Background
Tumour recurrence is common after resection of intrahepatic cholangiocarcinoma (ICC). Repeated resection is a potential curative treatment, but outcomes are not well‐defined thus far. The ...aim of this retrospective multicentre cohort study was to show the feasibility and survival of repeated resection of ICC recurrence.
Methods
Data were collected from 18 German hepato‐pancreatico‐biliary centres for patients who underwent repeated exploration of recurrent ICC between January 2008 and December 2017. Primary end points were overall (OS) and recurrence‐free survival from the day of primary and repeated resection.
Results
Of 156 patients who underwent repeated exploration for recurrent ICC, 113 underwent re‐resection. CA19‐9 prior to primary resection, R status of first liver resection and median time to recurrence were significant determinants of repeated resectability. Median OS in the repeated resection group was 65.2 months, with consecutive 1‐, 3‐ and 5‐year OS of 98%, 78% and 57% respectively. After re‐exploration, median OS from primary resection was 46.7 months, with a consecutive 1‐, 3‐ and 5‐year OS of 95%, 55% and 22% respectively. From the day of repeated resection, the median OS was 36.8 months, with a consecutive 1‐, 3‐ and 5‐year OS of 86%, 51% and 34% respectively. Minor morbidity (grade I+II) was present in 27%, grade IIIa‐IVb morbidity in 20% and mortality in 3.5% of patients.
Conclusion
Repeated resection of ICC has acceptable morbidity and mortality and seems to be associated with improved long‐term survival. Structured follow‐up after resection of ICC is necessary for early identification of these patients.
Purpose
One of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the ...impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction.
Methods
Twenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT).
Results
The mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (
p
= 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia.
Conclusion
Vertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.
Purpose
Low rectal anastomoses can safely be performed, usually secured by a diverting ostomy. However, in cases of inflammation, extensive scarring, after extensive radiation, or after severe ...stapler dysfunction the risk for an anastomotic leak may become prohibitively high. We present a novel use for endoluminal vacuum-assisted therapy (EVAT) for otherwise “impossible” low rectal anastomoses.
Methods
Our initial series consisted of 14 consecutive patients who underwent prophylactic EVAT treatment due to unsafe low colorectal anastomosis. The vacuum sponge was placed intraoperatively in cases otherwise calling for a Hartmann’s procedure. An open-pored polyurethane sponge was placed prophylactically transanally for a mean duration of 11 days. Patient characteristics, complications, and risk factors were prospectively collected from medical records and analyzed.
Results
Between March 2017 and September 2019, we performed this novel technique in 14 patients enabling us to perform an anastomosis. Our collective consisted of 4 female (29%) and 10 male (71%) patients with a medium age of 59 years. Underlying disease was colorectal cancer in 10 patients, ovarian cancer, perforated sigmoid diverticulitis, ischemic colitis and sarcoma in one patient each. Dominant factors putting the anastomosis at extremely high risk were acute inflammation (
n
= 2), frozen pelvis (
n
= 2), intraoperative local chemotherapy (
n
= 2), stapler dysfunction (
n
= 2), non-closable rectal stump (
n
= 2), empty pelvis (
n
= 1) and ultra-low anastomosis (
n
= 3). Prophylactic EVAT was successful in 92% and gastrointestinal continuity was preserved in all patients.
Conclusion
This is the first description of prophylactic EVAT treatment. It seems to be a simple and safe method to enforce the high-risk low rectal anastomosis.
Recently, we have shown that after partial hepatectomy (PHx), an increased hepatic blood flow initiates liver growth in mice by vasodilation and mechanically-triggered release of angiocrine signals. ...Here, we use mass spectrometry to identify a mechanically-induced angiocrine signal in human hepatic endothelial cells, that is, myeloid-derived growth factor (MYDGF). We show that it induces proliferation and promotes survival of primary human hepatocytes derived from different donors in two-dimensional cell culture, via activation of mitogen-activated protein kinase (MAPK) and signal transducer and activator of transcription 3 (STAT3). MYDGF also enhances proliferation of human hepatocytes in three-dimensional organoids. In vivo, genetic deletion of MYDGF decreases hepatocyte proliferation in the regenerating mouse liver after PHx; conversely, adeno-associated viral delivery of MYDGF increases hepatocyte proliferation and MAPK signaling after PHx. We conclude that MYDGF represents a mechanically-induced angiocrine signal and that it triggers growth of, and provides protection to, primary mouse and human hepatocytes.
High tumor recurrence and dismal survival rates after curative intended resection for hepatocellular carcinoma (HCC) are still concerning. The primary goal was to assess predictive factors associated ...with disease-free (DFS) and overall survival (OS) in a subset of patients with HCC undergoing hepatic resection (HR).
Between 08/2004-7/2021, HR for HCC was performed in 188 patients at our institution. Data allocation was conducted from a prospectively maintained database. The prognostic impact of clinico-pathological factors on DFS and OS was assessed by using uni- and multivariate Cox regression analyses. Survival curves were generated with the Kaplan Meier method.
