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Fichtinger RS, Aldrighetti LA, Abu Hilal M, Troisi RI, Sutcliffe RP, Besselink MG, Aroori S, Menon KV, Edwin B, D'Hondt M, Lucidi V, Ulmer TF, Díaz-Nieto R, Soonawalla Z, White S, Sergeant G, Olij B, Ratti F, Kuemmerli C, Scuderi V, Berrevoet F, Vanlander A, Marudanayagam R, Tanis P, Dewulf MJL, Dejong CHC, Eminton Z, Kimman ML, Brandts L, Neumann UP, Fretland ÅA, Pugh SA, van Breukelen GJP, Primrose JN, van Dam RM. Laparoscopic Versus Open Hemihepatectomy: The ORANGE II PLUS Multicenter Randomized Controlled Trial. J Clin Oncol 2024:JCO2301019. [PMID: 38640453 DOI: 10.1200/jco.23.01019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/13/2023] [Accepted: 01/17/2024] [Indexed: 04/21/2024] Open
Abstract
PURPOSE To compare outcomes after laparoscopic versus open major liver resection (hemihepatectomy) mainly for primary or metastatic cancer. The primary outcome measure was time to functional recovery. Secondary outcomes included morbidity, quality of life (QoL), and for those with cancer, resection margin status and time to adjuvant systemic therapy. PATIENTS AND METHODS This was a multicenter, randomized controlled, patient-blinded, superiority trial on adult patients undergoing hemihepatectomy. Patients were recruited from 16 hospitals in Europe between November 2013 and December 2018. RESULTS Of the 352 randomly assigned patients, 332 patients (94.3%) underwent surgery (laparoscopic, n = 166 and open, n = 166) and comprised the analysis population. The median time to functional recovery was 4 days (IQR, 3-5; range, 1-30) for laparoscopic hemihepatectomy versus 5 days (IQR, 4-6; range, 1-33) for open hemihepatectomy (difference, -17.5% [96% CI, -25.6 to -8.4]; P < .001). There was no difference in major complications (laparoscopic 24/166 [14.5%] v open 28/166 [16.9%]; odds ratio [OR], 0.84; P = .58). Regarding QoL, both global health status (difference, 3.2 points; P < .001) and body image (difference, 0.9 points; P < .001) scored significantly higher in the laparoscopic group. For the 281 (84.6%) patients with cancer, R0 resection margin status was similar (laparoscopic 106 [77.9%] v open 122 patients [84.1%], OR, 0.60; P = .14) with a shorter time to adjuvant systemic therapy in the laparoscopic group (46.5 days v 62.8 days, hazard ratio, 2.20; P = .009). CONCLUSION Among patients undergoing hemihepatectomy, the laparoscopic approach resulted in a shorter time to functional recovery compared with open surgery. In addition, it was associated with a better QoL, and in patients with cancer, a shorter time to adjuvant systemic therapy with no adverse impact on cancer outcomes observed.
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Affiliation(s)
- Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Luca A Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
- Department of Surgery, Poliambulanza Hospital, Brescia, Italy
| | - Roberto I Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Transplantation Service, Federico II University, Naples, Italy
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Robert P Sutcliffe
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Somaiah Aroori
- Department of Surgery, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - Krishna V Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bjørn Edwin
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge, Kortrijk, Belgium
| | - Valerio Lucidi
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Tom F Ulmer
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Rafael Díaz-Nieto
- Department of Hepato-Biliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Steve White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Gregory Sergeant
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Jessa Hospital, Hasselt, Belgium
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Christoph Kuemmerli
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Vincenzo Scuderi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of Surgery, Free University Hospital, AZ Jette Hospital, Brussels, Belgium
| | - Ravi Marudanayagam
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pieter Tanis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Maxime J L Dewulf
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Deceased
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Merel L Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, University Hospital Essen, Essen, Germany
| | - Åsmund A Fretland
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Siân A Pugh
- Department of Oncology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gerard J P van Breukelen
- Department of Methodology and Statistics, CAPHRI Care and Public Health Research Institute Maastricht University, Maastricht, the Netherlands
| | - John N Primrose
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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2
