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Introduction: In current literature, the participation of residents in surgical procedures is discussed as a negative outcome factor, particularly due to an increase of postoperative complications. This study investigated whether minor proctologic surgery with resident participation has a higher rate of postoperative complications., Patients and Methods: All patients who underwent an elective Milligan-Morgan hemorrhoidectomy or a resection of pilonidal sinus with rotational flap closure between January 2007 and December 2013 where included in a retrospective database. Primary outcome measure was postoperative complications rate with and without resident participation., Results: Forty-two (6 females: 36 males) patients underwent resection of pilonidal sinus and 61 (17 females: 44 males) patients received a hemorrhoidectomy. Twenty-two patients with pilonidal sinus and 26 patients with hemorrhoids were operated by residents. There were no differences in patient demographics. Residents need significantly more time to perform a pilonidal sinus resection (54min vs. 34.5min; P = 0.004). For hemorrhoidectomy, there were no significant differences in operative time (24min vs. 23.5min; P = 0.656). There were no significant differences in the resident and the consultant group, neither in hemorrhoidectomy nor in pilonidal sinus resection regarding readmission or outpatient visits. In the group of patients with pilonidal sinus resections, 3 patients developed a recurrence, leading to a recurrence rate of 7.1% without significant differences between the two groups (0 vs. 3; P = 0.09)., Conclusion: The participation of residents in proctologic procedures is not associated with higher postoperative complication rates. Residents should be exposed to proctology procedures on a regular basis, even though the operative time will be prolonged., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: The International Study Group of Liver Surgery (ISGLS) defined posthepatectomy liver failure as pathological values for the international normalized ratio (INR) and bilirubin 5 days after liver resection. The occurrence of biliary leakage was defined as a drainage bilirubin to serum bilirubin ratio > 3 at day 3 or later after resection or interventional surgical revision due to biliary peritonitis. A confirmatory explorative analysis was carried out., Patients and Methods: The study involved an evaluation of primary liver resection from the years 2009 and 2010. Primary endpoints were the incidence of posthepatectomy liver failure and biliary leakage in accordance with the ISGLS definition. Secondary endpoints were complications and 90-day mortality. Results are displayed as median values (minimum and maximum)., Results: A total of 214 liver resections were included from the years 2009 and 2010. Patients were an average of 61.5 years old (min. 18, max. 83 years). The incidence of liver failure was 7.4 % (16 out of 214) and fatal in 7 patients. In 31 % (65 out of 214) a biliary leakage occurred, 14 (23 %) patients developed a type B, 1 patient(5 %) a type C leakage and 50 leakages were clinically inapparent. The incidence of clinically relevant biliary leakages was 7 % (15 out of 214). The sensitivity of the definition was 100 % and the specificity 75 %. The incidence of Dindo-Calvien complications > 3b was 10.2 %, of sepsis 5.6 % and the 90-day mortality was 6.5 %. Multivariate analysis did not reveal independent predictive factors for biliary leakage or liver failure., Conclusion: The definition for posthepatectomy liver failure was found to be valid in this cohort. The incidence of postoperative biliary leakage is over-estimated with the current definition and delivers a large number of false positive results without clinical relevance.

Background: Today, mesh repair is the preferred technique in surgery of inguinal hernia. Whether the mesh should be placed laparoscopically or by open techniques is still controversial., Methods: A comparison of open mesh and laparoscopic techniques was made with the help of meta-analyses and prospective trials. Outcome variables analysed were recurrence, chronic pain, recovery, morbidity and costs., Results: With regard to recurrence rates, both techniques gave comparable results. The laparoscopic technique shows advantages in terms of morbidity, recovery and especially a lower rate of chronic pain. Open mesh repair has the advantage of a lower risk of some rare severe intra-abdominal complications and seems to be more cost-effective., Conclusion: Both techniques of inguinal hernia repair are effective and safe. Each technique has its advantages and disadvantages. Therefore, today no single technique can be recommended as a gold standard.

