Introduction: Biliary leakage after biliary reconstruction (BR) is a common complication.Bile duct resection with combined liver resection (LR) increases the risk of complications even further. Literature on surgical outcome for BR in combination with LR is sparse and clinical management challenging. We therefore aimed to determine the incidence and risk factors for complications after combined liver and bile duct resection with a focus on operative or endoscopic re-interventions. Method: Data from consecutive patients who underwent LR and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases. Results: Within a median follow-up of 34 months, 921 patients underwent LR with concomitant BR. Re-intervention (surgical or endoscopical) rate was 5.4%. Male sex (p=0.048), perineural infiltration (p<0.001), preoperative jaundice (p<0.001), use of preoperative biliary drainage (p<0.001), intraoperative biliary drainage (p=0.007), Pringle maneuver (p<0.001) and postoperative abdominal drainage (p<0.001) increased the risk of re-intervention after LR and BR. Moreover, overall morbidity other than related to BR was 84%. Re-intervention correlated with increased incidence of postoperative liver failure (p=0.036), bile leakage on cut surface, cholangitis, hemorrhage and sepsis (all p<0.001). Median overall survival was comparable for patients with and without need for re-intervention (36 vs. 32months). Conclusions: This multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients` postoperative course negatively.

Background: The value of liver resection (LR) for metachronous pancreatic ductal adenocarcinoma (PDAC) metastases remains controversial. However, in light of increasing safety of liver resections, surgery might be a valuable option for metastasized PDAC in selected patients. Methods: We performed a retrospective, multicenter study including patients undergoing hepatectomy for metachronous PDAC liver metastases between 2004 and 2015 to analyze postoperative outcome and overall survival. All patients were operated with curative intent. Patients with oligometastatic metachronous liver metastasis with definitive chemotherapy (n = 8) served as controls. Results: Overall 25 patients in seven centers were included in this study. The median age at the time of LR was 63.8 years (56.9-69.9) and the median number of metastases in the liver was 1 (IQR 1-2). There were eight non anatomical resections (32%), 15 anatomical minor (60%) and 2 major LR (8%). Postoperative complications occurred in eleven patients (eight Clavien-Dindo grade I complications (32%) and three grade IIIa complications (12%), respectively). The 30-day mortality was 0%. The median length of stay was 8.6 days (IQR 5-11). Median overall survival following LR was 36.8 months compared to 9.2 months in patients with metachronous liver metastasis with chemotherapy (p = 0007). Discussion: Liver resection for metachronous PDAC metastasis is safe and feasible in selected patients. To address general applicability and to find factors for patient selection, larger trials are urgently warranted.

Background: While the number of laparoscopic liver resections (LLRs) is increasing worldwide, its impact on physical recovery remains unclear. We hypothesized that LLR is associated with better physical recovery than open liver resection (OLR). To address this question, we investigated the impact of laparoscopic liver resection compared to open liver resection on physical recovery in a prospective trial. Methods: Twenty-one patients who underwent LR were included in this study (11 OLR (52.4%) and 10 LLR (47.6%), respectively). Physical recovery was measured by bicycle stress testing at months 1 and 6 after surgery and compared to preoperative stress testing. Standardized performance for bicycle stress testing was calculated based on age, sex, height and weight. Physical recovery was compared between groups as change of performance (%). Results: Median age was 58 years (Inter Quartile Range (IQR): 44-68), and the main indications for LR were colorectal liver metastases (n = 10; 45%) and hepatocellular carcinoma (n = 6; 27%). The one-month change of performance level was - 8% (IQR: -12-1) compared to the preoperative level with no significant difference between open and laparoscopic LR (LLR: -8% (-11 - 1); OLR: -6% (-12 - 4), p = 0.833). Furthermore, 6 months postoperatively, patients in both groups had not reached back their preoperative performance level (LLR: -5.7% ( - 8.4 - 18.6); OLR -4. 8% ( -12.6 - 1.9), p = 0.833). Conclusion: In this study, we report an impaired physical recovery after LR that was not fully restored 6 months after surgery. There was no significant difference between open and laparoscopic LR in terms of bicycle stress testing. Limitations of the study include the limited sample size and differences, albeit non-statistically significant, in the baseline characteristics of the two groups. To rule out a possible role of age or underlying indication for liver resection on physical recovery, future randomized controlled trials need to be performed.

BACKGROUND: It is not clear to what extent laparoscopic hepatectomies can replace conventional open liver resections for colorectal cancer liver metastases (CLM) following the same parenchymal sparing strategy. METHODS: Preoperative imaging results of 254 consecutive open liver resections for CLM were retrospectively analyzed regarding rates of potential laparoscopic resections and differences in the surgical strategy. RESULTS: Group A: the same strategy as in open surgery seemed possible in 77 (30.3%) resections; group B: a different laparoscopic strategy appeared necessary in 54 (21.3%) resections; and group C: laparoscopic resection was currently not recommendable in 123 (48.4%) resections. CONCLUSIONS: Laparoscopic resection seemed a feasible alternative to open surgery in 131 cases (groups A+B, 52%). Potential disadvantages of a more liberal use of large anatomical resections should limit laparoscopic surgery to patients undergoing the same type of resection as in open surgery (group A, 30.3%).