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Korenblik R, Heil J, Smits J, James S, Olij B, Bechstein WO, Bemelmans MHA, Binkert CA, Breitenstein S, Williams M, Detry O, Dewulf MJL, Dili A, Grochola LF, Grote J, Heise D, Kalil JA, Metrakos P, Neumann UP, Pappas SG, Pennetta F, Schnitzbauer AA, Tasse JC, Winkens B, Olde Damink SWM, van der Leij C, Schadde E, van Dam RM. Liver regeneration after portal and hepatic vein embolization improves overall survival compared with portal vein embolization alone: mid-term survival analysis of the multicentre DRAGON 0 cohort. Br J Surg 2024; 111:znae087. [PMID: 38662462 PMCID: PMC11044894 DOI: 10.1093/bjs/znae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The purpose of this study was to compare 3-year overall survival after simultaneous portal (PVE) and hepatic vein (HVE) embolization versus PVE alone in patients undergoing liver resection for primary and secondary cancers of the liver. METHODS In this multicentre retrospective study, all DRAGON 0 centres provided 3-year follow-up data for all patients who had PVE/HVE or PVE, and were included in DRAGON 0 between 2016 and 2019. Kaplan-Meier analysis was undertaken to assess 3-year overall and recurrence/progression-free survival. Factors affecting survival were evaluated using univariable and multivariable Cox regression analyses. RESULTS In total, 199 patients were included from 7 centres, of whom 39 underwent PVE/HVE and 160 PVE alone. Groups differed in median age (P = 0.008). As reported previously, PVE/HVE resulted in a significantly higher resection rate than PVE alone (92 versus 68%; P = 0.007). Three-year overall survival was significantly higher in the PVE/HVE group (median survival not reached after 36 months versus 20 months after PVE; P = 0.004). Univariable and multivariable analyses identified PVE/HVE as an independent predictor of survival (univariable HR 0.46, 95% c.i. 0.27 to 0.76; P = 0.003). CONCLUSION Overall survival after PVE/HVE is substantially longer than that after PVE alone in patients with primary and secondary liver tumours.
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Affiliation(s)
- Remon Korenblik
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jan Heil
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Germany
| | - Jens Smits
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sinead James
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bram Olij
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Wolf O Bechstein
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Germany
| | - Marc H A Bemelmans
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Christoph A Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Stefan Breitenstein
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Michael Williams
- Department of Surgery, Rush University Medical Center Chicago, Chicago, Illinois, USA
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, University of Liege, CHU Liege, Liege, Belgium
| | - Maxime J L Dewulf
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Alexandra Dili
- Department of Abdominal Surgery, CHU-UC Louvain-Namur, Yvoir, Belgium
| | - Lukasz F Grochola
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Jon Grote
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Daniel Heise
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - Jennifer A Kalil
- Department of Surgery, Section of Hepato-pancreatico-biliary Surgery, McGill University Health Centre, Montreal, Québec, Canada
| | - Peter Metrakos
- Department of Surgery, Section of Hepato-pancreatico-biliary Surgery, McGill University Health Centre, Montreal, Québec, Canada
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - Sam G Pappas
- Department of Surgery, Rush University Medical Center Chicago, Chicago, Illinois, USA
| | - Francesca Pennetta
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Andreas A Schnitzbauer
- Department of General, Visceral and Transplant Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Germany
| | - Jordan C Tasse
- Department of Radiology, Rush University Medical Center Chicago, Chicago, Illinois, USA
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
- NUTRIM—School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Christiaan van der Leij
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of Surgery, Rush University Medical Center Chicago, Chicago, Illinois, USA
- Surgical Centre, Hirslanden Clinic Zurich, Zurich, Switzerland
- Switzerland Surgical Centre, Hirslanden Clinic St Anna Luzern, Luzern, Switzerland
| | - Ronald M van Dam
- GROW—School for Oncology and Reproduction, 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
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Knapen RRMM, Korenblik R, James S, Dams G, Olij B, de Boer SW, van Dam RM, van der Leij C. The Effect of Microwave and Radiofrequency Ablation (MWA/RFA) on Liver Volume in Patients with Primary and Secondary Liver Tumours: A Retrospective Analysis. Cardiovasc Intervent Radiol 2023:10.1007/s00270-023-03503-0. [PMID: 37430014 PMCID: PMC10382361 DOI: 10.1007/s00270-023-03503-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/21/2023] [Indexed: 07/12/2023]
