Search

Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy. This single-center retrospective study included 812 open pancreaticoduodenectomies (2012–2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification. There were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P <.01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P =.01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P =.001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P =.023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12–0.92], P =.034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1–20.3, P <.001) was predictive of this complication. Arterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results. [ABSTRACT FROM AUTHOR]

Objective: To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). Background: LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. Although references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. Methods: Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from 3 continents over 5 years (2016--2020), with a minimum follow-up of 1 year. Benchmark criteria included a Model for End-stage Liver Disease ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no intensive care unit admission. Benchmark cutoffs were derived from the 75th percentile of all centers' medians. Results: Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs, including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), nonanastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-liver transplantation (LT) (≤3.6%), at 1-year were below the deceased donor LT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and Comprehensive Complication Index (CCI®) (≤56) were above the deceased donor LT benchmarks, whereas mortality (≤9.1%) was comparable. The right hemiliver graft, compared with the left, was associated with a lower CCI® score (34 vs 21, P < 0.001). Preservation of the middle hepatic vein with the right hemiliver graft had no impact neither on the recipient nor on the donor outcome.Asian centers outperformed other centers with CCI® score (21 vs 47, P < 0.001), graft loss (3.0% vs 6.5%, P = 0.002), and redo-LT rates (1.0% vs 2.5%, P = 0.029). In contrast, nonbenchmark low-volume centers displayed inferior outcomes, such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). Conclusions: Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness, and centralization policy are, however, mandatory to achieve benchmark outcomes worldwide. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether and how experience accumulation and technical refinements simultaneously implemented in auxiliary orthotopic liver transplantation (AOLT) may impact on outcomes. Background: AOLT for acute liver failure (ALF) provides the unique chance of complete immunosuppression withdrawal after adequate native liver remnant regeneration but is a technically demanding procedure. Our department is a reference center for ALF and an early adopter of AOLT. Methods: This is a single-center retrospective before/after study of a prospectively maintained cohort of 48 patients withALF who underwent AOLT between 1993 and 2019. In 2012, technical refinements were implemented to improve outcomes: (i) favoring the volume of the graft rather than that of the native liver, (ii) direct anastomosis of graft hepatic artery with recipient right hepatic artery instead of the use of large size vessels, (iii) end-to-side hepaticocholedocostomy instead of bilioenteric anastomosis. Early experience (1993--2011) group (n=26) and recent experience (2012--2019) group (n=22) were compared. Primary endpoint was 90-day severe morbidity rate (Clavien- Dindo≥IIIa) and secondary endpoints were overall patient survival and complete immunosuppression withdrawal rates. Results: Compared with the earlier experience group, the recent experience group was associated with a lower severe complication rate (27% vs 65%, P<0.001), as well as less biliary (18% vs 54%, P=0.017) and arterial (0% vs 15%, P=0.115) complications. The 1-, 3-, and 5-year patient survival was significantly improved (91%, 91%, 91% vs 76%, 61%, 60%, P=0.045). The rate of complete immunosuppression withdrawal increased to 94% vs 70%, (P=0.091) with no need of long-term graft explant. Conclusion: These technical refinements favoring the liver graft and reducing morbidity may promote AOLT implementation among LT centers. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to evaluate the impact of the use of a reinforced stapler (RS) during distal pancreatectomy (DP) on postoperative outcomes. Background: DP remains associated with significant postoperative morbidity owing to pancreatic fistula (PF). To date, there is no consensus on the management of the pancreatic stump. The use of an RS potentially represents a simple way to decrease the rate of PF. Methods: The REPLAY study (NCT03030170) is a prospective, multicenter, randomized study. Patients who underwent DP were randomized (1:1 ratio) in 2 groups for the use of a standard stapler (SS) or an RS to close remnant pancreatic parenchyma. The primary endpoint was the rate of overall PF. Secondary endpoints included severity of PF, length of hospital stay, overall morbidity, and rate of readmission for a PF within 90 days. Participants were blinded to the procedure actually carried out. Results: A total of 199 were analyzed (SS, n=99; RS, n=100). One patient who did not undergo surgery was excluded. Baseline characteristics were comparable in both groups. The rate of overall PF was higher in RS group (SS: 67.7%, RS: 83%, P =0.0121), but the rate of clinically relevant PF was similar (SS: 11.1%, RS: 14%, P =0.5387). Mean length of total hospital stay, readmission for PF, postoperative morbidity, and mortality at 90 days were similar. Conclusion: The results of this randomized clinical trial did not favor the use of RS during DP to reduce the rate of PF. [ABSTRACT FROM AUTHOR]

