Mixed reality combined with ALPPS for colorectal liver metastases, a case report.

INTRODUCTION: Improvement of treatments for patients suffering from colorectal carcinoma and extended liver metastases has increased the overall survival and enables more patients to undergo surgical therapy. If the future liver remnant (FLR) is expected to be low, Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a potential treatment with high feasibility and an increase in overall survival. The evolving mixed reality technology could support hepatobiliary surgery. This case report demonstrates for the first time the combination of mixed reality technology and ALPPS procedure for a patient with low expected FLR. PRESENTATION OF CASE: A 49-year-old patient is presented with adenocarcinoma of the caecum with bilateral liver metastasis. After colon resection, a palliative chemotherapy was administered with good response and partial remission, so curative liver resection was intended. Based on the low expected FLR, calculated from the 3D-model of the liver, we decided to perform an in-situ split resection supported by mixed reality intraoperatively. The total operation time was 6 + 2 h. During both steps no blood transfusion was required and no major complication occurred. The patient was discharged 15 days after the second step. Final pathology revealed multiple predominantly necrotic metastases of the pre-existing colon carcinoma (ypM1, R0). DISCUSSION: After the first step of ALPPS, an increase of the FLR up to 57 % was achieved, so the second step was performed on postoperative day (POD)11. The 3D-model and the intraoperative use of mixed reality supported our decision making and intraoperative navigation. This technique could be implemented on a larger scale to support complex liver resections. CONCLUSION: The combination of mixed reality with ALPPS resulted in a good surgical outcome and should be considered as a potential alternative for liver resections.

Comparison of the sixth and the seventh editions of the UICC classification for intrahepatic cholangiocarcinoma.

BACKGROUND: The current seventh edition of the TNM classification for intrahepatic cholangiocarcinoma (ICC) includes tumor number, vascular invasion, lymph node involvement but no longer the tumor size as compared to the sixth edition. The impact of the seventh edition on stage-based prognostic prediction for patients with ICC was evaluated. METHODS: Between 03/2001 and 02/2013, 98 patients with the diagnosis of an ICC were surgically treated at our center. Median survival times were calculated for these patients after separate classification by both sixth and seventh editions. RESULTS: Median overall survival was increased in patients classified to the lower tumor stages I and II using the seventh as compared to the sixth edition: stage I (54.9 vs. 47.3 months), stage II (19.9 vs. 18.9 months), stage III (17.2 vs. 19.9 months), and stage IV (23.2 vs. 15.3 months), respectively. The seventh edition definition of the T category resulted in an increased median survival regarding the T1 (50.4 vs. 47.3 months) as well as the T2 category (19.9 vs. 15.6 months) and revealed a reduced median survival of patients within the T3 (21.6 vs. 24.8 months) as well as the T4 category (19.9 vs. 27.0 months). CONCLUSIONS: The UICC seventh edition TNM classification for ICC improves separation of patients with intermediate stage tumors as compared to the sixth edition. The prognostic value of the UICC staging system has been improved by the seventh edition. Trial registration The data for this study have been retrospectively registered and the study has been approved by the ethic committee of the medical faculty of the University Hospital of Essen, Germany (license number 15-6353-BO).

Vascular and nerval damage after intraoperative radiation therapy of the liver hilum in a large animal model.

It has been demonstrated that intraoperative radiotherapy is a therapeutic option for patients suffering from perihilar cholangiocarcinoma. Aim of our study was to investigate vascular and nerve damages after irradiation of the liver hilum in a pig model. Twenty-four pigs underwent central bile duct resection followed by biliodigestive anastomosis. Nine pigs underwent this surgical procedure alone (group 1). Ten pigs were treated with additional intraoperative radiation therapy (IORT) of 20Gy to the liver hilum (group 2). And five pigs received operation and IORT with 40Gy to the area of anastomosis (group 3). Six weeks after operation and treatment the animals were sacrificed and histopathological examination was performed. Histology showed no vascular or nerve damage in non-irradiated perihilar tissue. Significant changes of nerve structures occurred, as well as vascular damage in large and even more in small hilar arteries in the irradiated neighboring liver tissue. In detail for small hilar arteries: intima proliferation (p ≤ .0001), endothelial swelling (p ≤ .0001), fibrinoid arterial wall necrosis (p ≤ .0001), and arterial thrombosis (p = .0079) were detected. Venous vessels did not show significant dose dependant cell damage. Overall, 20Gy as a single dose application during operation showed similar damage to vessels and nerves compared to 40Gy. A radiation dosage of 20Gy seems to be sufficient to induce necrosis due to vascular and nerve damage in potential malignant liver tissue with acceptable damage to surrounding tissue. Perineural invaded tumor cells might be diminished due to IORT.

AST 17600 U/l after liver transplantation, what are you up to? - A case report.

