Should We Deny Surgery for Malignant Hepato-Pancreatico-Biliary Tumors to Elderly Patients?

Malignant hepato-pancreatico-biliary (HPB) tumors have their highest incidence within the sixth to eighth decades of life. The aging of the world population has resulted in a dramatic increase in the number of elderly patients considered for resection of malignant HPB tumors. Because elderly patients are more likely to have more co-morbidities, cognitive impairment, and decreased life expectancy, the benefit and appropriateness of these procedures must be scrutinized for geriatric patients. Therefore, many surgeons have compared the perioperative and long-term outcome of hepatic and pancreatic resections for elderly and younger patients. In most series the elderly population was defined by an age of 70 years or older. The results demonstrate that hepatic resection for hepatocellular carcinoma and colorectal liver metastases can be safely performed in well-selected elderly patients with long-term outcome comparable to younger patients. Similar findings are also reported for pancreatic resection in elderly patients with either ampullary or pancreatic cancer. Although the survival benefit of pancreatico-duodenectomy is limited in all age groups, the absence of competitive therapy justifies this procedure as the sole curative option in younger as well as older patients. Data on resection of gallbladder cancer and hilar bile duct cancer in the elderly are sparse, but there is evidence from large series on resection of these types of tumors that advanced age per se is not a risk factor for reduced outcome. Therefore, surgical options should not be denied to elderly patients with a malignant HPB tumor, and the evaluation should include surgeons expert in HPB surger

"State of the Art” in Liver Resection and Living Donor Liver Transplantation: A Worldwide Survey of 100 Liver Centers

Background: New strategies have been developed to expand indications for liver surgery. The objective was to evaluate the current practice worldwide regarding critical liver mass and manipulation of the liver volume. Methods: A survey was sent to 133 liver centers worldwide, which focused on (a) critical liver volume, (b) preoperative manipulation of the liver mass, and (c) use of liver biopsy and metabolic tests. Results: The overall response rate to the survey was 75%. Half of the centers performed more than 100 resections per year; 86% had an associated liver transplant program. The minimal remnant liver volume for resection was 25% (15-40%) in cases of normal liver parenchyma and 50% (25-90%) in the presence of underlying cirrhosis. The minimal remnant liver volume for living donors was 40% (30-50%), whereas the accepted graft body weight ratio was 0.8 (0.6-1.2). Portal vein occlusion to manipulate the liver volume before resection was performed in 89% of the centers. Conclusions: Limits of liver volume and the current practice of liver manipulation before resection were comparable among different centers and continents. The minimal remnant liver volume in normal liver was 25%, and more than 80% of the centers performed portal vein occlusio

Contrast-enhanced MR cholangiography with Gd-EOB-DTPA in patients with liver cirrhosis: visualization of the biliary ducts in comparison with patients with normal liver parenchyma

The purpose of this study was to assess the quality of biliary duct visualization using Gd-EOB-DTPA-enhanced magnetic resonance cholangiography (EOB-MRC) in patients with liver cirrhosis. Forty adult patients with liver cirrhosis (cirrhosis group) and 20 adult individuals with normal liver parenchyma (control group) underwent EOB-MRC using T1-weighted GRE imaging up to 180min after Gd-EOB-DTPA administration. Two observers assessed the visualization of each biliary structure and the overall anatomical visualization of the biliary tree. Child-Pugh, MELD score and laboratory findings were compared. The grade of visualization for each evaluated biliary structure was statistically different in the two groups (P = 0.004 to <0.001). The overall EOB-MRC quality was rated as sufficient for anatomical visualization of the biliary tree in all individuals of the control group 20min after Gd-EOB-DTPA application, but in only 16/40 patients (40%) of the cirrhosis group within 30min after application. Analysis of the ROC curves revealed that the cut-off values, for non-sufficient visualization of the biliary tree 20min after Gd-EOB-DTPA application, were MELD scores ≥11 and total serum bilirubin levels ≥30 μmol/l. Consecutively, EOB-MRC in patients with liver cirrhosis resulted in a decreased or even non-visualization of the biliary tree in a substantial percentage of patient

A Quarter Century Experience in Liver Trauma: A Plea for Early Computed Tomography and Conservative Management for all Hemodynamically Stable Patients

Background: Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome. Methods: A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010). Results: 395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P=0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis. Conclusions: Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver traum

Patient Selection for Downstaging of Hepatocellular Carcinoma Prior to Liver Transplantation Adjusting the Odds?: Adjusting the Odds?