Abstract
PURPOSE It is known that thermal liver ablation can induce liver hypertrophy. However, exact impact in liver volume remains unclear. The aim of this study is to assess the influence of radiofrequency or microwave ablation (RFA/MWA) on liver volume in patients with primary and secondary liver lesions. Findings can be relevant in assessing the potential extra benefit of thermal liver ablation in preoperatively performed liver hypertrophy inducing procedures, such as portal vein embolization (PVE). METHODS Between January 2014-May 2022, 69 invasive treatment naïve patients with primary (n = 43) or secondary/metastatic (n = 26) liver lesions (in all segments, except in segments II/III) treated percutaneously by RFA/MWA were included. Total liver volume (TLV), segment II + III volume (serving as "distant liver volume"), ablation zone volume and absolute liver volume (ALV, calculated by subtracting the ablation zone volume from the TLV) were the study outcomes. RESULTS ALV in patients with secondary liver lesions increased to a median percentage of 106.87% (IQR = 99.66-113.03%, p = 0.016), volume of segments II/III increased to a median percentage of 105.81% (IQR = 100.06-115.65%, p = 0.003). ALV and segments II/III in patients with primary liver tumours remained stable, with a median percentage of 98.72% (IQR = 92.99-108.35%, p = 0.856) and 100.43% (IQR = 92.85-109.41%, p = 0.699), respectively. CONCLUSION In patients with secondary liver tumours, ALV and segments II/III increased after MWA/RFA by an average of approximately 6%, while ALV in patients with primary liver lesions remained unchanged. Besides the curative intent, these findings indicate the potential added benefit of thermal liver ablation on FLR hypertrophy inducing procedures in patients with secondary liver lesions. LEVEL OF EVIDENCE Level 3, non-controlled retrospective cohort study.
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Affiliation(s)
- Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.
- CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.
| | - Remon Korenblik
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Sinead James
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Glenn Dams
- Department of Radiology and Nuclear Medicine, Zuyderland, Sittard, Heerlen, The Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW, School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Sanne W de Boer
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW, School for Oncology and Reproduction, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Christiaan van der Leij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW, School for Oncology and Reproduction, Maastricht, The Netherlands
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4
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Nooijen LE, Franssen S, Buis CI, Dejong CHC, den Dulk M, van Delden OM, Ijzermans JN, Groot Koerkamp B, Kazemier G, van Lienden K, Klümpen HJ, Kuipers H, Olij B, Porte RJ, Rauws EA, Voermans RP, van Gulik TM, Erdmann JI, Roos E, Coelen RJ. Long-term follow-up of a randomized trial of biliary drainage in perihilar cholangiocarcinoma. HPB (Oxford) 2023; 25:210-217. [PMID: 36376222 DOI: 10.1016/j.hpb.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/02/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND AIMS The DRAINAGE trial was a randomized controlled trial comparing preoperative endoscopic (EBD) and percutaneous biliary drainage (PTBD) in patients with potentially resectable, perihilar cholangiocarcinoma (pCCA). The aim of this study was to compare the long-term outcomes. METHODS Patients were randomized in four tertiary referral centers. Follow-up data were available for all included patients. Primary outcome was overall survival (OS). Secondary outcomes were readmissions, and re-interventions not including in-trial interventions. RESULTS A total of 54 patients were randomized; 27 in both groups. Median follow-up for both groups was 62 months (95% CI 54-70). The median OS was 13 months (95% CI 7.9-18.1) in the EBD and 7 months (95% CI 0.0-17.2) in the PTBD group (P = 0.28). Twenty (37%, n = 8 EBD vs n = 12 PTBD, P = 0.43) of 54 patients were readmitted at least once, mostly due to drainage-related complications (n = 13, 24%). Of note, 14 out of the 54 patients died within the trial. A total of 76 drainage procedures (32 EBD and 44 PTBD) were performed in 28 patients. The median number of stent or drain placements was 2 (2-4) for the EBD group and 2 (1-3) for the PTBD group (P = 0.77). DISCUSSION Although this follow-up study represented a small cohort, no long-term differences in survival, readmissions, and drainage procedures for EBD and PTBD were found, even when comparing the resected and unresected group. However, this study demonstrates the complexity of biliary drainage for patients with potentially resectable pCCA, even in tertiary referral centers.
