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Zusammenfassung Hintergrund Für das fortgeschrittene hepatozelluläre Karzinom steht uns seit Kurzem ein deutlich erweitertes Spektrum an systemischen Therapieoptionen zur Verfügung. Insbesondere mit den immunonkologischen Kombinationstherapien können mittlerweile beeindruckende Ansprechraten und ein deutlich verlängertes Überleben bei insgesamt guter Verträglichkeit erreicht werden. Dabei werden diese Immun-Onkologie (IO)-basierten Kombinationen nicht nur zur Therapie des fortgeschrittenen HCC geprüft, sondern zunehmend auch in früheren Stadien im Sinne von periinterventionellen Therapiekonzepten und auch zum down-sizing zu lokalen Therapien. Im Kontext der Lebertransplantation (LTx) muss allerdings eine besonders kritische Nutzen-Risiko-Abwägung vor Einsatz von Immuntherapeutika im Rahmen multimodaler Konzepte erfolgen, da durch die Immuntherapie das Risiko einer potenziell letalen Abstoßung signifikant gesteigert werden kann. Methode Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche, die zwischen Dezember 2020 und April 2021 in den Datenbanken PubMed und Cochrane Library durchgeführt wurde. Leitlinien, Expertenmeinungen und Empfehlungen von Fachgesellschaften wurden besonders berücksichtigt. Ergebnisse Fast jede fünfte LTx in Deutschland erfolgt aufgrund eines HCC (DSO Jahresbericht 2019). Die LTx ist dabei eine kurative Therapieoption nicht nur für die zugrunde liegende Lebererkrankung, sondern auch für den malignen Tumor. Einzelfallbeschreibungen weisen darauf hin, dass auch eine IO-Therapie vor einer LTx das Risiko einer Abstoßung bzw. eines Leberversagens bei einer nachfolgenden LTx erhöhen kann. Seit ca. 2015 werden Immuntherapeutika vielfach auch zur Tumortherapie bei Patienten nach einer LTx eingesetzt. In kleinen Fallserien wurden dabei Abstoßungsraten von 36%, die mit einer abstoßungsbedingten Mortalität von 20% der behandelten Patienten einhergingen, beschrieben. Eine ähnliche Inzidenz von Abstoßungsreaktionen wurde auch nach dem Einsatz von Immuntherapeutika bei Patienten nach anderen Organtransplantationen beschrieben. Schlussfolgerung Im Zusammenhang mit einer Organtransplantation besteht durch eine IO-Therapie das Risiko einer Transplantatabstoßung, welches zum Verlust des Transplantates und auch zum Tod des Patienten führen kann. Unter Abwägung der oben dargelegten Überlegungen kann aber nach unserer sorgfältigen Nutzen-Risiko-Abwägung aus heutiger Sicht ein Einsatz einer IO-basierten Therapie im Kontext der Organtransplantation erfolgen.

ZusammenfassungEchte Viszeralarterienaneurysmata (VAA) und Viszeralarterienpseudoaneurysmata (VAPA) treten im Stromgebiet des Truncus coeliacus, der A. mesenterica superior und der A. mesenterica inferior auf. Neben der operativen Therapie stellt die endovaskuläre Versorgung viszeraler Aneurysmata sowie Pseudoaneurysmata eine interventionelle Alternativmethode dar, die sich in den letzten beiden Dekaden sprunghaft entwickelt hat und in vielen Zentren als Methode der ersten Wahl gilt. Das Verfahren zeichnet sich durch eine hohe technische Erfolgsrate bei niedriger Komplikationsrate aus. Der vorliegende Artikel zeigt die Grundprinzipien der endovaskulären Versorgung auf und diskutiert den Stellenwert sowie die Limitierungen des Verfahrens.

Purpose In patients suffering from autosomal dominant polycystic liver and kidney disease (ADPLKD), combined organ transplantation often poses a technical challenge due to the large volume of both organs. To simplify the transplantation procedure by improving the exposure of anatomical structures, we introduce a novel surgical technique of orthotopic liver and kidney transplantation. Methods The modified simultaneous liver and kidney transplantation technique via a right-sided L-incision included three steps: (1) right-sided nephrectomy in the recipient followed by (2) orthotopic liver transplantation in cava replacement technique and (3) the orthotopic kidney transplantation with arterial reconstruction to the right common iliac artery. Results In total, seven patients with ADPLKD were transplanted by using the modified transplantation technique. The mean operation time was 342.43 min (±68.77). Postoperative patients were treated for 6.28 days (±2.50) in the intensive care unit and were discharged from the surgical ward approximately 28 days (±5.66) after the operation with normal graft function. Complications associated with the use of the modified technique, such as bleeding, anastomotic stenosis, biloma, or urinoma, did not occur. Conclusion Modified simultaneous liver and kidney transplantation is a safe alternative for patients with ADPLKD. By combining right-sided nephrectomy and orthotopic graft transplantation, the approach optimizes the exposure of anatomical structures and simplifies the transplantation procedure. Additionally, the modified transplantation technique does not require a particular organ explantation procedure and can be applied for all liver and kidney grafts.

Die minimal-invasive Leberchirurgie ist sicher und kann mit nahezu gleichwertigen Ergebnissen wie die offene Chirurgie durchgefuhrt werden. Es stehen verschiedene Techniken der Parenchymdissektion und Blutstillung fur die sichere Durchfuhrung sowohl laparoskopisch als auch roboterbasiert zur Verfugung. Die roboterbasierte Chirurgie stellt durch ihre technischen Optionen die Weiterentwicklung der Laparoskopie dar. Eine Expertise in der minimal-invasiven und in der Leberchirurgie sind fur den Operateur unabdingbare Voraussetzungen.

