Perioperative outcome and long-term survival for intrahepatic cholangiocarcinoma after portal vein embolization and subsequent resection: A propensity-matched study.

INTRODUCTION: In view of the high therapeutic value of surgical resection for intrahepatic cholangiocarcinomas (ICC), our study addresses the question of clinical management and outcome in case of borderline resectability requiring hypertrophy induction of the future liver remnant prior to resection. METHODS: Clinical data was collected of all primary ICC cases receiving major liver resection with or without prior portal vein embolization (PVE) from a single high-volume center. PVE was performed via a percutaneous transhepatic access. Propensity score matching was performed. Perioperative morbidity was assessed as well as long-term survival with a minimum follow-up of 36 months. RESULTS: No significant difference in perioperative morbidity was seen between the PVE and the control group. For the PVE group, median OS was 28 months vs. 37 months for the control group (p = 0.418), median DFS 18 and 14 months (p = 0.703). Disease progression during hypertrophy was observed in 38% of cases. Here, OS and DFS was reduced to 18 months (p = 0.479) and 6 months (p = 0.013), respectively. In case of positive N-status or multifocal tumor (MF+) OS was also reduced (18 vs. 26 months, p = 0.033; MF+: 9 vs. 36months p = 0.013). CONCLUSION: Our results suggest that the surgical therapy in case of borderline resectability offers acceptable results with non-inferior OS rates compared to cases without preoperative hypertrophy induction and comparable oncological features. In the presence of additional risk factors (multifocal tumor, lymph node metastasis, PD during hypertrophy) the OS is notably reduced.

A propensity-matched study of full laparoscopic versus hand-assisted minimal-invasive liver surgery.

BACKGROUND AND AIM: The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching. METHODS: 309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed. RESULTS: MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p < 0.001) and major resections (p < 0.001). After propensity score matching (PMS), 70 cases remained in each group and all preoperative variables as well as resection extend were well balanced. A significantly higher rate of radical LAD (p = 0.039) and posterosuperior resections was found in the HALS group (p = 0.021). No significant differences between the matched groups were observed regarding operation time, conversion rate, frequency of major complications, length of intensive care unit (ICU) stay, overall hospital stay and R1 rate. CONCLUSION: Our analysis suggests MILS and HALS to be equivalent regarding postoperative outcomes. HALS might be particularly helpful to accomplish complex surgical procedures during earlier stages of the learning curve.

[Surgical treatment of malignant biliary tract diseases]. / Chirurgische Therapie maligner Gallengangserkrankungen.

BACKGROUND: Cancer of the intrahepatic and extrahepatic biliary tracts is characterized by a low incidence and a very heterogeneous appearance. OBJECTIVE: Summary and evaluation of current surgical strategies in the treatment of malignant biliary tract diseases. MATERIAL AND METHODS: An analysis of English language publications as well as European and American guidelines and recommendations for the surgical treatment of malignant diseases of the biliary tract was carried out. The results and recommendations were summarized and evaluated on the basis of experiences in this center. RESULTS: Surgery is considered to be the only curative treatment option; however, prospective randomized studies and existing guidelines are based on limited evidence. Surgical strategies and the extent of resection differ between carcinomas of the intrahepatic and extrahepatic bile ducts depending on localization, size and number of lesions as well as their proximity to surrounding structures. CONCLUSION: Sufficient experience in the treatment of these rare tumors is of special importance for the implementation of individualized overall concepts and for the sufficient performance of the mostly complex resections.

[Frontiers in liver transplantation in indication and techniques]. / Grenzbereiche der Lebertransplantation in Indikation und Technik.

BACKGROUND: The frontiers in liver transplantation are intrinsically expansions of indications, e.g. hepatocellular carcinoma and (perihilar) cholangiocarcinoma, recipients with more severe concomitant diagnoses or "soft" contraindications and technically demanding reconstruction procedures of vascular structures (for portal vein thrombosis or aorto-hepatic conduits). In addition, an extension of the donor pool with suboptimal donor organs (old donors and steatotic livers) is of interest. METHODS: This article presents the current situation based on personal experiences in daily practice and an appropriate literature review. RESULTS: A significant reduction of 1­year patient survival has been reported in Germany. The percentage of so-called marginal donor organs is inversely proportional to the very low donation rate and parallel to the waiting list mortality. Simultaneously, the proportion of inpatients with multiple organ failure is rising. CONCLUSION: Results-oriented and controlled liver transplantation currently prohibits making inroads into the previously intrinsic frontiers. As long as the current circumstances do not change, a shift in the intrinsic frontiers of that which is surgically feasible will not be possible. The current situation forces the transplant surgeon to apply a more restrictive indications and organ acceptance policy. With this approach we can try to regain the previously excellent short- and long-term results of a 1­year survival of 90% and a 20-year survival of 50%.