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Affiliation(s)
- Lynn E Nooijen
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Stijn Franssen
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Carlijn I Buis
- University Medical Center Groningen, University of Groningen, Department of Surgery, Groningen, the Netherlands
| | - Cornelis H C Dejong
- Maastricht University Medical Center, Department of Surgery, Maastricht, the Netherlands
| | - Marcel den Dulk
- Maastricht University Medical Center, Department of Surgery, Maastricht, the Netherlands
| | - Otto M van Delden
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Radiology and Nuclear Sciences, Amsterdam, the Netherlands
| | - Jan N Ijzermans
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Geert Kazemier
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Krijn van Lienden
- RAKU, Department of Radiology and Nuclear Sciences, Nieuwegein, the Netherlands
| | - Heinz-Josef Klümpen
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Medical Oncology, Amsterdam, the Netherlands
| | - Hendrien Kuipers
- University Medical Center Groningen, University of Groningen, Department of Surgery, Groningen, the Netherlands
| | - Bram Olij
- Maastricht University Medical Center, Department of Surgery, Maastricht, the Netherlands
| | - Robert J Porte
- University Medical Center Groningen, University of Groningen, Department of Surgery, Groningen, the Netherlands
| | - Erik A Rauws
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Gastroenterology, Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands; Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
| | - Joris I Erdmann
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - E Roos
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Pathology, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - R J Coelen
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands.
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5
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Olij B, Fichtinger RS, Kimman M, Aldrighetti LA, Hilal MA, Troisi R, Suttcliffe R, Besselink MG, Aroori S, Menon K, Edwin B, D'Hondt M, Lucidi V, Ulmer TF, Diaz-Nieto R, Soonawalla Z, White S, Sergeant G, Primrose JN, Van Dam RM. Patient reported outcomes after laparoscopic versus open hemihepatectomy within an enhanced recovery program, the ORANGE-II-PLUS Randomized Clinical trial: A Quality of Life and Body image analysis. European Journal of Surgical Oncology 2023. [DOI: 10.1016/j.ejso.2022.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Chang X, Korenblik R, Olij B, Knapen RRMM, van der Leij C, Heise D, den Dulk M, Neumann UP, Schaap FG, van Dam RM, Olde Damink SWM. Influence of cholestasis on portal vein embolization-induced hypertrophy of the future liver remnant. Langenbecks Arch Surg 2023; 408:54. [PMID: 36680689 PMCID: PMC9867667 DOI: 10.1007/s00423-023-02784-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 12/22/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE In the pre-clinical setting, hepatocellular bile salt accumulation impairs liver regeneration following partial hepatectomy. Here, we study the impact of cholestasis on portal vein embolization (PVE)-induced hypertrophy of the future liver remnant (FLR). METHODS Patients were enrolled with perihilar cholangiocarcinoma (pCCA) or colorectal liver metastases (CRLM) undergoing PVE before a (extended) right hemihepatectomy. Volume of segments II/III was considered FLR and assessed on pre-embolization and post-embolization CT scans. The degree of hypertrophy (DH, percentual increase) and kinetic growth rate (KGR, percentage/week) were used to assess PVE-induced hypertrophy. RESULTS A total of 50 patients (31 CRLM, 19 pCCA) were included. After PVE, the DH and KGR were similar in patients with CRLM and pCCA (5.2 [3.3-6.9] versus 5.7 [3.2-7.4] %, respectively, p = 0.960 for DH; 1.4 [0.9-2.5] versus 1.9 [1.0-2.4] %/week, respectively, p = 0.742 for KGR). Moreover, pCCA patients with or without hyperbilirubinemia had comparable DH (5.6 [3.0-7.5] versus 5.7 [2.4-7.0] %, respectively, p = 0.806) and KGR (1.7 [1.0-2.4] versus 1.9 [0.8-2.4] %/week, respectively, p = 1.000). For patients with pCCA, unilateral drainage in FLR induced a higher DH than bilateral drainage (6.7 [4.9-7.9] versus 2.7 [1.5-4.2] %, p = 0.012). C-reactive protein before PVE was negatively correlated with DH (ρ = - 0.539, p = 0.038) and KGR (ρ = - 0.532, p = 0.041) in patients with pCCA. CONCLUSIONS There was no influence of cholestasis on FLR hypertrophy in patients undergoing PVE. Bilateral drainage and inflammation appeared to be negatively associated with FLR hypertrophy. Further prospective studies with larger and more homogenous patient cohorts are desirable.
