Minimally invasive liver surgery for benign liver tumors and lesions

Einleitung und Fragestellung: Die minimalinvasive Chirurgie der Leber hat in den letzten Jahren zunehmend an Bedeutung gewonnen und stellt bei malignen Raumforderungen eine Alternative zur konventionell-offenen Chirurgie dar. Da gutartige Raumforderungen der Leber meist nicht behandlungsbedürftig sind, ist der Stellenwert der minimalinvasiven Chirurgie bisher unzureichend geklärt. In der vorliegenden Forschungsarbeit soll die laparoskopische Leberresektion (LLR) mit der konventionell offen-chirurgischen Leberresektion (OLR) bei benignen Lebertumoren und -läsionen hinsichtlich postoperativer Sicherheit und Effektivität verglichen werden. Methodik: Im Zeitraum von Januar 2009 bis Dezember 2017 wurden retrospektiv 182 Patienten mit gutartigen Lebertumoren und -läsionen identifiziert, welche eine Leberresektion erhielten. Nach Exklusion von 15 Patienten verblieben 167 Patienten in der Studie und wurden in eine LLR-Gruppe bzw. OLR-Gruppe aufgeteilt und in Hinblick auf präoperative Patientencharakteristika sowie perioperative Verläufe verglichen. Um einen möglichen Selektionsbias zu verringern, wurde ein 1:1 Propensity Score Matching (PSM) durchgeführt. Ergebnisse: Vor dem PSM zeigten sich keine signifikanten Unterschiede der präoperativen Patientencharakteristika zwischen der LLR-Gruppe (n=54) und der OLR-Gruppe (n=113). In der OLR-Gruppe wurden signifikant mehr Major-Resektionen durchgeführt, welche in einer anschließenden Subgruppenanalyse gesondert verglichen wurden (OLR, n=59, 52,2%; LLR, n=8, 14,8%). Nach dem PSM verblieben jeweils 35 Patienten in der Matched-LLR und Matched-OLR Gruppe. Ein hoher chirurgischer Schwierigkeitsgrad lag in 25,7% (n=9) bei Matched-LLR und in 20,0% (n=7) bei Matched-OLR vor (p=0,317). Die Konversionsrate lag bei 3,1% (n=1). Die Rate an Major-Komplikationen lag bei 11,4% nach Matched-LLR und bei 2,9% nach Matched-OLR (p=0,375). Die Matched-LLR Gruppe hatte dennoch eine signifikant kürzere Verweildauer auf der Intensivstation (Matched-LLR, 1d, 0-4d; Matched-OLR, 1d, 0-3d; p=0,009) als auch im Krankenhaus im Vergleich zu Matched-OLR-Gruppe (Matched-LLR, 7d, 4-14d; Matched-OLR, 10d, 5-16d; p<0,001). In einer Subgruppenanalyse der Major-Resektionen zeigte sich eine signifikant längere Operationsdauer bei Major-LLR (Major-LLR, 403min, 240-501min; Major-OLR, 221,5min, 111-529min; p<0,001). Die Komplikationsrate nach Major-LLR lag bei 0% (Major-OLR 16,9% (n=10), p=0,207), was in einer signifikant kürzeren Krankenhausverweildauer der Major-LLR-Gruppe resultierte (Major-LLR, 7d, 5-14d; Major-OLR, 9d, 7-129d; p=0,013). Schlussfolgerung: Die minimalinvasive Leberchirurgie stellt unabhängig vom Resektionsausmaß eine sichere und effektive Alternative zur konventionell-offenen Chirurgie gutartiger Tumore und Läsionen dar. Vorteile der minimalinvasiven Chirurgie zeigen sich vor allem in einer schnelleren Erholungsphase und kürzerer Intensivstations- bzw. im Krankenhausverweildauer im Vergleich zur konventionell-offenen Chirurgie.Background and Aim: In recent years minimally invasive liver surgery has gained markedly in importance, particularly as potential alternative to conventional open surgery in malignant liver tumors. As benign liver tumors and lesions usually do not require treatment, potential benefits of minimally invasive techniques remain uncertain. The aim of this work was to compare results between laparoscopic liver resection (LLR) and open liver resection (OLR) in benign liver tumors and lesions regarding postoperative safety and efficiency. Methods: We retrospectively analyzed characteristics of 182 patients who underwent liver resection for benign liver tumors and lesions between January 2009 and December 2017. After exclusion of 15 patients the remaining 167 patients were divided into LLR-group and OLR-group and compared regarding preoperative characteristics and perioperative outcomes. To reduce a potential selection bias a 1:1 Propensity-Score Matching (PSM) was conducted. Results: Before PSM no differences between LLR-group (n=54) and OLR-group (n=113) regarding preoperative characteristics were observed. In the OLR-group significantly more patients underwent major resections, which were subsequently analysed in subgroups (OLR, n=59, 52.2%; LLR, n=8, 14.8%). After PSM a total of 70 patients remained evenly split between the Matched-LLR and Matched-OLR groups. A high surgical difficulty score was seen in 25.7% (n=9) in the Matched-LLR group and 20.0% (n=7) in the Matched-OLR group (p=0.317). The conversion rate was 3.1% (n=1). The rate of major complication was 11.4% in the Matched-LLR group and 2.9% in the Matched-OLR group (p=0.375). Nevertheless, the Matched-LLR group had a significantly shorter intensive care unit stay (Matched-LLR, 1d, 0-4d; Matched-OLR, 1d, 0-3d; p=0.009) and shorter length of hospitalization (Matched-LLR, 7d, 4-14d; Matched-OLR, 10d, 5-16d; p<0.001). Patients undergoing Major-LLR had a significantly longer duration of operation (Major-LLR, 403min, 240-501min; Major-OLR, 221.5min, 111-529min; p<0.001). The major complication rate was 0% (n=0) in Major-LLR group (16.9% (n=10) in Major-OLR group, p=0.207), resulting in a shorter hospitalization (Major-LLR, 7d, 5-14; Major-OLR, 9d, 7-129; p=0.013) compared to the Major-OLR group. Conclusion: Minimally invasive liver surgery is suggested to be a safe and efficient alternative to open surgery in benign liver tumors and lesions. Obvious benefits of the laparoscopic approach include a faster functional recovery with shorter ICU and hospital stay when compared to the open approach

