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.

A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data, surgical outcome and cost-effectiveness

PURPOSE

Laparoscopic techniques have been used and refined in hernia surgery for several years. The aim of this study was to compare an established method such as laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) with ventral Transabdominal Preperitoneal Patch Plasty (ventral-TAPP) in abdominal wall hernia repair.

METHODS

Patient-related data of 180 laparoscopic ventral hernia repairs between June 2014 and August 2020 were extracted from our prospectively maintained database. Of these patients, 34 underwent ventral-TAPP and 146 lap. IPOM. After excluding hernias with a defect size > 5 cm and obtaining balanced groups with propensity-score matching, a comparative analysis was performed in terms perioperative data, surgical outcomes and cost-effectiveness.

RESULTS

Propensity-score matching suggested 27 patients in each of the two cohorts. The statistical evaluation showed that intake of opiates was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.001). The Visual Analogue Scale (VAS) score after lap. IPOM repair was significantly higher at movement (p = 0.008) and at rest (p = 0.023). Also, maximum subjective pain during hospital stay was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.004). No hernia recurrence was detected in either group. The material costs of ventral-TAPP procedure (34.37 ± 0.47 €) were significantly lower than those of the lap. IPOM group (742.57 ± 128.44 € p = 0.001). The mean operation time was 65.19 ± 26.43 min in the lap. IPOM group and 58.65 ± 18.43 min in the ventral-TAPP cohort. Additionally, the length of hospital stay in the lap. IPOM cohort was significantly longer (p = 0.043).

CONCLUSION

Ventral-TAPP procedures represent an alternative technique to lap. IPOM repair to reduce the risk of complications related to intra-peritoneal position of mesh and fixating devices. In addition, our study showed that postoperative pain level, material costs and hospital stay of the ventral-TAPP cohort are significantly lower compared to lap. IPOM patients.

[Digital documentation of complications in visceral surgery: possibilities and evaluation of an instrument for quality management]

Against the background of the growing economization of clinical medicine, in the last decades the topics of risk and complication management have also become more important in surgical disciplines. The standardization and reproducible documentation of outcome and complication data play a key role for valid quality control. In this article a digital system implemented at the surgical clinic of the Charité University Medicine in Berlin is analyzed with respect to its practicability for perioperative and postoperative monitoring of complications within the framework of quality assurance.

Surgery for Renal Hyperparathyroidism in the Era of Cinacalcet: A Single-Center Experience

BACKGROUND AND AIMS

There are only few data on the influence of cinacalcet on the outcome of parathyroidectomy in patients with renal hyperparathyroidism. Indication and timing of surgery have changed since its introduction, especially with regard to kidney transplantation. Therefore, we retrospectively analyzed patients undergoing parathyroidectomy for renal hyperparathyroidism in our institution.

MATERIAL AND METHODS

Between 2008 and 2015, 196 consecutive operations in 191 patients were analyzed. About 80 operations (41%) were performed in patients receiving cinacalcet compared with 116 operations (59%) in patients without cinacalcet. Clinical data, preoperative medication, pre- and postoperative laboratory values, type and details of surgery including complications, as well as cardiovascular complications and kidney transplantation with graft function were recorded.

RESULTS

Demographical data were similar in patients with or without cinacalcet treatment. A total of 54% of patients received a kidney graft before or after parathyroidectomy. Pre- and postoperative parathormone levels were similar in both groups (preoperatively 755 vs 742 ng/L, postoperatively 50 vs 46 ng/L, p > 0.10), whereas patients with cinacalcet showed significantly lower calcium levels preoperatively (2.28 vs 2.41 mmol/L, p = 0.0002). There was no difference in recurrence or persistence of hyperparathyroidism, duration of surgery, hospital stay, or complication rate. Creatinine levels in patients with tertiary hyperparathyroidism were similar after 1-year follow-up.

CONCLUSION

Cinacalcet did not influence outcome of patients with parathyroidectomy for renal hyperparathyroidism and can be safely offered to patients not responding to medical treatment.

Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors

Introduction

As in the rest of the world, in Germany, inguinal hernia operations are among the most common operations. From an economic standpoint, very little is known about the influence of demographic, clinical or hernia-related parameters on the cost of inguinal hernia repair. We, therefore, evaluated individual patient parameters associated with higher costs with a special focus on multimorbidity.

Methods

A total of 916 patients underwent hernia repair for primary or recurrent inguinal hernia between 2014 and 2017 at a single university center and were included in the analysis. The clinical and financial data of these patients were analyzed to identify cost-increasing parameters.

Results

A majority of patients were male (90.7%), with a mean age of 55 years. The surgical methods utilized were mainly the TAPP (57.2%) and Lichtenstein (41.7%) procedures, with an average duration of surgery of 85 min and an average duration of anesthesia of 155 min. The mean cost of all procedures was 3338.3 € (± 1608.1 €).

Older age, multimorbidity, emergency operations with signs of incarceration, longer hospital stays and postoperative complications were significant cost-driving factors. On the other hand, sex, the side of the hernia (left vs. right) and the presence of recurrent hernias had no influence on the overall direct costs.

Conclusion

From a purely economic point of view, older age and multimorbidity are demographic cost-driving factors that cannot be influenced. The national hospital reimbursement system needs to consider and compensate for these factors. Emergency operations need to be prevented by early elective treatment. Long postoperative stays and postoperative complications need to be prevented by proper preoperative check-ups and accurate treatment.

