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ZusammenfassungDie Transplantation ist eine effiziente und standardisierte Therapie in der Behandlung des irreversiblen Organversagens. Damit möglichst viele geeignete Patienten in Deutschland von dieser Therapieoption profitieren, muss der im internationalen Vergleich niedrige Organmangel in Deutschland als ein zentrales Problem der Transplantationsmedizin behoben werden. Die Ursachenanalyse des Organmangels führte zu Änderungen im Gesetz über die Spende, Entnahme und Übertragung von Organen und Gewebe (Transplantationsgesetz – TPG), welche konsekutiv Prozessanpassungen und Strukturverbesserungen der Rahmenbedingungen der Organspende in Deutschland zur Folge hatten und zu einer Steigerung der Organspenderzahlen beitragen sollten. Die aktuellen Organspenderzahlen zeigen, dass die angestoßenen strukturellen Maßnahmen kurzfristig nicht zu einer Trendwende führten. Das geänderte Transplantationsgesetz wird aber nur dann langfristige Effekte erzielen, wenn die gemeinschaftliche Aufgabe zur Organspende in der deutschen Gesellschaft breiten Konsens findet. Ein rationaler öffentlicher Diskurs in Deutschland über die Optionen zur Behebung des Organspendemangels – dazu gehören auch die Widerspruchslösung und die Organspende nach Herz- und Kreislauftod (DCD) – ist dringend geboten.

BACKGROUND Varices of the upper gastrointestinal tract are due to portal hypertension and can result from occlusion of the portal venous system. This report is of a 55-year-old man with recurrent gastrointestinal bleeding due to stricture of the portal vein anastomotic site to inferior vena cava (IVC) 12 years after combined pancreas and kidney transplantation. CASE REPORT A 55-year-old man presented bleeding episodes requiring transfusion of more than 70 units of red blood cells (RBCs), complicated by bacterial and viral infection episodes including cytomegalovirus (CMV) reactivation and hepatitis E and transient impairment of function of the renal allograft. Endoscopy, computed tomography (CT) scan, and angiography revealed jejunal varices due to anastomotic stricture at the portal vein to IVC as the cause of the hemorrhage. Neither conservative therapy nor an anastomosis between the splenic vein of the graft and the internal iliac vein as a bypass could stop the life-threatening bleeding. During the recurrent bleeding, CD4 T lymphocytes were low, indicating immunodeficiency despite paused immunosuppressive therapy. After the hemorrhage resolved and immunosuppression was restarted, CD4 T lymphocyte levels normalized. Finally, to stop the hemorrhage and save the transplanted kidney and the patient's life, graft pancreatectomy was performed. Long-term damage to the renal transplant was not found. CONCLUSIONS This report is of a rare case of portal hypertension as a long-term complication of transplant surgery. Although acute venous thrombosis at the anastomotic site is a recognized postoperative complication of pancreatic transplant surgery, this case highlights the importance of post-transplant follow-up and diagnostic imaging.

Background and Aims: In patients with Rat sarcoma proto-oncogene (RAS) wild-type metastatic colorectal cancer (mCRC), anti-epidermal growth factor receptor (EGFR) antibodies have been established in first- and further therapy lines. Due to limited treatment options upon disease progression, anti-EGFR re-exposure is increasingly employed in real-world oncology. The aim of this study was to assess clinical implementation and utility of anti-EGFR retreatment strategies in real-world mCRC patients. Methods: In this monocentric retrospective study, we included 524 patients with CRC and identified patients who received an anti-EGFR-based treatment as well as anti-EGFR rechallenge (progression on first-line anti-EGFR therapy) or reintroduction (discontinuation due to intolerance/toxicity/other). Results: In total, 143 patients received an anti-EGFR-based first- or second-line treatment, showing a similar overall survival (OS) compared to the non-anti-EGFR treatment group (38.3 vs. 39.6 months, p = 0.88). Thirty-three patients met the inclusion criteria for anti-EGFR re-exposure and were either assigned to rechallenge (n = 21) or reintroduction (n = 12) subgroups. The median FU after re-exposure was 45.8 months. Cetuximab and Panitumumab were used in 21 and 12 patients, respectively, and the main chemotherapy at re-exposure was FOLFIRI in 39.4%. Anti-EGFR re-exposure was associated with a distinct trend towards a better outcome (median OS 56.0 vs. 35.4 months, p = 0.06). In a subgroup comparison, reintroduction was associated with a higher OS and PFS in trend compared to the rechallenge (mOS 66 vs. 52.4, n.s., mPFS 7.33 vs. 3.68 months, n.s.). Conclusions: This retrospective study provides real-world evidence underscoring that anti-EGFR re-exposure strategies might benefit patients independently of the reason for prior discontinuation.

