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Contains fulltext : 290866.pdf (Publisher’s version ) (Open Access) BACKGROUND: Management of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA), is multidisciplinary and subject to practice variation. We aimed to evaluate variation in clinical management of FNH and HCA in Europe. METHODS: We distributed an online survey (November 2021-March 2022) among 294 European experts. The survey included questions on local practice and included eight clinical vignettes. The clinical vignettes focused on FNH or HCA management in the setting of sex, lifestyle modification, and pregnancy. RESULTS: The response rate was 32% and respondents included surgeons (38%), gastroenterologists/hepatologists (25%), radiologists (32%), and pathologists (1.6%) from ten European countries. We observed practice variation with regard to lifestyle modification and imaging follow-up in patients with FNH, and with regard to the management of HCA >5 cm before and during pregnancy. Finally, the management of HCA >5 cm after lifestyle modification deviated from EASL guideline recommendations. CONCLUSION: Our survey illustrates variability in FNH and HCA management in Europe. Several areas were identified for future research and guideline recommendations, including FNH follow-up and the management of HCA >5 cm. We propose the organization of Delphi consensus meetings to prioritize areas of research and update current guidelines to optimize management for all patients with benign liver tumors.

Indocyanine green (ICG) opens up numerous possibilities for applications in hepatobiliary surgery, due to its exclusive hepatic excretion and its fluorescence properties in the near infrared (NIR) spectrum.Systematic review of the literature on the application of ICG imaging in open and laparoscopic liver surgery.Literature review and summary of the recent scientific original articles and reviews.The ICG fluorescence imaging is increasingly being used in liver surgery. It allows real-time display of the segmental anatomy of the liver. Moreover, depending on the tumor entity, direct or indirect visualization of liver tumors and metastases is also possible. The detection of bile leaks might also be facilitated. Recent experiences in liver surgery have shown that ICG imaging enables a more sensitive intraoperative detection of additional foci and probably also a higher R0 resection rate; however, the application is mainly helpful for superficial lesions, since the depth of penetration of NIR is only 8-10 mm.Fluorescence staining using ICG is a valuable supplementary tool in modern liver surgery. It is particularly helpful in laparoscopic surgery where tactile control is eliminated and three-dimensional orientation is difficult. These disadvantages can be partially compensated by additional real-time imaging using ICG.

Benign biliary diseases comprise entities, which present with very similar pathognomonic symptoms despite fundamental etiological differences. Obstructions of intrahepatic and extrahepatic bile ducts due to stones, tumors or parasites as well as stenoses and cystic alterations belong to the group of benign biliary diseases.This article provides a systematic overview of the indications and differential treatment of benign biliary diseases with special emphasis on the surgical treatment.The presented recommendations are in accordance with national and international guidelines, current scientific papers and expert opinions.Essentially the surgical options for benign biliary diseases consist of revision, reconstruction through bilioenteric anastomosis, resection and complete organ replacement in the sense of liver transplantation. The location of the affected segment of the biliary tree, the symptoms, the progress of the disease and suspected malignancy essentially determine the level of escalation in the described treatment level scheme.The treatment of benign biliary diseases is complex and requires achievement of unimpaired, unobstructed bile drainage. It serves the purpose of resolving cholestasis and thereby avoiding recurrent cholangitis and long-term complications, such as biliary cirrhosis and malignant transformation; however, in some cases of premalignant lesions of the bile ducts the strategy resembles cancer surgery, including resection of the affected tissue.

HyperSpectral Imaging (HSI) technology enables quantitative tissue analyses beyond the limitations of the human eye. Thus, it serves as a new diagnostic tool for optical properties of diverse tissues. In contrast to other intraoperative imaging methods, HSI is contactless, noninvasive, and the administration of a contrast medium is not necessary. The duration of measurements takes only a few seconds and the surgical procedure is only marginally disturbed. Preliminary HSI applications in visceral surgery are promising with the potential of optimized outcomes. Current concepts, possibilities and new perspectives regarding HSI technology together with its limitations are discussed in this article.