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Affiliation(s)
- Xinwei Chang
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Breast Tumor Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Remon Korenblik
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Robrecht R. M. M. Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christiaan van der Leij
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Daniel Heise
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Ulf P. Neumann
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Frank G. Schaap
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Ronald M. van Dam
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Steven W. M. Olde Damink
- Department of Surgery, Maastricht University Medical Center, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
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7
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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: )
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Stoop TF, Mackay TM, Brada LJH, van der Harst E, Daams F, Land FRV‘, Kazemier G, Patijn GA, van Santvoort HC, de Hingh IH, Bosscha K, Seelen LWF, Nijkamp MW, Stommel MWJ, Liem MSL, Busch OR, Coene PPLO, van Dam RM, de Wilde RF, Mieog JSD, Quintus Molenaar I, Besselink MG, van Eijck CHJ, de Meijer VE, Olij B, den Dulk M, Ramaekers M, Bonsing BA, Michiels N, Koerkamp BG, Festen S, Wit F, Lips DJ, Draaisma W, Manusama E, te Riele W. Pancreatectomy with arterial resection for periampullary cancer: outcomes after planned or unplanned events in a nationwide, multicentre cohort. Br J Surg 2022; 110:638-642. [PMID: 36308339 PMCID: PMC10364546 DOI: 10.1093/bjs/znac353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/09/2022] [Accepted: 09/30/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | - Tara M Mackay
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | - Lilly J H Brada
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | | | - Freek Daams
- Cancer Center Amsterdam , Amsterdam , The Netherlands
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery , Amsterdam , The Netherlands
| | - Freek R van ‘t Land
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center , Rotterdam , The Netherlands
| | - Geert Kazemier
- Cancer Center Amsterdam , Amsterdam , The Netherlands
- Amsterdam UMC, location Vrije Universiteit, Department of Surgery , Amsterdam , The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics , Zwolle , The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital , Eindhoven , The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital , ‘s Hertogenbosch , The Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | - Maarten W. Nijkamp
- Department of Surgery, University Medical Center Groningen , Groningen , The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente , Enschede , The Netherlands
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | | | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center , Maastricht , The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen , Aachen , Germany
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center , Rotterdam , The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center , Leiden , The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht/St. Antonius Hospital Nieuwegein , Utrecht & Nieuwegein , The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery , Amsterdam , The Netherlands
- Cancer Center Amsterdam , Amsterdam , The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center , Rotterdam , The Netherlands
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9
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Korenblik R, Olij B, Aldrighetti LA, Hilal MA, Ahle M, Arslan B, van Baardewijk LJ, Baclija I, Bent C, Bertrand CL, Björnsson B, de Boer MT, de Boer SW, Bokkers RPH, Rinkes IHMB, Breitenstein S, Bruijnen RCG, Bruners P, Büchler MW, Camacho JC, Cappelli A, Carling U, Chan BKY, Chang DH, Choi J, Font JC, Crawford M, Croagh D, Cugat E, Davis R, De Boo DW, De Cobelli F, De Wispelaere JF, van Delden OM, Delle M, Detry O, Díaz-Nieto R, Dili A, Erdmann JI, Fisher O, Fondevila C, Fretland Å, Borobia FG, Gelabert A, Gérard L, Giuliante F, Gobardhan PD, Gómez F, Grünberger T, Grünhagen DJ, Guitart J, Hagendoorn J, Heil J, Heise D, Herrero E, Hess GF, Hoffmann MH, Iezzi R, Imani F, Nguyen J, Jovine E, Kalff JC, Kazemier G, Kingham TP, Kleeff J, Kollmar O, Leclercq WKG, Ben SL, Lucidi V, MacDonald A, Madoff DC, Manekeller S, Martel G, Mehrabi A, Mehrzad H, Meijerink MR, Menon K, Metrakos P, Meyer C, Moelker A, Modi S, Montanari N, Navines J, Neumann UP, Peddu P, Primrose JN, Qu X, Raptis D, Ratti F, Ridouani F, Rogan C, Ronellenfitsch U, Ryan S, Sallemi C, Moragues JS, Sandström P, Sarriá L, Schnitzbauer A, Serenari M, Serrablo A, Smits MLJ, Sparrelid E, Spüntrup E, Stavrou GA, Sutcliffe RP, Tancredi I, Tasse JC, Udupa V, Valenti D, Fundora Y, Vogl TJ, Wang X, White SA, Wohlgemuth WA, Yu D, Zijlstra IAJ, Binkert CA, Bemelmans MHA, van der Leij C, Schadde E, van Dam RM. Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy. Cardiovasc Intervent Radiol 2022; 45:1391-1398. [PMID: 35790566 PMCID: PMC9458562 DOI: 10.1007/s00270-022-03176-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/08/2022] [Indexed: 12/02/2022]
Abstract
STUDY PURPOSE The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. METHODS The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. RESULTS Not applicable. CONCLUSION DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. TRIAL REGISTRATION Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).
