Outcomes after resection and/or radiofrequency ablation for recurrence after treatment of colorectal liver metastases.

BACKGROUND: Repeat liver resection for colorectal liver metastases (CRLMs) is possible in a limited number of patients, with radiofrequency ablation (RFA) as an alternative for unresectable CRLMs. The aim of this study was to analyse survival rates with these interventions. METHODS: This was a database analysis of patients who underwent first and repeat interventions for synchronous and metachronous CRLMs between 2000 and 2013. Descriptive and survival statistics were calculated. RESULTS: Among 431 patients who underwent resection or RFA for CRLMs, 305 patients developed recurrences for which 160 repeat interventions (resection and/or RFA or ablative radiotherapy) were performed. In total, after 707 first or repeat interventions, 516 recurrences (73·0 per cent) developed, of which 276 were retreated curatively. At the time of first intervention, independent risk factors for death were lymph node-positive primary tumour (hazard ratio (HR) 1·40; P = 0·030), more than one CRLM (HR 1·53; P = 0·007), carcinoembryonic antigen level exceeding 200 ng/ml (HR 1·89; P = 0·020) and size of largest CRLM greater than 5 cm (HR 1·54; P = 0·014). The 5-year overall survival rates for liver resection and percutaneous RFA as first intervention were 51·9 and 53 per cent, with a median overall survival of 65·0 (95 per cent c.i. 47·3 to 82·6) and 62·1 (52·2 to 72·1) months, respectively. CONCLUSION: RFA had good oncological outcomes in patients with unresectable CRLMs. Radiofrequency ablation is progressively more applied with each additional intervention.

Staging laparoscopy in patients scheduled for pancreaticoduodenectomy minimizes hospitalization in the remaining life time when metastatic carcinoma is found.

OBJECTIVE: To compare the burden of total hospitalization as a ratio of survival of staging laparoscopy versus prophylactic bypass surgery in patients with unresectable periampullary adenocarcinoma. BACKGROUND: Periampullary adenocarcinoma is an aggressive cancer with up to 35% of the patients at surgery found to be unresectable. Palliative prophylactic surgical bypass versus endoscopic stenting has been addressed by randomized controlled trials, but none reported on the burden of hospitalization. METHODS: From a prospective database all patients with periampullary adenocarcinomas with a preoperative patent biliary stent and absent gastric outlet obstruction, but found unresectable during surgery, were analysed. They underwent a staging laparoscopy only versus prophylactic palliative bypass surgery. In-hospital days of the initial admission as well as all consecutive admission days during the remaining life span were compared both in absolute numbers and as relative impact. RESULTS: The inclusion criteria were met by 205 patients. Of these 131 patients underwent a staging laparoscopy detecting metastases in 21 patients. In 184 laparotomies 54 patients underwent prophylactic palliative bypass surgery for unresectable disease. Median total in-hospital-stay in the Laparoscopy Group was 3 days versus 11 days in the Palliative Bypass Group (p = 0.0003). Patients with metastatic disease found during laparoscopy stayed 3.5% of the remaining life time in hospital vs. 10.0% (p = 0.029) in patients with metastatic disease who underwent bypass surgery. CONCLUSIONS: Staging laparoscopy and early discharge in patients with metastatic peri-ampullary carcinoma resulted in reduced hospitalization, both in absolute number of days and as a rate of survival time.

Course of life into adulthood of patients with biliary atresia: the achievement of developmental milestones in a nationwide cohort.

PURPOSE: To investigate the course of life of young adults diagnosed with biliary atresia (BA) in infancy by comparing patients who did and did not underwent transplantation with an age-matched Dutch reference group. METHODS: All patients from the Dutch BA registry, aged >18 years, were invited to complete the course of life questionnaire. RESULTS: Forty patients participated (response = 74%). Twenty-five had not undergone transplantation; 15 had undergone orthotopic liver transplantation. One significant between-group difference was found, namely in substance use and gambling. BA patients who underwent transplantation reported less use than the reference group (p = .01, moderate effect size). Additional moderate effect sizes were found for differences in psychosexual and social development and antisocial behavior. Patients who underwent transplantation had lower scores than one or both other groups. CONCLUSIONS: Development of BA survivors who did not undergo transplantation seems not delayed, whereas that of transplanted patients does seem somewhat delayed. However, patients who underwent transplantation display less risk behavior. Larger samples are necessary to confirm these findings.

Risk factors for central bile duct injury complicating partial liver resection.

BACKGROUND: Bile duct injury is a serious complication following liver resection. Few studies have differentiated between leakage from small peripheral bile ducts and central bile duct injury (CBDI), defined as an injury leading to leakage or stenosis of the common bile duct, common hepatic duct, right or left hepatic duct. This study analysed the incidence, risk factors and consequences of CBDI in liver resection. METHODS: Patients undergoing liver resection between 1990 and 2007 were included in this study. Those having resection for bile duct-related pathology or trauma, or after liver transplantation were excluded. Characteristics and outcome variables were collected prospectively and analysed retrospectively. RESULTS: There were 19 instances of CBDI in 462 liver resections (4·1 per cent). One-third of patients with CBDI required surgical reintervention and construction of a hepaticojejunostomy. Resection type (P < 0·001), previous liver resection (P = 0·039) and intraoperative blood loss (P = 0·002) were associated with an increased risk of CBDI. Of all resection types, extended left hemihepatectomy was associated with the highest incidence of CBDI (2 of 9 procedures). CONCLUSION: Patients undergoing extended left hemihepatectomy or repeat hepatectomy were at increased risk of CBDI.

