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Associating liver partition and portal vein ligation for staged hepatectomy induces rapid and effective hypertrophy of the future liver remnant to prevent postoperative liver failure. The aim of this study was to determine cofactors, including sarcopenia, influencing the kinetic growth rate, and subsequently future liver remnant, in terms of safety, complications, and posthepatectomy liver failure.Patients undergoing associating liver partition and portal vein ligation for staged hepatectomy between 2010 and 2020 were included in this study. Kinetic growth rate was defined as the quotient of the degree of hypertrophy and the time interval between the 2 steps. The sarcopenia muscle index was defined as the skeletal muscle area of both psoas major muscles normalized to the patient's height.During the study period, 90 patients underwent associating liver partition and portal vein ligation for staged hepatectomy. The association between kinetic growth rate and posthepatectomy liver failure indicates a significant nonlinear effect (P = .02). The incidence of posthepatectomy liver failure significantly increased at a kinetic growth rate below 7% per week (31%) compared to patients with a kinetic growth rate7%/wk (7%, P = .02). In patients with a low kinetic growth rate (7%/wk), the sarcopenia muscle index was significantly lower compared to patients with a high kinetic growth rate (7%/wk). Furthermore, a low sarcopenia muscle index and a high body mass index turned out to be independent risk factors for a low kinetic growth rate.After the first step of the associating liver partition and portal vein ligation for staged hepatectomy procedure, a low kinetic growth rate (7%/wk) increases the risk of posthepatectomy liver failure. The presence of a low sarcopenia muscle index and a high body mass index are profoundly correlated with clinically substantial impaired liver regeneration, which can result in increased liver dysfunction after associating liver partition and portal vein ligation for staged hepatectomy.

Background Complex liver resection is a risk factor for the development of AKI, which is associated with increased morbidity and mortality. Aim of this study was to assess risk factors for acute kidney injury (AKI) and its impact on outcome for patients undergoing complex liver surgery. Methods AKI was defined according to the KDIGO criteria. Primary endpoint was the occurrence of AKI after liver resection. Secondary endpoints were complications and mortality. Results Overall, 146 patients undergoing extended liver resection were included in the study. The incidence of AKI was 21%. The incidence of chronic kidney disease (CKD) and hepatocellular carcinoma were significantly higher in patients with AKI. In the AKI group, the proportion of extended right hepatectomies was the highest (53%), followed by ALPPS (43%). Increased intraoperative blood loss, increased postoperative complications and perioperative mortality was associated with AKI. Besides age and CKD, ALPPS was an independent risk factor for postoperative AKI. A small future liver remnant seemed to increase the risk of AKI in patients undergoing ALPPS. Conclusion Following extended liver resection, AKI is associated with an increased morbidity and mortality. ALPPS is a major independent risk factor for the development of AKI and a sufficient future liver remnant could avoid postoperative AKI.

To explore potential sex differences in outcomes and regenerative parameters post major hepatectomies.Although controversial, sex differences in liver regeneration have been reported for animals. Whether sex disparity exists in human liver regeneration is unknown.Data from consecutive hepatectomy patients (55 females, 67 males) and from the international ALPPS (Associating-Liver-Partition-and-Portal-vein-ligation-for-Staged-hepatectomy, a two stage hepatectomy) registry (449 females, 729 males) were analyzed. Endpoints were severe morbidity (≥3b Clavien-Dindo grades), Model for End-stage Liver Disease (MELD) scores, and ALPPS interstage intervals. For validation and mechanistic insight, female-male ALPSS mouse models were established. t , χ 2 , or Mann-Whitney tests were used for comparisons. Univariate/multivariate analyses were performed with sensitivity inclusion.Following major hepatectomy (Hx), males had more severe complications ( P =0.03) and higher liver dysfunction (MELD) P =0.0001) than females. Multivariate analysis established male sex as a predictor of complications after ALPPS stage 1 (odds ratio=1.78; 95% confidence interval: 1.126-2.89; P =0.01), and of enhanced liver dysfunction after stage 2 (odds ratio=1.93; 95% confidence interval: 1.01-3.69; P =0.045). Female patients displayed shorter interstage intervals (2 weeks, 64% females versus 56% males, P =0.01), however, not in postmenopausal subgroups. In mice, females regenerated faster than males after ALPPS stage 1, an effect that was lost upon estrogen antagonism.Poorer outcomes after major surgery in males and shorter ALPPS interstage intervals in females not necessarily suggest a superior regenerative capacity of female liver. The loss of interstage advantages in postmenopausal women and the mouse experiments point to estrogen as the driver behind these sex disparities. Estrogen's benefits call for an assessment in postmenopausal women, and perhaps men, undergoing major liver surgery.

