Loss, M.
Jung, E. M.
Scherer, M. N.
Farkas, S. A.
Schlitt, H. J.
The treatment of liver metastases has become more and more complex in recent years. More individualized therapeutic concepts have become feasible by the increase in different treatment options (surgical, interventional and oncological). In the field of surgery the definition of resectability could be broadened. More extensive liver resections are being performed, which are partly carried out as staged resections after neoadjuvant chemotherapy in combination with portal vein embolization (PVE), radio frequency ablation (RFA) or other procedures in order to increase complete resection rates and patient survival. Consequently the overall 5 year survival rate of patients with resected colorectal liver metastases has doubled from 30% to nearly 60% in the past decade. Due to the complexity of the different treatment approaches an interdisciplinary assessment of the individual patient in experienced centers is necessary.
Goessmann, H.
Lang, S. A.
Fichtner-Feigl, S.
Scherer, M. N.
Schlitt, H. J.
Stroszczynski, C.
Schreyer, A. G.
Schnitzbauer, A. A.
Techniques for biliodigestive anastomoses are a frequent indication in primary surgical interventions. Moreover, they are required to manage secondary complications of hepatobiliary surgery. Evidence for the management of complications following biliodigestive anastomoses is low. Biliodigestive anastomoses can be performed as hepaticojejunostomy, hepatojejunostomy/portoenterostomy and hepaticoduodenostomy using running or single stitch suture techniques. Complication management in the hands of experienced hepatopancreatobiliary surgeons should consider a time delay to the primary operation and an interdisciplinary surgical and/or endoscopic or radiologic interventional approach. The therapy may be protracted and requires repeated critical reflection of the particular complication.
Schlitt, H. J.
Hackl, C.
Knoppke, B.
Brunner, S. M.
Sinner, B.
Peschel, G.
Weigand, K.
Melter, M.
Scherer, M. N.
Kirchner, G. I.
The extreme shortage of donor organs in Germany has led to a major discrepancy between availability and requirement of organs for liver transplantation, and-as aconsequence-to an allocation dilemma. This results on one hand in a high lethality on the waiting list and, on the other, to worse results after transplantation, due to the current organ allocation policy favoring extremely ill patients. Potential solutions are (1) increasing the number of donor organs; (2) innovative approaches for improved use of suboptimal donor organs (e.g., from older, multimorbid donors, fatty livers); (3) an increase in living organ donation; and (4) modified/optimized allocation rules. Measures 2 and 3 would benefit from more centralization of liver transplantation in Germany. Since all four options are probably not realizable in Germany in the near future, organ shortage and the dilemma in organ allocation will persist.
Kroemer, A.
Sabet-Baktach, M.
Doenecke, A.
Ruemmele, P.
Scherer, M. N.
Schlitt, H. J.
Breidert, M.
Eosinophilic cholangitis is a rare clinical entity characterised by transmural eosinophilic infiltration of the biliary system. The aetiology of this disease is still unclear. We report on a 49-year-old male patient who presented with symptoms of obstructive jaundice and imaging suggestive for periampullary carcinoma. After partial pancreatoduodenectomy for suspected pancreatic cancer, pathology revealed massive eosinophilic cholecystitis as well as intra- and extrahepatic eosinophilic cholangitis with pseudopolypoid papillary lesions. Our case illustrates the diagnostic pitfalls in eosinophilic cholangitis as careful imaging procedures - optimally interdisciplinary - should be considered and performed in such patients. In conclusion, eosinophilic cholangitis is an uncommon, inflammatory condition that needs to be considered as a differential diagnosis for periampullary malignancies.
Girlich, C.
Schacherer, D.
Lamby, P.
Scherer, M. N.
Schreyer, A. G.
Jung, E. M.
