Background Training in HPB surgery lacks uniformity across regions covered by the E-AHPBA. Accreditation has been in place for centers and fellowship programs, but with low uptake. The decision whether to continue, change or cease such accreditation is being discussed. Thus, a strengths, weaknesses, opportunities, and threats (SWOT) analysis was conducted. Methods A mixed-methods, cross-sectional study among stakeholders in E-AHPBA, ESSO and UEMS under the E-AHPBA executive council was founded, ensuring representation by gender and geographic distribution. Results Responses were collected from across E-AHPBA regions, with response from 15 of 24 subchapters. The most frequent and recurring themes are presented in a SWOT matrix which allows for paired evaluations of factors deemed to be helpful (Strengths and Opportunities), those that are harmful (Weaknesses and Threats). Conclusion This study identified both helpful and harmful effects to an accreditation process of HPB centers or HPB fellowship training across the E-AHPBA membership region.Formal accreditation of centers is not within the scope, nor jurisdiction nor financial capacity for E-AHPBA in the current situation. A strong interest in formal HPB training should be capitalized into E-AHPBA strategic planning towards a structured accreditation system for HPB fellowship programs or HPB training tracks.

Background Hypertrophy-inducing procedures, such as portal vein embolization (PVE), improve future liver remnant (FLR) volume and function and help overcome limitations to resection. Mainly due to tumor progression while awaiting sufficient liver growth, 30-40% fail to achieve surgery after PVE. In the DRAGON 0 study, simultaneous portal and hepatic vein embolization (PVE/HVE) has shown to increase FLR-hypertrophy, kinetic growth rate and resectability substantially compared to PVE alone. The purpose of this study is to compare the 3-year overall survival after PVE/HVE versus PVE in patients undergoing liver resection for primary and secondary cancers of the liver.

Background: The method of transecting the pancreatic parenchyma during pancreatic resection may influence the rate of complications, including pancreatic fistula and bleeding. The objective of this study was to compare the transection of the pancreatic parenchyma during pancreatoduodenectomy with monopolar electrocautery versus scalpel in terms of postoperative complications. Methods: A retrospective analysis of patients with open pancreatoduodenectomy from the German DGAV StuDoQ|Pancreas registry (January 2013 to December 2021) was performed. Transection of the pancreatic parenchyma with a scalpel versus monopolar electrocautery was compared regarding postoperative pancreatic fistula B/C, post-pancreatectomy hemorrhage B/C, and major complications (Clavien -Dindo classification >= 3) rates. Multivariable analysis with adjustment for potential confounders and surgical center cluster effect was performed. Results: Overall, 6,752 patients were included in the study. In 4,072 (60.3%), transection was performed with a scalpel and, in 2,680 (39.7%), with electrocautery. Transection with electrocautery was associated with higher postoperative pancreatic fistula B/C (15.4% vs 12.8%; P = .003), post-pancreatectomy hemorrhage B/C (11% vs 7.4%; P < .001), and major complications (33.4% vs 29.6%; P = .001) rates. In the multivariable analysis, after adjustment for potential confounders and surgical center, the association of the transection method with postoperative pancreatic fistula B/C (odds ratio = 1.01; 95% CI, 0.79-1.2; P = .962), post-pancreatectomy hemorrhage B/C (odds ratio = 1.23; 95% CI, 0.94-1.6; P = .127), and major complications (odds ratio = 1.09; 95% CI, 0.93-1.27; P =.297) was not significant. Conclusion: The study found no significant association between transection of the pancreatic parenchyma during open pancreatoduodenectomy with a scalpel compared with monopolar electrocautery regarding pancreatic fistula, postoperative bleeding, or overall major complication rates. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Objective Splenectomy is regularly performed in total and distal pancreatectomy due to technical reasons, lymph node dissection and radicality of the operation. However, the spleen serves as an important organ for competent immune function, and its removal is associated with an increased incidence of cancer and a worse outcome in some cancer entities1–3. The impact of splenectomy in pancreatic cancer is not fully resolved4,5. Methods We therefore compared the outcome of 193 pancreatic cancer patients who underwent total or distal pancreatectomy with (Sp) or without splenectomy (NoSp) between 2015 and 2021 using the StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery. In addition, we integrated our data into the existing literature in a meta-analysis of studies on splenectomy in pancreatic cancer patients. Results There was no difference between the Sp and NoSp groups regarding histopathological parameters, number of examined or affected lymph nodes, or residual tumor status. We observed a significantly prolonged survival in pancreatic cancer patients who underwent total pancreatectomy, when a spleen-preserving operation was performed (median survival: 9.6 vs. 17.3 months, p = 0.03). In this group, splenectomy was identified as an independent risk factor for shorter overall survival [HR (95%CI): 2.4 (1.18–4.9)]. In a meta-analysis of the existing literature in combination with our data, we confirmed splenectomy as a risk factor for a shorter overall survival in pancreatic cancer patients undergoing total pancreatectomy, distal pancreatectomy, or pancreatic head resection [HR (95%CI): 1.53 (1.11–1.95)]. Conclusion Whenever technically possible, preservation of the spleen should be considered during total pancreatectomy for resection of pancreatic cancer, as the spleen seems to affect the long-term survival in this subgroup. The immunological reasons behind this observation deserve further investigation.

