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Background: Tumor necrosis and peritumoral fibrosis have both been suggested to have a prognostic value in selected solid tumors. However, little is known regarding their influence on tumor progression and prognosis in hilar cholangiocarcinoma (HC). Methods: Surgically resected tumor specimens of HC ( n = 47) were analyzed for formation of necrosis and extent of peritumoral fibrosis. Tumor necrosis and grade of fibrosis were assessed histologically and correlated with clinicopathological characteristics, tumor recurrence, and patients' survival. Univariate Kaplan-Meier analysis and a stepwise multivariable Cox regression model were applied. Results: Mild peritumoral fibrosis was evident in 12 tumor samples, moderate peritumoral fibrosis in 20, and high-grade fibrosis in 15. Necrosis was evident in 19 of 47 tumor samples. Patients with tumors characterized by necrosis showed a significantly decreased 5-year recurrence-free survival (37.9 vs. 25.7 %; p < .05) and a significantly decreased 5-year overall survival (42.6 vs. 12.4 %; p < .05), when compared with patients with tumors showing no necrosis. R status, tumor recurrence, and tumor necrosis were of prognostic value in the univariate analysis (all p < .05). Multivariate survival analysis confirmed tumor necrosis ( p = .038) as the only independent prognostic variable. Conclusions: The assessment of tumor necrosis appears as a valuable additional prognostic tool in routine histopathological evaluation of HC. These observations might have implications for monitoring and more individualized multimodal therapeutic strategies. [ABSTRACT FROM AUTHOR]

Background: The TNM classification for distal cholangiocarcinoma was first introduced in the 7th edition, which was published in 2009; however, prognostic accuracy compared with the 5th and 6th editions has not yet been evaluated and requires validation. Methods: A prospective histological database of patients with distal bile duct cancer was analyzed, and histological parameters and stage of the distal cholangiocarcinoma were assessed according to the 5th, 6th, and 7th editions of the TNM classification. Results: Between 1994 and 2012, a total of 516 patients underwent pancreatic head resection, of whom 59 patients (11.4 %) experienced histologically confirmed distal cholangiocarcinoma. The median overall survival time was 22.2 months (13.1-31.4). Tumor recurrence occurred in 23 patients after a median disease-free survival time of 14.1 months. The 7th edition showed a monotonicity of all gradients, with a stepwise increase of mortality related to a stepwise increase of tumor stage (log-rank test; p < 0.05) demonstrating best discrimination of all tested editions [area under the receiver operating characteristic curve (AUC) 0.82; 95 % CI 0.70-0.95; p = 0.012]. The discrimination rate was low for the 5th (AUC 0.67; 95 % CI 0.42-0.91; p = 0.18) and 6th editions (AUC 0.70; 95 % CI 0.47-0.93; p = 0.11), while the log-rank test did not reach statistical significance. On multivariate analysis, lymph node involvement and positive resection margins were positive and independent predictors of inferior survival ( p < 0.05). Conclusions: The 7th edition of the TNM classification was favorable in terms of predicting outcome, and generated a monotonicity of all grades. Strikingly, the 7th edition, but not the 5th and 6th editions, was of prognostic significance to predict outcome. [ABSTRACT FROM AUTHOR]

Introduction: Portal vein embolization (PVE) is a well-established technique to enhance functional hepatic reserves of segments II and III before curative extended right hepatectomy for tumors of the right liver lobe. However, an adequate hepatopetal flow of the left lateral portal vein branches is required for a sufficient PVE-associated hypertrophy. Case report: Here, we report a 65-year old patient suffering from a locally advanced intrahepatic cholangiocarcinoma in the right liver lobe and segment IV. A curative extended right hepatectomy after preoperative PVE of liver segments IV-VIII was initially impossible because of partial thrombosis of the left lateral portal vein branches resulting in an ischemic-type atrophy of segments II and III. However, due to a massive hypertrophy of the caudate lobe following PVE of liver segments IV-VIII, subsequent extended right hepatectomy with intraoperative thrombectomy of segments II and III was made possible. Conclusions: To our knowledge this is the first case in which an extended right hepatectomy for a liver malignancy, in the presence of atrophic left lateral section, was made possible by a massive PVE-associated hypertrophy of the caudate lobe. [ABSTRACT FROM AUTHOR]