The postoperative 1-, 3- and 5- year overall DFS and OS rates were 77.9%, 49.7%, 41% and 72.7%, 54.7%, 38.8%, respectively. Tumor diameter ≥ 45 mm HR 1.725; (95% CI 1.091-2.727); p = 0.020, intra-abdominal abscess HR 3.812; (95% CI 1.859-7.815); p < 0.0001, and preoperative chronic alcohol abuse HR 1.831; (95% CI 1.102-3.042); p = 0.020 were independently predictive for DFS while diabetes mellitus HR 1.714; (95% CI 1.147-2.561); p = 0.009), M-Stage HR 2.656; (95% CI 1.034-6.826); p = 0.042, V-Stage HR 1.946; (95% CI 1.299-2.915); p = 0.001, Sepsis HR 10.999; (95% CI 5.167-23.412); p < 0.0001, and ISGLS B/C HR 2.008; (95% CI 1.273-3.168); p = 0.003 were significant determinants of OS.
Despite high postoperative recurrence rates, an acceptable long-term survival in patients after curative HR could be achieved. The Identification of parameters related to OS and DFS improves patient-centered treatment and surveillance strategies.
In-situ splitting of the liver before extended resection has gained broad attention. This two-step procedure requires several measures to make an effective and safe procedure. Although the procedure ...is performed in many institutions, there is no consensus on a uniform technique. The two steps can be divided into different parts and a standardized technique may render the procedure safer and the results will be easier to evaluate. In this paper, we describe a detailed approach to in-situ splitting that allows making both procedures safe, avoids liver necrosis, and is easily reproducible. In the first procedure the portal branches to segments I and IV to VIII are divided, the arterial branches and bile ducts to these segments are preserved and encircled and the parenchyma between segments II/III and IVa/b is divided. This avoids necrosis and bile leaks of segments I and IV and avoids urgent completion operations. In particular, the handling of vital structures close to the dissection line seems important to us. Complete splitting and securing the right and middle hepatic vein will make the second step of this procedure a minimal-risk procedure at a stage where the patient is still recovering from the more demanding first step.
Right extended liver resection is frequently required to achieve tumor-free margins. Portal venous embolization (PVE) of the prospective resected hepatic segments for conditioning segments II/III ...does not always induce adequate hypertrophy in segments II and III (future liver remnant volume (FLRV)) for extended right-resection. Here, we present the technique of in situ split dissection along segments II/III plus portal disruption to segments IV-VIII (ISLT) as a salvage procedure to overcome inadequate gain of FLRV after PVE.
In eight patients, FLRV was further pre-conditioned following failed PVE prior to hepatectomy (ISLT-group). We compared FLRV changes in the ISLT group with patients receiving extended right hepatectomy following sufficient PVE (PVEres-group). Survival of the ISLT-group was compared to PVEres patients and PVE patients with insufficient FLRV gain or tumor progress who did not receive further surgery (PVEnores-group).
Patient characteristics and surgical outcome were comparable in both groups. The mean FLRV-to-body-weight ratio in the ISLT group was smaller than in the PVEres-group pre- and post-PVE. One intraoperative mortality due to a coronary infarction was observed for an ISLT patient. ISLT was successfully completed in the remaining seven ISLT patients. Liver function and 2-year survival of ~ 50% was comparable to patients with extended right hepatectomy after efficient PVE. Patients who received a PVE but who were not subsequently resected (PVEnores) demonstrated no survival beyond 4 months.
Despite extended embolization of segments I and IV-VIII, ISLT should be considered if hypertrophy was not adequate. Liver function and overall survival after ISLT was comparable to patients with trisectionectomy after efficient PVE.
Background: In patients with prostatic and breast cancer the application of peridural anesthesia (PDA) showed a beneficial effect on prognosis. This was explained by reduced requirements for general ...anesthetics and perioperative opioids as well as a lower perioperative stress level. The impact of PDA in patients with more aggressive types of cancer has not been completely elucidated. Here, we analyzed the prognostic influence of PDA on overall survival after surgery as primary in patients that underwent radical resection of pancreatic adenocarcinoma. Methods: Records of 98 consecutive patients were reviewed. In 70 of these cases PDA was applied. Patient characteristics such as demographics, TNM stage, and operative data were retrospectively collected from medical records and analyzed. Survival data were analyzed by Cox’s proportional hazard regression model. Results: Overall, no significant prognostic influence of PDA on recurrence or overall survival (p = 0.762, Hazard Ratio HR 0.884, 95% confidence interval CI 0.398–1.961) was found. However, there was a trend towards a longer overall survival (p = 0.069, HR 0.394, 95% CI 0.144–1.078) associated with PDA in a subgroup of patients with better differentiation of pancreatic adenocarcinoma. Conclusion: The observation of longer survival associated with PDA in our subgroup of patients with better-differentiated pancreatic carcinomas is in line with previous reports on various other less aggressive tumor entities. Our results indicate that PDA might improve the oncological outcome of patients with pancreatic adenocarcinoma.
Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The 'dorsal track control' ...(DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.
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