The role of surgical treatment of hepato-pancreatic metastases from renal cell carcinoma is still under discussion.We report about 52 patients of whom 33 underwent surgery for liver metastases and 19 for pancreatic metastases from 1995 to 2018.The 5‑year survival rate of all patients with partial liver resection was statistically significantly lower (38%, median survival time 34 months) than with pancreas resection (69%, median survival time 69 months, p = 0.017). Of the patients 21 survived the resection of metastases longer than 5 years and 4 patients longer than 10 years. In R0 resected patients, recurrences were observed in 13 cases after liver resection and in 9 cases after pancreas resection. The cumulative recurrence rate after 5 years was 38% for the liver and 57% for the pancreas. In R0 partial liver resections, an interval24 months between nephrectomy and liver resection as well as multiple metastases were negative prognostic factors.In spite of high recurrence rates, surgical treatment for hepato-pancreatic metastases from renal cell carcinoma yielded very good long-term results, in particular with complete resection of solitary metachronous metastases. Repeated surgery for completely resectable metastases, resulted in long tumor-free intervals and thus contributed to good long-term results.HINTERGRUND: Der Stellenwert der chirurgischen Therapie hepatopankreatischer Metastasen des oligometastasierten Nierenzellkarzinoms ist Gegenstand der aktuellen Diskussion.Wir berichten über 51 Patienten, von denen 33 wegen Lebermetastasen und 19 wegen Pankreasmetastasen im Zeitraum von 1995 bis 2018 operiert wurden.Die 5‑Jahres-Überlebensrate aller Patienten nach Leberteilresektion war statistisch signifikant geringer (38 %, mediane Überlebenszeit 34 Monate) als nach Pankreasresektion (69 %, mediane Überlebenszeit 69 Monaten; p = 0,017). 21 Patienten haben bislang die Metastasenentfernung länger als 5 Jahr überlebt, 4 Patienten länger als 10 Jahre. Bei den R0-resezierten Patienten wurden Rezidive in 13 Fällen nach Leber- und 9 Fällen nach Pankreasresektion beobachtet. Die kumulative Rezidivrate nach 5 Jahren betrug bei der Leber 38 % und beim Pankreas 57 %. Bei R0-Leberteilresektionen erwiesen sich ein Intervall von24 Monaten zwischen Nephrektomie und Leberresektion sowie multiple Metastasen als negative Prognosefaktoren.Unsere Ergebnisse gestatten eine aktive chirurgische Strategie in der Behandlung hepatopankreatischer Metastasen oligometastasierter Nierenzellkarzinome, insbesondere bei kompletter Resektion solitärer, metachroner Metastasen. Wiederholte Eingriffe bei komplett resektablen Metastasen führen zu langen tumorfreien Intervallen und tragen damit zu guten Langzeitergebnissen bei.

Patients with chronic liver disease and patients after solid organ transplantation (SOT) are vulnerable to severe coronavirus disease 2019 (COVID-19). We evaluated fears, attitudes, and opinions associated with COVID-19 in 365 SOT recipients (95% liver, 5% pancreas/kidney), 112 SOT candidates, and 394 immediate household contacts in 2 German transplant centers. Seven (1.5%) patients and 10 (2.5%) controls had contact with confirmed COVID-19 cases. Fear of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was expressed by 65% of SOT recipients and by 55% of SOT candidates. SOT recipients had higher levels of fear of infection and more often wore personal protective gear than household controls. Female sex, steroid treatment, and using the local newspaper as a primary source of information were independently associated with expressed fear of infection in SOT recipients. Younger age and more recent transplantation correlated with concerns about severe COVID-19 expressed by patients and with concerns about worse medical care expressed by household controls. One third of the patients expressed fear that immunosuppression could worsen COVID-19 but only 15% used the transplantation center as a source of information. These data show that fears associated with the SARS-CoV-2 pandemic are frequently expressed but measures to prevent infection are regularly followed by patients before and after SOT.

Liver transplantation for colorectal cancer has regained renewed interest with reported good overall survival in selected patients. The scarcity of grafts is a major obstacle to wider implementation and exploration of this field of transplant oncology. The use of small segmental auxiliary grafts from deceased or living donors might be one way to expand the donor pool with minimal negative impact on the waiting list for deceased donor transplantation and minimal risk for the donor in case of living donor liver transplantation. This review provides an insight into the physiological background for this technique and summarizes technical and surgical considerations and the experiences with this novel concept. Although the international experience still is very limited, the short term outcome could suggest that this is technically feasible. There is not sufficient data to assess long term oncological outcome. The RAPID concept (i.e. resection and partial liver segment 2-3 transplantation with delayed total hepatectomy) is still an experimental surgical procedure and should be reserved for prospective clinical trials. Herein, we describe the main technical issues of RAPID procedure from deceased and from living donor as well and report preliminary results of the first cases performed worldwide.

Liver transplantation has become established as a standard procedure in the treatment of end-stage liver diseases. Despite intense efforts by all parties involved up to the amendment of the German Transplantation Act, the lack of suitable donor organs was still one of the limiting factors of this therapeutic procedure. One way out of this problem is to make so-called marginal organs usable, e.g. with the help of machine perfusion or by utilizing living liver donation, which are used in some countries for more than 90% of organ donations. In general, there is no difference in the indications for liver transplantation between a (partial) organ obtained by post-mortem or living donation. Before any living donation, a thorough evaluation of the donor is carried out in order to minimize postoperative morbidity as far as possible. Technically the partial liver donation is based on the oncological liver resection, while the partial liver transplantation is a further development of split liver transplantation after post-mortem liver donation. In specialized centers comparable or even better results can nowadays be achieved using living liver donation instead of post-mortem donation.

Objectives Acute drug-induced liver failure is a rare indication for liver transplant. There is only one case of flupirtine-induced liver failure requiring transplant in the literature. In February 2018, the European Medicines Agency issued a withdrawal of approval for flupirtine medication in European countries as a result of the risk of acute liver failure. Materials and methods The aim of this study was a German-wide collection of data regarding patients with liver transplant as a result of flupirtine-associated liver failure. Results A total of 9 patients received transplants. All patients were women with a mean age of 43 years. Indication for flupirtine medication was musculoskeletal symptoms and migraine headache. The medication was taken over a period of approximately 3 months. All patients developed progressive acute liver failure, and no patient had previous chronic liver disease or cirrhosis. The mean laboratory Model for End Stage Liver Disease score for the patients was 31 ± 7 at time of transplant. Eight of the 9 patients were listed as "high urgency" for transplant. After transplant, they had an uneventful course with a prolonged mean intensive care unit stay of 13 ± 8.7 days. The whole hospitalization time was 43 ± 21 days. Conclusions This is the largest published series of patients who received liver transplant after a drug-induced acute liver failure from flupirtine medication.

Background It has been shown that local ablative procedures enable downsizing, reduce drop-out from the waiting list and improve prognosis after liver transplantation. It is still unclear whether a response to the local ablative therapy is due to a favorable tumor biology or if a real benefit in tumor stabilization exists, particularly in complete pathological response. Method Data of 163 HCC patients who underwent liver transplantation were extracted from our prospectively maintained registry. We analyzed the tumor load, pre-transplant α-fetoprotein levels, child stage aside the application and success of local ablative therapies as bridging procedures before transplantation. Results 87 patients received multiple and/or combined local therapies. In 20 cases, this resulted in a complete remission of the tumor as observed in the explant histology. The other 76 patients underwent no bridging procedure. The observed 5- and 10-year survival rates for patients with bridging were 67% and 47% and without bridging 56% and 46%, respectively. Tumor-related 10-year survival showed a statistically significant difference between both groups (81% versus 59%). In the multivariate analyses bridging, number of lesions and α-fetoprotein level showed an independent statistically significant influence on tumor-related survival in these patients. Conclusions Successful local ablative therapy before liver transplantation is an independent statistically significant factor in long-term tumor-related survival for patients with HCC in cirrhosis and reduces tumor recurrences.