Background: Simultaneous pancreas-kidney transplantation (SPK) is still associated with the highest rate of morbidity among solid organ transplantations. Although improved long-term survival following SPK has been proven in IDDM patients, a further decrease in morbidity would be desirable., Methods: A retrospective, single-center study was performed to investigate the morbidity following SPK and to compare the results to kidney transplantation alone (KTA). Parameters included the rates of relaparotomies, septic complications (urinary tract infection, wound infection, pneumonia), and graft function., Results: Between September 2000 and August 2001, 99 patients underwent transplantation (34 SPK, 63 KTA, 2 pancreas transplants alone). Relaparotomies were performed in six SPK patients (17.6%), mostly due to complications related to the pancreatic graft (n=5). Three reoperations (4.8%) were necessary in KTA patients (p=0.085). Septic complications occurred more often in SPK than in KTA patients (55.9% vs 30.2%, p<0.05). This difference resulted from the high rate of wound infections in SPK patients (35.3%). No intra-abdominal infection or sepsis occurred in any patient. There was one hospital death in SPK and KTA patients, respectively. The rejection rate was similar in SPK (17.6%) and KTA (12.7%, p=0.72). At discharge 91.2% of SPK patients were insulin free and 97.1% free of dialysis. At discharge 96.8% of KTA patients were free of dialysis., Conclusion: SPK is still associated with a higher morbidity (relaparotomies, septic complications) than KTA, although life-threatening complications were rare. There was no increased mortality following SPK.

Primary malignancy after solid organ transplantation has a more than three-fold incidence compared to the normal population. Causes are intensity and duration of immunosuppression, pre-operatively undetected, occult malignancy or pre-cancerous lesions in the recipient, direct or indirect tumor transmission via the transplant and environmental factors. Measures for prevention comprise antiviral treatment of individuals at risk for primary EBV-infection and prevention of sun exposure. Early detection follows general medical guidelines and, in addition, selective screening of certain risk groups of patients. Treatment of solid tumors follows established guidelines of professional working parties. Post-transplant lymphoproliferative disorders can often be treated with anti-CD antibody (rituximab). Antiproliferative immunosuppressants like rapamycin may seem promising with regard to a possibly reduced incidence of de-novo malignancy in the future.

Liver failure following trauma or surgery is associated with a mortality of between 15-->50%, depending on the extent of the operation, pre-operative functional impairment of the liver as well as the occurrence of concomitant infectious disease. The liver can be the source as well as the target of posttraumatic liver failure (PLF). PLF can be caused by a reduction of liver perfusion due to hypotension, catecholamines or increased intraabdominal pressure. Further contributing factors include prolonged parenteral nutrition, endotoxemia, and potentially hepatotoxic drugs (sedatives, anticonvulsive drugs, antibiotics etc.). PLF is mostly associated with MOF. The Child classification and the APACHE score may predict prognosis before surgery and serum bilirubin levels thereafter. Prevention and therapy is based on treatment of shock and tissue hypoxia. It should be accompanied by appropriate diagnostic measures and followed by an aggressive medical and surgical approach.

Resistance formation is a major problem in antiviral treatment of hepatitis B recurrence after liver transplantation. One possible therapeutic approach is an antiviral combination therapy with synergistic drugs. Four patients who were transplanted for chronic hepatitis B were analyzed retrospectively. All patients had reinfection of the graft and breakthrough of hepatitis B virus (HBV) during consecutive famciclovir and lamivudine monotherapy. Subsequently a combination therapy of lamivudine and interferon alpha 2a (3 times 3 million units weekly) was initiated. Addition of interferon markedly reduced viral replication rate in all patients. Three patients became HBV-DNA negative despite lamivudine resistance, but only two had a sustained response. No patient seroconverted to anti-HBe or lost HBsAg, but all patients showed a normalization of alanine aminotransferase and aspartate aminotransferase levels. No severe complications, and especially no rejection episodes occurred. Therefore lamivudine combined with interferon might be used for the therapy of hepatitis B reinfection after liver transplantation.

Iatrogenic bile duct lesions are serious complications during laparoscopic cholecystectomy and include biliary leakage and major bile duct injury. The incidence of biliary lesions following laparoscopic cholecystectomy is up to threefold higher than that of the open procedure. A total of 108 patients with bile duct lesions after laparoscopic cholecystectomy were treated at our institution. Endoscopic treatment was successful in 68 cases, 6 patients were treated by external drainage, and 34 patients required surgical therapy. Selection criteria for the type of treatment included the etiology, anatomical situation, and diagnostic interval of the biliary lesion. We suggest a classification of bile duct injury and a proposal for diagnosis and treatment of these complications.

