1
|
Kamali C, Brunnbauer P, Kamali K, Saqr AHA, Arnold A, Harman Kamali G, Babigian J, Keshi E, Mohr R, Felsenstein M, Moosburner S, Hillebrandt KH, Bartels J, Sauer IM, Tacke F, Schmelzle M, Pratschke J, Krenzien F. Extracellular NAD + response to post-hepatectomy liver failure: bridging preclinical and clinical findings. Commun Biol 2024; 7:991. [PMID: 39143151 PMCID: PMC11324947 DOI: 10.1038/s42003-024-06661-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 07/31/2024] [Indexed: 08/16/2024] Open
Abstract
Liver fibrosis progressing to cirrhosis is a major risk factor for liver cancer, impacting surgical treatment and survival. Our study focuses on the role of extracellular nicotinamide adenine dinucleotide (eNAD+) in liver fibrosis, analyzing liver disease patients undergoing surgery. Additionally, we explore NAD+'s therapeutic potential in a mouse model of extended liver resection and in vitro using 3D hepatocyte spheroids. eNAD+ correlated with aspartate transaminase (AST) and bilirubin after liver resection (AST: r = 0.2828, p = 0.0087; Bilirubin: r = 0.2584, p = 0.0176). Concordantly, post-hepatectomy liver failure (PHLF) was associated with higher eNAD+ peaks (n = 10; p = 0.0063). Post-operative eNAD+ levels decreased significantly (p < 0.05), but in advanced stages of liver fibrosis or cirrhosis, this decline not only diminished but actually showed a trend towards an increase. The expression of NAD+ biosynthesis rate-limiting enzymes, nicotinamide phosphoribosyltransferase (NAMPT) and nicotinamide mononucleotide adenylyltransferase 3 (NMNAT3), were upregulated significantly in the liver tissue of patients with higher liver fibrosis stages (p < 0.0001). Finally, the administration of NAD+ in a 3D hepatocyte spheroid model rescued hepatocytes from TNFalpha-induced cell death and improved viability (p < 0.0001). In a mouse model of extended liver resection, NAD+ treatment significantly improved survival (p = 0.0158) and liver regeneration (p = 0.0186). Our findings reveal that eNAD+ was upregulated in PHLF, and rate-limiting enzymes of NAD+ biosynthesis demonstrated higher expressions under liver fibrosis. Further, eNAD+ administration improved survival after extended liver resection in mice and enhanced hepatocyte viability in vitro. These insights may offer a potential target for future therapies.
Collapse
Affiliation(s)
- Can Kamali
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Philipp Brunnbauer
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kaan Kamali
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Al-Hussein Ahmed Saqr
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Alexander Arnold
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Pathology, Charitéplatz 1, 10117, Berlin, Germany
| | - Gulcin Harman Kamali
- University of Health Sciences, Prof. Dr. Cemil Taşçıoğlu City Hospital, Department of Pathology, Istanbul, Turkey
| | - Julia Babigian
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Eriselda Keshi
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - Raphael Mohr
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Hepatology and Gastroenterology - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthäus Felsenstein
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - Simon Moosburner
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - Karl-Herbert Hillebrandt
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program, Charitéplatz 1, 10117, Berlin, Germany
| | - Jasmin Bartels
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Igor Maximilian Sauer
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Frank Tacke
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Hepatology and Gastroenterology - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Schmelzle
- Hannover Medical School, Department of General, Visceral and Transplant Surgery, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Johann Pratschke
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Surgery - Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
- Charité - Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Institute of Pathology, Charitéplatz 1, 10117, Berlin, Germany.
| |
Collapse
|
2
|
Chan SM, Cornman-Homonoff J, Lucatelli P, Madoff DC. Image-guided percutaneous strategies to improve the resectability of HCC: Portal vein embolization, liver venous deprivation, or radiation lobectomy? Clin Imaging 2024; 111:110185. [PMID: 38781614 DOI: 10.1016/j.clinimag.2024.110185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 04/20/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Despite considerable advances in surgical technique, many patients with hepatic malignancies are not operative candidates due to projected inadequate hepatic function following resection. Consequently, the size of the future liver remnant (FLR) is an essential consideration when predicting a patient's likelihood of liver insufficiency following hepatectomy. Since its initial description 30 years ago, portal vein embolization has become the standard of care for augmenting the size and function of the FLR preoperatively. However, new minimally invasive techniques have been developed to improve surgical candidacy, chief among them liver venous deprivation and radiation lobectomy. The purpose of this review is to discuss the status of preoperative liver augmentation prior to resection of hepatocellular carcinoma with a focus on these three techniques, highlighting the distinctions between them and suggesting directions for future investigation.
