Liver regeneration: a spotlight on the novel role of platelets and serotonin

The development of novel approaches in liver surgery in the last decade has saved the lives of a large number of patients via resection of liver tumours previously thought to be non-resectable. Concurrently, living donor liver transplantation has emerged as one of the ways of lowering mortality on the waiting lists. These breakthroughs demanded a rigorous understanding of the mechanisms of liver regeneration after partial hepatectomy. Based on our previous studies on blood platelets and cold ischaemic injury, platelets and serotonin have attracted attention due to their theoretical potential contribution to liver regeneration. Both platelets and serotonin have been proven to be crucially involved in liver regeneration after partial hepatectomy. This review article provides an overview on the process of liver regeneration, with emphasis on its molecular basis and the coordinate contribution of several cells to restoring the organ's original volume and function. The role of platelets and serotonin is highlighted as novel contributors in this process

Parastomal hernia incarceration due to migrated intragastric balloon

The temporary placement of intragastric balloons is a common method to achieve rapid weight loss before planned metabolic surgery. We report the case of a 48-year-old morbidly obese patient. Ten years ago the patient underwent emergency sigmoidectomy with creation of a double-barreled ileostomy for perforated diverticulitis. Over time he developed a giant parastomal hernia. For preoperative weight reduction before planned restoration of intestinal continuity, an intragastric balloon was inserted 3years ago. The patient was admitted to our emergency department with peritonism and a septic shock. After computed tomography showing small bowel ileus, laparotomy was performed, revealing marked ischemia of incarcerated small and large intestine. Only postoperatively was the intragastric balloon found in the resected small bowel, causing a mechanical ileus with consecutive incarceration of the bowel. We review the literature on complications due to the migration of intragastric balloons. This clinical case gives a fair warning of the possible deleterious outcome of intragastric balloons, especially in hernia patient

Was ist "evidence based" in der Adipositaschirurgie?

Zusammenfassung: Seit den 1990er Jahren gilt in den USA der Konsens, dass die bariatrische Chirurgie die beste Therapie zur Erzielung eines lang anhaltenden Gewichtsverlustes wie auch zur Behandlung der adipositasassoziierten Komorbiditäten ist. In der Folge kam es zu einem regelrechten Boom in der bariatrischen Chirurgie. Diese Entwicklung wurde zusätzlich beschleunigt durch das Aufkommen der laparoskopischen Techniken, welche die Morbidität des Eingriffes deutlich verkleinerten. Eine einheitliche Vorgehensweise und Verfahrenswahl existiert bis zum heutigen Zeitpunkt nicht. Vergleichende Studien zwischen verschiedenen Verfahren sind rar und die wissenschaftliche Evidenz zur Therapie der Fettleibigkeit ist mager. Allgemein wird anerkannt, dass die Abklärung im Vorfeld einer Operation interdisziplinär im Team erfolgt und dass die behandelnden Ärzte eine lebenslange Nachsorge der Patienten sicherstellen müssen. Der bariatrisch-chirurgische Eingriff sollte heute primär laparoskopisch durchgeführt werden, da dadurch die Folgen des offenen Zuganges wie Wundinfekt- und Narbenhernienraten massiv gesenkt werden. Die verschiedenen Verfahren beinhalten restriktive, malabsorptive und kombinierte Wirkmechanismen. Rein restriktive Verfahren wie das Magenbanding sind den kombinierten und malabsorptiven Verfahren in Bezug auf den erzielbaren Gewichtsverlust unterlegen. Ebenfalls werden Komorbiditäten wie der Diabetes mellitus und die arterielle Hypertonie durch letztere Methoden wirkungsvoller behandelt. Diese Erkenntnisse sollten daher die Grundlage zur Verfahrenswahl bei der chirurgischen Behandlung der morbiden Adipositas bilde

Clinical value of a combined multi-phase contrast enhanced DOPA-PET/CT in neuroendocrine tumours with emphasis on the diagnostic CT component

