Value of sarcopenia in the resection of colorectal liver metastases-a systematic review and meta-analysis.

Introduction: Sarcopenia is defined as a decline in muscle function as well as muscle mass. Sarcopenia itself and sarcopenic obesity, defined as sarcopenia in obese patients, have been used as surrogates for a worse prognosis in colorectal cancer. This review aims to determine if there is evidence for sarcopenia as a prognostic parameter in colorectal liver metastases (CRLM). Methods: PubMed, Embase, Cochrane Central, Web of Science, SCOPUS, and CINAHL databases were searched for articles that were selected in accordance with the PRISMA guidelines. The primary outcomes were overall survival (OS) and disease-free survival (DFS). A random effects meta-analysis was conducted. Results: After eliminating duplicates and screening abstracts (n = 111), 949 studies were screened, and 33 publications met the inclusion criteria. Of them, 15 were selected after close paper review, and 10 were incorporated into the meta-analysis, which comprised 825 patients. No significant influence of sarcopenia for OS (odds ratio (OR), 2.802 (95% confidence interval (CI), 1.094-1.11); p = 0.4) or DFS (OR, 1.203 (95% CI, 1.162-1.208); p = 0.5) was found, although a trend was defined toward sarcopenia. Sarcopenia significantly influenced postoperative complication rates (OR, 7.905 (95% CI, 1.876-3.32); p = 0.001) in two studies where data were available. Conclusion: Existing evidence on the influence of sarcopenia on postoperative OS as well as DFS in patients undergoing resection for CRLM exists. We were not able to confirm that sarcopenic patients have a significantly worse OS and DFS in our analysis, although a trend toward this hypothesis was visible. Sarcopenia seems to influence complication rates but prospective studies are needed.

Cardiovascular outcomes after simultaneous pancreas kidney transplantation compared to kidney transplantation alone: a propensity score matching analysis.

BACKGROUND: Coronary heart disease due to arteriosclerosis is the leading cause of death in type 1 diabetic patients with end-stage renal disease (ESRD). The aim of this study was to evaluate the effect of simultaneous pancreas kidney transplantation (SPKT) compared to kidney transplantation alone (KTA) on survival, cardiovascular function and metabolic outcomes. METHODS: A cohort of 127 insulin-dependent diabetes mellitus (IDDM) patients with ESRD who underwent either SPKT (n = 100) or KTA (n = 27) between 1998 and 2019 at the University Hospital of Leipzig were retrospectively evaluated with regard to cardiovascular and metabolic function/outcomes as well as survival rates. An additional focus was placed on the echocardiographic assessment of systolic and diastolic cardiac function pretransplant and during follow-up. To avoid selection bias, a 2:1 propensity score matching analysis (PSM) was performed. RESULTS: After PSM, a total of 63 patients were identified; 42 patients underwent SPKT, and 21 patients received KTA. Compared with the KTA group, SPKT recipients received organs from younger donors (p < 0.05) and donor BMI was higher (p = 0.09). The risk factor-adjusted hazard ratio for mortality in SPKT recipients compared to KTA recipients was 0.63 (CI: 0.49-0.89; P < 0.05). The incidence of pretransplant cardiovascular events was higher in the KTA group (KTA: n = 10, 47% versus SPKT: n = 10, 23%; p = 0.06), but this difference was not significant. However, the occurrence of cardiovascular events in the SPKT group (n = 3, 7%) was significantly diminished after transplantation compared to that in the KTA recipients (n = 6, 28%; p = 0.02). The cardiovascular death rate was higher in KTA recipients (19%) than in SPK recipients with functioning grafts (3.3%) and comparable to that in patients with failed SPKT (16.7%) (p = 0.16). In line with pretransplant values, SPKT recipients showed significant improvements in Hb1ac values (p = 0.001), blood pressure control (p = < 0.005) and low-density lipoprotein/high-density lipoprotein (LDL/HDL) ratio (p = < 0.005) 5 years after transplantation. With regard to echocardiographic assessment, SPKT recipients showed significant improvements in left ventricular systolic parameters during follow-up. CONCLUSIONS: Normoglycaemia and improvement of lipid metabolism and blood pressure control achieved by successful SPKT are associated with beneficial effects on survival, cardiovascular outcomes and systolic left ventricular cardiac function. Future studies with larger samples are needed to make predictions regarding cardiovascular events and graft survival.