Eine intraoperative Diagnostik bei offenen gefaschirurgischen Eingriffen sollte die diagnostische Sicherheit wahrend der Operation erhohen und eine Qualitatskontrolle darstellen mit dem Ziel, vermeidbare Komplikationen zu reduzieren. Die Evidenz der verschiedenen diagnostischen Verfahren hinsichtlich besserer postoperativer Ergebnisse ist jedoch sowohl fur die Karotisendarteriektomie als auch die periphere Bypassanlage nicht gesichert. Dennoch ist eine intraoperative Diagnostik prinzipiell angeraten. Bei der chirurgischen Rekonstruktion von Bypassverschlussen sowie akuten thrombembolischen Verschlussen ist der Vorteil belegt und zu fordern.

Background Computed tomography (CT) can be used as the primary screening modality for the evaluation of patients suspected of having acute mesenteric ischemia known to show high sensitivity and specificity rates. Purpose To prove the value of CT in patients with pathological abdominal findings following cardiac surgery. Material and Methods In a retrospective case-control study, 12 different CT scan parameters of patients with or without mesenteric ischemia following cardiac surgery were compared using univariate and logistic regression analyses. Results Of 14,176 patients, 133 (0.9%) received an abdominal CT scan during postoperative care due to pathological abdominal findings. Sixty-eight patients were diagnosed with acute mesenteric ischemia. In-hospital mortality was 73.5% for this group. CT parameters with the highest specificity for indicating colonic ischemia were intestinal (99%) or porto-venous (96%) pneumatosis, abnormal contrast medium enhancement (89%), and occlusion of the proximal inferior mesenteric artery (81%). All of those parameters showed low sensitivity levels in the range of 15%–23%. A statistically significant association between acute mesenteric ischemia and CT appearance was obtained for contrast medium enhancement (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5–99.2) and intestinal pneumatosis (OR 21.0, 95% CI 2.7–165.2) only. Conclusion The typical CT criteria indicating mesenteric ischemia lose their accuracy in patients under critical clinical conditions. As CT remains the first-line diagnostic imaging modality for abnormal abdominal findings following cardiac surgery, negative signs should not prevent early laparotomy if clinical suspicion remains high.

Background Caroli Disease (CD) and Caroli Syndrome (CS) are rare disorders presenting with dilation of the intrahepatic bile ducts. CD/CS are associated with cholangiocarcinoma (CCA). However, the true incidence of CCA is still unclear, although it may serve as an indication for surgery. In this paper, we analyzed (I) the incidence of CCA in German centers, (II) reviewed our single center population together with its clinical presentation and (III) performed a thorough literature review. Methods 17 large HPB-centers across Germany were contacted and their patients after surgical treatment due to CD/CS with histopathology were included. Medline search for all studies published in English or German literature was performed. Patients who underwent surgery at our department between 2012 and 2020 due to CD or CS were analyzed. Results In the multicenter study, 79 patients suffered from CD and 119 patients from CS, with a total number of 198 patients. In 14 patients, CCA was found (Overall: 7,1%; CD: 6,3%, CS 7,6%). Between 2012 and 2020, 1661 liver resections were performed at our department. 14 patients underwent surgery due to CD or CS. Histological examination showed synchronous cholangiocarcinoma in one patient. The literature review revealed a CCA-rate of 7,3% in large series, whereas in case reports a rate of 6,8% was found. Conclusion There is risk of malignant transformation and patients with CD might also benefit from resection due to improvement of symptoms. Therefore, resection is strongly advised. As certain patients with CS require transplantation, treatment should not be guided by the relatively low rate of CCA but by the concomitant diseases that come along with hepatic failure.

Das Alter der Bevolkerung in Deutschland nimmt dem weltweiten Trend folgend stetig zu. Betrachtet man die hinzugewonnenen „krankheitsfreien“ Lebensjahre, so steigen diese jedoch in Deutschland im internationalen Vergleich signifikant geringer. Als Konsequenz daraus erhoht sich die Anzahl der behandlungspflichtigen und operationspflichtigen alteren, aber vor allem gebrechlicheren Patienten relevant. Mit dem Ziel, das perioperative Risiko dieser Patientengruppen besser zu erfassen, wurden bereits zahlreiche Scoring-Systeme veroffentlicht. Klinisch etabliert haben sich diese Systeme zur Risikoabschatzung in der Chirurgie bis zum aktuellen Zeitpunkt nicht. Die Gruppe der gebrechlichen Patienten in der Chirurgie ist somit insgesamt unterdiagnostiziert. Jedoch gerade diese Patienten bedurfen oft einer individualisierten Behandlung oder einer Anpassung der routinemasigen perioperativen Betreuung. Es konnte bereits sicher gezeigt werden, dass gebrechliche Patienten eine deutlich hohere Inzidenz fur bestimmte Risikofaktoren (postoperatives Delir, Hypovolamie, pharmakologische Nebenwirkungen und Medikamenteninteraktionen) aufweisen. Bei bis zu 70 % der Personen dieser Patientengruppe kann bereits bei der stationaren Aufnahme eine Mangelernahrung nachgewiesen werden. Unbemerkt und unbehandelt fuhren diese Risikofaktoren zu hoheren Komplikationsraten, einer eingeschrankten Rehabilitationsfahigkeit, einer verlangerten Liegedauer bis hin zu einer erhohten Mortalitat. Spezielle praoperative Risikoscores, welche sowohl physische und psychische als auch soziale Aspekte beleuchten, sollten flachendeckend in den chirurgischen Kliniken implementiert werden. Eine standardisierte Risikoabschatzung und darauf aufbauende evidenzbasierte Prarehabilitationsprogramme, implementiert an gerontochirurgischen Zentren, konnen so in Zukunft helfen, das Outcome dieser fragilen Patientengruppe zu verbessern.

Anastomotic or stump leakage is a common and serious complication of colorectal surgery. The objective of this study was to retrospectively investigate the clinical use and potential benefit of transanal rinsing treatment (TRT) using an innovative rinsing catheter (RC) after treatment with endoscopic vacuum therapy (EVT). Patients with leakage after low colorectal surgery who had been treated with EVT were retrospectively analyzed. A subset of patients was trained to perform TRT with a specially developed RC. We investigated the rate of complete healing of the leakage, septic complications, failure of the therapy, surgical revisions, ostomy closure rate, and complications related to endoscopic therapy. Between February 2007 and January 2014, 98 patients with local complications after low colorectal surgery, treated with EVT, were identified. Eighty-nine patients were analyzed (the treatment of nine patients was stopped due to medical or technical problems): 31 patients were treated with EVT only (EVT group) and 58 patients with EVT followed by TRT (EVT/TRT group). Complete healing of the leakage was significantly better in the EVT/TRT group [84% vs. 58% (p < 0.009)], and significantly fewer septic complications needing surgical revision were detected [3% vs. 11% (p = 0.001)]. No significant differences regarding endoscopy-related complications and ostomy closure were found between EVT and EVT/TRT patients. The use of patient-administered TRT with an innovative, customized RC after EVT is technically feasible and reliable and significantly improves therapeutic results. Further prospective trials with larger patient groups are needed to validate the results of our study.

