[Why are too few patients with colorectal liver metastases submitted to resection?] / Warum werden zu wenige Patienten mit kolorektalen Lebermetastasen zur Resektion vorgestellt?

The resection of colorectal liver metastases (CRLM) within the framework of a multimodal treatment concept is a generally accepted and potentially curative treatment approach. Despite the fact that liver surgery represents a survival extension for patients with a good quality of life, this treatment option is offered to nowhere near all patients. This article summarizes the results of liver resection for CRLM patients and discusses the reasons for the different estimations of resectability even by experienced liver surgeons. The complexity of the treatment is exemplarily shown based on a case report.

Metachronous hepatic resection for liver only pancreatic metastases.

BACKGROUND: The value of liver resection (LR) for metachronous pancreatic ductal adenocarcinoma (PDAC) metastases remains controversial. However, in light of increasing safety of liver resections, surgery might be a valuable option for metastasized PDAC in selected patients. METHODS: We performed a retrospective, multicenter study including patients undergoing hepatectomy for metachronous PDAC liver metastases between 2004 and 2015 to analyze postoperative outcome and overall survival. All patients were operated with curative intent. Patients with oligometastatic metachronous liver metastasis with definitive chemotherapy (n = 8) served as controls. RESULTS: Overall 25 patients in seven centers were included in this study. The median age at the time of LR was 63.8 years (56.9-69.9) and the median number of metastases in the liver was 1 (IQR 1-2). There were eight non-anatomical resections (32%), 15 anatomical minor (60%) and 2 major LR (8%). Postoperative complications occurred in eleven patients (eight Clavien-Dindo grade I complications (32%) and three grade IIIa complications (12%), respectively). The 30-day mortality was 0%. The median length of stay was 8.6 days (IQR 5-11). Median overall survival following LR was 36.8 months compared to 9.2 months in patients with metachronous liver metastasis with chemotherapy (p = 0007). DISCUSSION: Liver resection for metachronous PDAC metastasis is safe and feasible in selected patients. To address general applicability and to find factors for patient selection, larger trials are urgently warranted.

[Navigated liver surgery : Current state and importance in the future]. / Navigierte Leberchirurgie : Aktueller Stand und Bedeutung in der Zukunft.

The preoperative computer-assisted resection planning is the basis for every navigation. Thanks to modern algorithms, the prerequisites have been created to carry out a virtual resection planning and a risk analysis. Thus, individual segment resections can be precisely planned in any conceivable combination. The transfer of planning information and resection suggestions to the operating theater is still problematic. The so-called stereotactic liver navigation supports the exact intraoperative implementation of the planned resection strategy and provides the surgeon with real-time three-dimensional information on resection margins and critical structures during the resection. This is made possible by a surgical navigation system that measures the position of surgical instruments and then presents them together with the preoperative surgical planning data. Although surgical navigation systems have been indispensable in neurosurgery and spinal surgery for many years, these procedures have not yet become established as standard in liver surgery. This is mainly due to the technical challenge of navigating a moving organ. As the liver is constantly moving and deforming during surgery due to respiration and surgical manipulation, the surgical navigation system must be able to measure these alterations in order to adapt the preoperative navigation data to the current situation. Despite these advances, further developments are required until navigated liver resection enters clinical routine; however, it is already clear that laparoscopic liver surgery and robotic surgery will benefit most from navigation technology.

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]. / Vorgehen bei Leber­, Milz­ und Pankreasverletzungen inklusive "damage control surgery" bei Terroranschlägen.

BACKGROUND: Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management. METHOD: A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit. CONCLUSION: Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

[Perihilar cholangiocarcinoma (Klatskin tumor)]. / Zentrales Gallengangskarzinom (Klatskin-Tumor).

Perihilar cholangiocarcinoma or Klatskin tumors are a rare entity arising from the extrahepatic bile duct bifurcation. Considering the close anatomical relationship of the bile duct bifurcation with the portal vein bifurcation and hepatic arteries, surgical treatment is demanding. With an incidence of only 2-4 cases/100,000 population/year patients should be referred to a specialized center. The tumors are usually poorly differentiated adenocarcinomas growing diffusely along the duct and also the perineural sheath. Only radical surgery offers a curative option and currently surgical strategy usually consists of en bloc resection of the bile duct, extended liver resection and portal vein resection. Proximal and lateral safety margin R0 resections are technically very demanding procedures because of the local anatomy.

[EHEC-associated colon stenosis after ulcerous-chronic haemorrhagic colitis and consecutive resulting ileus]. / EHEC-assoziierte Kolonstenose nach ulzerös-chronisch hämorrhagischer Kolitis mit konsekutivem Ileus.

We report on the case of a segmentally emphasised, ulcerous chronic haemorrhagic colitis with the development of granulation tissue und scarred fibrosis with consecutive resulting stenosis of the colon. A 49-year-old male patient was infected with enterohaemorrhagic Escherichia coli bacteria during the EHEC-epidemic in northern Germany in early summer 2011. In the course of the infection the patient suffered from haemolytic uraemic syndrome (HUS) with acute renal failure and neurological symptoms. Haemodialysis and plasmapheresis had become mandatory. A simultaneous ileus was estimated to be of paralytic origin. One month after treatment of the acute phase of the infection a CT scan of the abdomen was performed and discovered a symptomatic stenosis of the proximal colon transversum. This obstruction needed to be treated by performing a right hemicolectomy with an ileo-transverso anastomosis. After surgery the patient recovered continuously. The histopathological examination verified an ulcerous-chronic haemorrhagic colitis on the background of an EHEC infection.

