Publications by authors named "Elias Khajeh"

55 Publications

Systematic reviews in surgery-recommendations from the Study Center of the German Society of Surgery.

Langenbecks Arch Surg 2021 Sep 15;406(6):1723-1731. Epub 2021 Jun 15.

Study Center of the German Society of Surgery (SDGC), University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.

Background: Systematic reviews are an important tool of evidence-based surgery. Surgical systematic reviews and trials, however, require a special methodological approach.

Purpose: This article provides recommendations for conducting state-of-the-art systematic reviews in surgery with or without meta-analysis.

Conclusions: For systematic reviews in surgery, MEDLINE (via PubMed), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) should be searched. Critical appraisal is at the core of every surgical systematic review, with information on blinding, industry involvement, surgical experience, and standardisation of surgical technique holding special importance. Due to clinical heterogeneity among surgical trials, the random-effects model should be used as a default. In the experience of the Study Center of the German Society of Surgery, adherence to these recommendations yields high-quality surgical systematic reviews.
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http://dx.doi.org/10.1007/s00423-021-02204-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8481197PMC
September 2021

Endocystectomy as a conservative surgical treatment for hepatic cystic echinococcosis: A systematic review with single-arm meta-analysis.

PLoS Negl Trop Dis 2021 05 12;15(5):e0009365. Epub 2021 May 12.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Background: In patients with hepatic cystic echinococcosis (CE), treatment effectiveness, outcomes, complications, and recurrence rate are controversial. Endocystectomy is a conservative surgical approach that adequately removes cyst contents without loss of parenchyma. This conservative procedure has been modified in several ways to prevent complications and to improve surgical outcomes. This systematic review aimed to evaluate the intraoperative and postoperative complications of endocysectomy for hepatic CE as well as the hepatic CE recurrence rate following endocystectomy.

Methods: A systematic search was made for all studies reporting endocystectomy to manage hepatic CE in PubMed, Web of Science, and Cochrane CENTRAL databases. Study quality was assessed using the methodological index for non-randomized studies (MINORS) criteria and the Cochrane revised tool to assess risk of bias in randomized trials (RoB2). The random-effects model was used for meta-analysis and the arscine-transformed proportions were used to determine complication-, mortality-, and recurrence rates. This study is registered with PROSPERO (number CRD42020181732).

Results: Of 3,930 retrieved articles, 54 studies reporting on 4,058 patients were included. Among studies reporting preoperative anthelmintic treatment (31 studies), albendazole was administered in all of them. Complications were reported in 19.4% (95% CI: 15.9-23.2; I2 = 84%; p-value <0.001) of the patients; biliary leakage (10.1%; 95% CI: 7.5-13.1; I2 = 81%; p-value <0.001) and wound infection (6.6%; 95% CI: 4.6-9; I2 = 27%; p-value = 0.17) were the most common complications. The post-endocystectomy mortality rate was 1.2% (95% CI: 0.8-1.8; I2 = 21%; p-value = 0.15) and the recurrence rate was 4.8% (95% CI: 3.1-6.8; I2 = 87%; p-value <0.001). Thirty-nine studies (88.7%) had a mean follow-up of more than one year after endocystectomy, and only 14 studies (31.8%) had a follow-up of more than five years.

Conclusion: Endocystectomy is a conservative and feasible surgical approach. Despite previous disencouraging experiences, our results suggest that endocystectomy is associated with low mortality and recurrence.
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http://dx.doi.org/10.1371/journal.pntd.0009365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8143402PMC
May 2021

Impact of EGFR and EGFR ligand expression on treatment response in patients with metastatic colorectal cancer.

Oncol Lett 2021 Jun 7;21(6):448. Epub 2021 Apr 7.

Department of General, Visceral and Transplantation Surgery, University of Heidelberg, D-69120 Heidelberg, Germany.

Up to 50% of patients with colorectal cancer (CRC) have either synchronous or metachronous hepatic metastases in the course of their disease. Patients with metastatic CRC (mCRC) whose tumors express wild-type KRAS benefit from treatment with monoclonal antibodies (such as cetuximab or panitumumab) that target the epidermal growth factor receptor (EGFR). However, the therapeutic response to these antibodies is variable, and further predictive models are required. The present study examined whether expression of different EGFRs or their ligands in tumors was associated with the response to cetuximab treatment. Tumor tissues, collected during liver resection in 28 patients with mCRC, were analyzed. The protein expression levels of EGFR/ErbB1, ErbB2, ErbB3 and the EGFR ligands heregulin and amphiregulin were determined using Luminex 200 and enzyme-linked immunosorbent assays. Computed tomography or magnetic resonance imaging was performed 4 weeks before and 6-8 weeks after treatment with cetuximab. Response to treatment was assessed using the response evaluation criteria for solid tumors (RECIST). The association between the protein expression levels of different EGFRs and their ligands with RECIST criteria was then analyzed to determine whether these protein levels could predict the treatment response to cetuximab. A total of 12 patients exhibited a partial response, 9 exhibited stable disease and 7 exhibited progressive disease after cetuximab therapy according to RECIST. The expression levels of EGFRs (EGFR/ErbB1, ErbB2 and ErbB3) and their ligands (heregulin and amphiregulin) were not significantly associated with the response to cetuximab therapy. Therefore, the present study indicated that EGFR or EGFR ligand expression did not predict treatment response in patients with CRC with liver metastases following cetuximab therapy.
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http://dx.doi.org/10.3892/ol.2021.12709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045155PMC
June 2021

Portal vein arterialization as a salvage procedure in hepatopancreatobiliary surgery: a systematic review.

Can J Surg 2021 03 19;64(2):E173-E182. Epub 2021 Mar 19.

From the Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany (Majlesara, Ghamarnejad, Khajeh, Golriz, Gharabaghi, Hoffman, Büchler, Mehrabi); and the Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (Chang).

Background: Portal vein arterialization (PVA) is a possible option when hepatic artery reconstruction is impossible during liver resection. The aim of this study was to review the literature on the clinical application of PVA in hepatopancreatobiliary (HPB) surgery.

