The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy ...(TSH) in a randomized controlled trial (RCT).
Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression.
A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome-RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention.
Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% 95% confidence interval (CI) 84%-100% (44/48) in the ALPPS arm compared with 57% (95% CI 43%-72%) (28/49) in the TSH arm rate ratio 8.25 (95% CI 2.6-26.6); P < 0.0001. No differences in complications (Clavien-Dindo ≥3a) 43% (19/44) vs 43% (12/28) 1.01 (95% CI 0.4-2.6); P = 0.99, 90-day mortality 8.3% (4/48) vs 6.1% (3/49) 1.39 95% CI 0.3-6.6; P = 0.68 or R0 RRs 77% (34/44) vs 57% (16/28) 2.55 95% CI 0.9-7.1; P = 0.11) were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS.
ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.
To evaluate the oncological outcome for patients with colorectal liver metastases (CRLM) randomized to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) or 2-stage ...hepatectomy (TSH).
TSH with portal vein occlusion is an established method for patients with CRLM and a low volume of the future liver remnant (FLR). ALPPS is a less established method. The oncological outcome of these methods has not been previously compared in a randomized controlled trial.
One hundred patients with CRLM and standardized FLR (sFLR) <30% were included and randomized to resection by ALPPS or TSH, with the option of rescue ALPPS in the TSH group, if the criteria for volume increase was not met. The first radiological follow-up was performed approximately 4 weeks postoperatively and then after 4, 8, 12, 18, and 24 months. At all the follow-ups, the remaining/recurrent tumor was noted. After the first follow-up, chemotherapy was administered, if indicated.
The resection rate, according to the intention-to-treat principle, was 92% (44 patients) for patients randomized to ALPPS compared with 80% (39 patients) for patients randomized to TSH (P = 0.091), including rescue ALPPS. At the first postoperative follow-up, 37 patients randomized to ALPPS were assessed as tumor free in the liver, and also 28 patients randomized to TSH (P = 0.028). The estimated median survival for patients randomized to ALPPS was 46 months compared with 26 months for patients randomized to TSH (P = 0.028).
ALPPS seems to improve survival in patients with CRLM and sFLR <30% compared with TSH.
Postoperative pancreatic fistula is the leading cause of morbidity after distal pancreatectomy. Strategies investigated to reduce the incidence have been disappointing. Recent data showed a reduction ...in postoperative pancreatic fistula with the use of synthetic mesh reinforcement of the staple line.
An RCT was conducted between May 2014 and February 2016 at four tertiary referral centres in Sweden. Patients scheduled for distal pancreatectomy were eligible. Enrolled patients were randomized during surgery to stapler transection with biological reinforcement or standard stapler transection. Patients were blinded to the allocation. The primary endpoint was the development of any postoperative pancreatic fistula. Secondary endpoints included morbidity, mortality, and duration of hospital stay.
Some 107 patients were randomized and 106 included in an intention-to-treat analysis (56 in reinforced stapling group, 50 in standard stapling group). No difference was demonstrated in terms of clinically relevant fistulas (grade B and C): 6 of 56 (11 per cent) with reinforced stapling versus 8 of 50 (16 per cent) with standard stapling (P = 0.332). There was no difference between groups in overall postoperative complications: 45 (80 per cent) and 39 (78 per cent) in reinforced and standard stapling groups respectively (P = 0.765). Duration of hospital stay was comparable: median 8 (range 2-35) and 9 (2-114) days respectively (P = 0.541).
Biodegradable stapler reinforcement at the transection line of the pancreas did not reduce postoperative pancreatic fistula compared with regular stapler transection in distal pancreatectomy. Registration number: NCT02149446 (http://www.clinicaltrials.gov).
Objectives
To develop and evaluate a procedure for quantifying the hepatocyte-specific uptake of Gd-BOPTA and Gd-EOB-DTPA using dynamic contrast-enhanced (DCE) MRI.
Methods
Ten healthy volunteers ...were prospectively recruited and 21 patients with suspected hepatobiliary disease were retrospectively evaluated. All subjects were examined with DCE-MRI using 0.025 mmol/kg of Gd-EOB-DTPA. The healthy volunteers underwent an additional examination using 0.05 mmol/kg of Gd-BOPTA. The signal intensities (SI) of liver and spleen parenchyma were obtained from unenhanced and enhanced acquisitions. Using pharmacokinetic models of the liver and spleen, and an SI rescaling procedure, a hepatic uptake rate,
K
Hep
, estimate was derived. The
K
Hep
values for Gd-EOB-DTPA were then studied in relation to those for Gd-BOPTA and to a clinical classification of the patient’s hepatobiliary dysfunction.