Objective: To assess the clinical value of multi-phase, contrast-enhanced DOPA-PET/CT with emphasis on the diagnostic CT component in patients with neuroendocrine tumours (NET). Methods: Sixty-five patients with NET underwent DOPA-cePET/CT. The DOPA-PET, multi-phase CT and combined DOPA cePET/CT data were evaluated and diagnostic accuracies compared. The value of ceCT in DOPA cePET/CT concerning lesion detection and therapeutic impact was evaluated. Sensitivities, specificities and accuracies were calculated. Histopathology and clinical follow-up served as the standard of reference. Differences were tested for statistical significance by McNemar's test. Results: In 40 patients metastatic and/or primary tumour lesions were detected. Lesion-based analysis for the DOPA-PET showed sensitivity, specificity and accuracy of 66%, 100% and 67%, for the ceCT data 85%, 71% and 85%, and for the combined DOPA cePET/CT data 97%, 71% and 96%. DOPA cePET/CT was significantly more accurate compared with dual-phase CT (p < 0.05) and PET alone (p < 0.05). Additional lesion detection was based on ceCT in 12 patients; three patients underwent significant therapeutic changes based on the ceCT findings. Conclusion: DOPA cePET/CT was significantly more accurate than DOPA-PET alone and ceCT alone. The CT component itself had a diagnostic impact in a small percentage but contributed to the therapeutic strategies in selected patient

Selective Intra-arterial Chemotherapy with Floxuridine as Second- or Third-Line Approach in Patients with Unresectable Colorectal Liver Metastases

Background: An outcome assessment was performed of patients with unresectable colorectal liver metastases (CRLM) treated in second or third line with floxuridine (FUDR)-based hepatic artery infusion (HAI). Methods: Twenty-three patients who were pretreated with systemic (immuno)chemotherapy received FUDR-HAI alone or combined with systemic chemotherapy. We reviewed patient charts and our prospective patient database for survival and associated risk factors. Results: Patients received FUDR-HAI for unresectable CRLM from January 2000 to September 2010. Twelve patients (52%) received concurrent systemic chemotherapy. Median overall survival (OS), progression-free survival (PFS), and hepatic PFS were 15.6months (range, 2.5-55.7months), 3.9months (range, 0.7-55.7months), and 5.5months (range, 1.6-55.7months), respectively. The liver resection rate after HAI was 35%. PFS was better in patients undergoing secondary resection than in patients without resection (hazard ratio [HR] 0.21; 95% confidence interval [95% CI] 0.07-0.66; P=0.0034), while OS showed a trend toward improvement (HR 0.4; 95% CI 0.13-1.2; P=0.09). No differences were observed in OS (P=0.69) or PFS (P=0.086) in patients who received FUDR-HAI alone compared with patients treated with combined regional and systemic chemotherapy. No statistically significant differences were seen in patients previously treated with one chemotherapy line compared with patients treated with two lines. Presence of extrahepatic disease was a negative risk factor for PFS (liver-only disease: HR 0.03; 95% CI 0.0032-0.28; P<0.0001). Toxicities were manageable with dose modifications and supportive measures. Conclusions: FUDR-HAI improves PFS and results in a trend toward improved OS in selected patients able to undergo liver resection after tumor is downsize

Intraoperative adverse events during laparoscopic colorectal resection—better laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients

Purpose: Intraoperative adverse events significantly influence morbidity and mortality of laparoscopic colorectal resections. Over an 11-year period, the changes of occurrence of such intraoperative adverse events were assessed in this study. Methods: Analysis of 3,928 patients undergoing elective laparoscopic colorectal resection based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery was performed. Results: Overall, 377 intraoperative adverse events occurred in 329 patients (overall incidence of 8.4%). Of 377 events, 163 (43%) were surgical complications and 214 (57%) were nonsurgical adverse events. Surgical complications were iatrogenic injury to solid organs (n = 63; incidence of 1.6%), bleeding (n = 62; 1.6%), lesion by puncture (n = 25; 0.6%), and intraoperative anastomotic leakage (n = 13; 0.3%). Of note, 11% of intraoperative organ/puncture lesions requiring re-intervention were missed intraoperatively. Nonsurgical adverse events were problems with equipment (n = 127; 3.2%), anesthetic problems (n = 30; 0.8%), and various (n = 57; 1.5%). Over time, the rate of intraoperative adverse events decreased, but not significantly. Bleeding complications significantly decreased (p = 0.015), and equipment problems increased (p = 0.036). However, the rate of adverse events requiring conversion significantly decreased with time (p < 0.001). Patients with an intraoperative adverse event had a significantly higher rate of postoperative local and general morbidity (41.2 and 32.9% vs. 18.0 and 17.2%, p < 0.001 and p < 0.001, respectively). Conclusions: Intraoperative surgical complications and adverse events in laparoscopic colorectal resections did not change significantly over time and are associated with an increased postoperative morbidity