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C E Broelsch

Publications and source records attributed to C E Broelsch.

At least 73 records · Page 4Linked to original sources
PubMed2001

[Early operation as a treatment measure in thyrotoxic crisis].

INTRODUCTION: Thyroid storm is a rare disease, occurring in less than 1% of all thyrotoxicoses. Diagnosis and therapy still have serious problems. METHODS: We review 14 patients who were operated on between 1992 and 1999 because of thyroid storm. RESULTS: All of the ten women and four men, aged 27 to 77 years, had an underlying thyroid disease. Autonomies were found in seven, Grave's disease in four, and a nodular goiter in three patients. The precipitating events were in five patients an antiarrhythmic therapy with amiodarone, on three occasions application of contrast medium, two times omission of antithyroid drugs and in one patient severe hyperglycemia with acidosis. In three patients no triggering factor was discovered. All patients were treated with high-dose antithyroid therapy. On admission, four patients were graded as stage-one thyroid crisis, three patients had stage-two and seven patients stage-three disease. All patients were operated on within 18 h of admission. Surgical procedure was in seven cases a bilateral subtotal resection, four times thyroidectomy, and in three patients a Dunhill procedure. After the operation, 12 patients improved rapidly. Two 77 and 74-year-old women died 1 or 2 days after the operation, respectively, one from heart failure and the other from multiple organ failure. Both had been diagnosed as thyrotoxic crisis stage three. CONCLUSION: Early operation should be adopted as a standard option in thyroid storm that cannot be controlled medically. Best results are achieved if the operation is done at stage one or two of the disease.

Adult↗
PubMed2001

Serum bile acids in liver transplantation--early indicator for acute rejection and monitor for antirejection therapy.

We studied the course of serum bile acids to investigate its reliability in the diagnosis of acute rejection after liver transplantation in relation to pathohistological findings. Serum bile acid concentration, bilirubin and transaminases were measured in 41 patients who underwent liver transplantation. Their course was correlated to liver biopsy. Group I (n = 19) patients were without acute rejection, whereas group II (n = 22) patients showed acute rejection. Bile acid concentrations in group II showed a statistically highly significant (P < or = 0.001) threefold increase 3 days prior to biopsy. Successful antirejection treatment was correlated with a statistically significant (P = 0.008) decrease of serum bile acid 1 day after initiation of therapy. Patients without acute rejection showed a baseline bile acid concentration at the time of biopsy. Bilirubin and transaminases did not show any statistically significant correlation to acute rejection. Infection did not lead to a significant bile acid increase. Our study shows that serum bile acids monitored after liver transplantation can easily be used to detect acute rejection and at the same time they reflect the success of antirejection therapy.

Acute Disease↗
PubMed2001

Posterior retroperitoneoscopic adrenalectomy: lessons learned within five years.

Posterior retroperitoneoscopic adrenalectomy is one of the new endoscopic methods in endocrine surgery. In a prospective clinical study 142 posterior retroperitoneoscopic adrenalectomies (72 right, 70 left) were performed in 130 patients (52 males, 78 females, age 49.1 +/- 14.9 years). Indications were primary adrenal tumors (unilateral, n = 118; bilateral, n = 2), adrenal metastases (n = 2), and bilateral ACTH-dependent hyperplasias (n = 10). Tumor size ranged from 0.5 to 7.0 cm (mean 2.7 +/- 1.4 cm). Partial adrenalectomies were performed in 39 patients. Conversion to open posterior adrenalectomy was necessary in five patients and seven procedures (5%). Intraoperative and postoperative complications were minor and occurred in 5% and 13%, respectively. Mortality was zero. Operating time was 101 +/- 39 minutes (range 35-285 minutes) and depended on tumor type (pheochromocytoma versus others; p < 0.01), tumor size (< 3 vs. > or = 3 cm; p < 0.05), gender (p < 0.05), and extent of resection (partial versus complete, p < 0.05. Twenty-three adrenalectomies (17%) were performed within 1 hour or less. Blood loss was 54 +/- 72 ml. Consumption of analgesics was low (mean 6 mg piritramide postoperatively). Median duration of hospitalization was 3 days. Posterior retroperitoneoscopic adrenalectomy is a safe method that has become a standard procedure in endocrine surgery.

