Prognostic value of deep learning-derived body composition in advanced pancreatic cancer-a retrospective multicenter study

BACKGROUND

Despite the prognostic relevance of cachexia in pancreatic cancer, individual body composition has not been routinely integrated into treatment planning. In this multicenter study, we investigated the prognostic value of sarcopenia and myosteatosis automatically extracted from routine computed tomography (CT) scans of patients with advanced pancreatic ductal adenocarcinoma (PDAC).

PATIENTS AND METHODS

We retrospectively analyzed clinical imaging data of 601 patients from three German cancer centers. We applied a deep learning approach to assess sarcopenia by the abdominal muscle-to-bone ratio (MBR) and myosteatosis by the ratio of abdominal inter- and intramuscular fat to muscle volume. In the pooled cohort, univariable and multivariable analyses were carried out to analyze the association between body composition markers and overall survival (OS). We analyzed the relationship between body composition markers and laboratory values during the first year of therapy in a subgroup using linear regression analysis adjusted for age, sex, and American Joint Committee on Cancer (AJCC) stage.

RESULTS

Deep learning-derived MBR [hazard ratio (HR) 0.60, 95% confidence interval (CI) 0.47-0.77, P < 0.005] and myosteatosis (HR 3.73, 95% CI 1.66-8.39, P < 0.005) were significantly associated with OS in univariable analysis. In multivariable analysis, MBR (P = 0.019) and myosteatosis (P = 0.02) were associated with OS independent of age, sex, and AJCC stage. In a subgroup, MBR and myosteatosis were associated with albumin and C-reactive protein levels after initiation of therapy. Additionally, MBR was also associated with hemoglobin and total protein levels.

CONCLUSIONS

Our work demonstrates that deep learning can be applied across cancer centers to automatically assess sarcopenia and myosteatosis from routine CT scans. We highlight the prognostic role of our proposed markers and show a strong relationship with protein levels, inflammation, and anemia. In clinical practice, automated body composition analysis holds the potential to further personalize cancer treatment.

Impact of encorafenib on survival of patients with BRAFV600E-mutant metastatic colorectal cancer in a real-world setting

PURPOSE

Patients with BRAFV600E-mutant metastatic colorectal cancer (mCRC) have a dismal prognosis. The best strategies in these patients remain elusive. Against this background, we report the clinical course of patients with BRAFV600E-mutant mCRC to retrieve the best treatment strategy.

PATIENTS AND METHODS

Clinico-pathological data were extracted from the electronic health records. Kaplan-Meier method was used to estimate overall (OS) and progression-free survival (PFS). Objective response rate (ORR) was assessed according to RECIST 1.1.

RESULTS

In total, 51 patients were enrolled. FOLFOXIRI was administered to 12 patients; 29 patients received FOLFOX or FOLFIRI as first-line treatment. Median OS was 17.6 months. Median PFS with FOLFOXIRI (13.0 months) was significantly prolonged (HR 0.325) as compared to FOLFOX/FOLFIRI (4.3 months). However, this failed to translate into an OS benefit (p = 0.433). Interestingly, addition of a monoclonal antibody to chemotherapy associated with superior OS (HR 0.523). A total of 64.7% patients received further-line therapy, which included a BRAF inhibitor in 17 patients. Targeted therapy associated with very favourable OS (25.1 months).

CONCLUSION

Patients with BRAFV600E-mutated mCRC benefit from the addition of an antibody to first-line chemotherapy. Further-line treatment including a BRAF inhibitor has a dramatic impact on survival.

Smaller panel, similar results: genomic profiling and molecularly informed therapy in pancreatic cancer

BACKGROUND

Pancreatic cancer has a dismal prognosis. One reason is resistance to cytotoxic drugs. Molecularly matched therapies might overcome this resistance but the best approach to identify those patients who may benefit is unknown. Therefore, we sought to evaluate a molecularly guided treatment approach.

MATERIALS AND METHODS

We retrospectively analyzed the clinical outcome and mutational status of patients with pancreatic cancer who received molecular profiling at the West German Cancer Center Essen from 2016 to 2021. We carried out a 47-gene DNA next-generation sequencing (NGS) panel. Furthermore, we assessed microsatellite instability-high/deficient mismatch repair (MSI-H/dMMR) status and, sequentially and only in case of KRAS wild-type, gene fusions via RNA-based NGS. Patient data and treatment were retrieved from the electronic medical records.

RESULTS

Of 190 included patients, 171 had pancreatic ductal adenocarcinoma (90%). One hundred and three patients had stage IV pancreatic cancer at diagnosis (54%). MMR analysis in 94 patients (94/190, 49.5%) identified 3 patients with dMMR (3/94, 3.2%). Notably, we identified 32 patients with KRAS wild-type status (16.8%). To identify driver alterations in these patients, we conducted an RNA-based fusion assay on 13 assessable samples and identified 5 potentially actionable fusions (5/13, 38.5%). Overall, we identified 34 patients with potentially actionable alterations (34/190, 17.9%). Of these 34 patients, 10 patients (10/34, 29.4%) finally received at least one molecularly targeted treatment and 4 patients had an exceptional response (>9 months on treatment).