Methods: We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the PubMed, Embase and Web of Science databases until December 2019. Experimental (animal) studies, review articles and letters were excluded.

Results: Twenty studies involving 57 patients were included. Cholangiocarcinoma was the most common indication for surgery (40 patients [74%]). An end-to-side anastomosis between a celiac trunk branch and the portal vein was the main PVA technique (35 patients [59%]). Portal hypertension was the most common longterm complication (12 patients [21%] after a mean of 4.1 mo). The median followup period was 12 (range 1-87) months. The 1-, 3- and 5-year survival rates were 64%, 27% and 20%, respectively.

Conclusion: Portal vein arterialization can be considered as a rescue option to improve the outcome in patients with acute liver de-arterialization when arterial reconstruction is not possible. To prevent portal hypertension and liver injuries due to thrombosis or overarterialization, vessel calibre adjustment and timely closure of the anastomosis should be considered. Further prospective experimental and clinical studies are needed to investigate the potential of this procedure in patients whose liver is suddenly de-arterialized during HPB procedures.
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http://dx.doi.org/10.1503/cjs.012419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064267PMC
March 2021

Prognostic role of the Donor Risk Index, the Eurotransplant Donor Risk Index, and the Balance of Risk score on graft loss after liver transplantation.

Transpl Int 2021 05 1;34(5):778-800. Epub 2021 May 1.

Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.

This study aimed to identify cutoff values for donor risk index (DRI), Eurotransplant (ET)-DRI, and balance of risk (BAR) scores that predict the risk of liver graft loss. MEDLINE and Web of Science databases were searched systematically and unrestrictedly. Graft loss odds ratios and 95% confidence intervals were assessed by meta-analyses using Mantel-Haenszel tests with a random-effects model. Cutoff values for predicting graft loss at 3 months, 1 year, and 3 years were analyzed for each of the scores. Measures of calibration and discrimination used in studies validating the DRI and the ET-DRI were summarized. DRI ≥ 1.4 (six studies, n = 35 580 patients) and ET-DRI ≥ 1.4 (four studies, n = 11 666 patients) were associated with the highest risk of graft loss at all time points. BAR > 18 was associated with the highest risk of 3-month and 1-year graft loss (n = 6499 patients). A DRI cutoff of 1.8 and an ET-DRI cutoff of 1.7 were estimated using a summary receiver operator characteristic curve, but the sensitivity and specificity of these cutoff values were low. A DRI and ET-DRI score ≥ 1.4 and a BAR score > 18 have a negative influence on graft survival, but these cutoff values are not well suited for predicting graft loss.
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http://dx.doi.org/10.1111/tri.13861DOI Listing
May 2021

Meta-analysis of the effect of the pringle maneuver on long-term oncological outcomes following liver resection.

Sci Rep 2021 Feb 8;11(1):3279. Epub 2021 Feb 8.

Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.

Hepatic pedicle clamping reduces intraoperative blood loss and the need for transfusion, but its long-term effect on survival and recurrence remains controversial. The aim of this meta-analysis was to evaluate the effect of the Pringle maneuver (PM) on long-term oncological outcomes in patients with primary or metastatic liver malignancies who underwent liver resection. Literature was searched in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (via PubMed), and Web of Science databases. Survival was measured as the survival rate or as a continuous endpoint. Pooled estimates were represented as odds ratios (ORs) using the Mantel-Haenszel test with a random-effects model. The literature search retrieved 435 studies. One RCT and 18 NRS, including 7480 patients who underwent liver resection with the PM (4309 cases) or without the PM (3171 cases) were included. The PM did not decrease the 1-year overall survival rate (OR 0.86; 95% CI 0.67-1.09; P = 0.22) or the 3- and 5-year overall survival rates. The PM did not decrease the 1-year recurrence-free survival rate (OR 1.06; 95% CI 0.75-1.50; P = 0.75) or the 3- and 5-year recurrence-free survival rates. There is no evidence that the Pringle maneuver has a negative effect on recurrence-free or overall survival rates.
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http://dx.doi.org/10.1038/s41598-021-82291-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870962PMC
February 2021

A fast and easy-to-learn technique for liver resection in a porcine model.

J Int Med Res 2021 Feb;49(2):300060521990219

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Objective: Despite the recent advances in surgical techniques and perioperative care, liver resection (especially extended hepatectomy) is still a high-risk procedure with considerable morbidity and mortality. Experimental large animal models are the best option for studies in this regard. The present study was performed to present an easy-to-learn, fast, and multipurpose model of liver resection in a porcine model.

Method: Stepwise liver resections (resection of segments II/III, IVa/IVb, and VIII/IV) were performed in eight pigs with intraoperative monitoring of hemodynamic parameters. The technical aspects, tips, and tricks of this method are explained in detail.

Results: Based on the specific anatomical characteristics of the porcine liver, all resection types including segmental resection, hemihepatectomy, and extended hepatectomy could be performed in one animal in an easy-to-learn and fast technique. All animals were hemodynamically stable following stepwise liver resection.

Conclusion: Stepwise liver resection using stapler in a porcine model is a fast and easy-to-learn method with which junior staff and research fellows can perform liver resection up to extended hepatectomy under stable conditions.
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http://dx.doi.org/10.1177/0300060521990219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876770PMC
February 2021

Systematic review and meta-analysis of the efficacy of prophylactic abdominal drainage in major liver resections.

Sci Rep 2021 Feb 4;11(1):3095. Epub 2021 Feb 4.

Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.