Hepatocellular carcinoma (HCC) is the most common primary malignant liver tumor and a leading cause of cancer-related deaths worldwide. However, current diagnostic tools are often invasive and technically limited. In the last decade, non-invasive liquid biopsies have transformed the field of clinical oncology, showcasing the potential of various liquid-biopsy derived analytes, including extracellular vesicles (EVs), to diagnose and monitor HCC progression and metastatic spreading, serving as promising novel biomarkers. A prospective single-center cohort study including 37 HCC patients and 20 patients with non-malignant liver disease (NMLD), as a control group, was conducted. Serum EVs of both groups were analyzed before and after liver surgery. The study utilized microbead-based magnetic particle sorting and flow cytometry to detect 37 characteristic surface proteins of EVs. Furthermore, HCC patients who experienced tumor recurrence (R-HCC) within 12 months after surgery were compared to HCC patients without recurrence (NR-HCC). EVs of R-HCC patients (n = 12/20) showed significantly lower levels of CD31 compared to EVs of NR-HCC patients (p = 0.0033). EVs of NMLD-group showed significantly higher expressions of CD41b than EVs of HCC group (p = 0.0286). The study determined significant short-term changes in CD19 dynamics in EVs of the NMLD-group, with preoperative values being significantly higher than postoperative values (p = 0.0065). This finding of our pilot study suggests EVs could play a role as potential targets for the development of diagnostic and therapeutic approaches for the early and non-invasive detection of HCC recurrence. Further, more in-depth analysis of the specific EV markers are needed to corroborate their potential role as diagnostic and therapeutic targets for HCC.

Background The development of a medical device requires strict adherence to regulatory processes. Prehabilitation in this context is a new area in surgery that trains, coaches, and advises patients in mental well-being, nutrition, and physical activity. As staff is permanently drained from clinical care, remote and digital solutions with real-time assessments of data, including patient-related outcome reporting, may simplify preparation before major surgeries. Objective This study aimed to evaluate the usability engineering process for the Prehab App, a newly developed medical device, in order to identify and adapt any design and usability flaws found. Methods We hypothesized that formative and summative usability testing would achieve 80% interrater and intrarater reliability and consistency and that the safety-relevant scenarios would uncover undetected risks of the medical device (stand-alone software class IIa). In total, 8 experts and 8 laypersons (patients and potential patients) were asked to evaluate paper-based mockups, followed by an evaluation of the minimal viable product (MVP) of the Prehab App at least more than 8 weeks later after instruction and training. The experts had to face 5 and the laypersons 6 usability scenarios. Their evaluations were measured with the Mobile App Rating Scale (MARS) and trustworthiness checklists (range 0-64, with higher scores indicating trustworthiness), and the usability scenarios were evaluated with the After Scenario Questionnaire (ASQ) and a judgment by an observer. The time taken for the scenarios was also recorded. Results MARS achieved constant scores of more than 4 out of 5 points for both experts and laypersons. The mean trustworthiness score was 51.3 (SD 2.7) for the experts and 50.8 (SD 2.1) for the laypersons (P=.68) in task I. The interrater correlation, shown by the Fleiss-Kappa value, was 0.87 (range 0.85-0.89) for all raters (N=16), 0.86 (range 0.82-0.91) for the experts (n=8, 50%), and 0.88 (range 0.84-0.93) for the laypersons (n=8, 50%), reflecting almost perfect agreement between the raters. This indicated the high quality of the usability. The usability scenarios were performed with ease, except for the onboarding part, when the wearable was required to be connected; this took a considerable amount of time and was recognized as a challenge to good usability. Conclusions The formative and summative evaluation of the Prehab App design resulted in good-to-acceptable results of the design and usability of the critical and safety-relevant areas of the medical device and stand-alone software. Usability testing improves medical devices early in the design and development process, reduces errors, and mitigates risks, and in this study, it delivered a profound ethical and medical justification for a randomized controlled trial (RCT) of the Prehab App in a remote setting as a next step in the development process. Trial Registration German Registry for Clinical Trials (DRKS00026985); https://drks.de/search/en/trial/DRKS00026985

