk of mortality of patients with liver cirrhosis and is commonly used to prioritize organ allocation. Despite the usefulness of the MELD, updated metrics could further improve the accuracy of estimates of survival. To assess and compare the prognostic ability of an enzymatic 13C-based liver function test (LiMAx) and distinct markers of liver function to predict 3-month mortality of patients with chronic liver failure. We prospectively investigated liver function of 268 chronic liver failure patients without hepatocellular carcinoma. Primary study endpoint was liver-related death within 3 months of follow-up. Prognostic values were calculated using Cox proportional hazards and logistic regression analysis. The Cox proportional hazard model indicated that LiMAx (p

Both liver transplantation (LT) and liver resection (LR) represent curative treatment options for hepatocellular carcinoma (HCC) in patients with liver cirrhosis. In this study, we have compared outcomes between historical and more recent patient cohorts scheduled either for LT or LR, respectively. Clinicopathological data of all patients with HCC and cirrhosis who underwent LT or LR between 1989 and 2011 were evaluated. Overall survival of patients with HCC within the Milan criteria (MC) was analyzed focusing on changes between different time periods. In total, 364 and 141 patients underwent LT and LR for HCC in cirrhosis, respectively. Among patients with HCC within MC, 214 and 59 underwent LT and LR, respectively. Postoperative morbidity (37 vs. 11%, P

Background Since perioperative morbidity and mortality in ALPPS are extraordinarily high, a deeper understanding of actual liver function during the procedure is essential to make the approach safer. Methods Data from 17 patients who underwent ALLPS were analyzed regarding their course of liver function capacity assessed with the LiMAx test and compared to an equal-sized matched cohort of patients that underwent PVE. Results A comparison of LiMAx prior to and following ALPPS Step I (330 [258–385] vs. 197 [144–224] μg/kg/h, p = 0.003) and prior to and following PVE (386 [330–519] vs. 378 [336–455] μg/kg/h, p = 0.534) demonstrated a significant drop in function after ALLPS. A volume/function analysis predicting FLR function regarding step II revealed an excellent correlation of predicted versus assessed postoperative liver function with a mean relative difference of 9 (−6 to 18)% and an ICC of 0.905 (123 [74–138] vs. 107 [77–175] μg/kg/h, p = 0.310). Conclusions We provide evidence that liver function capacity is significantly impaired due to ALPPS step I. This is particularly notable when compared to PVE. Our data also shows that the portal ligated liver lobe still continues to contribute significantly to overall liver function. Therefore, FLR function after step II is still predictable by volume/function analysis.

Background and aim Hepatic encephalopathy (HE) is a frequent complication of cirrhosis, characterized by cognitive deficits that negatively impact patients' quality of life. The mild, minimal hepatic encephalopathy (mHE) can only be detected by psychometric tests and early mHE detection can prevent more severe complications or even survival times. Here, we aimed to investigate the feasibility and validity of the novel-developed electronic number connection test (eNCT), which is designed as a fast and easy-to-perform mHE patient self-test. Methods The eNCT design was inspired by the paper-pencil number connection test version A, showing 25 numbers on the screen (1-25), in a random order. The time required to tap on all digits in the correct order was measured. A total of 238 individuals (112 patients with liver cirrhosis) were enrolled in this study and eNCT times were compared with well-established paper-pencil tests. The Psychometric Hepatic Encephalopathy Score test battery was used to detect mHE and cut-off values for mHE detection by the eNCT were defined. Results Overall, cirrhotic patients showed significantly slower test completion times compared with control participants. The eNCT performance was inversely correlated with Psychometric Hepatic Encephalopathy Score test performance in cirrhotic patients, independent of the HE status. Thirty cirrhotic patients fulfilled the mHE criteria and receiver operating characteristic curve analysis showed high sensitivity (>82%) and specificity (>85%) for mHE detection. Finally, the eNCT showed excellent test-retest reliability (intraclass correlation coefficient=0.94). Conclusion The novel eNCT is a reliable HE self-test to monitor cognitive function and detect cognitive impairment in cirrhotic patients.