Few studies compared laparoscopic and open pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy. Retrospective cohort of patients who underwent laparoscopic or open pancreatoduodenectomy for resectable or borderline resectable pancreatic ductal adenocarcinoma after chemoradiotherapy between 2012 and 2023 was analyzed. Open pancreatoduodenectomy patients could theoretically benefit from the laparoscopic approach. We used a 1:2 (laparoscopic-to-open pancreatoduodenectomy) propensity score matching analysis stratified on age, gender, and body mass index. We included 128 patients (33 laparoscopic and 95 open pancreatoduodenectomy), and after propensity score matching, 33 laparoscopic pancreatoduodenectomy and 66 open pancreatoduodenectomy were compared. There was no difference in demographic data except for lower tobacco use in laparoscopic pancreatoduodenectomy group (9% vs 30%, P =.023) with similar clinical presentation. Laparoscopic pancreatoduodenectomy compared to open pancreatoduodenectomy showed a longer median operative duration (380 vs 255 minutes, P <.001), shorter median length of resected vein (15 vs 23 mm, P =.01), longer median venous clamping time (29 vs 15 minutes, P =.005), similar median blood loss (300 vs 300 mL, P =.223), similar rate of hard pancreas (97% vs 85%, P =.094), and a larger median size of Wirsung duct (5 vs 4 mm, P =.02). Postoperative outcomes showed similar 90-day mortality rates (3% vs 3%, P >.99), Clavien-Dindo III-IV complications (6% vs 14%, P =.158), median lengths of hospital stay (12 vs 13 days, P =.409), and readmission rates (9% vs 18%, P =.366). Pathologic data showed similar R0 resection rates (88% vs 82%, P =.568). With a similar rate of adjuvant chemotherapy (P =.324) and shorter median follow-up with laparoscopic pancreatoduodenectomy (18 vs 34 months, P =.004), 3-year overall (P =.768) and disease-free (P =.839) survival rates were similar. In selected patients, laparoscopic pancreatoduodenectomy for pancreatic ductal adenocarcinoma after neoadjuvant chemoradiotherapy appears to be safe and feasible when performed in experienced centers. [Display omitted] [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective. Background: Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature. Study Design: This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival. Results: The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT. Conclusion: When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC. [ABSTRACT FROM AUTHOR]

Laparoscopic liver resections of lesions in the postero-superior segments (Sg 4a, 7, 8) can be technically challenging. A profound experience in open and laparoscopic surgery is essential to ensure success without compromising surgical safety and oncologic efficiency when applying the laparoscopic approach for these segments. While many experienced surgeons have initially called the postero-superior segments the non-laparoscopic segments, this dogma has been challenged by different groups reporting good results in terms of safety and feasibility for parenchymal-sparing non-anatomical and, however less so, for anatomical resections (AR). Parenchymal-sparing liver resection is nowadays the gold standard for the treatment of colorectal liver metastases where repeated resections have demonstrated to improve patient's cancer related short and long-term outcome. This can be achieved by performing anatomical or non-anatomical segmental resections. Different surgical techniques to facilitate such resections have been described. The diamond technique has specifically been developed for the non-anatomical resection of non-peripheral lesions in the postero-superior segments and reported to be feasible, reproducible and moreover, oncologic efficient. Similarly, techniques for AR have been described acknowledging that in the minimally invasive setting such resections are technically more demanding requiring precise preoperative planning and a standardized surgical technique to allow pursuing oncological quality of the parenchyma sparing principle. We herein discuss technique, results and tips and tricks of applying the diamond technique for non-anatomical liver resection as well as the practice for AR of lesions in the postero-superior segments. [ABSTRACT FROM AUTHOR]