LI-cadherin belongs to the family of 7D-cadherins that is characterized by a low sequence similarity to classical cadherins, seven extracellular cadherin repeats (ECs), and a short cytoplasmic domain. Nevertheless, LI-cadherins mediates Ca-dependent cell-cell adhesion and induces an epitheloid cellular phenotype in non-polarized CHO cells. Whereas several studies suggest that classical cadherins cis-dimerize in a Ca-dependent manner and interact in trans by strand-swapping tryptophan 2 of EC1, little is known about the molecular interactions of LI-cadherin, which lacks tryptophan 2. We thus expressed fluorescent LI-cadherin fusion proteins in HEK293 and CHO cells, analyzed their cell-cell adhesive properties and studied their cellular distribution, cis-interaction, and lateral diffusion in the presence and absence of Ca. LI-cadherin highly concentrates in cell contact areas but rapidly leaves those sites upon Ca depletion and redistributes evenly on the cell surface, indicating that it is only kept in the contact areas by trans-interactions. Fluorescence resonance energy transfer analysis of LI-cadherin-CFP and -YFP revealed that LI-cadherin forms cis-dimers that resist Ca depletion. As determined by fluorescence redistribution after photobleaching, LI-cadherin freely diffuses in the plasma membrane as a cis-dimer ( D = 0.42 ± 0.03 μm/s). When trapped by trans-binding in cell contact areas, its diffusion coefficient decreases only threefold to D = 0.12 ± 0.01 μm/s, revealing that, in contrast to classical and desmosomal cadherins, trans-contacts formed by LI-cadherin are highly dynamic. [ABSTRACT FROM AUTHOR]

Purpose: Rapamycin, an immunosuppressive in transplant surgery, has an additional antiproliferative effect. The aim of this study was to investigate the potential protective effects of rapamycin on postoperative adhesion development. Methods: Ten rats per group underwent midline incision laparotomy and adhesion induction including bowel sutures. Therapy groups received daily intraperitoneal rapamycin injections (1.5 mg/kg body weight) for 3 weeks postoperatively. Controls were rats without any postoperative treatment, rats receiving the rapamycin solvent or a hyaluronic acid-carboxymethylcellulose membrane (Seprafilm). Results: Postoperative rapamycin application led to enhanced adhesion development and there was a higher rate of wound infections. In addition, Seprafilm did not reduce adhesions, in subgroups there were even more. Conclusions: Rapamycin is not recommendable for perioperative immunosuppression, it enhances adhesion development and leads to a higher rate of wound infections. Surprisingly, the established Seprafilm membrane led to more adhesions in our experimental setting. [ABSTRACT FROM AUTHOR]

Purpose: Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed 'hilar en bloc resection.' The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy. Patients: During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this 'no-touch' technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded). Results: The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively ( P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival ( P = 0.036). Conclusions: In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors. [ABSTRACT FROM AUTHOR]

Purpose: The roles of angiogenesis and the most prominent angiogenic vascular endothelial growth factor (VEGF) in diseases of the pancreas remain controversial. We compared microvessel density (MVD) and VEGF status in normal pancreatic, chronic pancreatic, and pancreatic cancer (PC) tissues to establish their prognostic relevance. Methods: Eighty samples of PC tissue, 32 samples of normal pancreatic tissue, and 20 samples of chronic pancreatitis (cP) tissue were immunostained with monoclonal anti-CD31 and polyclonal anti-VEGF antibody. The MVD was correlated with clinicopathological features and survival. Results: Microvessel density was higher in PC than in cP ( P < 0.001). Residual tumor status was highly predictive for survival ( P < 0.001). After stratification for residual tumor status, we identified lymph node metastasis (LNM) in more than two lymph nodes ( P < 0.04) and high MVD ( P < 0.03) as risk factors for mortality. Multivariate analysis revealed only a high MVD ( P = 0.03, odds ratio 0.441, 95% confidence interval 0.211-0.821) as an independent predictor of poor survival. Vascular endothelial growth factor was found over stromal cells in cP and over ductal adenocarcinoma cells in PC. Vascular endothelial growth factor expression status was not predictive of survival ( P < 0.07). Conclusion: This study confirms the role of angiogenesis in PC and identifies MVD as an independent prognostic factor in patients with curatively resected PC. [ABSTRACT FROM AUTHOR]