Background Portal venous embolization (PVE) is a minimal invasive preoperative strategy that aims to increase future liver remnant (FLR) in order to facilitate extended hemihepatectomy. We analyzed our data retrospectively regarding complications and degree of hypertrophy (DH). Methods: 88 patients received PVE either by particles / coils (n = 77) or by glue / oil (n = 11), supported by 7 right hepatic vein embolizations (HVE) by coils or occluders. All complications were categorized by the Clavien- Dindo (CD) and the CIRSE classification. Results In 88 patients (median age 68 years) there was one intervention with a biliary leak and subsequent drainage (complication grade 3 CD, CIRSE 3), two with prolonged hospital stay (grade 2 CD, grade 3 CIRSE) and 13 complications grade 1 CD, but no complications of grade 4 or higher neither in Clavien- Dindo nor in CIRSE classification. The median relative increase in FLR was 47% (SD 35%). The mean pre-intervention standardized FLR rose from 23% (SD 10%) to a post-intervention standardized FLR of 32% (SD 12%). The degree of hypertrophy (DH) was 9,3% (SD 5,2%) and the kinetic growth rate (KGR) per week was 2,06 (SD 1,84). Conclusion PVE and, if necessary, additional sequential HVE were safe procedures with a low rate of complications and facilitated sufficient preoperative hypertrophy of the future liver remnant.

The human tongue is a muscular hydrostat, comprising a group of orthogonally oriented and interdigitated muscles without skeletal support. Key characteristics of the tongue as a muscular hydrostat include that the tongue’s volume is constant, and any decrease in one dimension will be compensated by an increase in another dimension. This work aims to identify causal relationships among internal muscles in protrusive muscle contractions, which is vital to understand their underlying muscle coordination patterns. We investigated four muscles known to contribute to tongue protrusion, including transverse, verticalis, superior longitudinal, and genioglossus muscles. To capture tongue structure and function, we acquired diffusion MRI and tagged MRI to estimate the muscle fiber geometry of the four muscles and the motion patterns of tongue protrusion, respectively. We first computed Lagrangian strains along muscle fiber direction in each voxel, reflecting muscle fiber shortening. Average strain values in each muscle, defined by a vocal tract atlas, were then input into a linear vector autoregression Granger causality model, to investigate their causal relationships. Our findings on the strain patterns over time as well as the pairwise causal relationships were consistent in part with the muscular hydrostat theory, which helps elucidate the tongue muscle coordination patterns.

Background Transcriptional enhanced associated domain (TEAD) transcription factors are nuclear effectors of several oncogenic signalling pathways including Hippo, WNT, TGF-s and EGFR pathways that interact with various cancer genes. The subcellular localization of TEAD regulates the functional output of these pathways affecting tumour progression and patient outcome. However, the impact of the TEAD family on pancreatic ductal adenocarcinoma (PDAC) and its clinical progression remain elusive. Methods A cohort of 81 PDAC patients who had undergone surgery was established. Cytoplasmic and nuclear localization of TEAD1, TEAD2, TEAD3 and TEAD4 was evaluated with the immunoreactive score (IRS) by immunohistochemistry (IHC) using paraffin-embedded tissue. Results were correlated with clinicopathological data, disease-free and overall survival. Results Nuclear staining of all four TEADs was increased in pancreatic cancer tissue. Patients suffering from metastatic disease at time of surgery showed a strong nuclear staining of TEAD2 and TEAD3 (p cytoplasmic ratio of TEAD2 and TEAD3 was associated with a shorter overall survival and TEAD2 emerged as an independent prognostic factor for disease-free survival. Conclusion Our study underlines the importance of TEAD transcription factors in PDAC as a nuclear localization was found to be associated with metastatic disease and an unfavourable prognosis after surgical resection.

