Influence of high-dose aprotinin on hemostasis and blood requirement in orthotopic liver transplantation.
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Adult↗
Biomedical subjects
H Grosse
Publications and source records attributed to H Grosse.
[Risk of cancer following cholecystectomy, hysterectomy or appendectomy].
Patients with previous cholecystectomy, hysterectomy or appendectomy have an increased risk of developing cancer of other organs such as the bowel, breast kidney or ovary, particularly if they have undergone more than one operation. Previous nephrectomy, strumectomy, prostatectomy or gastric resection for gastroduodenal ulcer do not increase the risk of bowel cancer.
Appendectomy↗
The use of high dose aprotinin in liver transplantation: the influence on fibrinolysis and blood loss.
Orthotopic liver transplantation (OLT) is frequently associated with systemic fibrinogenolysis and diffuse bleeding. At present antifibrinolytic treatment has not been initiated routinely in OLT. Therefore the influence of high dose aprotinin in OLT (2 million kallikrein inactivator units (KIU) given after induction of anesthesia followed by a 500,000 KIU/h infusion throughout the operation) on intraoperative blood loss and fibrinolysis was studied in 25 patients compared to 25 patients without aprotinin. The incidence of fibrinolysis shown in thrombelastography was 72% in the control group versus 16% in the aprotinin group. Oozing after reperfusion of the graft caused by severe fibrinolysis defined as a clot lysis index below 15% was only observed in the control group (42.8%). In contrast no significant difference was found between the groups in the course of fibrin and fibrinogen degradation product levels (FbDP, FgDP) although the mean concentrations of both parameters were evidently lower in the aprotinin treated patients. Levels of tissue-type plasminogen activator (t-PA) activity were initially high in both groups and peaked during and after the anhepatic period. After aprotinin there was a trend of lower t-PA levels which reached significance at the time of reperfusion (p less than 0.02). In both groups the course of thrombin antithrombin complex was in line with the variations of FbDP and FgDP. No correlation between thrombin formation and t-PA activity was found. Mean homologous blood requirement was reduced by 50% (5.6 +/- 4.0 vs. 11.2 +/- 8.6 units, p less than 0.005). The blood saving effect was more pronounced in the postanhepatic period (p less than 0.000001). In conclusion high dose aprotinin inhibits hyperfibrinolysis and reduces intraoperative homologous blood requirement. Therefore its routine use in OLT is recommended.
Adult↗
Hemostatic studies of ex situ hepatic surgery.
Ex situ hepatic surgery, in which a diseased liver is resected from outside the body, was first reported in 1988. This study investigates the hemostatic changes occurring during such surgery in two cases. During the anhepatic period of more than 5 hours, veno-venous bypass without heparin was performed. The tests included platelet count, prothrombin activity (PT), partial thromboplastin time (PTT), fibrinogen (Fbg), factor II (F.II), factor V (F.V), and thromboelastography (TEG). Three to 4 hours after entering the anhepatic phase, marked fibrinolysis and a fall in the values of PT, Fbg and F.V. were observed. Every parameter temporarily deteriorated immediately after revascularization of the graft, however, all returned to almost normal values within 1-2 hours after hepatic reperfusion except for F.V and platelets. In conclusion, the coagulopathy during ex situ hepatic surgery is caused by the marked fibrinolysis and depletion of hemostatic factors which develop 3-4 hours after the onset of the anhepatic phase.
Adult↗
Coagulation disorder during liver transplantation.
Detailed haemostatic changes were investigated during eight liver transplantations. The patients were divided into two groups; group 1 had minor operative bleeding (four cases) and group 2 had major bleeding (four cases). Group 2 had lower levels of platelets, fibrinogen, factor V (FV), and alpha 2-antiplasmin than group 1, and the thromboelastography showed fibrinolysis. In both groups, plasma tissue-plasminogen activator levels rose slightly. After revascularization of the graft liver, reductions in the values of PT, fibrinogen, FV and FVII were noted, along with a prolongation of the PTT and an increase in thrombin-antithrombin III complex levels. Plasma levels of protein C, protein S, antithrombin III, and plasminogen remained relatively stable throughout the operation. These results show that the preceding fibrinolysis and subsequent superimposed activation of the clotting system are the main causes of coagulopathy during liver transplantation, which correlate with the amount of operative haemorrhage and the abnormalities found in haemostatic tests.
