Background: International guidelines recommend monitoring the use and outcome of minimally invasive pancreatic surgery (MIPS). However, data from prospective international audits on minimally ...invasive distal pancreatectomy (MIDP) are lacking. This study examined the use and outcome of robot-assisted (RDP) and laparoscopic (LDP) distal pancreatectomy in the E-MIPS registry. Patients and methods: Post-hoc analysis in a prospective audit on MIPS, including consecutive patients undergoing MIDP in 83 centers from 19 European countries (01-01-2019/31-12-2021). Primary outcomes included intraoperative events (grade 1: excessive blood loss, grade 2: conversion/change in operation, grade 3: intraoperative death), major morbidity, and in-hospital/30-day mortality. Multivariable logistic regression analyses identified high-risk groups for intraoperative events. RDP and LDP were compared in the total cohort and high-risk groups. Results: Overall, 1672 patients undergoing MIDP were included; 606 (36.2%) RDP and 1066 (63.8%) LDP. The annual use of RDP increased from 30.5% to 42.6% ( P <0.001). RDP was associated with fewer grade 2 intraoperative events compared with LDP (9.6% vs. 16.8%, P <0.001), with longer operating time (238 vs. 201 min, P <0.001). No significant differences were observed between RDP and LDP regarding major morbidity (23.4% vs. 25.9%, P =0.264) and in-hospital/30-day mortality (0.3% vs. 0.8%, P =0.344). Three high-risk groups were identified; BMI greater than 25 kg/m 2 , previous abdominal surgery, and vascular involvement. In each group, RDP was associated with fewer conversions and longer operative times. Conclusion: This European registry-based study demonstrated favorable outcomes for MIDP, with mortality rates below 1%. LDP remains the predominant approach, whereas the use of RDP is increasing. RDP was associated with fewer conversions and longer operative time, including in high-risk subgroups. Future randomized trials should confirm these findings and assess cost differences.
Major hepatectomy in perihilar cholangiocarcinoma (pCCA) patients with a small future liver remnant (FLR) often risks posthepatectomy liver failure (PHLF). This study examines combined portal and ...hepatic vein embolisation (PVE/HVE) to increase preoperative FLR volume and potentially decrease PHLF rates.
In this retrospective, multicentre, observational study, data was collected from centres affiliated with the DRAGON Trial Collaborative and the EuroLVD registry. The study included pCCA patients who underwent PVE/HVE between July 2016 and January 2023.
Following PVE/HVE, 28% of patients (9/32) experienced complications, with 22% (7/32) necessitating biliary interventions for cholangitis. The median degree of hypertrophy after a median of 16 days was 16% with a kinetic growth rate of 6.8% per week. 69% of patients (22/32) ultimately underwent surgical resection. Cholangitis after PVE/HVE was associated with unresectability. After resection, 55% of patients (12/22) experienced complications, of which 23% (5/22) were Clavien-Dindo grade III or higher. The 90-day mortality after resection was 0%.
PVE/HVE quickly enhances the kinetic growth rate in pCCA patients. Cholangitis impairs chances on resection significantly. Resection after PVE/HVE is associated with low levels of 90-day mortality. The study highlights the potential of PVE/HVE in improving safety and outcomes in pCCA undergoing resection.
Objective: The objective of this study was to evaluate the long-term oncological outcomes of patients with colorectal liver metastasis (CRLM) randomized for associating liver partition and portal ...vein ligation for staged hepatectomy (ALPPS) or 2-stage hepatectomy (TSH). Introduction: For advanced CRLM, TSH or ALPPS may be needed for tumor freedom. The randomized, controlled, multicenter trial LIGRO showed an increased resection rate in patients who underwent ALPPS but no difference in morbidity or mortality. The 2-year survival analysis revealed better overall survival in the ALPPS group. Here, the long-term survival analysis from the LIGRO trial is reported. Methods: In the LIGRO trial, 100 patients were randomized to TSH or ALPPS, with the option of rescue ALPPS if insufficient growth was found after the initial step of TSH. Patients were enrolled between June 2014 and August 2016. Follow-up data for this study were collected between November 2022 and February 2023. Results: In total, 16 patients were alive at the end of the follow-up period. The estimated median follow-up time was 93 months. Estimated median overall survival times were 45 months in the ALPPS group and 27 months in the TSH group ( P = 0.057), with 5-year survival rates of 31% and 20%, respectively. Positive prognostic factors were liver tumor-free status at the first follow-up and rectal primary tumor. Negative prognostic factors were extrahepatic disease and increasing CLRM size. Conclusion: Liver tumor-free status is a predictor of long-term survival, along with extrahepatic disease, large CRLM size, and rectal primary tumor. Survival did not significantly differ between patients treated with ALPPS or TSH.
Purpose: Surgery is an essential part of the curative plan for most patients affected with solid tumors. The outcome of such surgery, e.g., recurrence rates and ultimately patient survival, depends ...on several factors where the resection margin is of key importance. Presently, the resection margin is assessed by classical histology, which is time-consuming (several days), destructive, and basically only gives two-dimensional information. Clearly, it would be advantageous if immediate feedback on tumor extension in all three dimensions were available to the surgeon intraoperatively.
Approach: We investigate a laboratory propagation-based phase-contrast x-ray computed tomography system that provides the resolution, the contrast, and, potentially, the speed for this purpose. The system relies on a liquid-metal jet microfocus source and a scintillator-coated CMOS detector. Our study is performed on paraffin-embedded non-stained samples of human pancreatic neuroendocrine tumors, liver intrahepatic cholangiocarcinoma, and pancreatic serous cystic neoplasm (benign).