Although surgical resection of colorectal liver metastases (CRLM) remains to be the only option for long term survival, traditional surgical concepts have been challenged by the introduction of the liver first approach or neoadjuvant chemotherapy in resectable CRLM and interventional therapies. The aim of this study was to identify prognostic factors for postoperative morbidity and survival and to externally evaluate the recently introduced resection severity index (RSI), in order to optimize patient selection and treatment strategies.This is a retrospective single centre analysis of 213 patients undergoing surgery for CRLM in curative intent between January 2010 and December 2018.Median follow up after liver resection was 28.56 (0.01-111.46) months. Severe postoperative complications (Clavien-Dindo ≥ IIIa) were observed in 46 (21.6%) cases. Preoperative leukocytosis (OR: 3.114, CI-95%: 1.089-8.901; p = 0.034) and operation time in minutes (OR: 1.007, CI-95%: 1.002-1.011; p = 0.002) were determined as independent risk factors. Overall survival (OS) was 46.68 months with a 5-year survival rate of 40.5%. Independent prognostic factors were preoperative leukocytosis (HR: 2.358, CI-95%: 1.170-4.752; p = 0.016), major hepatectomy (HR: 1.741, CI-95%: 1.098-2.759; p = 0.018) and low grading of the primary intestinal tumour (HR: 0.392, CI-95%: 0.231-0.667; p 0.001). The RSI (ASAT (U/l) divided by Quick (%) multiplied by the extent of liver resection in points) was identified as independent risk factor for OS only in patients without neoadjuvant chemotherapy.Detection of leukocytosis in patients prior resection of CRLM was associated with increased postoperative morbidity and decreased OS and could therefore prove valuable for perioperative risk stratification.

Haemangiomas of the liver are benign tumours, which are often diagnosed randomly. With an increase in size haemangiomas could become symptomatic. In this case therapeutic options, surgical or interventional, have to be weighted to a conservative approach. We present a case of a 36-year old woman with a symptomatic giant haemangioma of the right liver lobe. Because of the size of the tumor and the small future liver remnant we decided to perform a major liver resection after hypertrophy induction with a preoperative portal vein embolization; an option mainly used for major hepatectomies in malignant tumors of the liver. But however, this case shows, that using a hypertrophy concept also for benign liver tumours is the safer approach, if an extended resection is necessary and the future liver remnant is critical.

Highlights • A Patient was treated with portal vein arterialization for iatrogenic occlusion of the hepatic artery after pancreatoduodenectomy. • Portal vein arterialization is an old surgical method, which could be helpful to reduce the failure-to-rescue rate of patients with a dearterialised liver. • Portal vein arterialization is a rare but safe technique to supply arterial blood to the liver., Introduction Portal Vein Arterialization is a rare procedure for total de-arterialized livers to ensure arterial inflow to the liver. Presentation of case A 55-year-old male patient underwent pancreatoduodenectomy for chronic pancreatitis. One month after discharge the patient was re-admitted because of bleeding from a pseudoaneurysm of the ligated gastroduodenal artery. During radiological intervention a coil dislocated and a complete occlusion of the hepatic artery occurred. Extraction of the coil was not possible, therefore, the patient was transferred to our hospital for surgical revascularization. We performed a side-to-side running anastomosis between a branch of a mesenteric artery and the corresponding vein to supply arterial blood to the liver. The postoperative course was uneventful. Radiologic examinations showed a patent arterio-portal shunt. Discussion Portal vein arterialization might be a lifesaving procedure in complication management. Conclusion PVA is an old surgical method, which could be helpful to reduce the failure-to-rescue rate.