Background The quest to cure or to contain the disease in cancer patients leads to new strategies and techniques being added to the armamentarium of oncologists. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a recently described surgical technique which is being evaluated at many centers for the management of peritoneal metastasis (PM). The present study is a systematic review to evaluate the current role of PIPAC in the management of gastric cancer associated PM. Methods A systematic search was conducted in Pubmed and EMBASE database using relevant keywords and confirming to the PRISMA guidelines to identify the articles describing the role of PIPAC in gastric cancer associated PM. All the studies which were published prior to July 1, 2018 in English literature and reported the role of PIPAC in gastric cancer associated PM were included in the systematic review. Results The search yielded 79 articles; there were ten published studies which have reported the use of PIPAC in gastric cancer associated PM. A total of 129 patients with gastric cancer associated PM were treated in the studies. Only two studies had an exclusive cohort of gastric cancer patients while eight other studies had a heterogeneous population with a small proportion of gastric cancer patients. There was only one study highlighting the role of PIPAC in neoadjuvant setting to downgrade the peritoneal carcinomatosis index. All the studies revealed that PIPAC is feasible and has minimal perioperative morbidity, even after repeated applications. Conclusion There is a scarcity of English literature related to the role of PIPAC in gastric cancer associated PM. PIPAC is a safe and well-tolerated procedure which has the potential to contain spreading PM. Further studies are warranted to better define the role of PIPAC in gastric cancer associated PM.

Background Surgical procedures in patients with underlying liver disease are still burdened by a high rate of postoperative morbidity, especially posthepatectomy liver failure (PHLF), ranging from 1.2 to 33.8%. The aim of this study was to investigate the prognostic value of volume/function analysis for the prediction of hepatectomy-related morbidity in patients with hepatocellular carcinoma. Methods Clinicopathological data were analysed in 261 patients who underwent liver resection for HCC between 2001 and 2014. Future liver remnant volume (FLRV) and future liver remnant function (FLRF) based on LiMAx test were obtained retrospectively. A subgroup analysis for high-risk patients with impaired liver function was conducted. Univariate and multivariate regression analysis was performed to identify risk factors for major complications, defined by Dindo ≥ IIIb and PHLF grade ≥ B. Results In the total cohort, FLRF was independently associated with major complications. FLRV, resected liver volume, and FLRF were independent risk factors for PHLF. In a subgroup analysis of high-risk patients, FLRF was identified as the only independent risk factor for major complications and PHLF development. Discussion These results suggest the superior value of FLRF to FLRV in predicting postoperative complications as well as PHLF in patients with chronic liver disease.

The need for primary human hepatocytes is constantly growing for basic research, as well as for therapeutic applications. However, the isolation outcome strongly depends on the quality of liver tissue, and we are still lacking a preoperative test that allows the prediction of the hepatocyte isolation outcome. In this study, we evaluated the "maximal liver function capacity test" (LiMAx) as predictive test for the quantitative and qualitative outcome of hepatocyte isolation. This test is already used in clinical routine to measure preoperative and to predict postoperative liver function. The patient's preoperative mean LiMAx was obtained from the patient records, and preoperative computed tomography and magnetic resonance images were used to calculate the whole liver volume to adjust the mean LiMAx. The outcome parameters of the hepatocyte isolation procedures were analyzed in correlation with the adjusted mean LiMAx. Primary human hepatocytes were isolated from partial hepatectomies (n = 64). From these 64 hepatectomies we included 48 to our study and correlated their isolation outcome parameters with volume corrected LiMAx values. From a total of 11 hepatocyte isolation procedures, metabolic parameters (albumin, urea, and aspartate aminotransferase or AST) were assessed during the hepatocyte cultivation period of 5 days. The volume adjusted mean LiMAx showed a significant positive correlation with the total cell yield (p = 0.049; r = 0.242; n = 48). The correlations of volume adjusted LiMAx values with viable cell yield and cell viability did not reach statistical significance. To create a more homogenous study group regarding tumor entities, subgroup analyses were performed. A subgroup analysis of isolations from patients with colorectal metastasis revealed a significant correlation between volume adjusted mean LiMAx and total cell yield (p = 0.012; r = 0.488; n = 21) and viable cell yield (p = 0.034; r = 0.405; n = 21), whereas a subgroup analysis of isolations of patients with carcinoma of the biliary tree showed significant correlations of volume adjusted mean LiMAx with cell viability (r = 0.387; p = 0.046; n = 20) and lacked significant correlations with total cell yield (r = -0.060; p = 0.401; n = 20) and viable cell yield (r = 0.012; p = 0.480; n = 20). The volume-adjusted mean LiMAx did not show a significant correlation with any of the metabolic parameters. In conclusion, the LiMAx test might be a useful tool to predict the quantitative outcome of hepatocyte isolation, as long as underlying liver disease is taken into consideration.