[Transanal total mesorectal excision-Indications, technique and results]

Total mesorectal excision (TME) has become the standard treatment for rectal cancer in the middle and lower third. Meanwhile, many international trials have confirmed the noninferiority of laparoscopic TME compared to the open technique. Nevertheless, in the presence of anatomical limitations, such as narrow, obese, male pelvises as well as large rectal tumors, the adequate resection of the lower third of the rectum according to oncological criteria, is still challenging even for specialized colorectal surgeons. Therefore, the implementation of innovative approaches, such as robotic-assisted and transanal TME (TaTME) should shed light on this anatomically complex region and guarantee an oncological radical resection and the best possible preservation of neural structures. The advantages of this technique have so far only been provided by retrospective cohort studies by large international centers. Therefore, international prospective randomized trials are currently recruiting patients to analyze the surgical and oncological outcome of TaTME compared to conventional techniques. This article describes the TaTME technique per se, the fields of application and the current data situation. Practical recommendations for the safe implementation of this operative procedure are also presented. The TaTME procedure is reserved for highly specialized colorectal centers with a high volume of rectal cancer cases and appropriate expertise in minimally invasive visceral surgery.Die totale mesorektale Exzision (TME) ist der Goldstandard im Kontext der multimodalen Behandlung des Rektumkarzinoms im mittleren und unteren Drittel. Der transanale Zugang ist eine Ergänzung des zunehmend laparoskopischen Vorgehens, welcher gerade bei anatomischen Limitationen bei der onkologisch adäquaten Resektion des distalen Rektums Abhilfe schaffen soll. Die Nichtunterlegenheit in chirurgischen und onkologischen Parametern wird gegenüber konventionellen (laparoskopisch/offen) Operationsmethoden derzeit intensiv beforscht. Eine sichere Implementation dieser herausfordernden Technik ist an ein modulares Trainingskurrikulum gebunden.

[Laparoscopic versus open gastrectomy for advanced gastric cancer : Operative and postoperative results]

BACKGROUND

Minimally invasive gastrectomy is increasingly becoming established worldwide as an alternative to open gastrectomy (OG); however, the majority of available articles in the literature refer to Asian populations and early stages of gastric cancer. This makes an international comparison difficult due to a discrepancy in patient populations and tumor biology as well as Asian and western treatment approaches. Little is known, therefore, whether laparoscopic gastrectomy (LG) can be performed in advanced cancer, in particular with respect to laparoscopic D2 lymphadenectomy, with sufficient radicality and safety in this country.

MATERIAL AND METHODS

All gastrectomies performed for the treatment of advanced gastric cancer with clinical UICC stages 2 and 3 between 2005 and 2017 were analyzed. A case match by age, gender and UICC stage was performed to compare the operative and early postoperative results of LG and OG.

RESULTS

A total of 243 patients with advanced gastric cancer were analyzed. Of these 81 patients (33.3%) underwent LG. The operative time for LG was around 74 min longer (279.2 min vs. 353.4 min, OG vs. LG; p < 0.001), the hospital stay after LG was around 4 days shorter (22.9 days vs. 18.4 days, OG vs. LG; p < 0.001). Significantly more lymph nodes were resected by LG (24.1 lymph nodes vs. 28.8 lymph nodes, OG vs. LG; p < 0.001). In terms of morbidity and mortality there were no differences between the groups.

CONCLUSION

The present study showed that minimally invasive gastrectomy can be performed safely and with comparable histopathological results to open surgery, even in advanced gastric cancer in western populations; however, larger case series and evidence from high-quality studies are urgently needed especially to compare short-term and long-term survival.

[Innovations in surgery-How can new technologies be safely implemented in the clinical practice?]

Modern surgery is currently undergoing a significant change in the sense of the introduction of modern technologies and innovative techniques. Robotic-assisted surgery and modern techniques of visualization confront surgery with unprecedented challenges with respect to possible and meaningful areas of application for these innovations. If an innovation is not to remain only an interesting singularity as proof of feasibility and a sign of unchecked progress but is to have a fixed place within the framework of standardized treatment processes, firm regulations are required which flank the path from innovation to introduction into clinical practice. This overview article critically examines the deficits of the currently practiced models of introducing new technologies into the clinical practice and discusses new aspects that can improve the introduction of innovations with particular respect to patient safety.

Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma

INTRODUCTION

Pancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures.

PATIENTS AND METHODS

We retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003-2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification.

RESULTS

The median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety.

CONCLUSIONS

Often extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.

Intraabdominal continuous negative pressure therapy for secondary peritonitis: an observational trial in a maximum care center

Background: Acute secondary peritonitis is afflicted with a high morbidity and mortality. Intensive care therapy, antibiotics and surgical procedures are mandatory. Continuous negative pressure therapy (cNPT) seems to be beneficial but it is unclear which patients will benefit most from this procedures.Methods: We performed a prospective observational trial including all patients that needed to undergo an exploratory laparotomy for the suspicion of acute secondary peritonitis and were treated with cNPT in one year.Results: Thirty nine patients fitted the criteria. Median hospitalization length was 40 days. The vacuum therapy treatment was applied for a median of 4 days. The subgroup analysis between patients, who received the cNPT-dressing for one time (Group A) and patients, in whom the cNPT was continued after first relaparotomy (Group B) showed no differences concerning patients' characteristics. The Mannheimer Peritonitis Index (MPI) during the first operation was significantly correlated with the number of dressing changes (Spearman's rho 0.518, p = .002).Conclusions: Fast acting in acute secondary peritonitis for elimination of the source, abdominal lavage, derivation of the exsudat and interdisciplinary treatment is the treatment of choice. The MPI could be beneficial for the decision process of using cNPT.

