Short-term postoperative outcomes of lymphadenectomy for cholangiocarcinoma, hepatocellular carcinoma and colorectal liver metastases in the modern era of liver surgery: Insights from the StuDoQ|Liver registry

INTRODUCTION

The clinical role of lymphadenectomy (LAD) as part of hepatic resection for malignancies of the liver remains unclear. In this study, we aimed to report on the use cases and postoperative outcomes of liver resection and simultaneous LAD for hepatic malignancies (HM).

MATERIALS AND METHODS

Clinicopathological data from patients who underwent surgery at 13 German centers from 2017 to 2022 (n = 3456) was extracted from the StuDoQ|Liver registry of the German Society of General and Visceral Surgery. Propensity-score matching (PSM) was performed to account for the extent of liver resection and patient demographics.

RESULTS

LAD was performed in 545 (16%) cases. The most common indication for LAD was cholangiocarcinoma (CCA), followed by colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC). N+ status was found in 7 (8%), 59 (35%), and 56 cases (35%) for HCC, CCA, and CRLM, respectively (p < 0.001). The LAD rate was highest for robotic-assisted resections (28%) followed by open (26%) and laparoscopic resections (13%), whereas the number of resected lymph nodes was equivalent between the techniques (p = 0.303). LAD was associated with an increased risk of liver-specific postoperative complications, especially for patients with HCC.

CONCLUSION

In this multicenter registry study, LAD was found to be associated with an increased risk of liver-specific complications. The highest rate of LAD was observed among robotic liver resections.

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Surgical therapy for major lung parenchymal damage from late coronavirus disease complication: case report and literature review

Background

Coronavirus disease [severe acute respiratory syndrome coronavirus disease 19 (SARS COVID-19)] has emerged as one of the most challenging diseases of recent decades. After the pandemic outbreak, our knowledge of the virus has expanded and developed, but we face a new wave of atypical complications that require special attention. In addition to the acute complications of COVID-19 infection, late complications of the disease are taking an increasingly important part in the management of affected patients, which are grouped under the collective term "Long COVID". In this work, we present our therapy strategy in three cases of pulmonary cavity as a late complication after COVID-19, as well as perform a literature review of published articles in this matter.

Case Description

This study includes 3 cases of pulmonary cavities as a late COVID complication. Among them only one patient was vaccinated. The mean duration between the occurrence of Long COVID and SARS COVID-19 disease was 4 weeks in our patients. All patients underwent adequate medical therapy after Long COVID. However, due to the disease progression and significant elevated infections parameters, all patients underwent surgical therapy. One patient underwent uniportal video-assisted thoracoscopic surgery (VATS) lobectomy and decortication of the empyema, whereas we performed thoracotomy for other patients. All patients treated successfully and discharged shortly after the operation. Our literature review provides a total of 12 publications with only 50 patients. No patients received vaccination. The mean interval time between acute infection and the appearance of pulmonary cavities was about 4 weeks. The results showed that most patients were treated with conservative therapies. Only two patients were treated using invasive therapies. Both patients were successfully treated and recovered from the procedures.

Conclusions

This group of late complications COVID patients requires individualized treatment strategy. In the case of an underlying pulmonary cavities, depending on the findings, despite increased perioperative risks, very good results can be achieved by presentation to a specialized and experienced thoracic surgery center.

A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery

BACKGROUND

Surgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures.

METHODS

A systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review.

RESULTS

Seven "core" indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries.

CONCLUSIONS

This work presents a core set of internationally agreed QPI for HPB surgery.

[Potential risk to patient safety by discontinuation of production of classical T-drains? : Nationwide survey in Germany and statement of the surgical working group for liver, gall bladder and pancreatic diseases (CALGP) of the German Society for General and Visceral Surgery (DGAV)]

The revision of the medical device regulation (MDR) legislation by the European Union and supplementations by the member states has been implemented for good reasons but causes dramatic side effects. It is no longer allowed to produce some rarely used medical devices by various manufacturers that have been successfully used for decades. Before production, a new application to the MDR would be necessary, which is not a realistic business case for companies producing rarely used devices. This problem currently relates to the Kehr T‑drain made from soft rubber or latex that has been in use since the late nineteenth century. A surgically placed T‑drain, although rarely necessary nowadays, is still in use worldwide for special indications in an attempt to avoid severe complications. These special indications include complex hepato-pancreato-biliary (HPB) procedures and perforations of the upper gastrointestinal (GI) tract where T‑drains may be used to secure the hepatojejunostomy or to create a stable fistula. The HPB working group (CALGP) of the German Society of General and Visceral Surgery (DGAV) provides a statement from a surgical perspective on this matter after a survey of all its members. Politics should be very careful not to generalize when implementing useful new regulations at a European and national level. Established and comprehensible treatment concepts should not be restricted and exemption permits should be quickly granted in these cases because the discontinuation of these niche products may lead to potential patient safety issues and even fatalities.