ObjectivesPost‐hepatectomy liver failure has a major impact on patient outcome. This study aims to explore the impact of the integration of a novel patient‐centred evaluation, the LiMAx algorithm, on perioperative patient outcome after hepatectomy.MethodsTrends in perioperative variables and morbidity and mortality rates in 1170 consecutive patients undergoing elective hepatectomy between January 2006 and December 2011 were analysed retrospectively. Propensity score matching was used to compare the effects on morbidity and mortality of the integration of the LiMAx algorithm into clinical practice.ResultsOver the study period, the proportion of complex hepatectomies increased from 29.1% in 2006 to 37.7% in 2011 (P= 0.034). Similarly, the proportion of patients with liver cirrhosis selected for hepatic surgery rose from 6.9% in 2006 to 11.3% in 2011 (P= 0.039). Despite these increases, rates of post‐hepatectomy liver failure fell from 24.7% in 2006 to 9.0% in 2011 (P

The maximal liver function capacity (LiMAx) test, a novel

Introduction Health-related quality of life (HRQOL) is severely impaired in advanced liver disease. The purpose of this study was to evaluate the impact of actual liver function and disease-specific factors on HRQOL of patients evaluated for liver transplantation. Patients and Methods Disease-specific QOL was analyzed in 142 patients evaluated for liver transplantation using the German version of the Chronic Liver Disease Questionnaire (CLDQ-D). We performed quantitative liver function tests and collected clinical and demographical data of patients after their referral to our transplant department. Values were correlated with CLDQ-D scores. Results Neither model for end-stage liver disease (MELD) nor dynamic liver function test results were related to quality of life. Serum albumin concentration was a strong but not independent factor correlated with global CLDQ-D (r = 0.269, p

End-stage liver disease is accompanied by decreased serum levels of insulin-like growth factor 1 (IGF1) and inversely increased serum levels of growth hormone (GH). Previous reports have demonstrated rapid GH/IGF1 axis recovery after orthotopic liver transplantation. This study investigated the effect in an adult-to-adult living donor liver transplantation (LDLT) model and characterized GH/IGF1 alterations and liver regeneration in both donors and recipients. Sequential blood samples were prospectively collected from 30 donor-recipient pairs during the perioperative course of LDLT. A distinct set of biochemical parameters, including serum GH, serum IGF1, and standard liver blood tests, was analyzed at different time points (preoperatively and during 12 months of follow-up after surgery). Recipients showed significantly higher GH serum levels and lower IGF1 serum levels in comparison with donors before surgery and throughout the first postoperative days (PODs). The GH serum levels of recipients declined, whereas donor levels inversely increased during the early postoperative period to a normal range. Recipients' IGF1 serum levels were restored within the first operative week. In parallel, donor IGF1 levels decreased by 50% after living donation, and preoperative serum levels were restored after 6 months. Donors showed delayed recovery of liver function in comparison with recipients. The dynamics of IGF1 strongly correlated with routine laboratory parameters of liver function. In conclusion, recipients showed a rapid recovery of the GH/IGF1 hormonal axis and liver function after LDLT, whereas donors showed altered GH signaling and regenerative delay in the early PODs after living donation.