CONCLUSIONS

Here, we show that a small-sized gene panel can suffice to identify relevant therapeutic options for pancreatic cancer patients. Informally comparing with previous large-scale studies, this approach yields a similar detection rate of actionable targets. We propose molecular sequencing of pancreatic cancer as standard of care to identify KRAS wild-type and rare molecular subsets for targeted treatment strategies.

Multimodal survival prediction in advanced pancreatic cancer using machine learning

Background

Existing risk scores appear insufficient to assess the individual survival risk of patients with advanced pancreatic ductal adenocarcinoma (PDAC) and do not take advantage of the variety of parameters that are collected during clinical care.

Methods

In this retrospective study, we built a random survival forest model from clinical data of 203 patients with advanced PDAC. The parameters were assessed before initiation of systemic treatment and included age, CA19-9, C-reactive protein, metastatic status, neutrophil-to-lymphocyte ratio and total serum protein level. Separate models including imaging and molecular parameters were built for subgroups.

Results

Over the entire cohort, a model based on clinical parameters achieved a c-index of 0.71. Our approach outperformed the American Joint Committee on Cancer (AJCC) staging system and the modified Glasgow Prognostic Score (mGPS) in the identification of high- and low-risk subgroups. Inclusion of the KRAS p.G12D mutational status could further improve the prediction, whereas radiomics data of the primary tumor only showed little benefit. In an external validation cohort of PDAC patients with liver metastases, our model achieved a c-index of 0.67 (mGPS: 0.59).

Conclusions

The combination of multimodal data and machine-learning algorithms holds potential for personalized prognostication in advanced PDAC already at diagnosis.

•

We developed a machine-learning-based prediction model that outperforms the AJCC staging system and mGPS.

•

Applying our model to an external validation cohort demonstrates generalizability.

•

Explainable machine learning enables to understand the decision making of our model and identifies relevant parameters.

•

Combining clinical, imaging and genetic data holds potential for personalized prognostication in advanced PDAC.

[Imatinib and beyond-what is important for surgery?]

The treatment of gastrointestinal stromal tumors (GIST) has dramatically improved since the introduction of small molecule KIT proto-oncogene receptor tyrosine kinase inhibitors. Nevertheless, the cure of patients is still based on surgical treatment of the primary tumor. The chance of long-term tumor control by tyrosine kinase inhibitors (TKI) even in the metastatic setting also appears to be improved after achieving a surgical complete resection. The decision on which patients will most likely profit from multimodal treatment approaches is increasingly based on complex molecular predictors in addition to clinical factors and also a profound understanding of the biology of GIST that requires discussion in a multidisciplinary, highly experienced treatment team. Novel, more potent inhibitors enable a response to treatment in so far treatment-refractory GIST subtypes, such as the platelet-derived growth factor receptor (PDGFR) D842V mutated GIST subtype and also appear to show treatment benefits even in KIT mutated GIST after the failure of all approved treatments. These treatments are expected to profoundly change treatment algorithms in the near future.

Solid Organ Transplantation After Retrieval From Deceased Donors With Abdominal Aortic Grafts

INTRODUCTION

Organ procurement from deceased donors has been steadily augmented over the last 20 years. With a more aged donor population, a higher incidence of intraabdominal pathologies, including abdominal aortic aneurysms and atherosclerotic aortic disease, is commonly being encountered. The objective of our study was to report our institutional experience with abdominal aortic grafts during solid organ harvesting.

PATIENTS AND METHODS

Data concerning the presence of aortic grafts in deceased solid organ donors during a 36-month period were retrospectively reviewed.

RESULTS

During the study period, the organ retrieval team of our institution performed 246 multiorgan retrievals from deceased donors. More specifically, we harvested 6 livers and 12 kidneys from 6 donors with abdominal aortic grafts, which were not known/diagnosed to the organ retrieving team prior to the harvesting procedure. Severe atherosclerosis was present in all these donors. All 18 harvested organs were successfully transplanted. Apart of the absence of the aortic patch in 5 kidney grafts, no further special technical difficulties have been reported by the transplant teams. Data analysis of the recipient and graft outcome was performed through the Eurotransplant database.

CONCLUSION

There are so far no literature data on the outcome of recipients and grafts from deceased donors with abdominal aortic grafts. Although retrieval of such organs is very challenging and requires a very experienced team, the transplantation of the corresponding organs can be performed without special technical problems.

