Value of palliative surgery in perihilar cholangiocarcinoma.

PURPOSE: The survival rate of patients with irresectable perihilar cholangiocarcinoma is remarkably poor. An essential part of palliation is treatment of obstructive cholestasis caused by the tumor. Currently, this is mainly performed endoscopically by stent or via PTBD, requiring frequent changes of the stents and limiting health-related quality of life due to the multiple hospital stays needed. The aim of this study was to evaluate surgical palliation via extrahepatic bile duct resection as an option for palliative treatment. METHODS: Between 2005 and 2016, we treated 120 pCCC patients with primary palliative care. Three treatment strategies were retrospectively considered: extrahepatic bile duct resection (EBR), exploratory laparotomy (EL), and primary palliative (PP) therapy. RESULTS: The EBR group required significantly less stenting postoperatively, and the overall morbidity was 29.4% (EBR). After the surgical procedure, fewer subsequent endoscopic treatments for stenting or PTBD were necessary in the EBR group over time. The 30-day mortality was 5.9% (EBR) and 3.4% (EL). The median overall survival averaged 570 (EBR), 392 (EL), and 247 (PP) days. CONCLUSIONS: In selected pCCC patients, palliative extrahepatic bile duct resection is a feasible option for treatment of obstructive cholestasis and should be reconsidered as a therapy option for these patients even in a palliative setting.

Pathogen detection in patients with perihilar cholangiocarcinoma: Implications for targeted perioperative antibiotic therapy.

BACKGROUND: Cholestasis should be relieved by biliary drainage prior to major liver resection. This condition is often associated with bacterial colonization of the otherwise sterile biliary system. Cholangitis reduces the regenerative capacity of the remaining liver. Therefore, targeted antibiotic therapy is a key feature in perioperative treatment in patients with perihilar cholangiocarcinoma (pCCC). METHODS: Between December 1999 and December 2017, 251 pCCC patients were treated in our center. In total, 115 patients underwent a microbiological analysis. In addition to the characterization of the specific microorganisms and antibiotic resistance, we analyzed subgroups according to preoperative intervention. RESULTS: Enterococci (87/254, 34%) and Enterobacteria (65/254, 26%) were the most frequently detected genera. In 43% (50/115) of patients, Enterococcus faecalis was found in the bile duct sample. Enterococcus faecium (29/115) and Escherichia coli (29/115) were detected in 25% of patients. In patients with percutaneous transhepatic biliary drainage (3/8, 38%) or stents (24/79, 30%), Enterococcus faecium was diagnosed most frequently (P < 0.05). Enterococcus faecium and Klebsiella oxytoca were significantly more frequently noted in the time period after 2012 (P < 0.05). With regard to fungal colonization, the focus was on various Candida strains, but these strains generally lacked resistance. CONCLUSIONS: pCCC patients exhibit specific bacterial colonization features depending on the type of preoperative biliary intervention. Specifically, targeted antibiosis should be applied in this patient cohort to minimize the risk of biliary complications after major liver resection. In our cohort, the combination of meropenem and vancomycin represents an effective perioperative medical approach.

Experiences with surgically treated primary or secondary hepatic sarcoma.

PURPOSE: Liver resection in hepatic sarcoma is rare, but other alternative treatment options are scarce. Surgery offers the only aggressive approach to achieve a tumour-free state. The aim of this investigation was to evaluate the outcome and survival of these patients at a single hepato-biliary university hospital. METHODS: Between January 2004 and July 2013, 896 anatomical liver resections were performed. Eleven liver resections (1.2%) were performed due to primary hepatic sarcoma or hepatic sarcoma metastases. The demographic and clinical parameters were collected from the institutional patients' records. RESULTS: In eight patients (83%), liver resection was performed due to hepatic sarcoma metastases. The surgical procedures were as follows: two patients (18%) had segmentectomy, six patients (55%) had hemihepatectomy or extended hemihepatectomy and three patients (27%) had multivisceral resections. In nine patients (82%), the resection margins were tumour free. In 55% (n = 6) of the patients, the maximal tumour diameter was greater than 10 cm. The postoperative morbidity was low with a Clavien-Dindo score of 2 (range 0-5). One patient died on postoperative day 2 after multivisceral resection. During the follow-up of 932 days (range 2-2.220 days) the 1-, 2- and 3-year survival rates were 91, 63 and 45%, respectively. Tumour recurrence was detected in seven patients (63%). CONCLUSIONS: Liver resections in patients with primary or secondary hepatic sarcoma are rare. The main goal in these patients is to achieve complete tumour resection because chemotherapy offers no suitable alternative, but the long-term survival rates are limited because of high a recurrence rate even after aggressive surgical approaches.

