Marking Disappearing Colorectal Liver Metastases After Complete Response to Neoadjuvant Chemotherapy via CT - A Pilot Study.

BACKGROUND/AIM: The liver is a frequent site for metastases of colorectal cancer. Approximately 15% of patients have hepatic metastases at the time of diagnosis and another 50% develop them over the course of their disease. Only 10-25% of patients are candidates for liver resection. The aim of this study was to assess the benefit of preoperative computed tomography (CT)-guided wire marking of disappearing colorectal liver metastases (CRLMs) (radiological disappearance of metastases) before surgical resection. PATIENTS AND METHODS: Between January 2011 and January 2014, 20 patients with potentially disappearing CRLMs were selected for CT-guided wire marking. Following treatment with neoadjuvant chemotherapy, disappearing CRLMs were marked via CT guidance. Afterwards, the marked sites were resected. RESULTS: Complete histological response to neoadjuvant chemotherapy was only in 10 resected sites (18%), and 46 (82%) resected liver metastases showed metastatic tissue present. Both overall survival and the disease-free rates in patients after using our method were 55%. CONCLUSION: This study demonstrated the usefulness of CT-guided wire marking to mark disappearing CRLMs in order to improve long-term effectiveness of surgical treatment.

The Value of Lymph Node Dissection in the Surgery of Colorectal Cancer Liver Metastases.

BACKGROUND/AIM: Liver resection is the best treatment for metastatic colorectal cancer (CRC). Hepatic lymph node metastases are considered as extrahepatic disease and represent an unfavorable prognostic factor. However, extrahepatic disease, when resectable, provides no contraindication for surgical therapy. The aim of this study was to evaluate the prevalence of hepatic lymph node involvement in our patients' cohort. PATIENTS AND METHODS: Twenty patients submitted to resection for colorectal liver metastases were studied prospectively. Three areas for lymph node dissection were defined and analyzed separately. Lymph nodes were examined by hematoxylin and eosin staining and immunohistochemistry for Pan-Keratin. RESULTS: In average, 5 lymph nodes were harvested per patient. Macroscopic enlargement was not a definite sign for metastatic involvement. No morbidity or mortality was associated with lymphadenectomy. In our patients' collective, no cases of lymph node metastases occurred. CONCLUSION: There is no evidence of a survival benefit after lymph node dissection in patients with CRC liver metastases in the literature. Systematic lymphadenectomy can, however, provide a prognostic tool to better plan further treatment.

Effectiveness of porcine dermal collagen in giant hernia closure in patients with deleterious fascia constitution after orthotopic liver transplantation.

Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P < 0.05). All of them were managed with antibiotics; two of the PDC patients required surgical drainage. Histological analysis of PDC mesh biopsies indicated good angiogenesis and integration of the PDC into the abdominal wall. PDC was effective in our study for incisional hernia repair, and our results compared favourably with those of patients in whom direct hernia closure was feasible.

Hepatobiliary transporter expression and post-operative jaundice in patients undergoing partial hepatectomy.

BACKGROUND AND AIMS: Post-operative hyperbilirubinaemia in patients undergoing liver resections is associated with high morbidity and mortality. Apart from different known factors responsible for the development of post-operative jaundice, little is known about the role of hepatobiliary transport systems in the pathogenesis of post-operative jaundice in humans after liver resection. METHODS: Two liver tissue samples were taken from 14 patients undergoing liver resection before and after Pringle manoeuvre. Patients were retrospectively divided into two groups according to post-operative bilirubin serum levels. The two groups were analysed comparing the results of hepatobiliary transporter [Na-taurocholate cotransporter (NTCP); multidrug resistance gene/phospholipid export pump(MDR3); bile salt export pump (BSEP); canalicular bile salt export pump (MRP2)], heat shock protein 70 (HSP70) expression as well as the results of routinely taken post-operative liver chemistry tests. RESULTS: Patients with low post-operative bilirubin had lower levels of NTCP, MDR3 and BSEP mRNA compared to those with high bilirubin after Pringle manoeuvre. HSP70 levels were significantly higher after ischaemia-reperfusion (IR) injury in both groups resulting in 4.5-fold median increase. Baseline median mRNA expression of all four transporters prior to Pringle manoeuvre tended to be lower in the low bilirubin group whereas expression of HSP70 was higher in the low bilirubin group compared to the high bilirubin group. DISCUSSION: Higher mRNA levels of HSP70 in the low bilirubin group could indicate a possible protective effect of high HSP70 levels against IR injury. Although the exact role of hepatobiliary transport systems in the development of post-operative hyper bilirubinemia is not yet completely understood, this study provides new insights into the molecular aspects of post-operative jaundice after liver surgery.

Surgery for liver metastases originating from sarcoma-case series.