In patients withIn this monocentric retrospective study, we included 524 patients with CRC and identified patients who received an anti-EGFR-based treatment as well as anti-EGFR rechallenge (progression on first-line anti-EGFR therapy) or reintroduction (discontinuation due to intolerance/toxicity/other).In total, 143 patients received an anti-EGFR-based first- or second-line treatment, showing a similar overall survival (OS) compared to the non-anti-EGFR treatment group (38.3 vs. 39.6 months,This retrospective study provides real-world evidence underscoring that anti-EGFR re-exposure strategies might benefit patients independently of the reason for prior discontinuation.

Hemorrhage after trauma in the area of the upper abdominal organs and the kidneys can represent a life-threatening situation. The primary treatment options are conservative or surgical treatment. Only in exceptional cases can endovascular treatment with an angiographic depiction of the active bleeding and, if necessary, intervention by means of embolization be used as an alternative.Blutungen nach einem Trauma im Bereich der Oberbachorgane und der Nieren können eine lebensbedrohliche Situationen darstellen. Die primären Therapieoptionen liegen in einer konservativen oder chirurgischen Therapie. Nur in Ausnahmefällen kann alternativ eine endovaskuläre Therapie mit angiographischer Darstellung der aktiven Blutung und ggf. einer Intervention mithilfe Embolisation eingesetzt werden.

4008 Background: Chemotherapy (CT) is the standard of care in nonresectable locally advanced pancreatic cancer. The CONKO-007 trial studied the role of sequential CT and chemoradiotherapy (CRT). Methods: In this randomized multicenter phase III trial resectability was judged by an independent surgical board. Patients (pts) received induction chemotherapy (IC) for 3 months (3 cycles gemcitabine (Gem, 1000 mg/m² d1, 8, 15, q4w) or FOLFIRINOX (6 cycles, q2w)). After IC pts without progression were randomized to either continuing CT for another 3 months or receiving CRT (cumulative dose of 50.4Gy, single dose 1.8Gy + Gem 300 mg/m² weekly, followed by 1 cycle of Gem 1000 mg/m² at d1, 8, 15). The primary endpoint of the study was overall survival (OS) since the begin of IC. Determination of sample size calculated 590 pts to be randomized. Due to the exclusion of pts with progressive disease after IC a total of 830 pts should be enrolled. Due to delayed patient accrual the primary endpoint was changed to R0 resection rate resulting in an estimated sample size of 525 pts. Results: Between 04/2013 and 02/2021 a total of 525 pts were enrolled in 47 sites. 402 pts received IC with FOLFIRINOX and 93 pts with Gem. After IC 190 pts were excluded due to progression or toxicity, 335 were randomized, their median FU was 16 months. Hematological toxicities were significantly increased in the CRT arm, non-hematological toxicities were comparable. R0 CRM- resection rate and pCR rate was significantly higher in the CRT arm. R1-resections occurred significantly more often in the CT arm. Median progression-free survival (PFS) (HR 0.919, 95% CI 0.702-1.203, p=0.540) and OS (HR 0.964, 95% CI 0.760-1.225, p=0.766) did not differ significantly in both arms, whereas the PFS rate tended to be higher in the CRT arm after 2 years. OS rates for CRM- R0 surgery with 87.5. ± 0.05% (1y) and 67.2 ± 0.05% (2y) were significantly higher (p