Prophylactic drainage after major liver resection remains controversial. This systematic review and meta-analysis evaluate the value of prophylactic drainage after major liver resection. PubMed, Web of Science, and Cochrane Central were searched. Postoperative bile leak, bleeding, interventional drainage, wound infection, total complications, and length of hospital stay were the outcomes of interest. Dichotomous outcomes were presented as odds ratios (OR) and for continuous outcomes, weighted mean differences (MDs) were computed by the inverse variance method. Summary effect measures are presented together with their corresponding 95% confidence intervals (CI). The certainty of evidence was evaluated using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach, which was mostly moderate for evaluated outcomes. Three randomized controlled trials and five non-randomized trials including 5,050 patients were included. Bile leakage rate was higher in the drain group (OR: 2.32; 95% CI 1.18-4.55; p = 0.01) and interventional drains were inserted more frequently in this group (OR: 1.53; 95% CI 1.11-2.10; p = 0.009). Total complications were higher (OR: 1.71; 95% CI 1.45-2.03; p < 0.001) and length of hospital stay was longer (MD: 1.01 days; 95% CI 0.47-1.56 days; p < 0.001) in the drain group. The use of prophylactic drainage showed no beneficial effects after major liver resection; however, the definitions and classifications used to report on postoperative complications and surgical complexity are heterogeneous among the published studies. Further well-designed RCTs with large sample sizes are required to conclusively determine the effects of drainage after major liver resection.
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http://dx.doi.org/10.1038/s41598-021-82333-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862226PMC
February 2021

Considering extended right lobe grafts as major extended donor criteria in liver transplantation is justified.

Transpl Int 2021 04 27;34(4):622-639. Epub 2021 Feb 27.

Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Germany.

The outcomes of split-liver transplantation are controversial. This study compared outcomes and morbidity after extended right lobe liver transplantation (ERLT) and whole liver transplantation (WLT) in adults. MEDLINE and Web of Science databases were searched systematically and unrestrictedly for studies on ERLT and its impact on graft and patient survival, and postoperative complications. Graft loss and patient mortality odds ratios (OR) and 95% confidence intervals (CI) were assessed by meta-analyses using Mantel-Haenszel tests with a random-effects model. Vascular and biliary complications, primary nonfunction, 3-month, 1-, and 3-year graft and patient survival, and retransplantation after ERLT and WLT were analyzed. The literature search yielded 10 594 articles. After exclusion, 22 studies (n = 75 799 adult transplant patients) were included in the analysis. ERLT was associated with lower 3-month (OR = 1.43, 95% CI = 1.09-1.89, P = 0.01), 1-year (OR = 1.46, 95% CI = 1.08-1.97, P = 0.01), and 3-year (OR = 1.37, 95% CI = 1.01-1.84, P = 0.04) graft survival. WL grafts were less associated with retransplantation (OR = 0.57; 95% CI = 0.41-0.80; P < 0.01), vascular complications (OR = 0.53, 95% CI = 0.38-0.74, P < 0.01) and biliary complications (OR = 0.67; 95% CI = 0.47-0.95; P = 0.03). Considering ERLT as major Extended Donor Criteria is justified because ERL grafts are associated with vasculobiliary complications and the need for retransplantation, and have a negative influence on graft survival.
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http://dx.doi.org/10.1111/tri.13824DOI Listing
April 2021

PREventive effect of FENestration with and without clipping on post-kidney transplantation lymphatic complications (PREFEN): study protocol for a randomised controlled trial.

BMJ Open 2020 10 13;10(10):e032286. Epub 2020 Oct 13.

Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany

Introduction: Peritoneal fenestration is an effective preventive method for reducing the rate of lymphatic complications in kidney transplantation (KTx). The size of the fenestration plays an important role in its effectiveness. A large peritoneal window is no longer indicated, due to herniation and difficulties in performing biopsies. Small preventive fenestration is effective but will be closed too early. The aim of this study is to evaluate whether metal clips around the edges of a small fenestration result in optimal effects with minimum fenestration size.

Methods And Analysis: This trial has been initiated in July 2019 and is expected to last for 2 and a half years. All patients older than 18 years, who receive kidneys from deceased donors, will be included. The kidney recipients will be randomly allocated to either a control arm (small fenestration alone) or an intervention arm (small fenestration with clipping). All fenestrations will be round, maximum 2 cm, and close to the kidney hilum. Clipping will be performed with eight metal clips around the peritoneal window (360°) in every 45° in an oblique position. The primary endpoint is the incidence of symptomatic post-KTx lymphatic complications, which require interventional treatment within 6 months after KTx. Secondary endpoints are intraoperative and postoperative outcomes, including blood loss, operation time, severity grade of lymphocele/lymphorrhea and relative symptoms.

Ethics And Dissemination: This protocol study received approval from the Ethics Committee of the University of Heidelberg (Registration Number S-318/2017). A Standard Protocol Items: Recommendations for Interventional Trials checklist is available for this protocol. The results will be disseminated through peer-reviewed journals and conference presentations.

Trial Registration Number: ClinicalTrials.gov Registry (NCT03682627).
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http://dx.doi.org/10.1136/bmjopen-2019-032286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554503PMC
October 2020

Evaluation of the impact of Tacrolimus-based immunosuppression on Heidelberg liver transplant cohort (HDTACRO): Study protocol for an investigator initiated, non-interventional prospective study.

Medicine (Baltimore) 2020 Sep;99(39):e22180

Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital.

Background: Tacrolimus-based immunosuppression has resulted in enormous improvements on liver transplantation (LTx) outcomes. However, dose adjustment and medication adherence play a key role in post-transplant treatment success. The aim of the present study is to assess the trough levels and the need for adaptation of therapeutic doses in de novo LTx patients treated with Tacrolimus in the clinical routine, without any intervention to the treatment regimen.

Methods And Analysis: This is a pilot, prospective, exploratory, monocentric, non-interventional and non-randomized investigator-initiated study. Prospectively maintained data of 100 patients treated with various oral Tacrolimus-based immunosuppressants (Prograf or Envarsus) will be analyzed. The number of required dose adjustments of Tacrolimus formulations used in clinical routine for achieving the target trough level, Tacrolimus trough level, Tacrolimus dosing, concentration/dose ratio, routine laboratory tests, efficacy data (incl. survival, acute rejection, re-transplantation), patients therapy adherence, and infections requiring the need to reduce individual immunosuppressant dosing will be evaluated for each patient.

Result: This study will evaluate the trough levels and the need for adaptation of therapeutic doses in de novo LTx patients treated with Tacrolimus in the clinical routine, without any intervention to the treatment regimen.

