PubMed Health⌕ Search

Biomedical subjects

D C Broering

Publications and source records attributed to D C Broering.

At least 19 recordsLinked to original sources
PubMed2005

Hypogammaglobulinemia in pediatric liver transplant recipients.

Hypogammaglobulinemia has been reported after solid organ transplantation in adults, however immunoglobulin replacement [intravenous immunoglobulins (IVIG)] is only necessary in a minority of affected patients. We here present three pediatric patients with severe post-transplant hypogammaglobulinemia following liver transplantation (LTx) receiving a cyclosporine-based standard immunosuppression. Patient 1 was transplanted at the age of 10 months for biliary atresia. Eight weeks post-Ltx the serum IgG was 1.7 g/L. Patient 2 was transplanted at the age of 12 yr for acute liver failure. Four weeks post-Ltx the IgG dropped to 2.6 g/L. Patient 3 was transplanted at the age of 4 months for biliary atresia. Ten weeks post-Ltx severe hypogammaglobulinemia (IgG < 1.48 g/L) was diagnosed during a severe infectious complication. Patients 1 and 3 received a steroid bolus therapy for acute graft rejection. All patients had normal IgG concentrations prior to Ltx and lymphocyte subsets were post-operatively in the normal range. There was no extensive loss of protein by ascites. IGIV were replaced in the three patients monthly without further complications. In two of the patients (1 and 3) IVIG therapy was discontinued 8 and 10 months after Ltx when the immunosuppression has been reduced and serum IgG concentrations were found in the normal range without further immunoglobulin replacement. Severe hypogammaglobulinemia is a rare phenomenon following pediatric LTx and seems to be mainly caused by immunosuppressive drugs, however, the exact underlying mechanisms are unclear. A screening for hypogammaglobulinemia is useful after pediatric LTx, especially in patients with an intensified immunosuppression. Moreover, further immunologic research in affected patients is necessary.

Agammaglobulinemia↗
PubMed2004

Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies.

In modern surgical and transplantation procedures the recognition of anatomic vascular abnormalities of the hepatic arteries is of greater importance than ever. The purpose of this study was to evaluate and classify these variations with respect to their impact on visceral surgery. A total of 604 selective celiac and superior mesenteric angiographies performed on patients with known or suspected liver cirrhosis or hepatic or pancreatic malignancies and on donors of partial liver grafts were analyzed retrospectively. The vascular anatomy of the liver was classified according to different established systems and with particular attention to rare variations. Hepatic arterial anatomy as considered normal in textbook descriptions was found in 79.1%, an aberrant or accessory left hepatic artery (LHA) arising from the left gastric artery in 3.0% and an aberrant or accessory right hepatic artery (RHA) branching off the superior mesenteric artery in 11.9% of the cases. In 1.4% of the cases there was a combination of anomalies of both the LHA and RHA. Variants of the celiac trunk, double hepatic arteries branching at the celiac trunk or hepatic arteries arising directly from the aorta, occurred in 4.1% of the cases. Further atypical branches of the LHA and RHA were found in 0.5% of the cases. Since the incidence and pattern of different types of hepatic arterial anatomy can require specialized preoperative diagnostic as well as intraoperative strategies, knowledge of these abnormalities and their frequency is of major importance for the surgeon as well as the radiologist.

Angiography↗
PubMed2004

C2 blood concentrations of orally administered cyclosporine in pediatric liver graft recipients with a body weight below 10 kg.