Zusammenfassung Hintergrund Die Verwendung videobasierter Analysekonzepte gewinnt in der medizinischen Ausbildung zunehmend an Bedeutung. In erster Linie dienen diese Tools dazu, Informationen über die individuelle Performance eines Kandidaten zu bekommen und Feedback zu geben. Die vorliegende Studie untersucht, ob die Videoanalyse praktischer Fertigkeiten auch für die Weiterentwicklung des chirurgischen Unterrichts genutzt werden kann. Material und Methoden Zunächst wurde die Durchführung einer chirurgischen Nahtübung (Dauer: 3 min) bei Studierenden des 10. Semesters (n = 38) videobasiert dokumentiert. Im Anschluss folgte die Analyse des Videomaterials anhand von 10 spezifischen Kriterien. Die Analyse diente dann als Grundlage für die Entwicklung fehlerpräventiver Übungen. Nachfolgend wurden die Effekte der fehlerpräventiven Übungen auf die Ergebnisqualität der Nahtübung im Rahmen eines Pilotversuchs in einem 2-Gruppen-Vergleich untersucht. Ergebnisse Die Videosequenzen wurden von 2 Experten unabhängig voneinander begutachtet. Es konnten typische Fehler bei der Handhabung des chirurgischen Instrumentariums, der Handhabung des Nahtmaterials sowie im Bewegungsablauf beobachtet werden. Die daraufhin entwickelten zusätzlichen Übungseinheiten fokussierten sich auf die identifizierten Fehlerbereiche (z. B. Handhabung des Nadelhalters und des Nahtmaterials). Die Ergebnisse des 2-Gruppen-Vergleichs (vor und nach Integration der fehlerpräventiven Übungen in das Kurskonzept) zeigten, dass das Absolvieren der zusätzlichen Übungseinheiten einen mittelstarken Effekt auf die Ergebnisqualität einer Nahtübung hatte (Cohens d = 0,73). Schlussfolgerung Die Videoanalyse praktischer Fertigkeiten scheint eine geeignete Basis für die Weiterentwicklung des chirurgischen Unterrichts darzustellen. Typische Fehler können in Bezug auf Art und Häufigkeit identifiziert werden und es lassen sich fehlerpräventive Übungen entwickeln, die einen positiven Effekt auf die Ergebnisqualität einer praktischen Aufgabe haben.

This review highlights the current state regarding the preparation and characterization of tubular biocellulose materials as well as their application and application potential with a special focus on abdominal oncologic surgery. Biocellulose is a natural polymer synthesized by acetic acid bacteria from low molecular sugars and alcohols as a mechanically stable nanofiber network at the interface between the aqueous culture medium and air. This hydrogel is characterized by very high purity and biocompatibility, dimensional stability, and good surgical handling. With this property profile, biocellulose proves to be a promising candidate for the development of novel medical soft tissue implants. This requires close R&D cooperation between chemists, material scientists, biotechnologists, and surgeons. In this sense, this review spans from the natural polymer to the design of biocellulose implants and surgical suitability. It is also a concern of this article to show concretely the great need for such implants and the fields of application in oncological abdominal surgery where tubular biocellulose is or could be the focus of research. Furthermore, a critical assessment for the use of biocellulose materials concerning incidence malignancy and surgical interventions, complication rates, and current studies is emphasized. The regeneration of damaged bile ducts by the use of biocellulose implants is a first example.

Background Tumor recurrence is the leading cause of death after liver transplantation in patients with hepatocellular carcinoma. There is an ongoing debate as to whether metabolic indices such as tumor to liver standardized uptake value ratio in 18F-fluorodeoxyglucose positron emission tomography/computed tomography of the primary tumor can identify patients outside the Milan criteria with as low recurrence rates as patients inside Milan and thus should be added to the established prognostic factors. Methods This retrospective study analyzes 103 consecutive patients who underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomography before liver transplantation for hepatocellular carcinoma using data of clinical tumor registry. Primary endpoints were overall survival and 10-year cumulative recurrence rates. Results Tumor to liver standardized uptake value ratio of the primary tumor was statistically significant higher in Milan out tumors, “up-to-seven” out tumors, grade 3 tumors, α- fetoprotein level >400 ng/ml and lesions > 5cm in diameter. Factors with statistically significant influence on the 10- year overall survival in the univariate analysis were Milan, up-to-seven” criteria, number of lesions and pT-category. COX regression analysis did not show independently statistically significant factors for 10-year overall survival. Milan, “up-to-seven” criteria, grade, pV, number of lesions, size of lesion, pT-category, tumor to liver standardized uptake value ratio influenced 10-year cumulative recurrence rates statistically significant. Tumor to liver standardized uptake value ratio, grade and pT-category proved to be independently statistically significant factors for 10-year cumulative recurrence rates. Conclusions Our study suggests that tumor to liver standardized uptake value standardized uptake value ratio in 18F-fluorodeoxyglucose positron emission tomography/computed tomography is an independent prognostic factor in transplanted patients with hepatocellular carcinoma. If we focus on preoperative findings, such as tumor size, tumor number and AFP value adding the information given by TLR of 18F-FDG PET/CT allows to estimate the risk of tumor recurrence more accurate than the established classifications Milan and UTS. Therefore, it may add valuable information to other preoperative findings, such as tumor size, tumor number and AFP level.

Guidelines recommend vaccination against SARS-CoV-2 in transplant recipients, candidates, and their household contacts. However, little is known about the acceptance of COVID-19 vaccines in these groups.In March 2021, we surveyed 826 liver transplant recipients, candidates, and their household contacts to determine acceptance rates and factors influencing the acceptance of the COVID-19 vaccine; 341 patients (40%) and 237 household contacts (28%) returned the questionnaire. Ninety percent of patients returning the survey reported they were willing to receive the vaccine within the next 6 months or had already started vaccination. Only 2% of patients and 4% of household contacts reported refusing the vaccine, and 8% of patients and 9% of household contacts wanted to postpone vaccination because of concerns about side effects. Having received the influenza vaccine in the last 2 seasons was the strongest indicator of acceptance to receive the SARS-CoV-2 vaccine within 6 months (odds ratio 5.11; 95% confidence interval 2.43-10.74; p0.001). Thirty-two percent of responding patients reported fear of side effects as a reason for having refused vaccination before.Although the acceptance of the SARS-CoV-2 vaccine was particularly high among German liver transplant recipients, candidates, and household contacts in this survey, transplant physicians are encouraged to discuss safety concerns with patients who have refused the seasonal influenza vaccine in the past.Aktuelle Leitlinien empfehlen die Impfung gegen SARS-CoV-2 bei Patienten nach einer Organtransplantation, Patienten auf Wartelisten und bei Haushaltskontakten. Allerdings ist bislang wenig über die Akzeptanz dieser Impfung bei den Betroffenen bekannt.Wir haben daher im März 2021 in zwei deutschen Transplantationszentren an 826 Patienten nach Lebertransplantation, auf der Warteliste für eine Lebertransplantation und ihre Angehörige einen Fragebogen versandt, um die Akzeptanz der Impfung und Faktoren, die diese beeinflussen, zu erfragen. Es wurden 341 Fragebögen von Patienten (40%) und 237 von Angehörigen (28%) beantwortet. 90% der Patienten, die den Fragebogen beantwortet haben, gaben an, dass sie sich gegen SARS-CoV-2 innerhalb von 6 Monaten impfen lassen möchten oder bereits geimpft sind. Lediglich 2% der Patienten und 4% der Angehörigen gaben an, keine Impfung zu wollen, weitere 8 bzw. 9% wollen die Impfung aus Angst vor Nebenwirkungen verschieben. Der stärkste prädiktive Faktor für die Bereitschaft zur SARS-CoV-2 Impfung war eine durchgeführte Influenza-Impfung innerhalb der letzten 2 Jahre (OR 5,11, 95% Konfidenzintervall 2,43–10,74; p0,001). Der Hauptgrund für die Ablehnung einer Influenza-Impfung war bei 32% der Patienten ohne Impfung die Angst vor Nebenwirkungen.Auch wenn die Akzeptanz der SARS-CoV-2-Impfung unter den Befragten sehr hoch war, so sollten durch die Ärzte in den Transplantationszentren die Ängste vor Nebenwirkungen aktiv angesprochen und diskutiert werden, insbesondere bei Patienten, die bislang auch eine Influenza-Impfung abgelehnt haben.

