To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve.Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability.Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic volumetry was performed before ISS and before completion surgery.The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallbladder cancer: n = 1 or metastatic disease [colorectal liver metastasis]: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197-444 mL). After a median waiting period of 9 days (range = 5-28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273-881 mL), representing a median volume increase of 74% (range = 21%-192%) (P < 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%-0.49%) to 0.61% (range = 0.35-0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 after completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60-776 days) with an estimated overall survival of 86% at 6 months after resection.Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.
The non-operative management of hemodynamically stable patients with liver trauma has become the standard of care. Non-operative treatment has a success rate of >80%. In the majority of cases of hemodynamic instability or high grade liver injuries, however, a surgical approach is necessary. As for conservative treatment of liver trauma the surveillance of patients in the ICU is of utmost importance. Repeat CT scans are only necessary in patients with high grade injuries or in case of complications. Interventional procedures, such as the endoscopic retrograde cholangiopancreatography in cases of biliary complications or angiography for vascular complications, are increasingly being used in order to avoid surgery. The success rates of non-operative strategies have been improving continuously over the last decades.
ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) is a novel two-stage strategy to induce rapid hypertrophy of the future liver remnant (FLR) when patients are in danger of postoperative liver failure due to insufficient FLR. However, the effects of ALPPS on colorectal liver metastases (CRLM) are not clear so far. The aim of our study was to determine whether ALPPS induces proliferation, apoptosis, or vascularization compared to standard (one-stage) liver resection. Six patients who underwent ALPPS were matched with 12 patients undergoing standard liver resection regarding characteristics of the metastases (size, number), time of appearance (syn-/metachronous), preoperative chemotherapy, primary tumor (localization, TNM stage, grading), and patient variables (gender, age). The largest resected metastasis was used for the analyses. Tissue was stained for tumor cell proliferation (Ki67), apoptosis (TUNEL, caspase-3), vascularization (CD31), and pericytes (αSMA). Vascularization (CD31; p = 0.149), proliferation (Mib-1; p = 0.244), and αSMA expression (p = 0.205) did not significantly differ between the two groups, although a trend towards less proliferation and αSMA expression was observed in patients undergoing ALPPS. Concerning apoptosis, caspase-3 staining showed significantly fewer apoptotic cells upon ALPPS (p < 0.0001), but this was not confirmed by TUNEL staining (p = 0.7344). ALPPS does not induce proliferation, apoptosis, or vascularization of CRLM when compared to standard liver resection.
Introduction Biliary complications are still a major cause for morbidity and mortality after liver transplantation. Ischemia/reperfusions injury (IRI) leads to disruption of the biliary epithelium. Yet little is known about the underlying molecular mechanism. We introduce a novel model to study the effect of IRI on human cholangiocytes using extrahepatic cholangiocyte organoids (ECOs).
Due to the late onset of symptoms, retroperitoneal liposarcoma are often diagnosed in advanced stages when adjacent organs have been infiltrated and the tumours have reached extensive sizes. Surgery remains the first choice of therapy. We report on the primary resection of a 45-kg liposarcoma that was removed en-bloc including the left kidney and descending colon with -tumour-free margins. Nine months later, the follow-up revealed a right-sided recurrence of the tumour, which was surgically removed including the right ureter. Since then, the patient has been without any signs of tumour recurrence or metastases. This report demonstrates that even extreme-ly large tumours can be removed safely and that the size is not a contraindication for primary surgical treatment. Local recurrence is common as seen in our case, and occurs even after R0 resection up to 10 years after the first operation. Recurrences should be surgically removed as this is the only treatment which has been shown to increase survival in even R1 and R2 situations.