Consensus on definition and severity grading of lymphatic complications after kidney transplantation

BACKGROUND

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.

METHODS

Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.

RESULTS

Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.

CONCLUSION

A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

Incidence of incisional hernia after laparoscopic liver resection

BACKGROUND

Minimally invasive techniques have been broadly introduced to liver surgery during the last couple of years. In this study, we aimed to report the incidence and potential risk factors for incisional hernia (IH) as well as health-related quality of life (HRQoL) after laparoscopic liver resections (LLR).

METHODS

All patients undergoing LLR between January 2014 and June 2017 were contacted for an outpatient hernia examination. In all eligible patients, photo documentation of the scar was performed and IH was evaluated by clinical examination and by ultrasound. Patients also completed a questionnaire to evaluate IH-specific symptoms and HRQoL. Obtained results were retrospectively analyzed with regard to patients' characteristics, perioperative outcomes and applied minimally invasive techniques, such as multi-incision laparoscopic liver surgery or hand-assisted/single-incision laparoscopic surgery (HALS/SILS).

RESULTS

Of 184 patients undergoing surgery, 161 (87.5%) met the inclusion criteria and 49 patients (26.6%) participated in this study. After a median time of 26 months (range 19-50 months) after surgery, we observed an overall incidence of IH of 12%. Five of 6 patients were overweight or obese (BMI ≥ 25) and 5 of 6 hernias were located at the umbilical site. Univariate analysis suggested the performance status at time of operation (ASA score ≥ 3; HR 5.616, 95% CI 1.012-31.157, p = 0.048) and the approach (HALS/SILS, HR 6.571, 95% CI 1.097-39.379, p = 0.039) as potential risk factors for IH. A higher frequency of hernia-related physical restrictions (HRR; p = 0.058) and a decreased physical functioning (p = 0.17) were noted in patients with IH; however, both being short of statistical significance.

CONCLUSION

Advantages of laparoscopic surgery with regard to low rates of IH can be translated to minimally invasive liver surgery. Even though there are low rates of IH, patients with poor performance status at the time of operation should be monitored closely. While patients' characteristics are hard to influence, it might be worth focusing on surgical factors such as the approach and the closure of the umbilical site to further minimize the rate of IH.

[Elective treatment of inguinal hernia in university surgery-an economic challenge]

INTRODUCTION

Elective and emergency inguinal hernia surgery is a central task for general and abdominal surgeons. As a standard procedure it is regarded as having a relatively low income in the German diagnosis-related groups (DRG) system. This can lead to an economic imbalance, especially in a cost-intensive environment of a university hospital. The aim of this analysis was to investigate the influence of clinical factors on costs and the contribution margin as well as the overall economic evaluation of elective inguinal hernia surgery at a university hospital.

MATERIAL AND METHODS

All patients undergoing elective inguinal hernia surgery at two locations of the Charité University Medicine Berlin in 2014 and 2015 were included in the analysis. The influence of clinical, patient and surgical factors on the economic outcome of the cases was evaluated.

RESULTS

A total of 419 patients were included, mostly after a Lichtenstein operation (44.9%) and laparoscopic transabdominal preperitoneal (TAPP) surgery (53.9%). The greatest impact on the economic outcome was the occurrence of postoperative complications. Also, a patient clinical complexity level (PCCL) value of >1, more than 8 encoded secondary diagnoses and a duration of hospital stay of less than 2 days had a significantly negative impact on the contribution margin. Overall, elective inguinal hernia surgery led to a negative contribution margin of € 651 per case.

CONCLUSION

Elective inguinal hernia surgery in the environment of a university hospital has a high financial deficit; however, since a complete discontinuation of this treatment is not an alternative multifactorial approaches are required to improve the economic outcome.

De-novo Upper Gastrointestinal Tract Cancer after Liver Transplantation: A Demographic Report

BACKGROUND

Immunosuppression is essential after liver transplantation (LT). It, however, increases the risk for cancer.

OBJECTIVE

To evaluate the prevalence and outcome of upper gastrointestinal (GI) tract cancer in LT patients and assess the perioperative risk of surgery for the upper GI malignancies post-LT.

METHODS

2855 patients underwent LT at our clinic from 1988 to 2018. 20 patients developed upper GI cancer. Data were retrospectively extracted from our database. Analysis included patients' specific data, tumor histopathology and stage, the treatment given and survival.

RESULTS

23 patients developed upper GI malignancies (2 gastric and 18 esophageal cancers; 3 excluded), translating to a incidence of 26.4 per 100,000 population per year. All patients were male. 80% showed alcohol-induced cirrhosis before LT. Most of the tumors were diagnosed at a stage ≥III. 70% underwent surgery and 78.6% developed postoperative complications. One-year-survival was 50%. Total survival rate was 28.6% with a median follow-up of 10 months (range: 0-184).