Introduction In the literature, results after surgical treatment of non-colorectal non-neuroendocrine liver metastases (NCNNLM) are reported that are often inferior to those from colorectal liver metastases. The selection of patients with favorable tumor biology is currently still a matter of discussion. Materials/methods The retrospective data analysis was based on data that were collected for the multicenter study “Role of surgical treatment for non-colorectal liver metastases” in county Thuringia. Results For the study, 637 patients were included from 1995 to 2018. 5 and 10-year survival of R0 resected patients were 33% and 19%, respectively. In the multi-variate analysis of the entire group, sex, timing, disease-free interval, number of metastases, R-classification as well as lymph node status of the primary lesion showed an independent statistical influence on the 5-year survival. In the group of R0 resected patients, disease-free interval, number of metastases and lymph node status of the primary lesion influenced the 5-year survival in the multi-variate analysis. In kidney malignancies, R-classification, timing and number of liver metastases were statistically significant in the multi-variate analysis of the 5-year survival, in mamma carcinomas only the R-classification. Conclusion The Adam score identifies some risk factors which influence prognosis in most but not in all tumor entities. For kidney cancer and breast cancer it can be simplified.

Benign liver tumors are often detected during routine ultrasound examinations or as an incidental finding in radiological imaging. Only very few benign liver tumors are at risk of becoming malignant. In the majority of cases the differentiation from malignant tumors is currently carried out using imaging procedures. In a few cases of diagnostic uncertainty, a transcutaneous liver biopsy can lead to clarification. If the suspicion of malignancy is substantiated or this cannot be excluded with absolute certainty, the tumor should be removed by partial liver resection.

BACKGROUND The DIAMOND study of de novo liver transplant patients showed that prolonged-release tacrolimus exposure in the acute post-transplant period maintained renal function over 24 weeks of treatment. To assess these findings further, we performed a post-hoc analysis in patients according to baseline kidney function, Model for End-stage Liver Disease [MELD] scores, and donor age. MATERIAL AND METHODS Patients received prolonged-release tacrolimus (initial-dose, Arm 1: 0.2 mg/kg/day, Arm 2: 0.15-0.175 mg/kg/day, Arm 3: 0.2 mg/kg/day delayed until Day 5), mycophenolate mofetil and 1 steroid bolus. Arms 2 and 3 also received basiliximab. The recommended tacrolimus target trough levels to Day 42 post-transplantation were 5-15 ng/mL in all arms. In this post-hoc analysis, change in renal outcome, based on estimated glomerular filtration rate (eGFR), Modified Diet in Renal Disease-4 (MDRD4), values from baseline to Week 24 -post-transplantation, were assessed according to baseline patient factors: eGFR (≥60 and ˂60 mL/min/1.73 m²), MELD score (˂25 and ≥25) and donor age (˂50 and ≥50 years). RESULTS Baseline characteristics were comparable (Arms 1-3: n=283, n=287, n=274, respectively). Patients with baseline renal function, eGFR ≥60 mL/min/1.73 m², experienced a decrease in eGFR in all tacrolimus treatment arms. In patients with lower baseline renal function (eGFR ˂60 mL/min/1.73 m²), an advantage for renal function was observed with both the early lower-dose and delayed higher-dose tacrolimus regimens compared with the early introduction of higher-dose tacrolimus. At Week 24, renal function was higher in the early-lower tacrolimus arm with older donors, and the delayed higher-dose tacrolimus arm with younger donors, both compared with early higher-dose tacrolimus. CONCLUSIONS Pre-transplantation factors, such as renal function and donor age, could guide the choice of prolonged-release tacrolimus regimen following liver transplantation.

Die Anpassung an die geanderte Altersstruktur der Gesellschaft wird fur die Chirurgie eine der wesentlichen Herausforderungen der kommenden Jahre werden. Entscheidend fur das Outcome ist neben der praoperativen Konditionierung und den spezifischen, altersangepassten chirurgischen Strategien die generelle Gestaltung infrastruktureller Gegebenheiten. Hierzu gehoren spezielle Ernahrungs- und Trinkplane ebenso wie das kognitive Assessment und Strategien zur Verhinderung des postoperativen Delirs. Der mit dem Alter veranderte Metabolismus und die mit dem Alter einhergehenden Komorbiditaten sind in den meisten Fachdisziplinen sehr ahnlich. Die fehlende Definition von biologischem Alter, aber auch fehlende Anpassungen von z. B. Komplikationsscores machen eine exakte Bestandsaufnahme aktuell schwer. Bei fehlender Vergutung sind zudem strukturelle Anderungen in der Behandlung nur schwer herbeizufuhren. Damit bleibt das Ziel, systematische Strategien fur die notwendigen chirurgischen Therapien alterer Patienten zu gestalten, eine anspruchsvolle Aufgabe.

Background Colorectal cancer is the third most common malignancy worldwide. The occurrence of liver metastases worsens the prognosis of the patient significantly if the tumor burden is not resectable. Liver transplantation might be an option for otherwise irresectable colorectal liver metastases. In this study, we evaluate the role of two-stage hepatectomy in combination with a left-lateral living donor liver transplantation. Methods Patients with irresectable liver metastases having a stable disease or tumor regression after at least 8 weeks of systemic chemotherapy without an extrahepatic tumor burden (except resectable lung metastases) are suitable for study inclusion. A randomization is not planned since the control arm (systemic chemotherapy) is well established and the superiority of the transplantation procedure has to be expected. The surgical treatment consists of two steps: in a first operation, a left hemihepatectomy in the recipient will be performed. At this place, the left lateral liver lobe (segments II and III) of a living donor will be transplanted. To induce a growth of the graft, a portal vein ligation will be performed. Approximately after 2 weeks, the removal of the right hemiliver will be conducted if the control imaging shows a sufficient growth of the graft. Results The patient recruitment is ongoing. In total, three patients have been already transplanted with this protocol. Up to now, they are tumor-free and in good clinical health. Discussion With the design of the LIVER-T(W)O-HEAL study, it might be possible to offer patients with otherwise irresectable colorectal liver metastases a curative treatment option. The key point of this study will be, most probably, the patient’s selection. Trial registration Registered at Clinical Trials; NCT03488953; registered on April 5, 2018 Electronic supplementary material The online version of this article (10.1186/s12957-018-1549-5) contains supplementary material, which is available to authorized users.