Patients with “hepatic” bone disease exhibit increased fracture incidence. The effects on bone material properties, their changes due to orthotopic liver transplantation (OLT), as well as zolendronate (ZOL) treatment have not yet been investigated. We studied bone mineralization density distribution (BMDD) in paired transiliacal biopsies (at and 6 months after OLT) from patients (control CON n = 18, treatment group ZOL n = 21, the latter treated with i.v. ZOL at doses of 4 mg/month) for how bone at the material level was affected by the “hepatic” disease in general, as well as by OLT and ZOL in particular. (1) BMDD parameters at baseline reflected disturbed bone matrix mineralization in “hepatic” bone disease combined with low turnover. Trabecular bone displayed a decrease in mean and most frequent calcium concentration (CaMEAN −2.9% and CaPEAK −2.8%, respectively; both P < 0.001), increased heterogeneity of mineralization (CaWIDTH +12.2%, P = 0.01), and increased percentage of bone areas with low mineralization (CaLOW +32.4%, P = 0.02) compared to normal; however, there were no differences compared to cortical bone. (2) Six months after OLT, ZOL-treated trabecular bone displayed reduced CaLOW (−32.0%, P = 0.047), cortical bone increased CaMEAN (+4.2%, P = 0.009), increased CaPEAK (+3.3%, P = 0.040), and decreased CaLOW (−55.7, P = 0.038) compared to CON and increased CaMEAN compared to baseline (+1.9, P = 0.032) without any signs of hyper- or defective mineralization. These changes as consequence of the antiresorptive action of ZOL visible already after 6 months result in beneficial effects on bone matrix mineralization, likely contributing to the significant decrease in fracture incidence observed in these patients 2 years post transplantation.

Endoscopic procedure was: combination of balloon dilatation and endoprothesis insertion, or endoprothesis alone or ballon dilatation alone.Technical complication rate (5 of 184, 2.7%) was: mild pancreatitis (4 patients) and minor bleeding after sphinterotomy (one patient).Symptomatic prothesis obstruction occurred in 13 patients during the follow-up.Endoscopic treatment was successful in 45 of 61 patients (73%).There was no difference in survival between patients who did and did not undergo ERCP Conclusion: ERCP should be the first intention for diagnosis and treatment of BC after OLT.Endoscopic therapy is safe and effective for the majority of BC.11681

Aims Safety of liver surgery for colorectal cancer liver metastases after neoadjuvant chemotherapy has to be re-evaluated. Patients and methods Two hundred Patients were prospectively analyzed after surgery for colorectal cancer liver metastases between 2001 and 2004 at our institution. Special emphasis was given to perioperative morbidity and mortality under modern perioperative care. Results There was no in-hospital mortality and the perioperative morbidity was 10% (20/200). Four patients had to be reoperated due to bile leak or intraabdominal abscess. The remainder either had infectious complications or pleural effusion and/or ascites requiring tapping. Variables strongly associated with decreased survival were T, N, G and UICC (International Union against cancer) classification of the primary, hepatic lesions>5 cm and elevated tumour markers. Short disease free interval and neoadjuvant chemotherapy without response predicted impaired recurrence free survival (RFS). Multivariate analysis revealed lymph node status and differentiation of the primary, presence of extrahepatic tumour and gender as factors associated with decreased survival. Administration of neoadjuvant chemotherapy was not associated with higher postoperative morbidity or prolonged hospital stay. Conclusions Modern dissection techniques and improved perioperative care contributed to a very low rate of surgery-related morbidity (10%) and a zero percent mortality which was also observed in patients pretreated with neoadjuvant chemotherapy prior to resection. Liver resection in experienced hands has become a safe part in the potentially curative attempt of treating patients with metastatic colorectal cancer.

The Division of Transplantation at the Medical University of Vienna, Austria was established by Dr Franz Piza, who performed the first deceased donor kidney transplantation in Vienna in 1965. During the next 43 years, 4,849 transplants were performed at this unit. Data were analysed in the time period 1993-2006 for 2,165 deceased donor transplants (1,734 first and 431 regrafts) and 263 living donor transplants. Long-term follow-up was available for more than 95% of all grafts and all recipients had at least 9 months of follow-up. Two- and 6-year graft survival rates were 81.4% and 66.3%, respectively, for first deceased donor grafts, 76.1% and 61.8% for regrafts and 91.5% and 79.1% for living transplants. Appropriate immunosuppression, HLA matching and crossmatching supported by solid basic scientific research have proved successful in achieving good graft survival at our unit.