CONCLUSION

Upper GI malignancies are more common after LT compared to the general population. Men after LT, due to alcohol-induced liver cirrhosis, are at a higher risk. Upper GI surgery after LT can be safe, but the severe risk for complications and a poor survival require strict indications.

Hepatocyte Transplantation to the Liver via the Splenic Artery in a Juvenile Large Animal Model

Hepatocyte transplantation (HcTx) is a promising approach for the treatment of metabolic diseases in newborns and children. The most common application route is the portal vein, which is difficult to access in the newborn. Transfemoral access to the splenic artery for HcTx has been evaluated in adults, with trials suggesting hepatocyte translocation from the spleen to the liver with a reduced risk for thromboembolic complications. Using juvenile Göttingen minipigs, we aimed to evaluate feasibility of hepatocyte transplantation by transfemoral splenic artery catheterization, while providing insight on engraftment, translocation, viability, and thromboembolic complications. Four Göttingen Minipigs weighing 5.6 kg to 12.6 kg were infused with human hepatocytes (two infusions per cycle, 1.00E08 cells per kg body weight). Immunosuppression consisted of tacrolimus and prednisolone. The animals were sacrificed directly after cell infusion (n=2), 2 days (n=1), or 14 days after infusion (n=1). The splenic and portal venous blood flow was controlled via color-coded Doppler sonography. Computed tomography was performed on days 6 and 18 after the first infusion. Tissue samples were stained in search of human hepatocytes. Catheter placement was feasible in all cases without procedure-associated complications. Repetitive cell transplantations were possible without serious adverse effects associated with hepatocyte transplantation. Immunohistochemical staining has proven cell relocation to the portal venous system and liver parenchyma. However, cells were neither present in the liver nor the spleen 18 days after HcTx. Immunological analyses showed a response of the adaptive immune system to the human cells. We show that interventional cell application via the femoral artery is feasible in a juvenile large animal model of HcTx. Moreover, cells are able to pass through the spleen to relocate in the liver after splenic artery infusion. Further studies are necessary to compare this approach with umbilical or transhepatic hepatocyte administration.

[Surgical treatment of malignant biliary tract diseases]

BACKGROUND

Cancer of the intrahepatic and extrahepatic biliary tracts is characterized by a low incidence and a very heterogeneous appearance.

OBJECTIVE

Summary and evaluation of current surgical strategies in the treatment of malignant biliary tract diseases.

MATERIAL AND METHODS

An analysis of English language publications as well as European and American guidelines and recommendations for the surgical treatment of malignant diseases of the biliary tract was carried out. The results and recommendations were summarized and evaluated on the basis of experiences in this center.

RESULTS

Surgery is considered to be the only curative treatment option; however, prospective randomized studies and existing guidelines are based on limited evidence. Surgical strategies and the extent of resection differ between carcinomas of the intrahepatic and extrahepatic bile ducts depending on localization, size and number of lesions as well as their proximity to surrounding structures.

CONCLUSION

Sufficient experience in the treatment of these rare tumors is of special importance for the implementation of individualized overall concepts and for the sufficient performance of the mostly complex resections.

[High donor age for liver transplantation : Tackling organ scarcity in Germany]

BACKGROUND

Liver transplantation is the only curative treatment option for patients with end-stage liver disease; however, the 40% decline of available organ donors in recent years in Germany necessitates the optimization of available resources and possibly extending the criteria to older donors.

MATERIAL AND METHODS

All 2652 livers made available to the Charité Universitätsmedizin Berlin from 2010 to 2016 were retrospectively analyzed and the clinical outcome of 526 liver transplantations during this time frame were evaluated.

RESULTS

The median age of donors of transplanted organs increased from 49.3 years in 2010 to 57.3 years in 2016 (p = 0.02). Organs from donors ≥65 years were more frequently discarded than organs from younger donors (n = 344, 18.4% vs. n = 220, 28.1%; p = 0.005). Moreover, the older donors had higher rates of diabetes mellitus and hepatic steatosis. Organs from older donors had a higher donor risk index (2.8 vs. 2.2; p < 0.001) and were transplanted more often in patients with preserved liver function and hepatocellular carcinoma and liver cirrhosis (n = 121, 74.7% of indications). The 3‑year survival after liver transplantation from donors ≥65 and ≥80 years old was not significantly reduced in comparison to younger donors; however, there was an increased retransplantation rate (28.6%; p = 0.005) after transplantation of organs from donors ≥80 years old.

CONCLUSION

Despite conservative organ acceptance there were higher rates of retransplantation after transplantation from very old donors. In the light of an increasing scarcity of suitable organs this mandates caution and highlights the need for adequate assessment instruments for marginal donor organs before transplantation.

Secondary technical resectability of colorectal cancer liver metastases after chemotherapy with or without selective internal radiotherapy in the randomized SIRFLOX trial

Background

Secondary resection of initially unresectable colorectal cancer liver metastases (CRLM) can prolong survival. The added value of selective internal radiotherapy (SIRT) to downsize lesions for resection is not known. This study evaluated the change in technical resectability of CRLM with the addition of SIRT to FOLFOX‐based chemotherapy.