Background Esophageal perforations remain a life-threatening event requiring rapid diagnosis and treatment. Surgical repair and interventional endoscopic or conservative treatment are the common treatment methods. Methods From 1998 to 2006, the authors retrospectively analyzed 62 patients treated for esophageal perforation. Data were evaluated for cause of perforation, symptoms, therapeutic regimen, complications, and mortality. Results The causes of perforation were iatrogenic or suicidal (n = 33) or spontaneous (n = 29). In the first group, the causes were dilation of stenosis (n = 16), endoscopy (n = 7), transesophageal echography (n = 4), ingestion of acid or leach (n = 2), intubation (n = 2), ingestion of a foreign body (n = 1), and migration of a screw after osteosynthesis (n = 1). The spontaneous perforations were caused by tumors (n = 19), Boerhaave syndrome (n = 6), unknown origin (n = 3), and Barrett's ulcer (n = 1). The most frequent symptoms were dysphagia (n = 50), pain (n = 35), fever (n = 24), and vomiting (n = 18). At the time of perforation, 28 patients presented with cancer. Of these 28 patients, 18 had esophageal cancer. The treatment included surgery (n = 32), which consisted of double-layer suture (n = 26) or esophageal resection (n = 6). A total of 30 patients were treated interventionally with a stent (n = 21), clips (n = 1), or without further measures (n = 8). The patients in the surgery group presented with severe primary and postoperative general conditions including renal failure (25%), respiratory insufficiency (65.5%), and need for catecholamines (62.5%). This multiorgan involvement was found only occasionally in the conservative group. The overall hospital mortality rate was 14.5%, involving 9 patients (5 in the surgery group and 4 in the conservative group). Early treatment led to better survival than late treatment with a delay exceeding 24 h. Conclusion The treatment method still must be chosen on an individual basis. It appears that surgical treatment is necessary in cases of severe general conditions. The data from this study show that surgical repair and conservative treatment may be used successfully. The best outcome was obtained after immediate treatment. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Little is known about the function of tumor-associated neovascularization in the progression of intrahepatic cholangiocarcinoma (IHC). This study was conducted to evaluate the influence of tumor-associated angiogenesis and lymphangiogenesis on progression of IHC.METHODS:We analyzed tissue specimens of IHC (N=114) by immunohistochemistry using the endothelial-specific antibody CD31 and the lymphendothelial-specific antibody D2-40 and subsequently quantified microvessel density (MVD) and lymphatic microvessel density (LVD). To analyze the influence of tumor-associated angiogenesis and lymphangiogenesis on tumor progression, tumors were allocated according to mean MVD and LVD, respectively, into groups of “high” and “low” MVD and LVD, respectively, and various clinicopathological characteristics as well as recurrence and survival data were analyzed.RESULTS:IHC revealed an induction of tumor-associated angiogenesis and lymphangiogenesis. Tumors of “high” MVD displayed more frequently advanced primary tumor stages and multiple tumor nodes. Furthermore, patients with tumors of “high” MVD had an inferior curative resection rate and suffered more frequently from recurrence. A “high” LVD was correlated with increased nodal spread, and patients with “high” LVD tumors more frequently developed recurrence. In the univariate analysis, MVD and LVD revealed significant influence on survival, and MVD was identified as an independent prognostic factor for survival in the multivariate analysis. The 5-year survival of patients with “low” MVD tumors was 42.1%, compared with 2.2% in patients with “high” MVD tumors (P<0.001).CONCLUSIONS:This study suggests a critical function of tumor-associated angiogenesis and lymphangiogenesis for progression of IHC. Therefore, antiangiogenic and antilymphangiogenic approaches may have therapeutic potency in this tumor entity. [ABSTRACT FROM AUTHOR]