Background and Aims: Morphometric features such as the Milan criteria serve as standard criteria for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Since it has been recognized that these criteria are too restrictive and do not adequately display the tumor biology, additional selection parameters are emerging. Methods: Concise review of the current literature on patient selection for downstaging and LT for HCC outside the Milan criteria. Results: The major task in patients outside the Milan criteria is the need for higher granularity with patient selection, since the benefit through LT is not uniform. The recent literature clearly shows that beneath tumor size and number, additional selection parameters are useful in the process of patient selection for and during downstaging. For initial patient selection, the alpha fetoprotein (AFP) level adds additional information to the size and number of HCC nodules concerning the chance of successful downstaging and LT. This effect is quantifiable using newer selection tools like the WE (West-Eastern) downstaging criteria or the Metroticket 2.0 criteria. Also an initial PET-scan and/or tumor biopsy can be helpful, especially in the high risk group of patients outside the University of California San Francisco (UCSF) criteria. After this entry selection, the clinical course during downstaging procedures concerning the tumor and the AFP response is of paramount importance and serves as an additional final selection tool Conclusion: Selection criteria for liver transplantation in HCC patients are becoming more and more sophisticated, but are still imperfect. The implementation of molecular knowledge will hopefully support a more specific risk prediction for HCC patients in the future, but do not provide a profound basis for clinical decision-making at present

Right-sided ALPPS after preoperative emergency embolization of the right hepatic artery: case report with a favorable anatomy

In patients with extensive colorectal liver metastases (CRLM) and insufficient future liver remnant (FLR) a faster and more effective FLR augmentation than portal vein embolization is the associating liver partition and portal vein ligation in staged hepatectomy (ALPPS). Before ALPPS, the presence of arterial blood supply to the subsequently resected hemiliver must be ensured. We present a case with neoadjuvant-treated CRLM and insufficient FLR who developed a large intrahepatic hematoma after liver biopsy. For continuous bleeding, the right hepatic artery was embolized. Fortunately, an accessory right hepatic artery arising from the superior mesenteric artery was present, which enabled the ALPPS procedure to be performed. After ALPPS, the patient did not experience liver failure. The case exemplifies that preoperative evaluation of the vascular supply of the liver is of paramount importance in advanced hepatic surgery such as ALPPS

Prospective intraindividual comparison between respiratory-triggered balanced steady-state free precession and breath-hold gradient-echo and time-of-flight magnetic resonance imaging for assessment of portal and hepatic veins

The purpose of this study was to compare respiratory-triggered balanced steady-state free precession (bSSFP) with breath-hold contrast-enhanced dynamic two-dimensional (2D) gradient-echo (GRE) and time-of-flight (TOF) magnetic resonance imaging (MRI) for portal and hepatic vein visualization and assessment of portal and hepatic venous variants. Sixty patients with liver disease underwent nonenhanced bSSFP and contrast-enhanced GRE, bSSFP, and TOF imaging. Contrast-to-noise ratios (CNRs) for portal and hepatic veins were measured. Two readers rated the quality of portal and hepatic vein visualization on a 5-point Likert scale. The diagnostic performance of each MRI series in the detection of portal and hepatic venous variants was assessed in 40/60 patients who also underwent contrast-enhanced multidetector-row computed tomography (MDCT). CNRs for portal and hepatic veins were highest on contrast-enhanced bSSFP images. Image quality of portal and hepatic veins was rated higher for nonenhanced bSSFP than for contrast-enhanced GRE (p<0.03) and TOF (p<0.003) and higher for contrast-enhanced than for nonenhanced bSSFP (p<0.003). Compared with MDCT, portal and hepatic venous variants were identified with an accuracy of 99% on bSSFP images, with an excellent interobserver agreement (κ=0.97). Compared with MDCT, presence of surgically important portal and hepatic venous anatomical variants can be predicted with high accuracy on bSSFP image

Patient recruitment into clinical studies of solid malignancies during the COVID-19 pandemic in a tertiary cancer center

Background and purpose: To analyze clinical trial activities and patient recruitment numbers into prospective clinical studies for solid malignancies during the COVID-19 pandemic in a tertiary cancer center. Materials and methods: Patient recruitment numbers in prospective clinical studies of solid malignancies were retrospectively analyzed for the years 2019 – 2021 at the Comprehensive Cancer Center Zurich (CCCZ). Changes in recruitment numbers were tested for association with organ-specific subunits, as well as organizational and treatment-related trial characteristics. To assess differences between categorical variables, Chi-squared test was used. For uni- and multivariate analysis, Cox proportional hazards were calculated. Results: In 2019, there were a total of 107 studies (registry trials, clinical phase I-III trials, and translational studies) recruiting 304 patients at the CCCZ. During the COVID-19 pandemic in 2020 and 2021, there were 120 and 125 active trials with a total recruitment of 355 and 666 patients, respectively. No significant differences between the subunits and study characteristics in changes of patient recruitment in clinical phase I-III trials were identified when the year prior to the COVID-19 pandemic (2019) was compared to the first year of the pandemic (2020) and to 2020-2021. Conclusions: Despite healthcare systems around the world have experienced significant disruption due to the COVID-19 pandemic, data from our tertiary cancer center showed that clinical trial activities were maintained at a high level during the pandemic