Microbiology of the infected recurrent sacrococcygeal pilonidal sinus.

The aim of the present retrospective single centre study was to define the changes in the microbiological flora of the recurring sacrococcygeal pilonidal sinus (PS). Microbiological findings of swab samples of abscess-forming PS from 2000 to 2010 were evaluated. Within this time span, 73 swab samples were taken from primary sacrococcygeal pilonidal sinus (pPS) and 23 swab samples of patients with recurring sacrococcygeal pilonidal sinus (rPS). Our results show a statistically significant shift of the bacterial flora towards the gram-positive range (P = 0·029) and a shift with tendency towards the aerobic range (P = 0·090). Pathogens of pPS are not always solely anaerobic or gram-negative, and those of rPS not always aerobic or gram-positive. Therefore, antibiosis preceding microbiological examination should cover both the aerobic and anaerobic bacteria as well as the gram-positive and the gram-negative spectrum.

Suture granuloma mimicking a recurrent sacro-coccygeal pilonidal sinus after Limberg flap.

Sacro-coccygeal pilonidal sinus disease is classified as an asymptomatic, acutely abscess-forming or chronic subcutaneous inflammation in the sacro-coccygeal region featuring characteristic pits in the bottom cleft. Due to high rates of recurrence, two flap techniques have been established in the course of the past three decades. One of them is the Karydakis operation, the other option is a rotation flap named Limberg procedure. We report about a case of suture granuloma in the area of a Limberg flap after recurrent pilonidal sinus with extrusion of the suture material, thus mimicking recurrence. In case of recurrent pilonidal sinus following plastic coverage or primary closure, respectively, the differential diagnosis of suture granuloma should be considered.

[Individualized curative treatment for malignant diseases through liver transplantation]. / Individualisierte kurative Therapie bei malignen Erkrankungen durch Lebertransplantation.

BACKGROUND: For patients with primary and secondary liver tumors that are functionally or technically nonresectable, liver transplantation remains the sole curative treatment option. Over the years the benefits of transplantation have also been validated for conditions other than hepatocellular carcinoma. Currently, amidst a period of organ shortage the broadening of transplantation indications is a topic of ongoing debate. Although recent studies have confirmed the long-term success of transplantation within multimodal treatment regimens, this approach has yet to become the standard treatment for many conditions. OBJECTIVE: This article explores the potential of liver transplantation in individualized multimodal oncological treatment strategies. RESULTS AND CONCLUSION: Liver transplantation has become an integral component of the treatment regimen for hepatocellular carcinoma. In Germany there is a prioritized organ allocation facilitated by the granting of a standard exception for cases with a smaller tumor burden. Over the years numerous studies have demonstrated comparable long-term results using different listing criteria. Both intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma can be curatively treated with transplantation in Germany, although this is typically within the context of clinical studies. The neoadjuvant therapy and patient selection, based on tumor burden and the response to preliminary treatment, play a crucial role in influencing long-term survival and recurrence rates. The success of transplantation for liver metastases from neuroendocrine malignancies or colorectal carcinomas, which cannot be removed by partial resection, also significantly hinges on the patient selection. The role of living donor liver transplantation is becoming increasingly more pivotal in this context.

Rare tumours of the pancreas: monocentric study.