Adenoma↗
PubMed2001

Efficacy and tolerability of interleukin-2 receptor blockade with basiliximab in pediatric renal transplant recipients.

Rejection remains a major threat in pediatric renal transplantation (Tx), causing graft failure and increased exposure to drugs. The new chimeric antibody, basiliximab, directed against the alpha-chain of the interleukin-2 receptor (IL-2R), has been shown to be effective in preventing rejection episodes in adult renal transplant recipients. In our single-center experience from Essen, Germany, we evaluated prospectively the efficacy and tolerability of basiliximab, in combination with cyclosporin A (CsA) and prednisone, in 38 unselected pediatric patients. Mean patient age at Tx was 10.1 yr. Twenty-eight children received a cadaveric organ and 10 children received living-related donor grafts. The 1-yr patient survival rate was 100% and the 1-yr graft survival rate was 95% (36/38 patients). No graft was lost as a result of immunological factors, and single rejection episodes were observed in eight patients (21%). Two of these rejections were steroid-resistant and responded to tacrolimus rescue therapy. The rate of infections was not enhanced; overt cytomegalovirus (CMV) disease was observed in two patients only. Malignancies have not been seen to date. The blockade of the alpha-chain of the IL-2R lasted for up to 6 weeks. We conclude that the addition of basiliximab to standard immunosuppression in pediatric renal transplant recipients is well tolerated and results in a low incidence of rejection. The simple mode of application and the lack of side-effects make basiliximab an especially useful adjunct in pediatric patients.

Adolescent↗
PubMed2001

From living related to in-situ split liver transplantation: how to reduce waiting-list mortality.

The insufficient number of suitable cadaveric organs for pediatric recipients is the cause of high pretransplant mortality rates and long waiting times. With the introduction of split and living related liver transplantation, the waiting list mortality rate has dropped from greater than 15% to less than 5% and children are transplanted more rapidly. A 5-year patient and graft survival rate of greater than 80% has been obtained in those centers where split and living related liver transplantations are routinely performed. The data analyzed in this paper show that the only current solution to cadaveric organ shortage is a 'multimodal' approach, where whole liver cadaveric transplantation is associated with split and living related liver transplantation.

Adolescent↗
PubMed2001

Anticoagulation with hirudin for continuous veno-venous hemodialysis in liver transplantation.

Postoperative encephalopathy after orthotopic liver transplantation can be difficult to diagnose. We report a case of heparin-induced thrombocytopenia in a liver transplant patient who had seizures. Due to poor liver function the patient developed hepatorenal syndrome requiring continuous veno-venous hemodialysis (CVVHD). Initially we used heparin as the anticoagulant. After the diagnosis of heparin-induced thrombocytopenia (HIT) was made, we switched to r-hirudin. No serious side effects, e.g. bleeding or immune sensitization, were seen.

Adult↗
PubMed2001

Ethical considerations and rationale of adult-to-adult living donor liver transplantation.

Adult-to-adult living donor liver transplantation (ALDLT) is a reality; shortly after its introduction into clinical practice, it is being performed in approximately 50 centers throughout the United States and Europe. The quick development of ALDLT and some deaths among donors repropose old ethical dilemmas and confront the transplant community with new urgent problems. To minimize risks for recipients and, especially, donors, two key questions are addressed: (1) who can or should perform the procedure, and (2) what patient should undergo the procedure. The high risks taken by live donors undergoing a hemihepatectomy seem to be justified by the steadily increasing mortality of adult recipients waiting for transplantation. A comprehensive consent procedure is at the base of responsible decision making for both donors and recipients. In adherence to basic medical criteria, the autonomy of decision of donors and recipients may allow the extension of indications to patients not suitable to undergo transplantation with cadaveric grafts. The broadening of indications is appropriate only in centers with adequate experience and proven expertise in ALDLT. The medical community faces the duty of regulating ALDLT before external influences force undesired policy changes, particularly if not based on medical grounds. Individual centers and patients are ultimately responsible for the correct use of LDLT.