Hepatic trauma is a rare surgical emergency with significant morbidity and mortality. Therapeutic strategies have been controversially discussed during the last decades. The medical records of 47 consecutive patients with hepatic trauma treated at the University Hospital of Leipzig between 2004 and 2008 were retrospectively reviewed for the severity of liver injury, management, morbidity, and mortality and compared to a preceding cohort. Logistic regression analysis was performed to identify risk factors influencing mortality. Compared to 63 patients treated between 1993 and 2003, moderate liver injuries (grades I–III) occurred more frequently ( p = 0.0006), and the proportion of patients that were managed operatively decreased from 68.9% to 37.5%. Twenty patients (42.6%) were treated conservatively (all grades I to III) and 27 surgically (47.4%). In detail, five patients were treated by hepatic packing alone, 13 by suture or coagulation, five by atypical resection, and four by hemihepatectomy. The overall mortality was 8.5% with a liver-related mortality rate of 2.1%. According to severity grades I–III, IV, and V, mortality rates were 0%, 18.2%, and 50.0%, respectively. Univariate analysis identified Injury Severity Score (ISS) >30, Moore grades IV and V, hemoglobin at admission <6.0 mmol/L, and need for transfusion of >12 erythrocyte concentrates to be significant risk factors for early posttraumatic death, while multivariate analysis only ISS >30 revealed to be of prognostic significance for early postoperative survival. Compared to a previous cohort in the same hospital, more patients were treated conservatively. Management of liver injuries presented with a low liver-related mortality rate. Grades I–III injuries can safely be treated by conservative means with excellent results. However, complex hepatic injuries may often require surgical treatment ranging from packing to complex hemihepatectomy. Hence, for selection of appropriate therapeutic options, patients with hepatic injuries should be treated in a specialized institution. [ABSTRACT FROM AUTHOR]

Introduction Simultaneous pancreas-kidney (SPK) transplantation s state-of-the-art therapy for patients with type-1 diabetes mellitus and end-stage renal failure. Improvement of long-term organ function and long-term survival after transplantation is the main focus of current research, but improvement of the early postoperative course is very important for the patient. Pancreas transplantation is associated with postoperative complications. We defined and identified donor- and recipient-specific factors related to postoperative complications. Patients and methods We carried out 210 SPKs from April 1995 to December 2007. The early postoperative course until first discharge from hospital was analyzed. Complications (pancreas-specific and surgical) were revisited. Donor-specific factors such as sex, age, body mass index (BMI), laboratory values, catecholamine administration, time in the intensive care unit, preprocurement blood substitution, and asystolic periods, as well as factors related to the organ donation procedure, were assessed. Recipientspecific factors such as age, sex, BMI, and blood group were correlated with the prevalence of complications and postoperative outcome. Donor-specific risk factors correlating with postoperative complications included donor age, BMI, and blood transfusion in the donor before organ donation. Results Graft preservation with histidine-tryptophan-ketoglutarate perfusion solution was related to a significantly higher number of surgical complications.When analyzing recipient-specific factors, pre-existing cardiac diseases influenced the prevalence of postoperative complications. The duration of the transplantation procedure was associated with significantly more complications. The anastomosis time was not significantly related to an increased prevalence of complications. The choice of immunosuppression had a significant effect on pancreas-specific complications, demonstrating that antithymocyte globulin instead of daclizumab had a negative effect. Initial immunosuppression with tacrolimus combined with mycophenolate mofetil (MMF) caused significantly fewer pancreas-related complications in comparison with tacrolimus combined with rapamycin as well as compared with cyclosporine combined with MMF. A high level of C-reactive protein within the first 7 days after transplantation was significantly related to an increased prevalence of complications. Conclusions Early postoperative complications after combined pancreas-kidney transplantation have a considerable effect on short- and long-term outcomes. Several statistically relevant factors related to pancreas- or surgeryassociated complications could be identified. These data may help to improve early outcome after SPK by consideration of relevant risk factors when choosing an organ and a recipient for transplantation. [ABSTRACT FROM AUTHOR]