Abstract Background Fluid and pain management during liver surgery (eg, low central venous pressure) is a classic topic of controversy between anesthesiologists and surgeons. Little is known about practices worldwide. The aim of this study was to assess perioperative practices in liver surgery among and between surgeons and anesthesiologists worldwide that could guide the design of future international studies. Methods An online questionnaire was sent to 22 societies, including 4 international hepatopancreatobiliary societies, the American Society of Anesthesiologists, and 17 other (inter-)national societies. Results A total of 913 participants (495 surgeons and 418 anesthesiologists) from 66 countries were surveyed. A large heterogeneity in fluid management practices was identified, with 66% using low central venous pressure, 22% goal-directed fluid therapy, and 6% normovolemia. In addition, large heterogeneity was found regarding pain management practices, with 49% using epidural analgesia, 25% patient-controlled analgesia with opioids, and 12% regional techniques. Most participants assume that there is a relation between perioperative pain management and morbidity and mortality (78% of surgeons vs 89% of anesthesiologists; P <.001). Both surgeons and anesthesiologists have the highest expectations for minimally invasive surgery and enhanced recovery pathways for improving outcomes in liver surgery. No clear differences between continents were found. Conclusion Worldwide there is a large heterogeneity in fluid and pain management practices in liver surgery. This survey identified several areas of interest for future international studies aiming to improve outcomes in liver surgery. [ABSTRACT FROM AUTHOR]

Background The impact of portal hemodynamic variations after portal vein embolization on liver regeneration remains unknown. We studied the correlation between the parameters of hepatic venous pressure measured before and after portal vein embolization and future hypertrophy of the liver remnant after portal vein embolization. Methods Between 2014 and 2017, we reviewed patients who were eligible for major hepatectomy and who had portal vein embolization. Patients had undergone simultaneous measurement of portal venous pressure and hepatic venous pressure gradient before and after portal vein embolization by direct puncture of portal vein and inferior vena cava. We assessed these parameters to predict future liver remnant hypertrophy. Results Twenty-six patients were included. After portal vein embolization, median portal venous pressure (range) increased from 15 (9–24) to 19 (10–27) mm Hg and hepatic venous pressure gradient increased from 5 (0–12) to 8 (0–14) mm Hg. Median future liver remnant volume (range) was 513 (299–933) mL before portal vein embolization versus 724 (499–1279) mL 3 weeks after portal vein embolization, representing a 35% (7.4–83.6) median hypertrophy. Post–portal vein embolization hepatic venous pressure gradient was the most accurate parameter to predict failure of future liver remnant to reach a 30% hypertrophy (c-statistic: 0.882 [95% CI: 0.727–1.000], P < 0.001). A cut-off value of post–portal vein embolization hepatic venous pressure gradient of 8 mm Hg showed a sensitivity of 91% (95% CI: 57%–99%), specificity of 80% (95% CI: 52%–96%), positive predictive value of 77% (95% CI: 46%–95%) and negative predictive value of 92.3% (95% CI: 64.0%–99.8%). On multivariate analysis, post–portal vein embolization hepatic venous pressure gradient and previous chemotherapy were identified as predictors of impaired future liver remnant hypertrophy. Conclusion Post–portal vein embolization hepatic venous pressure gradient is a simple and reproducible tool which accurately predicts future liver remnant hypertrophy after portal vein embolization and allows early detection of patients who may benefit from more aggressive procedures inducing future liver remnant hypertrophy. (Surgery 2018;143:1-2.) [ABSTRACT FROM AUTHOR]