Collapse
Affiliation(s)
- Shin Mei Chan
- Department of Radiology & Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA; Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Joshua Cornman-Homonoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Pierleone Lucatelli
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA; Department of Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, CT, USA; Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
3
|
Sundaravadanan S, Welsh FK, Sethi P, Noorani S, Cresswell BA, Connell JJ, Knapp SK, Núñez L, Brady JM, Banerjee R, Rees M. Novel multiparametric MRI detects improved future liver remnant quality post-dual vein embolization. HPB (Oxford) 2024; 26:764-771. [PMID: 38480098 DOI: 10.1016/j.hpb.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 02/11/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Optimisation of the future liver remnant (FLR) is crucial to outcomes of extended liver resections. This study aimed to assess the quality of the FLR before and after dual vein embolization (DVE) by quantitative multiparametric MRI. METHODS Of 100 patients with liver metastases recruited in a clinical trial (Precision1:NCT04597710), ten consecutive patients with insufficient FLR underwent quantitative multiparametric MRI pre- and post-DVE (right portal and hepatic vein). FLR volume, liver fibro-inflammation (corrected T1) scores and fat percentage (proton density fat fraction, PDFF) were determined. Patient metrics were compared by Wilcoxon signed-rank test and statistical analysis done using R software. RESULTS All patients underwent uncomplicated DVE with improvement in liver remnant health, median 37 days after DVE: cT1 scores reduced from median (interquartile range) 790 ms (753-833 ms) to 741 ms (708-760 ms) p = 0.014 [healthy range <795 ms], as did PDFF from 11% (4-21%), to 3% (2-12%) p = 0.017 [healthy range <5.6%]. There was a significant increase in median (interquartile range) FLR volume from 33% (30-37%)% to 49% (44-52%), p = 0.002. CONCLUSION This non-invasive and reproducible MRI technique showed improvement in volume and quality of the FLR after DVE. This is a significant advance in our understanding of how to prevent liver failure in patients undergoing major liver surgery.
Collapse
Affiliation(s)
- Senthil Sundaravadanan
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom.
| | - Fenella Ks Welsh
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom
| | - Pulkit Sethi
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom
| | - Shaheen Noorani
- Department of Interventional Radiology, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom
| | - Ben A Cresswell
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom
| | | | | | - Luis Núñez
- Perspectum, Gemini One, Oxford, United Kingdom
| | | | | | - Myrddin Rees
- Department of Hepatobiliary Surgery, Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, United Kingdom
| |
Collapse
|
4
|
Haruki K, Tsunematsu M, Gomisawa K, Ashida H, Furukawa K, Shirai Y, Yamada Y, Sato S, Onda S, Ikegami T. Histological and radiological analysis of simultaneous dual hepatic vein embolization for right-sided major hepatectomy. Surg Today 2024:10.1007/s00595-024-02859-1. [PMID: 38689197 DOI: 10.1007/s00595-024-02859-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-sided hepatectomy, with good results for liver hypertrophy and function. However, the histological and radiological findings of DHVE have not been thoroughly investigated. METHODS This study included 14 patients who underwent DHVE before right-sided major hepatectomy. DHVE was performed if the future liver remnant was < 35% or borderline, but with concomitant vascular resection. The liver function was assessed using the signal intensity on Gd-EOB-DTPA-MRI. A histological evaluation of the area of DHVE and portal vein embolization (PVE) were performed. RESULTS The median pre- and post-functional liver remnants were 363 ml and 498 ml, respectively (p < 0.001). The median growth rate was 48.6%, and there was no post-hepatectomy liver failure in the patients who underwent DHVE. The signal intensity ratio in the area of DHVE was lower than that in the areas of PVE and the remnant liver (p < 0.01). The degree of congestion and necrosis was greater in the area of DHVE than in the area of PVE alone (p < 0.01 and p = 0.04, respectively). CONCLUSIONS We observed good liver hypertrophy after DHVE and histological and radiological changes in the area of DHVE. Our findings provide a compelling rationale for further investigation of the mechanism of liver hypertrophy in DHVE.
Collapse
Affiliation(s)
- Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kazutaka Gomisawa
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirokazu Ashida
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yuta Yamada
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shun Sato
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| |
Collapse
|
5
|
Dixon MEB, Pappas SG. Utilization of Multiorgan Radiomics to Predict Future Liver Remnant Hypertrophy After Portal Vein Embolization: Another Tool for the Toolbox? Ann Surg Oncol 2024; 31:705-708. [PMID: 38062291 DOI: 10.1245/s10434-023-14659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Matthew E B Dixon
- Division of Surgical Oncology, Rush University Medical Center, Chicago, IL, USA.
| | - Sam G Pappas
- Division of Surgical Oncology, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
6
|
Maclean E, Delriviere L, Johansson M, Hodder R. Resection of previously inoperable retroperitoneal liposarcoma. BMJ Case Rep 2023; 16:e256479. [PMID: 37945281 PMCID: PMC10649782 DOI: 10.1136/bcr-2023-256479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
We present a case of successful resection of a large right upper quadrant retroperitoneal dedifferentiated liposarcoma involving multiple adjacent organs, initially considered inoperable in a patient in his 40s. This case highlights the importance of extensive preoperative planning and a multidisciplinary approach in achieving a greater chance of curative resection. Preoperative optimisation included neoadjuvant chemotherapy, concurrent portal vein embolisation and hepatic vein embolisation. The patient then underwent en-bloc resection, including total pancreatectomy, hemihepatectomy and vena caval resection in conjunction with extracorporeal membrane oxygenation and percutaneous venovenous bypass.
