Technical aspects and learning curve of complex laparoscopic hepatectomy: how we do it.

INTRODUCTION: Laparoscopic liver surgery has advanced significantly, offering benefits, such as reduced intraoperative complications and quicker recovery. However, complex laparoscopic hepatectomy (CLH) is technically demanding, requiring skilled surgeons. This study aims to share technical aspects, insightful tips, and outcomes of CLH at our center, focusing on the safety and learning curve. METHODS: We reviewed all patients undergoing liver resection at our center from July 2017 to December 2023, focusing on those who underwent CLH. Of 135 laparoscopic liver resections, 63 (46.7%) were CLH. The learning curve of CLH was also assessed through linear and piecewise regression analyses considering the operation time and intraoperative blood loss. RESULTS: Postoperative complications occurred only in 4.8% of patients, with a 90-day mortality rate of 3.2%. The mean operation time and blood loss significantly decreased after the first 20 operations, marking the learning curve's optimal cut-off. Significant improvements in R0 resection (p = 0.024) and 90-day mortality (p = 0.035) were noted beyond the learning curve threshold. CONCLUSION: CLH is a safe and effective approach, with a relatively short learning curve of 20 operations. Future large-scale studies should further investigate the impact of surgical experience on CLH outcomes to establish guidelines for training programs.

Beyond the visible: preliminary evaluation of the first wearable augmented reality assistance system for pancreatic surgery.

PURPOSE: The retroperitoneal nature of the pancreas, marked by minimal intraoperative organ shifts and deformations, makes augmented reality (AR)-based systems highly promising for pancreatic surgery. This study presents preliminary data from a prospective study aiming to develop the first wearable AR assistance system, ARAS, for pancreatic surgery and evaluating its usability, accuracy, and effectiveness in enhancing the perioperative outcomes of patients. METHODS: We developed ARAS as a two-phase system for a wearable AR device to aid surgeons in planning and operation. This system was used to visualize and register patient-specific 3D anatomical models during the surgery. The location and precision of the registered 3D anatomy were evaluated by assessing the arterial pulse and employing Doppler and duplex ultrasonography. The usability, accuracy, and effectiveness of ARAS were assessed using a five-point Likert scale questionnaire. RESULTS: Perioperative outcomes of five patients underwent various pancreatic resections with ARAS are presented. Surgeons rated ARAS as excellent for preoperative planning. All structures were accurately identified without any noteworthy errors. Only tumor identification decreased after the preparation phase, especially in patients who underwent pancreaticoduodenectomy because of the extensive mobilization of peripancreatic structures. No perioperative complications related to ARAS were observed. CONCLUSIONS: ARAS shows promise in enhancing surgical precision during pancreatic procedures. Its efficacy in preoperative planning and intraoperative vascular identification positions it as a valuable tool for pancreatic surgery and a potential educational resource for future surgical residents.

Short-term postoperative outcomes of lymphadenectomy for cholangiocarcinoma, hepatocellular carcinoma and colorectal liver metastases in the modern era of liver surgery: Insights from the StuDoQ|Liver registry.

INTRODUCTION: The clinical role of lymphadenectomy (LAD) as part of hepatic resection for malignancies of the liver remains unclear. In this study, we aimed to report on the use cases and postoperative outcomes of liver resection and simultaneous LAD for hepatic malignancies (HM). MATERIALS AND METHODS: Clinicopathological data from patients who underwent surgery at 13 German centers from 2017 to 2022 (n = 3456) was extracted from the StuDoQ|Liver registry of the German Society of General and Visceral Surgery. Propensity-score matching (PSM) was performed to account for the extent of liver resection and patient demographics. RESULTS: LAD was performed in 545 (16%) cases. The most common indication for LAD was cholangiocarcinoma (CCA), followed by colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC). N+ status was found in 7 (8%), 59 (35%), and 56 cases (35%) for HCC, CCA, and CRLM, respectively (p < 0.001). The LAD rate was highest for robotic-assisted resections (28%) followed by open (26%) and laparoscopic resections (13%), whereas the number of resected lymph nodes was equivalent between the techniques (p = 0.303). LAD was associated with an increased risk of liver-specific postoperative complications, especially for patients with HCC. CONCLUSION: In this multicenter registry study, LAD was found to be associated with an increased risk of liver-specific complications. The highest rate of LAD was observed among robotic liver resections.

Surgical therapy for major lung parenchymal damage from late coronavirus disease complication: case report and literature review.