Long-term follow-up of patients with GIST undergoing metastasectomy in the era of imatinib -- analysis of prognostic factors (EORTC-STBSG collaborative study)

BACKGROUND

Long-term complete remissions remain a rare exception in patients with metastatic gastrointestinal stromal tumors (GIST) treated with IM (imatinib). To date the therapeutic relevance of surgical resection of metastatic disease remains unknown except for the use in palliative intent.

PATIENTS AND METHODS

We analyzed overall survival (OS) and progression-free survival (PFS) in consecutive patients with metastatic GIST who underwent metastasectomy and received IM therapy (n = 239).

RESULTS

Complete resection (R0+R1) was achieved in 177 patients. Median OS was 8.7 y for R0/R1 and 5.3 y in pts with R2 resection (p = 0.0001). In the group who were in remission at time of resection median OS was not reached in the R0/R1 surgery and 5.1 y in the R2-surgery (p = 0.0001). Median time to relapse/progression after resection of residual disease was not reached in the R0/R1 and 1.9 years in the R2 group of patients, who were resected in response. No difference in mPFS was seen in patients progressing at time of surgery.

CONCLUSIONS

Our analysis implicates possible long-term survival in patients in whom surgical complete remission can be achieved. Incomplete resection, including debulking surgery does not seem to prolong survival. Despite the retrospective character and likely selection bias, this analysis may help in decision making for surgical approaches in metastatic GIST.

Liver transplantation for hepatocellular carcinoma using extended criteria donor grafts

BACKGROUND

Liver transplantation (OLT) represents the treatment of choice for small hepatocellular carcinomas (HCC) in patients with end-stage liver disease. However, because of organ scarcity, alternative options must be explored, such as the use of extended criteria donor (ECD) grafts.

PATIENTS AND METHODS

We reviewed data of transplanted HCC patients using ECD grafts. Statistical analysis included uni- and multivariate Cox proportional hazards regression and survival analysis using the Kaplan-Meier method with the log-rank test.

RESULTS

Over a 6-year period, we transplanted 53 HCC patients with ECD grafts. The 38 men and 15 women showed a mean age of 56.3 ± 8.26 years. Thirty-four patients underwent a bridging treatment before OLT. Thirty-eight patients (72%) were outside the Milan criteria. The median value for alpha fetoprotein (AFP) level was 30.7 ng/dL. Pathologic tumor grade was G1 (n = 4), G2 (n = 32), G3 (n = 6), or Gx (n = 11). Median follow-up time was 23 months (range, 9-75). Overall 3- and 5- year patient survivals were 79% and 74%, respectively. The 5-year survivals for patients within or outside the Milan criteria were 87% versus 69%, respectively (P = .3728). Donor transaminases and post-OLT hemodialysis were prognostic factors for patient survival upon mutivariate regression analysis (P = .0043 and P = .0003, respectively).

CONCLUSION

OLT with ECD grafts constitutes an additional option for patients with HCC and cirrhosis, particularly subjects outside the Milan criteria. The risk- benefit ratio in these instances should be evaluated on a case-by-case basis.

Cholecystectomy due to symptomatic gallbladder disease after orthotopic liver transplantation: report of three cases

Although biliary stones and sludge are relatively common after liver transplantation (OLT), symptomatic cholecystolithiasis or acute cholecystitis have rarely been reported. Until the early 1990s few transplant centers preserved the donor's gallbladder for transplantation with the liver graft. This technique allows one to perform procedures, such as cholecystojejunostomy or a donor gallbladder conduit for biliary tract reconstruction, to treat posttransplant biliary complications. Herein we have reported three cases of successful either laparoscopic or open cholecystectomy for symptomatic cholecystolithiasis or acute cholecystitis between 14 and 19 years after OLT, as well as a systematic literature review.

When the heart kills the liver: acute liver failure in congestive heart failure

Congestive heart failure as a cause of acute liver failure is rarely documented with only a few cases.

Although the pathophysiology is poorly understood, there is rising evidence, that low cardiac output with consecutive reduction in hepatic blood flow is a main causing factor, rather than hypotension. In the setting of acute liver failure due to congestive heart failure, clinical signs of the latter can be absent, which requires an appropriate diagnostic approach.

As a reference center for acute liver failure and liver transplantation we recorded from May 2003 to December 2007 202 admissions with the primary diagnoses acute liver failure. 13/202 was due to congestive heart failure, which was associated with a mortality rate of 54%. Leading cause of death was the underlying heart failure. Asparagine transaminase (AST), bilirubin, and international normalized ratio (INR) did not differ significantly in surviving and deceased patients at admission. Despite both groups had signs of cardiogenic shock, the cardiac index (CI) was significantly higher in the survival group on admission as compared with non-survivors (2.1 L/min/m² vs. 1.6 L/min/m², p = 0.04). Central venous - and pulmonary wedge pressure did not differ significantly. Remarkable improvement of liver function was recorded in the group, who recovered from cardiogenic shock.