Recurrence of Hepatocellular Carcinoma After Liver Transplantation is Associated with Episodes of Acute Rejections.

Purpose The impact of acute rejection (AR) after liver transplantation (LT) for hepatocellular carcinoma (HCC) on patient outcome is uncertain. This aim of this study is to investigate whether AR is associated with HCC relapse and overall survival. Patients and Methods Patients undergoing LT for HCC between 2001 and 2015 were retrospectively analyzed with regard to histopathological proven AR within the median time until recurrence. Cox's regression analysis was conducted revealing risk factors for HCC recurrence. Results HCC recurred in 47 of 252 analyzed patients with a median time to recurrence of 20 months. Patients with AR (28.6%) had a significantly higher frequency of recurrence compared to patients without AR (13.0%, p=0.002). Multiple Cox regression analyses identified AR within 20 months to be an independent risk factor for HCC recurrence both as dichotomized (HR=2.91, 95%CI: 1.30-6.53; p=0.009) and as a continuous variable (HR=1.81, 95%CI: 1.28-2.54; p=0.001). HCC recurrence and AR were associated with higher grades of liver fibrosis one year after LT, when compared to patients without AR (p=0.019). Conclusion Our results demonstrate an association of AR with HCC recurrence after LT with implications for intervals of monitoring in tumor surveillance. Graft fibrosis and immune mechanisms are potentially related and causal interactions are worth further investigation

Outcome after pediatric liver transplantation for staged abdominal wall closure with use of biological mesh—Study with long‐term follow‐up