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Affiliation(s)
- R Korenblik
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht Universiteitssingel 40 room 5.452, 6229 ET, Maastricht, The Netherlands.
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - B Olij
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht Universiteitssingel 40 room 5.452, 6229 ET, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - M Abu Hilal
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - M Ahle
- Deparment of Radiology, University Hospital, Linköping, Sweden
| | - B Arslan
- Department of Radiology, Rush University Medical Center, Chicago, USA
| | - L J van Baardewijk
- Department of Radiology, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - I Baclija
- Department of Radiology, Clinic Favoriten, Vienna, Austria
| | - C Bent
- Department of Radiology, Bournemouth and Christuchurch, The Royal Bournemouth and Christchurch Hospitals, Bournemouth and Christuchurch, UK
| | - C L Bertrand
- Department of Surgery, CHU UCLouvain Namur, Namur, Belgium
| | - B Björnsson
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University Hospital, Linköping, Sweden
| | - M T de Boer
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - S W de Boer
- Deparment of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R P H Bokkers
- Department of Radiology, University Medical Center Groningen, Groningen, The Netherlands
| | - I H M Borel Rinkes
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S Breitenstein
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - R C G Bruijnen
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Bruners
- Department of Radiology, University Hospital Aachen, Aachen, Germany
| | - M W Büchler
- Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - J C Camacho
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - A Cappelli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - U Carling
- Department of Radiology, University Hospital Oslo, Oslo, Norway
| | - B K Y Chan
- Department of Surgery, Aintree University Hospitals NHS, Liverpool, UK
| | - D H Chang
- Department of Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - J Choi
- Department of Surgery, Western Health Footscray, Footscray, Australia
| | - J Codina Font
- Department of Radiology, University Hospital Dr. Josep Trueta de Girona, Girona, Spain
| | - M Crawford
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
| | - D Croagh
- Department of Surgery, Monash Health, Clayton, Australia
| | - E Cugat
- Department of Surgery, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - R Davis
- Department of Radiology, Aintree University Hospitals NHS, Liverpool, UK
| | - D W De Boo
- Department of Radiology, Monash Health, Clayton, Australia
| | - F De Cobelli
- Department of Radiology, Ospedale San Raffaele, Milan, Italy
| | | | - O M van Delden
- Department of Radiology, Amsterdam University Medical Centers Location AMC, Amsterdam, The Netherlands
| | - M Delle
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - O Detry
- Department of Surgery, CHU de Liège, Liège, Belgium
| | - R Díaz-Nieto
- Department of Surgery, Aintree University Hospitals NHS, Liverpool, UK
| | - A Dili
- Department of Surgery, CHU UCLouvain Namur, Namur, Belgium
| | - J I Erdmann
- Department of Surgery, Amsterdam University Medical Centers Location AMC, Amsterdam, The Netherlands
| | - O Fisher
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, Australia
| | - C Fondevila
- Department of Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Å Fretland
- Department of Surgery, University Hospital Oslo, Oslo, Norway
| | - F Garcia Borobia
- Department of Surgery, Hospital Parc Taulí de Sabadell, Sabadell, Spain
| | - A Gelabert
- Department of Radiology, Hospital Parc Taulí de Sabadell, Sabadell, Spain
- Department of Radiology, University Hospital Mútua Terassa, Terassa, Spain
| | - L Gérard
- Department of Radiology, CHU de Liège, Liège, Belgium
| | - F Giuliante
- Department of Surgery, Gemelli University Hospital Rome, Rome, Italy
| | - P D Gobardhan
- Department of Surgery, Amphia, Breda, The Netherlands
| | - F Gómez
- Department of Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - T Grünberger
- Department of Surgery, HPB Center Vienna Health Network, Clinic Favoriten, Vienna, Austria