Ingested toothpicks are a relatively rare event, but may cause serious gut injuries with peritonitis, sepsis, or death. Numerous case reports describing the clinical course in this setting are available but there is no concise guideline. The aim of the present study was to develop practical guidelines to aid clinicians in the diagnosis and management of acute tooth pick ingestion. Our Medline search identified 116 publications containing case reports of ingested toothpicks. We then performed a retrospective analysis of patients’ characteristics, medical history, diagnostics, therapy, and clinical outcome. A total of 136 cases (74 % male, age 52 [5–92] years) have been reported in the literature. From the available information, more than 50 % (n = 48) of patients were not aware of having swallowed a toothpick. The most common presenting symptoms were abdominal pain (82 %), fever (39 %), and nausea (31 %). The toothpick caused gut perforation in 79 % of all patients. The locations of toothpicks prior removal were esophagus (2 %), stomach (20 %), duodenum (23 %), small intestine (18 %), and large intestine (37 %). The diagnostic procedures included endoscopy (63 %), computed tomography scan (63 %), and ultrasound (47 %); however, in 35 % of cases these investigations failed to detect the toothpick. Therapy was surgery in most cases (58 %). The overall mortality was 9.6 %. Toothpick ingestion is a medical emergency. Perforations of the intestine are common and the associated mortality is high. Adequate therapy depends on localization of the toothpick in the gastrointestinal tract. Ingested toothpicks should be kept in mind as an important differential diagnosis in patients with acute abdomen.

Chemotherapy of colorectal liver metastases (CLMs) prior to liver resection implies the risk of chemotherapy-associated liver injury, leading to increased postoperative morbidity and mortality OBJECTIVE: The aim of this study was to evaluate the LiMAx (liver maximum capacity) test for diagnosis of chemotherapy-associated liver injury.This was a retrospective analysis of patients with CLMs, prior to liver resection. We performed preoperative assessment of liver function using biochemical parameters and the LiMAx test. The individual history of chemotherapy within 12 months, including regimen, number of cycles, and therapy-free interval were collected, and histopathological evaluation of tumor-free liver tissue was performed in resected patients.A total of 204 patients were included, of whom 127 (62%) had received previous chemotherapy. The LiMAx test was worse after chemotherapy (340 ± 95 vs. 391 ± 82 µg/kg/h; p 0.001). Impaired LiMAx results (315 µg/kg/h) were determined in 49% of patients after chemotherapy, and no effects of chemotherapy, liver steatosis or fibrosis on biochemical parameters were observed. LiMAx impairment was dependent on the number of oxaliplatin cycles, the therapy-free interval, and obesity in multivariate analysis. In addition, the LiMAx test was worse in patients with relevant steatosis, fibrosis and steatohepatitis. Patients with an impaired LiMAx showed sufficient regeneration during chemotherapy cessation when surgery was postponed (272 ± 57 - 348 ± 72 µg/kg/h; p = 0.003).The LiMAx test enables non-invasive preoperative diagnosis of chemotherapy-associated liver injury. Preoperative performance of the LiMAx test can augment surgical strategy and timing of surgery after previous chemotherapy, thus avoiding increased postoperative morbidity.

Chemotherapy-associated liver injury of patients undergoing therapy for colorectal liver metastases stimulates concerns on surgical safety. No common guidelines for the optimal timing of liver surgery after the application of systemic chemotherapy (chemotherapy-free interval) have been established and effects on individual liver function remain unexplored. Maximum liver function capacity (LiMAx) and indocyanine green plasma disappearance rate (ICG-PDR) were measured in 20 patients with colorectal cancer receiving adjuvant oxaliplatin-based chemotherapy (OBC) prior to the first and after the last treatment course as well as 4 and 8 weeks thereafter. Comparison of pre- and post-chemotherapy test results demonstrated a significant decrease of LiMAx to 73.2 % ± 19.0 % (p = 0.001) and ICG-PDR to 78.2 % ± 21.3 % (p = 0.001) after cessation of OBC. The dynamics of LiMAx indicate an interindividual effect on vulnerability to systemic chemotherapy with subsequent functional regeneration after 8 weeks (pre-OBC 530 ± 144 μg/kg/h vs. 4 weeks post-OBC 463 ± 111 μg/kg/; p = 0.012 and vs. 8 weeks post-OBC 494 ± 138 μg/kg/h; p = 0.134). An analysis of individual regeneration after chemotherapy yielded a highly different course of functional recovery with patients regaining pre-chemotherapy function within 4 weeks, whereas others still showed deterioration after 8 weeks after cessation of chemotherapy. Enzymatic liver function (LiMAx) is significantly reduced after oxaliplatin-based chemotherapy and subsequently recovers within 8 weeks after cessation of chemotherapy. However, pace of regeneration appears to be highly different among patients suggesting patient individual chemotherapy-free interval monitored by LiMAx.

