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Background: This study aimed to assess a potential organ protective effect of volatile sedation in a scenario of severe inflammation with an early cytokine storm (in particular IL-6 elevation) in patients suffering from COVID-19-related lung injury with invasive mechanical ventilation and sedation. Methods: This is a small-scale pilot multicenter randomized controlled trial from four tertiary hospitals in Switzerland, conducted between April 2020 and May 2021. 60 patients requiring mechanical ventilation due to severe COVID-19-related lung injury were included and randomized to 48-hour sedation with sevoflurane vs. continuous intravenous sedation (= control) within 24 h after intubation. The primary composite outcome was determined as mortality or persistent organ dysfunction (POD), defined as the need for mechanical ventilation, vasopressors, or renal replacement therapy at day 28. Secondary outcomes were the length of ICU and hospital stay, adverse events, routine laboratory parameters (creatinine, urea), and plasma inflammatory mediators. Results: 28 patients were randomized to sevoflurane, 32 to the control arm. The intention-to-treat analysis revealed no difference in the primary endpoint with 11 (39%) sevoflurane and 13 (41%) control patients (p = 0.916) reaching the primary outcome. Five patients died within 28 days in each group (16% vs. 18%, p = 0.817). Of the 28-day survivors, 6 (26%) and 8 (30%) presented with POD (p = 0.781). There was a significant difference regarding the need for vasopressors (1 (4%) patient in the sevoflurane arm, 7 (26%) in the control one (p = 0.028)). Length of ICU stay, hospital stay, and registered adverse events within 28 days were comparable, except for acute kidney injury (AKI), with 11 (39%) sevoflurane vs. 2 (6%) control patients (p = 0.001). The blood levels of IL-6 in the first few days after the onset of the lung injury were less distinctly elevated than expected. Conclusions: No evident benefits were observed with short sevoflurane sedation on mortality and POD. Unexpectedly low blood levels of IL-6 might indicate a moderate injury with therefore limited improvement options of sevoflurane. Acute renal issues suggest caution in using sevoflurane for sedation in COVID-19. Trial registration: The trial was registered on ClinicalTrials.gov (NCT04355962) on 2020/04/21. [ABSTRACT FROM AUTHOR]

Background: Regenerative liver surgery expands the limitations of technical resectability by increasing the future liver remnant (FLR) volume before extended resections in order to avoid posthepatectomy liver failure (PHLF). Portal vein rerouting with ligation of one branch of the portal vein bifurcation (PVL) or embolization (PVE) leads to a moderate liver volume increase over several weeks with a clinical dropout rate of 20–40%, mostly due to tumor progression during the waiting period. Accelerated liver regeneration by the Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS) was poised to overcome this limitation by reduction of the waiting time, but failed due increased perioperative complications. Simultaneous portal and hepatic vein embolization (PVE/HVE) is a novel minimal invasive way to induce rapid liver growth without the need of two surgeries. Purpose: This article summarizes published results of PVE/HVE and analyzes what is known about its efficacy to achieve resection, safety, and the volume changes induced. Conclusions: PVE/HVE holds promise to induce accelerated liver regeneration in a similar safety profile to PVE. The demonstrated accelerated hypertrophy may increase resectability. Randomized trials will have to compare PVE/HVE and PVE to determine if PVE/HVE is superior to PVE. [ABSTRACT FROM AUTHOR]

Colorectal liver metastases (CRLM) affect over 50 % of all patients with colorectal cancer, which is the second leading cause of cancer in the western world. Resection of CRLM may provide cure and improves survival over chemotherapy alone. However, resectability of CLRM has to be decided in multidisciplinary tumor boards and is based on oncological factors, technical factors and patient factors. The advances of chemotherapy lead to the abolition of contraindications to resection in favor of technical resectability, but somatic mutations and molecular subtyping may improve selection of patients for resection in the future. Technical factors center around anatomy of the lesions, volume of the remnant liver and quality of the liver parenchymal. Multiple strategies have been developed to overcome volume limitations and they are reviewed here. The least investigated topic is how to select the right patients among an elderly and frail patient population for the large variety of technical options specifically for bi-lobar CRLM to keep 90-day mortality as low as possible. The review is an overview over the current state-of-the art and a systematic guide to the topic of resectability of CRLM for both clinicians and patients. [ABSTRACT FROM AUTHOR]