Collapse
Affiliation(s)
- Ellen Maclean
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Luc Delriviere
- Department of Surgical Transplant, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Mikael Johansson
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Rupert Hodder
- Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| |
Collapse
|
7
|
Pascale MM, Ratti F, Cipriani F, Marino R, Catena M, Clocchiatti L, Buonanno S, Aldrighetti L. A "cui prodest" evaluation on the development of a minimally invasive liver surgery program: a differential benefit analysis of open and laparoscopic approach for left and right hemihepatectomies. Surg Endosc 2023; 37:8204-8213. [PMID: 37648797 DOI: 10.1007/s00464-023-10382-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/06/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The correlation between technical feasibility and short-term clinical advantage provided by laparoscopic over open technique for major hepatectomies is unclear. This monocentric retrospective study investigates the possible differences in the benefit provided by minimally invasive approach between left and right hepatectomy, deepening the concept of differential benefit in the setting of anatomical major resections. METHODS All hemihepatectomies performed from January 2004 to December 2021 were identified in the institutional database. A propensity score method was used to match minimal invasive (MILS) and open pairs in the left hemihepatectomies (LH) and right hemihepatectomies (RH) groups with a 1:1 ratio to adjust any potential selection bias. The differential benefit for left and right hepatectomy provided by laparoscopic over open technique was evaluated in a pure analysis (i.e., including cases converted to open) and a risk-adjusted analysis (i.e., after excluding open conversion from the laparoscopic series). RESULTS The analysis of the risk-adjusted differential benefit demonstrated better result of the MILS in the RH group than in the LH group, in terms of blood loss (∆ blood loss - 150 and - 350, respectively; differential benefit: 200 mL, p < 0.05), morbidity (∆ rate of morbidity - 11.3% and - 18.1%, respectively; differential benefit: 6.8%, p < 0.05) and length of stay, LOS (∆ LOS - 1 day and - 3 days, respectively; differential benefit: 2 days, p < 0.05). CONCLUSION While MILS is associated with improved clinical outcomes both in left and right hepatectomy procedures, the greater advantage provided by laparoscopy was documented in patients undergoing right hepatectomy, i.e. for more technically demanding procedures. A MILS program should include the broadest range of liver resections to ensure the full benefits of the laparoscopic technique.
Collapse
Affiliation(s)
- Marco Maria Pascale
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy.
- Faculty of Medicine, University Vita-Salute San Raffaele, 20132, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Lucrezia Clocchiatti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Silvia Buonanno
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, 20132, Milan, Italy
| |
Collapse
|
8
|
Pal K, Kuban JD, Murthy R, Odisio BC, Metwalli ZA. A Sticky Situation: Glue Migration during Hepatic Vein Embolization. Semin Intervent Radiol 2023; 40:254-257. [PMID: 37484445 PMCID: PMC10359129 DOI: 10.1055/s-0043-1769773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
The addition of hepatic venous embolization to portal venous embolization to achieve ipsilateral liver venous deprivation before major hepatectomy has been suggested to increase the extent of hypertrophy of the future liver remnant. The presented case discusses a hepatic vein embolization procedure complicated by the unintended migration of a glue cast used to achieve hepatic venous occlusion and subsequent management with endovascular retrieval of the glue cast from the inferior vena cava. The emerging role of hepatic venous embolization and associated complications are also discussed.
Collapse
Affiliation(s)
- Koustav Pal
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joshua D. Kuban
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ravi Murthy
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruno C. Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeyad A. Metwalli
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
9
|
Knott EA, Partovi S, McBride A, Levitin A, Gadani S. Liver Venous Deprivation Using Amplatzer Vascular Plug-Assisted N-Butyl Cyanoacrylate Embolization of the Portal and Hepatic Veins: How Do I Do it? Semin Intervent Radiol 2023; 40:197-211. [PMID: 37333744 PMCID: PMC10275680 DOI: 10.1055/s-0043-1768610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Affiliation(s)
- Emily A. Knott
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Sasan Partovi
- Section of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron McBride
- Section of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Abraham Levitin
- Section of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sameer Gadani
- Section of Vascular and Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
10
|
Surgical management of liver metastasis from colorectal cancer. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2023. [DOI: 10.1007/s12254-022-00868-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
SummaryThis short review illustrates the benefits of a multidisciplinary team approach, especially when it comes to the treatment of patients with colorectal cancer liver metastasis. Therefore, the classification to resectable and primarily unresectable disease has to be determined prior to the first treatment decision. Particularly the use of conversion chemotherapy has the potential of altering initially unresectable liver metastasis to a potentially resectable disease. The three possible therapy choices for synchronously metastasized colorectal cancer will be reflected in this review, as well as local therapeutic alternatives or combinations.