Die Lebertransplantation mit postmortalen Organen ist heute ein klinisches Routineverfahren zur Behandlung terminaler Lebererkrankungen und stellt oft die einzige Uberlebenschance dar. Unter optimalen Bedingungen konnen sehr gute Langzeitergebnisse mit 15-Jahres-Uberlebensraten von deutlich uber 60 % erreicht werden. In Deutschland hat die Ergebnisqualitat der Lebertransplantation seit Einfuhrung der Allokation nach Dringlichkeit erheblich abgenommen. Deutschlandweit versterben aktuell etwa 25 % der Empfanger innerhalb des ersten Jahres nach Lebertransplantation. Die Einjahresuberlebensraten in den meisten anderen Landern, wie z. B. in den USA oder im Vereinigten Konigreich liegen mit etwa 90 % deutlich hoher. Als Grunde hierfur sind vor allem die Organallokation auf zunehmend krankere Empfanger, aber auch die ungunstige Spendersituation in Deutschland zu nennen. Es stehen im internationalen Vergleich wenige Spender zur Verfugung und diese weisen noch dazu ein uberdurchschnittlich hohes Risikoprofil auf. Die aktuelle Kombination von Organmangel und Allokationsregeln stellt eine grose Herausforderung fur die kunftige Ausrichtung der Lebertransplantation dar, aus der sich viele Konflikte ergeben. Diese konnen nicht medizinisch gelost werden, sondern erfordern einen gesellschaftlichen Konsens. Insgesamt sollte aus unserer Sicht sowohl aufgrund der momentanen Ergebnisqualitat als auch aufgrund der damit verbundenen Kosten eine Veranderung der Allokationsstruktur, aber auch der Zentrumsstrukturen in Deutschland diskutiert werden. Neben der Dringlichkeit sollte kunftig auch der optimale Nutzen als Parameter zur Organvergabe berucksichtigt werden.

Klatskin-Tumoren konnen durch eine radikale Operationstaktik mit tumorferner Praparation kurativ behandelt und damit 5-Jahres-Uberlebensraten von 30–50% erreicht werden. Dies erfordert zwingend eine Leberresektion en bloc mit extrahepatischer Gallengangresektion und oft auch eine zusatzliche vaskulare Resektion. Trotzdem kann nicht immer der angestrebte Sicherheitsabstand von 0,5–1 cm jenseits der makroskopischen Tumorgrenzen eingehalten werden. Dabei gilt, dass anatomisch bedingt bei erweiterter Hemihepatektomie rechts mit Pfortadergabelresektion die Wahrscheinlichkeit eines ausreichenden Sicherheitsabstands hoher ist als bei Hemihepatektomie links. Allerdings kommt bei einem Teil der Falle aufgrund einer Atrophie des linken Lappens nur eine Hemihepatektomie links in Betracht. Sind beide Verfahren moglich, wird bei ausreichender Leberfunktion meist der erweiterten Hemihepatektomie rechts der Vorzug gegeben. Insbesondere Leberfunktionsstorungen, aber auch Galleleckagen nach anspruchsvoller biliarer Rekonstruktion – oft mit mehreren, zarten intrahepatischen Gallengangen – tragen zur Komplikationsrate bei diesem komplexen chirurgischen Krankheitsbild bei.

Die orthotope Lebertransplantation (OLT) hat die Behandlung der terminalen Leberinsuffizienz fundamental verandert, Zehnjahreslangzeituberlebensraten liegen inzwischen bei etwa 70%. Die Langzeitergebnisse fur Patienten mit OLT aufgrund Hepatitis-B/C-bedingter Zirrhose werden wesentlich durch die Rezidivgefahr beeinflusst. Referiert werden aktuelle Strategien und Perspektiven fur das Management des Virushepatitisrezidivs. Besprochen werden zudem das Monitoring vor und nach OLT (routinemasig entnommene Biopsien nach Transplantation auch bei ausbleibendem Transaminasenanstieg, Vakzinierungsstrategien, Probleme der Resistenzentwicklung und der antiviralen Therapie (wie Umstellung der Therapie bei ausbleibender/nicht anhaltender virologischer Response, Modifikation durch Mycophenolatmofetil) – auch vor einer Transplantation. Eigenen Untersuchungen zufolge ist die effektive, Synergismen nutzende antivirale Therapie der wichtigste Faktor zur Verhinderung von mit Hepatitis-C-Reinfektion assoziierten Transplantatverlusten.

Die Inzidenz von GallenwegskarzinomGallenwegskarzinomen steigt im hoheren Lebensalter stark an, so dass sich auch bei uber 70- und 80-jahrigen Patienten immer ofter die Frage nach einer chirurgischen Therapie stellt. Allerdings erfordert dies meist eine grose Leberoperation, so dass eine sorgfaltige Abklarung obligat ist. Hierzu sollte neben kardiopulmonaler Diagnostik auch eine Leberfunktionsmessung mit Volumetrie gehoren. Insbesondere bei eingeschrankter Funktionsreserve der Leber sollten im hohen Alter soweit wie moglich parenchymsparende Resektionen bzw. prakonditionierende Masnahmen (z. B. Pfortaderembolisation) erwogen werden. Wenn sich keine Kontraindikationen ergeben, sollten auch geeignete alte Patienten reseziert werden, da sie in ahnlichem Mase wie junge Patienten von einer kurativen Operation profitieren.

