Background Postoperative mortality commonly is defined as death occurring within 30 days of surgery or during hospitalization. After resection for liver malignancies, this definition may result in ...underreporting, because mortality caused by postoperative complications can be delayed as the result of improved critical care. The aim of this study was to estimate statistically the acute postoperative period (APP) after partial hepatectomy and to compare mortality within this phase to standard timestamps. Methods From a prospective database, 784 patients undergoing resection for primary and secondary hepatic malignancies between 2003 and 2013 were reviewed. For estimation of APP, a novel statistical method applying tests for a constant postoperative hazard was implemented. Multivariable mortality analysis was performed. Results The APP was determined to last for 80 postoperative days (95% confidence interval 40–100 days). Within this period, 55 patients died (7.0%; 80-day mortality). In comparison, 30-day mortality ( N = 32, 4.0%) and in-hospital death ( N = 39, 5.0%) were relevantly less. No patient died between postoperative days 80 and 90. The causes of mortality within 30 days and from days 30–80 did not greatly differ, especially regarding posthepatectomy liver failure (44% vs 39%, P = .787). Septic complications, however, tended to cause late deaths more frequently (43% vs 25%, P = .255). Comorbidities (Charlson comorbidity index ≥3; P = .046), increased preoperative alanine aminotransferase activity ( P = .030), and major liver resection ( P = .035) were independent risk factors of 80-day mortality. Conclusion After liver resection for primary and secondary malignancies, 90-day rather than 30-day or in-hospital mortality should be used to avoid underreporting of deaths.
Pedicle clamping (PC) during liver resection for colorectal metastases (CRLM) is used to reduce blood loss and allogeneic blood transfusion (ABT). The effect on long-term oncologic outcomes is still ...under debate. A retrospective analysis of the impact of PC on ABT-demand regarding overall (OS) and recurrence-free survival (RFS) in 336 patients undergoing curative resection for CRLM was carried out. Survival analysis was performed by both univariate and multivariate methods and propensity-score (PS) matching. PC was employed in 75 patients (22%). No increased postoperative morbidity was monitored. While the overall ABT-rate was comparable (35% vs. 37%,
= 0.786), a reduced demand for more than two ABT-units was observed (
= 0.046). PC-patients had better median OS (78 vs. 47 months,
= 0.005) and RFS (36 vs. 23 months,
= 0.006). Multivariate analysis revealed PC as an independent prognostic factor for OS (HR = 0.60;
= 0.009) and RFS (HR = 0.67;
= 0.017). For PC-patients, 1:2 PS-matching (
= 174) showed no differences in the overall ABT-rate compared to no-PC-patients (35% vs. 40%,
= 0.619), but a trend towards reduced transfusion requirement (>2 ABT-units: 9% vs. 21%,
= 0.052; >4 ABT-units: 2% vs. 11%,
= 0.037) and better survival (OS: 78 vs. 44 months,
= 0.088; RFS: 36 vs. 24 months;
= 0.029). Favorable long-term outcomes and lower rates of increased transfusion demand were observed in patients with PC undergoing resection for CRLM. Further prospective evaluation of potential oncologic benefits of PC in these patients may be meaningful.
The therapy of patients with colorectal liver metastases (CRLM) has undergone significant changes. Extended survival has been observed to be associated with adoption of hepatic resection and improved ...chemotherapy.
This review summarizes standards, developments and controversies on the management of these patients. Literature search was performed with focus on work published within the last ten years.
Patients with CRLM should undergo surgery whenever possible with careful and experienced patient selection as hepatic resection offers the best long-term prognosis. The multidisciplinary approach has markedly evolved and has increased the number of patients in whom curative-intended surgery is possible. Patients with resectable metastases can undergo upfront surgery or may receive perioperative chemotherapy in selected cases, a decision which is under debate and remains individual. Patients with non-resectable metastases that may become resectable upon conversion treatment should receive polychemotherapy with or without local ablative therapy as pretreatment with the main goal of achieving resectability. In patients with synchronous CRLM, the optimal sequence of treatment remains unclear. Depending on the hepatic tumor burden and its dynamics as well as the type and stage of the primary tumor, simultaneous resection or either the sequential "bowel-first" or reversed "liver-first" approach represent suitable options to achieve complete tumor clearance.
The improvements in the management of CRLM due to multidisciplinary treatment and novel developments are a great example of successfully pushing the boundaries of cure in metastatic cancer. Surgery aiming at complete tumor clearance represents the central instrument to achieve long-term survival.