Collapse
|
11
|
Santhakumar C, Ormiston W, McCall JL, Bartlett A, Duncan D, Holden A. Portal vein embolization with absolute ethanol to induce hypertrophy of the future liver remnant. CVIR Endovasc 2022; 5:36. [PMID: 35869399 PMCID: PMC9307697 DOI: 10.1186/s42155-022-00312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background Preoperative portal vein embolization (PVE) is widely used prior to major liver resection to reduce the risk of post-hepatectomy liver failure (PHLF). We evaluated the efficacy and safety of PVE using absolute ethanol. Methods Consecutive patients undergoing preoperative PVE between February 2003 and February 2020 at a high-volume tertiary institution were retrospectively reviewed. Hypertrophy of the future liver remnant (FLR) was determined by comparing volumetric data using semi-automated software on computed tomography or magnetic resonance imaging before and after PVE. Efficacy of absolute ethanol was evaluated by the percentage increase in the FLR volume and the ratio of the FLR to the total liver volume (TLV). Technical success and complications following PVE were evaluated. Feasibility of hepatectomy following PVE and the incidence of PHLF were determined. Results Sixty-two patients underwent preoperative PVE using absolute ethanol. The technical success rate was 95.2%. Median time interval between PVE and follow-up imaging was 34 days (range 6–144 days). The mean increase in FLR volume and ratio of the FLR to TLV were 43.6 ± 34.4% and 12.3 ± 7.7% respectively. Major adverse events occurred in 3 cases (4.8%) and did not preclude consideration of surgery. Forty-two patients (67.8%) proceeded to surgery for intended hepatectomy of which 36 patients (58.1%) underwent liver resection. Major post-operative complications occurred in 4 patients (11.1%) and there were no cases of PHLF. Conclusion Preoperative PVE with absolute ethanol is effective and safe in inducing hypertrophy of the FLR before partial hepatectomy to prevent PHLF.
Collapse
|
12
|
Wang Y, Strazzabosco M, Madoff DC. Locoregional Therapy in the Management of Intrahepatic Cholangiocarcinoma: Is There Sufficient Evidence to Guide Current Clinical Practice? Curr Oncol Rep 2022; 24:1741-1750. [PMID: 36255606 PMCID: PMC10878124 DOI: 10.1007/s11912-022-01338-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Intrahepatic cholangiocarcinoma (iCCA) carries a dismal prognosis and, despite increasing incidence, still lacks effective treatments. In this scenario, locoregional therapies (LRT) are gaining interest as they may be effective at local tumor control and complementary to surgical and non-surgical approaches. In this article, we will review the evolving role of LRT performed by interventional radiologists in the management of iCCA. RECENT FINDINGS Accumulating retrospective evidence indicates that ablative therapies and transarterial embolizations are of benefit for iCCA with unresectable disease, demonstrating promising safety profiles and prolonged or comparable survival outcomes compared to systemic therapy and surgery. Additionally, for surgical candidates, portal ± hepatic venous embolization can improve the safety of hepatectomy by inducing preoperative hypertrophy of the non-involved liver lobe. LRTs are playing an increasingly important role in the multimodal treatment of iCCA from various perspectives with reduced toxicity relative to traditional treatments. To expand the scope of applications for LRTs in this setting, future prospective randomized studies are needed to confirm their efficacy and advantage.
Collapse
Affiliation(s)
- Yifan Wang
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Mario Strazzabosco
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - David C Madoff
- Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, New Haven, CT, USA.