[Indocyanine green fluorescence staining in liver surgery]. / Indocyaningrünfluoreszenzfärbung in der Leberchirurgie.

BACKGROUND: 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. OBJECTIVE: Systematic review of the literature on the application of ICG imaging in open and laparoscopic liver surgery. MATERIAL AND METHODS: Literature review and summary of the recent scientific original articles and reviews. RESULTS: 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. CONCLUSION: 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.

[Possibilities and perspectives of hyperspectral imaging in visceral surgery]. / Möglichkeiten und Perspektiven der Hyperspektralbildgebung in der Viszeralchirurgie.

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.

[Single Incision Laparoscopic Cholecystectomy (SILC) - A Novel Technique in Comparison with the Gold Standard]. / Single-Port-Cholezystektomie: Ein Vergleich mit dem Goldstandard.

BACKGROUND: Currently multiport laparoscopic cholecystectomy (LC) represents the gold standard for gall bladder removal. However, a single-incision approach might succeed it as the future leading technique. To date, final proof for safety and applicability remain elusive. METHODS: A retrospective analysis of prospectively collected data from 459 patients subjected to multiport (LC) or single incision laparoscopic cholecystectomy (SILC) was performed. RESULTS: From 2010 to 2011, 115 SILC (25 %) and 344 LC (75 %) interventious were performed. Mean follow-up was 13.2 (2.1/24.6) months. The SILC group comprised more females (SILC: m : f 1 : 3.4 vs. LC: 1 : 1.2) and younger patients (SILC: 44.7 vs. LC: 54.9 years) with a slightly lower (ASA) score (SILC:1.7 ± 0.3 vs. LC:1.9 ± 0.5). SIL cholecystectomy was performed more frequently in an elective setting (SILC: 81.7 vs. LC: 55.5 %). Complication rates were low and did not differ significantly between groups (wound infections: SILC: 2.3 vs. LC: 3.19 %; incisional hernias: SILC: 0.86 vs. LC: 2.3 %, bile leakage: SILC: 0.86 vs. LC: 0.57 %). SILC was associated with shorter operative times (SILC: 70 ± 31 vs. LC: 80 ± 27 minutes; p < 0.001) and reduced postoperative hospital stay (SILC: 3.02 ± 1.4 vs. LC: 4.6 ± 2.8 days; p < 0.001). No conversion to open surgery was required with SILC when compared to LC (6 %; 21/334). Within the SILC group, additional ports had to be placed in 2.6 % (3/115). CONCLUSION: SILC displays a minimised surgical trauma. Compared to LC, SILC showed no disadvantage concerning risk profiles, operative times or hospital stay. We believe that SILC can be regarded as a natural evolution in the era of minimally invasive surgery.

[Management of intraoperative and postoperative bleeding in liver surgery]. / Management intra- und postoperativer Blutungen in der Leberchirurgie.

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.

Significant weight loss and rapid resolution of diabetes and dyslipidemia during short-term follow-up after laparoscopic sleeve gastrectomy.

BACKGROUND: Bariatric surgery has been established as the best option of treatment for morbid obesity. Recently, laparoscopic sleeve gastrectomy (SG) has become very popular because of good postoperative weight loss and low morbidity. The aim of this study was to report our single-center experience with SG regarding feasibility, morbidity, and outcome. METHODS: From January 2006 to December 2011, 93 patients (68 female) with a median age of 46 years underwent laparoscopic SG at our department. Thirteen patients had a history of gastric banding with insufficient weight loss or band-related complications. Clinical outcome and laboratory findings were analyzed. RESULTS: The mean preoperative and postoperative body mass index (BMI) was 44.1 ± 6.9 and 33.4 ± 6.8 kg/m(2), respectively (p < 0.001). The mean excessive body weight loss after a median follow-up of 11.9 months was 55.7 % ± 24.9 %. Three bleedings, two staple line leakages, and a deep wound infection required conversion to laparotomy (n = 1), reoperation (n = 4), or endoscopic stent implantation (n = 2). Resolution of diabetes and dyslipidemia was seen in 85 and 50 % of patients, respectively. Blood test results of HbA1c, cholesterols, triglycerides, and leptin showed significant postoperative improvement. CONCLUSIONS: Laparoscopic SG represents a feasible bariatric procedure with good short-term weight loss, low morbidity rate, and efficient resolution of diabetes and dyslipidemia, especially in patients with lower BMI. The significant decrease of leptin necessitates further studies to understand the ambiguous role of leptin in bariatric surgery.

