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Objectives Liver transplantation (LT) is associated with high stress on the cardiovascular system. Ruling out coronary artery disease (CAD) is an important part of evaluation for LT. The aim of our study was to assess whether CT-derived fractional flow reserve (CT-FFR) allows for differentiation of hemodynamically significant and non-significant coronary stenosis in patients evaluated for LT. Methods In total, 201 patients undergoing LT evaluation were included in the study. The patients received coronary computed tomography angiography (CCTA) to rule out CAD and invasive coronary angiography (ICA) to further evaluate coronary lesions found in CCTA if a significant (≥ 50 % on CCTA) stenosis was suspected. CT-FFR was computed from CCTA datasets using a machine learning–based algorithm and compared to ICA as a standard of reference. Coronary lesions with CT-FFR ≤ 0.80 were defined as hemodynamically significant. Results In 127 of 201 patients (63%), an obstructive CAD was ruled out by CCTA. In the remaining 74 patients (37%), at least one significant stenosis was suspected in CCTA. Compared to ICA, sensitivity, specificity, PPV, and NPV of the CT-FFR measurements were 71% (49–92%), 90% (82–98%), 67% (45–88%), and 91% (84–99%), respectively. The diagnostic accuracy was 85% (85–86%). In 69% of cases (52 of 75 lesions), additional analysis by CT-FFR correctly excluded the hemodynamic significance of the stenosis. Conclusions Machine learning–based CT-FFR seems to be a very promising noninvasive approach for exclusion of hemodynamic significant coronary stenoses in patients undergoing evaluation for LT and could help to reduce the rate of invasive coronary angiography in this high-risk population. Key Points • Machine learning–based computed tomography-derived fractional flow reserve (CT-FFR) seems to be a very promising noninvasive approach for exclusion of hemodynamic significance of coronary stenoses in patients undergoing evaluation for liver transplantation and could help to reduce the rate of invasive coronary angiography in this high-risk population.

Patients with liver cirrhosis develop symptoms comparable to those of patients with sepsis, who have increased total vascular compliance, which may cause blood pooling in the venous pool. No previous studies have evaluated the effect of using norepinephrine on the intravascular blood volume. We investigated the norepinephrine infusion's effect on the mean systemic filling pressure, venous return, and cardiac preload in patients undergoing liver transplantation.Overall, 33 patients who underwent living donor liver transplantation were included in this study. Cardiac output (CO) was measured using a PiCCO device (Pulsion Medical Systems, Munich, Germany). The mean systemic filling pressure was calculated using the inspiratory hold maneuver at four time intervals - at baseline, 10 min after the norepinephrine infusion, 5 min after norepinephrine discontinuation, and after infusion of 500 cc of 5% albumin. Other hemodynamic parameters, including the mean arterial pressure (MAP), pulse pressure variation, stroke volume variation, global end-diastolic volume, and mitral inflow velocity (E wave), were also evaluated.The norepinephrine infusion increased MAP and systemic vascular resistance in all patients. Moreover, it increased CO, mean systemic filling pressure, and global end-diastolic volume in 20 patients (60%), whereas there were no changes in these variables in 13 patients (40%). In all patients, norepinephrine infusion discontinuation caused a significant decrease in MAP, CO, resistance to venous return, and mean systemic filling pressure. Infusion of 500 cc colloid increased CO; however, interestingly, it was associated with a significant decrease in systemic vascular resistance; hence, MAP and mean systemic filling pressure showed no changes.The norepinephrine infusion at 0.1 µg

Abrupt return to normothermia has been shown a genuine factor contributing to graft dysfunction after transplantation. This study tested the concept to mitigate reperfusion injury of liver grafts by gentle warming-up using ex vivo machine perfusion prior to reperfusion. In a single center randomized controlled study, livers were assigned to conventional static cold storage (SCS) alone or to SCS followed by 90 min of ex vivo machine perfusion including controlled oxygenated rewarming (COR) by gentle and protracted elevation of the perfusate temperature from 10°C to 20°C. Primary outcome mean peak aspartate aminotransferase (AST) was 1371 U/L (SD 2871) after SCS versus 767 U/L (SD 1157) after COR (p = 0.273). Liver function test (LiMAx) on postoperative day 1 yielded 187 μg/kg/h (SD 121) after SCS, but rose to 294 μg/kg/h (SD 106) after COR (p = 0.006). Likewise, hepatic synthesis of coagulation factor V was significantly accelerated in the COR group immediately after transplantation (103% [SD 34] vs. 66% [SD 26]; p = 0.001). Fewer severe complications (Clavien-Dindo grade ≥3b) were reported in the COR group (8) than in the SCS group (15). Rewarming/reperfusion injury of liver grafts can be safely and effectively mitigated by controlling of the rewarming kinetics prior to blood reperfusion using end-ischemic ex vivo machine perfusion after cold storage. OA Förderung 2022