ALPPS is a two-stage hepatectomy that induces more rapid liver growth compared to conventional strategies. This report aims to establish a risk-score to avoid adverse outcomes of ALPPS only for patients with colorectal liver metastases (CRLM) as primary indication for ALPPS. All patients with CRLM included in the ALPPS registry were included. Risk score analysis was performed for 90-day mortality after ALPPS, defined as death within 90 days after either stage. Two risk scores were generated i.e. one for application before stage-1, and one for application before stage-2. Logistic regression analysis was performed to establish the risk-score. In total, 486 patients were included, of which 35 (7%) died 90 days after stage-1 or 2. In the stage-1 risk score, age ≥67 years (OR 3.7), FLR/BW ratio <0.40 (OR 2.9) and total center-volume (OR 2.4) were included. For the stage-2 score age ≥67 years (OR 3.7), FLR/BW ratio <0.40 (OR 2.8), bilirubin 5 days after stage-1 >50 μmol/L (OR 2.4), and stage-1 morbidity grade IIIA or higher (OR 6.3) were included. The CRLM risk-score to predict mortality after ALPPS demonstrates that older patients with small remnant livers in inexperienced centers, especially after experiencing morbidity after stage-1 have adverse outcomes. The risk score may be used to restrict ALPPS to low-risk patient populations. [ABSTRACT FROM AUTHOR]

Background A minimum future liver remnant (FLR) of 30% is required to avoid post hepatectomy liver failure (PHLF). Portal vein occlusion (PVO) is the main strategy to induce hypertrophy of the FLR, but some patients will not reach sufficient FLR hypertrophy to enable resection. Recently ALPPS has emerged as a “Salvage Procedure” for PVO failure. The aim of this study was to report the short term outcomes of ALPPS following PVO failure. Methods A retrospective analysis of patients enrolled within the international ALPPS Registry between October 2012 and November 2015 (NCT01924741) was performed. Patients with documented PVO failure were included. The outcomes reported included feasibility, FLR growth rate and safety of ALPPS. Complications were recorded as per Clavien-Dindo classification. Results From 510 patients enrolled in the Registry there were 22 patients with previous PVO failure. Two patients were excluded due to missing data and twenty patients were analysed. All of them completed the proposed ALPPS with a medium FLR increase of 88% (23–115%) between two stages and no 90-day mortality. Conclusion In experienced centers, ALPPS following PVO failure is feasible and safe. The FLR hypertrophy was similar to other ALPPS series. ALPPS is a potential rescue strategy after PVO failure. [ABSTRACT FROM AUTHOR]

Background: ALPPS was developed to induce accelerated future liver remnant (FLR) hypertrophy in order to increase hepatic tumour resectability and reduce the risk of post-operative liver failure. While early studies demonstrated concerning complication rates, others reported favourable results. This inconsistency may be due to variability in surgical indications and technique. Methods: A web-based survey was sent to surgeons participating in the International ALPPS Registry in September of 2014. Questions addressed surgeon demographics and training, surgical indications and technique, and clinical management approaches. Results: Fifty six out of 85 surgeons from 78 centers responded (66%) and half (n = 30) had training in liver transplantation. Forty seven (84%) did not reserve ALPPS solely for colorectal liver metastases (CRLM) and 30 (54%) would perform ALPPS for an FLR over 30%. Neoadjuvant chemotherapy for CRLM was recommended by 37 (66%) respondents. Surgical approaches varied considerably, with 30% not preserving outflow to the middle hepatic vein and 39% believing it necessary to skeletonize the hepatoduodenal ligament. Twenty five (45%) surgeons have observed segment 4 necrosis. Conclusion: There is considerable variability in how ALPPS is performed internationally. This heterogeneity in practice patterns may explain the current incongruity in published outcomes, and highlights the need for standardization. [ABSTRACT FROM AUTHOR]

Background: Portal vein occlusion to increase the size of the future liver remnant (FLR) is well established, using portal vein ligation (PVL) or embolization (PVE) followed by resection 4-8 weeks later. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) combines PVL and complete parenchymal transection, followed by hepatectomy within 1-2 weeks. ALPPS has been recently introduced but remains controversial. We compare the ability of ALPPS versus PVE or PVL for complete tumor resection. Methods: A retrospective review of all patients undergoing ALPPS or conventional staged hepatectomies using PVL or PVE at four high-volume HPB centres between 2003 and 2012 was performed. Patients with primary liver tumors and liver metastases were included. Primary endpoint was complete tumor resection. Secondary endpoints include 90-day mortality, complications, FLR increase, time to resection, and tumor recurrence. Results: Forty-eight patients with ALPPS were compared with 83 patients with conventional-staged hepatectomies. Eighty-three percent (40/48 patients) of ALPPS patients achieved complete resection compared with 66 % (55/83 patients) in PVE/PVL (odds ratio 3.34, p = 0.027). Ninety-day mortality in ALPPS and PVE/PVL was 15 and 6 %, respectively ( p = 0.2). Extrapolated growth rate was 11 times higher in ALPPS (34.8 cc/day; interquartile range (IQR) 26-49) compared with PVE/PVL (3 cc/day; IQR2-6; p = 0.001). Tumor recurrence at 1 year was 54 versus 52 % for ALPPS and PVE/PVL, respectively ( p = 0.7). Conclusions: This study provides evidence that ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors at the cost of a high mortality. The technique is promising but should currently not be used outside of studies and registries. [ABSTRACT FROM AUTHOR]