In conclusion, patients with acute liver failure require an appropriate diagnostic approach. Congestive heart failure should always be considered as a possible cause of acute liver failure.

Cost-effectiveness of hypothermic machine preservation versus static cold storage in renal transplantation

Static cold storage (CS) is the most widely used organ preservation method for deceased donor kidney grafts but there is increasing evidence that hypothermic machine perfusion (MP) may result in better outcome after transplantation. We performed an economic evaluation of MP versus CS alongside a multicenter RCT investigating short- and long-term cost-effectiveness. Three hundred thirty-six consecutive kidney pairs were included, one of which was assigned to MP and one to CS. The economic evaluation combined the short-term results based on the empirical data from the study with a Markov model with a 10-year time horizon. Direct medical costs of hospital stay, dialysis treatment, and complications were included. Data regarding long-term survival, quality of life, and long-term costs were derived from literature. The short-term evaluation showed that MP reduced the risk of delayed graft function and graft failure at lower costs than CS. The Markov model revealed cost savings of $86,750 per life-year gained in favor of MP. The corresponding incremental cost-utility ratio was minus $496,223 per quality-adjusted life-year (QALY) gained. We conclude that life-years and QALYs can be gained while reducing costs at the same time, when kidneys are preserved by MP instead of CS.

The prognostic value of renal resistance during hypothermic machine perfusion of deceased donor kidneys

Vascular renal resistance (RR) during hypothermic machine perfusion (HMP) is frequently used in kidney graft quality assessment. However, the association between RR and outcome has never been prospectively validated. Prospectively collected RR values of 302 machine-perfused deceased donor kidneys of all types (standard and extended criteria donor kidneys and kidneys donated after cardiac death), transplanted without prior knowledge of these RR values, were studied. In this cohort, we determined the association between RR and delayed graft function (DGF) and 1-year graft survival. The RR (mmHg/mL/min) at the end of HMP was an independent risk factor for DGF (odds ratio 38.1 [1.56-934]; p = 0.026) [corrected] but the predictive value of RR was low, reflected by a c-statistic of the receiver operator characteristic curve of 0.58. The RR was also found to be an independent risk factor for 1-year graft failure (hazard ratio 12.33 [1.11-136.85]; p = 0.004). Determinants of transplant outcome are multifactorial in nature and this study identifies RR as an additional parameter to take into account when evaluating graft quality and estimating the likelihood of successful outcome. However, RR as a stand-alone quality assessment tool cannot be used to predict outcome with sufficient precision.

Efficacy and safety of linezolid in liver transplant patients

Bacterial infections are the main cause of death within the first year after liver transplantation, and the increased incidence of multidrug-resistant gram-positive pathogens has created a major challenge in the treatment of these patients. Linezolid, the first US Food & Drug Administration-approved oxazolidinone, offers a valuable novel treatment option for serious gram-positive infections. Linezolid is relatively non-toxic but prolonged treatment with linezolid was associated with thrombocytopenia. Here we report on the experience of linezolid treatment in adult liver transplant patients, who are at an increased risk for thrombocytopenia because of hypersplenism. From November 2003 until December 2009, we evaluated the clinical course of 46 liver transplant patients (27 male/19 female) in our surgical intensive care unit. For proven or probable gram-positive infection, all patients received linezolid 600 mg intravenously every 12 h. On clinical improvement, treatment was changed to oral linezolid 600 mg twice daily. Treatment duration was 11 ± 7 days. Treatment indications were pneumonia (n = 8), blood stream infection (n = 30), and surgical site/abdominal infection (n = 3). Clinical cure was achieved in 43 out of 46 patients. During the course of treatment, no cases of severe thrombocytopenia occurred and a statistically significant platelet count increase was seen from day 1 (110 ± 73/nL) to day 7 (165 ± 116/nL) and day 14 (180 ± 140/nL). We did not observe any further adverse events, especially no severe neurological complications (e.g., serotonin syndrome) or signs of lactate acidosis. Two patients died from uncontrolled vancomycin-resistant Enterococcus faecium sepsis with septic shock and one due to uncontrolled methicillin-resistant Staphylococcus aureus pneumonia. These deaths were considered to be unrelated to linezolid treatment, and linezolid was regarded as the optimal treatment choice in these patients. A subgroup analysis of patients treated for >14 days revealed no statistically significant differences when compared with patients on shorter treatment. In particular, no cases of thrombocytopenia occurred during longer treatment. In conclusion, linezolid is a safe and effective treatment for adult liver transplant patients with gram-positive infections.

Laparoscopic live donor nephrectomy: Are ten cases per year enough to reach the quality standards? A report from a single small-volume transplant center

BACKGROUND

Laparoscopic live donor nephrectomy is the preferred method of kidney donation in high-volume US transplant centers, but for small transplant programs the question of the minimal case load per year necessary to reach the quality standards is open.