Purpose Abscess or fistula of the anal region is an uncommon presentation of malignancy. Under the assumption of a benign condition, diagnostics is often delayed, resulting in advanced tumour stages at first diagnosis. Due to the case rarity, treatment guidelines for cancers of anorectal region masquerading as abscess or fistula are missing. Methods We analysed all patients presenting with an abscess or fistula of the anal region in our department between January 2004 and August 2020. The malignancies were included to our study to acquire data on clinical presentation, treatment and outcome. Furthermore, a systematic review to present adenocarcinomas and squamous cell carcinomas associated to an abscess or fistula was performed. Results 0.5% of the patients treated for an abscess or fistula of the anal region met the selection criteria. Mean time from the onset of symptoms to diagnosis of malignancy was 100 days. Histology revealed adenocarcinoma and squamous cell carcinoma each in two patients. All patients had locally advanced tumours without distant metastases, in two cases with regional lymph-node metastases. Neoadjuvant chemoradiation was applied in two patients. All patients underwent abdomino-perineal resection of the rectum. The overall outcome reveals a recurrence-free survival of 4.5 and 3 years for two patients. Further two patients died within 5 months after the primary resection. Conclusion Advanced carcinomas of the anorectal region may masquerade as abscess or fistula, cause diagnostic problems and delay oncologic treatment. However, even in these very advanced situations, surgical therapy with curative intent should be attempted.

Purpose FDG PET/CT has been described for noninvasive grading, detection of extrahepatic spread, and recurrence in hepatocellular carcinoma (HCC). As compared with localized imaging approaches (MRI, ultrasonography), FDG PET/CT not only focuses on the liver, but covers a long field of view from the base of the skull to the thighs, visualizing pathologic findings not related to HCC. The aims of this retrospective study were to (1) describe the frequency of relevant incidental findings on FDG PET/CT in HCC patients, (2) evaluate the impact on treatment strategy in HCC patients considered for liver transplantation, and (3) to discuss the role of FDG PET/CT in patients considered for transplantation in general. Methods Four hundred thirty-nine FDG PET/CT examinations of 345 HCC patients were screened for incidental findings. The clinical information system was searched for examinations performed after FDG PET/CT and aimed at verification of incidental findings. Of 345 HCC patients, 81 patients were considered for liver transplantation. The impact of incidental findings was recorded separately for this subgroup. Results One hundred one patients with incidental findings in 439 FDG PET/CT examinations were identified. The incidental findings comprised 22 neoplasms (9 malignant) and 52 inflammations. Liver transplantation was not performed because of an incidental finding on FDG PET/CT in 9 (11.1%) of 81 patients. Conclusions FDG PET/CT is capable of identifying relevant incidental findings (ie, secondary malignancy, benign tumors, and inflammation) in HCC patients and HCC patients considered for liver transplantation and thus influencing HCC patient management. FDG PET/CT might also be beneficial in patients considered for transplantation of different organs.

Purpose Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy. Methods In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses. Results Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown. Conclusion This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.La incidencia de complicaciones linfáticas tras el trasplante renal (post-kidney-transplantation lymphatic, PKTL) varía considerablemente en la literatura. Esto se debe en parte a que no se ha establecido una definición universalmente aceptada. Este estudio tuvo como objetivo proponer una definición aceptable para las complicaciones PKTL y un sistema de clasificación de la gravedad basado en la estrategia de tratamiento. MÉTODOS: Se realizó una búsqueda sistemática de la literatura relevante en MEDLINE y Web of Science. Se logró un consenso para la definición y la clasificación de gravedad de las PKTL entre veinte centros de trasplante de alto volumen.En 32 de los 87 estudios incluidos se definía la linforrea/linfocele. Sesenta y tres artículos describían como se trataban las PKTL, pero ninguno calificó la gravedad de las mismas. La definición propuesta para la linforrea fue la de un débito diario superior a 50 ml de líquido (no orina, sangre o pus) a través del drenaje o del orificio cutáneo tras su retirada, más allá del 7º día postoperatorio del trasplante renal. La definición propuesta para linfocele fue la de una colección de líquido de tamaño variable adyacente al riñón trasplantado, tras haber descartado un urinoma, hematoma o absceso. Las PKTL de grado A fueron aquellas con escaso impacto o que no requirieron tratamiento invasivo; las PKTL de grado B fueron aquellas que precisaron intervención no quirúrgica y las PKTL de grado C aquellas en que fue necesaria la reintervención quirúrgica. CONCLUSIÓN: Se propone una definición clara y una clasificación de gravedad basada en la estrategia de tratamiento de las PKTLs. La definición propuesta y el sistema de calificación en 3 grados son razonables, sencillos y fáciles de comprender, y servirán para estandarizar los resultados de las PKTL y facilitar las comparaciones entre los diferentes estudios.

Purpose According to the Barcelona Clinic Liver Cancer (BCLC) staging classification, transarterial chemoembolization (TACE) is the treatment of choice for intermediate hepatocellular carcinoma (HCC). Thereby, the use of drug-eluting beads (DEB) as embolic agents has been recently established in clinical practice. The aim of this study was to evaluate tumor response after DEB-TACE. Methods This retrospective study was approved by the institutional ethics committee. Overall, 89 patients with HCC (Child Pugh A or B) receiving DEB-TACE as palliative treatment option or as bridging before liver transplantation were included in the study. Tumor response was assessed by modified response evaluation criteria in solid tumors (mRECIST) and a tumor growth rate. Survival analysis was performed using Kaplan-Meier estimator with log-rank testing and Cox proportional hazards. Results A total of 188 TACE procedures were performed between 2006 and 2010. After the last intervention, 18% achieved complete response, 45% achieved partial response, 28% had stable disease and 9% had progressive disease. Using the tumor growth rate, 90% of all patients showed a tumor reduction between first and final response evaluation. The 6-month, 1-, 2- and 3-year overall survival rates were 86.5%, 67.4%, 47.2%, and 33.7%, with a median survival of 45, 24, 15, and 14 months for complete response, partial response, stable disease, and progressive disease, respectively. Tumor reduction showed a positive effect on survival. Conclusion DEB-TACE offers conclusive response results with mRECIST and proves a strong tendency of tumor reduction on survival benefits. Therefore, tumor growth rate represents a possible parameter to predict survival.