BACKGROUND:Transplant nephrectomy (TN) has historically been associated with high morbidity and mortality rates. Our objective is to share our own experience and compare indications and surgical outcomes between early and late TN and intracapsular (ICAN) and extracapsular allograft nephrectomy (ECAN) techniques. MATERIAL AND METHODS:Our study included all 69 TN procedures performed between January 2010 and February 2021. Of these, 17 TN procedures were performed within the first 60 days after transplantation (referred to as 'early'), while the remaining 52 procedures were performed later ('late'). Within the late allograft nephrectomy (AN) group, we compared the outcomes of intracapsular (ICAN) and extracapsular (ECAN) techniques. We conducted a statistical analysis using the chi-square test and the 2-sample t test. RESULTS:The primary indication for early TN was surgical transplant complications (94.1%), with 58.8% of these cases requiring emergency surgery. Morbidity (major complications) occurred in 47.1% of cases, and mortality was 5.9%. In contrast, graft intolerance syndrome was the leading indication for late TN (76.9%), with elective surgery performed in 88.5% of cases. Morbidity (major complications) occurred in 11.5% of cases, and mortality was 3.8%. Within the late TN group, 82.7% of cases were treated with ICAN and 17.3% with ECAN. Blood transfusion was required during surgery in 17.3% of cases, with no significant difference between the groups. Multivariate logistic regression analysis revealed that the timing of surgery was the only statistically significant predictor of complication occurrence. CONCLUSIONS:Our data suggest that TN can be performed with relatively low morbidity. However, early TN remains the only independent risk factor for developing adverse outcomes.

Explant-based models for assessing HCC recurrence after liver transplantation serve as the gold standard, guiding post-liver transplantation screening and immunosuppression adjustment. Incorporating alpha-fetoprotein (AFP) levels into these models, such as the novel R3-AFP score, has notably enhanced risk stratification. However, validation of these models in high-evidence data is mandatory. Therefore, the aim of the present research was to validate the R3-AFP score in a randomized clinical trial. We analyzed the intention-to-treat population from the 2-arm SiLVER trial (NCT00355862), comparing calcineurin-based ([calcineurin inhibitors]-Group A) versus mammalian target of rapamycin inhibitors-based (sirolimus-Group B) immunosuppression for post-liver transplantation HCC recurrence. Competing risk analysis estimated sub-hazard ratios, with testing of discriminant function and calibration. Overall, 508 patients from the intention-to-treat analysis were included (Group A, n = 256; Group B, n = 252). The R3-AFP score distribution was as follows: 42.6% low-risk (n = 216), 35.7% intermediate-risk (n = 181), 19.5% high-risk (n = 99), and 2.2% very-high-risk (n = 11) groups. The R3-AFP score effectively stratified HCC recurrence risk, with increasing risk for each stratum. Calibration of the R3-AFP model significantly outperformed other explant-based models (Milan, Up-to-7, and RETREAT), whereas discrimination power (0.75 [95% CI: 0.69; 0.81]) surpassed these models, except for the RETREAT model ( p = 0.49). Subgroup analysis showed lower discrimination power in the mammalian target of rapamycin group versus the calcineurin inhibitors group ( p = 0.048). In conclusion, the R3-AFP score accurately predicted HCC recurrence using high-quality evidence-based data, exhibiting reduced performance under mammalian target of rapamycin immunosuppression. This highlights the need for further research to evaluate surveillance schedules and adjuvant regimens.