PURPOSE: The biology of rare pancreatic tumours, which differs from that of ductal pancreatic cancer, requires increased attention. Although the majority of rare pancreatic tumours are benign, it is difficult to decide whether an invasive component exists without complete removal of the lesion, despite considerable progress in diagnosis. We are investigating a large cohort of patients with histologically confirmed epithelial non-ductal non-neuroendocrine neoplasms of the pancreas. METHODS: Here we analyze long-term survival from patients, who underwent resection of histologically confirmed epithelial non-ductal non-neuroendocrine neoplasms of the pancreas. At our department between Jan 1st, 1999, and Dec 31st, 2019. The median follow-up was 61 (range 0-168) month. All statistical analyses were performed using SPSS 26.0 (IBM, Chicago, IL, USA) software. RESULTS: 46 patients (48%) were followed up for more than 5 years, 18 patients (19%) for more than 10 years. The 5-year and 10-year survival rates for rare non-invasive pancreatic tumours were 72% and 55% respectively. The proportion of rare tumour entities (non-ductal and non-neuroendocrine) increased continuously and statistically significantly (p = 0.004) from 4.2 to 12.3% in our clinic between 1999 and 2019. If there is no invasive growth yet, there is a varying risk of malignant degeneration in the course of the disease. Therefore, the indication for pancreatic resection is still the subject of discussion. CONCLUSION: The long-term prognosis of rare epithelial pancreatic tumours after R0 resection-even if they are already malignant-is much better than that of ductal pancreatic cancer.

Liver Transplantation for Hepatocellular Carcinoma beyond the Milan Criteria: A Specific Role for Living Donor Liver Transplantation after Neoadjuvant Therapy.

PURPOSE: This study was designed to elucidate the various new classifications and the use of LDLT and bridging therapy for HCC in this context beyond the Milan criteria (MC). METHODS: The clinical data of patients with HCC outside the MC who underwent LT at Jena University between January 2007 and August 2023 were retrospectively analysed. Eligible patients were classified according to various classification systems. Clinicopathological features, overall and disease-free survival rates were compared between LT and LDLT within the context of bridging therapy. THE RESULTS: Among the 245 patients analysed, 120 patients did not meet the MC, and 125 patients met the MC. Moreover, there were comparable overall survival rates between patients outside the MC for LT versus LDLT (OS 44.3 months vs. 28.3 months; 5-year survival, 56.4% vs. 40%; p = 0.84). G3 tumour differentiation, the presence of angioinvasion and lack of bridging were statistically significant risk factors for tumour recurrence according to univariate and multivariate analyses (HR 6.34; p = 0.0002; HR 8.21; p < 0.0001; HR 7.50; p = 0.0001). Bridging therapy before transplantation provided a significant survival advantage regardless of the transplant procedure (OS: p = 0.008; DFS: p < 0.001). CONCLUSIONS: Patients with HCC outside the MC who underwent LT or LDLT had worse outcomes compared to those of patients who met the MC but still had a survival advantage compared to patients without transplantation. Nevertheless, such patients remain disadvantaged on the waiting list, which is why LDLT represents a safe alternative to LT and should be considered in bridged HCC patients because of differences in tumour differentiation, size and tumour marker dynamics.

Adipose tissue induces a better liver regeneration after living liver donation in normal weight donors.

Background: Extrahepatic body fat could be a relevant factor affecting liver regeneration after partial hepatectomy. The aim of this study was to evaluate the potential role of body fatty tissue in liver regeneration capacity after liver resection in a cohort of living donors. Methods: We observed liver regeneration in 120 patients: 70 living donors who underwent right hepatectomy and 50 recipients who got a right graft transplantation. Liver volumetry and body fat analysis were performed based on the computed tomography images with volumetry software. The gain of liver volume was calculated between three points in time considering the absolute and percentage values: before surgery and early (median 10 days, range 4-21 days) and late (median 27 weeks, range 18-40 weeks) after surgery. Pearson's correlation was used to examine the potential correlation between adipose tissue and liver regeneration. Results: Pearson's correlation showed a significant correlation between the subcutaneous fat mass index (sFMI) and early (r=0.173, P=0.030), as well late (r=0.395, P=0.0004) percental liver volume gain in the whole collective. Under stratification in donor's and recipient's collectives, the effect of extrahepatic adipose tissue appears in multiple regression only in the donor's collective: early (ß =0.219, T =2.137, P=0.036) and late (ß =0.390, T =2.552, P=0.015) percental volume gain. Conclusions: Subcutaneous adipose tissue is a positive predictive factor to estimate the goodness of liver regeneration after partial hepatectomy in normosthenic donors.