Abdominal wall closure after pediatric liver transplantation (pLT) in infants may be hampered by graft-to-recipient size discrepancy. Herein, we describe the use of a porcine dermal collagen acellular graft (PDCG) as a biological mesh (BM) for abdominal wall closure in pLT recipients. Patients <2 years of age, who underwent pLT from 2011 to 2014, were analyzed, divided into definite abdominal wall closure with and without implantation of a BM. Primary end-point was the occurrence of postoperative abdominal wall infection. Secondary end-points included 1- and 5-year patient and graft survival and the development of abdominal wall hernia. In five out of 21 pLT recipients (23.8%), direct abdominal wall closure was achieved, whereas 16 recipients (76.2%) received a BM. BM removal was necessary in one patient (6.3%) due to abdominal wall infection, whereas no abdominal wall infection occurred in the no-BM group. No significant differences between the two groups were observed for 1- and 5-year patient and graft survival. Two late abdominal wall hernias were observed in the BM group vs none in the no-BM group. Definite abdominal wall closure with a BM after pLT is feasible and safe when direct closure cannot be achieved with comparable postoperative patient and graft survival rates

COVID-19 government measures and their impact on mental health: a cross-sectional study of older primary care patients in Germany

BackgroundWith the outbreak of COVID-19, government measures including social distancing and restrictions of social contacts were imposed to slow the spread of the virus. Since older adults are at increased risk of severe disease, they were particularly affected by these restrictions. These may negatively affect mental health by loneliness and social isolation, which constitute risk factors for depressiveness. We aimed to analyse the impact of perceived restriction due to government measures on depressive symptoms and investigated stress as mediator in an at-risk-population in Germany.MethodsData were collected in April 2020 from the population of the AgeWell.de-study, including individuals with a Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score ≥9, using the depression subscale of the Brief Symptom Inventory (BSI-18) and the Perceived Stress Scale (PSS-4). Feeling restricted due to COVID-19 government measures was surveyed with a standardized questionnaire. Stepwise multivariate regressions using zero-inflated negative binomial models were applied to analyse depressive symptoms, followed by a general structural equation model to assess stress as mediator. Analysis were controlled for sociodemographic factors as well as social support.ResultsWe analysed data from 810 older adults (mean age = 69.9, SD = 5). Feeling restricted due to COVID-19 government measures was linked to increased depressiveness (b = 0.19; p &lt; 0.001). The association was no longer significant when adding stress and covariates (b = 0.04; p = 0.43), while stress was linked to increased depressive symptoms (b = 0.22; p &lt; 0.001). A final model confirms the assumption that the feeling of restriction is mediated by stress (total effect: b = 0.26; p &lt; 0.001).ConclusionWe found evidence that feeling restricted due to COVID-19 government measures is associated with higher levels of depressive symptoms in older adults at increased risk for dementia. The association is mediated by perceived stress. Furthermore, social support was significantly associated with less depressive symptoms. Thus, it is of high relevance to consider possible adverse effects of government measures related to COVID-19 on mental health of older people

Stress, Coping and Considerations of Leaving the Profession&mdash;A Cross-Sectional Online Survey of Teachers and School Principals after Two Years of the Pandemic

Teaching is amongst the six professions with the highest stress levels and lowest job satisfaction, leading to a high turnover rate and teacher shortages. During the pandemic, teachers and school principals were confronted with new regulations and teaching methods. This study aims to examine post-pandemic stress levels, as well as resilience factors to proactively cope with stress and thoughts of leaving the profession among teachers and school principals. We used a cross-sectional online survey. The validated instruments Perceived Stress Scale (PSS-10) and Proactive Coping Subscale (PCI) were used. We included 471 teachers and 113 school principals in the analysis. Overall, respondents had a moderate stress level. During the pandemic, every fourth teacher (27.2%) and every third principal (32.7%) had serious thoughts of leaving the profession. More perceived helplessness (OR = 1.2, p &lt; 0.001), less self-efficacy (OR = 0.8, p = 0.002), and poorer coping skills (OR = 0.96, p = 0.044) were associated with a higher likelihood of thoughts of leaving the profession for teachers, whereas for school principals, only higher perceived helplessness (OR = 1.2, p = 0.008) contributed significantly. To prevent further teacher attrition, teachers and school principals need support to decrease stress and increase their ability to cope

COVID-19-related future anxiety is associated with the health-related quality of life in school-aged children and adolescents—A cross-sectional study