Background: Coronavirus disease [severe acute respiratory syndrome coronavirus disease 19 (SARS COVID-19)] has emerged as one of the most challenging diseases of recent decades. After the pandemic outbreak, our knowledge of the virus has expanded and developed, but we face a new wave of atypical complications that require special attention. In addition to the acute complications of COVID-19 infection, late complications of the disease are taking an increasingly important part in the management of affected patients, which are grouped under the collective term "Long COVID". In this work, we present our therapy strategy in three cases of pulmonary cavity as a late complication after COVID-19, as well as perform a literature review of published articles in this matter. Case Description: This study includes 3 cases of pulmonary cavities as a late COVID complication. Among them only one patient was vaccinated. The mean duration between the occurrence of Long COVID and SARS COVID-19 disease was 4 weeks in our patients. All patients underwent adequate medical therapy after Long COVID. However, due to the disease progression and significant elevated infections parameters, all patients underwent surgical therapy. One patient underwent uniportal video-assisted thoracoscopic surgery (VATS) lobectomy and decortication of the empyema, whereas we performed thoracotomy for other patients. All patients treated successfully and discharged shortly after the operation. Our literature review provides a total of 12 publications with only 50 patients. No patients received vaccination. The mean interval time between acute infection and the appearance of pulmonary cavities was about 4 weeks. The results showed that most patients were treated with conservative therapies. Only two patients were treated using invasive therapies. Both patients were successfully treated and recovered from the procedures. Conclusions: This group of late complications COVID patients requires individualized treatment strategy. In the case of an underlying pulmonary cavities, depending on the findings, despite increased perioperative risks, very good results can be achieved by presentation to a specialized and experienced thoracic surgery center.

A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery.

BACKGROUND: Surgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures. METHODS: A systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review. RESULTS: Seven "core" indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries. CONCLUSIONS: This work presents a core set of internationally agreed QPI for HPB surgery.

[Potential risk to patient safety by discontinuation of production of classical T-drains? : Nationwide survey in Germany and statement of the surgical working group for liver, gall bladder and pancreatic diseases (CALGP) of the German Society for General and Visceral Surgery (DGAV)]. / Potenzielle Patientengefährdung durch Produktionsstopp klassischer T-Drainagen? : Deutschlandweite Umfrage und Stellungnahme der Chirurgischen Arbeitsgemeinschaft für Leber­, Galle- und Pankreaserkrankungen (CALGP) der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV).

The revision of the medical device regulation (MDR) legislation by the European Union and supplementations by the member states has been implemented for good reasons but causes dramatic side effects. It is no longer allowed to produce some rarely used medical devices by various manufacturers that have been successfully used for decades. Before production, a new application to the MDR would be necessary, which is not a realistic business case for companies producing rarely used devices. This problem currently relates to the Kehr T­drain made from soft rubber or latex that has been in use since the late nineteenth century. A surgically placed T­drain, although rarely necessary nowadays, is still in use worldwide for special indications in an attempt to avoid severe complications. These special indications include complex hepato-pancreato-biliary (HPB) procedures and perforations of the upper gastrointestinal (GI) tract where T­drains may be used to secure the hepatojejunostomy or to create a stable fistula. The HPB working group (CALGP) of the German Society of General and Visceral Surgery (DGAV) provides a statement from a surgical perspective on this matter after a survey of all its members. Politics should be very careful not to generalize when implementing useful new regulations at a European and national level. Established and comprehensible treatment concepts should not be restricted and exemption permits should be quickly granted in these cases because the discontinuation of these niche products may lead to potential patient safety issues and even fatalities.

[Parenchyma sparing or Anatomical Resections for Colorectal Liver Metastases?] / Parenchymsparende Operationen oder anatomische Resektionen bei Lebermetastasen des kolorektalen Karzinoms?

Colorectal cancer is one of the leading causes of death in the Western world. Half of the patients develop colorectal liver metastases (CRLM), while only less than 30% of the patients have surgically resectable metastasis at the time of diagnosis. In case of resectability, classical anatomical (major) hepatectomy offers a high R0 resection rate, but with simultaneously increased perioperative morbidity and mortality. Over the past two decades, the potential benefits of parenchyma-sparing hepatectomy (PSH) for overall oncological outcomes, survival, and re-resection in case of recurrence ("salvageability") have been demonstrated. This article summarizes the current evidence on PSH as a surgical treatment option, and discusses the current "state of the art" in different therapy scenarios.