Conclusion: The HDTACRO study will be the first study to systematically and prospectively evaluate various oral Tacrolimus-based immunosuppressants in de novo liver transplanted patients. If a difference between the therapy-subgroups is evident at the end of the trial, a randomized control trial will eventually be designed. Registration number: ClinicalTrials.gov: NCT04444817.
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http://dx.doi.org/10.1097/MD.0000000000022180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523857PMC
September 2020

Oral Preconditioning of Donors After Brain Death With Calcineurin Inhibitors vs. Inhibitors of Mammalian Target for Rapamycin in Pig Kidney Transplantation.

Front Immunol 2020 18;11:1222. Epub 2020 Jun 18.

Department of General, Abdominal and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany.

The systemic inflammatory cascade triggered in donors after brain death enhances the ischemia-reperfusion injury after organ transplantation. Intravenous steroids are routinely used in the intensive care units for the donor preconditioning. Immunosuppressive medications could be potentially used for this purpose as well. Data regarding donor preconditioning with calcineurin inhibitors or inhibitors of mammalian target for Rapamycin is limited. The aim of this project is to investigate the effects of (oral) donor preconditioning with a calcineurin inhibitor (Cyclosporine) vs. an inhibitor of mammalian target for Rapamycin (Everolimus) compared to the conventional administration of steroid in the setting of donation after brain death in porcine renal transplantation. Six hours after the induction of brain death, German landrace donor pigs (33.2 ± 3.9 kg) were randomly preconditioned with either Cyclosporine ( = 9) or Everolimus ( = 9) administered via nasogastric tube with a repeated dose just before organ procurement. Control donors received intravenous Methylprednisolone ( = 8). Kidneys were procured, cold-stored in Histidine-Tryptophane-Ketoglutarate solution at 4°C and transplanted in nephrectomized recipients after a mean cold ischemia time of 18 h. No post-transplant immunosuppression was given to avoid confounding bias. Blood samples were obtained at 4 h post reperfusion and daily until postoperative day 5 for complete blood count, blood urea nitrogen, creatinine, and electrolytes. Graft protocol biopsies were performed 4 h after reperfusion to assess early histological and immunohistochemical changes. There was no difference in the hemodynamic parameters, hemoglobin/hematocrit and electrolytes between the groups. Serum blood urea nitrogen and creatinine peaked on postoperative day 1 in all groups and went back to the preoperative levels at the conclusion of the study on postoperative day 5. Histological assessment of the kidney grafts revealed no significant differences between the groups. TNF-α expression was significantly lower in the study groups compared with Methylprednisolone group ( = 0.01) Immunohistochemistry staining for cytochrome c showed no difference between the groups. Oral preconditioning with Cyclosporine or Everolimus is feasible in donation after brain death pig kidney transplantation and reduces the expression of TNF-α. Future studies are needed to further delineate the role of oral donor preconditioning against ischemia-reperfusion injury.
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http://dx.doi.org/10.3389/fimmu.2020.01222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7316124PMC
April 2021

Pringle Maneuver in Extended Liver Resection: A propensity score analysis.

Sci Rep 2020 06 1;10(1):8847. Epub 2020 Jun 1.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Despite the ongoing decades-long controversy, Pringle maneuver (PM) is still frequently used by hepatobiliary surgeons during hepatectomy. The aim of this study was to investigate the effect of PM on intraoperative blood loss, morbidity, and posthepatectomy hemorrhage (PHH). A series of 209 consecutive patients underwent extended hepatectomy (EH) (≥5 segment resection). The association of PM with perioperative outcomes was evaluated using multivariate analysis with a propensity score method to control for confounding. Fifty patients underwent PM with a median duration of 19 minutes. Multivariate analysis revealed that risk of excessive intraoperative bleeding (≥1500 ml; odds ratio [OR] 0.27, 95%-confidence interval [CI] 0.10-0.70, p = 0.007), major morbidity (OR 0.41, 95%-CI 0.18-0.97, p = 0.041), and PHH (OR 0.22, 95%-CI 0.06-0.79, p = 0.021) were significantly lower in PM group after EH. Furthermore, there was no significant difference in 3-year recurrence-free-survival between groups. PM is associated with lower intraoperative bleeding, PHH, and major morbidity risk after EH. Performing PM does not increase posthepatectomy liver failure and does not affect recurrence rate. Therefore, PM seems to be justified in EH.
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http://dx.doi.org/10.1038/s41598-020-64596-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264345PMC
June 2020

Corrigendum to "Meta-analysis of the efficacy of preoperative biliary drainage in patients undergoing liver resection for perihilar cholangiocarcinoma" [Eur. J. Radiol. 125 (2020) 108897].

Eur J Radiol 2020 Jul 29;128:109004. Epub 2020 Apr 29.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Liver Cancer Center Heidelberg, Ruprecht Karls University, Heidelberg, Germany.

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http://dx.doi.org/10.1016/j.ejrad.2020.109004DOI Listing
July 2020

Intraoperative evaluation of hepatic artery blood flow during pancreatoduodenectomy (HEPARFLOW): Protocol of an exploratory study.

Int J Surg Protoc 2020 4;21:21-26. Epub 2020 Apr 4.

Department of General, Visceral and Transplant Surgery, University of Heidelberg, Germany.

Introduction: Pancreatoduodenectomy is the treatment of choice for a range of benign and malignant diseases. The pancreatic head must be separated from its supplying vessels, especially the gastroduodenal artery, during this operation. However, dissection of the gastroduodenal artery can disturb blood supply to the liver and result in liver ischemia. There is currently no well-established algorithm to evaluate and ensure sufficient blood flow in patients with altered hepatic artery blood flow. To address this important issue, this study aims to establish a basis for assessing liver blood supply during pancreatoduodenectomy. Furthermore, factors influencing arterial blood flow and related postoperative complications will be evaluated.

Methods And Analysis: The HEPARFLOW study is a single institutional single-arm prospective exploratory observational clinical trial. All consecutive patients undergoing elective partial or total pancreatoduodenectomy will be screened for inclusion until 100 patients are enrolled. Blood flow in the proper hepatic artery, gastroduodenal artery, portal vein, and additional vessels supplying the liver will be measured during pancreatoduodenectomy using Doppler flowmetry. All patients will be followed up for 90 days after surgery. At each visit, standard clinical data, postoperative complications and mortality will be recorded.