Methods

Baseline and follow‐up hepatic imaging of patients who received modified FOLFOX (mFOLFOX6: fluorouracil, leucovorin, oxaliplatin) chemotherapy with or without bevacizumab (control arm) versus mFOLFOX6 (with or without bevacizumab) plus SIRT using yttrium‐90 resin microspheres (SIRT arm) in the phase III SIRFLOX trial were reviewed by three or five (of 14) expert hepatopancreatobiliary surgeons for resectability. Reviewers were blinded to one another, treatment assignment, extrahepatic disease status, and information on clinical and scanning time points. Technical resectability was defined as at least 60 per cent of reviewers (3 of 5, or 2 of 3) assessing a patient's liver metastases as surgically removable.

Results

Some 472 patients were evaluable (SIRT, 244; control, 228). There was no significant baseline difference in the proportion of technically resectable liver metastases between SIRT (29, 11·9 per cent) and control (25, 11·0 per cent) arms (P = 0·775). At follow‐up, significantly more patients in both arms were deemed technically resectable compared with baseline: 159 of 472 (33·7 per cent) versus 54 of 472 (11·4 per cent) respectively (P = 0·001). More patients were resectable in the SIRT than in the control arm: 93 of 244 (38·1 per cent) versus 66 of 228 (28·9 per cent) respectively (P < 0·001).

Conclusion

Adding SIRT to chemotherapy may improve the resectability of unresectable CRLM.

Anastomotic leak after transanal total mesorectal excision: grading of severity and management aimed at preservation of the anastomosis

AIM

The transanal approach to total mesorectal excision (TaTME) as an alternative to conventional anterior resection offers an improved view to otherwise restricted anatomical regions in obese and narrow male pelves and unfavourable tumour locations. Guidelines for the management of anastomotic leakage (AL) following low rectal resections are scarce.

PATIENTS AND METHODS

Prospectively collected data of all consecutive patients undergoing TaTME between December 2014 and April 2017 in our centre were analysed retrospectively. Existing classification systems for AL were modified with regard to transanal anastomotic-preserving management.

RESULTS

TaTME was performed in 66 patients with a median age of 56.2 years. The overall incidence of AL was 12.1% (n = 8). AL grading was differentiated in Grades I to V according to the severity of necrosis and abscess development. Two patients suffered from AL Grade II, one patient from Grade III, three patients from Grade IV and two patients from Grade V. Preservation of the anastomosis following AL was achieved by the damage control concept in six of eight patients (75%) with a median duration of hospital stay of 36 days. Two patients received a Hartmann procedure (Grades IV and V).

CONCLUSION

Our study demonstrates that management of AL following TaTME is challenging but definitely amenable to strategies aimed at preserving the anastomosis by appropriate damage control. The modified classification system might serve as guidance for anastomosis-preserving management.

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery

AIM

Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers.

METHOD

This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement.

RESULTS

Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring.

CONCLUSION

A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

[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.

Laparoscopic versus open hemihepatectomy-a cost analysis after propensity score matching

INTRODUCTION

Cost efficiency is important for hospitals in order to provide high-quality health care for all patients. As hemihepatectomies are increasingly being performed laparoscopically, the aims of this study were to evaluate the costs of laparoscopic hemihepatectomy and to compare them to conventional open techniques.

PATIENTS AND METHODS

This is a retrospective analysis of clinical outcomes and financial calculations of all patients who underwent hemihepatectomy between January 2015 and December 2016 at the Department of Surgery, Campus Charité Mitte and Campus Charité Virchow-Klinikum, Berlin, Germany, being allocated to the DRG (diagnosis-related group) H01A (complex operations of the liver and pancreas with complex intensive care treatment) or H01B (operations of the liver and pancreas without complex intensive care treatment). To overcome selection bias, a 1:1 propensity score matching (PSM) analysis was performed.

RESULTS

After PSM, a total of 64 patients were identified; 32 patients underwent laparoscopic hemihepatectomy (LH); and 32 patients received open hemihepatectomy (OH). After PSM, no significant differences were observed in clinical baseline characteristics. The duration of surgery was significantly longer for patients undergoing LH compared to OH (LH, 334 min, 186-655 min; OH, 274 min, 176-454 min; p = 0.005). Patients in the LH group had a significantly shortened median hospital stay of 5 d, when compared to OH (LH, 9.5 d, 3-35 d; OH, 14.5 d, 7-37d; p = 0.005). We observed a significant higher rate of postoperative complication in the OH group (p = 0.022). Cost analysis showed median overall costs of 17,369.85€ in the LH group and 16,103.64€ in the OH group (p = 0.390).

CONCLUSION

Our data suggest that higher intraoperative costs of laparoscopic liver surgery, e.g., for surgical devices and due to longer operation times, are compensated by fewer postoperative complications and consecutive shorter length of stay when compared with OH.

Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a "Damage Control Strategy"

PURPOSE

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a "Damage Control Strategy" (DCS).

MATERIALS AND METHODS

Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis ∓ loop ileostomy or a Hartmann's procedure) after 24-48 h.

RESULTS

Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30-92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n = 17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n = 5), and median postoperative hospital stay was 18.5 days (3-66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).

CONCLUSION

The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

A comparison of laparoscopic and open repair of subxiphoid incisional hernias

INTRODUCTION

Incisional hernias to the subxiphoid region are rare and anatomically challenging, with bony and cartilaginous structures attaching, as well as conflating abdominal fascia. The repair of hernias in this region is, therefore, difficult and prone to recurrence. The surgical treatment can be done by open or laparoscopic repair but very little is known about which method is superior. We, therefore, reviewed our data of patients undergoing repair of subxiphoid hernias.

