Analysis of open and laparoscopic liver resections in a german high-volume liver tumor center

In recent years laparoscopic liver surgery established itself into today’s standard of care regarding surgical liver treatment. It was a long way for minimally invasive liver resection to develop and popularize as it was accompanied by initial reservations and concerns. Some of these already had been clarified while other questions still remain and require further investigation in the complex field of laparoscopic liver surgery. Initial concerns with respect to oncological inferiority and technical inapplicability in contrast to open surgery treatment could have been disproved within the framework of retrospective studies. In contribution to that, the aim of the study was to compare the surgical results and postoperative outcomes of consecutive laparoscopic liver resections (LLR) and open liver resections (OLR) at the high-volume liver tumor center of Leipzig university hospital. Since common classification systems for open liver surgery cannot be applied for LLR, the introduction of specific difficulty scoring systems for LLR helps to assess and classify the complexity of minimal invasive liver resection. With an increase in experience, modification of hybrid surgery and the application of novel visualization techniques such as indocyanine green (ICG) staining or hyperspectral imaging (HSI), more challenging procedures were accomplished, that initially would have been contraindicated for the laparoscopic approach (e.g. perihilar cholangiocarcinoma (pCCA) requiring biliary reconstruction). During the years 2018 and 2019 42% of all liver resections were approached laparoscopically at the Leipzig University hospital. A retrospective data analysis of n=231 patients undergoing LLR or OLR for the years 2018 and 2019 was performed and previously determined variables were collected. As a primary outcome measure, the short-term surgical and postoperative outcome of patients receiving LLR (=LLR group) compared to the patient cohort being treated by open resection (=OLR group) was evaluated. All liver resections were executed or assisted by the same two surgeons. Prior to surgery, every case was reviewed in a multidisciplinary tumor-board meeting and primarily assessed for possible minimal invasive approach. Analysis for patient demographics, pathologic diagnosis, radiologic findings and peri- and intraoperative surgical data was carried out. For LLRs intraoperatively, ICG counter perfusion staining was used in anatomic liver resection and direct ICG tumor staining was employed for tumor demarcation. With respect to classification, the extent of OLR was graded according to the Brisbane 2000 terminology in minor and major resections, whereas LLRs were categorized by means of difficulty (in accordance with Ban et al. and Di Fabio et al.). For measurement of surgical complication and assessment of morbidity, the Clavien-Dindo classification was applied. OLR was performed in n=124 (57%) and LLR in n=93 (43%). From all minimally invasive treated patients, 79% were operated totally laparoscopic and 16% were laparoscopic-hand-assisted due to infeasible lesions in the posterosuperior segments 7, 8 and 4a. In 5 cases a conversion to open surgery was necessary because of inaccessibility, tumor infiltration or morbid obesity. 28% of patients had previous upper abdominal surgery, whereof 36% in the OLR group and 19% in the LLR group. Regarding patient demographics, the mean age was significantly higher in OLR and the sex ratio was in favor of men for both groups. Malignant tumor lesions comprised 77%, while 24% were benign lesions. In both groups this larger number of malignant oncologic operation remained valid. The most common benign indications comprised focal nodular hyperplasia (FNH) and liver adenomas. It was shown that patients with CCA and Colorectal liver metastases (CRLM) were predominantly treated by open surgery, while patients with HCC diagnosis received LLR to a greater extent. Concerning the type of liver resection, non-anatomical resections were the most frequent in the cohort with 47%, thereof 55% LLR and 40% OLR. Followed second most by anatomic right and left hemihepatectomies and third most by left lateral resections, which were predominantly performed in laparoscopic technique. On the other hand, extended resections and trisectionectomies were predominantly operated by OLR. Radical lymphadenectomy was performed to a greater extent during OLR. Results showed that the mean operative time was longer for OLR (341 minutes in median) compared to LLR (273 minutes in median). Also the mean length of hospital stay was shorter for LLR patients, as well as abdominal drains were placed to lesser extent in LLR compared to OLR. In regard to R0-resection, R0-rates were higher in LLR with 98% vs. 86% in OLR. Thereby being highest for CRLM resections, followed by HCC and CCA. Putting all liver resections into classification systems, it was found that of all open procedures, 52% had major and 48% underwent minor resection according to Brisbane 2000. From the LLR group, in accordance with Di Fabio et al. 39% were classified as laparoscopic major hepatectomies, comprising 44% laparoscopic traditional major hepatectomies (LTMH) and 56% laparoscopic posterosuperior major hepatectomies (LPMH), which were technically challenging. The difficulty index stated by Ban et al. was classified as low for 8% of all performed LLRs, intermediate for 45% and of high difficulty in even 47%. Relating to morbidity (=Clavien-Dindo 3b or greater), patients with LLR had significantly lower morbidity compared to OLR. The same applies for in-hospital mortality. Our data show that despite the high number of complex and high-difficulty-classified liver resections that were performed, morbidity and mortality rates were low. As mentioned before, R0 resection rate in the LLR group was better than in the OLR group, however, this was not a case matched study, so a direct comparison is not valid. But still the study could demonstrate that the high number of LLRs being performed at the Leipzig University hospital, did not impair R0-resection rates. With an overall hospital mortality rate of 5.9% in the cohort, good results were achieved. Particularly the low rate of 1% in the LLR group speaks for itself and confirms that the development of a minimal invasive liver resection program should be on the right track. The majority of patients in the LLR and OLR group received an oncologic resection, what also resembles the global attitude that minimally invasive techniques are not reserved for selected tumor entities. Still it should be emphasized, the indication for a liver resection should not be loosened just due to minimal invasive accessibility, especially in benign liver lesions. Nevertheless, in the study the majority of benign lesions was operated by LLR. A few patients diagnosed with CCA received LLR. Thereof predominantly iCCA cases were indicated for a minimal invasive approach without biliary duct reconstruction and satisfying short-term outcomes over OLR could be obtained. However, only one case of pCCA which required Roux-Y bile duct reconstruction was treated with LLR in the study group, so if laparoscopic surgery is capable to replace the open approach in terms of treatment strategies for pCCA remains questionable. Patients with CRLM represent the centerpiece of our study population, still only 13% received LLR. The main reason of applying OLR was the high tumor load requiring future liver remnant augmentation strategies. As liver resection is confirmed to be the approach of choice for patients with HCC in cirrhosis, it is not surprising that HCC diagnosis accounted for the major part of LLRS in our collective.:Vorbemerkung und Bibliographie, 3 Abkürzungsverzeichnis, 4 Einführung, 5 - 1. Development of minimal invasive liver surgery, 5 - 2. Prior concerns of LLR, 6 - 3. Benefits of laparoscopic surgery, 6 3.1 General advantages of minimal invasive surgery, 6 3.2 Specific benefits of applying LLR, 7 - 4. Indications for LLR, 7 4.1 Benign liver lesions, 8 4.2 Malignant liver lesions, 8 4.3 Liver transplantation, 9 - 5. Technical supplement, 9 5.1 Hybrid and hand-assisted techniques, 10 - 6. Classification systems, 11 6.1 Difficulty scoring, 11 6.2 Clavien-Dindo Classification ,12 - 7. Limitations of LLR, 12 - 8. Aim of the study, 13 Publikation, 14 Zusammenfassung, 26 Literaturverzeichnis, 30 Darstellung des eignen Beitrags, 34 Selbstständigkeitserklärung, 3