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications. OA Förderung 2022

Although fertility is reduced in patients with liver cirrhosis, recovery of menstrual cycle is acquired after liver transplantation (LT) in most patients, and pregnancy in LT recipients is not unusual. The aim of this study was to evaluate the outcomes of pregnancies in LT recipients in our center.Data of 24 pregnancies in 14 LT recipients were collected and statistically analyzed. Demographic and clinical data were documented in each trimester of pregnancy and thereafter. The analysis was conducted in accordance with the 1975 Declaration of Helsinki and was approved by the ethics committee of the University Hospital Essen.Median patient age was 21.5 years (range, 2-32 years) at LT and 31 years (range, 19-41 years) at conception. Median time between LT and conception was 126 months (range, 38-332 months), and median gestation time of completed pregnancies was 38 weeks (range, 29-40 weeks). Seven pregnancies terminated in abortions (29%). Of all deliveries, 6 resulted in preterm births (35%) with median gestation time of 34.5 weeks (range, 29-37 weeks). Gestational diabetes mellitus was the most common maternal complication, occurring in 4 patients (17%). One patient suffered from preeclampsia (4%). Pregnancy-induced hypertension or acute cellular rejection was not reported in our cohort. None of the children had serious complications.Our data show favorable outcome for pregnancy in LT recipients for mother and offspring. However, these patients are still at risk, particularly regarding high rates of preterm delivery, and preconception counseling and multidisciplinary monitoring are crucial to manage possible complications.

The value and safety of percutaneous liver biopsy (PLB) in brain-dead donors before organ removal and its impact on organ allocation and costs of liver transplantation (LT) in the Eurotransplant (ET) region is still a matter of ongoing debate.A PLB was performed in 36 brain-dead organ donors. The complication rate, ultrasonography findings, macroscopic evaluation and histological results of PLB and donor characteristics were analyzed. Additionally, a nationwide survey was conducted among 11 liver transplantation experts. The need for PLB and its impact on the liver allocation process were evaluated. Possible cost savings were calculated for different scenarios based on cost data provided by the German Organ Transplantation Foundation.No complications of PLB were observed. The survey revealed that the PLB has a substantial impact on the allocation of donor organs, especially in organs fulfilling extended donor criteria (EDC). The cost calculation revealed an enormous potential for cost savings due to an optimized organ allocation process and avoidance of futile organ procurement.The PLB is a safe procedure and has tremendous potential for the optimization of the organ allocation process before organ procurement by reducing the cold ischemia time, avoiding unnecessarily discarding donor organs and saving costs. These data emphasize the clinical relevance and impact of PLB on the organ allocation process.HINTERGRUND: Der Stellenwert und die Sicherheit einer perkutanen Leberbiopsie (PLB) bei hirntoten Spendern vor Organentnahme sowie der Einfluss der PLB auf die Organallokation und die Kosten im Rahmen der Lebertransplantation (LT) in der Eurotransplant-Region (ET), werden weiterhin diskutiert.Eine perkutane Leberbiopsie vor Organentnahme erfolgte bei 36 hirntoten Spendern. Die Komplikationsrate, Spendercharakteristika, Ultraschallbefunde, die makroskopische Einschätzung und die histologischen Ergebnisse der PLB wurden analysiert. Zusätzlich wurde eine landesweite Umfrage unter 11 Lebertransplantationsexperten durchgeführt. Der Bedarf einer PLB und ihre Auswirkungen auf den Prozess der Organallokation wurden evaluiert. Mögliche Kosteneinsparungen wurden für verschiedene Szenarien auf der Grundlage von Kostendaten der Deutschen Stiftung Organtransplantation berechnet.Es wurden keine Komplikationen durch die PLB beobachtet. Die Umfrage ergab, dass das Ergebnis der PLB einen erheblichen Einfluss auf die Allokation von Spenderorganen hat, insbesondere bei solchen mit „extended donor criteria (EDC)“. Die Kostenberechnung ergab ein enormes Kosteneinsparungspotenzial durch eine optimierte Allokation und die Vermeidung unnötiger Organentnahmen.Die PLB ist ein sicheres Verfahren und besitzt ein enormes Potenzial für die Optimierung der Organallokation vor Organentnahme durch eine Reduzierung der kalten Ischämiezeit, Vermeidung unnötiger Verwerfungen von Spenderorganen sowie Kosteneinsparungen. Die klinische Relevanz und der Einfluss der PLB auf die Organallokation konnte durch unsere Daten herausgestellt werden.