Discussion: This will be the first study to prospectively assess intraoperative flow rates of the hepatic artery and portal vein to evaluate liver blood supply during pancreatoduodenectomy. The preoperative and intraoperative factors influencing blood flow in the hepatic arteries will be identified. This study may also reveal the hemodynamic and clinical relevance of a compression of the celiac axis during pancreatoduodenectomy.

Ethics And Dissemination: This study was approved by the Ethics Committee of the University of Heidelberg (S-073/2018). The results will be published in a peer-reviewed journal and will be presented at medical meetings.
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http://dx.doi.org/10.1016/j.isjp.2020.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182758PMC
April 2020

Expanding pancreas donor pool by evaluation of unallocated organs after brain death: Study protocol clinical trial (SPIRIT Compliant).

Medicine (Baltimore) 2020 Mar;99(10):e19335

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg.

Background: Pancreas graft quality directly affects morbidity and mortality rates after pancreas transplantation (PTx). The criteria for pancreas graft allocation are restricted, which has decreased the number of available organs. Suitable pancreatic allografts are selected based on donor demographics, medical history, and the transplant surgeon's assessment of organ quality during procurement. Quality is assessed based on macroscopic appearance, which is biased by individual experience and personal skills. Therefore, we aim to assess the histopathological quality of unallocated pancreas organs to determine how many unallocated organs are potentially of suitable quality for PTx.

Methods And Analysis: This is a multicenter cross-sectional explorative study. The demographic data and medical history of donor and cause of rejection of the allocation of graft will be recorded. Organs of included donors will be explanted and macroscopic features such as weight, color, size, and stiffness will be recorded by 2 independent transplant surgeons. A tissue sample of the organ will be fixed for further microscopic assessments. Histopathologic assessments will be performed as soon as a biopsy can be obtained. We will evaluate up to 100 pancreata in this study.

Result: This study will evaluate the histopathological quality of unallocated pancreas organs from brain-dead donors to determine how many of these unallocated organs were potentially suitable for transplantation based on a histopathologic evaluation of organ quality.

Conclusion: The comprehensive findings of this study could help to increase the pancreas graft pool, overcome organ shortage, reduce the waiting time, and also increase the number of PTx in the future. Registration number: ClinicalTrials.gov: NCT04127266.
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http://dx.doi.org/10.1097/MD.0000000000019335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478640PMC
March 2020

Meta-analysis of the efficacy of preoperative biliary drainage in patients undergoing liver resection for perihilar cholangiocarcinoma.

Eur J Radiol 2020 Apr 13;125:108897. Epub 2020 Feb 13.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Liver Cancer Center Heidelberg, Ruprecht Karls University, Heidelberg, Germany.

Purpose: A systematic review was performed to evaluate the effect of preoperative biliary drainage (PBD) on outcomes after liver resection in perihilar cholangiocarcinoma (PHCC) patients.

Method: MEDLINE and Web of Science were searched up to March 2019. All studies assessing morbidity, mortality, or recurrence in patients who received PBD and hepatectomy for PHCC were included. Mantel-Haenszel tests with a random-effects model were used for meta-analysis.

Results: Sixteen studies involving 2162 patients were included. PBD was associated with higher major morbidity odds ratio [OR] = 1.51; 95 % confidence interval [CI] = 1.14-2.00). Selecting patients for PBD based on simple selection criteria was associated with significantly higher major morbidity (OR = 1.57; 95 % CI = 1.10-2.25). In contrast, selecting patients for PBD according to strict criteria resulted in lower major morbidity compared with patients without PBD (OR = 0.51; 95 % CI = 0.18-1.42). PBD did not influence mortality (OR = 1.06; 95 % CI = 0.70-1.61). Tumor recurrence was significantly higher in the PBD group (OR = 2.07; 95 % CI = 1.38-3.11). To decrease PBD-related complications, the duration between PBD and hepatectomy should be shorter than two weeks. Most reports described PBD on the future liver remnant side.

Conclusions: Routine PBD cannot be recommended but it may be useful in highly selected patients suffering from cholangitis, malnutrition, and long lasting jaundice, for whom an extended hepatectomy is planned. However, However, routine PBD cannot be recommended due to higher morbidity rate after hepatectomy clear patient selection criteria can be defined for PBD in future multicenter randomized controlled studies.
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http://dx.doi.org/10.1016/j.ejrad.2020.108897DOI Listing
April 2020

How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis.

Ann Surg 2020 Jan 16. Epub 2020 Jan 16.

Swiss HPB & Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.

Objective: The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective.

Background: Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature.

Study Design: This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival.

Results: The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT.

Conclusion: When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.
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http://dx.doi.org/10.1097/SLA.0000000000003753DOI Listing
January 2020

Comparative Analysis of the Discriminatory Performance of Different Well-Known Risk Assessment Scores for Extended Hepatectomy.

Sci Rep 2020 01 22;10(1):930. Epub 2020 Jan 22.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, 69120, Germany.

The aim of this study was to assess and compare the discriminatory performance of well-known risk assessment scores in predicting mortality risk after extended hepatectomy (EH). A series of 250 patients who underwent EH (≥5 segments resection) were evaluated. Aspartate aminotransferase-to-platelet ratio index (APRI), albumin to bilirubin (ALBI) grade, predictive score developed by Breitenstein et al., liver fibrosis (FIB-4) index, and Heidelberg reference lines charting were used to compute cut-off values, and the sensitivity and specificity of each risk assessment score for predicting mortality were also calculated. Major morbidity and 90-day mortality after EH increased with increasing risk scores. APRI (86%), ALBI (86%), Heidelberg score (81%), and FIB-4 index (79%) had the highest sensitivity for 90-day mortality. However, only the FIB-4 index and Heidelberg score had an acceptable specificity (70% and 65%, respectively). A two-stage risk assessment strategy (Heidelberg-FIB-4 model) with a sensitivity of 70% and a specificity 86% for 90-day mortality was proposed. There is no single specific risk assessment score for patients who undergo EH. A two-stage screening strategy using Heidelberg score and FIB-4 index was proposed to predict mortality after major liver resection.
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http://dx.doi.org/10.1038/s41598-020-57748-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6976620PMC
January 2020

Interdisciplinary approach allows minimally invasive, nerve-sparing removal of retroperitoneal peripheral nerve sheath tumors.