Development and internal validation of the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score: is the patient suitable for Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS)?

Background: Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is not always reliable with currently available scores, particularly in patients with primary liver tumor. This study aims to (I) to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and (II) to create a score predicting 90-day mortality preoperatively. Methods: Thirteen high-volume centers participated in this retrospective multicentric study. A risk analysis based on patient characteristics, underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score. A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index (CCI), the age-adjusted CCI (aCCI), the ALPPS risk score before Stage 1 (ALPPS-RS1) and Stage 2 (ALPPS-RS2). The model was internally validated applying bootstrapping. Results: A total of 451 patients were included. Mortality was 14.4%. The CAPRA score is calculated based on the following formula: (0.1 × age) - (2 × BSA) + 1 (in the presence of primary liver tumor) + 1 (in the presence of severe cardiovascular disease) + 2 (in the presence of moderate or severe diabetes) + 2 (in the presence of renal disease) + 2 (if classic ALPPS is planned). The predictive ability was 0.837 for the CAPRA score, 0.443 for CCI, 0.519 for aCCI, 0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2. After 1,000 cycles of bootstrapping the C statistic was 0.793. The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70. Conclusions: Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure. By assessing the patient's preoperative condition in relation to ALPPS, the CAPRA score has a very good ability to predict postoperative mortality.

Primary adenocarcinoma of an ileostomy in a Crohn patient: a case report.

Proctocolectomy with ileostomy is an established surgical treatment in patients with inflammatory bowel disease. Adenocarcinoma of an ileostomy is a rare complication in long-term ileostomies. We present the case of a 69-year-old man who presented with bloody stools and a tumour at the ileostomy site 37 years after ileostomy formation. Biopsies confirmed the presence of an adenocarcinoma. Imaging did not show any metastases or advanced local infiltration. A resection of the ileostomy with a broad safety margin and reimplantation of a new Ileostomy was performed. At 18-month follow-up, there is no sign of recurrence. Ileostomy adenocarcinoma in a Crohn's disease patient is rare with only four cases described in literature. An en-bloc resection and relocation of the ileostomy is the recommended treatment. Education of patients and healthcare professionals on this long-term ileostomy complication is vital for the early diagnosis and treatment.

Intraoperative (Contrast-Enhanced) Ultrasound Has the Highest Diagnostic Accuracy of Any Imaging Modality in Resection of Colorectal Liver Metastases.

AIM: Defining sensitivity, specificity, diagnostic accuracy for detection of colorectal liver metastases in imaging compared to intraoperative assessment. Defining a cutoff, where accuracy of detection is impaired. METHODS: Prospective single-institution clinical trial (clinicaltrials.gov: NCT01522209). Patients underwent CEUS, MDCT, and 3 Tesla EOB-MRI within 2 weeks preoperatively. Intraoperative palpation, IOUS, and CEIOUS were performed. A patient and lesion-based database was analyzed for accuracy of detection of CEUS, CT, MRI, and Palp/IOUS/CEIOUS combined read. Histology was standard of reference. RESULTS: Forty-seven high tumor load (mean 5, 4 lesions) patients were analyzed. Histopathology confirmed 264 lesions (245 malignant: 19 benign). Accuracy for detection of all lesions: CEUS 63%, CT 71%, MRI 92%, and PALP/IOUS/CEIOUS 98%. ROC analysis for lesion size showed severe impairment of accuracy in lesion detection smaller than 5mm. Intraoperative imaging was not impaired by lesion size. Patient-based analysis revealed a change of resection plan after IOUS/CEIOUS in 35% of patients. CONCLUSION: At 5-mm lesion size, preoperative imaging shows a drop in accuracy of detection. In patients with multiple lesions, addition of MRI to MDCT seems useful. Accuracy of intraoperative ultrasound is not impacted by lesion size and should be mandatory. CEIOUS can improve intraoperative decision-making. TRIAL REGISTRATION: Study registered with clinicaltrials.gov : NCT01522209.

Ipsilateral access portal venous embolization (PVE) for preoperative hypertrophy exhibits low complication rates in Clavien-Dindo and CIRSE scales.

