Perioperative outcome and long-term survival for intrahepatic cholangiocarcinoma after portal vein embolization and subsequent resection: A propensity-matched study

INTRODUCTION

In view of the high therapeutic value of surgical resection for intrahepatic cholangiocarcinomas (ICC), our study addresses the question of clinical management and outcome in case of borderline resectability requiring hypertrophy induction of the future liver remnant prior to resection.

METHODS

Clinical data was collected of all primary ICC cases receiving major liver resection with or without prior portal vein embolization (PVE) from a single high-volume center. PVE was performed via a percutaneous transhepatic access. Propensity score matching was performed. Perioperative morbidity was assessed as well as long-term survival with a minimum follow-up of 36 months.

RESULTS

No significant difference in perioperative morbidity was seen between the PVE and the control group. For the PVE group, median OS was 28 months vs. 37 months for the control group (p = 0.418), median DFS 18 and 14 months (p = 0.703). Disease progression during hypertrophy was observed in 38% of cases. Here, OS and DFS was reduced to 18 months (p = 0.479) and 6 months (p = 0.013), respectively. In case of positive N-status or multifocal tumor (MF+) OS was also reduced (18 vs. 26 months, p = 0.033; MF+: 9 vs. 36months p = 0.013).

CONCLUSION

Our results suggest that the surgical therapy in case of borderline resectability offers acceptable results with non-inferior OS rates compared to cases without preoperative hypertrophy induction and comparable oncological features. In the presence of additional risk factors (multifocal tumor, lymph node metastasis, PD during hypertrophy) the OS is notably reduced.

Limited liver resections in the posterosuperior segments: international multicentre propensity score-matched and coarsened exact-matched analysis comparing the laparoscopic and robotic approaches

Background

Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII).

Methods

This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed.

Results

Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P < 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P < 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery.

Conclusion

Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

Hepatocellular carcinoma tumor thrombus entering the right atrium treated with combining percutaneous and intravenous high-dose-rate brachytherapy: a case report

The presented report describes a case of a Hepatocellular carcinoma (HCC) tumor thrombus (TT) infiltrating the inferior vena cava (IVC) and the right atrium (RA) in a 66-year old male patient who initially presented with TT related symptoms. CT-guided high-dose-rate brachytherapy (HDRBT) was performed for both, the intraparenchymal primary and the TT. A marked improvement of the tumor-related symptoms and shrinkage of the tumor mass were achieved six months after treatment initiation. The combination of intravascular and percutaneous HDRBT demonstrating a promising approach to palliate tumor-related symptoms in advanced HCC with macrovascular invasion.

[Treatment of hepatocellular carcinoma in the cirrhotic and non-cirrhotic liver]

BACKGROUND AND OBJECTIVES

The treatment of hepatocellular carcinoma (HCC) includes surgical, interventional and systemic approaches. This review highlights the importance of surgical treatment approaches in the multimodal treatment of HCC, based on the currently available literature, corresponding German guidelines as well as current developments in organ donation in Germany.

RESULTS

Curative treatment options for HCC include liver transplantation, partial liver resection, and local ablative procedures depending on the lesion size. In the case of an early HCC in a cirrhotic liver fulfilling the Milan criteria, liver transplantation is the treatment of choice. In view of the organ shortage in Germany and improved results after partial liver resection, surgery can alternatively be performed in patients with a sufficient liver function. In selected patients with multinodular HCC, regional lymph node metastases or macrovascular invasion, the possibility of liver resection must be decided on an individual basis; however, the latter two criteria are contraindications for transplantation. Local ablative procedures can be considered as an alternative to resection in selected patients with early solitary HCC. Surgery of HCC in the non-cirrhotic liver with a curative intent is guided by the general principles of oncological liver surgery.

DISCUSSION

Curative treatment options for HCC include liver transplantation, partial liver resection and local ablative procedures. Current developments in the area of organ donation and technical advances in minimally invasive liver surgery should be included in decision-making in tumor boards.

Mid- and long-term results after replacement of infected peripheral vascular prosthetic grafts with biosynthetic collagen prosthesis

AIM

We assess mid- and long-term outcome after prosthetic graft replacement with biosynthetic collagen prosthesis (Omniflow II®) in the presence of graft infection.

METHODS

Between December 2010 and January 2012, an analysis of 9 consecutive patients was performed, who underwent replacement of an infected peripheral graft with a biosynthetic prosthesis. Morbidity, in-hospital mortality, primary and secondary patency were analyzed. FDG-PET was performed to diagnose graft infection, and exclude reinfection at long-term follow-up.

RESULTS

Graft infection occurred after a median of 12 (range 3-97) months after the initial procedure. Replacement surgery was performed successfully in all 9 patients without intraoperative complications. Microbiological cultures revealed pathogenic infection in 7 cases. In 2 patients, no pathogen was isolated. The morbidity rate was 55.5% with no in-hospital deaths. Early and late bypass occlusion occurred in 2 patients. One high above-knee amputation was performed due to patient deterioration. The median length of stay was 23 (range 12-122) days and after graft replacement 13 (range 10-62) days. The median time of follow up was 23 (range 8-25) months. Primary and secondary patency rates were 66.6% and 78% at 19 months, respectively. FDG-PET was performed in 6 (85.5%) patients after a median follow up period of 19 (range 3-23) months, and excluded graft reinfection in all patients.

CONCLUSION

Replacement of infected peripheral prosthetic grafts with the prosthesis (Omniflow II®) has encouraging results. The collagen prosthesis appears to be a promising alternative with a low reocclusion rate and no reinfection.

[Early results after peripheral vascular replacement with biosynthetic collagen prosthesis in cases of graft infection]

INTRODUCTION

Vascular graft infection in peripheral bypass surgery represents a highly significant risk with regard to limb loss and morbidity. In the absence of autologous superficial veins, finding a suitable replacement material can be difficult. Silver-coated polyester grafts, homografts, or use of deep veins can pose additional risks. Use of a biosynthetic collagen prosthesis on a Dacron matrix ("Omniflow-II®") was investigated as an alternative method, and the cost-effectiveness was evaluated.

MATERIALS AND METHODS

From December 2010 to December 2011, eight patients with clinical symptoms of vascular graft infection, confirmed by imaging, were treated. Graft function or acute graft failure due to the infection was necessary for enrollment in the study. Infected material was removed, microbiological specimens taken and, in the absence of superficial veins, an "Omniflow-II®" prosthesis was implanted in an orthotopic position. Patients were followed up to evaluate their outcome, and the cost-effectiveness of the procedure was also analysed.

RESULTS

The technical feasibility of the procedure was assessed in all cases. Pathogens were detected in five of eight cases. After a mean follow-up of 8 months, seven of eight patients showed that they were clinically cured of infection. Primary patency was 63%, secondary patency was 75%, and prevalence of limb salvage was 88%. One patient had to undergo limb amputation to avoid sepsis, and another unsuccessfully underwent thrombectomy after 12 months. Four PET-CT follow-up studies showed a reduction of uptake in the affected area. To generate adequate revenue by using this technique, specialised knowledge of the diagnosis-related group system is necessary.

DISCUSSION

Treatment of vascular graft infections in peripheral bypass surgery in the absence of endogenous material necessitates the use of infection-resistant materials. The present study showed promising results using a collagen-biosynthetic prosthesis. Due to a lack of long-term results, the graft should be used only after detailed informed consent is obtained from the patient. The expenses incurred by using the biosynthetic graft should be covered adequately by revenues from these patients.