Langenbecks Arch Surg 2020 Mar 11;405(2):199-205. Epub 2020 Jan 11.

Department of Neurosurgery, University Hospital Heidelberg, INF 400, 69120, Heidelberg, Germany.

Purpose: En bloc resection of retroperitoneal peripheral nerve sheath tumors (PNST) is advocated by a variety of surgical disciplines. Yet, microsurgical, nerve-sparing tumor resection might be better suited to improve symptoms and maintain neurological function, especially in cases where patients present with preoperative neurological deficits. However, neurosurgeons, versed in nerve-sparing techniques to remove PNST, are generally unfamiliar with the visceral approaches to retroperitoneal PNST.

Methods: We retrospectively evaluate a series of 16 patients suffering from retroperitoneal PNST. Patients were treated by a unique interdisciplinary approach, combining the visceral surgeon's skills to navigate the complex anatomy of the retroperitoneal space and the neurosurgeon's familiarity with microsurgical, nerve-sparing tumor removal. Specifically, we assess whether our interdisciplinary approach is suited to improve preoperative symptoms and maintain neurological function and study whether oncological outcome, surgical morbidity, and operative times are comparable to those reported for "classical" retroperitoneal PNST resection. In addition, we study two cases of suspected PNST that were diagnosed as malignant peripheral nerve sheath tumors (MPNST) after surgery.

Results: Total macroscopic tumor resection was achieved in 14/16 PNST patients. Mean intraoperative blood loss was 680.6 ml (95% CI, 194.3-1167.0 ml) and mean operative time was 162.5 min (95% CI, 121.6-203.4 min). We did not record any major postoperative surgical or neurological complications. A total of 8/11 patients with preoperative pain symptoms reported long-lasting improvement of their symptoms. In terms of oncological outcome, all patients that had been subjected to total tumor removal and for whom follow-up was available, were tumor-free after a mean follow-up of 761.9 days (95% CI, 97.6-1426.0 days). One of the two MPNST patients, who presented with tumor progress 15 months after initial surgery, was subjected to radical re-resection.

Conclusions: Interdisciplinary, nerve-sparing removal of retroperitoneal PNST is well suited to improve preoperative symptoms and maintain neurological function, while achieving an oncological outcome and a surgical morbidity similar to previously reported results for radical retroperitoneal PNST resection. Radical re-resection was feasible in a patient with post hoc MPNST diagnosis.
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http://dx.doi.org/10.1007/s00423-019-01851-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239799PMC
March 2020

Liver Grafts with Major Extended Donor Criteria May Expand the Organ Pool for Patients with Hepatocellular Carcinoma.

J Clin Med 2019 Oct 15;8(10). Epub 2019 Oct 15.

Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany.

The major extended donor criteria (maEDC; steatosis >40%, age >65 years, and cold ischemia time >14 h) influence graft and patient outcomes after liver transplantation. Despite organ shortages, maEDC organs are often considered unsuitable for transplantation. We investigated the outcomes of maEDC organ liver transplantation in patients with hepatocellular carcinoma (HCC). Two hundred and sixty-four HCC liver transplant patients were eligible for analysis. Risk factor analysis was performed for early allograft dysfunction; primary nonfunction; 30-day and 90-day graft failure; and 30-day, 90-day, and 1-year patient mortality. One-year graft survival was higher in recipients of no-maEDC grafts. One-year patient survival did not differ between the recipients of no-maEDC and maEDC organs. The univariate and multivariate analyses revealed no association between maEDC grafts and one-year patient mortality. Graft survival differed between the recipients of no-maEDC and maEDC organs after correcting for a laboratory model of end-stage liver disease (labMELD) score with a cut-off value of 20, but patient survival did not. Patient survival did not differ between recipients who did and did not meet the Milan criteria and who received grafts with and without maEDC. Instead of being discarded, maEDC grafts may expand the organ pool for patients with HCC without impairing patient survival or recurrence-free survival.
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http://dx.doi.org/10.3390/jcm8101692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832253PMC
October 2019

Evaluation of the role of transhepatic flow in postoperative outcomes following major hepatectomy (THEFLOW): study protocol for a single-centre, non-interventional cohort study.

BMJ Open 2019 10 11;9(10):e029618. Epub 2019 Oct 11.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany

Introduction: Liver resection is the only curative treatment for primary and secondary hepatic tumours. Improvements in perioperative preparation of patients and new surgical developments have made complex liver resections possible. However, small for size and flow syndrome (SFSF) is still a challenging issue, rendering patients inoperable and causing postoperative morbidity and mortality. Although the role of transhepatic flow in the postoperative outcome has been shown in small partial liver transplantation and experimental studies of SFSF, this has never been studied in the clinical setting following liver resection. The aim of this study is to systematically evaluate transhepatic flow changes following major liver resection and its correlation with postoperative outcomes.

Methods And Analysis: The TransHEpatic FLOW (THEFLOW) study is a single-centre, non-interventional cohort study, and aims to enrol 50 patients undergoing major hepatectomy (defined as hemihepatectomy or extended hepatectomy based on the Brisbane classification) with or without prior chemotherapy. The portal venous flow, hepatic artery flow and portal venous pressure are measured before and after each resection. All patients are followed-up for 3 months after the operation. During each evaluation, standard clinical data, posthepatectomy liver failure and overall morbidity and mortality will be recorded. THEFLOW study was initiated on 25 March 2018 and is expected to progress for 2 years.

Ethics And Dissemination: This protocol study received approval from the Ethics Committee of the University of Heidelberg (registration number: S576/2017). The results of this study will be published in a peer-reviewed journal, and will also be presented at medical meetings.