BACKGROUND: Portal venous embolization (PVE) is a minimal invasive preoperative strategy that aims to increase future liver remnant (FLR) in order to facilitate extended hemihepatectomy. We analyzed our data retrospectively regarding complications and degree of hypertrophy (DH). METHODS: 88 patients received PVE either by particles / coils (n = 77) or by glue / oil (n = 11), supported by 7 right hepatic vein embolizations (HVE) by coils or occluders. All complications were categorized by the Clavien- Dindo (CD) and the CIRSE classification. RESULTS: In 88 patients (median age 68 years) there was one intervention with a biliary leak and subsequent drainage (complication grade 3 CD, CIRSE 3), two with prolonged hospital stay (grade 2 CD, grade 3 CIRSE) and 13 complications grade 1 CD, but no complications of grade 4 or higher neither in Clavien- Dindo nor in CIRSE classification. The median relative increase in FLR was 47% (SD 35%). The mean pre-intervention standardized FLR rose from 23% (SD 10%) to a post-intervention standardized FLR of 32% (SD 12%). The degree of hypertrophy (DH) was 9,3% (SD 5,2%) and the kinetic growth rate (KGR) per week was 2,06 (SD 1,84). CONCLUSION: PVE and, if necessary, additional sequential HVE were safe procedures with a low rate of complications and facilitated sufficient preoperative hypertrophy of the future liver remnant.

Appendicitis during the COVID-19 lockdown: results of a multicenter analysis in Germany.

PURPOSE: The COVID-19 pandemic has transformed medical care worldwide. General surgery has been affected in elective procedures, yet the implications for emergency surgery are unclear. The current study analyzes the effect of the COVID-19 lockdown in spring 2020 on appendicitis treatment in Germany. METHODS: Hospitals that provided emergency surgical care during the COVID-19 lockdown were invited to participate. All patients diagnosed with appendicitis during the lockdown period (10 weeks) and, as a comparison group, patients from the same period in 2019 were analyzed. Clinical and laboratory parameters, intraoperative and pathological findings, and postoperative outcomes were analyzed. RESULTS: A total of 1915 appendectomies from 41 surgical departments in Germany were included. Compared to 2019 the number of appendectomies decreased by 13.5% (1.027 to 888, p=0.003) during the first 2020 COVID-19 lockdown. The delay between the onset of symptoms and medical consultation was substantially longer in the COVID-19 risk group and for the elderly. The rate of complicated appendicitis increased (58.2 to 64.4%), while the absolute number of complicated appendicitis decreased from 597 to 569, (p=0.012). The rate of negative appendectomies decreased significantly (6.7 to 4.6%; p=0.012). Overall postoperative morbidity and mortality, however, did not change. CONCLUSION: The COVID-19 lockdown had significant effects on abdominal emergency surgery in Germany. These seem to result from a stricter selection and a longer waiting time between the onset of symptoms and medical consultation for risk patients. However, the standard of emergency surgical care in Germany was maintained.

Leiomyosarcoma of the inferior vena cava: A case report of a rare tumor entity.

INTRODUCTION: Leiomyosarcomas are rare and heterogeneous group of tumors that account for less than 1% of adult malignancies. More than 50% of all vascular leiomyosarcomas occur in the lower part of vena cava. Since the first description of Perl and Virchow in 1871, only approximately 450 cases have been reported in literature. PRESENTATION OF CASE: The patient presented due to abdominal pain and weight loss. Based on the imaging evaluations a retroduodenal tumor with compression of the inferior vena cava was observed. In the explorative laparotomy a leiomyosarcoma originating from the inferior vena cava was identified. Considering the extensive intramural and intraluminal tumor manifestation, the patient underwent a segmental resection of the vena cava. Reconstruction was achieved by implanting a polytetrafluoroethylene (PTFE) prosthesis. Postoperatively a stenosis developed due to a pericaval haematoma with consecutive compression of the prosthesis. An angiographic implantation of a stent was successfully performed. In the 24-month follow-up, the patient is free of symptoms and tumors. DISCUSSION: Leiomyosarcomas of the vena cava are classified anatomically according to their relationship to the liver and renal vessels. The clinical symptoms depend on the affected segment. The therapy of choice is radical en bloc tumor resection. After resection, the options for reconstruction include placement of a synthetic graft, primary repair and patch repair. CONCLUSION: Due to a variety of topographic and tumor biological sarcoma manifestations, no standard has been established for the resection of this entity. The extent of resection should be planned individually.

ALPPS in neuroendocrine liver metastases not amenable for conventional resection - lessons learned from an interim analysis of the International ALPPS Registry.