Vascular reconstruction is obligatory in transplantation surgery. A differentiation is made between routine vascular reconstructions, which are required for all solid organ transplantations and special cases. Because of the shortage of organs it is often necessary to use organs with complex anatomical vascular prerequisites, which requires high vascular surgical expertise for individualized reconstruction. Non-routine reconstructions are often also necessary on the side of the recipient. This review article presents both the routine and exceptional types of reconstruction.

Background: Bacterial community structures in human pancreatic and biliary tracts were evaluated. Methods: Gall bladder stones from 153 patients, 20 gall bladder walls, six common duct stones, 52 biliary stents, 21 duodenal biopsies, nine pancreatic duct biopsies, and five bile ducts were investigated using fluorescence in situ hybridisation (FISH) with ribosomal RNA targeted Cy3/Cy5 (carbocyanine) labelled oligonucleotide probes. Result: Duodenal, gall bladder, and bile duct walls were free of bacteria. A dense multispecies bacterial biofilm was present within the pancreatic duct of patients with calcific pancreatitis and within biliary stents, irrespective of diagnosis. The concentration, density, and amenability of the biofilm to FISH and DNA staining declined progressively with the grade of stent occlusion. The lowest detectable bacterial concentrations were found by FISH in completely occluded stents and brown/mixed gall stones. Bacteria were not detectable with FISH in cholesterol gall stones. Conclusions: A wide range of different branches and groups of bacteria participate in the development of biofilms on the surfaces of foreign bodies, such as biliary stents, mixed gall stones, or calcific pancreatic ducts, but not on the surface of pure cholesterol gall stones. Occlusion of stents leads to progressive extinction of the biofilm and mummification of its components. Deposition of cholesterol or other substances within the biofilm matrix may be a novel mechanism of host defence against bacteria present in these biofilms.

The management of bleeding in liver surgery is multidisciplinary. In most cases traumatic liver injury can be treated conservatively. Surgical treatment of severe liver trauma is associated with a high mortality rate due to extensive parenchymal and vascular injury as well as blood loss associated with the trauma. Fundamental knowledge of liver anatomy and refined surgical techniques help to reduce intraoperative blood loss and improve outcomes in elective liver surgery; nevertheless, severe blood loss and augmented transfusion requirements during extensive liver resection are still key factors for increased morbidity and mortality. Intraoperative lowering of central venous pressure and selective hepatic inflow occlusion or even total hepatic vascular exclusion are effective means of further reducing intraoperative blood loss. Furthermore, the application of sophisticated surgical instruments provides the surgeon with the potential to operate without the requirement of additional blood transfusions.

Retrospective analyses have shown a 20-40 % incidence of R1 resection in hilar cholangiocarcinoma, which therefore represents a significant issue to be addressed.We have reviewed the literature on the impact of R1 resection in hilar cholangiocarcinomas and on possible surgical options to increase the rate of complete tumour resections.To minimise the rate of R1 resections a preoperative risk assessment concerning the predisposed anatomic locations is required. During planning of the surgical strategy, liver function plays a central role prior to right-sided hemihepatectomies. Due to the loss of a high amount of functional liver parenchyma, contralateral portal vein embolisation is often used prior to right trisectionectomies. For left-sided hepatectomies the management of the right hepatic artery is fundamental. The right hepatic artery has a very close contact to the tumour region, although arterial invasion is rarely seen. However, the risk of manifest or occult R1 resection is relatively high along the right artery. In selected cases an arterial resection might be considered, but this increases the risk of postoperative complications. Arterial resection might be performed either via direct anastomosis or by using an interposition graft. As reserve procedures preoperative embolisation of the hepatic artery without reconstruction or an arterialisation of the portal vein are available. However, the latter two procedures come along with an increased rate of biliary complications. In selected lymph-node negative patients with irresectable hilar cholangiocarcinoma liver transplantation might be considered.Despite significant advances in surgical technique, R1 resection remains a problem, which is aggravated by the lack of evidence-based adjuvant measures.

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.

