Intraoperative liver steatosis characterization using diffuse reflectance spectroscopy.

BACKGROUND: Liver steatosis is associated with poor outcome after liver transplantation and liver resection. There is a need for an accurate and reliable intraoperative tool to identify and quantify steatosis. This study aimed to investigate whether surface diffuse reflectance spectroscopy (DRS) measurements could detect liver steatosis on humans during liver surgery. METHODS: The DRS instrumentation setup consists of a computer, a high-power tungsten halogen light source and two spectrometers, connected through a trifurcated optical fiber to a hand-held probe. Patients scheduled for open resection for liver tumors were considered for inclusion. Multiple DRS measurements were performed on the liver surface after mobilization. RESULTS: In total, 1210 DRS spectra originated from 38 patients, were analyzed. When applying the data to an analytical model the volumetric absorption ratio factor of fat and water specified an explicit distinction between mild to moderate, and moderate to severe steatosis (p < 0.001). There were significant differences between none-to-mild and moderate-to-severe steatosis grade for the following parameters: reduced scattering coefficient (p < 0.001), Mie to total scattering fraction (p < 0.001), Mie slope (p = 0.003), lipid/(lipid + water) (p < 0.001), blood volume (p = 0.044) and bile volume (p < 0.001). CONCLUSION: This study shows that it is possible to evaluate steatosis grades with hepatic surface diffuse reflectance spectroscopy measurements.

Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy.

BACKGROUND: Perioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications. METHODS: Data from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications. RESULTS: The weight change on postoperative day 1 ranged from -1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023). CONCLUSIONS: Fluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.

Significance of poor performance status after resection of colorectal liver metastases.

BACKGROUND: Performance status (PS) is known as one of the strongest prognostic factors for survival in metastatic colorectal cancer patients. The aim of the present study was to analyze factors associated with poor PS assessed after resection for colorectal liver metastases and the impact on survival. METHODS: All patients undergoing curative resection for colorectal liver metastases between 2010 and 2015 in a single center were reviewed retrospectively. RESULTS: A total of 284 patients were included, out of whom 74 patients (26%) presented with a postoperative PS WHO > 2 precluding administration of adjuvant chemotherapy. These patients had a shorter recurrence-free survival (P = 0.002) and shorter overall survival (P < 0.001). Multivariable analysis showed that patients with PS > 2 after surgery had higher preoperative ASA score, had a higher frequency of major complications after surgery, and had more frequently synchronous liver and lung metastases. PS was found to be the strongest independent factor predicting survival (hazard ratio 0.45). When patients with postoperative PS > 2 developed recurrent disease (54 of 74), 43 (80%) received tumor specific treatment. CONCLUSIONS: Patients with postoperative PS > 2 who did not receive adjuvant chemotherapy had decreased recurrence-free and overall survival after liver resection for colorectal liver metastases. After recurrence, a large majority of these patients had had improvement in PS allowing for administration of tumor specific treatment.

The role of irreversible electroporation (IRE) for locally advanced pancreatic cancer: a systematic review of safety and efficacy.

OBJECTIVES: Irreversible electroporation (IRE) is a new modality for tumor ablation. Electrodes are placed around the tumor, and a pulsed, direct current with a field strength of 2000 V/cm is delivered. The direct current drives cells into apoptosis and cell death without causing significant heating of the tissues, which spares the extracellular matrix and proteins. The purpose of this review was to evaluate current experience of IRE for the ablation of pancreatic cancer. MATERIAL AND METHODS: We searched PubMed for all studies of IRE in human pancreatic cancer in English reporting at least 10 patients. RESULTS: The search yielded 10 studies, comprising a total of 446 patients. Percutaneous IRE was done in 142 patients, while 304 patients were treated during laparotomy. Tumor sizes ranged from median 2.8 to 4.5 cm. Post-procedural complications occurred in 35% of patients, most of them were less severe. Nine patients (2.0%) died after the procedure. The technical success rate was 85-100%. The median recurrence-free survival was 2.7-12.4 months after IRE treatment. The median overall survival was 7-23 months postoperatively. The longest overall survival was noted when IRE was used in conjunction with pancreatic resection. CONCLUSIONS: IRE seems feasible and safe with a low post-procedural mortality. Further efforts are needed to address patient selection and efficacy of IRE, as well as the use of IRE for 'margin accentuation' during surgical resection.

Clinical outcome of percutaneous RF-ablation of non-operable patients with liver metastasis from breast cancer.