- Department of Internal Medicine, Section of Medical Oncology, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
13
|
Korenblik R, van Zon JFJA, Olij B, Heil J, Dewulf MJL, Neumann UP, Olde Damink SWM, Binkert CA, Schadde E, van der Leij C, van Dam RM, van Baardewijk LJ, Barbier L, Binkert CA, Billingsley K, Björnsson B, Andorrà EC, Arslan B, Baclija I, Bemelmans MHA, Bent C, de Boer MT, Bokkers RPH, de Boo DW, Breen D, Breitenstein S, Bruners P, Cappelli A, Carling U, Robert MCI, Chan B, De Cobelli F, Choi J, Crawford M, Croagh D, van Dam RM, Deprez F, Detry O, Dewulf MJL, Díaz-Nieto R, Dili A, Erdmann JI, Font JC, Davis R, Delle M, Fernando R, Fisher O, Fouraschen SMG, Fretland ÅA, Fundora Y, Gelabert A, Gerard L, Gobardhan P, Gómez F, Guiliante F, Grünberger T, Grochola LF, Grünhagen DJ, Guitart J, Hagendoorn J, Heil J, Heise D, Herrero E, Hess G, Hilal MA, Hoffmann M, Iezzi R, Imani F, Inmutto N, James S, Borobia FJG, Jovine E, Kalil J, Kingham P, Kollmar O, Kleeff J, van der Leij C, Lopez-Ben S, Macdonald A, Meijerink M, Korenblik R, Lapisatepun W, Leclercq WKG, Lindsay R, Lucidi V, Madoff DC, Martel G, Mehrzad H, Menon K, Metrakos P, Modi S, Moelker A, Montanari N, Moragues JS, Navinés-López J, Neumann UP, Nguyen J, Peddu P, Primrose JN, Olde Damink SWM, Qu X, Raptis DA, Ratti F, Ryan S, Ridouani F, Rinkes IHMB, Rogan C, Ronellenfitsch U, Serenari M, Salik A, Sallemi C, Sandström P, Martin ES, Sarría L, Schadde E, Serrablo A, Settmacher U, Smits J, Smits MLJ, Snitzbauer A, Soonawalla Z, Sparrelid E, Spuentrup E, Stavrou GA, Sutcliffe R, Tancredi I, Tasse JC, Teichgräber U, Udupa V, Valenti DA, Vass D, Vogl TJ, Wang X, White S, De Wispelaere JF, Wohlgemuth WA, Yu D, Zijlstra IJAJ. Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis. BJS Open 2022; 6:6844022. [PMID: 36437731 PMCID: PMC9702575 DOI: 10.1093/bjsopen/zrac141] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone. METHODS A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase. RESULTS Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients). CONCLUSION Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.
Collapse
Affiliation(s)
- Remon Korenblik
- Correspondence to: R. K., Universiteigssingel 50 (room 5.452) 6229 ER Maastricht, The Netherlands (e-mail: ); R. M. v. D., Maastricht UMC+, Dept. of Surgery, Level 4, PO Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: )
| | - Jasper F J A van Zon
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,GROW—Department of Surgery, School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Heil
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Maxime J L Dewulf
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands,Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany,NUTRIM—Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Christoph A Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Erik Schadde
- Department of General, Visceral and Transplant Surgery, Klinik Hirslanden, Zurich, Switzerland,Department of General, Visceral and Transplant Surgery, Hirslanden Klink St. Anna Luzern, Luzern, Switzerland
| | | | - Ronald M van Dam
- Correspondence to: R. K., Universiteigssingel 50 (room 5.452) 6229 ER Maastricht, The Netherlands (e-mail: ); R. M. v. D., Maastricht UMC+, Dept. of Surgery, Level 4, PO Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: )
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Sparrelid E, Olthof PB, Dasari BVM, Erdmann JI, Santol J, Starlinger P, Gilg S. Current evidence on posthepatectomy liver failure: comprehensive review. BJS Open 2022; 6:6840812. [PMID: 36415029 PMCID: PMC9681670 DOI: 10.1093/bjsopen/zrac142] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF. METHODS A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022. RESULTS Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited. DISCUSSION Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.
Collapse
Affiliation(s)
- Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pim B Olthof
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bobby V M Dasari
- Department of HPB Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jonas Santol
- Department of Surgery, HPB Center, Viennese Health Network, Clinic Favoriten and Sigmund Freud Private University, Vienna, Austria.,Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Patrick Starlinger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria.,Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, New York, USA
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
15
|
Vilgrain V. Techniques interventionnelles de modulation hépatique. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
16
|
Heil J, Schiesser M, Schadde E. Current trends in regenerative liver surgery: Novel clinical strategies and experimental approaches. Front Surg 2022; 9:903825. [PMID: 36157407 PMCID: PMC9491020 DOI: 10.3389/fsurg.2022.903825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
Liver resections are performed to cure patients with hepatobiliary malignancies and metastases to the liver. However, only a small proportion of patients is resectable, largely because only up to 70% of liver tissue is expendable in a resection. If larger resections are performed, there is a risk of post-hepatectomy liver failure. Regenerative liver surgery addresses this limitation by increasing the future liver remnant to an appropriate size before resection. Since the 1980s, this surgery has evolved from portal vein embolization (PVE) to a multiplicity of methods. This review presents an overview of the available methods and their advantages and disadvantages. The first use of PVE was in patients with large hepatocellular carcinomas. The increase in liver volume induced by PVE equals that of portal vein ligation, but both result only in a moderate volume increase. While awaiting sufficient liver growth, 20%–40% of patients fail to achieve resection, mostly due to the progression of disease. The MD Anderson Cancer Centre group improved the PVE methodology by adding segment 4 embolization (“high-quality PVE”) and demonstrated that oncological results were better than non-surgical approaches in this previously unresectable patient population. In 2012, a novel method of liver regeneration was proposed and called Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). ALPPS accelerated liver regeneration by a factor of 2–3 and increased the resection rate to 95%–100%. However, ALPPS fell short of expectations due to a high mortality rate and a limited utility only in highly selected patients. Accelerated liver regeneration, however, was there to stay. This is evident in the multiplicity of ALPPS modifications like radiofrequency or partial ALPPS. Overall, rapid liver regeneration allowed an expansion of resectability with increased perioperative risk. But, a standardized low-risk approach to rapid hypertrophy has been missing and the techniques used and in use depend on local expertise and preference. Recently, however, simultaneous portal and hepatic vein embolization (PVE/HVE) appears to offer both rapid hypertrophy and no increased clinical risk. While prospective randomized comparisons are underway, PVE/HVE has the potential to become the future gold standard.