Background and Aims. Systemic treatment with sorafenib has been the standard of care (SOC) in patients with advanced Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC) for more than a decade. TACE has been reported to allow better local tumor control in selected patients with BCLC stage C HCC. Methods. A retrospective analysis of patients with BCLC stage C HCC that were treated with sorafenib and TACE was conducted, they were compared to BCLC stage C patients treated either with TACE or sorafenib in the same period of time outside a clinical trial. Results. A total of 201 patients with BCLC stage C were identified, who were treated with either sorafenib and TACE (group A, n = 54), sorafenib (group B, n = 82) or TACE (group C, n = 65). No significant difference in baseline characteristics was observed. Time to progression was 7.0 months (95% CI: 4.3–9.7), 4.1 months (95% CI: 3.6–4.7) and 5.0 months (95% CI: 2.9–7.1) in groups A, B and C, respectively, and overall survival was 16.5 months (95% CI: 15.0–18.1), 8.4 months (95% CI: 6.0–10.8) and 10.5 months (95% CI: 7.5–13.6), respectively (group A vs. group B: p &lt, 0.001, group A vs. group C: p = 0.0023). Adverse events of grade 3/4 occurred in 34% of patients in group A. Conclusions. Although sorafenib is a SOC in patients with BCLC stage C HCC, TACE is frequently used as an additional locoregional treatment in selected patients. This combined approach resulted in a significant overall survival benefit in selected patients, although randomized trials have not yet proven this benefit.

A 46-year-old male received total arch replacement with frozen elephant trunk for acute non-A/non-B aortic dissection. Two months later, he underwent emergency reoperation for contained rupture of the left common carotid ostium at its insertion on the aortic arch. Three months after the reoperation, he developed tracheoesophageal fistula and infection of the prosthesis in the region of the aortic arch and the proximal descending aorta. Second reoperation was performed with replacement of the aorta with a composite of three aortic homografts, and the fistula was permanently closed with a direct suture and intercostal muscle flap

Background/aims: Hepatocellular carcinoma (HCC) is a leading indication for liver transplantation (LT) worldwide. Early identification of patients at risk for HCC recurrence is of paramount importance since early treatment of recurrent HCC after LT may be associated with increased survival. We evaluated incidence of and predictors for HCC recurrence, with a focus on the course of AFP levels. Methods: We performed a retrospective, single-center study of 99 HCC patients who underwent LT between January 28th, 1997 and May 11th, 2016. A multi-stage proportional hazards model with three stages was used to evaluate potential predictive markers, both by univariate and multivariable analysis, for influences on 1) recurrence after transplantation, 2) mortality without HCC recurrence, and 3) mortality after recurrence. Results: 19/99 HCC patients showed recurrence after LT. Waiting time was not associated with overall HCC recurrence (HR = 1, p = 0.979). Similarly, waiting time did not affect mortality in LT recipients both with (HR = 0.97, p = 0.282) or without (HR = 0.99, p = 0.685) HCC recurrence. Log10-transformed AFP values at the time of LT (HR 1.75, p = 0.023) as well as after LT (HR 2.07, p = 0.037) were significantly associated with recurrence. Median survival in patients with a ratio (AFP at recurrence divided by AFP 3 months before recurrence) of 0.5 was greater than 70 months, as compared to a median of only 8 months in patients with a ratio of 5. Conclusion: A rise in AFP levels rather than an absolute threshold could help to identify patients at short-term risk for HCC recurrence post LT, which may allow intensification of the surveillance strategy on an individualized basis.