Results
K
Hep
estimated using Gd-EOB-DTPA showed a significant Pearson correlation with
K
Hep
estimated using Gd-BOPTA (
r
= 0.64;
P
< 0.05) in healthy subjects. Patients with impaired hepatobiliary function had significantly lower
K
Hep
than patients with normal hepatobiliary function (
K
Hep
= 0.09 ± 0.05 min
-1
versus
K
Hep
= 0.24 ± 0.10 min
−1
;
P
< 0.01).
Conclusions
A new procedure for quantifying the hepatocyte-specific uptake of
T
1
-enhancing contrast agent was demonstrated and used to show that impaired hepatobiliary function severely influences the hepatic uptake of Gd-EOB-DTPA.
Key Points
•
The liver uptake of contrast agents may be measured with standard clinical MRI.
•
Calculation of liver contrast agent uptake is improved by considering splenic uptake.
•
Liver function affects the uptake of the liver-specific contrast agent Gd-EOB-DTPA.
•
Hepatic uptake of two contrast agents (Gd-EOB-DTPA, Gd-BOPTA) is correlated in healthy individuals.
•
This method can be useful for determining liver function, e.g. before hepatic surgery
Abstract Background Colorectal liver metastases (CRLM) not amenable for resection have grave prognosis. One limiting factor for surgery is a small future liver remnant (FLR). Early data suggests that ...associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) effectively increases the volume of the FLR allowing for resection in a larger fraction of patients than conventional two-stage hepatectomy (TSH) with portal vein occlusion (PVO). Oncological results of the treatment are lacking. The aim of this study was to assess the intermediate oncological outcomes after ALPPS in patients with CRLM. Material and methods Retrospective analysis of all patients with CRLM operated with ALPPS at the participating centres between December 2012 and May 2014. Results Twenty-three patients (16 male, 7 female), age 67 years (28–80) were operated for 6.5 (1–38) metastases of which the largest was 40 mm (14–130). Six (27.3%) patients had extra-hepatic metastases, 16 (72.7%) synchronous presentation. All patients received chemotherapy, 6 cycles (3–25) preoperatively and 16 (70%) postoperatively. Ten patients (43%) were rescue ALPPS after failed PVO. Severe complications occurred in 13.6% and one (4.5%) patient died within 90 days of surgery. After a median follow-up of 22.5 months from surgery and 33.5 months from diagnosis of liver metastases estimated 2 year overall survival was 59% (from surgery) and 73% (from diagnosis). Liver only recurrences (n = 8), were treated with reresection/ablation (n = 7) while lung recurrences were treated with chemotherapy. Conclusion The overall survival, rate of severe complications and perioperative mortality associated with ALPPS for patients with CRLM is comparable to TSH.
Background
About 20% of patients with colorectal cancer have liver metastases at the time of diagnosis, and surgical resection offers a chance for cure. The aim of the present study was to compare ...outcomes for patients that underwent simultaneous resection to those that underwent a staged procedure with the bowel-first (classical) strategy by using information from two national registries in Sweden.
Methods
In this prospectively registered cohort study, we analyzed clinical, pathological, and survival outcomes for patients operated in the period 2008–2015 and compared the two strategies.
Results
In total, 537 patients constituted the study cohort, where 160 were treated with the simultaneous strategy and 377 with the classical strategy. Patients managed with the simultaneous strategy had less often rectal primary tumors (22% vs. 31%,
p
= 0.046) and underwent to a lesser extent a major liver resection (16% vs. 41%,
p
< 0.001), but had a shorter total length of stay (11 vs. 15 days,
p
< 0.001) and more complications (52% vs. 36%,
p
< 0.001). No significant 5-year overall survival (
p
= 0.110) difference was detected. Twenty-five patients had a major liver resection in the simultaneous strategy group and 155 in the classical strategy group without difference in 5-year overall survival (
p
= 0.198).
Conclusion
Simultaneous resection of the colorectal primary cancer and liver metastases can possibly have more complications, with no difference in overall survival compared to the classical strategy.
We report on studies of the viability and sensitivity of the Askaryan Radio Array (ARA), a new initiative to develop a Teraton-scale ultra-high energy neutrino detector in deep, radio-transparent ice ...near Amundsen-Scott station at the South Pole. An initial prototype ARA detector system was installed in January 2011, and has been operating continuously since then. We describe measurements of the background radio noise levels, the radio clarity of the ice, and the estimated sensitivity of the planned ARA array given these results, based on the first five months of operation. Anthropogenic radio interference in the vicinity of the South Pole currently leads to a few-percent loss of data, but no overall effect on the background noise levels, which are dominated by the thermal noise floor of the cold polar ice, and galactic noise at lower frequencies. We have also successfully detected signals originating from a 2.5km deep impulse generator at a distance of over 3 km from our prototype detector, confirming prior estimates of kilometer-scale attenuation lengths for cold polar ice. These are also the first such measurements for propagation over such large slant distances in ice. Based on these data, ARA-37, the ∼200km2 array now in its initial construction phase, will achieve the highest sensitivity of any planned or existing neutrino detector in the 1016–1019eV energy range.
