Laparoscopic ablation for liver malignancies: initial experience at a Scandinavian high volume HPB center.

BACKGROUND: Ablation is an effective, parenchymal-sparing treatment for primary liver cancer and liver metastases. The purpose of this study was to report our initial experience with laparoscopic microwave ablation regarding postoperative complications, rate of conversions to open procedure, and technical efficacy. METHODS: This was a quality improvement project carried out at a tertiary care center in Denmark. Patients ≥ 18 years old with liver malignancies, not available for percutaneous ablation, and treated with ultrasound-guided laparoscopic ablation were included. RESULTS: From March 2023 to December 2023, 39 patients were referred for laparoscopic ablation after a multidisciplinary team conference. Of these, two procedures were converted to open procedures due to adhesion and tumor progression. Three patients rejected the sharing of medical information, two procedures were canceled and in one case the strategy was changed perioperatively. Therefore, 32 procedures in 31 patients were available for analysis. Complete ablation was evaluated after 1 month and was achieved in 100% of the procedures. None of the patients died, and no complications were reported in 21 cases (65.6%). Most patients with complications had a grade 1 complication based on the Clavien-Dindo classification, which among others included abdominal and shoulder pain, atrial fibrillation, and subcutaneous hematoma. Two patients had a complication grade 2 (wound infection and decompensated cirrhosis) and one had a grade 4b (sepsis due to pneumonia and urinary tract infection). The median Comprehensive Complication Index was 12.2 (interquartile range 8.7-24.2). Furthermore, univariable logistic regression showed that ≥ 2 tumors treated were associated with a higher risk of complications (odds ratio 6.37, 95% confidence interval [1.20;33.85], p-value = 0.0297). CONCLUSION: Ultrasound-guided laparoscopic microwave ablation of liver malignancies is feasible and safe with little risk for complications, a high technical efficacy, and a low rate of conversions to open procedures.

Prevalence of hyperthyroidism and hypothyroidism in liver transplant recipients and associated risk factors.

The prevalence of hyperthyroidism and hypothyroidism and associated risk factors are unknown in liver transplant recipients. We aimed to determine the prevalence of hyperthyroidism and hypothyroidism and associated risk factors in liver transplant recipients and to compare it with controls from the general population. As part of the Danish Comorbidity in Liver Transplant Recipients (DACOLT) Study, all Danish liver transplant recipients over the age of 20 were invited for measurements of concentrations of thyrotropin and thyroid hormones. The prevalence of hyperthyroidism and hypothyroidism was compared to age- and sex-matched controls from the Copenhagen General Population Study. Using logistic regression adjusted for age, sex, smoking, and body-mass index, we investigated potential risk factors. We recruited 489 liver transplant recipients and 1808 controls. Among liver transplant recipients, 14 (2.9%) had hyperthyroidism compared with 21 (1.2%) of controls (adjusted odds ratio [aOR] 2.24, 95% confidence interval [CI] 1.05-4.75, P = 0.04), while 42 (5.7%) had hypothyroidism compared with 139 (7.7%) of controls (aOR 0.68, 95% CI 0.43-1.08, P = 0.10). Female sex, and autoimmune hepatitis and primary sclerosing cholangitis as causes of transplantation were associated with hyperthyroidism after adjustments. Age, female sex, and autoimmune liver diseases as cause of transplantation were associated with hypothyroidism after adjustments. DACOLT is registered in ClinicalTrials.gov (NCT04777032).

Herpesvirus immunology in solid organ transplant recipients - liver transplant study (HISTORY): a retrospective and prospective observational cohort study.