Government Recovery of Medicare Overpayments and the Automatic Stay

Despite the importance of the automatic stay, in healthcare bankruptcies it is not always applied consistently, especially when the government is the creditor. Government agencies decide whether they will require the bankrupt healthcare provider to repay any Medicare overpayments previously paid. As such, government agencies may jump other creditors based on the equitable doctrine of recoupment. Recoupment is a doctrine recognized by bankruptcy courts allowing for creditors to offset their debts against payments. This is similar to setoff, an action that is not permitted under the Code. The author argues that government agencies should not be allowed to continue recoupment actions against healthcare entities that will jeopardize their reorganization processes. The author suggests that courts can fix this issue by narrowly applying the doctrine of recoupment and reducing the circumstances in which government agencies can collect from bankrupt healthcare entities without seeking relief from the automatic stay

School Leader Perceptions Regarding the Role of the School Based Speech-Language Pathologists

Through this research, school leaders’ knowledge-base, experiences, and perceptions regarding the role of the school-based speech-language pathologist were investigated. The purpose of this study was to address how school leaders perceived and interacted with speech-language pathologists and any barriers that affected leader perceptions. A qualitative instrumental case study design was selected for the study. Data obtained from personal interviews were analyzed and interpreted through a critical theory lens. Key themes that emerged from school leader perceptions included: (a) limited knowledge regarding the role of speech-language pathologists, (b) understanding of school-based challenges for speech-language pathologists, (c) limited knowledge on contributions speech-language pathologists provide, (d) school leader recognition of limited knowledge-base regarding speech-language pathologists, and (e) school leaders want to learn more about the complete role of the school-based, speech-language pathologist. Findings were interpreted relative to educational leadership, speech-language pathologists, and specific policies and practices related to school leadership

Carryout in the COVID-19 Crisis: The Environmental Impact of the Increased Reliance on Restaurant Carryout Materials During the World-Wide COVID-19 Pandemic

While carryout enables restaurants to maintain a reduced stream of income amidst the COVID-19 crisis, the incidental adverse effects of carryout is unduly placed on the environment, particularly with regard to non-reusable food containers. The environmental impact of carryout during COVID-19 does not simply begin when the consumer purchases their food from a restaurant. Rather, the environmental impacts of carryout containers during COVID-19 is galvanized. The impact of carryout containers begins during production of the containers, distribution to restaurants, delivery to customers, and does not end until and unless the containers are properly disposed of and their use is maximized

Sprague Dawley Rats Were Able To Ferment Purified Resistant Starch And Whole Grain Starch On Moderate And High Fat Diets