Development of resistance is a major issue in antiviral treatment of hepatitis B reinfection after liver transplantation. Antiviral combination therapy is discussed for therapy or prevention of this breakthrough of viral replication. Eight patients were enrolled into this retrospective analysis after liver transplantation for chronic hepatitis B infection. All had reinfection of the graft and breakthrough of HBV during consecutive famciclovir and lamivudine monotherapy. Subsequently a combination therapy with lamivudine and interferon-alpha 2a (group I, n = 4) or lamivudine and famciclovir (group II, n = 4) was initiated. Combination therapy was started 61 months (group I) and 25 months (group II) after liver transplantation. It markedly reduced the viral replication rate in all patients despite lamivudine resistance. In group I three of four patients and in group II two of four patients became HBV-DNA negative. Two long-term responders were observed in group I, and none in group II. No patient became HBsAg negative or lost HbeAg. Pretreatment elevated ALT and AST levels were significantly reduced. No severe complications, and especially no rejection episodes, occurred. Lamivudine in combination with other antiviral agents, especially interferon-alpha, might be a therapeutic option for hepatitis B reinfection after liver transplantation. Suppression of virus replication to the point of undetectable values is possible even in patients with lamivudine-resistant virus mutations.

From September 1988 through April 1998, 1,000 liver transplantations were performed on 911 patients. During the postoperative control examinations of 837 patients, we found 23 (2.74 %) with hepatic artery thromboses, 27 stenoses of the hepatic artery (3.22 %), and 6 aneurysms of the graft artery. Seventeen patients underwent retransplantation because of arterial complications. Depending on the clinical symptoms, we treated both the local situation as well as the resulting complications of inadequate arterial graft flow. The aneurysms were primarily treated surgically. The first choice of treatment of stenoses was balloon angioplasty. Early postoperative artery thromboses were also treated surgically by thrombectomy in selected cases. For the resulting biliary and local septic complications we preferred endoscopic and drainage procedures. Our clinical experiences have led us to find pretransplantation angiography recommendable, especially in the case of splanchnic artery stenoses, for bypassing from the aorta for arterial perfusion of the graft.

Since the introduction of famciclovir in the treatment of hepatitis B virus (HBV) infection after liver transplantation, promising results have been published. In this study, the long-term efficacy and safety of famciclovir were assessed. Twenty-four patients with recurrent hepatitis B and 6 patients with de novo infection after liver transplantation were enrolled in an open prospective trial. Patients received oral famciclovir, 500 mg three times daily. Serum HBV-DNA, viral serology, and liver enzymes were measured sequentially; liver histology was taken before and during treatment in 12 patients. In the reinfected patients, 17 patients initially responded well to treatment, with a mean decrease of HBV-DNA of 82%, 5 patients became HBV-DNA negative. The drug was effective for 1-51 months (mean 16 months), then viral replication increased again in 13 out of 17 patients. One patient did not respond to treatment. Six out of 24 patients already had severe cirrhosis at the time of enrollment and died shortly afterwards, due to the HBV infection. The 6 patients with de novo infection all had a decline of HBV-DNA for 2-42 months (mean 14 months); 1 patient converted to HBV-DNA negative. Five out of 6 patients experienced a viral breakthrough later on. No severe side-effects were observed. Therefore, famciclovir is effective in certain HBV-infected patients after orthotopic liver transplantation (OLT), but in the long term, most of the patients relapse.

Percutaneous liver biopsy is an important diagnostic tool for the management of patients following liver transplantation. However, it may be associated with severe complications. To evaluate the incidence and type of complications after liver biopsy, we retrospectively analyzed 919 patients who underwent orthotopic liver transplantation (OLT) from September 1988 to May 1998. A total 3,670 biopsies were performed with ultrasound guidance and use of the Menghini needle (1.6 mm diameter). The biopsies were performed according to the protocol on the 7th postoperative day and one, three, five years after OLT, or when clinically indicated. Patients with severe coagulopathy (thrombocytes < 30,000/nl and Quick < 40%) were excluded from this protocol. Biopsy was complicated by bleeding in 13 of 919 patients (1.41%). The incidence of procedure related complications was 13 of 3,670 (0.35%). Five patients showed intrahepatic hematoma, four patients developed a hematothorax, three patients had intraabdominal bleeding and one patient suffered from hemobilia. Seven of 13 patients (53%) required surgical intervention (laparotomy four, thoracotomy two, retransplantation one). Graft dysfunction after liver transplantation requires rapid assessment and specific treatment to achieve good results. Percutaneous liver biopsy is an important procedure in the evaluation and identification of graft dysfunction such as acute rejection, hepatitis reinfection or toxic alterations. From our data we conclude that percutaneous liver biopsy is a safe procedure and advocate is liberal use.

Portal vein thrombosis (PVT) is an infrequent complication following hepatic transplantation. However, deterioration of liver function and accompanying complications may be life threatening. Several attempts of surgical or percutaneous transhepatic procedures have been described. In some cases high dose fibrinolytic regimens have been successful. We describe the case of a male liver recipient with recurrent liver fibrosis due to hepatitis B reinfection and late portal vein thrombosis 45 months after transplantation. Complete recanalization was achieved using systemic low dose recombinant tissue plasminogen activator (rt-PA).