Intraoperative neuromonitoring has the limitation that the recurrent laryngeal nerve (RLN) is still at risk for damage between two stimulations with a handheld bipolar stimulation electrode. The purpose of this study was to establish the vagal anchor electrode for real-time monitoring of the RLN in surgical routine and to be alerted to imminent nerve failure by electromyography (EMG) signal analysis whereby the nerve damage becomes reversible. This fully implantable electrode has been used in addition to a conventional handheld bipolar stimulation electrode during thyroid surgery on 45 consecutive patients (78 nerves at risk) stratified to low- and high-risk groups. The signal analysis was performed as real-time audio/video feedback by the use of a new multichannel EMG system. No complications were attributable to the use of the anchor electrode. The mean delay to place the anchor electrode was 1.45 min, whereas the mean stimulation time of the vagus nerve was 38 min. Stable and repeatable signals were evocable in all cases with one exception. No permanent RLN paralyses occurred in this study. The vagal anchor electrode is safe and easy to use. It allows continuous neuromonitoring without any threats. The new technique will provide more security, especially during preparation steps on the RLN that are difficult for the surgeon. [ABSTRACT FROM AUTHOR]

Hepatocellular carcinoma (HCC) represents the sixth most frequent human cancer worldwide and is characterized by rapid progression as well as resistance to systemic chemotherapy. Recently, glycolysis has emerged as a potent driving force of tumor growth and therapy failure. The precise role of glycolysis for the pathogenesis of human HCC has not been elucidated thus far. Therefore, we have conducted a comprehensive analysis of the expression patterns of central glycolysis-related factors [glucose transporter-1 and -2 (Glut-1 and Glut-2), phosphoglycerate kinase-1 (PGK-1) and hypoxia-inducible factor-1α (HIF-1α)] in a large cohort of benign and malignant human liver samples. PGK-1 protein and gene expression was scant in normal liver, elevated in cirrhotic livers and most intense in HCC. Strong immunoreactivity of Glut-2 was noted in cirrhotic livers, whereas in HCC it was only expressed in 50% of examined cases. Strikingly, PGK-1 as well as Glut-2 protein expression was indicative of poor patient prognosis. Glut-1 protein was absent in neoplastic hepatocytes but prominent in tumor-associated endothelial cells. Specific nuclear staining of HIF-1α was noted in only 12% of HCC samples. Our data point toward a tumor-promoting function of glycolysis in HCC and establish PGK-1 as an independent prognostic parameter. Furthermore, the endothelial-specific expression of Glut-1 makes a special dependence of vessels on glucose reasonable to assume. In summary, we believe our analysis warrants the validation of glycolytic inhibitors as innovative treatment approaches of human HCC. [ABSTRACT FROM AUTHOR]

Experimental results from animal models as well as studies of human cancers indicate a critical role for tumor-associated lymphangiogenesis in tumor progression. However, its significance in hepatocellular carcinoma (HCC) is not well established. We analyzed tissue specimens from healthy liver ( n = 36), cirrhotic liver ( n = 24), and HCC ( n = 60) by immunohistochemistry, using antibody D2-40 specific for lymphendothelia. We subsequently quantified lymphatic microvessel density (LVD). The LVD was correlated with clinicopathological characteristics of the tumors as well as survival and disease-free survival of the patients. In contrast to healthy as well as cirrhotic liver, lymphangiogenesis was induced in HCC. Lymphatic vessels were detected in the intratumoral septa as well as within the bulk of tumor cells. Tumors with high LVD (24 of 60) had developed significantly more frequently in cirrhotic livers ( P = 0.001) and were more frequently restricted to one liver lobe ( P = 0.04). Univariate analysis revealed high LVD as a marker for reduced survival and disease-free survival disadvantage (median >60 vs. 21 months, P = 0.018, and 19 vs. 8 months, P = 0.047, respectively). In multivariate analysis, LVD showed a trend toward association with reduced survival ( P = 0.059) and represented an independent prognostic factor for disease-free survival ( P = 0.017). Tumor-associated lymphangiogenesis is involved in neovascularization of hepatocellular carcinoma. Quantitative analysis of LVD demonstrated a significant influence of lymphangiogenesis on survival and established LVD as an independent predictor of disease-free survival. Quantification of LVD may be helpful in identifying patients with a high risk of tumor recurrence. [ABSTRACT FROM AUTHOR]