The interdisciplinary guidelines at the S3 level on the diagnosis of and therapy for hepatocellular carcinoma (HCC) constitute an evidence- and consensus-based instrument that is aimed at improving the diagnosis of and therapy for HCC since these are very challenging tasks. The purpose of the guidelines is to offer the patient (with suspected or confirmed HCC) adequate, scientifically based and up-to-date procedures in diagnosis, therapy and rehabilitation. This holds not only for locally limited or focally advanced disease but also for the existence of recurrences or distant metastases. Besides making a contribution to an appropriate health-care service, the guidelines should also provide the foundation for an individually adapted, high-quality therapy. The explanatory background texts should also enable non-specialist but responsible colleagues to give sound advice to their patients concerning specialist procedures, side effects and results. In the medium and long-term this should reduce the morbidity and mortality of patients with HCC and improve their quality of life.

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.

Curative treatment of Klatskin tumors by radical surgical procedures with surgical preparation distant to the tumor region results in 5-year survival rates of 30-50%. This requires mandatory en bloc liver resection and resection of the extrahepatic bile duct often together with vascular resection. Nevertheless, the ideal safety margin of 0.5-1 cm remote from the macroscopic tumor extensions cannot be achieved in all cases. Based on hilar anatomy the probability of an adequate safety margin is higher using extended right hemihepatectomy together with portal vein resection compared to left hemihepatectomy. However, due to severe atrophy of the left liver lobe solely left-sided hepatectomy is feasible in some patients. In cases of eligibility for both procedures right hemihepatectomy is preferentially used due to the higher oncological radicality if sufficient liver function is present. Postoperative hepatic insufficiency and bile leakage after demanding biliary reconstruction, often with several small orifices, contribute to the postoperative complication rate of this complex surgical disease pattern.

Surgical resection is the only chance of cure for patients with colorectal liver metastases und significantly improves patient survival. The percentage of patients who can undergo curative resection as well as the survival after liver resection can be increased by using modern multimodal treatment algorithms. This has been achieved by not only innovations in pre- and postoperative chemotherapy but also by new surgical and interventional techniques and last but not least by individualisation of chemotherapeutic regimens. Due to the high number of new treatment modalities, a generally accepted treatment algorithm cannot be provided so far for all subgroups of the inhomogeneous group of patients with colorectal liver metastases. In the present review the current status of multimodal therapy is outlined and the pending questions mentioned.

Anastomotic leaks after oesophagojejunostomy usually are treated by endoluminal stenting with self-expandable metal or plastic stents. Here we present a patient with more than 4 years of oesophageal stenting for anastomotic leakage after gastrectomy. During the attempted removal of the stent he experienced a perforation of the jejunum. Emergency surgery with complete resection of the stent and transhiatal oesophagojejunostomy was performed. Generally, early removal of oesophageal stents 4-6 weeks after implantation is recommended, as later attempts often fail and may lead to extensive surgery.

Early enteral nutrition with fibre and probiotics has been effective in preventing bacterial translocation and is therefore expected to reduce the incidence of postoperative bacterial infections.In a prospective randomized trial including 172 patients following major abdominal surgery or liver transplantation, the incidence of bacterial infections was compared in patients receiving either a) conventional parenteral or enteral nutrition, b) enteral nutrition with fibre and lactobacillus plantarum 299 or c) enteral nutrition with fibre and heat inactivated lactobacilli (placebo). Liver transplant recipients were also treated with selective bowel decontamination (SBD). Routine laboratory parameters, nutritional parameters and the cellular immune status were measured preoperatively and on postoperative days 1, 5 and 10.Patients were comparable regarding preoperative ASA-classification, Child-Pugh classification of cirrhosis, operative data and immunosuppression. The incidence of bacterial infections after liver, gastric oder pancreas resection was 31 % in the conventional group a) compared to 4 % in the lactobacillus-group b) and 13 % in the placebo-group c). In the analysis of 95 liver transplant recipients, 13 % group b)-patients developed infections compared to 48 % group a)-patients and 34 % group c)-patients. The difference between groups a) and b) was statistically significant in both cases. In addition, the duration of antibiotic therapy was significantly shorter in the lactobacillus-group. Cholangitis and pneumonia were the most frequent infections and enterococci the most frequently isolated bacteria. Fibre and lactobacilli were well tolerated in most cases.Fibre and probiotics could lower the incidence of bacterial infections following major abdominal surgery in comparison to conventional nutrition with or without SBD. With this new concept, costs can be reduced by shortening the duration of antibiotic therapy and sparing SBD.