Background Two-stage liver resections with portal vein occlusion have become standard in patients with low volume future liver remnants. Whether they are associated with more complications is unclear. The aim of this study was to compare complications of one- and two-stage resections in a retrospective study. Methods Patients with two-stage right liver resections with a previous portal vein occlusion were compared with patients with one-stage right liver resections between 2002 and 2010. Primary endpoints were the incidence of complications by severity. Secondary endpoints were mortality, post-operative liver- and kidney function tests, length of hospitalization and transfusion events. Logistic and linear regression analyses were performed to adjust for confounders. Results The groups were comparable except for right trisectionectomies, pre-operative chemotherapy and underlying liver disease. Overall complications occurred in 25 out of 35 patients with two-stage and 106 out of 163 in one-stage procedures. Severe complications were observed in 47 out of 163 patients versus 9 out of 35 patients, respectively. Two-stage procedures had no increased adjusted risk for complications [relative risk ( RR) 0.9, P = 0.79]. Mortality (5.7% versus 3.7%) and post-operative liver failure rates (2.9% versus 3.1%) were low. Secondary endpoints showed no adjusted differences in risk. Conclusion This study suggests that liver resections in two stages are not associated with more post-operative complications than one-stage resections. These results should support the adoption of two-stage liver resections in selected patients. [ABSTRACT FROM AUTHOR]

A 64-year-old female patient with adenocarcinoma of the head of the pancreas with encasement of the common hepatic artery and portal vein stenosis was reexplored after six cycles of gemcitabine (1000 mg/m2). Prior to surgery, the patient underwent balloon dilation and stenting of the portal vein in addition to successful coil embolisation of the common hepatic artery, proper hepatic artery, and proximal gastro duodenal artery. After embolisation, a pylorus-preserving pancreaticoduodenectomy was performed with resection of the common hepatic artery and portal vein confluens. Pathological examination showed a moderately differentiated pT3N0 (Stage IIa, TNM 7th edition) tumor with negative section margins. We show with this case that in selected cases of periampullary cancer with encasement of the common hepatic artery, it is technically feasible to perform pancreaticoduodenectomy with hepatic artery resection and negative surgical margins. Nevertheless, the oncological benefit of extended arterial resections remains controversial. [ABSTRACT FROM AUTHOR]

We have used alemtuzumab in combination with triple maintenance immunosuppression in renal transplantation from donors after cardiac death between 2002 and 2006. We compared outcomes of induction therapy with alemtuzumab with interleukin-2 (IL-2) receptor antagonists (RA) and anti-lymphocyte antibodies. We used a retrospective sequential study design to examine 170 recipients of kidneys from donor after cardiac death (DCD) for survival, graft survival, time to first rejection, glomerular filtration and complications. Patients were stratified into high-risk and low-risk groups based on the following criteria: panel of reactive antibodies >20%, retransplants, Afro-American race. Induction with alemtuzumab was compared with anti-thymocyte globulin (ATG) in the high-risk and with IL-2RA in the low-risk group. Patients received triple immunosuppression with steroids, mycophenolate mofetil and calcineurin inhibitors. Patient survival, graft survival, rejection rate and glomerular filtration rate did not significantly differ between patients treated with alemtuzumab versus IL-2RAs or ATG. There was a trend towards reduced graft- and patient survival in the alemtuzumab group. There was an increased incidence of cytomegalovirus (CMV) infections in the alemtuzumab-induced group and a trend towards increased BK virus and bacterial infections. Induction of DCD kidney transplants with alemtuzumab compared to IL-2RA and ATG has no significant impact on acute rejection. It appears however that CMV infections are increased in patients induced with alemtuzumab. We therefore conclude that induction with alemtuzumab does not confer any advantage over traditional induction agents. [ABSTRACT FROM AUTHOR]