Recently, a novel virus, tentatively designated GB virus (GBV-C) was identified in patients with hepatitis. The frequency of this novel virus infection was therefore investigated in 58 patients with chronic hepatitis B virus (HBV) infection and in 74 patients with chronic hepatitis C virus (HCV) infection who had received orthotopic liver transplantation (OLT) because of decompensated liver cirrhosis. Before OLT, GBV-C sequences were found by reverse transcription nested polymerase chain reaction with primers derived from the helicase-like region in six (10%) of the HBV- and in six (8%) of the HCV-infected patients. Specificity of the polymerase chain reaction products was confirmed in eight of them by direct sequencing. Pretransplant GBV-6 viremia was associated with posttransplant viremia in 75% of patients. The comparison of GBV-C nucleotide and amino acid sequences within the helicase-like region revealed that pre- and posttransplant sequences differed only in 0-7 nucleotide exchanges, and with the exception of one, all of them were silent mutations. After OLT, 29% of the HBV- infected and 12% of the HCV-infected patients became GBV-C positive,indicating a high rate of "de novo" GBV-C infection. By correlating the GBV-C status with the frequency of the occurrence of graft hepatitis in both groups of patients, it became evident that posttransplant GBV-C viremia did not increase the risk for this clinical condition. However, we found a significantly higher percentage of hepatocellular carcinoma in patients with pre-OLT GBV-C/HCV coinfection compared with patients with HCV infection alone (5/6 vs. 16/68;P<0.01).

Unlabelled: The aim of this study was to analyse the causes of death after liver transplantation in order to find and to avoid preventable fatal complications if possible., Methods: Between September 1988 and September 1993 415 orthotopic liver transplantations in 382 patients were performed at the Rudolf Virchow University Hospital in Berlin. During the same interval 41 (10.7%) of these patients died. Their clinical records were reviewed., Results: The main cause of death was infection (29.3%), followed by recurrent malignancy (21.9%). Less patients died because of hepatitis B-reinfection (14.6%), chronic rejection (7.3%), hemorrhage (7.3%), cardiac failure (7.3%), trauma (4.8%), hypoxia (4.8%) and recurrence of alcoholic liver disease (4.8%). There was a wide spectrum of opportunistic infectious agents with CMV and Pneumocystis carinii being the most important pathogenic organisms. Only one isolated bacterial infection as principle cause of death was found. In all fatal infections the lung was the primary site of infection, 7 patients additionally developed sepsis. Altogether 75 patients (19.6%) with hepatitis B-cirrhosis were transplanted. Six of them (8%) developed a fatal hepatitis B-reinfection. Malignancy was the indication for OLT in 41 patients (10.7%). Six of these patients (14.6%) died because of recurrent tumor. Regarding the whole series, most deaths occurred four to twelve months (58.5%) and only five (12.2%) during the first month after OLT., Conclusion: Recurrence of primary disease is an important factor regarding total mortality. Therefore it is necessary to practise a careful selection of liver transplant recipients. In the future more attention needs to be drawn towards prevention, identification and management of opportunistic infections.

Introduction: Patients with solid-organ transplantation are at risk for Graft-versus-host disease (GVHD) even though GVHD is a rare phenomenon after orthotopic liver transplantation (OLT)., Case Report: The 30 yrs old male patient received an ABO compatible orthotopic liver graft for acute liver failure due to intoxication with amanita phalloides. Twenty-four days after OLT the patient developed high temperatures up to 40.0 degrees C and pancytopenia and was treated for CMV-infection. On postoperative day (POD) 32 an erythematous maculo-papular rash developed. A drug induced toxic epidermal necrolysis was suspected and treated with plasmapheresis for three days. Acute renal failure and respiratory insufficiency occurred while liver function was not impaired. A skin biopsy at that time showed no specific signs for GVHD. On POD 42 HLA-typing of circulating lymphocytes presented donor HLA phenotype and GVHD was established. Therapy with ATG was started but the clinical status of the patient did not improve. Following administration of OKT3 on POD 48 a reduction of activated CD-3 lymphocytes from 90% to 60% could be achieved. Due to the low platelet count the patient died of intracerebral hemorrhage on POD 52., Conclusion: Since a fully developed GVHD is rare after OLT and the similarity of the clinical findings to viral or drug induced diseases is high, diagnosis is often made late in the course of the disease. Furthermore, therapeutic measures for GVHD are scarce and diagnosis has to be established as early as possible, hence pretransplant procurement of donor and recipient mononuclear cells for later study should be considered to decrease the time period between clinical suspicion and diagnosis.