The best surgical approach for bilateral resections in the therapy of benign multinodular goiter is still controversial.The purpose of this study was to compare different modes of resection concerning differences in complication rates and risk factors influencing the outcome. 2235 thyroid resections for multinodular goiter between 1985 and 1999 were analysed.When compared to bilateral subtotal resection (n = 327; 14.6%), those patients who received lobectomy and contralateral subtotal resection (n = 952; 42.6%) showed a statistically significant higher incidence of temporary hypocalcaemia (22.6% versus 15.9%) only. The "nerve at risk"-analysis demonstrated no significant difference of laryngeal nerve paralysis between the side of lobectomy and subtotal resection, respectively. In comparison to the entire patient population operations for recurrent goiters had an equal operative risk, whereas patients with goiter WHO III or an intrathoracic location had significant higher rates of temporary laryngeal nerve paralysis and hypocalcaemia.Lobectomy and contralateral subtotal resection offers numerous advantages concerning intraoperative variability and definitive resection of suspicious nodules. With an adequate standardized surgical technique and identification of the laryngeal nerve, the complication rate is comparable to bilateral subtotal resection.

Before introduction of passive immunoprophylaxis and new antiviral nucleoside analogues the course of hepatitis B recurrence after liver transplantation could hardly be influenced. The result was a inferior graft survival. In the present retrospective analysis of the efficacy of hepatitis B therapy after liver transplantation was analysed retrospectively.Between 1988 and 1998 in total 179 patients were transplanted due to hepatitis B related liver failure at our centre. All patients received passive immunoprophylaxis with hepatitis B immunoglobulin. In case of reinfection after 1993 an antiviral therapy with famciclovir 1500 mg daily was initiated (n = 26), since 1996 lamivudine (100-150 mg daily) was used (n = 12). In case of viral breakthrough under famciclovir treatment or prophylaxis therapy was switched to lamivudine (n = 22). In case of ineffectiveness of lamivudine an antiviral combination therapy with lamivudine and interferon (n = 4) or lamivudine and famciclovir (n = 4) was initiated. Before availability of antiviral agents or in case of viral breakthrough in total 12 patients were retransplanted due to acute or chronic reinfection.With passive immunoprophylaxis reinfection rate was 33%, 43% and 44% after 1, 3 and 5 years respectively. Without antiviral treatment 52% of patients died within the first year after reinfection. Antiviral therapy with lamivudine or famciclovir improved the one year survival after reinfection to 79%. Suppression of viral replication was more effective with lamivudine. Under lamivudine 26 patients (76%) became HBV-DNA negative, 9 patients HBsAg negative (26%). In contrast no patient became HBsAg negative during famciclovir therapy. Lamivudine was effective also after famciclovir breakthrough in 94% of patients. In case of lamivudine resistant reinfection viral replication could be suppressed with an antiviral combination therapy up to negative HBV-DNA in the hybridization assay. Severe side effects were not observed during any of the antiviral therapies. The graft survival after retransplantation for hepatitis B reinfection was 42% and 25% after one and 3 years.Whereas it is generally accepted, that passive immunoprophylaxis lowers the reinfection rate it could be shown in the present study, that antiviral treatment lowers mortality of hepatitis B reinfection. The major problem of lamivudine and famciclovir is viral resistance formation. In this case an antiviral combination therapy might be useful, whereas retransplantation for hepatitis B reinfection should be considered carefully due to inferior graft survival rates.

Since the introduction of famciclovir in the treatment of hepatitis B virus (HBV) infection after liver transplantation, promising results have been published. In this study, the long-term efficacy and safety of famciclovir were assessed. Twenty-four patients with recurrent hepatitis B and 6 patients with de novo infection after liver transplantation were enrolled in an open prospective trial. Patients received oral famciclovir, 500 mg three times daily. Serum HBV-DNA, viral serology, and liver enzymes were measured sequentially; liver histology was taken before and during treatment in 12 patients. In the reinfected patients, 17 patients initially responded well to treatment, with a mean decrease of HBV-DNA of 82%, 5 patients became HBV-DNA negative. The drug was effective for 1-51 months (mean 16 months), then viral replication increased again in 13 out of 17 patients. One patient did not respond to treatment. Six out of 24 patients already had severe cirrhosis at the time of enrollment and died shortly afterwards, due to the HBV infection. The 6 patients with de novo infection all had a decline of HBV-DNA for 2-42 months (mean 14 months); 1 patient converted to HBV-DNA negative. Five out of 6 patients experienced a viral breakthrough later on. No severe side-effects were observed. Therefore, famciclovir is effective in certain HBV-infected patients after orthotopic liver transplantation (OLT), but in the long term, most of the patients relapse.