Primary adenocarcinoma of an ileostomy in a Crohn patient: a case report

Proctocolectomy with ileostomy is an established surgical treatment in patients with inflammatory bowel disease. Adenocarcinoma of an ileostomy is a rare complication in long-term ileostomies. We present the case of a 69-year-old man who presented with bloody stools and a tumour at the ileostomy site 37 years after ileostomy formation. Biopsies confirmed the presence of an adenocarcinoma. Imaging did not show any metastases or advanced local infiltration. A resection of the ileostomy with a broad safety margin and reimplantation of a new Ileostomy was performed. At 18-month follow-up, there is no sign of recurrence. Ileostomy adenocarcinoma in a Crohn's disease patient is rare with only four cases described in literature. An en-bloc resection and relocation of the ileostomy is the recommended treatment. Education of patients and healthcare professionals on this long-term ileostomy complication is vital for the early diagnosis and treatment.

Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis

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.

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

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).

Intraoperative (Contrast-Enhanced) Ultrasound Has the Highest Diagnostic Accuracy of Any Imaging Modality in Resection of Colorectal Liver Metastases

AIM

Defining sensitivity, specificity, diagnostic accuracy for detection of colorectal liver metastases in imaging compared to intraoperative assessment. Defining a cutoff, where accuracy of detection is impaired.

METHODS

Prospective single-institution clinical trial (clinicaltrials.gov: NCT01522209). Patients underwent CEUS, MDCT, and 3 Tesla EOB-MRI within 2 weeks preoperatively. Intraoperative palpation, IOUS, and CEIOUS were performed. A patient and lesion-based database was analyzed for accuracy of detection of CEUS, CT, MRI, and Palp/IOUS/CEIOUS combined read. Histology was standard of reference.

RESULTS

Forty-seven high tumor load (mean 5, 4 lesions) patients were analyzed. Histopathology confirmed 264 lesions (245 malignant: 19 benign). Accuracy for detection of all lesions: CEUS 63%, CT 71%, MRI 92%, and PALP/IOUS/CEIOUS 98%. ROC analysis for lesion size showed severe impairment of accuracy in lesion detection smaller than 5mm. Intraoperative imaging was not impaired by lesion size. Patient-based analysis revealed a change of resection plan after IOUS/CEIOUS in 35% of patients.

CONCLUSION

At 5-mm lesion size, preoperative imaging shows a drop in accuracy of detection. In patients with multiple lesions, addition of MRI to MDCT seems useful. Accuracy of intraoperative ultrasound is not impacted by lesion size and should be mandatory. CEIOUS can improve intraoperative decision-making.

TRIAL REGISTRATION

Study registered with clinicaltrials.gov : NCT01522209.

Appendicitis during the COVID-19 lockdown: results of a multicenter analysis in Germany

Purpose

The COVID-19 pandemic has transformed medical care worldwide. General surgery has been affected in elective procedures, yet the implications for emergency surgery are unclear. The current study analyzes the effect of the COVID-19 lockdown in spring 2020 on appendicitis treatment in Germany.

Methods

Hospitals that provided emergency surgical care during the COVID-19 lockdown were invited to participate. All patients diagnosed with appendicitis during the lockdown period (10 weeks) and, as a comparison group, patients from the same period in 2019 were analyzed. Clinical and laboratory parameters, intraoperative and pathological findings, and postoperative outcomes were analyzed.

Results

A total of 1915 appendectomies from 41 surgical departments in Germany were included. Compared to 2019 the number of appendectomies decreased by 13.5% (1.027 to 888, p=0.003) during the first 2020 COVID-19 lockdown. The delay between the onset of symptoms and medical consultation was substantially longer in the COVID-19 risk group and for the elderly. The rate of complicated appendicitis increased (58.2 to 64.4%), while the absolute number of complicated appendicitis decreased from 597 to 569, (p=0.012). The rate of negative appendectomies decreased significantly (6.7 to 4.6%; p=0.012). Overall postoperative morbidity and mortality, however, did not change.

Conclusion

The COVID-19 lockdown had significant effects on abdominal emergency surgery in Germany. These seem to result from a stricter selection and a longer waiting time between the onset of symptoms and medical consultation for risk patients. However, the standard of emergency surgical care in Germany was maintained.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02090-3.

Metachronous hepatic resection for liver only pancreatic metastases

BACKGROUND

The value of liver resection (LR) for metachronous pancreatic ductal adenocarcinoma (PDAC) metastases remains controversial. However, in light of increasing safety of liver resections, surgery might be a valuable option for metastasized PDAC in selected patients.

METHODS

We performed a retrospective, multicenter study including patients undergoing hepatectomy for metachronous PDAC liver metastases between 2004 and 2015 to analyze postoperative outcome and overall survival. All patients were operated with curative intent. Patients with oligometastatic metachronous liver metastasis with definitive chemotherapy (n = 8) served as controls.