METHODS

Between January 2010 and June 2015 twenty-eight patients were treated by laparoscopic (n = 8) or open (n = 20) hernia repair due to an incisional hernia in the subxiphoid region. Patients with ventral hernias with an origin more distal than the M1-area only extending into the subxiphoid region and those undergoing suture hernia repair were excluded.

RESULTS

The hernia sizes, in terms of length, width and EHS classification, did not vary between open and laparoscopic repair. The duration of laparoscopic surgery was significantly shorter than the mean operative time for an open subxiphoid hernia repair (168.1 min vs. 96.1 min, respectively; p = 0.012). The groups did not differ significantly in terms of overall postoperative complications (p = 0.568) but the grade (Clavien-Dindo) of complications was higher following open repair leading to three reoperations. Within the follow-up time, we diagnosed significantly (p = 0.031) more subxiphoid hernia recurrences after laparoscopic repair (37.5%, n = 3) than after open repair (0%).

CONCLUSION

Laparoscopic and open repair of subxiphoid incisional hernias are both technically challenging compared to other midline hernias. Referring to our results laparoscopic repair has shorter operative times, lower postoperative morbidity with a higher recurrence rate compared to open repair but the sample size is too small for an overall conclusion.

[Tips and technical issues for performing transoral endoscopic thyroidectomy with vestibular approach (TOETVA): a novel scarless technique for neck surgery]

BACKGROUND

Nowadays, minimally invasive thyroid and parathyroid gland resections for both benign and malignant tumors are rarely performed. Recently, promising new endoscopic transoral approaches to the anterior neck have been described with good results and few complications. This study describes the first clinical series in Germany using transoral endoscopic thyroidectomy-vestibular approach (TOETVA) and identifies technical issues and solutions.

METHODS

The technique is indicated for hemithyroidectomy in patients without pre-existing neck operations. The technical steps consist of a 10 mm incision at the center of the oral vestibule, followed by subplatysmal hydrodissection. A blunt dissector stick is inserted creating a space below the platysma to the anterior neck and the infrahyoid muscles then three trocars are inserted in the vestibular area. After separation of the infrahyoid muscles, the thyroid isthmus is transected. Anatomical structures, such as the superior thyroid artery, parathyroid glands and the recurrent laryngeal nerve can be easily identified with magnification. Intraoperative neuromonitoring is used routinely, adding safety in avoiding nerve damage.

RESULTS

An optimal operative field due to subplatysmal dissection enables exposure of the thyroid and parathyroid glands. Several critical steps and suitable solutions were identified in the study. 1 Positioning of the team and technical improvements using the a 4K laparoscopic tower allowing enhanced view of the anatomy especially for dissection of the recurrent laryngeal nerve. 2. Lateral and upper positioning of lateral trocars avoiding mental nerve injury. 3. Initial hydrodissection of the subplatysmal space. 4. Use of one dissector progressively creating the operative space in the anterior cervical region. 5. Using internal-external sutures to retract the infrahyoid muscles. 6. Intraoperative neuromonitoring used routinely through the trocars or percutaneously through a 1 mm incision. 7. Extraction of the specimen through a recovery bag. 8. Drainages are possible, but can be avoided in small operative fields.

CONCLUSION

The new TOETVA technique for thyroid surgery is a promising option for selected patients to enable transoral thyroid and parathyroid surgery through the vestibular approach. Further studies in clinical series, especially regarding safety are needed to evaluate the indications of the technique.

No augmentation of indoleamine 2,3-dioxygenase (IDO) activity through belatacept treatment in liver transplant recipients

Belatacept is a second-generation cytotoxic T lymphocyte antigen (CTLA)-4 immunoglobulin (Ig) fusion protein approved for immunosuppression in renal transplant recipients. It was designed intentionally to interrupt co-stimulation via CD28 by binding to its ligands B7·1 and B7·2. Experimental evidence suggests a potential additional mechanism for CTLA-4 Ig compounds through binding to B7 molecules expressed on antigen-presenting cells (APCs) and up-regulation of indoleamine 2,3-dioxygenase (IDO), an immunomodulating enzyme that catalyzes the degradation of tryptophan to kynurenine and that down-regulates T cell immunity. So far it remains unknown whether belatacept up-regulates IDO in transplant recipients. We therefore investigated whether belatacept therapy enhances IDO activity in liver transplant recipients enrolled in a multi-centre, investigator-initiated substudy of the Phase II trial of belatacept in liver transplantation (IM103-045). Tryptophan and kynurenine serum levels were measured during the first 6 weeks post-transplant in liver transplant patients randomized to receive either belatacept or tacrolimus-based immunosuppression. There was no significant difference in IDO activity, as indicated by the kynurenine/tryptophan ratio, between belatacept and tacrolimus-treated patients in per-protocol and in intent-to-treat analyses. Moreover, no evidence was found that belatacept affects IDO in human dendritic cells (DC) in vitro. These data provide evidence that belatacept is not associated with detectable IDO induction in the clinical transplant setting compared to tacrolimus-treated patients.