Pharmacokinetic studies in adult and pediatric liver transplant recipients have shown that the C(2) monitoring is superior to the traditional determination of CsA trough levels (C(0)) as an estimate of CsA exposure. However, target reference values for C(2) in very small infants have not been established yet. The objective of our study was to assess the distribution of C(2) levels in the first week following Ltx and to analyze enteral absorption of CsA for this group of patients. We documented CsA C(0) and C(2) levels in 25 infants with a body weight below 10 kg (median 6.8 kg; range 3.0-9.8 kg) in the first 7 days after Ltx. The infants had a median age at transplantation of 7 months (range 0.3-20.0 months). The underlying diagnoses were biliary atresia (n = 17), acute liver failure (n = 4), metabolic disease (n = 4). All children received CsA microemulsion (Neoral, initial 10 mg/kg/day), prednisolone, and two single doses of basiliximab as immunosuppressive drugs. The mean C(0) and C(2) levels were as follows: day 1: C(0) 77.0 +/- 39.6, C(2) 340.5 +/- 140.0 ng/mL; day 2: C(0) 135.5 +/- 53.2, C(2) 467.0 +/- 168.2 ng/mL; day 3: C(0) 146.5 +/- 70.8, C(2) 519.0 +/- 219.1 ng/mL; day 4: C(0) 168.5 +/- 55.1, C(2) 570.0 +/- 163.7 ng/mL; day 5: C(0) 156.5 +/- 38.0, C(2) 612.0 +/- 132.4 ng/mL; day 6: C(0) 177.0 +/- 41.1, C(2) 606.0 +/- 149.2 ng/mL; day 7: C(0) 174.0 +/- 27.2, C(2) 622.0 +/- 98.8 ng/mL (r = 0.82, p < 0.05). This analysis demonstrates that there is a good enteral absorption of CsA in very small children post-Ltx in the early post-operative period. Based on the C(2) levels achieved, we conclude that there is a good correlation between C(0) and C(2) levels even in very small infants.

Administration, Oral↗
PubMed2004

EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology.

BACKGROUND: Despite improvements of diagnostic modalities differentiation between benign and malignant hilar strictures remains a challenge. Hilar neoplasia requires preoperative tissue diagnosis to avoid risk of inappropriate extensive surgery. This is commonly attempted using various techniques at ERCP, which have variable sensitivity and accuracy. We used endosonography-guided fine-needle aspiration (EUS-FNA) for the preoperative diagnosis of hilar cholangiocarcinoma (HC). METHODS: Prospective evaluation of 44 patients (31 male, mean age: 59 yr) with strictures at the liver hilum were diagnosed by CT and/or ERCP. All were suspicious of HC but had inconclusive tissue diagnosis. They underwent EUS-FNA with linear echo endoscope and 22 gauge needles. RESULTS: Adequate material was obtained in 43 of 44 patients. Cytology revealed HC in 26 and other malignancies in 5 patients; 12 had benign results: sclerosing cholangitis (n = 4), primary sclerosing cholangitis (n = 4), inflammation (n = 3), sarcoid-like lesion (n = 1). There were no significant differences in age, lesion size, or echo features among patients with adenocarcinomas, other malignancies, or benign lesions. Thirty-two patients underwent surgery, 2 had autopsy, 10 were followed up clinically. Four of the benign results were false negatives. No complications occurred. Accuracy, sensitivity, and specificity were 91%, 89%, and 100%, respectively. EUS and EUS-FNA changed preplanned surgical approach in 27 of 44 patients. CONCLUSION: These results suggest that EUS-FNA is of value as a new, less-invasive approach for tissue diagnosis of hilar strictures of unknown cause. It was technically feasible without significant risks, when other diagnostic tests were inconclusive and was able to change preplanned management in about half of the patients.

Bile Duct Neoplasms↗
PubMed2004

Split liver transplantation: past, present and future.

The technique of liver splitting offers an effective way of increasing the donor pool and decreasing pediatric waiting list mortality. A donor liver is divided in such a way that the left lateral liver graft can be transplanted into a small child and the right extended liver graft into an adult. This innovative technique did not harm the adult recipient pool. Because of its technical complexity and the initial poor results after split liver transplantation (SLT) this procedure has slowly gained acceptance in the Transplantation Community after its first introduction in 1988 (4). Small children with end stage liver disease suffered the most from the extreme shortage of cadaveric donor organs due to the difficulty of finding size-matched donors. The successful surgical development of SLT and a better donor and recipient selection have led to a reduction of the pediatric pretransplant mortality to nearly zero and to results comparable with those after whole organ transplantation (WLT). By splitting a donor organ into two 'full' hemi-grafts and providing a small adult ( < 60 kg) or a big child ( > 30 kg) with the full left graft and a medium-sized adult (60-80 kg) with the full right graft, a small-for-size situation for adolescents or adults can be avoided and the total number of available grafts can be increased. It is the goal to provide each recipient with its customized graft in the near future. However, splitting for two adults requires high technical skills and profound knowledge of the anatomic variations and should be performed in centers with large transplantation experience.