AIM:Multidisciplinary management of metastatic colorectal liver metastases (CRLM) is still challenging. To assess postoperative complications in initially unresectable or borderline resectable CRLM, the prospective EORTC-1409 ESSO 01-CLIMB trial capturing 'real-life data' of European centres specialized in liver surgery was initiated.MATERIAL AND METHODS:A total of 219 patients were registered between May 2015 and January 2019 from 15 centres in nine countries. Eligible patients had borderline or initially unresectable CRLM assessed by pre-operative multidisciplinary team discussion (MDT). Primary endpoints were postoperative complications, 30-day and 90-days mortality post-surgery, and quality indicators. We report the final results of the 151 eligible patients that underwent at least one liver surgery.RESULTS:Perioperative chemotherapy with or without targeted treatment were administered in 100 patients (69.4%). One stage resection (OSR) was performed in 119 patients (78.8%). Two stage resections (TSR, incl. Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy (ALPPS)) were completed in 24 out of 32 patients (75%). Postoperative complications were reported in 55.5% (95% CI: 46.1-64.6%), 64.0% (95% CI: 42.5-82%), and 100% (95% CI: 59-100%) of the patients in OSR, TSR and ALPPS, respectively. Post-hepatectomy liver failure occurred in 6.7%, 20.0%, and 28.6% in OSR, TSR, and ALPPS, respectively. In total, four patients (2.6%) died after surgery.CONCLUSION:Across nine countries, OSR was more often performed than TSR and tended to result in less postoperative complications. Despite many efforts to register patients across Europe, it is still challenging to set up a prospective CRLM database.

ZusammenfassungDie Voraussetzungen der Universitätskliniken in Deutschland verändern sich. Gerade in operativen Fächern wird es schwieriger, die 3 Säulen der Universitätsmedizin – Klinik, Forschung und Lehre – adäquat zu bedienen. Ziel der vorliegenden Umfrage war es, den Status quo der universitären Allgemein- und Viszeralchirurgie ermitteln, um eine Grundlage für Lösungsvorschläge zu bieten.Für diese Onlineumfrage wurden 1505 viszeralchirurgische Ärzt*innen an den 38 Universitätskliniken kontaktiert. Der Fragebogen beinhaltete 29 Fragen zur Klinikstruktur, zur wissenschaftlichen Motivation, zu Möglichkeiten der Freistellung und zur Wertschätzung der akademischen Leistungen. Ebenso wurden Art und Umfang der Lehrveranstaltungen sowie die Vorbereitung hierauf ermittelt. Hinsichtlich der Krankenversorgung wurden Art und Anzahl von Diensten sowie der Ablauf der chirurgischen Weiterbildung untersucht.Durch die online veröffentlichten Daten der einzelnen Kliniken hinsichtlich Anzahl, Geschlecht, Position und akademischem Titel der beschäftigten Ärzt*innen konnte eine Demografie der universitären Viszeralchirurg*innen erstellt werden. An der Umfrage nahmen 352 Viszeralchirurg*innen teil, was einer Rücklaufquote von 23,4% entspricht. Es antworteten 31 Direktor*innen, 116 Oberärzt*innen, 252 Fachärzt*innen und 138 Assistenzärzt*innen. Von den Teilnehmenden waren 93,5% wissenschaftlich tätig, der Großteil im Bereich der klinischen Datenerhebung. Viele gaben an, auch in der translationalen und/oder experimentellen Forschung aktiv zu sein, während die Lehrforschung selten benannt wurde. Während ihrer Regelarbeitszeit wissenschaftlich arbeiten zu können, wurde von 45% bejaht. Die Honorierung dieser Tätigkeit gestaltete sich meist in Form von Freistellung für Kongresse und klinischer Wertschätzung. Die meisten Teilnehmenden waren an 3–4 Lehrveranstaltungen pro Woche beteiligt, wobei 24,4% angaben, darauf nicht adäquat vorbereitet zu werden.Die Vereinbarkeit der klassischen 3 Säulen Klinik, Forschung und Lehre besitzt weiterhin eine hohe Relevanz. Unter den teilnehmenden Viszeralchirurg*innen besteht eine hohe Motivation, trotz zunehmenden ökonomischen Druckes Forschung und Lehre nicht zu vernachlässigen. Es müssen allerdings Strukturen geschaffen werden, um Engagement in Forschung und Lehre zu honorieren und strukturiert zu fördern.