BACKGROUND:The aim of this study was to examine the relationship between surgical margin status and site of recurrence after potentially curative liver resection for colorectal metastases using an ultrasonic dissection technique.METHODS:Between January 2000 and December 2003, 176 patients underwent liver resection with curative intent for colorectal metastases at a single institution. Demographics, operative data, pathological margin status, site of recurrence and long-term survival data were collected prospectively and analysed.RESULTS:On pathological analysis, resection margins were positive in 43 patients, negative by 1-9 mm in 110, and clear by more than 9 mm in 23 patients. At a median follow-up of 33 months, 133 of 176 patients had developed a recurrence, only five of whom had recurrence at the surgical margin. Recurrence at the surgical margin was not significantly related to the size of the margin. Overall, the median time to recurrence was 12.6 months, which was independent of surgical margin size, although there was a significantly higher proportion of patients with multiple metastases in the group with a positive margin (P = 0.008). Margin status did not correlate significantly with either recurrence-free or overall survival.CONCLUSION:The rate of recurrence at the surgical margin was low and a positive margin was not associated with an increased risk of recurrence either at the surgical margin or elsewhere.

A randomized controlled prospective open-label single center trial was performed. At the time of transplantation patients were randomly assigned to one of two treatment arms: The study group of 47 patients received zoledronic acid (ZOL, 8 infusions at 4 mg during the first 12 months after LT), calcium (1000 mg/d) and vitamin D (800 IE/d). The control group consisted of 49 patients who received calcium and vitamin D at same doses (CON). The incidence of bone fractures or death was predefined as the primary endpoint. Secondary endpoints included bone mineral density (BMD), serum biochemical markers of bone metabolism, parameters of trabecular bone histomorphometry and mineralization density distribution (BMDD). Patients were followed up for 24 months. Analysis was performed on an intention-to-treat basis. The primary endpoint fracture or death was reached in 26% of patients in the ZOL group and 46% in the CON group (p = 0.047, log rank test). Densitometry results were different between the groups at the femoral neck at 6 months after LT (mean+/-SD BMD ZOL: 0.80 +/- 0.19 g/cm2 vs. CON: 0.73 +/- 0.14 g/cm2, p = 0.036). Mixed linear models of biochemical bone markers showed less increase of osteocalcin in the ZOL group and histomorphometry and BMDD indicated a reduction in bone turnover. Prophylactic treatment with the bisphosphonate zoledronic acid reduces bone turnover and fractures after liver transplantation.

BACKGROUND: The development of malignant tumors is a largely unresolved issue. Western medicine has made substantial contributions to cancer diagnosis and treatment. Negative multifactorial events appear to be plausible catalysts of such diseases. A holistic perspective in breast cancer treatment should not to be considered as antithetical, but should rather be applied in accordance with Western medicine, while more strongly focussing on a multifaceted pattern of development. METHODS: We summarize substantial insights emanating from holistic perspectives in oncology and discuss relevant publications with respect to prevention, nutrition and supplementation, diagnostic measures, psychooncology and symptom-oriented treatment. RESULTS: The examples and references reported here demonstrate the effectiveness of holistic oncological therapy and aim to make treating physicians more strongly aware of useful, yet in part unfamiliar treatment approaches. The methods that already can be applied to the prevention and treatment of malignant disease include a healthy life style and nutritional habits, a pleasant working area, psychohygiene, energy work and relaxation exercises. CONCLUSIONS: In sum, patients should today be seen as responsible partners within the "cancer disease" complex. We argue that by means of intensive clarification they be offered help in psychologically processing the possible causes for their cancer and thus cope with their disease as they personally think fit.

Zusammenfassung. Grundlagen: Die Entstehung von bösartigen Tumoren ist größtenteils ein noch ungelöstes Rätsel. Die Schulmedizin leistet einen wichtigen Beitrag in Diagnostik und Behandlung solcher Erkrankungen. Ein negatives multifaktorielles Geschehen erscheint plausibel als Auslöser von Erkrankungen. Der ganzheitliche Ansatz in der Behandlung von Krebspatienten stellt sich nicht als Gegensatz dar, sondern soll im Einklang mit der Schulmedizin erfolgen und berücksichtigt stärker ein vielfältiges Entstehungsmuster.

BACKGROUND:In January 1999 a new kidney allocation program was launched by the Eurotransplant Foundation, the 'Eurotransplant Senior Program' (ESP). Cadaveric donors above the age of 65 yr are allocated to kidney transplant recipients of the same age group.METHODS:Using a single-center database, 91 patients who underwent first renal transplantation at the age of 65 yr and older in the years 1999-2002 were identified. Fifty-six patients were transplanted through ESP allocation (study group) and 35 patients (control group) via normal Eurotransplant Kidney Allocation System (ETKAS) procedure.RESULTS:Age, sex and comorbid conditions did not differ by group. The rate of acute rejection episodes, primary non-function, delayed graft function, perioperative mortality did not differ by group. Serum creatinine was significantly lower in the ETKAS group (1.3 vs. 1.9 mg/dL; p=0.015) from six months after the transplantation on. Overall graft survival at six yr was 56% in the ETKAS group and 52% in the ESP group. With 73% in the ETKAS group and 71% in the ESP group, cumulative patient survival according to the Kaplan-Meier estimation was not statistically different at five yr.CONCLUSIONS:We did not find a relevant difference in the outcome between young and old kidney transplants in old recipients after this long observation period.