BACKGROUND: Surgery is the most effective treatment option for neuroendocrine liver metastases (NELM). This study investigated the role of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as a novel strategy in treatment of NELM. METHODS: The International ALPPS Registry was reviewed to study patients who underwent ALPPS for NELM. RESULTS: From 2010 to 2017, 954 ALPPS procedures from 135 international centers were recorded in the International ALPPS Registry. Of them, 24 (2.5%) were performed for NELM. Twenty-one patients entered the final analysis. Overall grade ≥3b morbidity was 9% after stage 1 and 27% after stage 2. Ninety-day mortality was 5%. R0 resection was achieved in 19 cases (90%) at stage 2. Median follow-up was 28 (19-48) months. Median disease free survival (DFS) was 17.3 (95% CI: 7.1-27.4) months, 1-year and 2-year DFS was 73.2% and 41.8%, respectively. Median overall survival (OS) was not reached. One-year and 2-year OS was 95.2% and 95.2%, respectively. CONCLUSIONS: ALPPS appears to be a suitable strategy for inclusion in the multimodal armamentarium of well-selected patients with neuroendocrine liver metastases. In light of the morbidity in this initial series and a high rate of disease-recurrence, the procedure should be taken with caution.

The MEGNA Score and Preoperative Anemia are Major Prognostic Factors After Resection in the German Intrahepatic Cholangiocarcinoma Cohort.

BACKGROUND: Surgical resection is associated with the best long-term results for intrahepatic cholangiocarcinoma (ICC); however, long-term outcomes are still poor. OBJECTIVE: The primary aim of this study was to validate the recently proposed MEGNA score and to identify additional prognostic factors influencing short- and long-term survival. PATIENTS AND METHODS: This was a retrospective analysis of a German multicenter cohort operated at 10 tertiary centers from 2004 to 2013. Patients were clustered using the MEGNA score and overall survival was analyzed. Cox regression analysis was used to identify prognostic factors for both overall and 90-day survival. RESULTS: A total of 488 patients undergoing liver resection for ICC fulfilled the inclusion criteria and underwent analysis. Median age was 67 years, 72.5% of patients underwent major hepatic resection, and the lymphadenectomy rate was 86.9%. Median overall survival was 32.2 months. The MEGNA score significantly discriminated the long-term overall survival: 0 (68%), I (48%), II (32%), and III (19%) [p <0.001]. In addition, anemia was an independent prognostic factor for overall survival (hazard ratio 1.78, 95% confidence interval 1.29-2.45; p <0.01). CONCLUSION: Hepatic resection provides the best long-term survival in all risk groups (19-65% overall survival). The MEGNA score is a good discriminator using histopathologic items and age for stratification. Correction of anemia should be attempted in every patient who responds to treatment. Perioperative liver failure remains a clinical challenge and contributes to a relevant number of perioperative deaths.

Defining Benchmark Outcomes for ALPPS.

OBJECTIVE: The aim of this study was to use the concept of benchmarking to establish robust and standardized outcome references after the procedure ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy). BACKGROUND AND AIMS: The recently developed ALPPS procedure, aiming at removing primarily unresectable liver tumors, has been criticized for safety issues with high variations in the reported morbidity/mortality rates depending on patient, disease, technical characteristics, and center experience. No reference values for relevant outcome parameters are available. METHODS: Among 1036 patients registered in the international ALPPS registry, 120 (12%) were benchmark cases fulfilling 4 criteria: patients ≤67 years of age, with colorectal metastases, without simultaneous abdominal procedures, and centers having performed ≥30 cases. Benchmark values, defined as the 75th percentile of the median outcome parameters of the centers, were established for 10 clinically relevant domains. RESULTS: The benchmark values were completion of stage 2: ≥96%, postoperative liver failure (ISGLS-criteria) after stage 2: ≤5%, ICU stay after ALPPS stages 1 and 2: ≤1 and ≤2 days, respectively, interstage interval: ≤16 days, hospital stay after ALPPS stage 2: ≤10 days, rates of overall morbidity in combining both stage 1 and 2: ≤65% and for major complications (grade ≥3a): ≤38%, 90-day comprehensive complication index was ≤22, the 30-, 90-day, and 6-month mortality was ≤4%, ≤5%, and 6%, respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic disease-free survival was ≥86%, ≥50%, ≥57%, and ≥65%, respectively. CONCLUSIONS: This benchmark analysis sets key reference values for ALPPS, indicating similar outcome as other types of major hepatectomies. Benchmark cutoffs offer valid tools not only for comparisons with other procedures, but also to assess higher risk groups of patients or different indications than colorectal metastases.