BACKGROUND: Miscellaneous clinical classifications of liver function after liver transplantation are rested upon elevation of transaminases which represent damaging of hepatocytes and with it of the liver. CASE REPORT: We report the case of a 35-year-old man suffering from hepatocellular carcinoma in the setting of alcoholic liver cirrhosis. The patient underwent liver transplantation and developed an extreme peak of transaminases due to prolonged cold ischemia time and additional extended donor criteria. On the first postoperative day the laboratory results showed peak transaminases as follows: AST 17577 U/l and ALT 9884 U/l. Frequent ultrasound revealed no signs of vascular complications. In spite of the dramatically elevated transaminases the liver showed a good primary function and the patient was cardiopulmonary stable. The entire postoperative course was uneventful. We discharged the patient after three weeks in a very good general state of health, with normal laboratory values. CONCLUSIONS: Exclusive extreme elevation of transaminases after liver transplantation combined with adequate liver synthesis does not always require re-transplantation, if situation of the patient is stable. Nevertheless re-transplantation should be reconsidered in any case of clinical deterioration of the patient.

Comparison of the sixth and the seventh editions of the UICC classification for perihilar cholangiocarcinoma.

BACKGROUND: The seventh edition of the TNM classification separates extrahepatic bile duct tumors into perihilar and distal tumors and further changes the definition of the TNM classification. The impact of the seventh edition on stage-based prognostic prediction for patients with perihilar cholangiocarcinoma was evaluated. METHODS: Between January 1998 and March 2010, 223 consecutive patients with perihilar cholangiocarcinoma underwent surgery at the West German Cancer Center. Median survival times were calculated for the 195 evaluable patients (excluding those with in-hospital mortality) after separate classification by both sixth and seventh editions. RESULTS: Median overall survival was increased in patients classified using the seventh compared with the sixth edition (UICC I: 56.5 vs 23.75 months; II: 45.9 vs 31.6 months; III: 21.3 vs. 8.76 months; IV: 7.03 vs 5.93 months). The T category of the seventh edition did not alter median survival times of T1 (54.07 months) and T4 (7.83 months) cases, but median survival was prolonged for T2 patients (29.4 vs 31.6 months), and shortened for T3 patients (19.43 vs 11.8 months) staged using the seventh edition. According to Cox proportional hazards regression analysis, patient survival was better predicted by the seventh edition UICC stage and pT categories (p=0.0014 and p=0.0396, respectively), than the corresponding sixth edition categories (p=0.4376 and p=0.0926, respectively). CONCLUSIONS: The UICC seventh edition TNM classification for perihilar cholangiocarcinoma improves separation of patients with intermediate stage tumors compared with the sixth edition. The prognostic value of the UICC staging system has been strengthened by the introduction of the seventh edition.

Klatskin-mimicking lesions: still a diagnostical and therapeutical dilemma?

BACKGROUND/AIMS: The preoperative as well as the intraoperative differentiation between Klatskin-mimicking lesions and malignant bile duct tumors at hilar bifurcation is still challenging. Our intention was to review the preoperative diagnostics including preoperative CA19-9 and bilirubin serum levels to compare benign and malignant tumors. METHODOLOGY: We analyzed our prospectively established bile duct tumor database. From 1999 to 2008, 238 patients suspicious for hilar cholangiocarcinoma underwent surgery. In 24 patients the postoperative histological diagnosis showed a Klatskin-mimicking lesion. The histological report from 20 out of the 24 patients showed a chronic inflammatory transformation of the bile ducts. The histology of two patients showed a primary sclerosing cholangitis and the histological examination of the two remaining patients diagnosed a sarcoidosis of the extrahepatic bile duct. RESULTS: Reassessment of preoperative diagnostics did not deliver any change of interpretation of the tumors' dignity compared to how it had been assessed preoperatively. Also, preoperative CA19-9 serum levels do not show a statistically reliable differentiation between benign or malignant dignity. CONCLUSION: Current diagnostics cannot differentiate malignant from benign tumor masses in the hepatic hilum with the necessitated reliability. Therefore surgical resection of suspect hilar tumors is still the only appropriate therapy.

Impact of intraoperative radiotherapy (IORT) on survival of patients with unresectable hilar cholangiocarcinoma.

BACKGROUND/AIMS: The cure or long-term survival of hilar cholangiocarcinoma patients can only be achieved after complete tumor resection. Many patients though suffer from unresectable hilar cholangiocarcinoma, and palliative treatment is therefore the only therapeutic option. In cases of unresectable bile duct cancer, intraoperative radiotherapy (IORT) is an additional option during surgery. The aim of this study was to compare the efficacy of IORT to surgery alone in patients with unresectable hilar cholangiocarcinoma. METHODOLOGY: Palliative IORT (group 1) was performed on 9 patients (4 female/5 male); surgery alone (group 2) was performed in a case-matched group of 9 patients (4 female, 5 male) with unresectable hilar cholangiocarcinoma. The mean ages were 52.9 years (group 1) and 57.2 years (group 2). The two groups had comparable local tumor extension and stages of tumor disease according to UICC 6th edition. Group 1 was also compared to all 36 patients (n=36) suffering from unresectable cholangiocarcinoma treated without IORT (Group 3). RESULTS: The survival of patients after IORT was significantly improved compared to surgery alone in this study. The median survival time was 23.3 months (group 1) versus 9.4 months (group 2) and 5.7 month (group 3). The one year and two year actuarial survival rates are: 56% and 42% (group 1), 33% and 0% (group 2), 25% and 8% (group 3). CONCLUSIONS: Palliative surgery including IORT is safe for patients with unresectable hilar cholangiocarcinoma. The benefit shown by this investigation is a significant improvement of survival time after application of IORT in the palliative situation. A prospective study with randomization is needed to confirm these first results in a larger cohort.