The early outcome of 201 liver grafts transplanted consecutively between September 1988 and November 1991 was investigated retrospectively. Donors were categorized according to their hospitalization periods in an intensive care unit (ICU) prior to harvesting, their causes of death, and the variables generally believed to be critical in liver donation, such as arterial hypotension (n = 69; 34.3%), cardiopulmonary resuscitation (n = 20; 9.9%), elevated serum-aminotransferases (s-AT) (n = 11; 5.5%), or an age over 50 years (n = 16; 8.0%). Ninety-one donors (45.3%) spent less than 24 h in an ICU; 29 donors (14.4%) and 14 donors (7.0%) had hospitalization periods generally considered critical of 4-6 days and more than 6 days, respectively. The most common causes of death were subarachnoidal bleeding (n = 70; 34.8%), isolated head injuries (n = 68; 33.8%), and polytraumata (n = 33; 16.4%). The postischemic hepatocellular damage was evaluated comparing peak post-transplant s-AT, which did not differ significantly between groups; nor did donor and recipient ages or cold ischemia times. Fourteen grafts (7.0%) showed a reversible preservation injury presenting with post-transplant s-AT elevated above 2000 IU/l. Five cases (2.5%) of a primary non-functioning graft (PNF) underwent early retransplantation successfully. Serum-aminotransferases (AST: 4944 +/- 2280 IU/l; ATL: 3186 +/- 1918 IU/l) were significantly (P < 0.01) elevated as compared to primary functioning grafts (AST: 699 +/- 935 IU/l; ALT: 620 +/- 701 IU/l). The donor structure of both groups reflected the distribution of variables in the entire collective. No significant overrepresentations were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial and fungal infections are a major cause of morbidity and mortality after orthotopic liver transplantation. In the immunocompromised host, infections are thought to arise from the gut, which is almost always colonized with potential pathogens. Using oral selective bowel decontamination (SBD), potential pathogens can be eradicated from the gut and infections prevented. In this catamnestic study we have reviewed gastrointestinal colonization, bacterial and fungal infections, and bacterial resistance to standard antibiotics in our first 206 liver transplant patients while under SBD. With few exceptions, gram-negatives were eradicated from the gastrointestinal tract and secondary colonization was inhibited. In spite of unsatisfactory elimination of Candida, probably because nystatin doses were too low, Candida infections were rare (n = 4) and none was fatal. One and two-year survival rates were 93% and 92%, respectively. The bacterial and fungal infection rate was 27.8% with an infection-related mortality of 1.95%. Infections with aerobic gram-positive bacteria prevailed and only 11 gram-negative and 11 fungal infections occurred; among the latter, Aspergillus and Mucor were the most serious and responsible for three of the six deaths in this series. With regard to the development of resistance, we found an increasing number of enterococci and coagulase-negative staphylococci resistant to ciprofloxacin and imipenem, respectively, but unlikely as a consequence of SBD.

269 orthotopic liver transplantations (OLT) were performed in 253 patients at our institution from September 1988 to May 1992. 121 patients had end-stage cirrhosis secondary to viral hepatitis type B, delta, or type non-A non-B and C respectively. Reinfection of the graft by persistent viruses is a potential complication in these cases. Passive immunization with anti-HBs hyperimmunoglobulin (HIg) can prevent clinically relevant reinfection of the graft in patients with hepatitis B virus (HBV) infection and low replication rates. Patients with high replication rates will rarely benefit from OLT. Patients with hepatitis delta virus (HDV) infection usually experience HDV reinfection of the graft with subsequent chronic hepatitis although prophylaxis with anti-HBs-HIg was performed. Treatment with interferon alpha had no apparent effect on the incidence of graft reinfection with HBV in this series, but the replication rate of HDV was reduced. Persistent hepatitis C viruses (HCV) usually infect the graft; this was demonstrated in 17 patients by means of the polymerase chain reaction. HCV infection usually causes a mild form of acute hepatitis with transition to a chronic course. Therefore the significance of persistent viral infection lies in the potential for chronic hepatitis in the transplanted organ rather than in the danger of acute injury of the allograft.

A 34 year old patient was diagnosed as suffering from congestive cirrhosis due to constrictive pericarditis 18 years ago. A terminal dystrophic episode of additionally acquired chronic aggressive hepatitis B led to rapidly progressive liver failure. Orthotopic liver transplantation was carried out. 10 months after transplantation the patient is alive and well. Presence of HBsAg and HBcAg can again be demonstrated in the liver graft, however, without histologic evidence of hepatitis. Problems of prognosis after liver transplantation for hepatitis B virus infection are discussed.