Hepatotoxicity following systemic therapy for colorectal liver metastases and the impact of chemotherapy-associated liver injury on outcomes after curative liver resection

Patients with colorectal liver metastases (CLM) have remarkably benefited from the advances in medical multimodal treatment and surgical techniques over the last two decades leading to significant improvements in long-term survival. More patients are currently undergoing liver resection following neoadjuvant chemotherapy, which has been increasingly established within the framework of curative-indented treatment strategies. However, the use of several cytotoxic agents has been linked to specific liver injuries that not only impair the ability of liver tissue to regenerate but also decrease long-term survival. One of the most common agents included in modern chemotherapy regimens is oxaliplatin, which is considered to induce a parenchymal damage of the liver primarily involving the sinusoids defined as sinusoidal obstruction syndrome (SOS). Administration of bevacizumab, an inhibitor of vascular endothelial growth factor (VEGF), has been reported to improve response of CLM to chemotherapy in clinical studies, concomitantly protecting the liver from the development of SOS. In this review, we aim to summarize current data on multimodal treatment concepts for CLM, give an in-depth overview of liver damage caused by cytostatic agents focusing on oxaliplatin-induced SOS, and evaluate the role of bevacizumab to improve clinical outcomes of patients with CLM and to protect the liver from the development of SOS.

Computed tomography-based survey of the vascular anatomy of the juvenile Göttingen minipig

Over the past 50 years, image-guided procedures have been established for a wide range of applications. The development and clinical translation of new treatment regimens necessitate the availability of suitable animal models. The juvenile Göttingen minipig presents a favourable profile as a model for human infants. However, no information can be found regarding the vascular system of juvenile minipigs in the literature. Such information is imperative for planning the accessibility of target structures by catheterization. We present here a complete mapping of the arterial system of the juvenile minipig based on contrast-enhanced computed tomography. Four female animals weighing 6.13 ± 0.72 kg were used for the analyses. Imaging was performed under anaesthesia, and the measurement of the vascular structures was performed independently by four investigators. Our dataset forms a basis for future interventional studies in juvenile minipigs, and enables planning and refinement of future experiments according to the 3R (replacement, reduction and refinement) principles of animal research.

[The Impact of Tumor Cell Proliferation on Occult Micrometastases, Tumor Recurrence and Patient Outcome Following Resection for Liver Malignancies]

Liver resection is currently considered to be essential part of the curative treatment of primary and secondary liver malignancies. However, long-term survival in these patients is limited by the high incidence of tumor recurrence. Recent clinical and experimental studies have indicated that cellular and molecular mechanisms associated with liver regeneration after partial hepatectomy may have a proliferative effect on occult micrometastases and circulating tumor cells and are thus responsible for recurrent disease. Growth factors and cytokines involved in liver regeneration have also been shown to influence tumour growth and metastasis. However, the underlying mechanisms explaining the interactions between regenerating liver tissue and tumour cell proliferation remain unclear. The development of modern agents specifically targeting these processes may improve disease-free and overall survival rates after oncological hepatectomy.

Mitarbeiterzufriedenheit im Arbeitszeitmodell: Längsschnittstudie zu Praxistauglichkeit und Gesetzeskonformität in einer chirurgischen Klinik der Maximalversorgung

Hintergrund In dem Spannungsfeld zwischen Klinikorganisation, Arbeitszeitgesetz, Patientensicherheit, Nachwuchsmangel und Wettbewerbsfähigkeit ist die Entwicklung bestmöglicher Arbeitszeitmodelle zur Aufrechterhaltung maximaler Versorgungsqualität bei gleichzeitiger Gesetzeskonformität unabdingbar. Hierzu ist die Evaluation der Auswirkungen der Dienstmodelle auf die Mitarbeiterzufriedenheit sinnvoll.

Material und Methoden Nach Abschaffung des traditionellen 24-Stunden-Dienstes 2007 in einer chirurgischen Klinik der Maximalversorgung wurden konsekutiv ein 18-Stunden-Dienst und nachfolgend 2008 ein 12-Stunden-Dienstmodell zur Verbesserung der Übergabequalität und Reduktion von Übergabeverlusten implementiert. In einer begleitenden Mitarbeiterbefragung wurden die Auswirkungen auf Arbeitsorganisation, Lebensqualität und Einkommen in anonymisierten Fragebögen evaluiert. 2014 wurde die Mitarbeiterbefragung erneut durchgeführt.

Ergebnisse Bei 95% Rücklaufquote der Fragebögen 2008 und 93% Rücklaufquote 2014 wurde das 12-Stunden-Modell aufgrund der deutlich höheren Dienstfrequenz mit entsprechend höherer sozialer Belastung schlechter bewertet. Ebenso wurde die körperliche Belastung und chronische Müdigkeit im 12-Stunden-Dienst am schlechtesten bewertet. Der 18-Stunden-Dienst war das Modell der 1. Wahl bei den Mitarbeitern. Der 24-Stunden-Dienst wurde als beste Kompromisslösung zwischen Erfordernissen der Arbeitsorganisation und Mitarbeiterbedürfnissen gewertet und das Dienstmodell daraufhin 2015 erneut angepasst.