Background
The prevalence of incidental gallbladder cancer is low when performing cholecystectomy for benign disease. The performance of routine or selective histological examination of the ...gallbladder is still a subject for discussion. The aim of this study was to assess the cost‐effectiveness of these different approaches.
Methods
Four management strategies were evaluated using decision‐analytical modelling: no histology, current selective histology as practised in Sweden, macroscopic selective histology, and routine histology. Healthcare costs and life‐years were estimated for a lifetime perspective and combined into incremental cost‐effectiveness ratios (ICERs) to assess the additional cost of achieving an additional life‐year for each management strategy.
Results
In the analysis of the four strategies, current selective histology was ruled out due to a higher ICER compared with macroscopic selective histology, which showed better health outcomes (extended dominance). Comparison of routine histology with macroscopic selective histology resulted in a gain of 12 life‐years and an incremental healthcare cost of approximately €1 000 000 in a cohort of 10 000 patients, yielding an estimated ICER of €76 508. When comparing a macroscopic selective strategy with no
histological assessment, 50 life‐years would be saved and
the ICER was estimated to be €20 708 in a cohort of 10 000
patients undergoing cholecystectomy.
Conclusion
A macroscopic selective strategy appears to be the most cost‐effective approach.
Antecedentes
La prevalencia del cancer incidental de vesícula biliar cuando se efectúa una colecistectomía por enfermedad benigna es baja. La realización de un estudio anatomopatológico de rutina o selectivo de la vesícula biliar sigue siendo un tema discutido. El objetivo de este estudio fue valorar el coste‐efectividad de los diferentes enfoques.
Métodos
Se evaluaron cuatro estrategias de actuación usando modelos analíticos de decisión: no efectuar estudio histológico, estudio histológico selectivo actual como es la práctica en Suecia, estudio histológico selectivo macroscópico y estudio histológico de rutina. Los costes de la atención sanitaria y los años de vida se estimaron en función de una perspectiva de por vida y se combinaron con las tasas de coste‐efectividad incrementales (incremental cost‐effectiveness ratios, ICERs) para evaluar el coste adicional de lograr un año de vida adicional para cada estrategia de actuación.
Resultados
En los análisis de las cuatro estrategias, se eliminó el estudio histológico selectivo actual debido a una mayor ICER en comparación con el estudio histológico selectivo macroscópico, que mostró mejores resultados de salud. La comparación del estudio histológico de rutina con el estudio histológico selectivo macroscópico dio como resultado una ganancia de 12 años de vida y un coste de atención sanitaria incremental de aproximadamente 1.000.000€ en una cohorte de 10.000 pacientes, lo que correspondía a una ICER estimada de 76.508€.
Conclusión
El estudio histológico selectivo macroscópico parece ser la estrategia con mayor coste‐efectividad.
The objective of this study was to assess the cost‐effectiveness of routine and selective gallbladder histopathology when performing cholecystectomy for benign disease. The most important factor for cost‐effectiveness was found to be the cost and number of histological analyses, due to large numbers of cholecystectomies relative to low prevalence of incidental gallbladder cancer. The model indicated that the macroscopic selective strategy was the most beneficial.
longer placements improve outcomes
Total pancreatectomy (TP) is a major surgical procedure that involves lifelong exocrine and endocrine pancreatic insufficiency. Qualitative evidence is sparse regarding patients' experiences after ...the operation. The aim of this study was to explore patients’ experiences of symptoms that occur after TP and how these symptoms affect their health and life situations.
A qualitative design with prospective consecutive sampling and an inductive thematic analysis was used. Semistructured interviews were postoperatively performed at 6–9 months with 20 patients undergoing TP in two university hospitals in Sweden.
Two main themes emerged from the analysis: “Changes in everyday life” and “Psychological journey”. Patients experienced symptoms related to diabetes as the major life change after the operation, and they were also limited by symptoms of exocrine insufficiency, difficulties with food intake and physical weakness. In the psychological journey that patients underwent, the support received from family, friends and the health care system was important. Moreover, patients experienced a general need for more extensive information, especially regarding diabetes.
Patients experience a lack of sufficient support and education after TP, particularly concerning their diabetes. Further efforts should be undertaken to improve information and the organization of diabetes care for this patient group.
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