Miscellaneous clinical classifications of liver function after liver transplantation are rested upon elevation of transaminases which represent damaging of hepatocytes and with it of the liver.We report the case of a 35-year-old man suffering from hepatocellular carcinoma in the setting of alcoholic liver cirrhosis. The patient underwent liver transplantation and developed an extreme peak of transaminases due to prolonged cold ischemia time and additional extended donor criteria. On the first postoperative day the laboratory results showed peak transaminases as follows: AST 17577 U/l and ALT 9884 U/l. Frequent ultrasound revealed no signs of vascular complications. In spite of the dramatically elevated transaminases the liver showed a good primary function and the patient was cardiopulmonary stable. The entire postoperative course was uneventful. We discharged the patient after three weeks in a very good general state of health, with normal laboratory values.Exclusive extreme elevation of transaminases after liver transplantation combined with adequate liver synthesis does not always require re-transplantation, if situation of the patient is stable. Nevertheless re-transplantation should be reconsidered in any case of clinical deterioration of the patient.

The aim of this study was to determine the efficacy, safety, and immunosuppressant adherence in 125 stable liver transplant (LT) patients converted from twice-daily tacrolimus (TAC BID) to once-daily TAC (TAC OD). Tacrolimus trough levels, laboratory parameters, metabolic disorders, selected patient reported outcomes, and adverse events were assessed. Mean TAC trough level concentration was 6.1 ± 2.3 ng/ml at study entry, decreased to 5.5 ± 2.1 ng/ml (P = 0.016) and 5.5 ± 2.2 ng/ml (P = 0.019) after 1 and 2 weeks, respectively, and tended to equal the baseline value during further follow-up. At week 1, TAC concentrations were lower in 62.4% of patients and higher in 36.0% when compared with baseline. Renal and cardiovascular risk factors remained stable and no rejection episodes occurred over 12 months. Adverse events were consistent with the safety profile known from previous studies with TAC BID. Nonadherence measured by the "Basel Assessment of Adherence Scale to Immunosuppressives" was evident in 66.4% at study entry and decreased to 30.9% postconversion (P0.0001). Prevalence of nonadherence at baseline was significantly higher in patients converted2 years after LT and in those ≤60 years of age. Conversion to TAC OD is safe, enhances immunosuppressant adherence and should be accompanied by a close TAC level monitoring during the initial period.

Pseudoaneurysm of the hepatic artery after a pancreaticoduodenectomy is a serious complication, which should always be considered in the differential diagnosis when late bleeding has occurred.We report a case of pseudoaneurysmal rupture of the common hepatic artery into the biliodigestive anastomosis. A 55 year old female patient with a history of pancreatic head cancer underwent a pylorus preserving pancreaticoduodenectomy at our hospital in September 2008. Six days postoperatively the patient underwent surgery because of sentinel bleeding of a portal vein branch. On the 40th postoperative day she presented melena. Upper gastrointestinal endoscopy indicated bleeding near the biliodigestive anastomosis. An emergency angiography demonstrated a pseudoaneurysm of the common hepatic artery. Transcatheter arterial embolization was performed and a hemodynamic stabilization of the patient was achieved. Six days after the embolization the patient developed hemorrhagic shock and an urgent relaparotomy was carried out. The explorative laparotomy revealed bleeding of the common hepatic artery into the biliodigestive anastomosis in the form of an arteriointestinal fistula. The anastomosis was opened, the ruptured pseudoaneurysm was sutured, and a new biliodigestive anastomosis was made. The patient has been well for two months with good liver function, without rebleeding.This case illustrates the occurrence of a rare complication (rupture of a hepatic artery pseudoaneurysm) inside the biliodigestive anastomosis after pancreaticoduodenectomy, appearing as upper gastrointestinal bleeding. Different modalities such as transarterial embolization and the use of stents give promising results, but ligation of the pseudoaneurysm and repair of the intestinal communication is also an effective modality of treatment.