RESULTS

Overall 25 patients in seven centers were included in this study. The median age at the time of LR was 63.8 years (56.9-69.9) and the median number of metastases in the liver was 1 (IQR 1-2). There were eight non-anatomical resections (32%), 15 anatomical minor (60%) and 2 major LR (8%). Postoperative complications occurred in eleven patients (eight Clavien-Dindo grade I complications (32%) and three grade IIIa complications (12%), respectively). The 30-day mortality was 0%. The median length of stay was 8.6 days (IQR 5-11). Median overall survival following LR was 36.8 months compared to 9.2 months in patients with metachronous liver metastasis with chemotherapy (p = 0007).

DISCUSSION

Liver resection for metachronous PDAC metastasis is safe and feasible in selected patients. To address general applicability and to find factors for patient selection, larger trials are urgently warranted.

ALPPS in neuroendocrine liver metastases not amenable for conventional resection - lessons learned from an interim analysis of the International ALPPS Registry

BACKGROUND

Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM.

METHODS

The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM.

RESULTS

From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19-48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1-27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively.

CONCLUSIONS

ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.

[Navigated liver surgery : Current state and importance in the future]

The preoperative computer-assisted resection planning is the basis for every navigation. Thanks to modern algorithms, the prerequisites have been created to carry out a virtual resection planning and a risk analysis. Thus, individual segment resections can be precisely planned in any conceivable combination. The transfer of planning information and resection suggestions to the operating theater is still problematic. The so-called stereotactic liver navigation supports the exact intraoperative implementation of the planned resection strategy and provides the surgeon with real-time three-dimensional information on resection margins and critical structures during the resection. This is made possible by a surgical navigation system that measures the position of surgical instruments and then presents them together with the preoperative surgical planning data. Although surgical navigation systems have been indispensable in neurosurgery and spinal surgery for many years, these procedures have not yet become established as standard in liver surgery. This is mainly due to the technical challenge of navigating a moving organ. As the liver is constantly moving and deforming during surgery due to respiration and surgical manipulation, the surgical navigation system must be able to measure these alterations in order to adapt the preoperative navigation data to the current situation. Despite these advances, further developments are required until navigated liver resection enters clinical routine; however, it is already clear that laparoscopic liver surgery and robotic surgery will benefit most from navigation technology.

Performance validation of the ALPPS risk model

BACKGROUND

Based on the International ALPPS registry, we have recently proposed two easily applicable risk models (pre-stage1 and 2) for predicting 90-day mortality in ALPPS but a validation of both models has not been performed yet.

METHODS

The validation cohort (VC) was composed of subsequent cases of the ALPPS registry and cases of centers outside the ALPPS registry.

RESULTS

The VC was composed of a total of 258 patients including 70 patients outside the ALPPS registry with 32 cases of early mortalities (12%). Development cohort (DC) and VC were comparable in terms of patient and surgery characteristics. The VC validated both models with an acceptable prediction for the pre-stage 1 (c-statistic 0.64, P = 0.009 vs. 0.77, P < 0.001) and a good prediction for the pre-stage 2 model (c-statistic 0.77, P < 0.001 vs. 0.85, P < 0.001) as compared to the DC. Overall model performance measured by Brier score was comparable between VC and DC for the pre-stage 1 (0.089 vs. 0.081) and pre-stage 2 model (0.079 vs. 0087).

CONCLUSION

The ALPPS risk score is a fully validated model to estimate the individual risk of patients undergoing ALPPS and to assist clinical decision making to avoid procedure-related early mortality after ALPPS.

Liver Resection with In Situ Hypothermic Perfusion: An Old but Effective Method

BACKGROUND

More than 40 years ago, patients with tumors infiltrating the confluence of the hepatic veins were deemed unresectable; however, in situ hypothermic perfusion, first described by Fortner et al. (Ann Surg 180(4):644-652, 1974), allowed resection of these tumors. In order to prevent liver ischemia after total vascular exclusion, the liver was flushed with a cooled organ preservation solution. The surgeon was able to resect the tumor and reconstruct the hepatic veins with occlusion of the hepatic inflow and outflow.

METHODS

A 55-year-old female suffering from a leiomyosarcoma of the inferior vena cava (IVC) presented to our clinic. Three years ago, the IVC was replaced with a synthetic graft. During the patient's follow-up, a computed tomography (CT) scan revealed three hepatic metastases of the sarcoma. A central metastasis in Segment 8 infiltrated the right hepatic vein (RHV), and two additional metastases were located in the left lateral segments. We used Fortner's technique to resect these tumors.

RESULTS

The postoperative course of the patient was prolonged due to a hematoma that partially compressed the new RHV graft. A re-laparotomy was performed and drains were placed. On the 15th postoperative day, the patient was discharged in good health.

CONCLUSIONS

Although nowadays patients with these unfortunate tumor locations can, to some extent, be managed non-operatively, surgery remains an option with a chance of cure. Azoulay et al. (Ann Surg 262(1):93-104, 2015) were able to show satisfactory 5-year-survival in 77 patients (30.4%), however 90-day mortality was high (19.5%). Therefore, patients need to be selected carefully. In the era of minimally invasive liver surgery, these old techniques should not vanish from the armamentarium of liver surgeons.

Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved?

Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.

Did the International ALPPS Meeting 2015 Have an Impact on Daily Practice? The Hamburg Barmbek Experience of 58 Cases

Background

ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) was introduced only 10 years ago and has gained wide acceptance as a variation of staged procedures in liver surgery. It has been criticized for its high morbidity and mortality, which all centers reported in their initial series.

Methods

After a world expert meeting in Hamburg in 2015 where all experts in the field met to discuss this method, caveats were extracted and formulated. We researched our complete prospective ALPPS database to see if the recommendations had any impact on outcome.

Results

In total, we performed 58 ALPPS procedures in our center. 33 patients were operated on before, 25 after the meeting. Results in terms of morbidity and mortality were significantly better after the meeting, as were patient selection and strategy.

Conclusion

In our own center's experience, the implementation of the meetings' recommendations and the information gathered through this valuable exchange had a dramatic impact on results. Having performed 58 ALPPS procedures in total, we can now conclude that ALPPS has become much safer in our hands since the 2015 meeting and that morbidity and mortality are no longer the issue to be discussed. Future research must focus on oncologic outcomes in these patients.

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]

BACKGROUND

Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management.

METHOD

A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit.

CONCLUSION

Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

The "Nouvelle Vague" of surgeons in pancreatic surgery: can they rise to the legacy of current surgeons?

PURPOSE

Pancreatic surgery is still thought as a challenging field even for experienced hepatobilliary (HPB) surgeons and high volume tertiary centers. The purpose of this study was to present the results (mortality and morbidity) of pancreatic surgery in a high volume center, in operations performed solely by inexperienced surgeons (two 6th year residents and a HPB fellow) under the supervision of expert surgeons on the field.

METHODS

Forty-one consecutive patients who underwent curative-intent pancreatic resection with a modified pancreaticojejunostomy between January 2010 and December 2014 at Asklepios Hospital Barmbek, Germany, were identified from our institutional computer-based database. Two 6th year residents and an HPB-fellow performed all pancreatic anastomoses under the instructions of an experienced surgeon. Perioperative outcomes were recorded and analyzed.

RESULTS

Median postoperative length of stay for all patients was 15 days (IQR:7-31). In the first 90 postoperative days, the postoperative mortality rate was 0% and morbidity rate reached 39%. Reoperation was required in 1 patient (2.44%). However, no reoperation was performed for pancreatic anastomotic failure. No postoperative hemorrhage requiring interventional procedure or reoperation occurred in any patient.

CONCLUSIONS

The outcomes of pancreatic surgery performed by less experienced surgeons are satisfactory. The instructions of an expert surgeon in a high volume hospital definitely secures a favorable outcome after pancreatic surgery with lower mortality and morbidity rates compared with current literature trends.

How much liver needs to be transected in ALPPS? A translational study investigating the concept of less invasiveness

BACKGROUND

ALPPS induces rapid liver hypertrophy after stage-1 operation, enabling safe, extended resections (stage-2) after a short period. Recent studies have suggested that partial transection at stage-1 might be associated with a better safety profile. The aim of this study was to assess the amount of liver parenchyma that needs to be divided to achieve sufficient liver hypertrophy in ALPPS.

METHODS

In a bi-institutional, prospective cohort study, nonfibrotic patients who underwent ALPPS with complete (n = 22) or partial (n = 23) transection for colorectal liver metastases were analyzed and compared with an external ALPPS cohort (n = 23). A radiologic tool was developed to quantify the amount of parenchymal transection. Liver hypertrophy and clinical outcome were compared between both techniques. The relationship of partial transection and hypertrophy was investigated further in an experimental murine model of partial ALPPS.

RESULT

The median amount of parenchymal transection in partial ALPPS was 61% (range, 34-86%). The radiologic method correlated poorly with the intraoperative surgeon's estimation (r_S = 0.258). Liver hypertrophy was equivalent for the partial ALPPS, ALPPS, and external ALPPS cohort (64% vs 60% vs. 64%). Experimental data demonstrated that partial transection of at least 50% induced comparable hypertrophy (137% vs 156%) and hepatocyte proliferation compared to complete transection.

CONCLUSION

The study provides clinical and experimental evidence that partial liver partition of at least 50% seems to be equally effective in triggering volume hypertrophy as observed with complete transection and can be re recommended as less invasive alternative to ALPPS.

Identification of cofactors influencing hypertrophy of the future liver remnant after portal vein embolization-the effect of collaterals on embolized liver volume

OBJECTIVE

The purpose of this retrospective study was to monitor hypertrophy of future liver remnant following portal vein embolization (PVE) before planned extended right hepatectomy. However, because individual responses to PVE are highly variable, our focus was to identify cofactors of successful hypertrophy.

METHODS

28 patients with primary or secondary liver tumours, mean age 64.1 ± 12.9 years, underwent PVE. Volumetric analysis of hypertrophy before and after PVE (median 39.0 ± 15.7 days) was performed. The embolized liver segments were investigated for occurrence of reperfusion of their portal branches. Blood parameters before PVE were additionally investigated.