Background Associating liver partition and portal vein ligation for staged hepatectomy induces an unprecedented liver hypertrophy and enables resection of otherwise unresectable liver tumors. The effect of associating liver partition and portal vein ligation for staged hepatectomy on tumor proliferation, however, remains a concern. This study investigated the impact of associating liver partition and portal vein ligation for staged hepatectomy on growth of colorectal metastases in mice and in humans. Methods The effect of associating liver partition and portal vein ligation for staged hepatectomy and 90% portal vein ligation on colorectal liver and lung metastases was investigated in mice. In vivo tumor progression was assessed by magnetic resonance imaging, histology, and survival experiments. The effects of associating liver partition and portal vein ligation for staged hepatectomy, portal vein ligation, and control sera on cultures of several colorectal cancer cell lines (MC38 and CT26) were tested in vitro. Additionally, the international associating liver partition and portal vein ligation for staged hepatectomy registry enabled us to identify patients with remaining tumor in the future liver remnant after associating liver partition and portal vein ligation for staged hepatectomy stage 1. Results Two and 3 weeks after associating liver partition and portal vein ligation for staged hepatectomy stage 1, portal vein ligation, or sham surgery, liver magnetic resonance images showed similar numbers ( P   =   . 14/0.82), sizes ( P   =   . 45/0.98), and growth kinetics ( P   =   . 58/0.68) of intrahepatic tumor. Tumor growth was not different between the associating liver partition and portal vein ligation for staged hepatectomy and portal vein ligation groups after completion of stage 2. Median survival after tumor cell injection was similar after sham surgery (36 days; 95% confidence interval; 27–57 days), completion of associating liver partition and portal vein ligation for staged hepatectomy (42 days; 95% confidence interval; 35–49 days), and portal vein ligation (39 days; 95% confidence interval; 34–43 days, P   =   . 237). Progression of pulmonary metastases and in vitro cell proliferation were comparable among groups. Observations in humans failed to identify any accelerated tumor growth in the future liver remnant within the regenerative phase after associating liver partition and portal vein ligation for staged hepatectomy stage 1. Conclusion The accelerated regeneration process associated with associating liver partition and portal vein ligation for staged hepatectomy does not appear to enhance growth of colorectal metastases. [ABSTRACT FROM AUTHOR]

Background Temporary portal vein embolization may be a safe alternative to permanent portal vein embolization. Such a new approach could be applied in living-related liver transplantation to increase graft volume before procurement. The impact of temporary portal vein embolization on occluded liver after recanalization, however, has never been assessed. Using a mouse model of temporary portal vein embolization, we investigated (1) the efficiency of temporary portal vein embolization in inducing nonoccluded liver hypertrophy and (2) the regeneration potential and functional recovery of embolized liver after recanalization. Methods Selected portal vein branches were occluded using gelfoam powder (temporary portal vein embolization) or embospheres (permanent portal vein embolization), n = 5/group. Magnetic resonance volumetry and angiography were used to determine volumes of the liver lobe and portal vein branch recanalization. In order to assess the functional and regenerative capacity of occluded liver lobes, nonoccluded lobes were resected 14 days (timespan of complete portal vein recanalization) after temporary portal vein embolization or permanent portal vein embolization. Subsequently, RNA sequencing was performed to compare the signaling pathways of early liver regeneration among the groups. Results Hypertrophy of nonoccluded lobes 30 days after temporary portal vein embolization and permanent portal vein embolization was similar (103 ± 26% and 129 ± 13%, P = .11). Temporary occluded lobes increased their volumes after nonoccluded lobes resection, reaching similar liver-to-body-weight ratios and similar functional capacity after 7 days compared with partial hepatectomy controls (4 ± 1% vs 4 ± 1%, P = .22). Partial hepatectomy activated similar signaling pathways in temporary occluded and native liver. Conclusion Temporary portal vein embolization induces hypertrophy of contralateral liver lobes similarly to permanent portal vein embolization in mice. This experimental work suggests that temporary portal vein embolization may be considered as a possibility in living liver donation, because regenerative and functional capacities are preserved in the embolized liver after recanalization in mice. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to identify predictors of 90-day mortality after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS), available after stage-1, either to omit or delay stage-2. Background data: ALPPS is a two-stage hepatectomy for patients with extensive liver tumors with predicted small liver remnants, which has been criticized for its high mortality rate. Risk factors for mortality are unknown. Methods: Patients in the International Registry undergoing ALPPS from April 2011 to July 2014 were analyzed. Primary outcome was 90-day mortality. Liver function after stage-1 was assessed using the criteria of the International Study Group for Liver Surgery (ISGLS) after stage-1 among others. A multivariable model was used to identify independent predictors of 90-day mortality. Results: Three hundred twenty patients registered by 55 centers worldwide were evaluated. Overall 90-day mortality was 8.8% (28/320). The predominant cause for 90-day mortality was postoperative liver failure in 75% of patients. Fourteen percent of patients developed liver failure according to ISGLS criteria already after stage-1 ALPPS. Those and patients with a model of end-stage liver disease (MELD) score more than 10 before stage-2 were at significantly higher risk for 90-day mortality after stage-2 with an odds ratio (OR) 3.9 [confidence interval (CI) 1.4-10.9, P=0.01] and OR 4.9 (CI 1.9- 12.7, P=0.006), respectively. Other factors, such as size of future liver remnant (FLR) before stage-2 and time between stages, were not predictive. Conclusions: This analysis of the largest cohort of ALPPS patients so far identifies those patients in whom stage-2 ALPPS surgery should be delayed or even denied. These findings may help to make ALPPS safer. [ABSTRACT FROM AUTHOR]