PATIENTS AND METHODS

From 1996 to 2007 we performed 130 live kidney donations including 93 laparoscopic donor nephrectomies followed by transplantation in a community hospital with an average case load of 10 laparoscopic cases per year. We compared the results after 37 open and 93 laparoscopic live donor operations with respect to operating time, conversion rate, complications, and recipients' outcome.

RESULTS

There were no significant differences in terms of safe outcome of donor patients after open or laparoscopic donor nephrectomy. The mean operating time was significantly shorter (p < 0.001) in the open group (125 min, OG) than in the laparoscopic group (150 min, LG). Mean hospital stay was significantly shorter (p < 0.001) in LG (6.8 days) versus OG (9.7 days). The conversion rate was 3.2% in the LG. Postoperative complication of donors consisted of temporary nerve irritation (two patients) and retroperitoneal hematoma (one patient) in the LG, and wound infection followed by hernia formation (one patient) and ileus 1 year after organ donation (one patient) in the OG. Safe outcome of the recipients after open (RaOD) or laparoscopic donation (RaLD) was similar. Uneventful transplantation occurred in 94.6% of the RaOD and in 92.5% of the RaLD. One kidney was lost due to renal vein thrombosis (RaLD). Mean postoperative creatinine after 4 weeks showed no difference between RaOD (1.6 mg/dl) and RaLD (1.7 mg/dl).

CONCLUSION

Approximately ten cases per year may be enough to ensure safety and quality of laparoscopic live donor nephrectomy.

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration.

RESULTS

Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively.

CONCLUSIONS

The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

[Kidney procurement and transplantation from a surgical perspective]

Kidney transplantation is the best therapeutic option in many patients with end-stage renal disease, because it significantly increases lifespan over that of patients who remain on dialysis. Because of organ shortage the average waiting time for a suitable kidney in Germany is about four years after the onset of dialysis treatment. Currently about 80% of all transplanted kidneys are obtained from brain-dead patients. The possibility for kidney transplantation after living donation reduces the minimum waiting time to a few weeks. An optimized organizational strategy as well as donor and recipient preparation are possible in living donation, resulting in excellent transplant quality and a short cold-ischemia time. Pre-emptive kidney transplantation after living donation is an attractive treatment option without the need for previous dialysis and is also an option for children. The excellent long-term results after kidney transplantation have been caused by improvement of operative technique, organizational strategy, donor preparation, postoperative care and, in particular, immunosuppression.

[Paraneoplastic thrombosis of the internal jugular and subclavian veins as first manifestation of gall bladder cancer]

HISTORY AND CLINICAL FINDINGS

A 69-year-old woman presented with a cervical swelling of unknown cause.

INVESTIGATION AND DIAGNOSIS

Computed tomograph (CT) and phlebography showed extensive thrombosis of sigmoid sinus and the internal jugular, brachiocephalic and subclavian veins on the left side. Blood coagulation tests were unremarkable. A paraneoplastic cause for the thrombosis could be ruled out as well. The CT revealed only cholecystolithiasis and anadrenal incidentaloma.

TREATMENT AND COURSE

Oral anticoagulation was initiated. One year later a carcinoma of the gall bladder with involvement of the liver was detected at laparoscopic cholecystectomy. Reoperation was performed but not all tumor tissue was resected. Nine months later an intraabdominal metastasis was excised.

CONCLUSION

If a paraneoplastic thrombosis but susected but the search for a tumor has been unsuccessful, even an asymptomatic cholecystolithiasis should be treated with a cholecystectomy.

Eurotransplant special request for high-urgency status after liver transplantation for hepatocellular carcinoma: a case report

Hepatic artery thrombosis after liver transplantation remains a major indication for retransplantation. We report the case of a 49-year-old man with a hepatocellular carcinoma in the setting of cirrhosis associated with chronic hepatitis B and C infections who underwent split liver transplantation. The patient experienced a complicated postoperative course, characterized by 2 relaparotomies for necrosis of segment IV, and a late hepatic artery thrombosis, first discovered on postoperative day 20. His subsequent course was characterized by relapsing cholangitis and liver abscesses requiring antibiotics and percutaneous drainage. Transient control of the septic complications allowed for the filing of a special high-urgency status request that was approved by Eurotransplant. The patient underwent retransplantation 1 week later with a full-size deceased donor graft. He is currently alive, well, with no evidence of tumor recurrence at 30 months posttransplantation. The existence of exceptions within the system, such as the "special high-urgency status" of Eurotransplant, as well as the aggressive treatment of complications to obtain a "window of clinical opportunity" saved this patient's life.

[The way to establish laparoscopic donor nephrectomy as the method of choice in live kidney donation--a single centre experience]

INTRODUCTION

In contrast to the USA, laparoscopic donor nephrectomy is rarely practised in German transplant centres. Safety concerns and difficulties with the learning curve of this advanced laparoscopic procedure are the main obstacles to the establishment of this operation.