Trial Registration Number: NCT03762876.
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http://dx.doi.org/10.1136/bmjopen-2019-029618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797302PMC
October 2019

Prognostic Impact of Ventral Versus Dorsal Tumor Location After Total Mesorectal Excision of Rectal Cancer.

Ann Surg Oncol 2020 Feb 23;27(2):430-438. Epub 2019 Sep 23.

Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.

Background: Multidisciplinary treatment of rectal cancer, including neoadjuvant treatment, total mesorectal excision, and adjuvant chemotherapy, have improved oncological outcome. Preoperative radiation therapy is advocated by national and international guidelines in all patients with AJCC stage II and III rectal cancer. Although this treatment reduces local recurrence rates with no effect on overall survival, there are possible short- and long-term side effects of radiation exposure, so patients should be carefully selected for neoadjuvant radiation therapy.

Methods: We analyzed whether ventral or dorsal tumor location affects local recurrence rates following radical rectal resection. Patients who underwent radical rectal resection for mid or low rectal cancer in our department between October 2001 and December 2013 were included. Prognostic indicators for local recurrence were analyzed using univariate and multivariate analyses.

Results: Overall, 480 patients met the inclusion criteria. Univariate analysis identified surgical procedure (hazard ratio [HR] 1.9, p = 0.006), ventral tumor location (HR 3.8, p < 0.001), and a pathologic circumferential resection margin (pCRM) (HR 9.3, p < 0.001) as prognostic factors of local recurrence. Multivariate analysis revealed tumor location (HR 3.5, p < 0.001) and pCRM (HR 6.0, p = 0.002) as independent factors for local recurrence. Neoadjuvant treatment of AJCC stage II and III tumors reduced the local recurrence rate at ventral but not at dorsal tumor locations (p < 0.001).

Conclusions: Ventral versus dorsal tumor location is an independent prognostic factor for local recurrence. Tumor location may aid in patient selection for neoadjuvant treatment.
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http://dx.doi.org/10.1245/s10434-019-07842-6DOI Listing
February 2020

Pre-transplant CD200 and CD200R1 concentrations are associated with post-transplant events in kidney transplant recipients.

Medicine (Baltimore) 2019 Sep;98(37):e17006

Department of General, Visceral and Transplant Surgery.

CD200 is an immunoglobulin superfamily membrane protein that binds to a myeloid cell-specific receptor and induces inhibitory signaling. The aim of this study was to investigate the role of CD200 and its receptor (CD200R1) on kidney transplant (KTx) outcome. In a collective of 125 kidney recipients (University hospital, Heidelberg, Germany), CD200 and CD200R1 concentrations were evaluated immediately before transplantation. Recipient baseline and clinical characteristics and KTx outcome, including acute rejection (AR), acute tubular necrosis, delayed graft function, cytomegalovirus (CMV) and human polyomaviridae (BK) virus infections, and graft loss were evaluated during the first post-transplant year. The association of CD200 and CD200R1 concentrations and CD200R1/CD200 ratios with the outcome of KTx was investigated for the first time in a clinical setting in a prospective cohort. There was a positive association between pre-transplant CD200R1 concentrations and CMV (re)activation (P = .041). Also, increased CD200R1 concentration was associated with a longer duration of CMV infection (P = .049). Both the frequency of AR and levels of creatinine (3 and 6 months after KTx) were significantly higher in patients with an increased CD200R1/CD200 ratio (median: 126 vs 78, P = .008). Increased pre-transplant CD200R1/CD200 ratios predict immunocompetence and risk of AR, whereas high CD200R1 concentrations predict immunosuppression and high risk of severe CMV (re)activation after KTx.
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http://dx.doi.org/10.1097/MD.0000000000017006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750316PMC
September 2019

Standardized endocystectomy technique for surgical treatment of uncomplicated hepatic cystic echinococcosis.

PLoS Negl Trop Dis 2019 06 21;13(6):e0007516. Epub 2019 Jun 21.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Background: Two surgical options are available for cystic echinococcosis (CE). The two principal approaches are radical (resection of the cyst) and conservative (evacuation of the cyst content and partial removal of the cyst capsule). Here, we describe a standardized endocystectomy technique for hepatic echinococcosis.

Subjects And Methods: Twenty-one patients (male/female: 4/3; median age: 28 years) with uncomplicated, isolated hepatic CE (cyst stages WHO CE1, 2, 3a, and 3b) that were treated with the standardized endocystectomy described in this paper. Before the operation and during the follow-up period (mean: 33.8 months, median: 24 months), patients underwent clinical and sonographical and/or magnetic resonance imaging assessment during regular visits managed by an interdisciplinary team.

Results: Forty-seven cysts were treated with the standardized endocystectomy technique. The median number of cysts per patient was two (range: 1-8). Nine patients (43%) had a single cystic lesion. The median operation time was 165 minutes and the median intraoperative bleeding volume was 200 mL. The median hospital stay was nine days (range: 6-28 days). Morbidity (Clavien-Dindo III) occurred in four patients (19%). No mortality and no recurrence were found during the median follow-up time of 24 months.

Conclusions: The standardized endocystectomy technique presented is a safe procedure with acceptable morbidity, no mortality, and without recurrences in our patient series. Important components of our CE management are interdisciplinary patient care, adequate diagnostic work-ups, and regular pre- and postoperative visits, including long-term follow-up for early and reliable capture of recurrences.
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http://dx.doi.org/10.1371/journal.pntd.0007516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6608982PMC
June 2019

Histopathological effects of modern topical sealants on the liver surface after hepatectomy: an experimental swine study.