PURPOSE: Despite improved anti-neoplastic treatment the prognosis for patients with liver metastases from metastatic breast cancer remains poor. MATERIALS AND METHODS: Thirty-two consecutive patients with metastatic breast cancer treated with radiofrequency ablation (RFA) at the Department of Oncology, Herlev Hospital, University of Copenhagen, from 1996 to 2010. RESULTS: Time to intrahepatic progression was median 11 months (range 1.6-184 months). Median survival after first RFA was 33.5 months. Survival at 1, 2 and 3 years was 87, 68 and 48 %, respectively. The local recurrence rate was 22 %. CONCLUSIONS: In this small, highly selected cohort we found RFA safe and efficacious with a low local recurrence rate and a median survival above that expected with systemic treatment. Our data are in line with previous studies and underscore the need for a large prospective study using optimal chemotherapy regimens and RFA/surgery to clarify whether intense treatment protocols can prolong survival for certain patient groups.

Endovascular Removal of the Viatorr Stent-Grafts. Report of Two Cases.

BACKGROUND: The dysfunction of misplaced or dislodged endovascular endoprostheses, may be a serious complication, and endovascular removal may be attempted in some cases. CASE REPORT: A Viatorr(®) stent-graft (Gore, Flagstaff, AR, USA) is an endoprosthesis designed and commonly used for creation of a transjugular intrahepatic portosystemic shunt (TIPS). Two Viatorrs were accidentally dislodged during TIPS procedure. In another patient, the Viatorr was malpositioned, with its distal end being placed in the bile duct. All endoprostheses were successfully removed without serious complications. CONCLUSIONS: Removal of a misplaced or dislodged Viatorr endoprosthesis is possible using interventional methods.

Fast-track program for liver resection--factors prolonging length of stay.

BACKGROUND/AIMS: Fast-track programs involving multi-modal measures to enhance recovery after surgery, reduce morbidity and decrease hospital length of stay (LOS) are used for different major surgical procedures. For liver resections, factors influencing LOS within a fast-track program have been studied only to a limited extent, which was the aim of the present study. METHODOLOGY: The present study comprises the first 64 patients included in a fast-track program for liver resections introduced in March 2012. Patient outcomes were compared to a historical cohort of patients (n=62) operated in 2009. Factors prolonging LOS was analyzed by uni- and multivariate analysis. RESULTS: Median LOS was 6 days (range 3-42 days) within the fast-track program as compared with 8 days (range 5-47 days) in the historical cohort (P=0.004). On multivariate analysis, factors increasing LOS in the fast-track group were found to be the presence of complication (P=0.018), extent of resection (major as compared to minor) (P=0.001) and inability to drink > 1250 ml on the day after surgery (P=0.002). CONCLUSION: Patients who can only drink limited amounts of fluid the day after liver resection represent a subset of patients that should be given special attention within a fast-track program.

Multimodal management of colorectal liver metastases and the effect on regeneration and outcome after liver resection.

Management of colorectal liver metastases (CRLM) has dramatically changed during the last decade and has now become more multimodal and aggressive, including the use of downstaging chemotherapy, portal vein embolization to increase the function of the liver remnant or both in combination. Radiofrequency ablation is also an option in CRLM, potentially combined with surgical resection. Results are quite convincing concerning the safety of liver resection also when performed following neoadjuvant chemotherapy. Sparing liver parenchyma in patients with bilobar liver metastatic disease subjected to liver resection may be possible without endangering surgical radicality. Sparing liver parenchyma when using neoadjuvant chemotherapy, a chemotherapy-free period of 6 weeks or more seems to positively affect liver regeneration. There is still the possibility to reresect recurrent liver lesions, though there seems to be a tendency toward fewer reresections following the use of adjuvant chemotherapy.

Surgical exploration without resection in pancreatic and periampullary tumors: Report from a national database.

BACKGROUND AND OBJECTIVE: Pancreatic and periampullary cancers are sometimes found to have a too advanced disease during surgery to allow resection. The aim was to describe characteristics, treatment, outcome, and time trends for patients that were planned for pancreatic surgery but found unresectable during surgery. METHODS: Data from the Swedish National Pancreatic and Periampullary Cancer Registry were used. All patients registered between January 2010 and August 2018 were included. The patient cohort was divided in two halves based on year of diagnosis. RESULTS: In total, 12,377 patients were included in the registry and finally 4568 patients were scheduled for surgery. During surgical exploration, 3879 (84.9%) patients underwent pancreatic resection, 658 (14.4%) patients were found unresectable, and 31 (0.7%) had no pancreatic resection due to other reasons (e.g. benign lesion, comorbidity). More patients underwent surgical exploration and resection during the second time period, but exploration without resection was unchanged (15.7% vs 13.7%; p = 0.062). Survival rates were lower among the unresectable patients with pancreatic and periampullary tumors compared to the resectable patients, including 30-day mortality (n = 17 (3.5%) vs n = 39 (1.6%), p = 0.004) and 90-day mortality (n = 72 (15.0%) vs n = 70 (2.8%), p < 0.001). Palliative surgery became less common during the second half of the time period (p < 0.001). CONCLUSIONS: Unresectability is associated with an unfavorable prognosis. The frequency did not decrease during the study period, but palliative surgical procedures became less common.