Whole grain (WG) and fat content of the diet have been previously shown to affect intestinal fermentation and phenotype conferred by high–amylose maize starch (HAM), a form of fermentable dietary fiber. The current study was designed to compare rodent gut health following consumption of whole grain and non–whole grain prebiotics on moderate fat (MF) and high fat (HF) diets using a 2x2x2 factorial design. MF and HF diets were prepared to contain the following diet sources: (1) control starch with no WG or RS [CON], (2) whole grain waxy corn flour with low RS [WWG], (3) purified HAM resistant starch (RS) [HAMRS], and (4) WG HAM flour rich in resistant starch (WG+RS) [HMWG]. The eight diet conditions were fed to Sprague Dawley rats for six weeks (n = 12 per group). After euthanasia, blood, cecal contents and cecal epithelial cells were collected and gastro–intestinal (GI) tract portions and fat pad (retroperitoneal, perirenal, and epididymal) weights recorded. The presence of purified RS2 resulted in greater fermentation as part of the RS*WG interaction whereas no WG with high RS had the lowest pH of cecal contents. There was a main effect of RS with the high RS groups having the lowest abdominal fat percent of body weight. The presence of WG resulted in consistency of fermentation as groups with WG had similar levels of short chain fatty acids with MF and HF diets as reflected by WG*FAT. No RS*FAT effect was observed because of the WG consistency. Also, a greater butyrate production with WG was demonstrated by RS*WG. Results were primarily driven by two major effects, reflected by the presence of and lack of some significant differences. Purified RS fermented better on MF than HF diets. Diets with RS+WG show similar fermentation on both types of diets. These effects may be driven by RS1 vs. RS2 as high RS2 ferments better with MF diets, but presence of RS1 may ferment better with HF diets

A Proper Little Lady and Other Twisted Tales of Adolescent Femininity.

The purpose of this ethnographic study is to explore the stories told by four adolescent females about how they construct a gendered identity amidst the conflicting and contradictory expectations of them as adolescents and as females. After situating the study within a feminist poststructuralist framework, the dominant cultural scripts that have dictated what constitutes normative adolescent and feminine behavior are examined. Of particular importance to this study is the way in which these dominant discourses of femininity and adolescence are manifested in the middle school that the participants attend, especially in the school\u27s attempt to mold its female students into proper little ladies. . As illuminated by the dominant metaphors the participants used to describe their lives (e.g. the cowboy, the gangster, the goddess, the good woman) as well as their stories about fighting, what constitutes normative femininity is a highly contested issue in the everyday lives of adolescents, and their stories reveal an understanding of masculinity and femininity as unfixed, fluid, and contextual. Also, their stories suggest that adolescence is not a universal construct, and how people experience adolescence is greatly impacted by their race (both Black and White girls are represented in the study), class, and gender. In short, these tales told by adolescent females illuminate sites of conflict and challenge us to unlearn the truth about gender, identity, adolescence, and schooling

Rats Fed Dietary Bioactive Components (Resistant Starch, Whole Grains, and Fat) Undergo Altered Biometrics and Gene Expression as a Result of Gut Fermentation

The whole grain and fat content of the diet have been previously shown to affect intestinal fermentation and phenotype conferred by high–amylose maize resistant starch (HAMRS), a form of fermentable dietary fiber. The current studies were designed to compare rodent gut health following consumption of whole grain and non–whole grain prebiotics on moderate fat (MF) and high fat (HF) diets, and to optimize health effect based on dosage of whole grain resistant starch prebiotics. Study 1: Diets were prepared to contain the following factors RS (Present/Absent), WG (Present/Absent), and Fat (HF/MF). A three–way ANOVA was performed with statistical slice on interactions and main effects. Study 2: Isocaloric diets (3.7 kcal/g) were prepared as follows: non–RS non–WG control, non–RS WG control, or with increasing WGRS (5, 10, 15, 20% wt.)]. One–way ANOVA with a priori contrasts (WG vs. all individually) were performed at p\u3c0.05 Both: Diets were fed to Sprague Dawley and lean Zucker Diabetic Fatty rats respectively, for six weeks. After euthanasia, blood, cecal contents and cecal epithelial cells were collected and gastro–intestinal (GI) tract portions and fat pad weights recorded. RT–qPCR was performed to analyze gluconeogenic enzymes, response to oxidative stress, and gut barrier resilience. For study 1, a few interactions were significant, but the RS main effect provided the most substantial changes in biometric and gene expression parameters. WG presence resulted in consistency of fermentation. Results were primarily driven by two major effects: purified RS fermented better on MF than HF diets and diets with RS+WG show similar fermentation on both levels of dietary fat. Although the 10–15% dosages were best for initiating benefits from fermentation in study 2, WG flour alone promoted fermentation with RS1 (a WG kernel component), and WGRS (RS1+RS2) promoted greater fermentation. Replacing traditional starch with a whole grain with resistant starch, as low as 5%, had some beneficial effects. These results suggest that a lower level of intake of fermentable fiber as RS is beneficial, but show that substantial WG (only low RS1) also had beneficial effects