BACKGROUND:Anastomotic leak (AL) after bilioenteric reconstruction (BR) is a feared complication after bile duct resection, especially in combination with liver resection. Literature on surgical outcome is sparse. This study aimed to determine the incidence and risk factors for AL after combined liver and bile duct resection with a focus on operative or endoscopic reinterventions.METHODS:Data from consecutive patients who underwent liver resection and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases.RESULTS:Within 921 patients, AL rate was 5.4% with a 30d mortality of 9.6%. Pringle maneuver (p<0.001),postoperative external biliary (p=0.007) and abdominal drainage (p<0.001) were risk factors for clinically relevant AL. Preoperative biliary drainage (p<0.001) was not associated with a higher rate of AL. AL was more frequent in stented patients (76.5%) compared to PTCD (17.6%) or PTCD+stent (5.9%,p=0.017). AL correlated with increased incidence of postoperative liver failure (p=0.036), cholangitis, hemorrhage and sepsis (all p<0.001).CONCLUSION: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.

Prähabilitation ist eine wirksame Maßnahme, um durch präoperative Verbesserungen modifizierbarer Faktoren für unsere Patienten ein besseres postoperatives Ergebnis zu erreichen. Die Phase der neoadjuvanten Behandlung oder 4 Wochen vor dem Operationszeitpunkt können dazu optimal genutzt werden. Mit einem gut ausgewählten Risikoscreening durch validierte Instrumente, wie beispielsweise den RAI-Score, das Nutritional-Risk-Screening und 6‑Minuten-Gehtest, können Patienten evaluiert und monitoriert werden. Ein individuelles Programm aus Ernährungsunterstützung wie proteinreicher Ernährung, Entwöhnung von Rauchen und Alkohol, Patient-Blood-Management, spezifischem Ausdauertraining und mentalen Trainingstechniken ist dabei zielführend und wissenschaftlich insbesondere bei Patienten vor kolorektaler Chirurgie durch gute und aktuelle randomisierte kontrollierte Studien belegt. Kostenersparnisse sowie eine Reduktion der Morbidität und Mortalität um 30–50

The requirements and challenges for the university hospitals in Germany are changing. Especially in surgical subjects, it is more and more difficult to adequately serve these three pillars of university medicine - clinic, research and education. This survey was intended to determine the status quo of general and visceral surgery at universities, in order to provide a basis for proposed solutions.For this online survey, 1505 visceral surgeons at the 38 university clinics were contacted. The questionnaire contained 29 questions on the structure of the clinic, scientific motivation, opportunities for time-off and the appreciation of academic achievements. The type and scope of student courses and the preparation for them were also determined. With regard to patient care, the type and number of services and the course of surgical training were examined. Based on the data published on the websites of the individual clinics on the number, gender, position and academic title of the doctors, a demographic analysis of university visceral surgeons could also be created.Of 1505 surgeons successfully contacted, 352 took part in the survey, which corresponds to a response rate of 23.4%. Of the participants, 93.5% were scientifically active, the majority being in the field of clinical data collection. Many indicated that they were also active in translational and/or experimental research, while educational research was rarely named. 45% confirmed that they could perform scientific work during their normal working hours. The reward for this activity was mostly in the form of time-off for congresses and clinical appreciation. Most participants stated that they were involved in 3-4 student courses per week, with 24.4% reporting that they were not adequately prepared for them.The compatibility of the classic three pillars of clinic, research and teaching continues to be of great relevance. There is a high level of motivation among the participating visceral surgeons not to neglect research and teaching, despite increasing economic pressure in the field of patient care. However, arrangements must be created in order to reward and promote commitment in research and teaching in a structured way.