Adult↗
Management of severe hepatic trauma by two-stage total hepatectomy and subsequent liver transplantation.
Even today major hepatic trauma remains a formidable surgical challenge with considerable deaths from exsanguination. Apart from conservative operative techniques that allow successful management in most cases, liver transplantation may be indicated in a more severe injury. This is a report on a patient with massive, unsalvageable liver trauma on whom the first two-staged procedure was successfully performed. After total hepatectomy as the first step and a prolonged anhepatic period of more than 14 hours, liver replacement by an allograft was carried out in a second operation. The patient recovered completely from the potentially lethal hepatic trauma and is alive more than 17 months later.
Accidents, Traffic↗
Technique and preliminary results of extracorporeal liver surgery (bench procedure) and of surgery on the in situ perfused liver.
The clinical experience with 11 patients undergoing ex situ operation of the liver (nine operations) or surgery on an in situ hypothermic perfused liver after vascular isolation (three operations) is described. These methods have been confined to situations and tumour stages otherwise deemed untreatable, or to situations where resection would not have been sufficiently radical. In one patient the ex situ approach avoided the need to undertake liver grafting for a benign tumour. To date, hepatocellular tumours and metastases not compromising global hepatic function or causing cholestasis are considered to be suitable conditions; cholestasis appears to be highly detrimental for the postoperative course after an ex situ procedure. Elaboration of methods for better grading of pre-existing liver damage and of its prognostic significance is essential. The assessment of the final therapeutic value of the described procedure requires further experience.
Adult↗
HTK-solution (Bretschneider) for human liver transplantation. First clinical experiences.
The cardioplegic HTK-solution (Bretschneider) has not been used in human liver transplantation as yet. Herein the first results obtained from 14 patients with HTK-preserved liver grafts are presented. The suitability of HTK-solution could be shown. All grafts functioned primarily except one, where initial non-function was obviously due to donor reasons. The early postoperative peak values of transaminases as a sign of ischemic damage were average and similar to the values of other flushout solutions. Using HTK primary function could be achieved even in livers prospectively assessed as only of fair quality, and livers with poor donor function tests (MegX) functioned from the beginning. HTK-solution therefore seems to allow widening of the acceptance criteria for donor livers. It was not the aim of this trial to extend cold ischemic time, but 3 livers with 11 h and 12 h 25 showed immediate function. How far cold ischemic time can be extended is a still open question. All livers were rapidly cooled and homogeneously flushed out due to the low viscosity of HTK-solution. All livers had a soft consistency after perfusion indicating a low degree of cell edema. HTK therefore is an effective solution for liver preservation.
Adenosine↗
Anaesthetic problems in ex situ resection of the liver.
Ex-situ resection of the liver is a new surgical technique for treatment of liver tumours not amenable to conventional surgery. This paper describes the cardiovascular and metabolic changes that occurred in nine consecutive such patients. No severe haemodynamic or pulmonary complications occurred. Specific problems were encountered during the prolonged anhepatic period, which lasted an average of 5.96 (SD 1.46) hours. Significant metabolic and coagulation disorders occurred 2 to 3 hours after hepatectomy because of complete loss of hepatic function. The predominant findings during the anhepatic period were hypoglycaemia and severe metabolic acidosis, mainly from increased levels of lactic acid. Exogenous administration of dextrose 5% at an average rate of 188 ml/hour was necessary to maintain normoglycaemia, while correction of metabolic acidosis required 403 (SD 159.79) mmol of sodium bicarbonate, supplemented by hyperventilation. Tris-hydroxymethylaminomethane was used when sodium overload was thought to be a problem. There was a marked decrease of Factor V and fibrinogen, a moderate thrombocytopenia and fibrinolysis. The severity of these alterations was dependent on the duration of the anhepatic period and the primary function of the re-implanted liver.