RESULTS

Patients were divided into responders (21/28) and non-responders (7/28) by post-PVE standardized future liver remnant being above or below 25%, respectively. No significant differences between the groups were found regarding biometric and volumetric parameters before PVE. In the entire group after PVE, the mean absolute increase of Segments 2 and 3 was 196.0 ± 84.7 cm³ and the median relative increase was 46.6 ± 98.8%. The formation of left to right hepatic portoportal collaterals exhibited a negative correlation to successful hypertrophy (p = 0.004) as well as low plasma total protein (p = 0.019). Successful embolization of Segment IV showed only a trend to significance (p = 0.098).

CONCLUSION

Cofactors associated with a favourable outcome regarding hypertrophy were the absence of collaterals in the control CT scans and high plasma total protein. Advances in knowledge: Portoportal collaterals negatively influence hypertrophy after PVE. On the other hand, plasma total protein is a positive prognostic indicator on hypertrophy of the liver in our cohort.

The risk of spontaneous rupture of liver hemangiomas: a critical review of the literature

BACKGROUND

The risk of spontaneous bleeding or rupture of liver hemangiomas still remains unknown. The aim of this review was to analyze the problem of spontaneous bleeding or rupture in liver hemangiomas and to identify factors leading to bleeding in these cases.

METHODS

A MEDLINE search was undertaken to identify articles in English, French, German, Italian, and Spanish from 1898 to 2010. Basic data such as age and sex of patients were collected. Additional data such as risk factors or causes of rupture were also analyzed. Cases were divided into spontaneous and non-spontaneous ruptures.

RESULTS

A total of 97 cases are described. In 51 of the 97 patients (52.6%) a non-spontaneous rupture was identified. Only in 46 out of the 97 cases (47.4%) was a spontaneous rupture found. Non-spontaneous rupture was significantly more frequent in patients aged <40 years than in older ones (p = 0.0099). Mean size of the ruptured lesions was 11.2 cm (range 1-37 cm). Massive bleeding occurred in 88 patients (90.7%). Reported mortality over the past 20 years has been significantly lower than before (p < 0.001). The overall mortality for the period under study was ~35%.

CONCLUSIONS

The spontaneous rupture of a hepatic hemangioma is to be considered an exceptional event. Preventive surgery should be considered only for lesions of at least 11-cm size in special cohorts of patients.

'Liver-first' approach for metastatic colorectal cancer

The liver-first approach was proposed for the first time in 2006 to obtain resectability of stage IV colorectal cancer patients and complete the therapeutic plan. From then some groups have used this new revolutionary approach reporting promising results. Other alternative strategies have been proposed for metastatic patients. The authors reviewed the literature weighing the pros and cons of each strategy proposed to manage these advanced tumor stages. The therapeutic options are analyzed in the light of oncologic problems and evidence. Also problems, questions and perspectives are given. Even if the 'liver-first' approach seems to be a promising strategy, the ideal diagnostic-therapeutic flowchart for metastatic colorectal cancer is still difficult to standardize. The great heterogeneity of this population of patients is one of the main problems. A 'tailored approach' philosophy is necessary to calibrate, in a multidisciplinary setting, a case-by-case choice of therapeutic options.

Large hemangiopericytoma of the pelvis--towards a multidisciplinary approach

Background

In 1942, Stout described tumors which derive from Zimmerman’s pericytes and suggested the term hemangiopericytoma (HPC). These tumors, which are often highly vascularized, pose difficulties in the surgical management regarding blood loss and complete resection. Therefore, preoperative management seems to be an essential part in dealing with these issues.

Case presentation

We present a 70-year-old female patient with a large HPC in the pelvis. Preoperative embolization of the tumor was performed, and 2 weeks after the intervention, we completely resected the tumor with minimal blood loss.

Conclusion

In which cases do we need preoperative treatment, especially emboliziation of hemangiopericytomas/solid fibrous tumors (SFT)? Although preoperative embolizations of tumors are now commonly undertaken, as for now, neither a clear statement nor a standardized approach has been given or developed. The purpose of this article is to provide our experience with preoperative embolization and to start a new discussion concerning a standardized approach.

ALPPS and simultaneous right hemicolectomy - step one and resection of the primary colon cancer

Background

Resection of the liver is often limited due to the volume of the parenchyma. To address this problem, several approaches to induce hypertrophy were developed. Recently, the ‘associating liver partition and portal vein ligation for staged hepatectomy’ (ALPPS) procedure was introduced and led to rapid hypertrophy in a short interval. Additionally to the portal vein occlusion, the parenchyma is transected, which disrupts the inter-parenchymal vascular connections.

Since the first description of the ALPPS procedure, various reports around the world were published. In some cases, due to the high morbidity and mortality, a decent oncologic algorithm is not deliverable in a timely manner. If a patient is to be treated with a liver-first approach, the resection of the primary could sometimes be severely protracted. To overcome the problem, a simultaneous resection of the primary tumor and step one of ALPPS were performed.