Adolescent↗
PubMed2003

[Primary squamous cell carcinoma of the liver. Surprising findings in dysontogenetic liver cysts].

HISTORY AND CLINICAL FINDINGS: A 60-year-old woman presented with intermittent fever and pain in the right upper abdomen. The patient had spent the last 30 years in the Middle East and Africa. EXAMINATION: Multiple hepatic lesions with cystic parts were demonstrated sonographically. Ecchinococcosis as well as amoebiasis had been excluded. Laboratory findings showed elevated levels of inflammatory parameters, lactate dehydrogenase (4107 U/l), squamous cell carcinoma antigen and CA -125. The liver enzymes were found to be within the normal range. DIAGNOSIS: A squamous cell carcinoma was detected by liver biopsy. The search for a possible primary site elsewhere in the body yielded negative results, so that the tumor must be regarded as primary in the liver. THERAPY: Because of the diffuse tumour growth surgical resection was impossible. The patient underwent chemotherapy. She died 9 month after the squamous cell carcinoma had been diagnosed. CONCLUSION: This case report and a medline research indicate that hepatic neoplasms sometimes must be suspected in patients with liver cysts.

Antineoplastic Agents↗
PubMed2003

[Evaluation of potential liver living donors. Logistic and financial aspects].

INTRODUCTION: The increasing shortage of cadaveric organs makes living-related liver transplantation a more and more important option. Safety for the donor has the highest priority, and therefore detailed and thorough evaluation is needed. MATERIALS AND METHODS: All potential donors who had been evaluated at our center from January 2001 to March 2002 ( n=100) were included in a retrospective study to analyse the qualitative, logistical, and economic aspects of the evaluation. RESULTS: Seventy-three percent of the potential donors were found to be unsuitable for living donation during the evaluation process. The main reasons were: uncompatible blood group, availability of cadaveric transplant by Eurotransplant, steatosis of more than 10% of hepatocytes in liver biopsy, insufficient liver volume, and psychosocial reasons. The expenditure for all scheduled investigations was 4,469 euro for a complete evaluation. CONCLUSION: While on the one hand, high standards of the evaluation process must be guaranteed, insufficient reimbursement on the other should not lead centers to reduce either quantity or quality of necessary examinations entered in the evaluation protocol.

Adult↗
PubMed2001

Th2 cytokine profile in infants predisposes to improved graft acceptance after liver transplantation.

BACKGROUND: The T helper cell type 1 (Th1) cytokines interleukin (IL)-2 and interferon (IFN)-gamma are mediators of acute graft rejection after liver transplantation and Th2 cytokines, such as IL-4 and IL-10, may have a protective role and correlate with graft acceptance. To test the hypothesis that infants aged <1 year have an immunological advantage with regard to graft acceptance because of a partially immature immune system with a physiological balance toward a Th2 cytokine profile, we conducted the present study. METHODS: We compared the T helper serum cytokine profiles in 105 infants and children after liver transplantation with or without acute graft rejection and analyzed the normal age-distributed concentrations of T helper cytokines in 51 healthy controls. RESULTS: The incidence of acute graft rejection was as follows: 0 to 12 months, 26.8%; 1 to 3 years, 40.0%; and >3 years, 71.8%. There was a significantly lower incidence of acute rejection in infants 0 to 12 months of age compared with children >1 year (11/41 vs. 38/64; P=0.001). In healthy infants, significant increasing Th1 cytokine concentrations and decreasing Th2 cytokine concentrations were found with increasing age. Patients with acute rejection had significantly higher values of Th1 cytokines compared with nonrejecting subjects, who had significantly higher concentrations of Th2 cytokines. A longitudinal analysis of serum cytokines from patients showed that changes of the cytokine patterns in the follow-up did not differ significantly from preoperative values, except in the 4 weeks posttransplant. CONCLUSIONS: We conclude from the data that the physiological balance toward a Th2 cytokine profile of infants in the first months of life predisposes to improved graft acceptance. Transplantation of children with biliary atresia as early as possible, avoiding Th1 stimulation by recurrent infections and vaccinations, may have a positive impact on overall tolerance.