Acidosis, Lactic↗
[Frequency, localization and associated disorders in urinary calculi. Analysis of 1671 autopsies in urolithiasis].
In the area of Rügen-Stralsund a maximum value of urolithiasis and cholelithiasis was found. In 27,133 autopsies the frequency of urolithiasis was 6%. Obesity, hypertension and diabetes mellitus may increase the tendency of cholelithiasis patients to develop additional urolithiasis. Ureteral and urinary bladder calculi are more frequently among male patients. In cases with benign prostatic hyperplasia the incidence of urolithiasis was not higher than in female patients. In the autopsy material multiple calculi and bilateral cases occur more frequently. Hypertension and increased heart weight did occur more frequently in patients suffering from oxalate lithiasis. Some of the calculi may develop in the terminal age of life.
Adolescent↗
[The importance of high-dose alpha-receptor blockade for blood volume and hemodynamics in pheochromocytoma].
This prospective clinical study evaluates the possible beneficial effects of increased phenoxybenzamine dosage in the preoperative treatment of patients with pheochromocytoma. For this purpose total blood volume (TBV) prior to and after treatment with phenoxybenzamine and hemodynamic changes during surgery were determined in two groups of patients: group I (n = 12) received a mean dosage of 140 mg, group II (n = 12) 270 mg/day. The mean TBV in group I showed no changes after treatment with phenoxybenzamine, while the TBV in group II increased by 5.6 ml/kg body weight, corresponding to an increase in plasma volume (PV) of 10.2%. These changes were not significant, however. The intraoperative vasodilator requirement for the treatment of catecholamine induced hypertension during tumor manipulation was significantly less for group II: total nitroprusside administration averaged 8.7 mg in group I and 0.8 mg in group II (P less than 0.0005). Patients in group I received a total of 2.6 mg nitroglycerin compared with only 0.5 mg for patients in group II (P less than 0.005). In conclusion, preoperative treatment of patients with pheochromocytoma with increased dosages of phenoxybenzamine is beneficial to intraoperative management by decreasing hemodynamic instability due to tumor manipulation and following resection. This treatment was effective for preventing complications such as excessive tachycardia, cardiac arrhythmias, hypertensive crises, or left ventricular failure.
Adrenal Gland Neoplasms↗
[Has the frequency of renal cell carcinoma increased in autopsies].
Earlier analyses of autopsy material may show no or only slight increase of renal cancer. However, in Scotland and Connecticut a significantly rise of male renal cell carcinoma was found. Since 1966 in the autopsy material of the area Rügen--Stralsund the frequency of female renal cell cancer have been significantly increased. In these cases the simultaneous occurrence of diabetes mellitus and earlier cholecystectomy is slightly elevated.
Adult↗
Systemic fibrinogenolysis in liver transplantation.
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Adult↗
[Ex situ surgery of the liver--anesthesiologic management].
In a 40-year old patient multiple liver tumours that were otherwise regarded as irresectable were removed in an ex situ operation--according to the authors' knowledge for the first time in a human. After protective perfusion with a hypothermic HTK solution hepatectomy was performed. After extirpation of the tumours ex situ, the residual liver was re-implanted. The total operation time was 13 h 50 min, the anhepatic period lasted for 6 h 9 min. During the anhepatic period a venous bypass shunted the blood from the a femoral and the portal vein to an axillary vein. Considerable blood loss was balanced by the transfusion of 26 units of banked blood. Severe disturbances of blood coagulation could be avoided by early substitution with fresh frozen plasma, platelets and fresh blood. The long anhepatic phase caused an acidosis that required the application of 330 mVal NaHCC3. In the discussion the necessity for an aggressive intraoperative monitoring of haemodynamic and laboratory parameters is emphasized.