Case presentation

A 73-year-old male patient underwent portal vein embolization (PVE) after suffering from a synchronous hepatic metastasized carcinoma of the right colic flexure in order to perform a right trisectionectomy. Sufficient hypertrophy could not be obtained by PVE. Thus a ‘Rescue-ALPPS’ was undertaken. During step one of ALPPS, we simultaneously performed a right hemicolectomy. The postoperative course after the first step was uneventful, and sufficient hypertrophy was achieved.

Conclusion

In order to achieve a macroscopic disease-free state and lead the patient as soon as possible to the oncologic path (with, for example, chemotherapy), sometimes a simultaneous resection of the primary with step one of the ALPPS procedure seems justified. A resection of the primary with step two is not advisable, due to the high morbidity and mortality after this step. This case shows that a simultaneous resection is feasible and safe. Whether other locations of the primary should be treated this way must be part of further investigations.

ALPPS for patients with colorectal liver metastases: effective liver hypertrophy, but early tumor recurrence

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a promising method to increase resectability rates of liver tumors. Little has been published about oncological results so far. This report describes clinical evidence regarding a possible effect of ALPPS on tumor recurrence.

METHODS

Ten ALPPS procedures were performed for otherwise non-resectable colorectal liver metastases. Seven of these ten patients had a follow-up of at least 3 months and were analyzed for tumor recurrence.

RESULTS

Six of these seven patients had tumor recurrence to the liver. Three of seven patients presented with lung metastases, occurring earlier than liver metastases in two of three cases. One patient with a follow-up of 3 months had no visible recurrent disease, but increasing carcinoembryonic antigen levels.

CONCLUSIONS

The patient group operable only through ALPPS is at high risk for recurrence and early tumor progression. Still, this new method is the only chance for an oncological treatment strategy including a surgical approach and possibly better outcome.

[Perihilar cholangiocarcinoma (Klatskin tumor)]

Perihilar cholangiocarcinoma or Klatskin tumors are a rare entity arising from the extrahepatic bile duct bifurcation. Considering the close anatomical relationship of the bile duct bifurcation with the portal vein bifurcation and hepatic arteries, surgical treatment is demanding. With an incidence of only 2-4 cases/100,000 population/year patients should be referred to a specialized center. The tumors are usually poorly differentiated adenocarcinomas growing diffusely along the duct and also the perineural sheath. Only radical surgery offers a curative option and currently surgical strategy usually consists of en bloc resection of the bile duct, extended liver resection and portal vein resection. Proximal and lateral safety margin R0 resections are technically very demanding procedures because of the local anatomy.

Current position of ALPPS in the surgical landscape of CRLM treatment proposals

The Authors summarize problems, criticisms but also advantages and indications regarding the recent surgical proposal of associating liver partition and portal vein ligation (PVL) for staged hepatectomy (ALPPS) for the surgical management of colorectal liver metastases. Looking at published data, the technique, when compared with other traditional and well established methods such as PVL/portal vein embolisation (PVE), seems to give real advantages in terms of volumetric gain of future liver remnant. However, major concerns are raised in the literature and some questions remain unanswered, preliminary experiences seem to be promising. The method has been adopted all over the world over the last 2 years, even if oncological long-term results remain unknown, and benefit for patients is questionable. No prospective studies comparing traditional methods (PVE, PVL or classical 2 staged hepatectomy) with ALPPS are available to date. Technical reinterpretations of the original method were also proposed in order to enhance feasability and increase safety of the technique. More data about morbidity and mortality are also expected. The real role of ALPPS is, to date, still to be established. Large clinical studies, even if, for ethical reasons, in well selected cohorts of patients, are expected to better define the indications for this new surgical strategy.

Extracorporeal tumor cell filtration during extended liver surgery: first clinical use of leukocyte depletion filters--case series

Background

During oncologic surgery, intraoperative manipulation of tumor tissue is almost unpreventable and causes a high risk of tumor cell dissemination into venous blood. A tumor cell-reducing effect of leukocyte adhesion filter systems has been shown under in vitro conditions.

Methods

In a first clinical attempt, leukocyte adhesion filters were integrated into veno-venous bypass systems in four patients undergoing extended liver surgery for secondary hepatic malignancies.

Practicability, handling, and safety aspects as well as potency of cell removal and clinical side effects of the filter system were analyzed.

Results

All patients tolerated the application of the system without problems during operative and postoperative follow-up. Immunohistochemical staining of perioperative blood samples detected cytokeratin positive (CK+) cells in three cases during the hepatic mobilization.

Conclusions

Effectiveness of CK+ cell depletion and safety of the procedure was shown. The presented surgical technique represents a safe and innovative tool; however, clinical significance has to be examined in a larger patient cohort.