The maximal liver function capacity (LiMAx) test, a novel 13C-methacetin breath test, has proven clinical validity in determining hepatic metabolic capacity. In contrast to prior 13C-methacetin breath test protocols, the LiMAx test is performed by intravenous body-weight-adjusted substrate administration. Furthermore, the DOB kinetics (delta over baseline of the time-dependent exhaled 13CO2/12CO2 ratio) are measured online at the bedside with a high time resolution in order to determine the maximum DOB. The aim of this study was to analyze the recorded DOB kinetics in a large population for further refinement of the test protocol. Two new methods of kinetic analysis are proposed in this article: the time dependency of the DOB kinetics and the time interval until half of the DOB maximum. A total of 10 100 LiMAx tests on 8483 patients performed during routine clinics at eight centers were available. The kinetic analysis revealed a specific pattern of DOB kinetics depending upon LiMAx result. In addition, potential co-factors for DOB kinetics, such as weight, height, gender and age, were analyzed, yielding a potential influence of gender and smoking behavior. Both the specific patterns and the proposed kinetic analysis have the potential to further improve the sensitivity and specificity of the test and its clinical applicability by shortening its duration.

BACKGROUND Metabolic disorders are common complications after orthotopic liver transplantation (OLT) and may lead to increased morbidity and mortality. METHODS Fasting glucose and lipid metabolism, and body weight of 81 patients undergoing primary OLT were prospectively analyzed. Patients were investigated preoperatively, on postoperative days 1, 3, 5, 10, 14, 28 as well as 6 months and 1 year after OLT. Data of nonfasted patients were excluded from the analysis. Standardized definitions and classifications for diabetes mellitus (DM), body mass index (BMI), and dyslipidemia were used. RESULTS Prevalence of new-onset diabetes after transplantation was 9.3%, and obesity was its only independent risk factor (odds ratio [OR], 16.5). Preoperative impaired glucose homeostasis (OR, 10.8) and initial poor graft function (OR, 6.89) were independent risk factors for postoperative DM. Maximum prevalence of hypertriglyceridemia and hypercholesterolemia was found on postoperative day 10 and 6 months post-OLT, respectively. Risk factors for hypercholesterolemia at 1 year were patient age (OR, 1.17) and postoperative renal dysfunction (OR, 16.33). Higher preoperative BMI was a risk factor for postoperative hypertriglyceridemia (OR, 1.17). Overall body weight and BMI significantly decreased over 1 year (P < 0.05). Prevalence of obesity was 22.2% before and 20.9% after OLT. CONCLUSION For the first time, initial poor graft function was identified as a risk factor for post-OLT DM. By ruling out any exogenous factors influencing metabolism, we believe we were able to show the true prevalence of metabolic disorders and therefore provided a valuable contribution to the identification of potential risk factors.

A personal health system platform for the management of patients with chronic liver disease that incorporates a novel approach to integrate decision support and guidance through care pathways for patients and their doctors is presented in this paper. The personal health system incorporates an integrated decision support engine that guides patients and doctors through the management of the disease by issuing tasks and providing recommendations to both the care team and the patient and by controlling the execution of a Care Flow Plan based on the results of tasks and the monitored health status of the patient. This Care Flow Plan represents a formal, business process based model of disease management designed off-line by domain experts on the basis of clinical guidelines, knowledge of care pathways and an organisational model for integrated, patient-centred care. In this way, remote monitoring and treatment are dynamically adapted to the patient's actual condition and clinical symptoms and allow flexible delivery of care with close integration of specialists, therapists and care-givers.