Simple Summary: Despite advances in surgical techniques and systemic therapy, some patients with multifocal, bilobar colorectal liver metastases remain unresectable. The surgical debulking of liver tumor burden may increase median survival in combination with chemotherapy compared to chemotherapy alone. This study retrospectively evaluated the efficacy of surgical debulking alongside chemotherapy versus chemotherapy alone and found those who underwent debulking surgery showed improved survival compared to those who did not. These findings advocate for further investigation through a randomized trial to evaluate intentional debulking as a potential treatment strategy for unresectable colorectal cancer liver metastases. (1) Background: Despite advances in surgical technique and systemic chemotherapy, some patients with multifocal, bilobar colorectal liver metastases (CRLM) remain unresectable. These patients may benefit from surgical debulking of liver tumors in combination with chemotherapy compared to chemotherapy alone. (2) Methods: A retrospective study including patients evaluated for curative intent resection of CRLM was performed. Patients were divided into three groups: those who underwent liver resection with recurrence within 6 months (subtotal debulked, SD), those who had the first stage only of a two-stage hepatectomy (partially debulked, PD), and those never debulked (ND). Kaplan–Meier survival curves and log-rank test were performed to assess the median survival of each group. (3) Results: 174 patients underwent liver resection, and 34 patients recurred within 6 months. Of the patients planned for two-stage hepatectomy, 35 underwent the first stage only. Thirty-two patients were never resected. Median survival of the SD, PD, and ND groups was 31 months, 31 months, and 19.5 months, respectively (p = 0.012); (4) Conclusions: Patients who underwent a debulking of CRLM demonstrated a survival benefit compared to patients who did not undergo any surgical resection. This study provides support for the evaluation of intentional debulking versus palliative chemotherapy alone in a randomized trial. [ABSTRACT FROM AUTHOR]

This animal study investigates the hypothesis of an immature liver growth following ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) by measuring liver volume and function using gadoxetic acid avidity in magnetic resonance imaging (MRI) in models of ALPPS, major liver resection (LR) and portal vein ligation (PVL). Wistar rats were randomly allocated to ALPPS, LR or PVL. In contrast-enhanced MRI scans with gadoxetic acid (Primovist®), liver volume and function of the right median lobe (=future liver remnant, FLR) and the deportalized lobes (DPL) were assessed until post-operative day (POD) 5. Liver function FLR/DPL was defined as the inverse value of time from injection of gadoxetic acid to the blood pool-corrected maximum signal intensity FLR/DPL multiplied by the volume FLR/DPL. In ALPPS (n = 6), LR (n = 6) and PVL (n = 6), volume FLR and function FLR increased proportionally, except on POD 1. Thereafter, function FLR exceeded volume FLR increase in LR and ALPPS, but not in PVL. Total liver function was significantly reduced after LR until POD 3, but never undercuts 60% of its pre-operative value following ALPPS and PVL. This study shows for the first time that functional increase is proportional to volume increase in ALPPS using gadoxetic acid avidity in MRI. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "ALPPS offers a better chance of complete resection in patients with primarily unresectable liver tumors compared with conventional-staged hepatectomies: results of a multicenter analysis" is presented.

Abbreviations ALPPS associating liver partition and portal vein ligation for staged hepatectomy BMI body mass index BSA body surface area sFLR the standardized future liver remnant share TLV total liver volume With interest, we read the analysis by Lopez-Lopez et al. on the patient intrinsic factors related to liver growth after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).1 All efforts to elaborate on the factors associated with liver regeneration can greatly benefit safe liver surgery. The authors identified height, weight and body mass index (BMI), a dependent variable of height and weight, amongst factors related to the standardized future liver remnant share (sFLR) before stage 2 and increase in sFLR between stages 1 and 2. Hepatobiliary scintigraphy to evaluate liver function in associating liver partition and portal vein ligation for staged hepatectomy: liver volume overestimates liver function. [Extracted from the article]

Background: Posthepatectomy liver failure is one of the most feared complications in extended hepatic resections. In 2012, a novel two-stage liver resection was developed, able to induce rapid and extensive hypertrophy by portal vein ligation and in situ liver splitting - Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). The technique became more widely employed but its use remained controversial due to reporting of high complication and mortality rates. Method: A national audit was performed to gather information about the safety of the procedure and to better understand the complications. The audit was offered to all high-volume hepatobiliary centers in Italy. Results: Of all Italian centers approached in January 2012, 12 centers with experience in ALPPS enrolled and participated in collection of data. Fifty patients underwent ALPPS between 2012 and 2014. In 48/50 patients completion of hepatectomy was performed successfully. Major morbidity occurred in 54% with a 20% 90-day mortality. Uni- and multivariate analysis showed that ALPPS for cholangiocarcinoma and a peak of bilirubin over 5 mg/dl between stages was associated with increase of 90-day mortality and worse survival. Discussion: It is proposed that a moratorium be introduced for classic ALPPS in cholangiocarcinoma and to abort ALPPS in patients who develop an interstage increase in bilirubin, due to the high risk of liver failure and mortality. [ABSTRACT FROM AUTHOR]