Navigation systems in liver surgery: the new challenge for surgical research

Abstract The authors describe the theoretical basis and development of simulation systems that led to the birth of "navigation in liver surgery." Navigation is a new technological application in the surgical field that has already been successfully used in neurosurgery and orthopedic surgery. A precondition to navigate a liver resection is the availability of a map. There are three main methods to acquire images and build a three-dimensional map. Efforts to make navigation "feasible" have been made, but some limits are still affecting the method. Lack of millimetric accuracy, deformation of the liver parenchyma during resection, and breathing movements are some of the most important criticisms of this method, which, however, is still in its infancy. Not only experimental applications but also current and future foreseeable applications of such a technology are overviewed. Goals of this technology should be to reduce the intraoperative stress on surgeons, to shorten resection time, and even indirectly to enlarge resectability of patients. Further developments of this new technology applied to liver surgery could lead in the near future to safer and more precise resections, reducing the risk of postoperative liver failure, even in the presence of large anatomical alterations or, even more frequently in this surgical field, anatomical variants.

[Anterior approach liver resection with the liver hanging maneuver. Technique and indications]

The anterior approach liver resection has advantages compared to conventional liver resection. Mobilization during conventional liver resection may cause local pressure on the tumor which could lead to tumor cell dissemination or even to tumor rupture. Furthermore, hemodynamic parameters tend to deteriorate during mobilization due to compression or twisting of the inferior vena cava. In addition, the left liver lobe often is compressed which can lead to tissue damage of the residual parenchyma. The risk of these complications can be reduced by the anterior approach technique which is facilitated by the so-called liver hanging maneuver. Appropriate indications for this technique are large tumors of the right liver lobe, tumors with infiltration of the right hepatic vein and infiltration of the vena cava from the right side, tumors with infiltration of the diaphragm and tumors of the right lobe after previous resections of the right lobe.

[EHEC-associated colon stenosis after ulcerous-chronic haemorrhagic colitis and consecutive resulting ileus]

We report on the case of a segmentally emphasised, ulcerous chronic haemorrhagic colitis with the development of granulation tissue und scarred fibrosis with consecutive resulting stenosis of the colon. A 49-year-old male patient was infected with enterohaemorrhagic Escherichia coli bacteria during the EHEC-epidemic in northern Germany in early summer 2011. In the course of the infection the patient suffered from haemolytic uraemic syndrome (HUS) with acute renal failure and neurological symptoms. Haemodialysis and plasmapheresis had become mandatory. A simultaneous ileus was estimated to be of paralytic origin. One month after treatment of the acute phase of the infection a CT scan of the abdomen was performed and discovered a symptomatic stenosis of the proximal colon transversum. This obstruction needed to be treated by performing a right hemicolectomy with an ileo-transverso anastomosis. After surgery the patient recovered continuously. The histopathological examination verified an ulcerous-chronic haemorrhagic colitis on the background of an EHEC infection.

Integration of 3D volumetry, portal vein transection and in situ split procedure: a new surgical strategy for inoperable liver metastasis

INTRODUCTION

The purpose of this study was to report on the feasibility of integrating 3D preoperative volumetry, portal vein transection and in situ split procedure. A 54-year-old female with now resectable colorectal liver metastasis (CRLM) (segments III, IVb, V-VIII) underwent a two-staged procedure.

METHODS

Segment III resection, right portal vein transection and an in situ split procedure (first stage) after 3D volumetry based on CT data and a right trisegmentectomy (second stage) were performed. RO resection of metastases was achieved, and the postoperative course was uneventful.

CONCLUSION

The proposed strategy seems to be a promising method to achieve higher resectability rates in CRLM patients.

Liver resection using heat coagulative necrosis: indications and limits of a new method

BACKGROUND

A new approach towards achieving bloodless liver resection is the use of heat coagulative necrosis. The latest stage of this technique is a four-probe device (Habib Sealer), which we used for a variety of resections to find the best indications for the method.

METHODS

Between 2005 and 2006 we performed 28 liver resections in 20 consecutive patients. The most common indication was metastatic colorectal cancer (75%). We treated a heterogeneous patient collective in terms of tumour localization and extent of resection. Resection was performed after creating a necrotic zone. The device achieved an area of coagulation of 1-cm width in which even larger vessels and bile ducts were safely sealed.

RESULTS

Operative spectrum covered atypical resections (8), one- or bisegmentectomies at different locations (15), hemihepatectomies (4) and one extended right hepatectomy. With one exception intra-operative blood loss was lower than 100 mL. Four patients (20%) developed operation-related complications comprising abscess formation at the resection site. Follow-up shows tumour-free survival for 13 of 18 patients 12 months after resection.

CONCLUSION

Liver resection using the sealer device seems safe. In proximity of hilar structures or large vessels the method is not favourable for the fear of thermal damage. Extended resections are possible but not parenchyma saving. Good indications are atypical (deep) resections - especially in Segment IVb.

Laparoscopic deroofing of hepatic cysts: The most effective treatment option

OBJECTIVES

With advances in laparoscopic surgery, laparoscopic deroofing has gained wide acceptance in the surgical community to treat symptomatic non-parasitic hepatic cysts. Published non-surgical data still favour aspiration and sclerotherapy as treatment in these cases, though morbidity is higher and recurrence rates are not acceptable. We reviewed all patients that had been treated by laparoscopic deroofing in our department over a period of 6 years in order to find out if the surgical approach should be considered the standard treatment.