Background Tumour recurrence is common after resection of intrahepatic cholangiocarcinoma (ICC). Repeated resection is a potential curative treatment, but outcomes are not well-defined thus far. The aim of this retrospective multicentre cohort study was to show the feasibility and survival of repeated resection of ICC recurrence. Methods Data were collected from 18 German hepato-pancreatico-biliary centres for patients who underwent repeated exploration of recurrent ICC between January 2008 and December 2017. Primary end points were overall (OS) and recurrence-free survival from the day of primary and repeated resection. Results Of 156 patients who underwent repeated exploration for recurrent ICC, 113 underwent re-resection. CA19-9 prior to primary resection, R status of first liver resection, and median time to recurrence were significant determinants of repeated resectability. Median OS in the repeated resection group was 65.2 months, with consecutive 1-, 3-, and 5-year OS of 98%, 78%, and 57%, respectively. After re-exploration, median OS from primary resection was 46.7 months, with a consecutive 1-, 3-, and 5-year OS of 95%, 55%, and 22%, respectively. From the day of repeated resection, the median OS was 36.8 months, with a consecutive 1-, 3-, and 5-year OS of 86%, 51%, and 34%, respectively. Minor morbidity (grade I+II) was present in 27%, grade IIIa-IVb morbidity in 20%, and mortality in 3.5% of patients. Conclusion Repeated resection of ICC has acceptable morbidity and mortality and seems to be associated with improved long-term survival. Structured follow-up after resection of ICC is necessary for early identification of these patients.

Background Cabozantinib was approved by the European Medicines Agency and the Federal Drug Administration as an option for sorafenib-resistant advanced hepatocellular carcinoma, increasing overall survival and progression-free survival compared with placebo. We evaluated the cost-effectiveness of cabozantinib in the second-line setting for patients with an advanced hepatocellular carcinoma from the German statutory health insurance perspective compared with an US scenario using US prices. Methods A Markov model was developed to compare the costs and effectiveness of cabozantinib with best supportive care in the second-line treatment of advanced hepatocellular carcinoma over a lifetime horizon. Health outcomes were measured in discounted life years and discounted quality-adjusted life years. Survival probabilities were estimated using parametric survival distributions based on CELESTIAL trial data. Utilities were derived from the literature. Costs contained drugs, monitoring and adverse events measured in US Dollars. Model robustness was addressed in univariable, scenario and probabilistic sensitivity analyses. Results Cabozantinib generated a gain of 0.18 life years (0.15 quality-adjusted life years) compared with best supportive care. The total mean cost per patient was $56,621 for cabozantinib and $2064 for best supportive care in the German model resulting in incremental cost-effectiveness ratios for cabozantinib of $306,778/life year and $375,470/quality-adjusted life year. Using US prices generated costs of $177,496 for cabozantinib and $4630 for best supportive care and incremental cost-effectiveness ratios of $972,049/life year and $1,189,706/quality-adjusted life year. Conclusions Our analysis established that assuming a willingness-to-pay threshold of $163,371/life year (quality-adjusted life year) for the German model and $188,559/life year (quality-adjusted life year) for the US model, cabozantinib is not cost-effective compared with best supportive care. Sensitivity analyses showed that cabozantinib was not cost-effective in almost all our scenarios.

Annals of surgical oncology (2020). doi:10.1245/s10434-019-08192-z, Published by Springer, Berlin [u.a.]

OBJECTIVE: The aim of this study was to evaluate the survival benefit of sirolimus in patients undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC) (exploratory analysis of the SiLVER-trial). SUMMARY AND BACKGROUND DATA: Patients receiving LT) for HCC are at a high risk for tumor recurrence. Calcineurin inhibitors have shown evidence to promote cancer growth, whereas mammalian target of rapamycin (mTOR) inhibitors like sirolimus have anticancer effects. In the SiLVER-trial (Clinicaltrials.gov: NCT00355862), the effect of sirolimus on the recurrence of HCC after LT was investigated in a prospective randomized trial. Although the primary endpoint of improved disease-free survival (DFS) with sirolimus was not met, outcomes were improved for patients in the sirolimus-treatment arm in the first 3 to 5 years. To learn more about the key variables, a multivariate analysis was performed on the SiLVER-trial data. PATIENTS AND METHODS: Data from 508 patients of the intention-to-treat analysis were included in exploratory univariate and multivariate models for overall survival (OS), DFS and a competing risk analysis for HCC recurrence. RESULTS: Sirolimus use for ≥3 months after LT for HCC independently reduced the hazard for death in the multivariate analysis [hazard ratio (HR): 0.7 (95% confidence interval, CI: 0.52-0.96, P = 0.02). Most strikingly, patients with an alpha-fetoprotein (AFP) ≥10 ng/mL and having used sirolimus for ≥3 months, benefited most with regard to OS, DFS, and HCC-recurrence (HR: 0.49-0.59, P = 0.0079-0.0245). CONCLUSIONS: mTOR-inhibitor treatment with sirolimus for ≥3 months improves outcomes in LT for HCC, especially in patients with AFP-evidence of higher tumor activity, advocating particularly for mTOR inhibitor use in this subgroup of patients. CLINICAL TRIAL REGISTRATION: EudraCT: 2005-005362-36 CLINICALTRIALS.GOV:: NCT00355862. ispartof: ANNALS OF SURGERY vol:272 issue:5 pages:855-862 ispartof: location:United States status: published

Die chirurgische Zytoreduktion (CRS) mit hyperthermer intraperitonealer Chemotherapie (HIPEC) kann bei geeigneten Patienten mit peritonealen Metastasen kolorektaler Karzinome das Gesamtuberleben im Vergleich zu reiner systemischer Chemotherapie signifikant verlangern. Entscheidend fur ein gutes onkologisches Ergebnis ist einerseits die makroskopisch komplette Zytoreduktion, andererseits aber auch eine moglichst fruhe chirurgische Therapie, da eine lineare Korrelation zwischen der peritonealen Tumorlast und dem Gesamtuberleben besteht. Eine synchrone Resektion von Lebermetastasen ist mit guten Ergebnissen moglich und hat keinen Einfluss auf die Morbiditat. Fur die intraperitoneale Chemotherapie sind die Substanzen Mitomycin C und Oxaliplatin derzeit als gleichwertig zu betrachten. Diskrepante Ergebnisse liegen zur perioperativen systemischen Chemotherapie vor, da einzelne Studien ein schlechteres Gesamtuberleben nach neoadjuvanter Therapie zeigten. Im Hinblick auf die adjuvante Therapie gibt es Hinweise auf einen Uberlebensvorteil, sofern mindestens 6 Zyklen verabreicht werden. Die derzeit noch schwierige Fruherkennung peritonealer Metastasen wird moglicherweise zukunftig durch den Einsatz von „liquid biopsies“ mit Nachweis freier Tumor-DNA oder -RNA sicherer und einfacher, bis dahin kommt fur Risikopatienten eine geplante Second-look-Laparotomie infrage. Erganzend hierzu wird in mehreren Studien derzeit der Stellenwert einer adjuvanten oder prophylaktischen HIPEC gepruft. Im Falle eines Rezidivs nach HIPEC sollte ein erneutes chirurgisches Vorgehen erwogen werden, wobei zur Indikationsstellung dieselben Kriterien anzuwenden sind wie fur den Primareingriff. Ein rezidivfreies Intervall >2 Jahre ist prognostisch gunstig.