Neovascularization was shown to be critically involved in the progression of multiple cancers, and treatment approaches targeting tumor-associated neovascularization provide convincing results in recent years in some tumor entities. However, little is known about the tumor-associated neovascularization in hilar cholangiocarcinoma. The present study was conducted to analyze tumor-associated neovascularization in hilar cholangiocarcinoma and to determine its influence on tumor growth, metastasis, recurrence, and prognosis. We analyzed tissue specimens of hilar cholangiocarcinoma ( n = 60) by immunohistochemistry using the endothelial-specific antibody CD31 and subsequently quantified the microvessel density (MVD). The MVD was correlated with clinicopathological characteristics and recurrence pattern of the tumors as well as survival of patients. Hilar cholangiocarcinoma revealed a high degree of vascularization, with a calculated mean MVD of 28.1 ± 14.5 vessels. Tumors with a high MVD had a significant higher incidence of lymph node involvement ( P = 0.009) and local recurrence ( P < 0.001). Furthermore, a high MVD was identified to be a significant overall survival disadvantage (3-year, 28% vs. 93%; 5-year, 8% vs. 78%; P < 0.001) as well as disease-free survival disadvantage (3-year, 7% vs. 88%, 5-year, 7% vs. 72%; P < 0.001), with MVD representing an independent prognostic factor for survival. Neovascularization is associated with nodal spread as well as local recurrence and serves as an independent prognostic factor for survival after curative resection of hilar cholangiocarcinoma. Therefore, tumor-associated neovascularization seems to be critically involved in the progression of this tumor entity. In addition, neovascularization may represent a potential target in he development of new therapeutic approaches in hilar cholangiocarcinoma. [ABSTRACT FROM AUTHOR]

Tumor-associated lymphangiogenesis has been shown to promote nodal spread and is of prognostic significance in some tumor entities. Currently, nothing is known about the impact of lymphangiogenesis on progression and prognosis in hilar cholangiocarcinoma. We analyzed tissue specimens of normal liver and hilar cholangiocarcinoma ( n = 60) by immunohistochemistry using the lymphendothelial-specific antibody D2-40 and subsequently quantified lymphatic microvessel density (LVD). The LVD was correlated with clinicopathological characteristics and recurrence pattern of the tumors as well as patients’ survival. In contrast to the low abundance of lymphatic vessels in nontransformed liver tissue, we found an induction of lymphangiogenesis in hilar cholangiocarcinoma. Tumors with a high LVD (34 out of 60) had a significant higher incidence of lymph node involvement ( p < 0.001), perivascular ( p = 0.017), and perineural ( p = 0.033) lymphangiosis and local recurrence ( p < 0.001). Furthermore, a high LVD was identified to be a significant overall (three-year: 24.4% versus 90.5%; five-year: 7.0% versus 76.4%; p < 0.001) and disease-free (three-year: 8.3% versus 76.6%; five-year: 5.9% versus 61.4%; p < 0.001) survival disadvantage, with LVD representing an independent prognostic factor for survival ( p < 0.001) in the multivariate analysis. Lymphangiogenesis is associated with increased frequency of tumor cells in lymphatics and lymph nodes in hilar cholangiocarcinoma. The prognostic importance of tumor-associated lymphangiogenesis was reflected by LVD serving as an independent prognostic factor. In addition, lymphangiogenesis may represent a potential target in the development of new therapeutic approaches in hilar cholangiocarcinoma. [ABSTRACT FROM AUTHOR]

The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection. Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival. Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer ( p = 0.004) and used less extensive liver resections ( p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection ( p = 0.012). The mortality after simultaneous liver resection ( n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection. Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection. [ABSTRACT FROM AUTHOR]