Colorectal foreign bodies are commonly seen in the emergency department. A delayed consultation may be associated with a worse outcome. Despite a low-lying position, the extraction can be a challenge and has to be done under general anesthesia. Sharp or potentially dangerous foreign bodies should be excluded before extraction manoeuvres and complications have to be ruled out after the retrieval.Data were retrospectively collected from 2002 to 2017. Overall 33 patients were included. In addition, a systematic search, employing the PRISMA criteria, was performed. The search was carried out on PubMed (1623), Cochrane Library (17) and Google Scholar (300). Case reports, papers not written in English and publications before 1980 were excluded.With an average delay of 33 h, patients admitted themselves to the emergency department. Attempts to remove foreign bodies in the emergency department were successful in 2 cases (6%). General anaesthesia was required in 31 (94%) patients. An emergency laparotomy was necessary in 3 cases (9%). No complications were noticed.A delayed consultation is not associated with a worse outcome. Complications should be ruled out by endoscopy. After a normal control, the patient can be discharged prematurely without further imaging.Kolorektale Fremdkörper sind ein nicht ungewöhnlicher Vorstellungsgrund in der Notaufnahme. Die häufig erst verspätete ärztliche Konsultation führt möglicherweise zu einer erhöhten Rate an Komplikationen. Vor jeder rektalen Manipulation sollte die Art des Fremdkörpers bekannt sein. Trotz Lokalisation im Rektum kann die Entfernung des Fremdkörpers schwierig sein und eine Narkose erfordern. Verletzungen sollten nach jeder Intervention ausgeschlossen werden.Retrospektiv wurden die Fälle mit der Diagnose „Fremdkörper im Anus und Rektum (inkl. Sigmoid)“ zwischen 2002 und 2017 ausgewertet. Von 56 Patienten konnten 33 (59%) Patienten in die Studie eingeschlossen werden. Zusätzlich wurde eine Literaturrecherche mit den Suchbegriffen „colon AND foreign bod*“, „rectum AND foreign bod*“ und „colorectal AND foreign bod*“ in den Datenbanken PubMed (1623) und Cochrane Libary (17) sowie in der Suchmaschine Google Scholar (300) vorgenommen.Durchschnittlich erfolgte die Vorstellung nach 33 h. Eine Entfernung in der Notaufnahme gelang in 2 Fällen (6%). 31 Patienten (94%) benötigten eine Narkose. Eine notfallmäßige Laparotomie wurde in 3 Fällen (9%) vorgenommen. Komplikationen traten nicht auf. Die Entlassung erfolgte im Schnitt nach 1,5 d.Eine verspätete Vorstellung führt nicht zu einem komplizierteren Verlauf. Nach abschließender Rektoskopie ist eine weitere Bildgebung nicht erforderlich. Eine kurzzeitige Überwachung ist nach unauffälliger Klinik ausreichend.

In the absence of extrahepatic metastases, improved survival can be achieved with surgical and interventional techniques. In resectable patients the resection of liver metastases can be performed in curative intention. Interventional techniques are defined either as percutaneous or intraoperative laparoscopy, applications of thermal ablation. In this review, we concentrate on the most established ablative techniques of radiofrequency ablation (RFA) and microwave ablation (MWA) for the treatment of colorectal liver metastases. These techniques allow safe ablation of metastases of up to 3 cm and have a low complication rate. In the current recommendations and guidelines, interventional therapies can be used for tumours that are surgically difficult to resect, in combination with surgery to reduce the surgical trauma or - in case of recurrent metastases - to avoid complicated repeat surgeries. Interventional therapies in combination with chemotherapy are superior to chemotherapy alone and should be considered especially in irresectable situations.Wenn keine extrahepatischen Metastasen vorliegen, kann ein verbessertes Überleben mit chirurgischen und interventionellen Techniken erreicht werden. Interventionelle Techniken sind entweder definiert als perkutane oder intraoperative Laparoskopie bzw. die Anwendung von thermischer Ablation. In diesem Review konzentrieren wir uns hierbei auf die beiden etablierten Techniken der Radiofrequenzablation (RFA) und der Mikrowellenablation (MWA) zur Therapie von kolorektalen Lebermetastasen. Diese beiden Techniken erlauben eine sichere Ablation von Metastasen bis zu 3 cm Größe und haben eine niedrige Komplikationsrate. In aktuellen Leitlinien haben beide Therapien ihren Stellenwert. Im Falle von schwierig zu resezierenden Metastasen stellen sie eine gute Alternative dar. Weiterhin können sie in Kombination mit Chirurgie eingesetzt werden, um das chirurgische Trauma zu reduzieren. Bei Rezidivmetastasen kann die Durchführung einer Intervention aufgrund des operativen Traumas niedrigere Morbidität für den Patienten bedeuten. Darüber hinaus sind die interventionellen Verfahren in Kombination mit einer systemischen Therapie der alleinigen Chemotherapie überlegen.

