European Surgery-Acta Chirurgica Austriaca最新文献

Background: In primary hyperparathyroidism (pHPT), quick intraoperative parathyroid hormone monitoring (IOPTH) is performed to predict complete excision of hyperfunctioning tissue and therefore cure. In recent years, efforts have been made to make this prediction more accurate and to shorten the duration of the test, respectively, and therefore reduce waiting and total operating time. The aim of this study was to evaluate the practicability and safety of a time-reduced criterion (decline ≥ 35% after 5 min) in a large cohort of patients.

Methods: In an 11-year period, all patients operated for pHPT were analyzed. After preoperative localization studies, hyperfunctioning parathyroid tissue was removed and IOPTH monitoring was performed. Intraoperatively, a decline of ≥50% from baseline 10 min after excision of the gland predicted cure. The performance of an interpretation model, using an earlier PTH level was analyzed retrospectively (decline ≥ 35% from baseline 5 min after excision). Differences in sensitivity, specificity, positive/negative predictive value and accuracy were calculated.

Results: According to the inclusion criteria, 1018 patients were analyzed. IOPTH predicted cure in 854 patients (83.9%) 10 min after gland excision with a false positive decline in 13 patients (1.5%). Applying the modified criterion (≥35% decline within 5 min), 814 patients (80%) showed an appropriate decline (false positive in 18 [2.2%]). Overall, multiple gland disease would have been missed in 7 patients. McNemar's test showed a significantly lower sensitivity, specificity and accuracy applying the "35%" criterion.

Conclusions: In an endemic goiter region, a criterion, demanding a ≥ 35% decline 5 min after excision can not be recommended for IOPTH monitoring in patients with pHPT.

Background: A right trisectionectomy with portal vein resection represents the conventional approach for hilar cholangiocarcinoma. Here, we present a technical modification of hilar en bloc resection in order to increase the remnant volume by partially preserving liver segment 4.

Methods: The caudal parenchymal dissection line starts centrally between the left lateral and left medial segments. Cranially, the resection line switches to the right towards Cantlie's line and turns again upwards perpendicularly. Hence, segment 4a and subtotal segment 4b are partially preserved by this novel technique. The left hepatic duct is dissected at the segmental ramification and reconstruction is performed as a single hepaticojejunostomy. The feasibility of the novel parenchyma-sparing approach for hilar cholangiocarcinoma was proven in a case series and medical records were reviewed retrospectively.

Results: Ten patients (6 male, 4 female) underwent segment 4 partially preserving right trisectionectomy for hilar cholangiocarcinoma. Estimated future liver remnant volume was significantly increased (FLRV 38.3%), when compared to standard right trisectionectomy (FLRV 23.9%; p < 0.01). Three of 10 liver resections were associated with major surgical complications (≥IIIb; n = 3); categorized according to the Dindo-Clavien classification. No patient died due to complications associated with postoperatively impaired liver function. Tumor-free margins could be achieved in 8 patients while median overall survival and disease-free survival were 547 and 367 days, respectively.

Conclusion: This novel parenchyma-sparing modification of hilar en bloc resection by partially preserving segment 4 allows to safely increase the remnant liver volume without neglecting principles of local radicality.

Background: The standardized Clavien-Dindo classification of surgical complications is applied as a simple and widely used tool to assess and report postoperative complications in general surgery. However, most documentation uses this classification to report surgery-related morbidity and mortality in a single field of surgery or even particular intervention. The aim of the present study was to present experiences with the Clavien-Dindo classification when applied to all patients on the general surgery ward of a tertiary referral care center.

Methods: We analyzed a period of 6 months of care on a ward with a broad range of general and visceral surgery. Discharge reports and patient charts were analyzed retrospectively and reported complications rated according to the most recent Clavien-Dindo classification version. The complexity of operations was assessed with the Austrian Chamber of Physicians accounting system.

Results: The study included 517 patients with 817 admissions, of whom 463 had been operated upon. Complications emerged in 12.5%, of which 19% were rated as Clavien I, 20.7% as Clavien II, 13.8% as Clavien IIIa, 27.6% as Clavien IIIb, 8.6% as Clavien IVa, and 10.3% as Clavien V. No Clavien grade IVb complication occurred within the investigation. Patients having undergone more complex surgery or with higher scores experienced significantly longer lengths of hospital stay.

Conclusion: The Clavien-Dindo classification can easily be used to document complication rates in general surgery, even though this collective was not included in the original validation studies of Clavien et al. and consisted of more heavily impaired patients.

[This corrects the article DOI: 10.1007/s10353-017-0507-8.].