Posttransplant lymphoproliferative disease (PTLD) is closely linked to primary Epstein–Barr virus (EBV) infection. A defect of EBV specific cellular immunity is postulated to play a pivotal role in the etiology of PTLD, but there is some debate as to whether EBV load in the peripheral blood of transplant patients predicts onset of PTLD or relapse after treatment. The current prospective, single-center study was undertaken to investigate the impact of therapy on EBV load in adult patients with PTLD. Fifteen patients with PTLD after solid organ transplantation were included and of these, seven had EBV-associated PTLD. All 15 patients received Rituximab as primary therapy. In cases of treatment failure or relapse after Rituximab treatment, patients received polychemotherapy according to the cyclophosphamide, vincristine, doxorubicin, and prednisone regimen. At onset of PTLD, the median EBV load in the peripheral blood of patients was higher in EBV-associated PTLD than PTLD with no associated EBV infection. After Rituximab therapy, four of seven patients with EBV-associated PTLD achieved long-lasting complete remissions. However, in two of these patients, EBV load increased to reach levels as high as those recorded at onset of PTLD. Another patient showed a dramatic decline of EBV load after the first dose of Rituximab while suffering from progressive disease. The other patient relapsed after Rituximab monotherapy, but his viral load stayed low. In total, discordance in EBV load and clinical course was observed in five of the seven patients with EBV-associated PTLD. We conclude that in adult patients with PTLD, EBV load does not correlate with treatment response and is not suitable as a predictive marker for PTLD relapse. [ABSTRACT FROM AUTHOR]

Background: Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years. Methods: The literature as well as our own experience after 133 resections of hilar cholangiocarcinomas were reviewed. Results: Tumor-free margins represent the most important prognostic parameter. Hilar resections as least radical resective procedure will generate rates of formally curative resections of less than 50%. Even after these formally curative resections, long-term survival cannot be achieved. Only additional liver resections will increase the number of long-term survivors to significant figures. In our series, the best 5-year survival rate of 72% was achieved after right trisegmentectomy with concomitant resection of the portal vein bifurcation. Conclusion: Right trisegmentectomy and combined portal vein resection represent the best way to comply with basic rules of surgical oncology for hilar cholangiocarcinoma. This procedure will provide the most pronounced benefit among various types of liver resection, whereas local resections of the extrahepatic bile duct must be considered as an oncologically inefficient procedure. [ABSTRACT FROM AUTHOR]

Patient death after liver resection for hepatocellular carcinoma in cirrhosis is caused by tumor recurrence as well as by complications of cirrhosis. Liver transplantation represents the only simultaneous treatment of tumor and primary liver disease. Certain criteria regarding the number (up to three) and size (up to 5 cm) of tumor nodules have to be observed in order to ensure a low risk of extrahepatic spread or vascular infiltration. Liver transplantation, as treatment for recurrent hepatocellular carcinoma, has to observe the same rules. Only few patients have undergone liver transplantation for recurrent hepatocellular carcinoma in cirrhosis. The reason for this restraint is not fully evident. Poor survival rates after liver transplantation as therapy for advanced hepatocellular carcinoma in the 1980s and an increasing shortage of donor grafts are certainly two factors. We report on two cases from our experience and review the European literature. Outcome in a few selected patients has been rather favorable, despite varying approaches. The only conclusion that can be drawn is that tumor control by liver transplantation is possible in individual patients suffering from recurrent hepatocellular carcinoma. Adult living donor liver transplantation is one way to overcome graft shortage. Other strategies, for example, salvage transplantation, are presented. [ABSTRACT FROM AUTHOR]

Up to 1989, 581 resections of hilar cholangiocarcinomas had been reported in the world literature by 40 authors, the largest experience originating from Professor Rudolf Pichelmayr's group in Hannover. Over the past decade, other centers in Germany have also adopted the more aggressive surgical approach instead of palliative biliary drainage, or even continued to develop further strategies, as the reported long-term results remained disappointing. In Berlin, we started a program of oncological hepatobiliary surgery in 1988. Since then, 104 patients have undergone resections of hilar cholangiocarcinomas, including 14 patients in whom a procedure combining liver transplantation and partial pancreatoduodenectomy, the so-called extended bile duct resection, was performed. Although the rate of curative resections increased significantly after this procedure, a comparable favorable effect with respect to survival figures was not evident. We observed the highest postoperative 5-year survival rates (59%) in the group of patients who had undergone right trisegmentectomy. Preoperative ipsilateral biliary decompression, i.e., of the remnant lobe, and arterial platinum coil embolization of the lobe to be resected are means to achieve a wider applicability of this method. [ABSTRACT FROM AUTHOR]