Pedicle clamping (PC) during liver resection for colorectal metastases (CRLM) is used to reduce blood loss and allogeneic blood transfusion (ABT). The effect on long-term oncologic outcomes is still ...under debate. A retrospective analysis of the impact of PC on ABT-demand regarding overall (OS) and recurrence-free survival (RFS) in 336 patients undergoing curative resection for CRLM was carried out. Survival analysis was performed by both univariate and multivariate methods and propensity-score (PS) matching. PC was employed in 75 patients (22). No increased postoperative morbidity was monitored. While the overall ABT-rate was comparable (35 vs. 37, p = 0.786), a reduced demand for more than two ABT-units was observed (p = 0.046). PC-patients had better median OS (78 vs. 47 months, p = 0.005) and RFS (36 vs. 23 months, p = 0.006). Multivariate analysis revealed PC as an independent prognostic factor for OS (HR = 0.60; p = 0.009) and RFS (HR = 0.67; p = 0.017). For PC-patients, 1:2 PS-matching (N = 174) showed no differences in the overall ABT-rate compared to no-PC-patients (35 vs. 40, p = 0.619), but a trend towards reduced transfusion requirement (>2 ABT-units: 9 vs. 21, p = 0.052; >4 ABT-units: 2 vs. 11, p = 0.037) and better survival (OS: 78 vs. 44 months, p = 0.088; RFS: 36 vs. 24 months; p = 0.029). Favorable long-term outcomes and lower rates of increased transfusion demand were observed in patients with PC undergoing resection for CRLM. Further prospective evaluation of potential oncologic benefits of PC in these patients may be meaningful.
Total hip arthroplasty (THA) is commonly performed using off-the-shelf implants. In the case of a severe mismatch between the anatomy of the proximal femur and the geometry of the stem, the use of ...custom-made stems might become necessary. The goal of this study was to investigate the precision of the implantation of custom-made stems of one manufacturer (CTX stem, AQ Implants) and to determine risk factors for malpositioning. All patients receiving a custom-made CTX stem between 2014 and 2020 at six high-volume academic centers were retrospectively recruited. The achieved position of the stem, as determined by stem version, stem coronal angle, and implantation depth on radiographs, was compared to the plan. The influence of radiographic and demographic parameters on the position was investigated. The results revealed a high variability of the achieved implant position in relation to the preoperative plan. While the stem coronal angle only differed slightly from the intended position, the stem version and the implantation depth showed a high frequency and amount of deviation. Right stems showed significantly higher positions than planned. Surgeons must be aware of this potential problem when implanting custom-made stems.
A moving correlation index (Mx-CPP) of cerebral perfusion pressure (CPP) and mean middle cerebral artery blood flow velocity (CBFV) allows continuous monitoring of dynamic cerebral autoregulation ...(CA) in patients with severe traumatic brain injury (TBI). In this study we validated Mx-CPP for TBI, examined its prognostic relevance, and assessed its relationship with arterial blood pressure (ABP), CPP, intracranial pressure (ICP), and CBFV. We tested whether using ABP instead of CPP for Mx calculation (Mx-ABP) produces similar results. Mx was calculated for each hemisphere in 37 TBI patients during the first 5 days of treatment. All patients received sedation and analgesia. CPP and bilateral CBFV were recorded, and GOS was estimated at discharge. Both Mx indices were calculated from 10,000 data points sampled at 57.4Hz. Mx-CPP > 0.3 indicates impaired CA; in these patients CPP had a significant positive correlation with CBFV, confirming failure of CA, while in those with Mx < 0.3, CPP was not correlated with CBFV, indicating intact CA. These findings were confirmed for Mx-ABP. We found a significant correlation between impaired CA, indicated by Mx-CPP and Mx-ABP, and poor outcome for TBI patients. ABP, CPP, ICP, and CBFV were not correlated with CA but it must be noted that our average CPP was considerably higher than in other studies. This study confirms the validity of this index to demonstrate CA preservation or failure in TBI. This index is also valid if ABP is used instead of CPP, which eliminates the need for invasive ICP measurements for CA assessment. An unfavorable outcome is associated with early CA failure. Further studies using the Mx-ABP will reveal whether CA improves along with patients' clinical improvement.
Information about online presence allows participants of instant messaging (IM) systems to determine whether their prospective communication partners will be able to answer their requests in a timely ...manner, or not. This makes IM more personal and closer than other forms of communication such as e-mail. On the other hand, revelation of presence constitutes a potential of misuse by untrustworthy entities, e.g. generation of presence logs. We argue that current IM systems do not take reasonable precautions to protect presence information. We propose an IM system designed to be robust against attacks to disclose a user's presence. It stores presence information in a distributed hash table (DHT) in a way that is only detectable and applicable for intended users and even not comprehensible for the DHT nodes. We apply an anonymous communication network to protect the users' physical addresses.
Information about online presence allows participants of instant messaging (IM) systems to determine whether their prospective communication partners are able to answer their requests in a timely ...manner, or not. This makes IM more personal and closer than other forms of communication such as e-mail. On the other hand, revelation of presence constitutes a potential of misuse by untrustworthy entities, e.g. generation of presence logs. We argue that current IM systems do not take reasonable precautions to protect presence information. We propose an IM system designed to be robust against attacks to disclose a user's presence. It stores presence information in a distributed hash table (DHT) in a way that is only detectable and applicable for intended users and even not comprehensible for the DHT nodes. We apply an anonymous communication network to protect the users' physical addresses
PDF