Background Postoperative pancreatic fistula (POPF) is a major factor for morbidity and mortality after pancreatic resection. Risk stratification for POPF is important for adjustment of treatment, selection of target groups in trials and quality assessment in pancreatic surgery. In this study, we built a risk-prediction model for POPF based on a large number of predictor variables from the German pancreatic surgery registry StuDoQ|Pancreas. Methods StuDoQ|Pancreas was searched for patients, who underwent pancreatoduodenectomy from 2014 to 2016. A multivariable logistic regression model with elastic net regularization was built including 66 preoperative und intraoperative parameters. Cross-validation was used to select the optimal model. The model was assessed via area under the ROC curve (AUC) and calibration slope and intercept. Results A total of N = 2488 patients were included. In the optimal model the predictors selected were texture of the pancreatic parenchyma (soft versus hard), body mass index, histological diagnosis pancreatic ductal adenocarcinoma and operation time. The AUC was 0.70 (95% CI 0.69–0.70), the calibration slope 1.67 and intercept 1.12. In the validation set the AUC was 0.65 (95% CI 0.64–0.66), calibration slope and intercept were 1.22 and 0.42, respectively. Conclusion The model we present is a valid measurement instrument for POPF risk based on four predictor variables. It can be applied in clinical practice as well as for risk-adjustment in research studies and quality assurance in surgery.

In western countries, hepatocellular carcinoma (HCC) is a major reason for orthotopic liver transplantation (OLT) with estimated recurrence rates between 15% and 20%. This selective literature review addresses follow-up care after OLT in HCC and current treatment options. Recurrence prediction is based on pathological tumor stage, vascular invasion, serum alfafetoprotein levels, and histological differentiation, but further advances are expected by molecular profiling techniques. Lower levels of immunosuppressive agents are associated with a lower risk for HCC recurrence. Retrospective studies indicate that mammalian target of rapamycin (mTOR) inhibitors as immunosuppression reduce the risk of HCC recurrence. However, prospective studies supporting this potential advantage of mTOR inhibitors are still lacking, and higher rejection rates were reported for sirolimus after OLT in HCC. Prognosis is poor in recurrent HCC, a longer interval between OLT and recurrence and feasibility of surgical resection are associated with improved survival. Systemic treatment with sorafenib is the current standard of care in patients with advanced-stage HCC not suitable for locoregional therapy. After OLT, combination of an mTOR inhibitor with sorafenib is feasible and frequently used in clinical practice. As safety and efficacy data are still limited, close clinical monitoring is mandatory.

BACKGROUND: Endoscopic treatment of stenosis of the anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but long term outcome and risk factors for recurrence are unknown. METHODS: All 374 patients who underwent OLT at Frankfurt University hospital were screened for occurrence of ABS. ABS was treated by endoscopic insertion of plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of both (57.4%). Long-term outcome and risk factors for occurrence and recurrence of ABS was determined through competing risk analysis. Mean follow-up time was 151 weeks and mean survival was 3.4 years. RESULTS: ABS was observed in 47 patients (12.6%). Mean (median) time from OLT to ABS was 16.3 months (3.3 months). Cumulative incidence rates of ABS were 0.09 after 12 months, 0.10 after 24 months and 0.11 after 36 months. In 12 cases (25.5%), ABS was observed later than 12 months after OLT. ABS recurred in 14 of 47 (29%). Ocurrence of ABS more than six weeks after OLT was a significant predictor of ABS recurrence (p=0.04, H.R. 0.235). There was a trend of HCV infection to be predominant in patients with recurrence of ABS (30% HCV vs. 4% non-HCV) in comparison to patients with non-recurrence (HCV 36%, non-HCV 30%); p0.05. Severity of initial stricture predicted recurrence of ABS (p = 0.046, HR=2.78), but did not influence overall survival. Long-term resolution of ABS was observed in 45 of 47 patients (95.7%), recurrence of ABS was treated with a second (n= 16, 34%), or a third endoscopic treatment attempt (1). CONCLUSION: Long-term success of endoscopic treatment of ABS is highly probable if recurrent strictures are again treated endoscopically. ABS might occur late (36 months) after OLT and life-long follow-up is essential in OLT patients to identify patients with ABS. © 2013 American Association for the Study of Liver Diseases.