Graft-versus-host disease (GVHD) is a rare complication after solid organ transplant. We present a case of GVHD after simultaneous pancreas kidney transplant. The patient was diagnosed with a cutaneous biopsy after developing the classic symptoms of maculopapular rash, diarrhea, and pancytopenia. However, this patient had unexplained elevations in donor-derived cell-free DNA (dd-cfDNA) for months before the onset of GVHD symptoms. We hypothesize that GVHD may be associated with elevated dd-cfDNA as a result of massive donor lymphocyte proliferation and turnover. Further investigation is warranted because earlier diagnosis and treatment could improve outcomes in an otherwise lethal disease. [ABSTRACT FROM AUTHOR]

Aim: Defining sensitivity, specificity, diagnostic accuracy for detection of colorectal liver metastases in imaging compared to intraoperative assessment. Defining a cutoff, where accuracy of detection is impaired. Methods: Prospective single-institution clinical trial (clinicaltrials.gov: NCT01522209). Patients underwent CEUS, MDCT, and 3 Tesla EOB-MRI within 2 weeks preoperatively. Intraoperative palpation, IOUS, and CEIOUS were performed. A patient and lesion-based database was analyzed for accuracy of detection of CEUS, CT, MRI, and Palp/IOUS/CEIOUS combined read. Histology was standard of reference. Results: Forty-seven high tumor load (mean 5, 4 lesions) patients were analyzed. Histopathology confirmed 264 lesions (245 malignant: 19 benign). Accuracy for detection of all lesions: CEUS 63%, CT 71%, MRI 92%, and PALP/IOUS/CEIOUS 98%. ROC analysis for lesion size showed severe impairment of accuracy in lesion detection smaller than 5mm. Intraoperative imaging was not impaired by lesion size. Patient-based analysis revealed a change of resection plan after IOUS/CEIOUS in 35% of patients. Conclusion: At 5-mm lesion size, preoperative imaging shows a drop in accuracy of detection. In patients with multiple lesions, addition of MRI to MDCT seems useful. Accuracy of intraoperative ultrasound is not impacted by lesion size and should be mandatory. CEIOUS can improve intraoperative decision-making. Trial Registration: Study registered with clinicaltrials.gov: NCT01522209 [ABSTRACT FROM AUTHOR]

Combined pancreas and kidney transplantation is the therapy of choice for type I diabetes patients with associated end-stage renal disease. To counterbalance increasing waiting lists, there is a clear need to extend the organ donor pool. Although results following simultaneous pancreas and kidney transplantation (SPK) using pediatric organs are encouraging, there is still reluctance in accepting them. This reflects the fear of graft thrombosis and graft failure because of small vessels and little absolute islet cell mass. Simpler transplant techniques for pediatric SPK might lower this threshold. In this article, a novel technique using a 'piggy-back' implantation of the pancreas onto the conduits of en-bloc grafted kidneys, performed in two consecutive cases, is presented. This technique is associated with less vascular manipulation, requiring only one arterial anastomosis onto the frequently arteriosclerotic arteries of the recipient for all three organs. One-year follow-up (14 and 12 months) proved excellent graft function of kidneys and pancreas. [ABSTRACT FROM AUTHOR]

Background: COVID‐19 epidemiologic studies comparing immunosuppressed and immunocompetent patients may provide insight into the impact of immunosuppressants on outcomes. Methods: In this retrospective cohort study, we assembled kidney or kidney‐pancreas transplant recipients who underwent transplant from January 1, 2010, to June 30, 2020, and kidney or kidney‐pancreas waitlisted patients who were ever on the waitlist from January 1, 2019, to June 30, 2020. We identified laboratory‐confirmed COVID‐19 until January 31, 2021, and tracked its outcomes by leveraging informatics infrastructure developed for an outcomes research network. Results: COVID‐19 was identified in 62 of 887 kidney or kidney‐pancreas transplant recipients and 20 of 434 kidney or kidney‐pancreas waitlisted patients (7.0% vs. 4.6%, p =.092). Of these patients with COVID‐19, hospitalization occurred in 48 of 62 transplant recipients and 8 of 20 waitlisted patients (77% vs. 40%, p =.002); intensive care unit admission occurred in 18 of 62 transplant recipients and 2 of 20 waitlisted patients (29% vs. 10%, p =.085); and 7 transplant recipients were mechanically ventilated and died, whereas no waitlisted patients were mechanically ventilated or died (11% vs. 0%, p =.116). Conclusions: Our study provides single‐center data and an informatics approach that can be used to inform the design of multicenter studies. [ABSTRACT FROM AUTHOR]