Adult↗
PubMed2001

[Diagnosis and treatment of persistent or recurrent hyperthyroidism].

Reasons for postoperative persistence of primary hyperparathyroidism (pHPT) are missed parathyroid adenoma, incomplete removal of multiple altered pararthyroid glands, and rare variants of localisation. A reoperation is indicated in symptomatic patients if calcium serum levels are elevated above 2.9 mmol/l. Preoperatively, cervical sonography and 99mTc sestamibi scintigraphy should be carried out. Additionally, selective venous blood sampling and nuclear magnetic resonance tomography can be of use. After successful localization, a unilateral approach is advisable. If position remains unclear, bilateral exploration is required. In secondary hyperparathyroidism (sHPT), renal function is crucial for development of recurrence. For postoperative persistence, identification of less than four pararthyroid glands or leaving of the thymus are the main reasons. Before reoperation it has to be clarified if parathyroid hyperfunction is caused by persisting cervical or mediastinal tissue, or if hyperfunction of autotransplanted tissue in the forearm is evident. Diagnostic and operative procedures are similar to those used in pHPT.

Adenoma↗
PubMed2001

[Donor risk in living-related liver transplantation - the surgeon's point of view].

Living-related liver transplantation is a successful clinical approach to overcome organ shortage in hepatic transplantation. Possible advantages for the recipient of a living-donor transplant are a much shorter waiting period until transplantation and an almost elective time of operation which results in a decreased operative risk. Furthermore graft function of a living-related transplant is better than in cadaveric transplantation because of the shorter ischemic time and a careful examination of graft quality before organ donation. Removal of even more than 50 % of liver volume during the donor operation does not lead to an impairment of liver function in the organ donor. Intraoperative blood loss can usually be managed by re-transfusion of donor's own blood. Postoperative morbidity is about 10 - 15 % depending on the extent of the removed liver lobe. Most frequent postoperative complications are biliary leckages, wound infections and gastric/duodenal ulcerations. Up till now in more than 1000 living-related liver donations only three deaths occured due to thromboembolic and septic complications (< 0,3 %) (until 12/1998).

Humans↗
PubMed2001

Effect of ursodeoxycholate in University of Wisconsin solution on long term preservation of rat livers.

OBJECTIVE: To find out whether the addition of ursodeoxycholate (UDC) to University of Wisconsin (UW) solution reduces injury during preservation of the liver. DESIGN: Controlled laboratory study. SETTING: University hospital, Germany. MATERIALS: Preserved livers from 12 rats. METHODS: Livers were flushed with 10 ml of ice-cold (0-1 degrees C) UW or iso-osmolar UW containing 5 mmol/l UDC. After preservation for 30 hours at 0-1 degrees C and 1 hour at 22 degrees C the livers were reperfused for 4 hours. Aspartate amino-transaminase, alanine aminotransferase, glutamate lactate dehydrogenase, and white blood cell (WBC) and platelet counts were measured during reperfusion. Bile flow and total bile salt secretion rate were also measured. RESULTS: Addition of UDC to UW reduced the release of liver enzymes, slightly increased platelet adherence, and reduced bile flow and bile salt secretion rate. CONCLUSION: The membrane-stabilising effect of UDC may explain the reduction in enzyme release. However, liver function, as expressed by bile salt secretion rate and bile flow was adversely affected.

Adenosine↗
PubMed2001

Current status of liver transplantation for treatment of hepatocellular carcinoma.