Endoscopic treatment for stenosis of an anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but the long-term outcomes and the risk factors for recurrence are unknown. All 374 patients who underwent OLT at Frankfurt University Hospital were screened for the occurrence of ABSs. ABSs were treated via the endoscopic insertion of a plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of the two (57.4%). The mean follow-up time was 151 weeks, and the mean survival time was 3.4 years. ABSs were observed in 47 patients (12.6%). The mean time from OLT to an ABS was 16.25 months (median = 3.25 months). The cumulative incidence rates for ABSs were 0.09 after 12 months, 0.10/24 m. and 0.11/36 m. In 12 cases (25.5%), ABSs were observed more than 12 months after OLT. ABSs recurred in 16 of the 47 patients (34%). The occurrence of an ABS 6 weeks or more after OLT was a significant predictor of ABS recurrence [P = 0.04, hazard ratio (HR) = 0.235]. There was a trend of hepatitis C virus (HCV) infections being predominant in patients experiencing ABS recurrence (30% for HCV etiology versus 4% for non-HCV etiology) in comparison with patients not experiencing recurrence (36% for HCV etiology versus 30% for non-HCV etiology, P 0.05). The severity of the initial stricture predicted ABS recurrence (P = 0.046, HR = 2.78), but it did not influence overall survival. The long-term resolution of ABSs was observed in 45 of the 47 patients (95.7%), and ABS recurrence was treated with another attempt (n = 16 or 34%) or 2 more attempts (n = 1) at endoscopic treatment. In conclusion, the long-term success of the endoscopic treatment of ABSs is highly probable if recurrent strictures are again treated endoscopically. ABSs might occur late (36 months) after OLT, and lifelong follow-up is essential for identifying OLT patients with ABSs.

Prevention of bleeding episodes in noncirrhotic patients undergoing partial hepatectomy remains unsatisfactory in spite of improved surgical techniques. The authors conducted a randomized, placebo-controlled, double-blind trial to evaluate the hemostatic effect and safety of recombinant factor VIIa (rFVIIa) in major partial hepatectomy.Two hundred four noncirrhotic patients were equally randomized to receive either 20 or 80 microg/kg rFVIIa or placebo. Partial hepatectomy was performed according to local practice at the participating centers. Patients were monitored for 7 days after surgery. Key efficacy parameters were perioperative erythrocyte requirements (using hematocrit as the transfusion trigger) and blood loss. Safety assessments included monitoring of coagulation-related parameters and Doppler examination of hepatic vessels and lower extremities.The proportion of patients who required perioperative red blood cell transfusion (the primary endpoint) was 37% (23 of 63) in the placebo group, 41% (26 of 63) in the 20-microg/kg group, and 25% (15 of 59) in the 80-microg/kg dose group (logistic regression model; P = 0.09). Mean erythrocyte requirements for patients receiving erythrocytes were 1,024 ml with placebo, 1,354 ml with 20 microg/kg rFVIIa, and 1,036 ml with 80 microg/kg rFVIIa (P = 0.78). Mean intraoperative blood loss was 1,422 ml with placebo, 1,372 ml with 20 microg/kg rFVIIa, and 1,073 ml with 80 microg/kg rFVIIa (P = 0.07). The reduction in hematocrit during surgery was smallest in the 80-microg/kg group, with a significant overall effect of treatment (P = 0.04).Recombinant factor VIIa dosing did not result in a statistically significant reduction in either the number of patients transfused or the volume of blood products administered. No safety issues were identified.

One of the key issues in successful pancreas transplantation is uncomplicated drainage of pancreas exocrine secretion.The aim of the study is to present results of side-to-side high duodeno-jejunal anastomosis as routine method of enteric drainage in simultaneous pancreas kidney transplantation (SPK).30 diabetic patients underwent SPK at the Department of Surgery, Ruhr University Bochum in 2001. The pancreas was drained using a portion of duodenal segment anastomosed to the first loop of jejunum about 20-40 cm distal to the Treitz ligament.Early relaparotomy was required in 20% patients. The mean time of first relaparotomy was 5.5 (range 1-11) days after transplantation. In 10% of cases graft pancreatectomy was necessary. Perioperative mortality was 3.3%. Currently 83.3% patients are insulin-free and 86.6% patients are free of dialysis.These data suggest, that side-to-side high duodeno-jejunal anastomosis is a safe method of drainage of pancreas exocrine secretion in SPK.