Objective: To evaluate cosmesis, body image, pain, and quality of life (QoL) after single-port laparoscopic cholecystectomy (SPLC) versus conventional 4-port laparoscopic cholecystectomy (4PLC). Background: The impact of SPLC on improving cosmesis, body image, pain, and QoL has not been evaluated in double-blinded randomized controlled trials (RCT). This approach therefore remains controversial. Methods: Between October 2011 and February 2014, 110 patients from 2 centers were randomly assigned to SPLC (n=55) or 4PLC (n=55). Primary endpoints were a validated cosmesis (3-24 points) and body image (5-20 points) score after 3 and 12 months. Secondary endpoints included operative duration, postoperative pain, complications, QoL, and length of hospital stay. Patients, physicians, and nurses were blinded until the seventh postoperative day. Results: Demographics were equally distributed between both groups (mean age: 46 years, SD: 14, 62 females, 34 males). The SPLC-group showed superior mean cosmesis and body image compared with the 4PLC-group at 12-weeks (21 vs 16, P<0.001 and 5 vs 6, P=0.013, respectively) and at 1-year (24 vs 16, P<0.001 and 5 vs 6, P<0.017, respectively). Operation duration was longer in the SPLC-group (mean 101 vs 90 minutes, p=0.031). Although postoperative pain was less in the SPLC-group (mean VAS 1 vs 2, p=0.005), there were no differences in complications, and length of hospital-stay. Conclusions: This is the first multicenter double-blinded RCT reporting superior short- and long-term cosmetic and body image, postoperative pain, and QoL in SPLC compared with 4PLC. Although cost-effectiveness is still a subject of ongoing debate, SPLC should be offered to patients undergoing surgery for benign gallbladder disease. [ABSTRACT FROM AUTHOR]

Background: There is an increasing demand for standardization in the choice of treatments for specific conditions, so-called personalized medicine. The task is far from trivial, because the perspectives from many stakeholders must be respected, including patients and health care providers, as well as payers or governments to better control costs while optimizing quality of care. One approach to provide widely accepted therapies is the consensus conference. Methods: We describe a novel methodology to achieve consensus in controversial areas with the main goal to minimize biases. Results: The principle of this approach relies on a clear distinction between those who provide the evidence (experts) and those who draw the final recommendations (the jury). The jury consists of individuals with sufficient background knowledge to cover the perspectives of all stakeholders' without being involved directly in the topic under evaluation. The organizing committee, the experts, and the jury interact within 3 phases: Preparation, the actual consensus conference, and deliberations. Each question is addressed by a panel of experts, leading to the proposition of recommendations at the conference meeting, which are challenged by the jury and the audience. Based on all available information, the jury finalizes the consensus recommendations, which are eventually published and made available to all. Conclusion: This novel model of consensus conference allows the construction of consensual, evidence-based, explicit recommendations for therapies in a process that may also identify issues for further research, eventually fostering progress in the field. [Copyright &y& Elsevier]