Living Donor Liver Transplantation for Intrahepatic Cholangiocarcinoma.

Intrahepatic cholangiocarcinoma is in most transplant regions a contraindication for liver transplantation, even ruling out an active waiting list registration. However, recent studies showed that well-selected patients after a neo-adjuvant treatment benefit from liver transplantation with good long-term outcomes. The role of living donor liver transplantation is unclear for this indication. The current study focuses on LDLT for intrahepatic cholangiocarcinoma.

Impact of successful local ablative bridging therapy prior to liver transplantation on long-term survival in patients with hepatocellular carcinoma in cirrhosis.

BACKGROUND: It has been shown that local ablative procedures enable downsizing, reduce drop-out from the waiting list and improve prognosis after liver transplantation. It is still unclear whether a response to the local ablative therapy is due to a favorable tumor biology or if a real benefit in tumor stabilization exists, particularly in complete pathological response. METHOD: Data of 163 HCC patients who underwent liver transplantation were extracted from our prospectively maintained registry. We analyzed the tumor load, pre-transplant α-fetoprotein levels, child stage aside the application and success of local ablative therapies as bridging procedures before transplantation. RESULTS: 87 patients received multiple and/or combined local therapies. In 20 cases, this resulted in a complete remission of the tumor as observed in the explant histology. The other 76 patients underwent no bridging procedure. The observed 5- and 10-year survival rates for patients with bridging were 67% and 47% and without bridging 56% and 46%, respectively. Tumor-related 10-year survival showed a statistically significant difference between both groups (81% versus 59%). In the multivariate analyses bridging, number of lesions and α-fetoprotein level showed an independent statistically significant influence on tumor-related survival in these patients. CONCLUSIONS: Successful local ablative therapy before liver transplantation is an independent statistically significant factor in long-term tumor-related survival for patients with HCC in cirrhosis and reduces tumor recurrences.

Liver Transplant Due to Flupirtine-Induced Acute Liver Failure.

OBJECTIVES: Acute drug-induced liver failure is a rare indication for liver transplant. There is only one case of flupirtine-induced liver failure requiring transplant in the literature. In February 2018, the European Medicines Agency issued a withdrawal of approval for flupirtine medication in European countries as a result of the risk of acute liver failure. MATERIALS AND METHODS: The aim of this study was a German-wide collection of data regarding patients with liver transplant as a result of flupirtine-associated liver failure. RESULTS: A total of 9 patients received transplants. All patients were women with a mean age of 43 years. Indication for flupirtine medication was musculoskeletal symptoms and migraine headache. The medication was taken over a period of approximately 3 months. All patients developed progressive acute liver failure, and no patient had previous chronic liver disease or cirrhosis. The mean laboratory Model for End Stage Liver Disease score for the patients was 31 ± 7 at time of transplant. Eight of the 9 patients were listed as "high urgency" for transplant. After transplant, they had an uneventful course with a prolonged mean intensive care unit stay of 13 ± 8.7 days. The whole hospitalization time was 43 ± 21 days. CONCLUSIONS: This is the largest published series of patients who received liver transplant after a drug-induced acute liver failure from flupirtine medication.

Biocellulose for Incisional Hernia Repair-An Experimental Pilot Study.

Ventral or incisional hernia are a common disease pattern in general surgery. Mostcommonly, a mesh repair is used for reconstruction, whereby the mesh itself might causecomplications, like infections or adhesions. Biological materials, like biocellulose, might reducethese clinical problems substantially. In this prospective rodent study, a biocellulose mesh(produced by Gluconacetobacter xylinus) was implanted either by a sublay technique or assupplementation of the abdominal wall. After an observation period of 90 days, animals weresacrificed. The adhesions after the reconstruction of the abdominal wall were moderate. Thehistologic investigations revealed that the biocellulose itself was inert, with a minimal regenerativeresponse surrounding the mesh. The explanted mesh showed a minimal shrinkage (around 15%) aswell as a minimal loss of tear-out force, which might be without clinical relevance. This is the firstin vivo study describing biocellulose as a suitable mesh for the repair of ventral hernia in twodifferent hernia models. The material seems to be a promising option for solving actual problems inmodern hernia surgery.