Acute Disease↗
PubMed2001

Strictureplasty for large bowel stenosis in Crohn's disease: quality of life after surgical therapy.

The aim of surgical therapy in Crohn's disease is to improve quality of life. Surgery does not provide cure with radical resection of inflamed bowel. Therefore strictureplasty has become a useful bowel-preserving surgical technique in the treatment of small-bowel stenosis. To preserve functional bowel we extended the indication of this surgical technique to strictures in large bowel. The aim of this retrospective study was to define the efficacy of strictureplasty and resection in patients with obstructive Crohn's disease of the colon. The results were evaluated in terms of postoperative complications, surgical recurrence, and quality of life. The charts of 58 patients with Crohn's colitis were analyzed retrospectively. Patients were either treated by strictureplasty or resection. Quality of life was evaluated in follow-up examinations using the Inflammatory Bowel Disease Questionnaire. The incidence of postoperative surgical recurrence was 36% in those treated by strictureplasty and 24% in those treated by resection (ns). Postoperative morbidity was 16.1% in the former and 22.3% in the latter. There was no significant difference between the groups in quality of life measures (177 versus 182 points). Strictureplasty in Crohn's colitis is a valuable surgical technique which results in low recurrence rates and in surgical outcome comparable to that in resection without sacrificing functional large bowel length. In our study quality of life after strictureplasty was comparable with quality of life after resection.

Adult↗
PubMed2001

First experience with basiliximab in pediatric liver graft recipients.

Several studies have shown a significant reduction of acute cellular graft rejection in adult liver and kidney graft recipients treated with monoclonal anti-interleukin-2 (IL-2)-receptor antibodies. The mechanism was inhibition of activated T-helper cells by blocking the alpha-chain (CD25) of the IL-2 receptor. The pilot study described here evaluated the use of basiliximab in pediatric liver transplantation (LTx), which is the first report on its use in children. Fifty-two liver-transplanted children were analyzed in this study. A matched-pair historical control group (n = 26) received cyclosporin A (CsA) and prednisolone, and patients in the basiliximab group (n = 26) were treated with low-dose CsA and basiliximab (after reperfusion and on day 4 post-transplant). The incidences were compared of acute graft rejections, infectious complications, and the adverse effects of immunosuppressive medication within the first 6 months post-transplant. The incidence of acute rejection was significantly higher in the control group (61.5% vs. 11.5%, p = 0.0004). The frequency of infectious complications was similar (46.1% vs. 53.8%). Patients in the basiliximab group showed less arterial hypertension; however, the differences were not statistically significant (30.7% vs. 7.7%, p = 0.07). Nephrotoxicity, hepatotoxicity or neurotoxicity were only seen in the control group (7.7%; 3.8%; 3.8%, respectively). Hence, the use of basiliximab in combination with CsA and steroids in pediatric liver transplant recipients is safe and reduces the incidence of acute graft rejection. Further studies are needed to confirm our preliminary results and to analyze long-term effects on post-transplant lymphoproliferative disease, chronic rejection, and patient survival.

Antibodies, Monoclonal↗
PubMed2001

Hepatic involvement in hereditary hemorrhagic telangiectasia: an unusual indication for liver transplantation.

Hereditary hemorrhagic telangiectasia (HHT) is a vascular disease with multiple organ manifestations. Severe hepatic involvement is an unusal indication for liver transplantation. We report on a 39-year-old woman diagnosed with HHT and decompensation of the disease during her second pregnancy. After delivery, hemobilia occurred, followed by severe therapy-resistant cholangitis and progressive liver dysfunction. Because of progressive loss of liver function, orthotopic liver transplantation needed to be performed. The various aspects of liver involvement in Osler's disease, diagnosis, and therapy are discussed.