The investigation of the predictors of outcome after hepatic resection for solitary colorectal liver metastasis. We recruited 350 patients with solitary colorectal liver metastasis at the University Hospitals of Jena and Magdeburg, who underwent curative liver resection between 1993 and 2014. All patients had follow-up until death or till summer 2016. The follow-up data concern 96.6% of observed patients. The 5- and 10-year overall survival rates were 47 and 28%, respectively. The 5- and 10-year disease-free survival rates were 30 and 20%, respectively. The analysis of the prognostic factors revealed that the pT category of primary tumour, size and grade of the metastasis and extension of the liver resection had no statistically significant impact on survival and recurrence rates. In multivariate analysis, age, status of lymph node metastasis at the primary tumour, location of primary tumour, time of appearance of the metastasis, the use of preoperative chemotherapy and the presence of extrahepatic tumour proved to be independent statistically significant predictors for the prognosis. Moreover, patients with rectal cancer had a lower intrahepatic recurrence rate, but a higher extrahepatic recurrence rate. The long-term follow-up of patients with R0-resected liver metastasis is multifactorially influenced. Age and comorbidity have a role only in the overall survival. More than three lymph node metastasis reduced both the overall and disease-free survival. Extrahepatic tumour had a negative influence on the extrahepatic recurrence and on the overall survival. Neither overall survival nor recurrence rates was improved using neoadjuvant chemotherapy.

Fruhkarzinome des Gallengangsystems sind auch heute noch schwer zu diagnostizieren. Bei Verdacht sollte daher eine Stufendiagnostik mit Computertomographie (CT), Magnetresonanztomographie (MRT) mit Magnetresonanzcholangiographie (MRC) und ggf. eine endoskopisch retrograde Cholangiopankreatikographie (ERCP) mit Burstenzytologie erfolgen. Besteht ein hinreichender Verdacht auf das Vorliegen einer Prakanzerose oder eines Fruhkarzinoms ergibt sich die Indikation zur radikalen Operation, da nur so die Rezidivrate gesenkt und das Langzeituberleben verbessert werden konnen. Beim Vorliegen der funktionellen Nichtresektabilitat kann auch bei Fruhkarzinomen die Indikation zur Lebertransplantation bedacht werden.

Zusammenfassung Hintergrund Das Magenkarzinom zählt zu den häufigsten Tumorerkrankungen weltweit. Trotz zahlreicher Innovationen in der Diagnostik und Therapie ist die Prognose weiterhin schlecht, da die Detektion der Erkrankung auf tumorassoziierte Symptome angewiesen ist, welche in der Mehrzahl der Fälle spät auftreten. Eine weitere Verbesserung der Behandlungsergebnisse kann durch eine differenziertere und individuellere Bewertung der Tumorbiologie erzielt werden. Wir stellen hierzu eine umfangreiche Analyse potenziell prognostisch bedeutsamer Faktoren vor. Material und Methoden In einer prospektiv fortgeführten Tumordatenbank wurden von 1995 bis 2011 Daten von 923 Patienten mit Magenkarzinom zusammengetragen. Es erfolgte eine monovariate und multivariate Faktorenanalyse. Für die statistische Analyse wurde das Programm SPSS Version 19.0 verwendet. Die Literaturrecherche erfolgte mithilfe von Medline. Ergebnisse 748 Patienten wurden chirurgisch exploriert. Die Resektionsrate betrug 87 % mit einer Morbidität und Letalität von 27 und 9 % (2004 bis 2011: 13 und 5 %). 36 und 29 % der Patienten zeigten ein 5-Jahres- bzw. 10-Jahres-Überleben. Das 5- und 10-Jahres-Gesamtüberleben nach kurativer Resektion betrug 58 und 46 %. Die TNM-assoziierten Kriterien, die Tumorgröße, das histologische Wuchsmuster, die intestinale Metaplasie, die Tumorlage und die Lauren-Klassifikation hatten in der monovariaten Analyse einen statistisch signifikanten Einfluss. Multivariat erwiesen sich die kurative Resektion, der Lymphknotenstatus und die Tumorgröße als unabhängige Prognosefaktoren. 90 % der 238 Tumorrezidive traten innerhalb der ersten 5 Jahre auf. Das mediane rezidivfreie Intervall betrug 16 Monate. Je nach Rezidivart waren unterschiedliche Überlebenszeiten festzustellen. Für die 228 Patienten mit nodal negativem, kurativ reseziertem Magenkarzinom zeigte sich eine deutlich bessere Langzeitprognose. Monovariat analysierte Prognosefaktoren waren der diffuse Typ nach Lauren, die Tumorgröße, das nicht tubuläre histologische Wuchsmuster, das weibliche Geschlecht und der Nachweis einer Serosainfiltration durch den Primärtumor. In der multivariaten Analyse erwies sich die Tumorgröße als unabhängiger signifikanter Prognosefaktor (p = 0,05). Schlussfolgerung Die Auswertung der Daten zeigt, dass die Bewertung des Magenkarzinoms durch weitere, bislang nicht etablierte Faktoren sinnvoll erweitert werden kann. Der Benefit einer individuell strukturierten Therapie und Nachsorge auf der Basis erweiterter Kriterien sollte in zukünftigen Studien geprüft werden.

Die perioperative Morbiditat bei Lebendspenden einer Teilleber entsteht hauptsachlich durch Infektionen und biliare Komplikationen. Varianten der Gallengangsanatomie, insbesondere des rechten Systems, werden hier als Ursache mitvermutet. Wir untersuchten bei Spenden des rechten Leberlappens, welchen Einfluss die Varianten der Gallengangsanatomie auf die Inzidenz von biliaren Spenderkomplikationen haben. Dazu wurden 103 Spenden analysiert. Bei 12 Patienten bestanden therapiebedurftige Gallelecks, die alle endoskopisch folgenlos zur Ausheilung gebracht wurden. Eine zentrale, extrahepatische Gallengangslasion Nagano Typ C sahen wir nicht. Die anatomische Variante Huang A3 ist die operationstechnisch anspruchsvolle anatomische Variante. Bei 3/17 Patienten mit einer biliaren Anatomie Huang A3 traten Leckagen auf. Die Gallengangsanatomie kann durch Magnetresonanz-Cholangiopankreatikographie und intraoperative Cholangiographie sorgfaltig evaluiert werden. Der anatomischen Variante Huang A3 sollte besondere Aufmerksamkeit beim Verschluss der Gallengangsostien gewidmet werden.