Das hepatozellulare Karzinom (HCC) wird zu einer immer groser werdenden soziookonomischen Herausforderung. Internationale Leitlinien sprechen sich vorwiegend gegen die pratherapeutische Bestimmung der α‑Feto-Protein(AFP)-Konzentration aus. Bezuglich der prognostischen Aussagekraft des AFP ist die europaische Studienlage nicht aussagekraftig genug. Diese Arbeit soll mogliche Aspekte des AFP-Spiegels aufzeigen und die prognostische Vorhersagekraft des AFP-Spiegels untersuchen sowie Anregungen fur zukunftige prospektive Studien geben. Eine prospektive Leberdatenbank (n = 1382) wurde im Hinblick auf HCC-Patienten, die einen histologisch gesicherten Tumor aufweisen (n = 92), ausgewertet. Es lagen Informationen zu T‑, N‑, M‑, G‑Stadium und R‑Status bzw. zu Geschlecht, Alter, Genese vor. Fur die Analyse teilten wir das Patientengut anhand von 3 Cut-off-Werten in 6 Gruppen ein. Des Weiteren fuhrten wir eine Uberlebensanalyse mittels Kaplan-Meier und eine multifaktorielle Analyse der Einflussfaktoren auf das Outcome durch. Es gibt einen statistisch signifikanten Zusammenhang zwischen dem AFP-Spiegel, dem Tumordurchmesser (T1/2 vs. T3/4) und dem Grading (G1/G2 vs. G3/G4). In allen Gruppen fiel die Uberlebensprognose in der jeweiligen Gruppe mit dem hoheren AFP-Spiegel signifikant schlechter aus (p 8 μg/l betrug 35 Monate; bei Patienten mit AFP-Spiegeln von >200 μg/l bzw. >400 μg/l betrug das mediane Uberleben 15 Monate bzw. 11 Monate. Hohe AFP-Spiegel sind unabhangig vom T‑Stadium, Alter und R‑Status des Patienten im Vergleich zu niedrigen AFP-Spiegeln ein signifikanter Einflussfaktor fur das Outcome. Unter Berucksichtigung der vorliegenden Ergebnisse kann dem AFP-Spiegel eine therapeutische Nutzlichkeit zugeschrieben werden. Es konnten sich aus der Hohe der gemessenen AFP-Konzentration therapeutische Konsequenzen im Hinblick auf die Therapiestrategie ergeben. Demnach empfehlen wir bei allen HCC-Patienten die pra- und postoperative Bestimmung des AFP-Spiegels.

Highlights • First Case Report about ALPPS for the treatment of an undifferentiated embryonal sarcoma of the Liver. • The feasibility of the ALPPS procedure in a newly faced tumor-entity. • Importance of an intraoperative histological evaluation of the parenchyma to estimate the individual risk for liver failure., Introduction Embryonal sarcomas of the liver (ESL) are extremely rare solid tumors appearing mainly in children. The therapeutic standard for an ESL is a margin free resection combined with chemotherapy. The Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) procedure as a surgical therapy offers a curative approach for liver tumors of various origins where the future liver remnant (FLR) would be insufficient after a one-staged (extended) hemihepatectomy. Presentation of Case A 19-year-old patient was diagnosed with an undifferentiated embryonal sarcoma of the liver (UESL) in the right liver lobe with oligometastatic spread to the lungs. After neoadjuvant chemotherapy remission was enough to plan a resection of the liver tumor. During the operation we changed our strategy from one-stage hepatectomy to ALPPS because of borderline FLR and macroscopic and histologic liver damage to avoid posthepatectomy liver failure. The interstage and postoperative course of the patient was uneventful beside postoperative bile leakage, which was treated by interventional drainage and stenting. Discussion The ALPPS-procedure as a comparatively new surgery was considered over a portal vein ligation or embolization. ALPPS shows a faster hypertrophy compared to standard one-staged hemihepatectomy with decreased or similar proliferation, apoptosis or angiogenesis (at least for CRLM) Conclusion In experienced centers the ALPPS-procedure is evolving as the safer approach in hemihepatectomys where the FLR is critical. Additionally, ALPPS can serve as an intraoperative option when liver volume and quality seem not to be sufficient and is to be considered when facing new tumor-entities.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery.; METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes.; RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P= .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ? .001). The need for vascular reconstruction was associated with higher mortality (P= .04). Two of the 4 patients transplanted died.; CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results. Copyright © 2022 Elsevier Inc. All rights reserved.