Portal vein ligation (PVL) induces liver growth prior to resection. Associating liver partition and portal vein ligation (PVL plus transection=ALPPS) or the addition of the prolyl-hydroxylase inhibitor dimethyloxalylglycine (DMOG) to PVL both accelerate growth via stabilization of HIF-α subunits. This study aims at clarifying the crosstalk of hepatocytes (HC), hepatic stellate cells (HSC) and liver sinusoidal endothelial cells (LSEC) in accelerated liver growth. In vivo, liver volume, HC proliferation, vascular density and HSC activation were assessed in PVL, ALPPS, PVL+DMOG and DMOG alone. Proliferation of HC, HSC and LSEC was determined under DMOG in vitro. Conditioned media experiments of DMOG-exposed cells were performed. ALPPS and PVL+DMOG accelerated liver growth and HC proliferation in comparison to PVL. DMOG alone did not induce HC proliferation, but led to increased vascular density, which was also observed in ALPPS and PVL+DMOG. Activated HSC were detected in ALPPS, PVL+DMOG and DMOG, again not in PVL. In vitro, DMOG had no proliferative effect on HC, but conditioned supernatant of DMOG-treated HSC induced VEGF-dependent proliferation of LSEC. Transcriptome analysis confirmed activation of proangiogenic factors in hypoxic HSC. Hypoxia signaling in HSC induces VEGF-dependent angiogenesis. HSC play a crucial role in the cellular crosstalk of rapid liver regeneration. [ABSTRACT FROM AUTHOR]

Background: Parenchymal-sparing hepatectomies (PSH) are liver resections with preservation of as much liver parenchyma as possible. PSH can be performed laparoscopically (LPSH), but access to the posterosuperior segments is difficult and they are challenging when there are multiple bilobar lesions; the procedure may require repositioning and may be long and cumbersome. The objective of this systematic review is to analyze the feasibility and limitations of laparoscopic PSH in the literature.Methods: A systematic review of the literature was performed by searching Medline/PubMed, Scopus, and Cochrane databases. Resections were categorized by segment(s), and data regarding operative time, blood loss, length of hospital stay, complications, and R0 resection were analyzed.Results: Of 351 studies screened for relevance, 48 studies were reviewed. Ten publications fulfilled inclusion criteria, reporting data from 579 patients undergoing LPSH. The most common indication was CRLM (58%) followed by hepatocellular carcinoma (16%). Only 92 patients were reported to have resections of more than one tumor; the maximum number of lesions resected was seven. Of resected lesions, 21.5% were located in the cranial segments. Mean operating time was 335.2 min, estimated blood loss was 462 cc, and hospital stay was 7.6 days. Conversion rate was 9.7%, and complications occurred in 19.4% of cases. No perioperative mortality was reported. R0 resections were achieved in 87.7% of cases.Conclusion: Laparoscopic PSH is performed and reported, but the data quality is low so far. The main limitation of LPSH is the low number of lesions resected, especially for bilobar, metastatic disease. Prospective reports with tumor-specific oncological data are desirable. [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism (VTE) occurs at high incidence in abdominal cancer surgery; therefore, a 4-week postoperative VTE prophylaxis is advocated. However, most patients with neuroendocrine tumors (NETs) have more favorable prognoses. This study aimed to determine the incidence of VTE in patients with abdominal NETs, compare these rates to other abdominal malignancies, and identify VTE risk factors.Methods: The ACS-NSQIP database was queried to identify patients with abdominal NETs and other abdominal malignancies who underwent surgery from 2008 to 2015. A 30-day postoperative VTE incidence for each group was compared. Univariable and multivariable analyses were used to identify VTE risk factors.Results: Of the 7226 operations for patients with benign (2154) and malignant (5072) abdominal NETs, 144 patients experienced a VTE without significant differences between groups. Subgroup analysis revealed a spectrum of VTE rates. Compared to VTE rates of other abdominal malignancies, patients with benign (1.1% vs. 2.4%, p < 0.001) or malignant (1.7% vs. 2.4%, p < 0.001) non-pancreatic abdominal NETs had significantly lower rates, malignant pancreatic NETs (PNETs) (3.4% vs. 2.4%, p = 0.03) had significantly higher rates, and benign PNETs (3.2% vs. 2.4%, p = 0.21) had comparable rates. Multivariable analysis identified pre-operative albumin (p < 0.001), bleeding disorders (p < 0.001), operative time (p < 0.001), and having a PNET (p = 0.04) as risk factors for VTE in abdominal NET patients.Conclusion: Routine extended VTE prophylaxis after surgery may be necessary in PNETs, but probably unnecessary in other abdominal NETs. However, clinicians should use risk factors identified in this study when considering to forego extended VTE prophylaxis in NET patients. [ABSTRACT FROM AUTHOR]