Hepatocellular carcinoma accounts for more than 5% of all malignancies with a continuous increase worldwide. The most important risk factor is liver cirrhosis, frequently associated with hepatitis B virus or hepatitis C virus infection. Liver resection is the only treatment that can potentially achieve cure. In carefully selected patients with a tumor smaller than 5 cm the 5-year survival is around 50%. The presence of liver cirrhosis and portal hypertension limits the feasibility of hepatic resection. Child-Pugh A patients without major associated risk factors may be considered as the ideal target group for resection. A significant local disease recurrence rate of more than 70% at 5 years is the main problem of hepatic resection. Orthotopic liver transplantation offers the possibility of removing a potentially multicentric tumor and the underlying end-stage liver disease. Due to pure selection of suitable candidates the initial reports on the efficacy of liver replacement in a cohort of patients with hepatocellular carcinoma were disappointing. Taking the shortness of donor organs and the high posttransplant tumor recurrence rate into account, several groups developed criteria qualifying transplantation. A tumor size of >6 cm and gross intrahepatic portal vein involvement seem to be of significant prognostic importance. Patients with smaller solitary tumors or less than 3 tumors with a total tumor diameter of <8 cm have the same survival after transplantation as those with benign liver disease. Living donor liver transplantation offers a new approach to overcome the organ shortage and to theoretically extend the indication for transplantation in hepatocellular carcinoma.

Carcinoma, Hepatocellular↗
PubMed2001

Management of iatrogenic lesions of the biliary tract.

A wide spectrum of iatrogenic biliary complications is encountered. Most are the results of preventable trauma or technical mishaps during cholecystectomy. There is no doubt that the incidence of iatrogenic lesions of the bile tract increased since the introduction of laparoscopic cholecystectomy. These include bile leakage, biliary tree obstruction, postsurgical strictures and various types of biliary fistulas. The purpose of this article is to review the clinical features of these iatrogenic lesions with emphasis of their interventional and surgical management.

Biliary Tract↗
PubMed2000

Hydrophilic bile salts protect bile duct epithelium during cold preservation: a scanning electron microscopy study.

Prolonged graft preservation is associated with postoperative bile duct strictures after liver transplantation. We previously showed that hydrophilic bile salts mitigate bile duct preservation injury in a pig model. Because this injury occurs at the epithelial level, scanning electron microscopy was performed to further characterize this effect in vitro. Swine livers were harvested after the intravenous infusion of 1 of 3 solutions: saline (n = 7), tauroursodeoxycholate ([TUDC] hydrophilic; n = 4), or taurodeoxycholate ([TDC] hydrophobic; n = 4). Livers were perfused with University of Wisconsin solution. The bile ducts were flushed retrograde, and the liver was stored at 0 degrees C to 1 degrees C for 20 hours. Bile duct samples were obtained at the time of harvest and 8, 12, 16, and 20 hours thereafter. In saline-infused controls at time 0, the epithelium was intact and composed of uniform cuboidal cells covered with fine regular microvilli. There were no spaces between individual cells. After 8 to 12 hours of preservation, cells were more irregular in shape, with loss of cell-cell contact. The cell surfaces showed fewer microvilli. Surface erosions suggested loss of cell-wall integrity. TUDC was protective, evidenced by normal-appearing cells with uniform microvilli after 16 hours. In contrast, TDC accelerated the injury process, causing cell-surface erosions, blebs, and loss of microvilli as early as time 0. Scanning electron microscopy is an excellent tool to study injury to bile duct epithelium. This study supports the hypothesis that hydrophilic bile salts protect bile ducts during preservation. To determine whether treatment with hydrophilic bile salts can prevent postoperative stricture, in vivo transplantation studies are needed.

Animals↗
PubMed2000

[Minimally invasive parathyroidectomy with local anesthesia in conjunction with ultrasonography, sestamibi scintigraphy and intraoperative parathyroid hormone measurement].