BACKGROUND: Life-long immunosuppressive treatment after liver transplantation (LT) prevents graft rejection but predisposes the LT recipient to infections. Herpesvirus infections are associated with morbidity and mortality among LT recipients. Among those, especially cytomegalovirus (CMV) and varicella-zoster virus (VZV) pose challenges after LT. The aim of this study is to provide an in-depth characterization of the cellular immune response against CMV and VZV infections in LT recipients and identify potential risk factors for infection. METHODS: The Herpesvirus Infections in Solid Organ Transplant Recipients - Liver Transplant Study (HISTORY) consists of an epidemiological and immunological substudy. The epidemiological substudy is a retrospective observational cohort study that includes all patients who underwent LT in Denmark between 2010 and 2023 (N ≈ 500). Using data from nationwide hospital records and national health registries, the incidence of and clinical risk factors for CMV and VZV infections will be determined. The immunological substudy is an explorative prospective observational cohort study including patients enlisted for LT in Denmark during a 1.5-year period (N > 80). Participants will be followed with scheduled blood samples until 12 months after LT. CMV- and VZV-derived peptides will be predicted for their likelihood to be presented in participants based on their HLA type. Peptide-MHC complexes (pMHC) will be produced to isolate CMV- and VZV-specific T cells from peripheral blood mononuclear cells before and after CMV and VZV infection. Their frequency, T cell receptor sequences, and phenotypic characteristics will be examined, and in a subset of participants, CMV- and VZV-specific T cells will be expanded ex vivo. DISCUSSION: This study will provide novel insight into T cell immunity required for viral control of CMV and VZV and has the potential to develop a prediction model to identify LT recipients at high risk for infection based on a combination of clinical and immunological data. Furthermore, this study has the potential to provide proof-of-concept for adoptive T cell therapy against CMV and VZV. Combined, this study has the potential to reduce the burden and consequence of CMV and VZV infections and improve health and survival in LT recipients. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05532540), registered 8 September 2022.

Pancreatic surgery during the COVID-19 pandemic 2020-2021: an observational cohort study from a third level referral center.

BACKGROUND: During the COVID pandemic there has been limited access to elective surgery including oncologic surgery in several countries world-wide. The aim of this study was to investigate if there was any lockdown effect on pancreatic surgery with special focus on malignant pancreatic and periampullary tumours. METHODS: Patients who underwent pancreatic surgery during the two Danish lockdown periods from 11. March 2020 and the following 12 months were compared with patients who were operated the preceding 3 years. Data on patients' characteristics, waiting time, operations, and clinical outcomes were evaluated. RESULTS: During lockdown and the previous three years the annual number of resections were 242, 232, 253, and 254, respectively (p = 0.851). Although the numbers were not significantly different, there were fluctuations in operations and waiting time during the lockdown. During the second outbreak of COVID October 2020 to March 2021 the overall median waiting time increased to 33 days (quartiles 26;39) compared to 23 (17;33) days during the first outbreak from March to May 2020 (p = 0.019). The same difference was seen for patients with malignant tumours, 30 (23;36) vs. 22 (18;30) months (p = 0.001). However, the fluctuations and waiting time during lockdown was like the preceding three years. Neither 30- nor 90-days mortality, length of stay, number of extended operations, and complications and tumour stage were significantly different from previous years. CONCLUSIONS: There were significant fluctuations in waiting time for operations during the lockdown, but these variations were not different from the preceding three years, wherefore other explanations than an impact from COVID are conceivable.

Transfer from point-of-care Ultrasonography training to diagnostic performance on patients--a randomized controlled trial.

BACKGROUND: Clinicians are increasingly using point-of-care ultrasonography for bedside examinations of patients. However, proper training is needed in this technique, and it is unknown whether the skills learned from focused Ultrasonography courses are being transferred to diagnostic performance on patients. METHODS: Thirty-one physicians were randomized to participate in a focused Ultrasonography course or control circumstances before they examined 4 patients with different abdominal conditions by ultrasonography. Performance scores and diagnostic accuracy were compared using independent samples t test and binary logistic regression, respectively. RESULTS: There was a significant difference in the performance score between the intervention group (27.4%) and the control group (18.0%, P = .004) and the diagnostic accuracy between the intervention group (65%) and the control group (39%, P = .014). CONCLUSIONS: Clinicians could successfully transfer learning from an Ultrasonography course to improve diagnostic performance on patients. However, our results also indicate a need for more training when new technologies such as point-of-care ultrasonography are introduced.