INTRODUCTION: Liver metastases originating from various types of sarcoma are a rare reason for hepatic resection. So far, even multicentre studies do hardly provide statistically relevant sample sizes. Thus, review of available data can provide surgeons with useful information in similar cases. Therefore, this study can be regarded more as a contribution to this pool of data than as a stand-alone paper. PATIENTS AND METHODS: The study includes 10 women and five men who underwent subtotal hepatic resection for solitary (n = 4) and multiple (n = 11) liver metastases originating from sarcoma. The median tumour diameter was 60 mm (range 20-200 mm). RESULTS: Morbidity was 33%. One patient died within 30 days after surgery. Resection was complete (R0) in 67%. Median overall survival was 33.6 months, 5-year survival 27%. The use of Pringle manoeuvre was significantly associated with poorer outcome (p = 0.014) and shorter period of recurrence-free survival (p = 0.012). Diameter of liver lesion over 50 mm showed significantly shorter recurrence-free survival (p = 0.042). CONCLUSION: Hepatic resection may be beneficial in patients with isolated sarcoma metastasis in the liver.

Working conditions and trainee shortage in operative disciplines--is our profession ready for the next decade?

BACKGROUND: Increasing concern has been expressed worldwide on the problem of finding young doctors to enter a training programme in an operative speciality. MATERIALS AND METHODS: A survey comprising 22 questions on working conditions and job satisfaction was placed on the homepage of the Austrian Society of Surgery; 667 questionnaires were completed. RESULTS: The question whether surgery is threatened by a trainee shortage was answered with "yes" by 68%. Only 37% were satisfied with their working conditions. The majority (61%) specified documentation as making up between 20% and 40% of their workload, 22.5% estimated an even higher percentage. Only 17.7% were satisfied with payment. A clear majority works 60 to 80 h per week or more. Only 32.5% stated that they can leave the hospital in the morning after weekend duty; for night duty during the week, this percentage decreased to just 4.2%. As for surgical training, 33.3% were satisfied. Regular assessments between the trainees and their department heads were confirmed by only 34%. A clear majority (96%) is in favour of rotations in other hospitals during residency for the sake of broader experience. CONCLUSION: Working hour restrictions are essential, but not enough: Substantial improvements in the professional profile and in training are required.

Prospective study comparing standard and robotically assisted laparoscopic cholecystectomy.

BACKGROUND AND AIMS: Laparoscopic surgery has become the treatment of choice for cholecystectomy. Many studies showed that while this approach benefits the patient, the surgeon faces such distinct disadvantages as a poor ergonomic situation and limited degrees of freedom with limited motion as a consequence. Robots have the potential to overcome these problems. To evaluate the efficiency and feasibility of robotically assisted surgery (RAC), we designed a prospective study to compare it with standard laparoscopic cholecystectomy (SLC). MATERIALS AND METHODS: Between 2001 and 2003, 26 patients underwent SLC and 20 patients underwent RAC using the ZEUS system. The feasibility, safety, and possible advantages were evaluated. To assess the efficacy, the total time in the operating room was divided into preoperative, operative, and postoperative time frames. RESULTS: For RAC in comparison with SLC, the preoperative phase including equipment setup was significantly longer. In the intraoperative phase, the cut-closure time and camera and trocar insertion times were significantly longer. It is interesting to note that the net dissection time for the cystic artery, duct, and the gall bladder was not different from SLC. CONCLUSIONS: The study demonstrates the feasibility of robotically assisted cholecystectomy without system-specific morbidity. There is time loss in several phases of robotic surgery due to equipment setup and deinstallation and therefore, presents no benefit in using the robot in laparoscopic cholecystectomy.

Accuracy of preoperative routine MRI for hepatic lesion detection.

BACKGROUND: The outcome of liver resections depends on complete removal of all detectable foci. Our aim was to determine the value of preoperative routine magnetic resonance imaging (MRI) for complete detection of hepatic lesions. METHODS: We compared 271 lesions seen on MRI in 182 patients to intraoperative findings (including intraoperative ultrasonography) and histology. RESULTS: The overall rate of lesions was 7% each for segments 2 and 3, as compared to 14-17% each for segments 5, 6, 7, and 8. Twenty-three additional lesions were found intraoperatively, two thirds of them in the left lobe (mean size: 1.4 cm; mean total number of lesions in those patients: 2.2). In segments 2 and 3, the relative frequency for intraoperative diagnosis of additional lesions was 17% and 20%, respectively. On the other hand, most of the 15 MRI lesions not verified intra- or postoperatively had been described in the right hepatic lobe (maximum: segment 6). CONCLUSION: MRI provided reliable preoperative lesion detection. Special attention should be paid to segments 2 and 3, which showed a lower total number of lesions but an elevated relative frequency of intraoperatively detected additional foci.

Surgical therapy options in polycystic liver disease.