Outstanding Response to Sorafenib in a Patient with Metastatic Gastrointestinal Stromal Tumour.

Gastrointestinal stromal tumour (GIST) is the most common sarcoma and can be seen in any part of the gastrointestinal tract. The effect of tyrosine kinase inhibitors varies with mutation status in receptor tyrosine kinase KIT and in platelet-derived growth factor receptor A (PDGFRA). This case presents a 61-year-old man, diagnosed with an 11-cm GIST located at the stomach with a high risk of recurrence. The patient showed intolerance to imatinib shortly after introduction and subsequently progressed on sunitinib and nilotinib. The patient started fourth-line treatment with sorafenib with an impressive response to a point at which metastases intra-abdominally and in the liver could be resected. After surgery, sorafenib was restarted. Due to toxicity, sorafenib dose was reduced over time. The dose was insufficient to control the disease since a new recurrence was detected. Mutation analyses revealed a GIST harbouring a deletion of codon p.I843_D846del, located at PDGFRA exon 18, right next to the codon D842 where mutations are known leading to imatinib resistance. In this case, the GIST was highly sensitive to sorafenib, and the response was dose related. It is mandatory to perform mutation analyses on primary tumour and at recurrence in the decision-making of the correct treatment for the patient. In March 2021, the patient had been in treatment with sorafenib for 12.5 years and was still without signs of recurrence. A multidisciplinary approach was essential for the long-term survival of the patient in this case.

Recurrent acute pancreatitis due to eosinophilic gastroenteritis. Case report and literature review.

CONTEXT: Eosinophilic gastroenteritis is characterized by eosinophilic infiltration of any gastrointestinal segment from the esophagus to the rectum, most commonly, the stomach and the duodenum. Clinical manifestations range from non-specific gastrointestinal complaints to more specific symptoms such as protein-losing enteropathy, malabsorption, luminal obstruction and eosinophilic ascites. CASE REPORT: We report the case of a 35-year-old woman with recurrent gastric outlet obstruction due to eosinophilic infiltration of the stomach and the duodenum. There was a history of two episodes of acute pancreatitis as well as eosinophilia of bone marrow and ascites. CONCLUSIONS: Although unusual, eosinophilic gastroenteritis may be complicated by symptomatic acute pancreatitis. Seven previous cases have been reported in the literature, and a comparison was made. The pancreatitis is probably due to duct obstruction, but some cases of eosinophilic gastroenteritis have pancreatic tissue eosinophilia. Most cases respond to medical treatment, and surgery is usually unnecessary.

Safety and preliminary efficacy of ultrasound-guided percutaneous irreversible electroporation for treatment of localized pancreatic cancer.

BACKGROUND: Irreversible electroporation (IRE) is a local tumor treatment. Thin needles are placed percutaneously around the tumor under ultrasound guidance. Short pulses of direct current sent through the tissue irreversibly increase cell membrane permeability leading to cell death. We report a phase 1 study assessing the safety of ultrasound guided percutaneous IRE in patients with localized pancreatic cancer (LPC). PATIENTS AND METHODS: Five patients (three males) with LPC, judged unsuitable for surgery, chemotherapy, or non-resectable after standard oncological treatment, were treated with IRE. The treatment was given under general anesthesia with muscle relaxation. RESULTS: No serious treatment-related adverse events were observed. There was no 30-day mortality. One patient went on to laparotomy and had a R0 pancreaticoduodenectomy with portal vein resection. Six months after the treatment, two patients had no signs of recurrence on computed tomography or contrast-enhanced ultrasound. CONCLUSION: IRE for LPC can be safely performed percutaneously under ultrasound guidance, with promising initial results regarding efficacy.

[Surgical treatment of pancreatic cancer]. / Kirurgisk behandling af cancer pancreatis.