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.

Highlights • Compression of the Vena cava leading to pulmonary embolism is a rare symptom of hemangioma. • Resection of Hemangioma to normalize the flow of the vena cava is a rare indication, but an effective and safe therapy. • The patient required no anticoagulation after the surgery., Introduction Hemangiomas are common hepatic lesions and are mostly asymptomatic. Operative removal should only be performed when the lesions are symptomatic, and removal of the hemangioma is deemed to be more beneficial than the risk of the operation itself. Presentation of the case The multiple hemangiomas of our patient were discovered nine years before first symptoms. The patient presented with pulmonary artery embolism due to a compression of the vena cava inferior by a hemangioma in segment I. No other cause of thromboembolic events could be diagnosed. We performed surgical enucleation of the hemangioma, which resulted in the normalization of blood flow in the inferior vena cava. As the inducing factor for clot development was removed, no permanent thrombosis prophylaxis was implicated. Discussion Pulmonary embolisms owing to compression of the inferior vena cave are rare. Conclusion Until now to our knowledge, pulmonary embolisms have never been described as an indication for hepatic hemangioma enucleation.

Die intraoperative Fluoreszenzangiographie und -cholangiographie mit Indocyaningrun (ICG) finden zunehmend Anwendung im klinischen Alltag des Leberchirurgen. Die Einsatzmoglichkeiten sind vielfaltig. Dies trifft besonders fur die minimal-invasive und Roboterchirurgie zu, bei der eine Verbesserung der intraoperativen Navigation die Sicherheit der Eingriffe erhohen kann. Bei der laparoskopischen Cholezystektomie konnen so die Gallenwege insbesondere bei anatomische Varianten oder komplizierten Entzundungsreaktionen ohne grosen Zeitaufwand visualisiert werden. Neben der Navigation im Gallenwegssystem, erlaubt die ICG-Fluoreszenz auch die Darstellung von Gefasen und ihrer Versorgungsgebiete, sodass Lebersegmente bzw. Territorien identifiziert werden konnen, was mit konventionellen Methoden nur eingeschrankt moglich ist. Anatomische Resektionen gewinnen z. B. bei der Therapie hepatozellularer Karzinome (HCC) an Bedeutung. Eine weitere nutzliche Anwendungsmoglichkeit besteht in der intraoperativen Detektion von Galleleckagen nach Leberresektionen. Besonders die intraoperative Uberprufung einer biliodigestiven Anastomose ist mit der ICG-Fluoreszenzcholangiographie moglich, die Morbiditat kann somit gesenkt werden. Auserdem konnen primare und sekundare Lebertumoren mit der ICG-Fluoreszenz detektiert werden. Wahrend hochdifferenzierte HCC-Tumoren homogen ICG speichern, haben entdifferenzierte HCC-Tumoren und Metastasen diese Eigenschaft nicht. Bei ihnen speichert jedoch das benachbarte Lebergewebe deutlich intensiver als gesundes Lebergewebe, sodass ringformige Fluoreszenzmuster entstehen. Dieses Fluoreszenzverhalten ermoglicht die Detektion okkulter Lebertumoren auf der Organoberflache. Abschliesend muss festgestellt werden, dass die Einsatzmoglichkeiten des ICG in der hepatobiliaren Chirurgie sehr vielfaltig sind, in Deutschland jedoch im internationalen Vergleich noch Nutzungspotenzial besteht.

