Optimisation of graft function in liver transplantation: functional and metabolic aspects

Part one of this thesis contains the general introduction to partial and whole liver transplantation. Chapter 2 addresses the concept of auxiliary partial liver transplantation. Auxiliary partial heterotopic liver transplantation was first introduced as a less invasive procedure for patients who could not tolerate a standard orthotopic liver transplantation. Later on the technique was proposed for patients with acute liver failure in whom regeneration of the native liver was expected, but due to its complications it never gained wide acceptance. Since 1990 a new concept of auxiliary partial liver transplantation was introduced where the graft is placed in the orthotopic position. In chapter 3 the development and current surgical technique of orthotopic liver transplantation are discussed. Initially the diseased liver was removed with the vena cava and replaced by a whole liver graft. With increasing waiting lists for donor organs, surgical techniques were developed to split the donor liver and transplant both partial liver grafts in the orthotopic position. In part two three studies regarding experimental auxiliary partial liver transplantation are presented. In chapter 4 we report the long-term correction of an inborn error of metabolism with an auxiliary partial liver graft placed in a heterotopic position. Since the distribution of portal blood flow between liver graft and native liver remains controversial in auxiliary liver transplantation, the success of metabolic correction was related to four different forms of portal inflow. With the introduction of auxiliary partial orthotopic liver transplantation several disadvantages of the placement of the graft in heterotopic liver transplantation were overcome. In chapter 5 we therefore assess the importance of portal flow diversion in an experimental model of auxiliary partial liver transplantation in the orthotopic position. The portal blood flow was measured with Doppler ultrasonography and changes in portal flow distribution were recorded after surgical intervention in the portal blood flow. In chapter 6 the metabolic correction following these interventions in portal flow were reported. Part three contains three studies performed in patients receiving an orthotopic whole liver transplantation. In chapter 7 we present the problem of graft dysfunction in the first 7 days after liver transplantation. We report our data on mitochondrial dysfunction in patients with primary graft dysfunction and the relation with toxic reaction products of the nitric oxide radical. In chapter 8 we report an increased incidence of fibrinolysis, the most prominent coagulation disorder during orthotopic liver transplantation, after introduction of virus inactivated plasma. Consequences of fibrinolysis and treatment options are discussed. In chapter 9 we evaluate patient and graft survival between patients transplanted with standard liver replacement or a vena cava preserving technique. Chapter 10 provides an overview of the development of different techniques for splitting of the donor liver in an attempt to alleviate the shortage of donor organs in paediatric and adult liver transplantation. Chapter 11 summarises the previous studies, bringing the data in perspective and provides future perspectives

Unsuccessful Stent Graft Repair of a Hepatic Artery Aneurysm Presenting with Haemobilia:Case Report and Comprehensive Literature Review

AIMS: To discuss treatment strategies for non-traumatic, non-iatrogenic hepatic artery aneurysms (HAAs) in the presence of an arteriobiliary fistula, illustrated by a case and followed by a comprehensive review of the literature. METHODS: Following the PRISMA guidelines, 24 eligible HAA cases presenting with haemobilia were identified. Characteristics of patients, aneurysms, treatment strategies and their outcomes were collected. RESULTS: A 69 year old patient with no previous hepatobiliary intervention or trauma, presented with jaundice and haemobilia caused by a HAA. Initial treatment by endovascular stenting was chosen to prevent ischaemic liver complications. Unfortunately, this strategy failed because of stent migration due to ongoing infection leading to a type 1A endoleak. The patient had to be converted to open surgery with ligation of the HAA. The patient recovered uneventfully and no complications occurred during the following 12 months. COMPREHENSIVE LITERATURE REVIEW: Of the 24 cases, nine had a true HAA and 15 were pseudo/mycotic aneurysms, mainly caused by endocarditis or cholecystitis. The majority were located in the right hepatic artery. In 20 cases, an endovascular first approach was chosen with embolisation, none with covered stents. Three of these cases had to be converted to open surgery because of rebleeding. In all open (primary or secondary) cases, ligation of the HAA was performed. One patient in these series died. No liver ischaemia or abscesses were reported, although one patient developed an ischaemic gallbladder. CONCLUSIONS: Patients who present with a HAA and haemobilia may be treated safely by embolisation or open ligation. Using a covered stent graft in these patients can cause problems due to ongoing infection and should be monitored closely by imaging. Publication bias and lack of long term follow up imply cautious interpretation of these findings

Satisfaction with caregivers during labour among low risk women in the Netherlands : the association with planned place of birth and transfer of care during labour