| | - D J Grünhagen
- Department of Surgery, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - J Guitart
- Department of Radiology, University Hospital Mútua Terassa, Terassa, Spain
| | - J Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Heil
- Department of Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - D Heise
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - E Herrero
- Department of Surgery, University Hospital Mútua Terassa, Terassa, Spain
| | - G F Hess
- Department of Surgery, Clarunis University Hospital, Basel, Switzerland
| | - M H Hoffmann
- Department of Radiology, St. Clara Spital, Basel, Switzerland
| | - R Iezzi
- Department of Radiology, Gemelli University Hospital, Rome, Italy
| | - F Imani
- Department of Radiology, Amphia, Breda, The Netherlands
| | - J Nguyen
- Department of Radiology, Western Health Footscray, Footscray, Australia
| | - E Jovine
- Department of Surgery, Ospedale Maggiore di Bologna, Bologna, Italy
| | - J C Kalff
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - G Kazemier
- Department of Surgery, Amsterdam University Medical Centers Location VU, Amsterdam, The Netherlands
| | - T P Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - J Kleeff
- Department of Surgery, University Hospital Halle (Saale), Halle, Germany
| | - O Kollmar
- Department of Surgery, Clarunis University Hospital, Basel, Switzerland
| | - W K G Leclercq
- Department of Surgery, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - S Lopez Ben
- Department of Surgery, University Hospital Dr. Josep Trueta de Girona, Girona, Spain
| | - V Lucidi
- Department of Surgery, Hôpital Erasme, Brussels, Belgium
| | - A MacDonald
- Department of Radiology, Oxford University Hospital NHS, Oxford, UK
| | - D C Madoff
- Department of Radiology, Yale School of Medicine, New Haven, USA
| | - S Manekeller
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - G Martel
- Department of Surgery, The Ottawa Hospital, Ottawa, Canada
| | - A Mehrabi
- Department of Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - H Mehrzad
- Department of Radiology, Queen Elizabeth Hospital Birmingham NHS, Birmingham, UK
| | - M R Meijerink
- Department of Radiology, Amsterdam University Medical Centers Location VU, Amsterdam, The Netherlands
| | - K Menon
- Department of Surgery, King's College Hospital NHS, London, UK
| | - P Metrakos
- Department of Surgery, McGill University Health Centre, Montréal, Canada
| | - C Meyer
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - A Moelker
- Department of Radiology and Nuclear Medicine, Erasmus Medisch Centrum, Rotterdam, The Netherlands
| | - S Modi
- Department of Radiology, University Hospital Southampton NHS, Southampton, UK
| | - N Montanari
- Department of Radiology, Ospedale Maggiore Di Bologna, Bologna, Italy
| | - J Navines
- Department of Surgery, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - U P Neumann
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - P Peddu
- Department of Radiology, King's College Hospital NHS, London, UK
| | - J N Primrose
- Department of Surgery, University Hospital Southampton NHS, Southampton, UK
| | - X Qu
- Department of Radiology, Zhongshan Hospital, Fundan University, Shanghai, China
| | - D Raptis
- Department of Surgery, Royal Free Hospital NHS, London, UK
| | - F Ratti
- Department of Surgery, Ospedale San Raffaele, Milan, Italy
| | - F Ridouani
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C Rogan
- Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - U Ronellenfitsch
- Department of Surgery, University Hospital Halle (Saale), Halle, Germany
| | - S Ryan
- Department of Radiology, The Ottawa Hospital, Ottawa, Canada
| | - C Sallemi
- Department of Radiology, Fondazione Poliambulanza, Brescia, Italy
| | - J Sampere Moragues
- Department of Radiology, University Hospital Germans Trias I Pujol, Badalona, Spain
| | - P Sandström
- Department of Surgery, Biomedical and Clinical Sciences, Linköping University Hospital, Linköping, Sweden
| | - L Sarriá
- Department of Radiology, University Hospital Miguel Servet, Saragossa, Spain
| | - A Schnitzbauer
- Department of Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - M Serenari
- Department of Surgery, General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - A Serrablo
- Department of Surgery, University Hospital Miguel Servet, Saragossa, Spain