Background Over the course of the COVID-19 pandemic, previous studies have shown that the physical as well as the mental health of children and adolescents significantly deteriorated. Future anxiety caused by the COVID-19 pandemic and its associations with quality of life has not previously been examined in school children. Methods As part of a cross-sectional web-based survey at schools in Mecklenburg-Western Pomerania, Germany, two years after the outbreak of the pandemic, school children were asked about COVID-19-related future anxiety using the German epidemic-related Dark Future Scale for children (eDFS-K). Health-related quality of life (HRQoL) was assessed using the self-reported KIDSCREEN-10. The eDFS-K was psychometrically analyzed (internal consistency and confirmatory factor analysis) and thereafter examined as a predictor of HRQoL in a general linear regression model. Results A total of N = 840 8–18-year-old children and adolescents were included in the analysis. The eDFS-K demonstrated adequate internal consistency reliability (Cronbach's α = 0.77), and the confirmatory factor analysis further supported the one-factor structure of the four-item scale with an acceptable model fit. Over 43% of students were found to have low HRQoL. In addition, 47% of the students sometimes to often reported COVID-19-related fears about the future. Children with COVID-19-related future anxiety had significantly lower HRQoL (B = – 0.94, p < 0.001). Other predictors of lower HRQoL were older age (B = – 0.63, p < 0.001), and female (B = – 3.12, p < 0.001) and diverse (B = – 6.82, p < 0.001) gender. Conclusion Two years after the outbreak of the pandemic, school-aged children continue to exhibit low HRQoL, which is further exacerbated in the presence of COVID-19-related future anxiety. Intervention programs with an increased focus on mental health also addressing future anxiety should be provided

Minimal-Invasive Versus Open Hepatectomy for Colorectal Liver Metastases: Bicentric Analysis of Postoperative Outcomes and Long-Term Survival Using Propensity Score Matching Analysis.

Minimal-invasive hepatectomy (MIH) has been increasingly performed for benign and malignant liver lesions with most promising short-term results. However, the oncological role of MIH in the treatment of patients with colorectal liver metastases (CRLM) needs further investigation. Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2017 at the Department of Surgery, Charité-Universitätsmedizin Berlin, and the Inselspital Bern were assessed. Postoperative outcomes und long-term survivals of patients following MIH were compared with those after conventional open hepatectomy (OH) after 1:1 propensity score matching. During the study period, 229 and 91 patients underwent liver resection for CRLM at the Charité Berlin and the Inselspital Bern, respectively. Patients who underwent MIH in one of the two centers (n = 69) were compared with a matched cohort of patients who underwent OH. MIH was associated with lower complication rates (23% vs. 44%, p = 0.011), shorter length of intensive care unit stay (ICU, 1 vs. 2 days, p = 0.043), shorter length of hospital stay (7 vs. 11 days, p < 0.0001), and a reduced need for intraoperative transfusions (12% vs. 25%, p = 0.047) compared to OH. R0 status was achieved in 93% and 75% of patients after MIH and OH, respectively (p = 0.005). After a median follow-up of 31 months, MIH resulted in similar five-year overall survival (OS) rate (56% vs. 48%, p = 0.116) in comparison to OH. MIH for CRLM is associated with lower postoperative morbidity, shorter length of ICU and hospital stay, reduced need for transfusions, and comparable oncologic outcomes compared to the established OH. Our findings suggest that MIH should be considered as the preferred method for the treatment of curatively resectable CRLM

Impact of Changes in Infection Control Measures on the Dynamics of COVID-19 Infections in Schools and Pre-schools