Collapse
Affiliation(s)
- Jan Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of General, Visceral, Transplant and Thoracic Surgery, University Hospital, Goethe University Frankfurt, Frankfurt, Germany
| | - Marc Schiesser
- Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland
- Chirurgie Zentrum Zentralschweiz (CZZ), Hirslanden St. Anna, Lucerne, Switzerland
| | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Chirurgisches Zentrum Zürich (CZZ), Klinik Hirslanden Zurich, Zurich, Switzerland
- Chirurgie Zentrum Zentralschweiz (CZZ), Hirslanden St. Anna, Lucerne, Switzerland
- Department of Surgery, Rush University Medical Center Chicago, Chicago, IL, United States
- Correspondence: Erik Schadde
| |
Collapse
|
17
|
Xiao Y, Peng L, Xu H, Huang M, Yang C, Liu G, Ouyang X, Li X, Wang Y, Sheng L, Zhai D, Lin L, Liu L, Liu G, Gong L. Mechanism of Liver Regeneration During ALPPS. Front Cell Dev Biol 2022; 10:916286. [PMID: 35756996 PMCID: PMC9213876 DOI: 10.3389/fcell.2022.916286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/26/2022] [Indexed: 12/24/2022] Open
Abstract
Liver cancer is one of the most lethal malignant tumors in the world, and surgical resection is the main treatment for liver cancer. Liver failure due to insufficient residual liver volume is a fatal complication after hepatectomy. How to effectively increase the residual liver volume after hepatectomy and improve the safety of hepatectomy has always been a problem to be solved in liver surgery. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) effectively reduces the occurrence of liver failure due to insufficient residual liver volume after hepatectomy, thereby increasing the probability of radical resection by inducing rapid proliferation of residual liver tissue. However, the molecular mechanism of residual liver tissue regeneration after primary ALPPS (combined liver partition and portal vein ligation) remains unclear. Here, we found that lots of circular RNAs (circRNAs) are upregulated after ALPPS in pig liver cells; then, we identified the orthologous circRNA in humans and pigs to detect their function in liver regeneration. The results showed that loss of circ-0067724 and circ-0016213 could suppress liver cell proliferation. Together, these findings suggest that circ-0067724 and circ-0016213 play an important role in liver cell proliferation, and this may help us to find new strategies to promote liver regeneration.
Collapse
Affiliation(s)
- Yao Xiao
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China.,Department of Nuclear Medicine, Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Lantao Peng
- Department of General Surgery, Hunan Yueyang Maternal and Child Health-Care Hospital, Yueyang, China
| | - Hongjuan Xu
- Department of Nuclear Medicine, Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Ming Huang
- Department of General Surgery, The First Hospital of Changsha, Changsha, China
| | - Chao Yang
- Department of Hepatobiliary Surgery, Shanxi Bethune Hospital, Taiyuan, China
| | - Guodong Liu
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.,Department of Geriatric Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Xiwu Ouyang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoli Li
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Yuanjing Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Langqing Sheng
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Denggao Zhai
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Ling Lin
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Ling Liu
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Gang Liu
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China
| | - Liansheng Gong
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,International Joint Research Center of Minimally Invasive Endoscopic Technology Equipment and Standards, Changsha, China.,Department of Nuclear Medicine, Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
18
|
Le TD, Than VS, Nguyen MD, Vu HL, Dao XH, Trinh HS. Mortality following transarterial embolization due to hemorrhage after liver venous deprivation. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii210034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thanh Dung Le
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Van Sy Than
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Minh Duc Nguyen
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
- Department of Radiology, Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | - Hoai Linh Vu
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Xuan Hai Dao
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Vietnam
| |
Collapse
|
19
|
Liver venous deprivation: an interesting approach for regenerative liver surgery. Updates Surg 2022; 74:385-386. [PMID: 35023040 DOI: 10.1007/s13304-021-01224-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
|
20
|
Abstract
Selective internal radiation therapy represents an endovascular treatment option for patients with primary liver malignancies, in different clinical stages. Potential applications of this treatment are in early-stage hepatocellular carcinoma, as a curative option, or in combination with systemic treatments in intermediate and advanced-stages. This review, based on existing literature and ongoing trials, will focus on the future of this treatment in patients with hepatocellular carcinoma, in combination with systemic treatments, or with the use of new devices and technological developments; it will also describe new potential future indications and structural and organizational perspectives.