Adult↗
[Liver transplantation in low portal vein flow: separation of portal vein areas with divided portal-venous and arterialized caval-venous liver perfusion. 1. Clinical case report].
A new method for the performance of a hepatic transplantation in spite of a low portal blood flow situation is described casuistically. In a 36-year-old-patient suffering from liver cirrhosis due to hepatitis B, the portal blood system of the right and left liver parts were divided, the left part was perfused with a low flow of portal blood, the right one with arterialized caval blood. The function of the transplanted liver and the early postoperative course were excellent. During the further postoperative course portal perfusion presumably diminished or stopped on the left side from three weeks and on the right side from two months postoperatively. Nevertheless the general condition of the patient improved continuously; transient elevations of transaminases may reflect the disturbance of portal perfusion. The technique of this arterialized caval blood perfusion of the portal system is presumably applicable also for situations, in which there is no portal blood flow available for perfusion of a liver graft. Thus, the absence of possibility for reconstruction of portal blood inflow or a situation with a hypoplastic portal vein may no longer be considered as a technical contraindication for liver grafting.
Adult↗
Liver grafting for malignant liver tumors.
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Carcinoma, Hepatocellular↗
Surgical aspects of familial pheochromocytoma.
During a 15-year-period (1973-1987), 13 patients with familial pheochromocytoma (PCC) underwent unilateral (n = 7) or bilateral (n = 6) total adrenalectomy without major operative morbidity (1 incidental splenectomy in 8 left-side adrenalectomies) and no mortality. 1 patient died 3 years after unilateral adrenalectomy from unrelated cause. The remaining patients were followed up for a mean time of 5.2 years and could be traced and investigated. 3 patients have been adrenalectomised on the contralateral side because of PCC 5, 6 and 10 years after unilateral adrenalectomy. No patient had metastatic PCC. 1 patient sustained recurrent Addisonian crises after bilateral total adrenalectomy. 1 patient developed recurrent hypertension after bilateral adrenalectomy, but without evidence of recurrent disease. In 3 patients bilateral total adrenalectomy with adrenal cortex autotransplantation was performed, however, complete hormone supplementation therapy had to be continued because of autograft functional insufficiency. In considering the number of patients in this study, who only needed a unilateral adrenalectomy in familial PCC, the more pragmatic surgical approach to familial PCC seems to be supported. Bilateral total adrenalectomy with adrenal cortex autotransplantation was not as effective functionally as supposed by histological examination of transplant biopsy.
Adolescent↗
[Changes in intraoperative total oxygen consumption in patients during liver transplantation].
The changes in O2-uptake (VO2) during 110 liver transplantations (LTX) were studied using Fick's principle (O2-uptake = cardiac index x arteriovenous O2-content difference). During each of the three operative periods [a dissecting period before clamping of the hepatic vessels (1), the anhepatic phase (2), and after reperfusion of the new liver (3)], two measurements (A and B) were taken. After removal of the liver (2A) the VO2 decreased about 11.4%, and increased after reperfusion (3A) about 44.0%; these changes were significant (P less than 0.001). To evaluate the influence of the various indications for LTX on the course of intraoperative VO2, the following patient groups were compared: patients with hepatic tumors (n = 17), patients with cirrhosis following hepatitis (n = 14), patients with primary biliary cirrhosis (n = 17), patients with cirrhosis plus tumor (n = 11), and patients in a hepatic coma (n = 20), regardless of the underlying liver disease. Groups with less than ten subjects were not considered. The drop of VO2 in the anhepatic period (1B----2A) was between -26.7% (patients with tumors) and -7.3% (patients with cirrhosis plus tumor). The patients with cirrhosis following hepatitis showed a special feature: their VO2 increased about 13.4% after cross-clamping the hepatic vessels. After revascularization, the VO2 increased in all groups between +37.2% and +69.8%. In all groups the level of VO2 was higher after reperfusion (3A) than in the dissecting period (1B), ranging from +5.3% in patients with tumors to +61.6% in patients with cirrhosis following hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenoma, Bile Duct↗