[Treatment of hepatocellular carcinoma in the cirrhotic and non-cirrhotic liver]. / Therapie des hepatozellulären Karzinoms in der zirrhotischen und nicht-zirrhotischen Leber.

BACKGROUND AND OBJECTIVES: The treatment of hepatocellular carcinoma (HCC) includes surgical, interventional and systemic approaches. This review highlights the importance of surgical treatment approaches in the multimodal treatment of HCC, based on the currently available literature, corresponding German guidelines as well as current developments in organ donation in Germany. RESULTS: Curative treatment options for HCC include liver transplantation, partial liver resection, and local ablative procedures depending on the lesion size. In the case of an early HCC in a cirrhotic liver fulfilling the Milan criteria, liver transplantation is the treatment of choice. In view of the organ shortage in Germany and improved results after partial liver resection, surgery can alternatively be performed in patients with a sufficient liver function. In selected patients with multinodular HCC, regional lymph node metastases or macrovascular invasion, the possibility of liver resection must be decided on an individual basis; however, the latter two criteria are contraindications for transplantation. Local ablative procedures can be considered as an alternative to resection in selected patients with early solitary HCC. Surgery of HCC in the non-cirrhotic liver with a curative intent is guided by the general principles of oncological liver surgery. DISCUSSION: Curative treatment options for HCC include liver transplantation, partial liver resection and local ablative procedures. Current developments in the area of organ donation and technical advances in minimally invasive liver surgery should be included in decision-making in tumor boards.

[Therapy of chronic persisting biloma after liver resection by enteral drainage]. / Therapie chronisch persistierender Biliome nach Leberresektion durch enterale Drainage.

Postoperative bile leaks represent a typical complication in liver surgery with a frequency ranging from 5 % to 12 % in large series. The treatment of choice is usually conservative. Using sufficient transcutaneous drainage with flushing of the biloma cavity and endoscopic retrograde cholangiography (ERC) with sphincterotomy and possibly stenting, the cure rate of bile leaks is approximately 95 %. In very rare cases all of these measures remain unsuccessful especially in cases of leakage from separated liver segments without connection to the main bile duct system. In relevantly separated liver segments this can lead to a chronically secreting bile fistula.We report a series of seven patients after complex liver resections, in which a chronic bile cavity was definitively treated with a jejunum loop as internal drainage. The prior conservative therapy included cavity suction drainage and optionally an additional ERC with or without stent insertion. After several weeks of bile leak persistence and radiological confirmation of suturable bile wall the operative treatment was carried out. The biloma cavity was careful dissected, opened and anastomosed with a jejunal loop. The further postoperative course was uncomplicated in all patients.It is possible to treat chronic persistent bile leaks safely and effectively by internal drainage through the jejunal loop after formation of a suturable biloma cavity membrane.

[Deceased donor liver transplantation]. / Lebertransplantation mit postmortalen Organen.

Deceased donor liver transplantation is nowadays a routine procedure for the treatment of terminal liver failure and often represents the only chance of a cure. Under given optimal conditions excellent long-term results can be obtained with 15-year survival rates of well above 60 %.In Germany the outcome after liver transplantation has deteriorated since the introduction of an allocation policy, which is based on the medical urgency. At present 25 % of liver graft recipients die within the first year after transplantation. In contrast 1-year survival in most other countries, e.g. in the USA or the United Kingdom is around 90 % and therefore significantly better. Reasons for the inferior results in Germany are on the one hand an increasing number of critically ill recipients and on the other hand an unfavorable situation for organ donation. In comparison with other countries the organ donation rate is low and moreover the risk profile of these donors is above average. This combination of organ shortage and organ allocation represents a big challenge for the future orientation of liver transplantation and creates the potential for conflict. These cannot be solved on a medical basis but require a social consensus.Because of the present inferior results and because of the high expenses of the present system we suggest a discussion on future allocation policies as well as on future centre structures in Germany. In addition to the medical urgency the maximum benefit should also be considered for organ allocation.