Impaired postoperative renal function is associated with increased morbidity and mortality after liver resection. The role of impaired renal function in the two-stage hepatectomy setting of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is unknown. An international multicenter cohort of ALPPS patients captured in the ALPPS Registry was analyzed. Particular attention was drawn to the renal function in the interstage interval to determine outcome after stage 2 surgery. Interstage renal impairment (RI) was defined as an increase of serum creatinine of ≥ 0.3 mg/dl referring to a preoperative value or an increase of serum creatinine of ≥ 1.5× of the preoperative value on the fifth postoperative day after stage 1. A total of 705 patients were identified of which 7.5% had an interstage RI. Patients developing an interstage RI were significantly older. During stage 1, a longer operation time, higher rate of intraoperative transfusions, and additional procedures were observed in patients that developed interstage RI. After stage 1, interstage RI patients had more major complications and higher interstage mortality (1% vs. 8%, p < 0.001). Furthermore, these patients developed more and severe complications after completion of stage 2. Mortality of patients with interstage RI was 38% vs. 8% without interstage RI. In 41% of patients with interstage RI, the renal function recovered before stage 2; however, the mortality after stage 2 remained 28% in those patients. Risk factors for the development of an interstage RI were age over 67 years, prolonged operative time, and additional procedure during stage 1. This study shows that interstage RI is a predictor for interstage and post-stage 2 morbidity and perioperative mortality. The causality of impaired renal function on outcome, however, remains unknown. Interstage RI may directly cause adverse outcome but may also be a surrogate marker for major complications.

Purpose The Hippo pathway has broadened in cancer research in the past decade and revealed itself to be an important driver for tumorigenesis and metastatic spread. In this study, we investigated the clinical relevance of the Hippo pathway with regard to metastatic invasion, patients’ outcome and histopathological features. Methods Protein expression of components of the Hippo pathway were analyzed by immunohistochemistry (IHC) using paraffin-embedded tissue from 103 patients who had been diagnosed with pancreatic ductal adenocarcinoma and had undergone surgery. Results were correlated with clinicopathological data, disease-free and overall survival. Results Immunohistochemistry studies in pancreatic tumour tissues revealed a significant upregulation of MST1, MST2, pLATS, pYAP and 14-3-3, representing the active Hippo pathway, in non-metastasized patients (p p Conclusion The Hippo pathway is inactive in metastasized patients releasing the pro-metastatic and proliferative potential of the pathway. Furthermore, our study underlines the prognostic relevance of the Hippo pathway as a shift in the balance towards the inactive pathway predicts an unfavorable OS and DFS.

Objectives: To analyze long-term oncological outcome along with prognostic risk factors in a large cohort of patients with colorectal liver metastases (CRLM) undergoing ALPPS. Background: ALPPS is a two-stage hepatectomy variant that increases resection rates and R0 resection rates in patients with primarily unresectable CRLM as evidenced in a recent randomized controlled trial. Long-term oncologic results, however, are lacking. Methods: Cases in- and outside the International ALPPS Registry were collected and completed by direct contacts to ALPPS centers to secure a comprehensive cohort. Overall, cancer-specific (CSS), and recurrence-free (RFS) survivals were analyzed along with independent risk factors using Cox-regression analysis. Results: The cohort included 510 patients from 22 ALPPS centers over a 10-year period. Ninety-day mortality was 4.9% and median overall survival, CSS, and RFS were 39, 42, and 15 months, respectively. The median follow-up time was 38 months (95% confidence interval 32-43 months). Multivariate analysis identified tumor-characteristics (primary T4, right colon), biological features (K/N-RAS status), and response to chemotherapy (Response Evaluation Criteria in Solid Tumors) as independent predictors of CSS. Traditional factors such as size of metastases, uni versus bilobar involvement, and liver-first approach were not predictive. When hepatic recurrences after ALPPS was amenable to surgical/ablative treatment, median CSS was significantly superior compared to chemotherapy alone (56 vs 30 months, P < 0.001). Conclusions: This large cohort provides the first evidence that patients with primarily unresectable CRLM treated by ALPPS have not only low perioperative mortality, but achieve appealing long-term oncologic outcome especially those with favorable tumor biology and good response to chemotherapy.