MATERIALS AND METHODS

Over a 6 year period, 34 laparoscopic deroofings were performed in 21 patients with symptomatic cysts. Patients underwent laparoscopy followed by radical deroofing using an Ultracision device.

RESULTS

All cases were completed laparoscopically, no intraoperative adverse events were recorded. Mean operation time was 101 ± 22.7 min. The mean size of treated cysts was 9.7 ± 2.18 cm. Follow up showed only one symptomatic recurrence (3.3%) two months after surgery.

CONCLUSION

Laparoscopic deroofing of hepatic cysts is a safe and effective treatment option. Recurrence rates are unprecedentedly low. Our data suggest that the risk of operation is justified and that the method is superior to sclerotherapy.

[Innovative application of radiofrequency in hepatic surgery. Preliminary experience]

Intraoperative blood loss has long been identified as one of the major morbidity and mortality predictors in liver surgery. A new approach towards achieving bloodless resection is the use of heat coagulative necrosis in healthy liver tissue, creating a zone of necrosis in which resection can be performed with a scalpel. We have used it for a variety of liver resections ranging from wedge resection to trisegmentectomy to establish the best indications. From March 2005 to June 2006 we performed 31 liver resections on 22 consecutive patients using this method. The most common indication was metastatic colorectal cancer (77.2%). We treated a heterogeneous patient series in terms of tumour location and extent of resection. Resectability was enhanced by means of downsizing chemotherapy (2 cases) and induction of portal hypertrophy (1 case). Twelve patients with metastatic colorectal cancer received adjuvant chemotherapy after the primary operation according to histological staging. Metastatic liver disease was synchronous in 7 cases and metachronous in 8 (mean time to metastasis 25.3 months). The operative spectrum ranged from parenchyma-saving atypical resections to extended right hepatectomy. With two exceptions, intraoperative blood loss was lower than 100 ml. Four patients (18.2%) developed surgery-related complications consisting in abscess formation at the resection site. Liver resection using the sealer device would appear to be a safe, time-efficient method, though it requires extensive knowledge of the anatomy of the intrahepatic vessels. Resections in the proximity of hilar structures or large vessels are not indicated for fear of thermal damage. Extended resections are possible if performed with a hybrid technique with conventional hilar preparation. In our experience this new application of radiofrequency-assisted liver resection seems to be effective and safe and may afford a number of advantages (no blood loss, short resection time. etc.) in selected cases.

[Hormone inactive parathyroid cyst: rare differential diagnosis in the evaluation of cervical cysts]

Parathyroid cysts are a very rare disease entity. Hormone activity is uncommon and they usually present without any clinical symptoms. The differential diagnosis of cystic neck masses should nevertheless include parathyroid cysts as surgical therapy can be very effective. We report the case of a 57-year-old patient presenting to our department with a hormone inactive parathyroid cyst. Final diagnosis was achieved eventually after histological examination of the resected specimen, which is the reason for evaluating the current data for preoperative management of this disease entity in this case report.

Value of staging laparoscopy for multimodal therapy planning in esophago-gastric cancer

The importance of multimodal treatment for advanced esophago-gastric cancer has contributed to the development of more accurate preoperative staging strategies. The impact of staging laparoscopy and cytology after conventional staging is evaluated in this study. Staging laparoscopy was performed in 125 patients with potentially resectable cancer of the distal esophagus or gastric cancer. Results were registered separately on a database according to the TNM classification of the International Union Against Cancer (UICC). Laparoscopy changed TNM classification in 46 cases. Explorative laparoscopy resulted in up-staging concerning the N-factor (n = 15) and M-factor (n = 28). Downstaging of the T-factor was recorded in three cases. Cytologic examination gave no additional information in our series. Our experience suggests a clear benefit of laparoscopy in staging of patients with distal esophagus or gastric malignancy. Laparoscopy is a safe and effective staging modality, avoiding unnecessary laparotomies and providing new means of directing appropriate treatment strategy.

Hepatic resection using heat coagulative necrosis. First report of successful trisegmentectomy after hypertrophy induction

INTRODUCTION

Intraoperative blood loss has been identified as one of the major mortality predictors for liver surgery. Different strategies have been used in the past to minimize blood loss during resection. A new method using heat coagulative necrosis in healthy tissue at the resection plane to achieve a bloodless resection has been described 3 years ago and has already gained acceptance for peripheral resections. A further developmental stage of this method is now available with the so-called Habib 4x sealer. So far, only resections ranging from segmentectomies to hemihepatectomies are reported.

MATERIALS AND METHODS

In the case reported here, the new method was challenged to perform an extended hepatic resection in a patient suffering from colorectal liver metastases. The resection was performed in a hybrid technique of regular hilar preparation and parenchymal dissection using the sealer.

CONCLUSION

The method showed to be safe and efficient even for an extended resection.