PATIENTS AND METHODS

From 1998-2005, we performed laparoscopic kidney procurement in 50 live kidney donors on an intention to treat basis harvesting a total of 29 left and 21 right kidneys for transplantation.

RESULTS

Negative adverse effects on the donor side were temporary nerve irritation (2 patients) and postoperative retroperitoneal hematoma. Reasons to convert to open nephrectomy were bleeding (2 patients) and adhesions (1 patient). On the recipient side, one kidney was lost due to renal vein thrombosis. Three patients required short-time dialysis after transplantation. All other kidney transplants worked without any problems.

CONCLUSION

Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our hospital.

Efficacy of C0 and C2 monitoring in adult liver transplant recipients treated with neoral, mycophenolate mofetil, and steroids

BACKGROUND

Adjustment of induction therapy with Neoral after liver transplantation according to C2 levels yields a reduced incidence of rejection compared with C0 monitoring. A combination with mycophenolate mofetil may further reduce episodes of acute rejection. The purpose of this analysis was to evaluate the predictive value of C0 and C2 monitoring and the influence of primary dysfunction in liver transplant recipients receiving induction therapy with Neoral, mycophenolate mofetil, and steroids.

PATIENTS AND METHODS

One hundred consecutive adult liver transplant recipients were analyzed. Neoral doses were solely adjusted according to C0 target levels in the first week by daily analysis of C0 levels. C2 levels were also measured, but results did not influence the decision process of daily Neoral adjustments.

RESULTS

The 3-month survival rate for all patients was 83%. For a further analysis, 35 patients were excluded, the remaining 65 patients experienced 15 rejections (23.1%). Patients who did reach C0 target levels by days 3, 5, or 7 had rejection rates no different from those who did not reach C0 target levels. The patients who did reach C2 target levels by day 7 showed a significantly lower rejection rate compared with those who did not reach these levels. Comparison of rejection rates among patients with primary function grades I and II versus grades III and IV revealed a significant difference. There was no correlation between Model for End-Stage Liver Disease (MELD) score and acute rejection episodes.

CONCLUSION

Achievement of C2 target levels by day 7, especially in the combination of Neoral with mycophenolate mofetil, led to a remarkably low acute rejection rate following liver transplantation.

Laparoscopic live donor nephrectomy for right kidneys: Experience in a German community hospital

BACKGROUND

Laparoscopic live donor nephrectomy has become the new gold standard for kidney procurement in many high-volume transplant centres worldwide, but it is often limited to left-sided donor kidneys. Concerns about adequate anatomical renal vessel length and sufficient surgical exposure are the main obstacles to the use of the laparoscopic approach for right kidney live donors as well.

MATERIAL AND METHODS

From 1998 to 2006 we performed laparoscopic kidney procurement in 73 live kidney donors on an intention-to-treat basis, harvesting a total of 48 left (LKG) and 25 right kidneys (RKG) for transplantation. We compared these two groups with respect to operating time, conversion rate, complications, hospital stay, and recipient outcome.

RESULTS

There were no differences in outcome of donor patients after left (D-LKG) or right laparoscopic donor nephrectomy (D-RKG). Operating time was 160 min in D-RKG versus 164 min in D-LKG. Warm ischemia was below 150 s in both groups. Hospital stay was 7.0 (D-RKG) versus 6.7 days (D-LKG). Negative events on the donor site were one temporary nerve irritation in each group and one postoperative retroperitoneal hematoma in the left kidney group. Reasons to convert to open nephrectomy were bleeding in two patients in the left kidney group and adhesions in one patient in the right kidney group. The outcome of the recipients after left (R-LKG) or right kidney (R-RKG) transplantation was similar. One kidney was lost due to renal vein thrombosis (R-LKG). Postoperative ureter complications occurred in one patient of each group. One patient of the R-RKG and two patients of the R-LKG required lymphocele fenestration. All other kidney transplants worked without problems.

CONCLUSION

Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our clinic. Laparoscopic procurement of right and left kidneys can be performed with comparable quality and outcome for donors and recipients.

Results of Kidney Transplantation With Simultaneous Implantation of Vascular Graft

BACKGROUND

Arteriosclerosis and calcification of iliac arteries are common in patients on dialysis. This study sought to evaluate the outcome after kidney transplantation and simultaneous implantation of vascular grafts.

PATIENTS AND METHODS

In a single center study we evaluated donor and recipient data among 443 kidney transplantations in adults performed between January 2002 and October 2006. In 11 recipients (2.5%) a vascular graft (Gore-Tex) was implanted due to severe arterioscleroses of the iliac vessels.