Background Repeated liver resections for the recurrence of colorectal liver metastasis (CRLM) are described as safe and have similar oncological outcomes compared to first hepatectomy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is performed in patients with conventionally non-resectable CRLM. Repeated resections after ALPPS has not yet been described. Methods Patients that underwent repeated liver resection in recurrence of CRLM after ALPPS were included in this study. The primary endpoint was morbidity and secondary endpoints were mortality, resection margin and survival. Results Thirty patients were included in this study. During ALPPS, most of the patients had classical split (60%, n = 18) and clearance of the FLR (77%, n = 23). Hepatic recurrence was treated with non-anatomical resection (57%, n = 17), resection combined with local ablation (13%, n = 4), open ablation (13%, n = 4), segmentectomy (10%, n = 3) or subtotal segmentectomy (7%, n = 2). Six patients (20%) developed complications (10% minor complications). No post-hepatectomy liver failure or perioperative mortality was observed. One-year patient survival was 87%. Five patients received a third hepatectomy. Conclusion Repeated resections after ALPPS for CRLM in selected patients are safe and feasible with low morbidity and no mortality. Survival seems to be comparable with repeated resections after conventional hepatectomy.

Background Various, often conflicting, estimates for post-operative morbidity and mortality following ALPPS have been reported in the literature, suggesting that considerable center-level variation exists. Some of this variation may be related to center volume and experience. Methods Using data from seventeen centers who were early adopters of the ALPPS technique, we estimated the variation, by center, in standardized 90-day mortality and comprehensive complication index (CCI) for patients treated between 2012 and 2018. Results We estimated that center-specific 90-day mortality following treatment with ALPPS varied from 4.2% (95% CI: 0.8, 9.9) to 29.1% (95% CI: 13.9, 50.9), and that center-specific CCI following treatment with ALPPS varied from 17.0 (95% CI: 7.5, 26.5) to 49.8 (95% CI: 38.1, 61.8). Declines in estimated 90-day mortality and CCI were observed over time, and almost all individual centers followed this trend. Patients treated at centers with a higher number of ALPPS cases performed over the prior year had a lower risk of post-operative mortality. Conclusion Despite considerable center-level variation in ALPPS outcomes, perioperative outcomes following ALPPS have improved over time and treatment at higher volume centers results in a lower risk of 90-day mortality. Morbidity and mortality remain concerningly high at some centers.

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates a ring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.

Background: The only curative treatment option for intrahepatic cholangiocarcinoma (iCCA) is liver resection. Due to central tumor localization and vascular invasion, complex liver resections play an important role in curative treatment. However, the long-term outcomes after complex liver resection are not known. Methods: A retrospective cohort study was conducted for all patients undergoing liver surgery for iCCA. Complex liver resections included ante situm resections, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and major liver resection with vascular reconstructions. Results: Forty-nine patients (34%) received complex liver resection, 66 patients (46%) received conventional liver resection and 28 patients (20%) were not resectable during exploration. Preoperative characteristics were not different between the groups, except for Union for International Cancer Control (UICC) stages. The postoperative course for complex liver resections was associated with more complications and perioperative mortality. However, long-term survival was not different between complex and conventional resections. Independent risk factors for survival were R0 resections and UICC stage. Four patients underwent ante situm resection without any mortality. Conclusions: Complex liver resections are justified in selected patients and survival is comparable with conventional liver resections. Survival in iCCA is affected by UICC stage or resections margins and not by the complexity of the case.