INTRODUCTION: The standard procedure in patients with primary hyperparathyroidism (pHPT) includes cervical exploration and identification of all four enlarged parathyroid glands. New localization techniques, i.e., ultrasonography associated with color duplex sonography, 99mTc-sestamibi scintigraphy and the possibility of intraoperative parathormone (iPTH) measurement permit minimally invasive parathyroidectomy (MIP). Three different methods have been established: minimally invasive open parathyroidectomy, endoscopic parathyroidectomy and video-assisted parathyroidectomy. We present our experience with open MIP with the patient under local anesthesia (LA). METHODS: In 25 patients with pHPT the operation was started under local anesthesia. Preoperatively, ultrasonography and sestamibi scintigraphy were performed in each patient. iPTH measurement was carried out intraoperatively. RESULTS: In 23 patients (92%) the operation was done successfully in LA. There were no postoperative complications. During follow-up none of the patients developed hypercalcemia again. CONCLUSION: MIP in connection with ultrasonography, sestamibi scintigraphy and intraoperative PTH measurement offers a promising treatment for patients with pHPT.

Adenoma↗
PubMed2000

Interaction of Hypericum perforatum (St. John's wort) with cyclosporin A metabolism in a patient after liver transplantation.

Immunosuppressive therapy in patients after liver transplantation requires careful monitoring of blood levels for immunosuppressive agents such as cyclosporin A. A variety of drugs are capable of interfering with the metabolism of cyclosporin A. We observed a 63-year-old patient who received a liver allograft for cryptogenic liver cirrhosis in 1998. This patient developed severe acute rejection 14 months after transplantation which was associated with a sudden drop in cyclosporin A levels. Two weeks previously, he had started taking the herbal drug Hypericum perforatum (2 x 900 mg/day) for increasing episodes of depression. The cyclosporin A dosage later had to be doubled, which caused some side effects. Finally, an assessment of oral cyclosporin A resorption suggested an enhanced cyclosporin A metabolism. Hypericum perforatum was stopped. Both cyclosporin A dosage and blood levels immediately returned to normal. The liver function recovered completely. In conclusion, this observation is a previously undescribed drug interaction of a widely used herbal drug (Hypericum perforatum, i.e. St. John's wort) in a patient after liver transplantation.

Antidepressive Agents↗
PubMed2000

Long-term results of pre-emptive liver transplantation in primary hyperoxaluria type 1.

In primary hyperoxaluria type 1 (PH 1), deficiency or mistargeting of hepatic alanine glyoxylate aminotransferase (AGT) results in over-production of oxalate and hyperoxaluria, leading to nephrocalcinosis and development of end-stage renal disease (ESRD) in the majority of patients. Renal transplantation (Tx) alone carries a high risk of disease recurrence as the metabolic defect is not cured. Therefore, combined liver/kidney Tx is recommended for patients with ESRD. An alternative approach is to cure PH 1 by pre-emptive isolated liver Tx (PLTx) before ESRD has occurred, but this approach has been carried out only occasionally and there are no uniformly accepted recommendations concerning the timing of this procedure. We report follow-up 3-5.7 yr after performing successful PLTx in four children (at the age of 3-9 yrs) with PH 1 prior to the occurrence of ESRD (glomerular filtration rate [GFR] range 27-98 mL/min/1.73 m2). There was no mortality or long-term morbidity associated with the Tx procedure. Plasma and urinary oxalate levels normalized rapidly within 4 weeks, and renal function did not deteriorate under immunosuppression, even in one patient with advanced chronic renal failure (GFR 27 mL/min/1.73 m2) who showed a stable course for more than 5.7 yrs. Although treatment must be individualized in this severe metabolic disorder, and PLTx has to be regarded as an invasive procedure, we consider that PLTx should be offered and considered early in the course of PH 1. PLTx cures the metabolic defect in PH 1 and can help to prevent, or at least delay, the progression to ESRD and systemic oxalosis.

Acute Kidney Injury↗