INTRODUCTION: Polycystic liver disease (PLD) is a rare affliction frequently observed in association with polycystic kidney disease. Only symptomatic patients require treatment, which can be conservative or surgical, i.e. laparoscopic or conventional. We report the results of our experience in the surgical management of polycystic liver disease. METHODS: Between 1994 and 2003, 19 patients (16 female, 3 male) were referred to our center for the management of PLD. Their median age was 50 years (range 33-72). All were symptomatic and their cysts had a median diameter of 11 cm (range 5-22). RESULTS: Laparoscopic management was undertaken in eight patients, with one conversion to open technique because of bleeding from a superficial hepatic vein. An open procedure was performed in 11 patients: one left hemihepatectomy, deroofing in two patients, segment resection 2/3 plus deroofing in six patients, and segment resection 5/6 plus deroofing in two patients. Four patients had complications: one case of biliary leakage was managed conservatively; two patients had pneumothorax caused by the cava catheter inserted for anesthesia, and one patient's abdominal drain tore off and had to be removed by relaparotomy on the fourth postoperative day. Median follow-up of all patients was 49 months (range 7-98). In one patient there was symptomatic recurrence with hepatomegaly and compression of the inferior vena cava 84 months after the first operation. CONCLUSIONS: Careful selection of patients and meticulous surgical technique are recommended in the management of PLD. The treatment of choice for symptomatic Gigot or Morino type 1 PLD is laparoscopic surgery, and for advanced stage PLD combined hepatic resection and cyst fenestration.

Minimally invasive management of dysontogenetic hepatic cysts.

BACKGROUND: Liver cysts occur with a prevalence of 4%-7% in the general population. Laparoscopic surgery is effective for solitary cysts and in selected patients with polycystic liver disease (PLD). We present our experience in the laparoscopic management of dysontogenetic cysts. PATIENTS AND METHODS: Between 1994 and 2002, 36 patients were referred to our centre for the management of dysontogenetic cystic liver disease. Management was laparoscopic in 16 cases. Indications were solitary giant cysts (n=9) and PLD (n=7). RESULTS: Laparoscopic procedures were completed in 15 patients. Mean operating time was 90 min. There were no deaths. In one case there was an intraoperative complication: bleeding from a superficial hepatic vein necessitated conversion to an open procedure. There were two postoperative complications: one patient with biliary leakage, which was managed conservatively, and one patient with a pneumothorax caused by the cava catheter installed for anaesthesia. Median follow-up was 36 months. There was no symptomatic recurrence. CONCLUSION: Laparoscopy can be recommended as the procedure of choice for symptomatic solitary giant cysts and PLD Gigot type I.

Is intraoperative ultrasonography during partial hepatectomy still necessary in the age of magnetic resonance imaging?

BACKGROUND/AIMS: The aim of our study was to determine if intraoperative ultrasonography is still necessary in the time of magnetic resonance imaging. METHODOLOGY: Our prospective study comprised 122 patients (82% with malignant tumors) undergoing partial hepatectomy with preoperative magnetic resonance imaging, done at the same institution using a standardized liver protocol as well as intraoperative ultrasonography performed in a systematic fashion. RESULTS: Seventeen additional malignant lesions in 16/122 patients (13.1%) were found intraoperatively [7 visible, 2 palpable, 8 (6.6%) diagnosed by intraoperative ultrasonography only; mean size: 1.5 cm; left:right lobe = 11:6]. This caused a change in surgical strategy in 14 patients (11.5%), including 6 patients (4.9%) with lesions seen on intraoperative ultrasonography only. The average total number of lesions in those patients was 3.4. Ten lesions (7 benign, 3 malignant) described on magnetic resonance imaging were not found on intraoperative ultrasonography, but no unnecessary operations resulted from this. In one patient additional micrometastases seen neither on magnetic resonance imaging nor on intraoperative ultrasonography were found histologically. CONCLUSIONS: Intraoperative ultrasonography is still worthwhile as it remains unsurpassed in the ultimate determination of the number of lesions, tumor extension and anatomical resolution. However, in the course of time its benefits may decrease further due to ongoing improvement of preoperative imaging.

[Endoscopic palliation of malignant gastric outlet obstruction by self-expanding metal stents]. / Endoskopische Palliation der malignen Magenausgangsstenose durch selbstexpandierbare Metallstents.

INTRODUCTION: Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract. PATIENTS AND METHODS: Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer. RESULTS: In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation. CONCLUSION: Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.

Pyloric obstruction caused by prolapse of a hyperplastic gastric polyp.

Hyperplastic gastric polyps account for the majority of benign gastric polyps and are generally diagnosed by routine gastroscopy as they rarely become symptomatic. We report a 79-year-old woman who presented with intermittent attacks of bloating, belching, nausea and vomiting. Endoscopy showed a pedunculated polyp in the gastric antrum prolapsing through the pylorus, thus obstructing the gastric outlet. The polyp was repositioned with an endoscopic forceps and then removed at its pedicle by endoscopic snare excision. Histologic examination showed a hyperplastic polyp without dysplasia or malignancy. The significance of gastric polyps is discussed from the clinical point of view.