RESULTS

Reconstruction of the lower limb blood supply was performed with an ileofemoral Gore-Tex-Bypass in 9 of 11 patients, with an aortofemoral bypass in 1 patient, and with a femoroiliac crossover bypass in 1 patient. Overall, 8 of 11 patients (73%) had an uneventful postoperative course. Six of 11 patients had primary graft function.

CONCLUSIONS

This analysis demonstrated that vascular reconstruction during kidney transplantation has to be performed rarely but has a strong impact on further life and kidney function. In 8 of 11 patients, kidney function at 6 months was good. Severe arteriosclerosis is usually not a contraindication for kidney transplantation. However, training in vascular surgery seems to be important to achieve satisfying results. In this series, simultaneous implantation of vascular prosthetic grafts was safe since there were no infectious complications of the graft itself.

Staging laparoscopy in gastric cancer

BACKGROUND

As patients with gastric cancer are offered choices between surgical resection, neoadjuvant or palliative chemotherapy, or symptomatic relief alone, the need for accurate preoperative staging becomes apparent. Laparoscopy has been suggested as an appropriate staging modality in a variety of upper gastrointestinal malignancies.

METHODOLOGY

Staging laparoscopy was performed in 45 patients with potentially resectable gastric cancer as determined by physical examination, gastroscopy, endosonography, transcutaneous ultrasonography and current generation computed tomography. Conventional clinic staging and laparoscopic staging according to the Tumor-Node-Metastases classification of the International Union against Cancer were registered separately on a database. Results were then compared to evaluate the agreement of both staging procedures.

RESULTS

Compared to conventional staging, laparoscopy resulted in up staging of 23 patients (51.1%). In 10 patients of them peritoneal seeding was first found during laparoscopy, whereas additional liver metastases were detected in 3 patients and Krukenberg's tumor in one. As a consequence, the therapy planning was changed and laparotomy was avoided in 14 of these patients as the first operative procedure. Sensitivity of clinical staging was especially poor for stage IV tumors (5.3%) and for the majority of stage IIIB tumors (42.9%). Cytologic examination of peritoneal fluid had no additional information in our series.

CONCLUSIONS

The value of laparoscopy in staging patients with gastric carcinoma could be demonstrated in this study. It is a safe and effective staging modality, helping to avoid unnecessary laparotomies and providing new means of directing appropriate treatment strategy.

Complicated diverticulitis of the sigmoid: a prospective study concerning primary resection with secure primary anastomosis

BACKGROUND

The Hartmann procedure remains the standard concerning the surgical treatment of acute complicated sigmoid diverticulitis. The aim of this study was to prove the possibility of performing a secure primary anastomosis without colostomy in patients with complicated acute diverticulitis.

METHODS

From June 1988 to October 1996, 113 patients suffering from acute complicated sigmoid diverticulitis were included in this prospective study. Within 24-48 h of hospital admission, when symptoms of the illness persisted despite the use of antibiotic therapy, the patients underwent primary resection of the sigmoid. In all patients primary anastomosis was performed, using CEEA staplers, avoiding colostomy and intraoperative colon irrigation.

RESULTS

During the observation period of 19 days, there was no anastomotic leakage found either by radiological methods or clinical parameters. Two patients died of early septic complications, 1 of therapy-resistant endocarditis.

CONCLUSION

The results of this study demonstrate the safety of primary anastomosis after primary resection of the sigmoid under antibiotic conditions, avoiding the disadvantages associated with two-stage procedures.

[Long-term results after tension-free inguinal hernia repair]

A total of 186 consecutive patients underwent open tension-free inguinal hernia repair, either on one or both sides. Overall, 220 hernias were repaired under local anesthesia conditions after intraoperatively classifying the size of the hernia. The follow-up investigation took place as planned in 165 hernias. The mean follow-up time was 15.5 months, with a range from 6.6 to 30. 8 months, and the follow-up rate was 75.0 %. During this first follow-up it was especially interesting to read the patients, self-assessment concerning their physical restrictions during the first month after the operation. Furthermore, we were interested in learning about the objective and subjective operation-linked consequences in the patients, inguinal region. Most patients (89.7 %) were able to do sports and drive their car; 86.1 % were able to manage their usual physical activity 4 weeks after the operation. Focusing on the operation site, patients complained about chronic unpleasant effects, such as mild pain (21.2 %), local hypoesthesia (12.1 %), weather-dependent changes in sensitivity (7.2 %), moderate pain (3.6 %), inguinal syndrome (1.8 %) and hyperesthesia (1.2 %). Persistent swelling in the parainguinal region was found in 1.8 % of the patients and only one recurrence was found (0.6 %). In the analysis we found that mild chronic pain was not related to the time period after the operation and the age or sex of the patient, but there was a correlation with the size of the hernia. Patients with small hernias significantly more often experienced chronic pain than patients with bigger hernias. These results suggest that open tension-free inguinal hernia repair according to Lichtenstein appears to be overtreatment in patients with small inguinal hernias.