The aim was to describe the perfusion pattern of the inflamed bowel wall and the surrounding tissue in inflammatory bowel disease and diverticulitis of the sigmoid colon applying a high resolution matrix transducer and the new hybrid technique. We performed contrast enhanced ultrasound (CEUS) using an updated version of the 1-5MHz (C1-5-D convex probe) and the 6-9 MHz probe (9L-D linear probe) as well as a matrix 6-15 MHz transducer (ML 6-15-D Matrix Array Linear Probe) and updated post-processing procedures to examine microvascularization of inflamed bowel wall in Crohn's disease (11 patients), ulcerative colitis (1 patient) and diverticulitis of the sigmoid colon (2 patients). Assessment of mural microvascularization was successful as well as identification of fistulas (2 patients) and covered perforation (1 patient). Moreover analysis of time intensity curves revealed increase of signal intensity up to 20 dB. Summarizing, application of high resolution linear probes and use of updated post-processing methods substantially improve detection of inflammation-caused increased microcirculation of the bowel wall and the surrounding tissue as well as identification of complications as fistulas or covered perforations.
Doenecke, A.
Tsui, T-Y.
Zuelke, C.
Scherer, M. N.
Schnitzbauer, A. A.
Schlitt, H-J.
Obed, A.
Background: Portal vein thrombosis (PVT) is a surgical challenge in liver transplantation (LTx). In contrast to LTx in decompensated liver disease, which are associated with a higher morbidity and mortality, PVT influence on outcome is still under debate. To evaluate this influence at different stages of liver decompensation, we compared the outcome of patients suffering from PVT to patients with patent portal vein within different score ranges. Methods: We included 193 LTx (24 with PVT) in our study, transplanted between 2004 and 2007 at our institution. Patients were divided into four Model of End-Stage Liver Disease (MELD) score groups, and outcome was compared between PVT- and non-PVT patients. Results: In non-decompensated liver disease (MELD <15), we found a significantly decreased survival in patients suffering from PVT (one-yr survival 57% vs. 89%). By contrast, MELD score > 15 (decompensated liver disease) leads to an equal or even better survival in PVT- patients compared with patients without PVT (one-yr survival 91% vs. 75%), with an only slightly increased morbidity. Conclusion: Outcome in patients with PVT seems to be dependent on pre-operative disease severity. In contrast to compensated liver disease, no influence of PVT on outcome could be found in decompensated liver disease, and should therefore not be considered as a contraindication in LTx.
Schlitt, H. J.
Scherer, M. N.
Becker, T.
Jauch, K. -W.
Nashan, B.
Schmidt, H.
Settmacher, U.
Rogiers, X.
Neuhaus, P.
Strassburg, C.
Liver transplantation represents a successful and well-established therapeutic concept for patients with advanced liver diseases. Organ donor shortage continues to pose a significant problem. To ensure fair and transparent allocation of too few post-mortem grafts, the model of end-stage liver disease (MELD)-based allocation was implemented in December 2006. This has decreased waiting list mortality from 20 to 10% but at the same time has reduced post OLT survival (1-year survival from almost 90% to below 80%), which is largely due to patients with a labMELD score >30. Following MELD introduction the regular allocation threshold has increased from a matchMELD of initially 25 to meanwhile 34. At the same time the quality of donor organs has seen a continuous deterioration over the last 10-15 years: 63% of organs are "suboptimal" with a donor risk index of >1.5. Moreover, the numbers of living-related liver transplantations have decreased. In Germany incentives for transplant centres are inappropriate: patients with decompensated cirrhosis, high MELD scores and high post-transplant mortality as well as marginal liver grafts are accepted for transplantation without the necessary consideration of outcomes, and against a background of the still absent publication and transparency of outcome results. The outlined development calls for measures for improvement: (i) the increase of donor grafts (e.g., living donation, opt-out solutions, non-heart beating donors), (ii) the elimination of inappropriate incentives for transplant centres, (iii) changes of allocation guidelines, that take the current situation and suboptimal donor grafts into account, and (iv) the systematic and complete collection of transplant-related data in order to allow for the development of improved prognostic scores.
Wiggermann, P.
Zuber-Jerger, I.
Zausig, Y.
Loss, M.
Scherer, M. N.
Schreyer, A. G.
Stroszczynski, C.
Jung, E. M.
