Induction of Tumor Growth After Preoperative Portal Vein Embolization: Is It a Real Problem?

Although preoperative portal vein embolization (PVE) is an effective means to increase future remnant liver (FRL) volume, little has been published on possible adverse effects. This review discusses the clinical and experimental evidence regarding the effect of PVE on tumor growth in both embolized and nonembolized liver lobes, as well as potential strategies to control tumor progression after PVE. A literature review was performed using MEDLINE with keywords related to experimental and clinical studies concerning PVE, portal vein ligation (PVL), and tumor growth. Cross-references and references from reviews were also checked. Clinical and experimental data suggest that tumor progression can occur after preoperative PVE in embolized and nonembolized liver segments. Clinical evidence indicating possible tumor progression in patients with colorectal metastases or with primary liver tumors is based on studies with small sample size. Although multiple studies demonstrated tumor progression, evidence concerning a direct increase in tumor growth rate as a result of PVE is circumstantial. Three possible mechanisms influencing tumor growth after PVE can be recognized, namely changes in cytokines or growth factors, alteration in hepatic blood supply and an enhanced cellular host response promoting local tumor growth after PVE. Post-PVE chemotherapy and sequential transcatheter arterial chemoembolization (TACE) before PVE have been proposed to reduce tumor mass after PVE. We conclude that tumor progression can occur after PVE in patients with colorectal metastases as well as in patients with primary liver tumors. However, further research is needed in order to rate this risk of tumor progression after PV

Staging Laparoscopy for Hilar Cholangiocarcinoma: Is it Still Worthwhile?

This study was designed to evaluate the benefit of staging laparoscopy (SL) in patients with suspected hilar cholangiocarcinoma (HCCA) during the past 10 years. Only 50-60% of patients with HCCA who undergo laparotomy are ultimately amenable to a potentially curative resection. In a previous study, we recommended routine use of SL to prevent unnecessary laparotomies. The accuracy of imaging techniques, however, has significantly improved during the past decade, which is likely to impact the yield and accuracy of SL. From 2000 to 2010, 195 patients with suspected HCCA were analyzed. The yield and accuracy of SL were calculated by dividing total number of avoided laparotomies by the total number of laparoscopies or by all patients with unresectable disease, respectively. Factors associated with better yield and accuracy were assessed. Of 195 patients with HCCA, 175 underwent SL. The yield of SL was 14% and the accuracy was 32%. Operative morbidity of SL was 3%, and operative morbidity of laparotomy for unresectable disease was 33%. No clear factors that influenced the yield of SL were found. Overall yield and accuracy of SL for HCCA in the present series decreased to 14% and 32%, respectively, compared with earlier reports. This finding is likely the result of improved imaging techniques that evolved during the past decade. The place of SL in the workup of patients with HCCA needs to be reconsidered, and one should decide whether the declining additional value of SL still outweighs the drawbacks of S

Intrabiliary Migrated Clips and Coils as a Nidus for Biliary Stone Formation: A Rare Complication following Laparoscopic Cholecystectomy

Clips inserted during laparoscopic cholecystectomy (LC) may migrate into the biliary system and function as a nidus for the formation of gallstones. Here, we present a series of 4 patients who presented with this rare complication 5–17 years after LC. All 4 patients presented with symptomatic choledocholithiasis with biochemical and radiological signs of biliary obstruction. Three patients also had fever and infectious parameters, compatible with concurrent cholangitis. All patients successfully underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and stone extraction. Patients with cholangitis also had antibiotic treatment. In 3 patients, obstruction of the common bile duct was caused by a single, relatively large stone that had formed around a clip (supposedly the cystic duct clip). In 1 patient, multiple stones had formed around an intrabiliary migrated cluster of coils that had been used for arterial embolization of a pseudo-aneurysm of the right hepatic artery. In conclusion, surgical clips and coils can migrate into the biliary tract and serve as a nidus for the formation of bile duct stones. Although rare, this complication should caution surgeons not to place clips “at random” during cholecystectomy. Patients with this rare complication are best managed by ERCP in combination with sphincterotomy and stone extraction

The entrance to the guild chamber of the Amsterdam Guild of Surgeons

In the 17th and 18th centuries the entrance to the guild chamber of the Amsterdam Guild of Surgeons was located in the right corner-tower of the Waag on the Nieuwmarkt in Amsterdam. The surgeons entered their guild chamber through this door for guild meetings or to take surgical exams. The entrance also gave access to the anatomy theatre, the 'Theatrum Anatomicum', where anatomical dissections - anatomy lessons - took place. There was a bust of Hippocrates in the facade above the door, and the inscription 'Theatrum Anatomicum'. The series of 'anatomy lessons' reminds us of the famous paintings that were commissioned by the Surgeons' Guild. At the beginning of the 17th century, a skeleton was painted on the door in the gateway, and this marked the entrance to the Surgeons' Guild for almost 200 years. We examined, from a historical perspective, how the gateway to the guild chamber of the Amsterdam Guild of Surgeons was transformed over time.</p

Combining partial liver resection and local ablation of liver tumours: a preliminary Dutch experience

BACKGROUND: The combination of partial liver resection and radiofrequency ablation (RFA) is a novel concept in the treatment of unresectable liver malignancies. The aim of this study is to evaluate the results of this combined strategy in the Netherlands. METHODS: Thirty-five patients treated with a combination of partial liver resection and RFA were identified from a prospectively registered pooled multicentre database. All patients were operated between June 1999 and November 2003 in 8 medical centres in the Netherlands. Main outcome parameters were morbidity, mortality, local success rate, and survival. RESULTS: Thirty-seven operations were performed in 35 patients. The group consisted of 20 male and 15 female patients with a median age of 59 years (range 41–76). Seventy-six lesions were resected and RFA was performed to ablate 82 unresectable liver tumours. Twelve patients developed a total of 24 complications, resulting in an overall perioperative morbidity rate of 32%. In two patients major complications resulted in postoperative death (postoperative mortality rate 5.4%). Local success rate after RFA was 88% and the estimated 1-, 2- and 3-year overall survival rates were 84%, 70% and 43%, respectively. CONCLUSION: This strategy should only be performed following strict patient selection and within the context of prospective clinical trials

Guild medals from the Surgeons' Guild of Amsterdam

Between around 1620 and the end of the eighteenth century, every surgeon working in Amsterdam was presented with a guild medal on passing their surgeon's exams. These medals actually represented membership of the Surgeon's Guild of Amsterdam and could be used as proof of attendance at meetings of the Guild. From 1864 onwards surgeons also received the Hortus medal, which allowed them entry to the Hortus Medicus. Less common medals include medals for ensuring the surgeon's apprentices attended lectures, funeral medals for ensuring correct procedures regarding casket bearing duties were followed at a funeral, and medals of honour recognising services to the Guild. The collection of 17th and 18th century Amsterdam Surgeon's Guild medals numbers some 230 examples, and is the largest and most varied collection of its kind in the world. A few of the medals that have been preserved actually belonged to surgeons depicted in the famous series of group portraits. We examined who these surgeons were and what the purpose of these medals was. </p