Collapse
|
21
|
Ben Khaled N, Jacob S, Rössler D, Bösch F, De Toni EN, Werner J, Ricke J, Mayerle J, Seidensticker M, Schulz C, Fabritius MP. Current State of Multidisciplinary Treatment in Cholangiocarcinoma. Dig Dis 2021; 40:581-595. [PMID: 34695826 DOI: 10.1159/000520346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/19/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cholangiocarcinoma (CCA) is a highly aggressive malignancy, and its incidence seems to be increasing over the last years. Given the high rate of irresectability at the time of initial diagnosis, new treatment approaches are important to achieve better patient outcomes. Our review provides an overview of current multimodal therapy options across different specialties of gastroenterology/oncology, surgery, and interventional radiology. SUMMARY CCA is subdivided into clinically and molecularly distinct phenotypes. Surgical treatment currently is the only potentially curative therapy, but unfortunately, the majority of all patients are not eligible for resection at the time of initial diagnosis due to anatomic location, inadequate hepatic reserve, metastatic disease, or limiting comorbidities. However, multimodal treatment options are available to prolong survival, relieve symptoms, and maintain life quality. KEY MESSAGES The treatment of CCA is complex and requires close interdisciplinary collaboration and individualized treatment planning to ensure optimal patient care at specialized centers. Molecular profiling of patients and inclusion into clinical trials is highly recommended.
Collapse
Affiliation(s)
- Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Sven Jacob
- Department of General-, Visceral- and Transplantation-Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Rössler
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Florian Bösch
- Department of General-, Visceral- and Transplantation-Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Jens Werner
- Department of General-, Visceral- and Transplantation-Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | | |
Collapse
|
22
|
Haruki K, Furukawa K, Ashida H, Shirai Y, Onda S, Tsunematsu M, Ikegami T. ASO Author Reflections: Dual Hepatic Vascular Embolization as the New Strategy for Promoting Remnant Liver Regeneration. Ann Surg Oncol 2021; 28:8247-8248. [PMID: 34236551 DOI: 10.1245/s10434-021-10437-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirokazu Ashida
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
23
|
Haruki K, Furukawa K, Ashida H, Shirai Y, Onda S, Tsunematsu M, Ikegami T. Simultaneous Dual Hepatic Vascular Embolization (DHVE) for Massive Hepatectomy. Ann Surg Oncol 2021; 28:8246. [PMID: 34235601 DOI: 10.1245/s10434-021-10433-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Simultaneous dual hepatic vein embolization (DHVE) has been proposed for safe right-side massive hepatectomy, (Kobayashi et al. in Surgery 167:917-923, 2020, Heil J, Schadde E. in Langenbecks Arch Surg 2020, Narita et al. in Ann Surg 256:e7-8, 2012) and has demonstrated comparable results to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) (Chan et al. in Transl Gastroenterol Hepatol 5:37, 2020) in terms of liver hypertrophy. In this video, we describe our DHVE techniques to perform a safe right trisectionectomy. METHODS A 40-year-old man with unresectable intrahepatic cholangiocarcinoma with multiple intrahepatic metastases and vena cava invasion received 20 cycles of gemcitabine plus cisplatin, resulting in remarkable shrinkage of the tumor. Conversion surgery was planned to achieve no evidence of disease status. The future liver remnant (FLR) after right trisectionectomy was 363 ml (29.6% of the whole liver) and simultaneous DHVE was performed. The right portal vein embolization was performed via a transhepatic approach, while the right and middle hepatic veins were accessed via a transjugular approach and self-expandable mesh devices were deployed. Remarkable atrophy of the right lobe and hypertrophy of the left lobe was observed 2 weeks after the procedure. Volumetry showed the FLR increased to 485 ml (40.2% of the whole liver). Three weeks after DHVE, right trisectionectomy with combined resection of the vena cava was performed. RESULTS The operation time was 311 min, and the blood loss was 420 ml. Pathological examination revealed complete resection of liver tumors, and the volumetry on postoperative day 7 revealed an increased remnant liver volume of 874 ml. He was discharged on postoperative day 10 without any complications. CONCLUSION Simultaneous DHVE could be an effective procedure to increase FLR with safety for massive hepatectomy.