Schlussfolgerung Essenzielle Grundlage einer chirurgischen Klinik ist ein an die Erfordernisse der Arbeitsabläufe, des Arbeitszeitgesetzes und Bedürfnisse der Mitarbeiter angepasstes Dienstmodell. Der optimalen Arbeitsorganisation kann ein 12-Stunden-Dienstmodell gerecht werden, aber nur bei entsprechendem Personalschlüssel gelingt dies ohne Inkaufnahme einer zu hohen Dienstfrequenz mit entsprechend stark empfundener Beeinträchtigung der Lebensqualität. Eine Mitarbeiterbefragung sollte regelmäßig durchgeführt werden, um die tatsächlichen Auswirkungen des Dienstsystems erfassen und weiter optimieren zu können. Das viel kritisierte 24-Stunden-Dienstsystem erscheint mit Augmentierung durch einen Entlastungsdienst in den Abendstunden deutlich besser als sein Ruf.

Doppler-guided haemorrhoidal artery ligation with suture mucopexy compared with suture mucopexy alone for the treatment of Grade III haemorrhoids: a prospective randomized controlled trial

AIM

Novel minimally invasive techniques aimed to reposition the haemorrhoidal zone have been established for prolapsing haemorrhoids. We present a prospective randomized controlled trial to evaluate the efficacy of additional Doppler-guided ligation of submucosal haemorrhoidal arteries (DG-HAL) in patients with symptomatic Grade III haemorrhoids. The trial was registered as ClinicalTrials.gov identifier NCT02372981.

METHOD

All consecutive patients with symptomatic Grade III haemorrhoids were randomly allocated to one of the two study arms: (i) Group A, DG-HAL with mucopexy or (ii) Group B, mucopexy alone. End-points were postoperative pain, faecal incontinence, bleeding, residual prolapse and alterations of the vascularization of the anorectal vascular plexus. Vascularization of the anorectal vascular plexus was assessed by transperineal contrast enhanced ultrasound. Patients recorded their symptoms in a diary maintained for a month.

RESULTS

Forty patients were recruited and randomized to the two study groups. Patients in Group A had less pain in the first two postoperative weeks. At the 12-month follow-up, two patients in Group A (10%) and one in Group B (5%) showed recurrent Grade III haemorrhoids (P = 0.274). No significant morphological changes were observed in the transperineal ultrasound findings between the preoperative assessment and the assessment at 1 and 6 months in either group (P > 0.05).

CONCLUSION

Mucopexy techniques for treating prolapsing haemorrhoids are effective, but DG-HAL does not add significantly to the results achieved by mucopexy. Repositioning the haemorrhoidal zone is the key to success, and mucopexy should be placed at the sites of the largest visible prolapse.

Acute Graft Dysfunction 17 Years After Liver Transplant: A Challenging Clinical and Histologic Manifestation of Hepatitis E

Acute hepatitis E virus infection after liver transplant is a challenging clinical phenomenon. Due to its unspecific clinical and histological presentation, the diagnosis of acute or chronic hepatitis E virus infection can be difficult in unclear cases of elevated liver enzymes. Here, we report the case of a 56-year-old male patient who presented to our center for 17-year follow-up after liver transplant with α1-antitrypsin deficiency. The patient was asymptomatic but had remarkably increased transaminases and cholestasis parameters. Blood levels for immunosuppressives were in the normal range, and cholestasis and deteriorated liver perfusion were excluded by ultrasonographic examination. A liver biopsy was performed that was histologically interpreted as acute cellular rejection grade I. Accordingly, the patient was treated with 5-day high-dose intravenous steroids and increased doses of the maintenance immunosuppressive agents, resulting in the slow normalization of the liver enzymes. Extended laboratory examinations revealed presence of acute hepatitis E virus infection, and a retrospectively immunohistologic staining of the liver biopsy was positive for hepatitis E virus antigen. Acute hepatitis E virus infection can be a reason for acute allograft dysfunction after liver transplant. This differential diagnosis should be kept in mind, especially when graft dysfunction occurs long after transplant.

Influence of different positioning of a local pain catheter on postoperative pain after paramedian laparotomy-a blinded, randomized trial

BACKGROUND

Continuous application of local anaesthetics reduces postoperative pain after different approaches for laparotomy. In this randomized, blinded trial, we investigated the effect of continuous application of local anaesthetics after paramedian laparotomy either with subfascial or subcutaneous catheter in addition to a standardized systemic analgesia.

MATERIALS AND METHODS

Patients with stage III/IV melanoma and indication for radical iliac lymph node dissection (RILND) were randomized to a continuous application of a local anaesthetic through either a subfascial or subcutaneous catheter. Participants and those assessing the outcomes were blinded. The main outcome criterion was the pain level on the first postoperative morning while exercising measured with a visual analogue scale. Minor criteria were the pain measured by the area-under-curve until the third postoperative day, the patient's satisfaction with analgesic treatment, the analgesic requirement, the overall complications and the day of discharge.

RESULTS

Fifty-two patients were evaluated. Pain therapy was sufficient in both groups during the postoperative course while resting and during mobilization. There were no significant differences regarding the main and minor outcome criteria. Doses of additional analgesics did not differ between groups. No adverse events or side effects were observed.

CONCLUSION

For patients who undergo paramedian laparotomy, none of the investigated techniques is superior to the other at a median pain level under visual analogue scale (VAS) 30 mm on the first postoperative morning.

TRIAL REGISTRATION NUMBER

DRKS00003632 (German Register of Clinical Trials).