Proper venous outflow reconstruction is essential for the success of living donor liver transplantation (LDLT). It has also a decisive impact on postoperative graft dysfunction. The accessory right inferior hepatic veins (IHVs) usually drain parts of the lateral sector of the right hemiliver graft (RHL). The purpose of our study was to: (1) evaluate the drainage patterns of the IHVs in right hemiliver grafts; (2) analyze the influence of IHVs on the dominance relationships between the right and middle hepatic veins in RHL's; (3) evaluate some potential correlation between drainage patterns of IHVs and the portal vein anatomy.We analyzed 3-dimensional CT-imaging reconstructions of 71 potential live liver donors evaluated at our Institution between January 2003 and October 2004.(1) Thirty-six (51%) donors had inferior hepatic veins (IHV) with detectable venous drainage territories, (2) the RHV/IHV-complex was dominant in 97% of cases, and the RHV as a single veinwithout anatomical IHV was dominant in 94% of right hemiliver grafts, (3) 27 of 71 livers (38%) showed a central (n=11) or peripheral (n=16) PV anomaly, (4) IHV provided a mean 32% of venous drainage in the right lateral sector, and in some cases drained up to 25% of the right medial sector irrespective of the PV anatomy, (5) such cases required IHV reconstruction to prevent severe tissue congestion in the right hemiliver graft.Accurate insight into the drainage patterns of the right and middle hepatic veins and precise knowledge of the functional volume drained by the IHV are essential when planning for the proper outflow reconstruction of right hemiliver grafts in LDLT.

To determine resectability rates in patients with hepatocellular carcinoma (HCC) evaluated for surgical therapy. Liver resection constitutes a potentially curative treatment for HCC. However, because of the co-existing cirrhosis or the late diagnosis, only a percentage of the patients evaluated can undergo surgery.We evaluated 333 patients with HCC admitted to our center with the intent to treat by means of tumor resection during a 6-year time period.Surgical resection with curative intent was undertaken in 116 patients (35%). In our series, resectability rates were significantly higher in patients with solitary HCCs (p0.001), unilobar tumor distribution (p=0.03), and no cirrhosis (p0.001). Transarterial chemoembolization (TACE) was the most frequent approach for nonresectable cases (18% of patients). A systematic literature review was performed in order to estimate resectability rates at other hepatobiliary centers offering multimodal treatment approaches to HCC. Results showed an overall resectability rate of 30%, with 1808 resections reported in 6108 cases. Resectability rates were significantly higher in Japanese and Eastern series when compared to American and Western studies respectively (p0.001).Treatment strategies for HCC require a multidisciplinary comprehensive approach encompassing surgeons, hepatologists, radiologists, and oncologists. Surgical resection was possible in only 35% and 30% of patients with HCC evaluated for surgical therapy in our series and in the world literature, respectively. TACE was the primary treatment modality for non-resectable cases. A "no therapy" option was chosen in 21% of cases worldwide.

Numerous clinical and experimental studies have been published concerning platelet receptor polymorphism and their role in causing myocardial infarction at an earlier age. It is still unclear, however, whether these polymorphisms are a risk factor for other occlusive diseases such as those in visceral arteries. We report a case of a young woman with acute celiac artery thrombosis and multiple platelet receptor polymorphisms. In addition, the intraoperative exploration showed some evidence of a local vascular compression syndrome. The patient was successfully treated with a bypass procedure and combined anticoagulation. It seems that platelet receptor polymorphisms are a moderate risk factor for local artery thrombosis regardless of vascular region. The obligatory precondition is pre-existing vascular damage, such as that caused by a local compression syndrome.