Surgery remains the only hope for cure in pancreatic cancer. The most common procedures are reviewed. Postoperative morbidity and mortality below 30% and 5%, respectively, are the standard. The benefit of extended lymph node dissection and portal-mesenteric vein resection is dubious. Selected patients with locally advanced cancer may be down-staged with chemo-radiotherapy and eventually resected. Endoscopic stent placement is the preferred method to relieve biliary and/or gastrointestinal obstruction. The outcome is better for patients treated at high-volume centres than at smaller hospitals.

[Abdominal fistula 7 years after laparoscopic cholecystectomy]. / Abdominalfistel syv år efter kolecystektomi.

A 64-year old female presented with fistulas on the abdomen 7 years after laparoscopic cholecystectomy. During fistula excision, several gallstones were found. Scrutiny of the medical records revealed that spillage of gallstones had occurred during the cholecystectomy. We conclude that spilled gallstones may cause fistulas or abscesses even several years after cholecystectomy. Preventive measures such as gentle handling of the gallbladder and vigorous efforts to retrieve all lost gallstones seem important.

[Future perspectives in liver surgery]. / Fremtidsperspektiver inden for leverkirurgi.

Resection of colorectal liver metastases will increase due to increased life expectancy and widened indications. Complex combinations of chemotherapy, surgery, and local ablation are used in advanced disease. Advances in laparoscopic and telerobotic liver resection are expected. Hepatocellular carcinoma is rare, results are poor, and better treatment is needed. The complex management of liver neoplasms requires a centralized effort. Further advances in xenotransplantation, artificial liver, and stem cell technology may influence liver transplantation as well as cancer surgery.

[Combined surgical and oncological management of colorectal liver metastases]. / Kombineret kirurgisk og onkologisk behandling af kolorektale levermetastaser.

Isolated colorectal liver metastases should be referred for multispecialist management at a liver centre. Long-time survival is possible after resection and adjuvant therapy. If unresectable, newer chemotherapy with oxaliplatin, irinitecan, bevacizumab and cetuximab may result in a median survival > 20 months. Selected patients may be down-staged and resected with good long-time survival. Bilateral, multiple and large metastases can also be treated by complex combinations of portal vein embolization/ligature, staged resections and local (radiofrequency) ablation.

[Retroperitoneal sarcomas - size not decisive]. / Retroperitonealt liposarkom - størrelsen er ikke afgørende.

A 70 year-old female presented with a 40 x 40 cm unresectable liposarcoma which showed progression during chemotherapy. After renewed evaluation, a radical resection was done. The second case concerns a 64 year-old male with a 19 x 15 cm liposarcoma in the upper abdomen. A radical tumour resection together with the pancreatic tail, the spleen and the transverse mesocolon/colon was carried out. Both patients recovered without complications, and remain disease-free at two years. Retroperitoneal sarcomas are notoriously "silent", and may grow to considerable size before diagnosis. The evaluation is difficult, and radical resection frequently demands multiorgan surgery. Management at a national "Sarcoma Unit" is essential for the prognosis.

[Retroperitoneal sarcoma: a multispecialist effort]. / Retroperitonealt sarkom: et multidisciplinaert samarbejde.

A 61-year-old woman presented with a 16 cm retroperitoneal sarcoma, which demanded a multispecialist effort. There was adherence to the left ureter, the iliac vessels, the mesosigmoideum and the small intestine. After angiographic embolization, the tumor, sigmoid colon and left ureter were excised. Histology, immunohistology and electron microscopy gave the diagnosis pleomorphic sarcoma. The microscopic radicality was doubtful, but we abstained from adjuvant radiotherapy due to the large field and risk of toxicity. The patient remains disease-free after 24 months.

Successful resection of an advanced duodenal gastrointestinal stromal tumor after down-staging with imatinib: report of a case.

The diagnosis of gastrointestinal stromal tumor (GIST) relies on a combination of the following criteria: anatomic location, typical histopathology, and the presence of CD 117-antigen (the tyrosine kinase receptor, c-kit) or CD 34-antigen. Imatinib mesylate, a specific tyrosine kinase inhibitor, is highly efficient against locally advanced or metastatic GIST. We report a case of unresectable duodenal GIST, which we were able to resect with curative intent after down-staging treatment with a dosage of imatinib 400 mg daily for 8 months. We performed Whipple's procedure combined with en bloc resection of the right kidney and adrenal gland. The patient was recurrence free at his 24-month follow-up examination. Down-staging treatment may be worthwhile in selected patients, but further prospective studies of imatinib in this setting are necessary. We think that imatinib should be continued postoperatively, as the risk of recurrence in these patients may be high.