Intravenous leiomyomatosis: report of two cases and strategy for surgical resection.

Intravenous leiomyomatosis is a rare smooth muscle tumour that arises from the myometrium and grows into the extrauterine venous system. It typically can extend into the vena cava inferior and even the cardiac chambers. This can lead to life threatening obstruction of cardiac valves. The only effective treatment is surgical resection. However, no clear guidelines with respect to surgical approach and further strategy are available in the literature. Especially the indications for a simultaneous thoracic approach and for either one-stage or two-stage approach are unclear. On the basis of two cases of intravenous leiomyomatosis with different levels of intracaval extension of the tumour, this article discusses a useful strategy for planning surgical resection, taking into account tumour characteristics and different levels of intracaval extension.

[Combined liver and kidney transplantation: indications and results at the University Medical Centre Groningen, 1994-2005]. / Gecombineerde lever-niertransplantatie: indicaties en resultaten in het Universitair Medisch Centrum Groningen, 1994/'05.

UNLABELLED: OBJECTIVE. To describe the experience with combined liver and kidney transplantation at the University Medical Centre Groningen, The Netherlands. DESIGN. Retrospective. METHOD: Data were analysed from all patients who underwent combined liver and kidney transplantation in the University Medical Centre Groningen, in the period November 1994-December 2005. RESULTS: During the study period 582 orthotopic liver transplantations and 1026 isolated kidney transplantations were performed. 16 patients underwent combined liver and kidney transplantation: 4 were children (aged 17 months-16 years) and 12 were adults (aged 19-59 years). For all patients, both organs were obtained from the same post-mortem donor. Indications for combined liver and kidney transplantation were primary hyperoxaluria type I (n=6), polycystic liver and kidney disease (n=3) and unrelated liver and kidney failure (n=7). The 1- and 5-year survival rate was 88% (14/16), which was not significantly different from the results after isolated liver transplantation. Two patients died 11 days and 74 months after combined transplantation, due to complications from unsuccessful retransplantation of the liver for hepatic artery thrombosis and secondary biliary cirrhosis, respectively. A third patient died 51 days after combined transplantation due to sepsis. CONCLUSION: Combined liver and kidney transplantation was a life-saving intervention in this selected group of patients with combined liver and kidney failure. Patient survival was comparable to that of patients undergoing isolated liver transplantation.

Intraoperative blood transfusion requirement is the main determinant of early surgical re-intervention after orthotopic liver transplantation.

Liver transplantation is the treatment of choice in selected patients with end-stage liver disease. Postoperative complications often require surgical re-intervention. This study is a retrospective single-centre study to assess the incidence and type of surgical re-intervention during the in-hospital period after liver transplantation and to identify predictors of this re-intervention. From 1994 to 2002, 231 consecutive adult liver transplantations were performed. Re-intervention was classified as biliary, vascular, bleeding, septicaemia, re-transplantation or as miscellaneous. One hundred and thirty-nine surgical re-interventions were performed in 79 of 231 patients (34%). Septicaemia (44%) and bleeding (27%) were the most frequent indications for re-intervention, followed by biliary (10%) re-intervention. Vascular re-intervention, re-transplantation, and re-intervention for miscellaneous reasons, were performed in 7% each. Of all analysed variables (gender, age, diagnosis, acute liver failure, Child-Pugh classification, Karnofsky score, previous abdominal surgery, creatinine clearance, prothrombin time, anti-thrombin, platelet count, surgical technique, cold ischaemia time, warm ischaemia time, functional anhepatic time, anatomic anhepatic time, revascularisation time, year of transplantation, aprotinin administration, transfused platelet concentrate, and red blood cell transfusion requirements), only the number of transfused red blood cell concentrates (RBCs) was identified as a predictor of surgical re-intervention. Median RBC transfusion requirement during liver transplantation was 2.9 l (range 0-18.8 l) in the re-intervention group compared with 1.5 l (range 0-13.4 l) in the non-re-intervention group (P<0.001). This study revealed intraoperative blood loss as the main determinant of early surgical re-intervention after liver transplantation and emphasises the need for further attempts to control blood loss during liver transplantation.

Portal and systemic serum growth factor and acute-phase response after laparotomy or partial hepatectomy in patients with colorectal liver metastases: a prognostic role for C-reactive protein and hepatocyte growth factor.

BACKGROUND: Growth factors play a role in wound healing and tumour growth. The aim of this study was to compare the effect of partial hepatectomy (PH) and laparotomy on serum levels of growth factors and acute-phase proteins in patients with colorectal liver metastases and to correlate these levels with prognosis after PH. METHODS: Epidermal growth factor (EGF), hepatocyte growth factor (HGF), insulin like growth factor-I (IGF-I), insulin, interleukin-6 (IL-6), C-reactive protein (CRP) and serum amyloid-A (SAA) were determined in portal and systemic serum in 24 PH patients and 9 laparotomy patients. RESULTS: No differences were found in the clinicopathological characteristics of PH and laparotomy patients with the exception of the number of metastases, blood loss and operation time. The response of SAA, CRP and IGF-I was lower in PH patients than in laparotomy patients (P < 0.02). PH was associated with a higher IL-6 (P = 0.02) and HGF (P = 0.055) response than laparotomy. A higher HGF and CRP response was associated with a poorer prognosis. Total IGF-I was negatively correlated with the resected liver volume (r = -0.48, P < 0.05). CONCLUSIONS: PH is associated with a lower acute-phase and total IGF-I response and a higher HGF and IL-6 response compared with laparotomy. HGF and CRP responses had an influence on the prognosis.