| | - M L J Smits
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E Sparrelid
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - E Spüntrup
- Department of Radiology, Klinikum Saarbrücken gGmbH, Saarbrücken, Germany
| | - G A Stavrou
- Department of Surgery, Klinikum Saarbrücken gGmbH, Saarbrücken, Germany
| | - R P Sutcliffe
- Department of Surgery, Queen Elizabeth Hospital Birmingham NHS, Birmingham, UK
| | - I Tancredi
- Department of Radiology, Hôpital Erasme, Brussels, Belgium
| | - J C Tasse
- Department of Radiology, Rush University Medical Center, Chicago, USA
| | - V Udupa
- Department of Surgery, Oxford University Hospital NHS, Oxford, UK
| | - D Valenti
- Department of Radiology, McGill University Health Centre, Montréal, Canada
| | - Y Fundora
- Department of Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - T J Vogl
- Department of Radiology, University Hosptital Frankfurt, Frankfurt, Germany
| | - X Wang
- Department of Surgery, Zhongshan Hospital, Fundan University, Shanghai, China
| | - S A White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS, Newcastle upon Tyne, UK
| | - W A Wohlgemuth
- Department of Radiology, University Hospital Halle (Saale), Halle, Germany
| | - D Yu
- Department of Radiology, Royal Free Hospital NHS, London, UK
| | - I A J Zijlstra
- Department of Radiology, Amsterdam University Medical Centers Location VU, Amsterdam, The Netherlands
| | - C A Binkert
- Department of Radiology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - M H A Bemelmans
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - C van der Leij
- Deparment of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - E Schadde
- Department of General and Visceral Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Surgery, Rush University Medical Center Chicago, Chicago, USA
| | - R M van Dam
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht Universiteitssingel 40 room 5.452, 6229 ET, Maastricht, The Netherlands.
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany.
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10
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van Woerden V, Olij B, Fichtinger RS, Lodewick TM, Coolsen MME, Den Dulk M, Heise D, Olde Damink SWM, Dejong CHC, Neumann UP, van Dam RM. The orange-III study: the use of preoperative laxatives prior to liver surgery in an enhanced recovery programme, a randomized controlled trial. HPB (Oxford) 2022; 24:1492-1500. [PMID: 35410783 DOI: 10.1016/j.hpb.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/18/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study evaluates the effect of preoperative macrogol on gastrointestinal recovery and functional recovery after liver surgery combined with an enhanced recovery programme in a randomized controlled setting. METHODS Patients were randomized to either 1 sachet of macrogol a day, one week prior to surgery versus no preoperative laxatives. Postoperative management for all patients was within an enhanced recovery programme. The primary outcome was recovery of gastrointestinal function, defined as Time to First Defecation. Secondary outcomes included Time to Functional Recovery. RESULTS Between August 2012 and September 2016, 82 patients planned for liver resection were included in the study, 39 in the intervention group and 43 in the control group. Median Time to First Defecation was 4.0 days in the intervention group (IQR 2.8-5.0) and 4.0 days in the control group (IQR 2.9-5.0), P = 0.487. Median Time to Functional Recovery was day 6 (IQR 4.0-8.0) in the intervention group and day 5 (IQR 4.0-7.5) in the control group, P = 0.752. No significant differences were seen in complication rate, reinterventions or mortality. CONCLUSION This randomized controlled trial showed no advantages of 1 sachet of macrogol preoperatively combined with an enhanced recovery programme, for patients undergoing liver surgery.
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Affiliation(s)
- V van Woerden
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Toine M Lodewick
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Daniel Heise
- Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany.
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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