Adult↗
PubMed2001

[Pathophysiology and clinical significance of the abdominal compartment syndrome].

Different causes, for example posttraumatic and postoperative complications, can lead to an elevated intra-abdominal pressure. Increased intraabdominal pressure effects cardiovascular, pulmonary and renal systems. The abdominal compartment syndrome can be defined as organ failure caused by an increased intra-abdominal pressure. Clinically the syndrome is characterised by a tensely distended abdomen, oliguria or anuria and/or inadequate ventilation. Early decompression by simple laparotomy and delayed closure is the treatment of choice. If untreated the abdominal compartment syndrome is lethal. Even treated it has a high morbidity and mortality as shown in our series where 2 out of 7 patients with this syndrome died despite surgical decompression.

Abdomen↗
PubMed2001

Is there still a need for living-related liver transplantation in children?

OBJECTIVE: To assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT). SUMMARY BACKGROUND DATA: The concept of SLT results from the development of reduced-size transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary. METHODS: Outcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method. RESULTS: After a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group. CONCLUSIONS: The short- and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.

Adolescent↗
PubMed2001

FDG PET in the diagnosis of hilar cholangiocarcinoma.

Resectional surgery offers a curative intent and a survival benefit for patients with hilar cholangiocarcinoma, but is associated with high morbidity. Since morphological imaging cannot solve differential diagnosis preoperatively, in order to exclude patients inappropriate to this aggressive surgery, we evaluated the impact of functional imaging using fluorodeoxyglucose positron emission tomography (FDG PET) in the detection of cholangiocarcinoma and its usefulness in the differentiation from benign Klatskin tumour-mimicking lesions. Fifteen consecutive patients aged 47-78 years underwent standardized whole-body FDG PET with attenuation correction before potentially curative surgery using a conventional full-ring PET scanner with an axial field-of-view of 16.2 cm. FDG PET was evaluated visually and semiquantitatively using tumour-to-background ratios (T/B) ratios. All lesions were evaluated histopathologically. FDG PET presumed to be indicative for carcinoma was positive in 12 of 15 patients, true positive in 10 (T/B ratio, 3.2+/-1.9) and false positive in two of them (T/B ratios, 2.1 and 2.8) with Klatskin tumour-mimicking lesions. While all true positive PET results were seen in the tubular type of cholangiocarcinoma with a high amount of tumour cells and only low production of mucus, a false negative FDG PET in three patients was observed in mucinous adenocarcinoma. Additionally, FDG PET detected locoregional lymph nodes in two patients and distant metastases in a further three patients. Due to false positive results FDG PET does not allow the differentiation of benign from malignant lesions, and FDG PET should be avoided in patients with mucinous cholangiocarcinoma. However, FDG PET may have significant influence on the treatment strategy in as much as 20% of the patients, since it may detect distant metastases.

Aged↗
PubMed2001

Quality of life after surgical therapy of small bowel stenosis in Crohn's disease.

BACKGROUND: Improvement in quality of life is one of the important determinants in the treatment of Crohn's disease. Since there is no cure with radical resection of inflamed bowel, strictureplasty has become a useful surgical technique in the treatment of small bowel obstruction. The scope of this study was to define the results of strictureplasty and resection in terms of quality of life, surgical recurrence and postoperative complications. METHODS: The charts of 67 patients with Crohn's disease of the small bowel were analyzed retrospectively. Patients were treated either by strictureplasty (group A) or resection (group B). Quality of life was evaluated in follow-up examinations using the Inflammatory Bowel Disease Questionnaire (IBDQ). RESULTS: Postoperative morbidity was 14.8% after strictureplasty and 17% after resection (p = 0.8). 50% of the patients treated by strictureplasty and 37% treated by resection developed recurrent disease (p = 0.40). Quality-of-life measurement revealed no significant difference between patients treated by strictureplasty or resection. CONCLUSION: Results after strictureplasty are comparable to those after resection in terms of complications, recurrence and quality of life in the treatment of small bowel strictures in Crohn's disease. In the long run there might be an advantage for strictureplasty because it prevents complications caused by resectional therapy such as short bowel syndrome.

Adolescent↗