Randomized clinical trial of conventional cholecystectomy versus minicholecystectomy

BACKGROUND

The main argument for laparoscopic cholecystectomy in preference to open cholecystectomy appears to be based on less traumatic incisions inflicted on the abdominal wall. To investigate the effects of different incision lengths on patients following elective open cholecystectomy, a randomized clinical study was conducted.

METHODS

In this study 130 patients were randomly assigned to undergo either open cholecystectomy through a transverse subcostal incision of mean length 5.8 cm, so called minicholecystectomy (65 patients), or to undergo conventional cholecystectomy through a paracostal incision of mean length 13.1 cm (65 patients). The perception of pain after operation was measured by a visual analogue scale. To register late complications the mean(s.d.) hospitalization period after operation was extended to 11.5(1.2) days in the minicholecystectomy group and 15.4(2.5) days in the conventional cholecystectomy group.

RESULTS

The perceived pain and analgesic requirements were found to be similar in both groups. Twelve of 65 patients in the minicholecystectomy group and four of 65 in the conventional cholecystectomy group developed wound haematoma.

CONCLUSION

On the basis of this prospective randomized study, the hypothesis that a smaller incision length on the abdominal wall could lower the level of perceived pain, and therefore decrease the postoperative analgesic intake after minicholecystectomy, could not be confirmed.

["Tension-free technique" in open inguinal hernia repair. A prospective, randomized study of postoperative pain perception ("tension-free reconstruction" vs. Shouldice technique)]

A prospective randomized study was performed on 64 patients suffering from primary inguinal hernia. Two groups were formed, each consisting of 32 patients. The patients either underwent tension-free surgical treatment or Shouldice herniorraphy. The aim of the study was to determine if the tension-free operative technique on inguinal hernia patients reduces postoperative pain intensity by 2 days in comparison to the patients receiving Shouldice repair treatment. By using the VAS was shown that at no time was there any significant difference in the pain sensation levels between the two groups. The amount of pain tablets consumed among the patients was similar in each group. The number of complications in both groups was also comparable. During the postoperative follow-up of 6 days six patients in the tension-free surgical group and four patients in the Shouldice group developed uncomplicated hematomas on the 4th day, which were traced to the heparin medication. One patient from the Shouldice group suffered from temporary swelling of the scrotum. The advantage of open tension-free repair using extraperitoneally placed polypropylene mesh is that the technique is simple, size-adapted, and can be carried out easily and at any time under local anesthesia. With regard to the lower recurrence rate of hernia as published in the American literature, this can only be verified by randomized studies.

[Extraperitoneal, "tension free" inguinal hernia repair with local anesthesia--a contribution to effectiveness and economy]

In this present randomized controlled study, two groups, each consisting of 45 patients, underwent tension-free inguinal hernia repair under general versus local anesthesia. Patients in the local anesthesia group described their pain during mobilisation by using the VAS and were found to have a significant pain level decrease from the first to the fifth postoperative day. In conclusion, it could be shown that tension-free hernia repair under local anesthesia is superior to tension-free hernia repair during general anesthesia concerning perception of pain and pain management.

Effect of low-dose subcutaneous heparin on postoperative wound hematomas: randomized clinical trial on hospitalized inguinal hernia patients in Germany

A randomized prospective study of low-dose heparin was performed in 89 surgical patients during and after Bassini-Lotheissen repair. The patients were divided into two groups: (1) Low-dose heparin: 5000 units 2 hours before operation and 5000 units every 8 hours for 5 days after the operation. (2) Dextran 40 (Rheomacrodex); administered during the operation, with an additional infusion of dextran (500 ml/day) for the next 3 days. The frequency of wound complications in 45 the heparin-treated patients was 22.0% (comprising 10 hematomas), compared to only 4.5% in the dextran-treated patients (n = 44 patients). These findings are significant (p < 0.05). Low-dose heparin should therefore be administered routinely only to patients with increased risk of thromboembolism.

[Quality of life after prograde jejunum interposition with and without pouch. A prospective study of stomach cancer patients on the reservoir as a reconstruction principle after total gastrectomy]

Out of 74 consecutive patients with gastric carcinoma only 39 patients fulfilled the inclusion criteria for this randomized study. These patients were divided into two groups intraoperatively, 21 were reconstructed with and 18 without performing a stapled interposed jejunal pouch. Quality of life was evaluated using Spitzer's QL index and Cuschieri's assessment for 6 months. Spitzer's QL index showed--as expected--no differences concerning the specific reconstruction in gastrointestinal complaints, whereas Cuschieri's assessment revealed an advantage in the pouch group. Cuschieri's assessment needs to be validated by larger comparable groups to prove its suitability for the determination of specific gastrointestinal complaints concerning the type of reconstruction in gastric cancer patients.