Collapse
Affiliation(s)
- Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirokazu Ashida
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
24
|
Dondorf F, Deeb AA, Bauschke A, Felgendreff P, Tautenhahn HM, Ardelt M, Settmacher U, Rauchfuss F. Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure. Langenbecks Arch Surg 2021; 406:1111-1118. [PMID: 33970336 PMCID: PMC8208903 DOI: 10.1007/s00423-021-02181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy. METHODS In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses. RESULTS Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown. CONCLUSION This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.
Collapse
Affiliation(s)
- F Dondorf
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - A Ali Deeb
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - A Bauschke
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - P Felgendreff
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | - H M Tautenhahn
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | - M Ardelt
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - U Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - F Rauchfuss
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| |
Collapse
|
25
|
Induction of liver hypertrophy for extended liver surgery and partial liver transplantation: State of the art of parenchyma augmentation-assisted liver surgery. Langenbecks Arch Surg 2021; 406:2201-2215. [PMID: 33740114 PMCID: PMC8578101 DOI: 10.1007/s00423-021-02148-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.
Collapse
|
26
|
Heil J, Korenblik R, Heid F, Bechstein WO, Bemelmans M, Binkert C, Björnsson B, Breitenstein S, Detry O, Dili A, Dondelinger RF, Gerard L, Giménez-Maurel T, Guiu B, Heise D, Hertl M, Kalil JA, Klein JJ, Lakoma A, Neumann UP, Olij B, Pappas SG, Sandström P, Schnitzbauer A, Serrablo A, Tasse J, Van der Leij C, Metrakos P, Van Dam R, Schadde E. Preoperative portal vein or portal and hepatic vein embolization: DRAGON collaborative group analysis. Br J Surg 2021; 108:834-842. [PMID: 33661306 DOI: 10.1093/bjs/znaa149] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/20/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The extent of liver resection for tumours is limited by the expected functional reserve of the future liver remnant (FRL), so hypertrophy may be induced by portal vein embolization (PVE), taking 6 weeks or longer for growth. This study assessed the hypothesis that simultaneous embolization of portal and hepatic veins (PVE/HVE) accelerates hypertrophy and improves resectability. METHODS All centres of the international DRAGON trials study collaborative were asked to provide data on patients who had PVE/HVE or PVE on 2016-2019 (more than 5 PVE/HVE procedures was a requirement). Liver volumetry was performed using OsiriX MD software. Multivariable analysis was performed for the endpoints of resectability rate, FLR hypertrophy and major complications using receiver operating characteristic (ROC) statistics, regression, and Kaplan-Meier analysis. RESULTS In total, 39 patients had undergone PVE/HVE and 160 had PVE alone. The PVE/HVE group had better hypertrophy than the PVE group (59 versus 48 per cent respectively; P = 0.020) and resectability (90 versus 68 per cent; P = 0.007). Major complications (26 versus 34 per cent; P = 0.550) and 90-day mortality (3 versus 16 per cent respectively, P = 0.065) were comparable. Multivariable analysis confirmed that these effects were independent of confounders. CONCLUSION PVE/HVE achieved better FLR hypertrophy and resectability than PVE in this collaborative experience.
Collapse
Affiliation(s)
- J Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland.,Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - R Korenblik
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - F Heid
- Institute of Physiology, University of Zurich, Zurich, Switzerland.,Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - W O Bechstein
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - M Bemelmans
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - B Björnsson
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - S Breitenstein
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - O Detry
- Department of Abdominal Surgery and Transplantation, University of Liege, Centre Hospitalier Universitaire de Liege, Liege, Belgium
| | - A Dili
- Department of Abdominal Surgery, Centre Hospitalier Universitaire Dinant Godinne Saint-Elisabeth - UCL-Namur, Yvoir, Belgium
| | - R F Dondelinger
- Department of Imaging, University Hospital Liege, Liege, Belgium
| | - L Gerard
- Department of Imaging, University Hospital Liege, Liege, Belgium
| | - T Giménez-Maurel
- Department of Surgery, Miguel University Hospital and University of Zaragoza, Zaragoza, Spain
| | - B Guiu
- Department of Radiology, St Eloi University Hospital, Montpellier, France
| | - D Heise
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - M Hertl
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - J A Kalil
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - J J Klein
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - A Lakoma
- Department of Surgery, Section of Hepato-Pancreatico-Biliary Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - U P Neumann
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - B Olij
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - S G Pappas
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - P Sandström
- Department of Surgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - A Schnitzbauer
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - A Serrablo
- Department of Surgery, Miguel University Hospital and University of Zaragoza, Zaragoza, Spain
| | - J Tasse
- Department of Radiology, Rush University Medical Center, Chicago, USA
| | - C Van der Leij
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - P Metrakos
- Department of Surgery, Section of Hepato-Pancreatico-Biliary Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - R Van Dam
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - E Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland.,Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland.,Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|