Background: The caregiver has an important influence on women's birth experiences. When transfer of care during labour is necessary, care is handed over from one caregiver to the other, and this might influence satisfaction with care. It is speculated that satisfaction with care is affected in particular for women who need to be transferred from home to hospital. We examined the level of satisfaction with the caregiver among women with planned home versus planned hospital birth in midwife-led care. Methods: We used data from the prospective multicentre DELIVER (Data EersteLIjns VERloskunde) cohort-study, conducted in 2009 and 2010 in the Netherlands. Women filled in a postpartum questionnaire which contained elements of the Consumer Quality index. This instrument measures 'general rate of satisfaction with the caregiver' (scale from 1 to 10, with cut-off of below 9) and 'quality of treatment by the caregiver' (containing 7 items on a 4 point Likert scale, with cut-off of mean of 4 or lower). Results: Women who planned a home birth (n = 1372) significantly more often rated 'quality of treatment by caregiver' high than women who planned a hospital birth (n = 829). Primiparous women who planned a home birth significantly more often had a high rate (9 or 10) for 'general satisfaction with caregiver' (adj.OR 1.48; 95% CI 1.1, 2.0). Also, primiparous women who planned a home birth and had care transferred during labour (331/553; 60%) significantly more often had a high rate (9 or 10) for 'general satisfaction' compared to those who planned a hospital birth and who had care transferred (1.44; 1.0-2.1). Furthermore, they significantly more often rated 'quality of treatment by caregiver' high, than 276/414 (67%) primiparous women who planned a hospital birth and who had care transferred (1.65; 1.2-2.3). No differences were observed for multiparous women who had planned home or hospital birth and who had care transferred. Conclusions: Planning home birth is associated to a good experience of quality of care by the caregiver. Transferred planned home birth compared to a transferred planned hospital birth does not lead to a more negative experience of care received from the caregiver

CIVIL JURISDICTION, INTELLECTUAL PROPERTY AND THE INTERNET

At the core of the civil litigation system is the notion of jurisdiction. In a narrow sense it refers to whether a court has the authority to hear a case in relation to specific people and activities (subject matter) but in a broader sense it also encompasses what law should be applied (choice of law), whether the court is a suitable court to hear the case (choice of court) and the enforcement of judgements. The notion of jurisdiction provides a tool for efficiently managing litigation and traditionally has been based upon notions of connection to a particular territory. In the global transnational world of the Internet the concept of jurisdiction has struggled to find a sensible meaning.1 Does jurisdiction lie everywhere that the Internet runs or is it more narrowly defined? In this chapter we examine recent cases concerning jurisdiction and the Internet before the courts of the People’s Republic of China (PRC) in matters relating to intellectual property. We also consider decisions in Australia and the United States of America (US) and international developments in the area

Self-Reported Executive Functioning in Young Adult Survivors of Childhood Bacterial Meningitis

Objective:This study investigated executive functions (EFs) in young adult survivors of childhood bacterial meningitis (BM). These skills are important for normal development, and their potential vulnerability in early years suggests that childhood BM could affect executive functions in the longer term.Method: The adult self-report Behavior Rating Inventory of Executive Function was administered to 474 young adult survivors of childhood BM who participated in the 20|30 Dutch Postmeningitis study. Average scores were compared to population-norm group scores. Subgroup scores were compared according to causative pathogen and age at onset.Results:Young adult survivors of childhood BM scored lower on overall metacognition than the age-matched population norm group. Young adult survivors of childhood BM caused by Streptococcus pneumoniae, S. agalactiae, or Escherichia coli had lower scores than cases caused by Neisseria meningitidis. Survivors with age-at-onset below 12 months had a higher (worse) overall EF score than survivors with age-at-onset above 12 months.Conclusions:Young adult survivors of childhood BM experience difficulties in EF. However, most of the self-reported EF scores were within the norm. Future studies need to additionally assess EF in adult survivors of childhood BM using performance-based tests

Does Routine Endoscopy or Contrast Swallow Study After Esophagectomy and Gastric Tube Reconstruction Change Patient Management?

Background: Anastomotic leakage is a severe complication after esophagectomy. The objective was to investigate the diagnostic and predictive value of routine contrast swallow study and endoscopy for the detection of anastomotic dehiscence in patients after esophagectomy. Methods: All patients who underwent contrast swallow and/or endoscopy within 7 days after oesophagectomy for cancer between January 2005 and December 2009 were selected from an institutional database. Results: Some 173 patients underwent endoscopy, and 184 patients underwent a contrast swallow study. The sensitivity of endoscopy for anastomotic leakage requiring intervention is 56 %, specificity 41 %, positive predictive value (PPV) 8 %, and negative predictive value (NPV) 95 %. The sensitivity of contrast swallow study for detecting leakage requiring intervention in patients without signs of leakage was 20 %, specificity 20 %, PPV 3 %, and NPV 97 %. Conclusions: In patients without clinical suspicion of leakage, there is no benefit to perform routine examinations