Prehabilitation is an effective measure to achieve a better postoperative outcome in patients through a preoperative improvement in modifiable factors. The phase of neoadjuvant treatment or the 4 weeks prior to the time of surgery can be optimally used for this purpose. Using a well-selected risk screening with validated instruments, such as the risk analysis index (RAI) score, the nutritional risk screening and the 6-minute walking test, patients can be evaluated and monitored. An individualized program made up of nutritional support, such as a protein-rich diet, cessation of smoking and alcohol consumption, patient blood management, specific endurance training and mental training techniques, is effective especially for patients undergoing colorectal surgery and has been scientifically confirmed by current randomized controlled studies. Reductions in costs, morbidity and mortality rates by 30-50% have been proven; however, the data situation is still heterogeneous especially in terms of significant results and patient inclusion criteria. Remuneration as well as digital applications for prehabilitation are current topics that are discussed.

BACKGROUND:Major surgery, along with preoperative cholestasis-related complications, are responsible for the increased risk of morbidity and mortality in perihilar cholangiocarcinoma (pCCA). The aim of the present survey is to provide a snapshot of current preoperative management and optimization strategies in Europe. METHODS:61 European centers, experienced in hepato-biliary surgery completed a 59-questions survey regarding pCCA preoperative management. Centers were stratified according to surgical caseload (<5 and ≥ 5 cases/year) and preoperative management protocols' application. RESULTS:The overall case volume consisted of 6333 patients. Multidisciplinary discussion was routinely performed in 91.8% of centers. Most respondents (96.7%) recognized the importance of a well-structured preoperative protocol. The preferred method for biliary drainage was percutaneous transhepatic biliary drainage (60.7%) while portal vein embolization was the preferred technique for liver hypertrophy (90.2%). Differences in preoperative pathologic confirmation of malignancy (35.8% vs 28.7%; p < 0.001), number of mismanaged referred patients (88.2% vs 50.8%; p < 0.001), biliary drainage (65.1% vs 55.6%; p = 0.015) and liver function evaluation (37.2% vs 5.6%; p = 0.001) were found between centers according to groups' stratification. CONCLUSION:The importance of a correct preoperative management is recognized. Nevertheless, the current lack of guidelines leads to wide heterogeneity of behaviors among centers. This survey can provide recommendations to improve pCCA perioperative outcomes.

There is growing evidence that liver transplantation (LT) is the most effective treatment for acute-on-chronic liver failure grade-3 (ACLF-3). This study examines whether and how this evidence translates into practice by analyzing the variability in intensive care unit (ICU) admissions, listing strategies, and LT activity for patients with ACLF-3 across transplantation centers in Europe. Consecutive patients who were admitted to the ICU with ACLF-3, whether or not they were listed and/or transplanted with ACLF-3, between 2018 and 2019 were included across 20 transplantation centers. A total of 351 patients with ACLF-3 were included: 33 had been listed prior to developing ACLF-3 and 318 had not been listed at the time of admission to the ICU. There was no correlation between the number of unlisted patients with ACLF-3 admitted to the ICU and the number listed or transplanted while in ACLF-3 across centers. By contrast, there was a correlation between the number of patients listed and the number transplanted while in ACLF-3. About 21% of patients who were listed while in ACLF-3 died on the waiting list or were delisted. The percentage of LT for patients with ACLF-3 varied from 0% to 29% for those transplanted with decompensated cirrhosis across centers (average = 8%), with an I2 index of 68% (95% confidence interval, 49%-80%), showing substantial heterogeneity among centers. The 1-year survival for all patients with ACLF-3 was significantly higher in centers that listed and transplanted more patients with ACLF-3 (>10 patients) than in centers that listed and transplanted fewer: 36% versus 20%, respectively (p = 0.012). Patients with ACLF-3 face inequity of access to LT across Europe. Waitlisting strategies for patients with ACLF-3 influence their access to LT and, ultimately, their survival.