[Anterior approach liver resection with the liver hanging maneuver. Technique and indications]. / Anterior-approach-Leberresektionen mit dem Liver-hanging-Manöver. Technik und Indikationen.

The anterior approach liver resection has advantages compared to conventional liver resection. Mobilization during conventional liver resection may cause local pressure on the tumor which could lead to tumor cell dissemination or even to tumor rupture. Furthermore, hemodynamic parameters tend to deteriorate during mobilization due to compression or twisting of the inferior vena cava. In addition, the left liver lobe often is compressed which can lead to tissue damage of the residual parenchyma. The risk of these complications can be reduced by the anterior approach technique which is facilitated by the so-called liver hanging maneuver. Appropriate indications for this technique are large tumors of the right liver lobe, tumors with infiltration of the right hepatic vein and infiltration of the vena cava from the right side, tumors with infiltration of the diaphragm and tumors of the right lobe after previous resections of the right lobe.

Liver remnant hypertrophy induction--how often do we really use it in the time of computer assisted surgery?

PURPOSE: To evaluate the significance of the hypertrophy concept in patients requiring extended liver resections for colorectal metastasis in the time of computer assisted surgery. METHODS: Retrospective analysis of patient collective undergoing major liver surgery. 2D CT, 3D CAS with Fraunhofer MeVis Sofware. Portal vein embolisation (PVE) with the Amplazer Plug, portal vein ligation (PVL) as 1. Stage operative procedure. RESULTS: 2D CT data identified 29 patients out of 319 (2002-2009) to be at risk for liver failure after resection. After 3D CAS analysis and virtual operation planning, only 7/29 were at true risk and were submitted to portal vein occlusion (PVO). Another 5 patients were submitted to the hypertrophy concept for intraoperative finding of insufficient parenchyma quality. In total, 12 patients underwent PVO (6 PVE/6 PVL). 9/12 patients went to stage 2 and were successfully operated. There was no difference in future remnant liver volume (FRLV) gain or waiting time to step 2 between the groups, though survival was better in the PVE group. CONCLUSION: PVO is an effective approach if the patient's future remnant liver (FRL) is too small on 2D CT volumetry. 3D CAS has great impact on the analysis of FRL capacity and in augmenting resectability - in our experience only patients with insufficient FRLV on the virtual resection plan have to take the risk of PVO to maintain the chance of liver resection.

Laparoscopic deroofing of hepatic cysts: The most effective treatment option.

OBJECTIVES: With advances in laparoscopic surgery, laparoscopic deroofing has gained wide acceptance in the surgical community to treat symptomatic non-parasitic hepatic cysts. Published non-surgical data still favour aspiration and sclerotherapy as treatment in these cases, though morbidity is higher and recurrence rates are not acceptable. We reviewed all patients that had been treated by laparoscopic deroofing in our department over a period of 6 years in order to find out if the surgical approach should be considered the standard treatment. MATERIALS AND METHODS: Over a 6 year period, 34 laparoscopic deroofings were performed in 21 patients with symptomatic cysts. Patients underwent laparoscopy followed by radical deroofing using an Ultracision device. RESULTS: All cases were completed laparoscopically, no intraoperative adverse events were recorded. Mean operation time was 101 ± 22.7 min. The mean size of treated cysts was 9.7 ± 2.18 cm. Follow up showed only one symptomatic recurrence (3.3%) two months after surgery. CONCLUSION: Laparoscopic deroofing of hepatic cysts is a safe and effective treatment option. Recurrence rates are unprecedentedly low. Our data suggest that the risk of operation is justified and that the method is superior to sclerotherapy.

Non-surgical management of a ruptured posttraumatic pancreatic pseudocyst in a child.

Generally speaking, isolated pancreatic injuries are rare after abdominal blunt trauma. However, the incidence of pancreatic injuries in children has risen in recent decades. Pancreatic pseudocyst represents a typical complication after acute pancreatitis due to blunt abdominal trauma. Spontaneous rupture of pseudocysts leading to acute abdominal pain has been described, however, it rarely occurs, especially in pediatric patients. We report the successful non-surgical management of a ruptured pancreatic pseudocyst in a 5-year-old girl which occurred 27 days after trauma. The traumatic acute pancreatitis was due to a handlebar injury.

[Hormone inactive parathyroid cyst: rare differential diagnosis in the evaluation of cervical cysts]. / Hormoninaktive Nebenschilddrüsenzyste: eine seltene Differenzialdiagnose bei zystischen Veränderungen im Halsbereich.

Parathyroid cysts are a very rare disease entity. Hormone activity is uncommon and they usually present without any clinical symptoms. The differential diagnosis of cystic neck masses should nevertheless include parathyroid cysts as surgical therapy can be very effective. We report the case of a 57-year-old patient presenting to our department with a hormone inactive parathyroid cyst. Final diagnosis was achieved eventually after histological examination of the resected specimen, which is the reason for evaluating the current data for preoperative management of this disease entity in this case report.