[Single incision laparoscopic sigmoidectomy SILS sigmoidectomy]. / Laparoskopische Single-Inzisions-Sigmaresektion.

PURPOSE: Laparoscopic colon resection has several proven advantages over open surgery including postoperative pain, early recovery and better cosmesis. Single-incision laparoscopic (SIL) surgery, the most recent development in minimally invasive surgery, allows operations to be carried out through only a single incision using special ports. SIL surgery combines in part the cosmetic advantage and decreases the parietal trauma of natural orifice surgery, but allows operative realisation with standard and validated laparoscopic instruments. We report here the feasibility and surgical technique of a transumbilical SIL sigmoidectomy. INDICATION: We describe a 40-year-old man (BMI 30 kg/m2) with previously documented diverticular abscess and recurrent diverticulitis. METHOD: The multichannel 50-mm single port (OCTO-Port®, AFS Medical, Austria) was placed at the umbilicus. Transumbilical SIL sigmoidectomy was feasible with conventional laparoscopic instruments. Operative time for SIL sigmoidectomy was 159 min. A total of 25 cm sigmoid was resected. Oral diet was resumed on postoperative day one. No intraoperative or postoperative complications were recorded. The patient convalesced without complication and went home 6 days after surgery. At the 1-month review, he was fully recovered and his single umbilical scar was well healed. CONCLUSION: Transumbilical SIL sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. Further studies are certainly warranted for this promising technique. It has to be determined whether SIL offers benefit to the patient, besides cosmesis, compared with standard laparoscopic sigmoidectomy.

Pancreatic graft survival despite partial vascular graft thrombosis due to splenocephalic anastomoses.

Thrombotic complications following pancreas transplantation are still the most common cause of nonimmunologic graft loss. The aim of this study was to analyze pancreatic graft function after partial arterial graft thrombosis and the investigation of the pancreatic arterial anatomy with regard to intraparenchymal anastomoses. We retrospectively analyzed the data for 175 consecutive pancreas transplants performed between January 2002 and October 2007. Selective Y-graft angiography was performed in 10 and rubber-milk injection in 5 fresh pancreas specimens. Thrombosis of one leg of the Y-graft was diagnosed in 18 (10.3%) patients. Only one of these patients with thrombosis of the splenic artery required exogenous insulin. Sufficient graft perfusion was demonstrated in all of the remaining grafts. One graft was lost due to acute rejection. In all specimens angiography showed an excellent perfusion of the pancreaticoduodenal arcade, even after selective cannulation of the splenic artery. Arterial collaterals between the gastroduodenal, splenic artery and the superior mesenteric artery were demonstrated. Our results demonstrate that global perfusion of the pancreatic graft and sufficient graft function is sustained after the thrombotic occlusion of one branch of the Y-graft by a complex system of intraparenchymal anastomoses. These anatomical findings may have consequences for resection strategies in pancreas surgery.

The effect of secretory leukocyte protease inhibitor (SLPI) on ischemia/reperfusion injury in cardiac transplantation.

We investigated the role of secretory leukocyte protease inhibitor (SLPI) in ischemia/reperfusion injury in cardiac transplantation. SLPI-/- mouse hearts and wild-type (WT) controls were transplanted immediately or after 10 h of cold ischemia (CI). Recombinant SLPI (rSLPI) was added to the preservation solution or given systemically. After evaluation of myocardial performance, grafts were investigated for histology, SLPI, TNF-alpha, TGF-beta, NF-kappaB and protease expression at indicated time points. Early myocardial contraction was profoundly impaired in SLPI-/- hearts exposed to CI and associated with high intra-graft protease expression. Systemic administration of rSLPI had no effect, however, when SLPI was added to the preservation solution, myocardial contraction was restored to normal. At 10 days, inflammation, myocyte vacuolization and necrosis were significantly more severe in SLPI-/- hearts. SLPI gene expression was detected in WT mice at 12 and 24 h and was significantly higher after CI. SLPI protein was observed at 24 h and 10 days. High intra-graft concentrations of SLPI after administration of rSLPI were inversely correlated with protease levels early and TGF-beta expression late after reperfusion. SLPI plays a crucial role in early myocardial performance and postischemic inflammation after cardiac transplantation. A dual inhibitory effect on protease and TGF-beta expression might be the underlying mechanism.