Background. Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are commonly present with metastatic disease, and the liver is the most frequent metastatic site. Herein, we studied whether primary tumor site affects survival in patients with GEP-NETs and liver metastases (NELM). As a secondary endpoint, we studied whether extrahepatic disease and surgical resection impact survival in this patient population. Methods. Patients with NELM diagnosed from 2006 to 2014 were identified from the National Cancer Database. Kaplan-Meier curves and nested Cox proportional hazards were used to assess variables associated with survival. Results. 2947 patients with well- or moderately differentiated GEP-NETs and NELM met the inclusion criteria for this study. Patients with small bowel NETs survived the longest of all GEP-NETs with NELM (median not reached). Rectal and gastric NETs with NELM had the shortest survival (median 31 months). Patients with extrahepatic metastases who underwent any operation survived longer than those managed nonoperatively (median survival 38.7 months vs. 18.6 months, p=0.01). On multivariable analysis, operations on the primary tumor and distant metastatic site (HR 0.23-0.43 vs. no surgery), treatment at an academic/research hospital, Charlson comorbidity index of 0, no extrahepatic metastases, and younger age were associated with prolonged survival (p<0.01). Conclusions. Primary tumor site affects survival in patients with GEP-NETs and NELM. Surgical resection seems beneficial for all GEP-NETs with NELM, even in the presence of extrahepatic metastases. [ABSTRACT FROM AUTHOR]

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces more rapid liver growth than portal vein ligation (PVL). Transection of parenchyma in ALPPS may prevent the formation of collaterals between lobes. The aim of this study was to determine if abrogating the formation of collaterals through parenchymal transection impacted growth rate.Methods: Twelve Yorkshire Landrace pigs were randomized to undergo ALPPS, PVL, or “partial ALPPS” by varying degrees of parenchymal transection. Hepatic volume was measured after 7 days. Portal blood flow and pressure were measured. Portal vein collaterals were examined from epoxy casts.Results: PVL, ALPPS, and partial ALPPS led to volume increases of the RLL by 15.5% (range 3–22), 64% (range 45–76), and 32% (range 18–77), respectively, with significant differences between PVL and ALPPS/partial ALPPS (p < 0.05). In PVL and partial ALPPS, substantial new portal vein collaterals were found. The number of collaterals correlated inversely with the growth rate (p = 0.039). Portal vein pressure was elevated in all models after ligation suggesting hyperflow to the portal vein-supplied lobe (p < 0.05).Conclusions: These data suggest that liver hypertrophy following PVL is inversely proportional to the development of collaterals. Hypertrophy after ALPPS is likely more rapid due to reduction of collaterals through transection. [ABSTRACT FROM AUTHOR]

Background Laparoscopic ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) has previously been reported but has been the authors' default option since 2015 in patients with small future liver remnant. Methods A retrospective analysis of all consecutive patients undergoing ALPPS at a single referral center was performed using a prospective database from July 2011 to June 2016. Feasibility was studied by assessing conversions. The 90-day mortality and complications were analyzed using a Dindo–Clavien score and the comprehensive complication index. Operative time, blood loss, volumetric growth, and hospital stay were examined. The CUSUM analysis was performed. Results ALPPS was performed in 30 patients, 10 of whom underwent a laparoscopic approach. There was no mortality and no complication grade ≥3A observed in laparoscopic ALPPS. In open ALPPS, 10 of 20 patients experienced complications grade ≥3A (p = 0.006) and one patient died. Liver failure was not observed after laparoscopic ALPPS, but two patients in the open ALPPS group developed complications that precluded the second stage. The total hospital stay was shorter in the laparoscopic ALPPS group. Conclusion Laparoscopic ALPPS is feasible as the default procedure for patients with very small FLR, and it is not inferior to the open approach. Surgeons experienced with complex laparoscopy should be encouraged to use a laparoscopic approach to ALPPS. [ABSTRACT FROM AUTHOR]