Although the type of hepatic artery revascularization technique is known to have an impact on patency rates, independent perioperative risk factors on patient outcomes are poorly defined. All consecutive adult patients undergoing cadaveric liver transplantation (n = 361) from July 2007 to June 2016 in a single institution were analyzed. Primary outcomes were early (

Although aortohepatic conduits (AHCs) provide an effective technique for arterialization in liver transplantation (LT) when the native recipient artery is unusable, various publications report higher occlusion rates and impaired outcome compared to conventional anastomoses. This systematic review and meta-analysis investigates the published evidence of outcome and risk of AHCs in LT using bibliographic databases and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Primary and secondary outcome were artery occlusion as well as graft and patient survival. Twenty-three retrospective studies were identified with a total of 22 113 patients with LT, of whom 1900 patients (9%) received an AHC. An AHC was used in 33% of retransplantations. Early artery occlusion occurred in 7% (3%-16%) of patients with AHCs, compared to 2% (1%-3%) without conduit (OR 3.70; 1.63-8.38; P = .001). The retransplantation rate after occlusion was not significantly different in both groups (OR 1.46; 0.67-3.18; P = .35). Graft (HR 1.38; 1.17-1.63; P < .001) and patient (HR 1.57; 1.12-2.20; P = .009) survival was significantly lower in the AHC compared to the nonconduit group. In contrast, graft survival in retransplantations was comparable (HR 1.00; 0.82-1.22; P = .986). Although AHCs provide an important rescue option, when regular revascularization is not feasible during LT, transplant surgeons should be alert of the potential risk of inferior outcome.

ObjectivesPost‐hepatectomy liver failure has a major impact on patient outcome. This study aims to explore the impact of the integration of a novel patient‐centred evaluation, the LiMAx algorithm, on perioperative patient outcome after hepatectomy.MethodsTrends in perioperative variables and morbidity and mortality rates in 1170 consecutive patients undergoing elective hepatectomy between January 2006 and December 2011 were analysed retrospectively. Propensity score matching was used to compare the effects on morbidity and mortality of the integration of the LiMAx algorithm into clinical practice.ResultsOver the study period, the proportion of complex hepatectomies increased from 29.1% in 2006 to 37.7% in 2011 (P= 0.034). Similarly, the proportion of patients with liver cirrhosis selected for hepatic surgery rose from 6.9% in 2006 to 11.3% in 2011 (P= 0.039). Despite these increases, rates of post‐hepatectomy liver failure fell from 24.7% in 2006 to 9.0% in 2011 (P

To understand whether quantitative measurement of minimal coronary luminal diameter is a better method than percent diameter narrowing for assessing the functional impairment of myocardial contractility produced by coronary artery stenoses, measurements were made from 37 stenotic segments in 27 patients with coronary artery disease and from corresponding segments in 10 subjects without coronary artery narrowing. An assessment of the reliability of the 2 types of measurements was made by correlating them with the physiologic parameters of both segmental wall motion and global ejection fraction response induced by atrial pacing. Digitally acquired coronary angiograms were used to facilitate quantitative analysis. Measurements by edge detection and videodensitometry correlated closely (r = 0.94). Percent diameter narrowing correlated moderately with the change in ejection fraction (r = -0.41) or with the change in segmental wall motion (r = -0.44). The measurement of minimal lumen diameter correlated with the change in global ejection fraction (r = 0.61) and did so even better with the change in segmental wall motion (r = 0.78, p less than 0.05). A minimal lumen diameter of less than or equal to 1.5 mm identified patients likely to have a functional impairment during atrial pacing as assessed by either global ejection fraction or segmental wall motion defects. We conclude that minimal coronary luminal diameter provides a better method than percent diameter narrowing calculations to measure the anatomic severity of coronary artery narrowing.