Sci Rep 2019 05 8;9(1):7088. Epub 2019 May 8.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

The present study aimed to determine the impact of different sealant materials on histopathological changes to the liver surface after liver resection. Thirty-six landrace pigs underwent left anatomical hemihepatectomy and were assigned to a histopathological control group (HPC, n = 9) with no bleeding control, a clinically simulated control group (CSC, n = 9) with no sealant but bipolar cauterization and oversewing of the liver surface, and two treatment groups (n = 9 each) with a collagen-based sealant (CBS) or a fibrinogen-based sealant (FBS) on resection surface. After postoperative day 6, tissue samples were histologically examined. There were no significant differences in preoperative parameters between the groups. Fibrin production was higher in sealant groups compared with the HPC and CSC groups (both p < 0.001). Hepatocellular regeneration in sealant groups was higher than in both control groups. A significantly higher regeneration was seen in the FBS group. Use of sealants increased the degree of fibrin exudation at the resection plane. Increased hepatocellular necrosis was seen in the CBS group compared with the FBS group. The posthepatectomy hepatocellular regeneration rate was higher in the FBS group compared with the CBS group. Randomized studies are needed to assess the impact of sealants on posthepatectomy liver regeneration in the clinical setting.
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http://dx.doi.org/10.1038/s41598-019-43694-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6506469PMC
May 2019

Prophylactic onlay reinforcement with absorbable mesh (polyglactin) is associated with less early wound complications after kidney transplantation: A preliminary study.

J Biomed Mater Res B Appl Biomater 2020 01 21;108(1):67-72. Epub 2019 Mar 21.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Incidence of wound complications after kidney transplantation (KTx) is still considerable. Here, we report the impact of prophylactic absorbable polyglactin (Vicryl®) mesh reinforcement on the incidence of short-term post-KTx wound complications. Sixty-nine patients were analyzed; 23 with and 46 without preventive onlay mesh reinforcement. Surgical site infections (SSI) were seen in six (26%) patients in the mesh group and in 17 (37%) patients in no-mesh group. A lower, but not statistically significant, rate of early postoperative wound complications occurred in the mesh group. Wound complications were observed in seven (30%) patients in the mesh group and in 23 (50%) patients in the no-mesh group. There was no association between mesh placement and SSI incidence (odds ratios [OR] 0.60, 95% confidence interval [CI] 0.20-1.82, p = 0.369) and wound complications (OR 0.44, 95% CI 0.15-1.26, p = 0.126). Therefore, we conclude that mesh reinforcement does not increase the risk of SSI and overall wound complications. Long-term outcomes have to be evaluated in a randomized trial setting. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 108B:67-72, 2020.
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http://dx.doi.org/10.1002/jbm.b.34366DOI Listing
January 2020

Technical Aspects of Stapled Hepatectomy in Liver Surgery: How We Do It.

J Gastrointest Surg 2019 06 28;23(6):1232-1239. Epub 2019 Feb 28.

Division of Liver Surgery, Department of General, Visceral, and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.

There are diverse approaches to parenchymal transection and the preferred approach remains controversial among liver surgeons. Stapling devices, which were initially established for vascular control, have been the standard parenchymal transection technique in many departments for more than 15 years. This article describes the technical aspects, tips, and tricks of stapled hepatectomy using right hemihepatectomy as an example. The existing literature on this topic is also reviewed.
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http://dx.doi.org/10.1007/s11605-019-04159-3DOI Listing
June 2019

Promising Long-Term Outcomes After Pelvic Exenteration.

Ann Surg Oncol 2019 May 5;26(5):1340-1349. Epub 2018 Dec 5.

Chirurgische Klinik I, Lukaskrankenhaus Neuss, Neuss, Germany.

Background: Pelvic exenteration (PE) is a complex and challenging surgical procedure. The reported results of this procedure for primary and recurrent disease are limited and conflicting.

Methods: This study analyzed patient outcomes after all PEs performed in the authors' department between October 2001 and December 2016. Relevant patient data were obtained from a prospective database. Morbidity and mortality were reported for all patients. For patients with malignant disease, differences in perioperative outcomes, prognostic indicators for overall survival, and local and systemic disease recurrence were analyzed using uni- and multivariate analyses.

Results: The study enrolled 187 patients. Of the 183 patients with malignant disease, 63 (38.2%) had primary locally advanced tumors and 115 (62.5%) had recurrent tumors. The 10-year overall survival rate was 63.5% for the patients with primary tumors that were curatively resected and 20.9% for the patients with recurrent disease (p = 0.02). The 10-year survival rate for the patients with extrapelvic disease who underwent curative resection was 37%. Multivariable analysis identified margin positivity (p < 0.01), surgery lasting longer than 7 h (p = 0.02), and recurrent disease (p < 0.01) as predictors of poor survival. Multivariate analysis of local and systemic disease recurrence showed recurrent disease (p < 0.01) as the only significant prognostic factor.

Conclusions: Pelvic exenteration has good long-term results, even for patients with extrapelvic disease. The oncologic outcome for patients with recurrent disease is worse than for patients with primary disease. However, even for these patients, long-time survival is possible.
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http://dx.doi.org/10.1245/s10434-018-07090-0DOI Listing
May 2019

Preoperative Thrombocytopenia May Predict Poor Surgical Outcome after Extended Hepatectomy.

Can J Gastroenterol Hepatol 2018 1;2018:1275720. Epub 2018 Nov 1.

Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.

Background: It is a novel idea that platelet counts may be associated with postoperative outcome following liver surgery. This may help in planning an extended hepatectomy (EH), which is a surgical procedure with high morbidity and mortality.

Aim: The aim of this study was to evaluate the predictive potential of platelet counts on the outcome of EH in patients without portal hypertension, splenomegaly, or cirrhosis.

Methods: A series of 213 consecutive patients underwent EH (resection of ≥ five liver segments) between 2001 and 2016. The association of preoperative platelet counts with posthepatectomy liver failure (PHLF), morbidity (based on Clavien-Dindo classification), and 30-day mortality was evaluated using multivariate analysis.

Results: PHLF was detected in 26.3% of patients, major complications in 26.8%, and 30-day mortality in 11.3% of patients. Multivariate analysis revealed that the preoperative platelet count is an independent predictor of PHLF (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.3-15.0, =0.020) and 30-day mortality (OR 4.4, 95% CI 1.1-18.8, =0.043).

Conclusions: Preoperative platelet count is associated with PHLF and mortality following extended liver resection. This association was independent of other related parameters. Prospective studies are needed to evaluate the predictive role and to determine the impact of preoperative correction of platelet count on postoperative outcomes after EH.
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http://dx.doi.org/10.1155/2018/1275720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236772PMC
May 2019
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