Bryan CF, Luger AM, Smith JL, Warady BA, Wakefield M, Schadde E, Murillo D, Nelson PW. Sharing kidneys across donor-service area boundaries with sensitized candidates can be influenced by HLA C. Clin Transplant 2010: 24: 56–61. © 2009 John Wiley & Sons A/S. The United Network for Organ Sharing (UNOS) implemented the virtual crossmatch system in UNet as a way to improve the likelihood of a negative crossmatch when kidneys are shared with HLA-sensitized candidates across donor service area (DSA) boundaries. The role of HLA C in that process is not universally appreciated. We recently experienced an unexpected positive flow T and B cell crossmatch for an imported, HLA zero-mismatched kidney because of donor-specific HLA C antibodies and transplanted it into the backup candidate. HLA C locus antigens were not typed by the OPO’s laboratory that sent the kidney so the UNet virtual crossmatch could not “strike” our candidate from the UNOS match run. HLA C locus typing data of donors for kidneys our DSA imported from other DSAs revealed that C typing was not performed in 23% (14/60) and was discrepant with our molecular type for 10% (6/60) and was concordant in 67% (40/60) of cases. The rate of positive donor-specific crossmatches was higher (83%) for HLA C discrepantly typed donors than for concordantly typed donors (44%). Sensitization for HLA C (42%) is less frequent than for A (80%) or B (83%) locus antigens but the immunogenicity of C locus antigens in patients who make C locus antibodies is equivalent in black and white patients. Finally, the transplant rate of imported kidneys into class I-sensitized candidates was 24%, and C locus-sensitized candidates comprised 55% of those transplanted. [ABSTRACT FROM AUTHOR]

Background: Conservative obesity treatment often leads to limited results. Bariatric surgery is highly efficient, but the candidates are at risk of developing perioperative complications. Bariatric outcomes have been well described in the past, but there are only few reports of perioperative outcomes. The aim of this study was to evaluate the incidence of anaesthetic and surgical complications of Roux-en-Y bypass. Methods: Data of all adult patients, who underwent primary Roux-en-Y gastric bypass surgery between 1/2006 and 12/2013 at the University Hospital Zurich were analysed. Using our clinical database, anaesthetic and surgical complications during the first 30 days after surgery were analysed and risk factors determined by multivariate analysis. Results: Seven hundred eleven patients (72% female, median age 40 years) were analysed. Overall, surgical complications occurred in 34% patient, while complications attributable to anaesthesia occurred in 37%. Post-operative nausea and vomiting (PONV) were observed in 34%, intubation-related complications in 4%, and delayed extubation in 2% of our patients. Within the first 30 days after surgery, 22% of the patients presented with an infection. Gastrointestinal complications were found in 8%, and bleeding complications in 3%. Anaesthesia complications were less common in older patients and in patients anaesthetized with a volatile anaesthetic. Severe complications were more common in patients with a lower body mass index (BMI) and with longer surgery. The risk to develop a postoperative infection was higher in diabetic patients. Conclusion: Roux-en-Y bariatric surgery has few anaesthetic complications, the most common is PONV. PONV is more common in younger patients and not more common with volatile anaesthetics. Major complications are overall rare and occur in patients with lower BMI and longer surgery, likely reflecting more difficult procedures. [ABSTRACT FROM AUTHOR]

Background: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces more rapid liver growth than portal vein ligation (PVL). Transection of parenchyma in ALPPS may prevent the formation of collaterals between lobes. The aim of this study was to determine if abrogating the formation of collaterals through parenchymal transection impacted growth rate.Methods: Twelve Yorkshire Landrace pigs were randomized to undergo ALPPS, PVL, or "partial ALPPS" by varying degrees of parenchymal transection. Hepatic volume was measured after 7 days. Portal blood flow and pressure were measured. Portal vein collaterals were examined from epoxy casts.Results: PVL, ALPPS, and partial ALPPS led to volume increases of the RLL by 15.5% (range 3-22), 64% (range 45-76), and 32% (range 18-77), respectively, with significant differences between PVL and ALPPS/partial ALPPS (p < 0.05). In PVL and partial ALPPS, substantial new portal vein collaterals were found. The number of collaterals correlated inversely with the growth rate (p = 0.039). Portal vein pressure was elevated in all models after ligation suggesting hyperflow to the portal vein-supplied lobe (p < 0.05).Conclusions: These data suggest that liver hypertrophy following PVL is inversely proportional to the development of collaterals. Hypertrophy after ALPPS is likely more rapid due to reduction of collaterals through transection. [ABSTRACT FROM AUTHOR]