Results: We observe tumors with distinct and sharp edges having cellular resolution (∼10 μm) as well as many assisting histological landmarks, allowing for resection margin assessment. All x-ray data are compared with classical histology. The agreement is excellent.
Conclusion: We conclude that the method has potential for intraoperative three-dimensional virtual histology.
Abstract Background For resection of colorectal cancer (CRC) liver metastases, pre-operative portal vein embolization (PVE) is used to increase the size of the future liver remnant (FLR) prior to ...advanced liver resection when indicated. PVE is speculated to cause tumour progression, but only a limited number of studies have analysed tumour growth after PVE in the context of pre-procedural chemotherapy, which was the aim of this retrospective study. Methods Patients treated with stabilizing chemotherapy and PVE before liver resection for CRC metastases were included. Tumour progression according to RECIST guidelines and a change in tumour volume was analysed on computed tomography (CT) scans prior to chemotherapy, before PVE and after PVE, respectively. Results Thirty-four patients were included, of whom 23 had bilobar disease. Of tumours in the embolized lobe, 3/34 showed progression after PVE as compared with 3/23 in the non-embolized lobe ( P = 0.677). A decrease in tumour volume of 16% and 11% was noted in the embolized and non-embolized lobe, respectively ( P = 0.368). Patients were off chemotherapy in a median of 16 days before PVE. There was a linear correlation between the growth of tumours and time between the end of chemotherapy and PVE ( r = 0.25, P = 0.0005). Conclusion The rate of progression of CRC liver metastases after PVE and pre-procedural chemotherapy was lower in the present study as compared with previous reports. This applies to tumours in both the embolized and non-embolized lobes and is associated with keeping the time between the end of chemotherapy and PVE short.
Background:Portal vein occlusion (PVO) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are two strategies employed to render patients with unresectable liver ...tumours resectable by increasing the size of the future liver remnant (FLR).There is still limited knowledge about several aspects of PVO and most aspects of ALPPS.Aims:To evaluate tumour progression after portal vein embolization (PVE) in patients with colorectal liver metastases (CRLM) treated with pre-procedural chemotherapy. To investigate if ALPPS performed after failed PVO in patients with CRLM treated with neoadjuvant chemotherapy is safe and feasible. To assess and compare liver volume and function in patients subjected to ALPPS. To study the levels of liver regenerative growth factors in ALPPS.Methods:In paper I, patients with CRLM and response to neoadjuvant chemotherapy, subjected to PVE at Skåne University Hospital (2005-2013) and Karolinska University Hospital(2004-2010) were included in the study and assessed for tumour progression. In paper II, patients subjected to ALPPS after failed PVO at Karolinska University Hospital were included and efficacy and safety of the procedure in these patients was evaluated. In paper III, the liver volume and function in patients subjected to ALPPS was studied with a multimodal approach(including repeated computed tomography and hepatobiliary scintigraphy). In paper IV, sequentially sampled tissue from patients operated with ALPPS was analysed to assess the levels of liver regenerative growth factors.Results:In paper I, 34 patients were identified and included. The median time between ended chemotherapy and PVE was 16 days. Three patients had tumour progression in the embolized liver lobe and three in the non-embolized lobe. Only two patients experienced tumour progression in the FLR that inhibited curative resection. In paper II, eleven patients operated with ALPPS after failed PVO were included. Six days after stage 1 the median growth of the FLR was 61.8% and all patients could proceed to stage 2 and resection of the liver tumours on day 7, with low morbidity and no 90-day mortality. In paper III, nine patients were studied and the increase in FLR-volume exceeded the increase in FLR-function at day 6 after stage 1, where functional increase only reached 50% of the volume increase in the FLR. In paper IV, ten patients were studied. The levels of HGF in plasma correlated with the degree of growth of the FLR and the levels of IL-6 correlated with the HGF levels.Conclusions:The rate of progression of CRLM after PVE with pre-procedural chemotherapy is lower than previously reported if the time between the end of chemotherapy and PVE is short. The powerful growth of the FLR associated with ALPPS seems to be maintained in patients with CRLM treated with neoadjuvant chemotherapy and previously failed PVO. In the inter stage period of ALPPS the high volume increase is not paralleled by a corresponding functional increase. The levels of HGF in plasma correlates with the degree of growth of the FLR and the levels of IL-6 correlates with the HGF levels in patients operated with ALPPS.
BackgroundPortal vein occlusion (PVO) is an established method to increase the volume of the future liver remnant (FLR). The main reasons for not proceeding to radical hepatectomy are lack of volume ...increase and tumor progression due to a wait-time interval of up to 8 weeks. The hypothesis was that the increase in FLR volume is not linear and is largest during the first weeks.MethodsPatients with colorectal liver metastases (CRLM) and standardized future liver remnant (sFLR) < 30% treated with PVO were prospectively included. All patients had at least one CT evaluation before radical hepatectomy.ResultsForty-eight patients were included. During the first week after PVO, the kinetic growth rate (KGR) was 5.4 (± 4), compared to 1.5 (± 2) between the first and second CT (p < 0.05). For patients reaching adequate FLR and therefore treated with radical hepatectomy, the KGR was 7 (± 4) the first week, compared to 4.3 (± 2) for patients who failed to reach a sufficient volume (p = 0.4). During the interval between the first and second CT, the KGR was 2.2 (± 2), respectively (± 0.1) (p = 0.017).DiscussionThe increase in liver volume after PVO is largest during the first week. As KGR decreases over time, it is important to shorten the interval between PVO and the first volume evaluation; this may aid in decision-making and reduce unnecessary waiting time.
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