Purpose: To assess the added value of depicting tumour microvascularisation, using dynamic contrast enhanced (CEUS), during radiofrequency ablation, as a means of achieving a complete ablation (CA) of malignant liver lesions. Material and methods: 18 consecutive patients (2 female, 16 male, age range 52-79 years, mean 64.1 +/- 9.9 years) with 22 histologically confirmed hepatic malignancies (HCC: n = 10, liver metastases: n = 12) underwent RFA. Before RFA treatment, conventional US, CEUS and contrast enhanced CT (ceCT) of the liver were performed. During the CT-guided RFA procedure, CEUS was performed to asses the ablation defect. In case of partial ablation a subsequent ablation was performed with a corrected electrode position and evaluated again using CEUS. This procedure was repeated until a CA was achieved. The number of ablations per patient was recorded. Secondary efficacy parameters assessed were lesion detectability in the different imaging modalities and contrast phases. Results: Overall intraprocedural CEUS led to a change in therapeutic management in 59% of cases, resulting in 17 additional ablation cycles. Lesion detectability during CT Fluoroscopy was the sole statistical significant predictor of incomplete ablations (p = 0.008). The mean number of ablations for detectable lesions was 1.27 vs. 2.27 ablations for not detectable lesions (p = 0.002). The combined CT and CEUS RFA procedure led to a CA for all treated lesions in follow up 3 month post intervention. Conclusion: CEUS does allow a reliable and immediate assessment of therapeutic efficacy of percutaneous RFA procedures of malignant liver lesions, through the continuous dynamic evaluation of tumour microcirculation.
Zuber-Jerger, I.
Zausig, Y.
Loss, M.
Scherer, M. N.
Schreyer, A. G.
Stroszczynski, C.
Jung, E. M.
Purpose: To assess the added value of depicting tumour microvascularisation, using dynamic contrast enhanced (CEUS), during radiofrequency ablation, as a means of achieving a complete ablation (CA) of malignant liver lesions.Material and methods: 18 consecutive patients (2 female, 16 male, age range 52-79 years, mean 64.1 +/- 9.9 years) with 22 histologically confirmed hepatic malignancies (HCC: n = 10, liver metastases: n = 12) underwent RFA. Before RFA treatment, conventional US, CEUS and contrast enhanced CT (ceCT) of the liver were performed. During the CT-guided RFA procedure, CEUS was performed to asses the ablation defect. In case of partial ablation a subsequent ablation was performed with a corrected electrode position and evaluated again using CEUS. This procedure was repeated until a CA was achieved. The number of ablations per patient was recorded. Secondary efficacy parameters assessed were lesion detectability in the different imaging modalities and contrast phases.Results: Overall intraprocedural CEUS led to a change in therapeutic management in 59% of cases, resulting in 17 additional ablation cycles. Lesion detectability during CT Fluoroscopy was the sole statistical significant predictor of incomplete ablations (p = 0.008). The mean number of ablations for detectable lesions was 1.27 vs. 2.27 ablations for not detectable lesions (p = 0.002). The combined CT and CEUS RFA procedure led to a CA for all treated lesions in follow up 3 month post intervention.Conclusion: CEUS does allow a reliable and immediate assessment of therapeutic efficacy of percutaneous RFA procedures of malignant liver lesions, through the continuous dynamic evaluation of tumour microcirculation.
Alin, Aylin
Martin, Michael A.
Beyaztas, Ufuk
Pathak, Pramod K.
Traditional resampling methods for estimating sampling distributions sometimes fail, and alternative approaches are then needed. For example, if the classical central limit theorem does not hold and the naive bootstrap fails, the m/n bootstrap, based on smaller-sized resamples, may be used as an alternative. An alternative to the naive bootstrap, the sufficient bootstrap, which uses only the distinct observations in a bootstrap sample, is another recently proposed bootstrap approach that has been suggested to reduce the computational burden associated with bootstrapping. It works as long as naive bootstrap does. However, if the naive bootstrap fails, so will the sufficient bootstrap. In this paper, we propose combining the sufficient bootstrap with the m/n bootstrap in order to both regain consistent estimation of sampling distributions and to reduce the computational burden of the bootstrap. We obtain necessary and sufficient conditions for asymptotic normality of the proposed method, and propose new values for the resample size m. We compare the proposed method with the naive bootstrap, the sufficient bootstrap, and the m/n bootstrap by simulation.
Let M be a compact manifold without boundary and let N be a connected manifold without boundary. For each k is an element of N the set of k times continuously differentiable maps between M and N has the structure of a smooth Banach manifold where the underlying manifold topology is the compact-open C-k topology. We provide a detailed and rigorous proof for this important statement which is already partially covered by existing literature. (C) 2019 Elsevier B.V. All rights reserved.
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