Introduction: With the increased emergence of SARS-CoV-2 variants, the impact on schools and preschools remains a matter of debate. To ensure that schools and preschools are kept open safely, the identification of factors influencing the extent of outbreaks is of importance. Aim: To monitor dynamics of COVID-19 infections in schools and preschools and identify factors influencing the extent of outbreaks. Methods: In this prospective observational study we analyzed routine surveillance data of Mecklenburg-Western Pomerania, Germany, from calendar week (CW) 32, 2020 to CW19, 2021 regarding SARS-CoV-2 infection events in schools and preschools considering changes in infection control measures over time. A multivariate linear regression model was fitted to evaluate factors influencing the number of students, teachers and staff tested positive following index cases in schools and preschools. Due to an existing multicollinearity in the common multivariate regression model between the variables “face mask obligation for children” and “face mask obligation for adults”, two further separate regression models were set up (Multivariate Model Adults and Multivariate Model Children). Results: We observed a significant increase in secondary cases in preschools in the first quarter of 2021 (CW8 to CW15, 2021), and simultaneously a decrease in secondary cases in schools. In multivariate regression analysis, the strongest predictor of the extent of the outbreaks was the teacher/ caregiver mask obligation (B = −1.9; 95% CI: −2.9 to −1.0; p < 0.001). Furthermore, adult index cases (adult only or child+adult combinations) increased the likelihood of secondary cases (B = 1.3; 95% CI: 0.9 to 1.8; p < 0.001). The face mask obligation for children also showed a significant reduction in the number of secondary cases (B = −0.6; 95% CI: −0.9 to −0.2; p = 0.004. Conclusion: The present study indicates that outbreak events at schools and preschools are effectively contained by an obligation for adults and children to wear face masks

Liver Transplantation Is Highly Effective in Children with Irresectable Hepatoblastoma

Background and Objectives: In children, hepatoblastoma preferentially is managed by liver resection (LR). However, in irresectable cases, liver transplantation (LT) is required. The aim of our study was to compare short- and long-term results after LR and LT for the curative treatment of hepatoblastoma. Materials and Methods: Retrospective analysis of all patients treated surgically for hepatoblastoma from January 2000 until December 2019 was performed. Demographic and clinical data were collected before and after surgery. The primary endpoints were disease free survival and patient survival. Results: In total, 38 patients were included into our analysis (n = 28 for LR, n = 10 for LT) with a median follow-up of 5 years. 36 patients received chemotherapy prior to surgery. Total hospital stay and intensive care unit (ICU) stay were significantly longer within the LT vs. the LR group (ICU 23 vs. 4 days, hospital stay 34 vs. 16 days, respectively; p p = 1.00). Severe complications (≥Clavien–Dindo 3a) were more frequent after LT (50% vs. 21.4%; p = 0.11). Recurrence rates were 10.7% for LR and 0% for LT at 5 years after resection or transplantation (p = 0.94). Overall, 5-year survival was 90% for LT and 96% for LR (p = 0.44). Conclusions: In irresectable cases, liver transplantation reveals excellent outcomes in children with hepatoblastoma with an acceptable number of perioperative complications

Serum Selenium Status as a Diagnostic Marker for the Prognosis of Liver Transplantation

The trace element selenium (Se) is taken up from the diet and is metabolized mainly by hepatocytes. Selenoprotein P (SELENOP) constitutes the liver-derived Se transporter. Biosynthesis of extracellular glutathione peroxidase (GPx3) in kidney depends on SELENOP-mediated Se supply. We hypothesized that peri-operative Se status may serve as a useful prognostic marker for the outcome in patients undergoing liver transplantation due to hepatocellular carcinoma. Serum samples from liver cancer patients were routinely collected before and after transplantation. Concentrations of serum SELENOP and total Se as well as GPx3 activity were determined by standardized tests and related to survival, etiology of cirrhosis/carcinoma, preoperative neutrophiles, lymphocytes, thyrotropin (TSH) and Child-Pugh and Model for End-Stage Liver Disease (MELD) scores. A total of 221 serum samples from 79 transplanted patients were available for analysis. The Se and SELENOP concentrations were on average below the reference ranges of healthy subjects. Patients with ethanol toxicity-dependent etiology showed particularly low SELENOP and Se concentrations and GPx3 activity. Longitudinal analysis indicated declining Se concentrations in non-survivors. We conclude that severe liver disease necessitating organ replacement is characterized by a pronounced Se deficit before, during and after transplantation. A recovering Se status after surgery is associated with positive prognosis, and an adjuvant Se supplementation may, thus, support convalescence