Portal vein embolization (PVE) before extended right hepatectomy leads to an increase of the future liver remnant (FLR) volume, but predictive factors for sufficient hypertrophy are still unclear. The purpose of this study was to investigate parameters influencing the growth of FLR.Patients undergoing PVE prior hepatic resection were evaluated. PVE was done using polyvinyl alcohol particles only. Volumetric analysis was performed before embolization and before hepatectomy. Success of PVE was determined as percental growth of the future liver remnant.Seventy-seven patients were included, and three cohorts were formed according to the hypertrophy of FLR. FLR increased from 448.2 ± 187 to 475.5 ± 191 in the poor, from 315.3 ± 86 to 469.1 ± 142 in the moderate, and from 283.4 ± 68 to 400.4 ± 110 in the good hypertrophy group. More cases of recanalization of the portal vein were observed in patients with poor hypertrophy (p = 0.016). Small FLR before PVE predict higher growth of the FLR (p = 0.006). Duration between PVE and surgery differed significantly: 22 (poor) vs. 32 (good) days (p = 0.040).No recanalization, small initial FLR and longer time were assessed with better FLR hypertrophy. More sufficient PVE techniques and postponed hepatectomy might improve the outcome. Small initial FLR should not be a disclosure for curative hepatectomy.

Background 13 C-liver function breath tests can facilitate the assessment of hepatic function in-vivo and may help surgeons to identify candidates for safe liver surgery. However, their acceptance into clinical practice is dependent on evaluation of technical efficacy and repeatability. The aims of this study were to evaluate the within-subject repeatability of the LiMAx (maximum liver function capacity) test in healthy individuals and in surgical patients to determine liver function in the perioperative workup. Material and methods The LiMAx test, which is based on intravenous injection of 13 C-methacetin at a dosage of 2 mg/kg body weight was performed in eighty-six healthy subjects to determine a reference range. Twenty-four subjects underwent repeat LiMAx testing the following day to assess within-subject repeatability. Twenty-one patients undergoing elective extra-abdominal surgery under general anesthesia (GA group) received pre- and post-operative examinations. Results The normal range of LiMAx was found to be 430 ± 86 μg/kg/h and revealed a one-sided cut-off value of 315 μg/kg/h. The intraclass correlation coefficient of the repeat LiMAx tests was 0.85 (95% confidence interval 0.69–0.93) in the control group and 0.81 (95% confidence interval 0.60–0.92) in the group of patients with GA. Conclusions The LiMAx test shows excellent reproducibility in subjects with normal liver function. GA has no effect on test results.

End-stage liver disease is accompanied by decreased serum levels of insulin-like growth factor 1 (IGF1) and inversely increased serum levels of growth hormone (GH). Previous reports have demonstrated rapid GH/IGF1 axis recovery after orthotopic liver transplantation. This study investigated the effect in an adult-to-adult living donor liver transplantation (LDLT) model and characterized GH/IGF1 alterations and liver regeneration in both donors and recipients. Sequential blood samples were prospectively collected from 30 donor-recipient pairs during the perioperative course of LDLT. A distinct set of biochemical parameters, including serum GH, serum IGF1, and standard liver blood tests, was analyzed at different time points (preoperatively and during 12 months of follow-up after surgery). Recipients showed significantly higher GH serum levels and lower IGF1 serum levels in comparison with donors before surgery and throughout the first postoperative days (PODs). The GH serum levels of recipients declined, whereas donor levels inversely increased during the early postoperative period to a normal range. Recipients' IGF1 serum levels were restored within the first operative week. In parallel, donor IGF1 levels decreased by 50% after living donation, and preoperative serum levels were restored after 6 months. Donors showed delayed recovery of liver function in comparison with recipients. The dynamics of IGF1 strongly correlated with routine laboratory parameters of liver function. In conclusion, recipients showed a rapid recovery of the GH/IGF1 hormonal axis and liver function after LDLT, whereas donors showed altered GH signaling and regenerative delay in the early PODs after living donation.

BACKGROUND Obesity is increasingly impacting the overall health status and the global costs for health care. The increase in body mass index (BMI) is also observed in kidney allograft recipients and deceased organ donors. METHODS In a retrospective single-center study, we analyzed 1132 deceased donor kidney grafts, transplanted at our institution between 2000 and 2009 for recipient and donor BMI and its correlation with delayed graft function (DGF). Recipients/donors were classified according to their BMI ( 30 kg/m(2)). DGF was defined as requirement for one dialysis within the first week after transplantation. RESULTS Overall DGF rate was 32.4%, mean recipient BMI was 23.64 ± 3.75 kg/m(2), and mean donor BMI was 24.69 ± 3.44 kg/m(2). DGF rate was 25.2%, 29.8%, 40.9%, and 52.6% in recipients with BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, and more than 30 kg/m, respectively (P