BACKGROUND:Tumour recurrence is common after resection of intrahepatic cholangiocarcinoma (ICC). Repeated resection is a potential curative treatment, but outcomes are not well-defined thus far. The aim of this retrospective multicentre cohort study was to show the feasibility and survival of repeated resection of ICC recurrence.METHODS:Data were collected from 18 German hepato-pancreatico-biliary centres for patients who underwent repeated exploration of recurrent ICC between January 2008 and December 2017. Primary end points were overall (OS) and recurrence-free survival from the day of primary and repeated resection.RESULTS:Of 156 patients who underwent repeated exploration for recurrent ICC, 113 underwent re-resection. CA19-9 prior to primary resection, R status of first liver resection and median time to recurrence were significant determinants of repeated resectability. Median OS in the repeated resection group was 65.2 months, with consecutive 1-, 3- and 5-year OS of 98%, 78% and 57% respectively. After re-exploration, median OS from primary resection was 46.7 months, with a consecutive 1-, 3- and 5-year OS of 95%, 55% and 22% respectively. From the day of repeated resection, the median OS was 36.8 months, with a consecutive 1-, 3- and 5-year OS of 86%, 51% and 34% respectively. Minor morbidity (grade I+II) was present in 27%, grade IIIa-IVb morbidity in 20% and mortality in 3.5% of patients.CONCLUSION:Repeated resection of ICC has acceptable morbidity and mortality and seems to be associated with improved long-term survival. Structured follow-up after resection of ICC is necessary for early identification of these patients.

BACKGROUND:There is evidence of a volume outcome relationship for liver transplantation. In Germany, there is a minimum volume threshold of 20 transplantations per year for each center. Thresholds potentially lead to centralization of the healthcare supply, generating longer travel times.OBJECTIVE:This study assessed whether patients are willing to travel longer times to transplantation centers for better outcomes (lower hospital mortality and higher 3-year survival) and identified patient characteristics influencing their choices.METHODS:Participants were recruited in hospitals and via random samples at registration offices. Discrete choice experiments were used to identify trade-offs in their choices between local and regional centers. Descriptive statistics and logistic regression models were used to measure patients' preferences and quantify potentially influencing characteristics.RESULTS:Overall, 82.22% (in-hospital mortality) and 84.44% (3-year survival) of the participants opted to accept a longer travel time in order to receive a liver transplantation with better outcomes.CONCLUSION:Most participants were willing to trade shorter travel times for lower mortality risks and higher 3-year survival in cases of liver transplantation.

Background Intraoperative blood salvage (IBS) is regarded as an alternative to allogeneic blood transfusion excluding the risks associated with allogeneic blood. Currently, IBS is generally avoided in tumor surgeries due to concern for potential metastasis caused by residual tumor cells in the erythrocyte concentrate. Methods The feasibility, efficacy and safety aspects of the new developed Catuvab procedure using the bispecific trifunctional antibody Catumaxomab was investigated in an ex-vivo pilot study in order to remove residual EpCAM positive tumor cells from the autologous erythrocyte concentrates (EC) from various cancer patients, generated by a IBS device. Results Tumor cells in intraoperative blood were detected in 10 of 16 patient samples in the range of 69–2.6 × 10 5 but no residual malignant cells in the final erythrocyte concentrates after Catuvab procedure. IL-6 and IL-8 as pro-inflammatory cytokines released during surgery, were lowered in mean 28-fold and 52-fold during the Catuvab procedure, respectively, whereas Catumaxomab antibody was detected in 8 of 16 of the final EC products at a considerable decreased and uncritical residual amount (37 ng in mean). Conclusion The preliminary study results indicate efficacy and feasibility of the new medical device Catuvab allowing potentially the reinfusion of autologous erythrocyte concentrates (EC) produced by IBS device during oncological high blood loss surgery. An open-label, multicenter clinical study on the removal of EpCAM-positive tumor cells from blood collected during tumor surgery using the Catuvab device is initiated to validate these encouraging results.