Reliable and valid assessment of point-of-care ultrasonography.

OBJECTIVE: To explore the reliability and validity of the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale for point-of-care ultrasonography (POC US) performance. BACKGROUND: POC US is increasingly used by clinicians and is an essential part of the management of acute surgical conditions. However, the quality of performance is highly operator-dependent. Therefore, reliable and valid assessment of trainees' ultrasonography competence is needed to ensure patient safety. METHODS: Twenty-four physicians, representing novices, intermediates, and experts in POC US, scanned 4 different surgical patient cases in a controlled set-up. All ultrasound examinations were video-recorded and assessed by 2 blinded radiologists using OSAUS. Reliability was examined using generalizability theory. Construct validity was examined by comparing performance scores between the groups and by correlating physicians' OSAUS scores with diagnostic accuracy. RESULTS: The generalizability coefficient was high (0.81) and a D-study demonstrated that 1 assessor and 5 cases would result in similar reliability. The construct validity of the OSAUS scale was supported by a significant difference in the mean scores between the novice group (17.0; SD 8.4) and the intermediate group (30.0; SD 10.1), P = 0.007, as well as between the intermediate group and the expert group (72.9; SD 4.4), P = 0.04, and by a high correlation between OSAUS scores and diagnostic accuracy (Spearman ρ correlation coefficient = 0.76; P < 0.001). CONCLUSIONS: This study demonstrates high reliability as well as evidence of construct validity of the OSAUS scale for assessment of POC US competence. Hence, the OSAUS scale may be suitable for both in-training as well as end-of-training assessment.

Non-operative versus operative treatment for blunt pancreatic trauma in children.

BACKGROUND: Pancreatic trauma in children is a serious condition with high morbidity. Blunt traumatic pancreatic lesions in children can be treated non-operatively or operatively. For less severe, grade I and II, blunt pancreatic trauma a non-operative or conservative approach is usually employed. Currently, the optimal treatment, of whether to perform operative or non-operative treatment of severe, grade III to V, blunt pancreatic injury in children is unclear. OBJECTIVES: To assess the benefits and harms of operative versus non-operative treatment of blunt pancreatic trauma in children. SEARCH METHODS: We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 5, 2013), MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED and CPCI-S) and ZETOC. In addition, we searched bibliographies of relevant articles, conference proceeding abstracts and clinical trials registries. We conducted the search on the 21 June 2013. SELECTION CRITERIA: We planned to select all randomised clinical trials investigating non-operative versus operative treatment of blunt pancreatic trauma in children, irrespective of blinding, publication status or language of publication. DATA COLLECTION AND ANALYSIS: We used relevant search strategies to obtain the titles and abstracts of studies that were relevant for the review. Two review authors independently assessed trial eligibility. MAIN RESULTS: The search found 83 relevant references. We excluded all of the references and found no randomised clinical trials investigating treatment of blunt pancreatic trauma in children. AUTHORS' CONCLUSIONS: This review shows that strategies regarding non-operative versus operative treatment of severe blunt pancreatic trauma in children are not based on randomised clinical trials. We recommend that multi-centre trials evaluating non-operative versus operative treatment of paediatric pancreatic trauma are conducted to establish firm evidence in this field of medicine.

[Gastric bezoar caused by barium sulphate]. / Ventrikelbezoar forårsaget af bariumsulfat.

We present the first case of a gastric bezoar caused by barium sulphate acting as an intermittently occluding mass in a patient who had undergone small bowel follow-through on suspicion of small bowel obstruction (SBO) after total pancreatectomy. The patient underwent acute surgery but intermittent symptoms of SBO persisted. A barium bezoar was seen on plain abdominal film and afterwards diluted and fragmented gastroscopically. A barium bezoar giving rise to SBO is a possible complication to barium follow-through in patients with impaired gastric transit time.

High mortality after emergency room laparotomy in haemodynamically unstable trauma patients.