An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.

Surgical resection remains the only proven curative treatment for peri-hilar cholangiocarcinoma. Despite recent advances in liver surgery techniques and perioperative care, resection for peri-hilar cholangiocarcinoma remains associated with significant morbidity and mortality. Considerable variation in the perioperative management of these patients exists. Optimal perioperative management has the potential to deliver improved outcomes. This article seeks to summarize the evidence underpinning best practice in the perioperative care of patients undergoing resection of peri-hilar cholangiocarcinoma. The authors also seek to identify areas where research efforts and future clinical trials should be targeted.

Background: Management of benign liver tumours (BLT) is still object of discussion. Uncertainty still exists about patient selection, details of management, indications for surgical intervention and potential surgery-related complications. The up-to-date strategies for management of the most common benign solid tumours are recapitulated in this article. In addition, recommendations concerning practical issues are presented.

Methods: Available data from peer-reviewed publications associated with the major controversies concerning treatment strategies of solid BLT were selected through a PubMed literature search.

Results: Non-randomized controlled trials, retrospective series and case reports dominate the literature. Conservative management in BLT is associated with low overall morbidity and mortality when applied in an appropriate patient population. Surgical intervention is indicated solely in the presence of progressive symptoms and suspicion of a malignant change. Linking abdominal symptoms to BLT should be interpreted with caution. No evidence is recorded for malignant transformation in haemangiomas and focal nodular hyperplasia (FNH), while a subgroup of hepatocellular adenoma (HCA) is associated with malignancy. Follow-up controls of BLT at 3 and 6 months should be sufficient to prove the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely. However, many questions regarding this topic remain without definitive answers in the literature.

Conclusion: Conservative management of solid BLT is a worldwide trend, but the available literature does not provide high-grade evidence for this strategy. Consequently, further prospective investigations on the unclear aspects are required. Hence, this article summarises practical highlights of therapeutic strategies.

Background: While liver surgery has become a safe and feasible operation technique, the incidence of postoperative liver dysfunction still remains a central problem. Approximately 10% of patients undergoing liver resection were shown to develop liver dysfunction, which is associated with an increased risk of morbidity and mortality. Yet, to date there is no effective treatment option for postoperative liver dysfunction available. The development of postoperative liver dysfunction was linked to a disruption in the liver's potential to regenerate. Thus, it is importance to elucidate the underlying mechanisms of liver regeneration and to find potential therapeutic targets for the treatment of patients with postoperative liver dysfunction.

Methods: A review of the literature was carried out.

Results: We report on potential future interventions for improvement of liver regeneration after surgical resection. Moreover, we evaluate the benefits and drawbacks of hepatic progenitor cell therapy and hematopoietic stem cell therapy. However, the most significant improvement seems to come from molecular targets. Indeed, von Willebrand factor and its pharmacologic manipulation are among the most promising therapeutic targets to date. Furthermore, using the example of platelet-based therapy, we stress the potentially adverse effects of treatments for postoperative liver dysfunction.

Conclusion: The present review reports on the newest advances in the field of regenerative science, but also underlines the need for more research in the field of postoperative liver regeneration, especially in regard to translational studies.

Background: Non-operative management (NOM) of blunt hepatic and splenic injuries has become popular in haemodynamically stable adult patients, despite uncertainty about efficacy, patient selection, and details of management. Up-to-date strategies and practical recommendations are presented.

Methods: A selective literature search was conducted in PubMed and the Cochrane Library (1989-2016).

Results: No randomized clinical trial was found. Non-randomized controlled trials and large retrospective and prospective series dominate. Few systematic reviews and meta-analyses are available. NOM of selected patients with blunt liver and spleen injuries is associated with low morbidity and mortality. Only data of limited evidence are available on intensity and duration of patient monitoring, repeat imaging, antithrombotic prophylaxis and return to normal activity. There is high-level evidence on early mobilisation and post-splenectomy vaccination.

Conclusion: NOM of blunt liver or spleen injuries is a worldwide trend, but the literature does not provide high-grade evidence for this strategy.

Whereas liver resection for colorectal metastasis has become standard of care, hepatectomy in patients with non-colorectal metastases remains controversial, mainly due to a heterogeneous tumor biology and missing data from prospective trials. This review aims at giving an overview about the indications and limits of liver surgery in patients with an advanced disease of a non-colorectal malignancy. Even though prospective trials are largely missing, results from retrospective studies indicate a survival benefit for liver resection in selected patients. Thus, in metastasized patients, treatment strategies should be developed in a multidisciplinary tumor board including an experienced liver surgeon.