INTRODUCTION: Hypovolaemic shock is a major course of death in trauma patients. The mortality in patients in profound shock at the time of arrival is extremely high and we wanted to investigate the outcome of patients undergoing laparotomy at the Trauma Care Unit (TCU). MATERIAL AND METHODS: Forty-four emergency laparotomies performed at the TCU at Rigshospitalet between January 2003 and December 2009 were registered. The indication for surgical intervention was based on persisting, unstable haemodynamics and either positive findings at focused abdominal sonography in trauma (FAST) or penetrating injury. In some patients, laparotomy was performed despite a negative FAST because of ongoing instability. The patients were stratified according to their systolic blood pressure (BP). RESULTS: After 24 hours, 46% (20 patients) of the patients were alive. The survival after 30 days was 41% (18 patients). Stratifying the patients into three categories according to the systolic BP at the time of arrival (BP > 80 mmHg (n = 14), 80 mmHg ≥ BP > 60 mmHg (n = 10) and BP ≤ 60 mmHg (n = 20) revealed a 64%, 50% and 34% survival rate within the first 24 hours (p = 0.04). In the group of patients with BP ≤ 60 mmHg, the survival decreased to 20% after 30 days. Stratification by penetrating or blunt trauma showed no significant difference in survival (40% versus 50% survival after 30 days) (p = 0.40). However, in those patients arriving with BP ≤ 60 mmHg (five penetrating and 15 blunt injuries), we found that the survival rate after laparotomy was 60% and 13%, respectively. CONCLUSION: The present study shows that haemodynamically unstable patients with abdominal or suspected abdominal injuries undergoing emergency laparotomy have a high mortality, especially those with BP ≤ 60 mmHg. Patients with a penetrating trauma have a far better prognosis than those with a blunt trauma.

Usefulness of contrast-enhanced transabdominal ultrasound for tumor classification and tumor staging in the pancreatic head.

OBJECTIVE: To evaluate contrast-enhanced ultrasound (CEUS) and compare it to ultrasound (US) and 64-slice-CT (64-CT) for diagnosing, staging and evaluation of resectability of pancreatic cancer. MATERIAL AND METHODS: US, CEUS and 64-CT were performed in 49 consecutive patients with pancreatic head tumors and with suspected cancer. After evaluation 44 patients had pancreatic head adenocarcinoma and 5 had chronic pancreatitis, all confirmed by histology. RESULTS: The sensitivity of US, CEUS and 64-CT for diagnosing malignant pancreatic head tumors was 89%, 86% and 93%, respectively, and the overall accuracy was 82%, 86% and 88% respectively. There was no significant difference in the malignant tumor size measurement between US and CEUS (p = 0.3619) or between US and 64-CT (p = 0.2129), but a significant difference was seen in the size measured by CEUS and 64-CT (p = 0.0197). The CEUS measurements on the tumor size were smaller. The overall accuracy for M staging of the patients who had surgery for adenocarcinoma was 86% and 90% for US + CEUS and 64-CT, respectively. By performing the CEUS and 64-CT we additionally found, respectively, 35% and 45% non-resectable patients of a group of patients, who were considered resectable on the primary radiological image material. CONCLUSIONS: CEUS may be a useful diagnostic tool in the diagnosis and staging of pancreatic head tumors. For the assessment of resectability CEUS did not prove useful. However, CEUS seemed very useful as an additional instrument in the detection of non-resectable patients already considered resectable on primary radiological image material.

[The use of topical negative pressure in an open abdomen]. / Brug af topical negative pressure ved åbent abdomen.

The article is a review of the literature concerning the use of topical negative pressure (TNP) in open abdomen. TNP appears to be superior to other methods in that the frequency of ventral hernia seems to be less after TNP than after other methods. TNP reduces both the cost of nursing and the damage to the abdominal wall. Vacuum-assisted closure (VAC) appears to be superior to the vacuum pack technique, but there is a lack of studies comparing the two methods of TNP in open abdomen.