Christian Benzing

Mental Status in Patients Before and After Liver Transplantation

BACKGROUND In contrast to the well-described beneficial organic effects of liver transplantation (OLT) in patients with end-stage liver disease, changes in the mental status of patients after OLT remain poorly understood. The current study seeks to evaluate the influence of OLT on anxiety, depression, and dispositional optimism in patients with end-stage liver disease. MATERIAL AND METHODS Questionnaires were sent to patients on the OLT waiting list and patients after OLT. Depression/anxiety and dispositional optimism were assessed using the HADS and LOT-R questionnaires, respectively. These findings were compared to results from the general population. RESULTS The number of returned questionnaires was 292 of 940 (31.1%; 57 patients on the liver transplant waiting list: waiting group, 235 liver transplant recipients: OLT group). Both depression and anxiety scores were significantly higher in the waiting group when compared to the OLT group (p<0.05) and the general population (anxiety: p<0.001, depression: p<0.05), respectively. The OLT group was characterized by significantly higher anxiety scores (p<0.001) compared to the general population. Depression and summation scores did not differ (p>0.05). Dispositional optimism was higher in the OLT group compared to the waiting group (p<0.05) and to the general population (p<0.01). The waiting group had equal values as the general population (p>0.05). CONCLUSIONS Besides beneficial effects on liver function, OLT appears to be associated with significant improvements in depression and anxiety and a more optimistic view of life.

Single incision laparoscopic liver resection (SILL) – a systematic review

Background: Today, minimally invasive liver resections for both benign and malignant tumors are routinely performed. Recently, some authors have described single incision laparoscopic liver resection (SILL) procedures. Since SILL is a relatively young branch of laparoscopy, we performed a systematic review of the current literature to collect data on feasibility, perioperative results and oncological outcome. Methods: A literature research was performed on Medline for all studies that met the eligibility criteria. Titles and abstracts were screened by two authors independently. A study was included for review if consensus was obtained by discussion between the authors on the basis of predefined inclusion criteria. A thorough quality assessment of all included studies was performed. Data were analyzed and tabulated according to predefined outcome measures. Synthesis of the results was achieved by narrative review. Results: A total of 15 eligible studies were identified among which there was one prospective cohort study and one randomized controlled trial comparing SILL to multi incision laparoscopic liver resection (MILL). The rest were retrospective case series with a maximum of 24 patients. All studies demonstrated convincing results with regards to feasibility, morbidity and mortality. The rate of wound complications and incisional hernia was low. The cosmetic results were good. Conclusions: This is the first systematic review on SILL including prospective trials. The results of the existing studies reporting on SILL are favorable. However, a large body of scientific evidence on the field of SILL is missing, further randomized controlled studies are urgently needed.

Impact of different immunosuppressive regimens on the health‐related quality of life following orthotopic liver transplantation

The influence of immunosuppression on the recipients’ quality of life (QoL) is of major importance after OLT and has not yet been evaluated.

Liver Transplantation and Liver Resection for Cirrhotic Patients with Hepatocellular Carcinoma: Comparison of Long-Term Survivals

BackgroundBoth liver transplantation (LT) and liver resection (LR) represent curative treatment options for hepatocellular carcinoma (HCC) in patients with liver cirrhosis. In this study, we have compared outcomes between historical and more recent patient cohorts scheduled either for LT or LR, respectively.MethodsClinicopathological data of all patients with HCC and cirrhosis who underwent LT or LR between 1989 and 2011 were evaluated. Overall survival of patients with HCC within the Milan criteria (MC) was analyzed focusing on changes between different time periods.ResultsIn total, 364 and 141 patients underwent LT and LR for HCC in cirrhosis, respectively. Among patients with HCC within MC, 214 and 59 underwent LT and LR, respectively. Postoperative morbidity (37 vs. 11%, P < .0001), but not mortality (3 vs. 1%, P = .165), was higher after LR than after LT for HCC within MC. In the period 1989–2004, overall survival (OS) was significantly higher in patients who underwent LT compared to LR for HCC within MC (5-year OS: 77 vs. 36%, P < .0001). Interestingly, in the more recent period 2005–2011, OS was comparable between LT and LR for HCC within MC (5-year OS: 73 vs. 61%, P = .07).ConclusionWe have noted an improvement of outcomes among patients selected for partial hepatectomy in recent years that were comparable to stable results after LT in cirrhotic patients with HCC. Whether those improvements are due to advances in liver surgery, optimized perioperative managament for patients with liver cirrhosis, and the development of modern multimodal treatment strategies for the recurrent lesions appears plausible.

Intra-abdominal Trocar-Free Vacuum Liver Retractor for Upper-Gastrointestinal Surgery: Preliminary Clinical Series Using the LiVac System

Background. In laparoscopic upper-gastrointestinal (GI) surgery, an adequate retraction of the liver is crucial. Especially in single-port surgery and obese patients, problems may occur during liver retraction. The current study seeks to evaluate the efficacy and safety of the LiVac trocar-free liver retractor in laparoscopic upper-GI surgery. Methods. The present study is a nonrandomized dual-center clinical series describing our preliminary results using the LiVac system for liver retraction. The primary end points of the present study included the effectiveness and safety of the LiVac device as well as complications and documentation of problems with the device during surgery. Results. The device was used in 11 patients for simple and complex laparoscopic procedures. The mean age of the study population was 59.6 years (SD = 20.6; range = 30-84). There were 6 female and 5 male patients with a mean body mass index (BMI) of 31.9 kg/m2 (SD = 8.1; range = 26.0-45.3). The efficacy of the device was excellent in all cases, reducing the number of trocars needed. There were no device-related complications. Conclusion. The LiVac liver retractor is easy to use and provides a good exposure of the operative field in upper-GI laparoscopic surgery, even in obese patients with a high BMI.

Pancreaticoduodenectomy in the Elderly Patient: Age-Adapted Risk Assessment

Background: Older patients are increasingly faced with pancreatic surgery because of shifting demographics. The differential effects of aging on surgical outcomes remain vague, while the elderly patient is often neglected in clinical trials. Methods: Medical records of 370 patients who underwent pancreaticoduodenectomy were analyzed. Patients were then subdivided into 3 groups according to age and comorbidities. Results: Overall mortality was 5% and did not significantly differ between age-matched groups. Increasing age was linked to a higher prevalence of diabetes mellitus (p < 0.001) and preoperative cardiovascular comorbidities (p < 0.001). Independent risk factors for major complications were age over 70 years (p = 0.018; OR 2.3), elevated body mass index (p = 0.004; OR 0.2) and cardiovascular comorbidities (p = 0.022; OR = 2.6). Patients who were older (>70 years), obese and had cardiovascular disease had an increased risk of major complications when compared with the younger study population (p = 0.010). Conclusions: Pancreatic surgery in elderly patients showed similar mortality rates as in younger patients. Nevertheless, a careful risk assessment is particularly important because older patients who are considered to be high risk suffer more frequently from major surgical complications compared with young patients that have similar risk profiles.

Prognostic significance of TIE2-expressing monocytes in hilar cholangiocarcinoma.

Angiopoietins (Angs) play a pivotal role in angiogenesis and inflammation, and are associated with prognosis in malignancies. Monocyte express Ang‐receptor TIE2 and correlate with prognosis in cancer. We aimed to investigate the prognostic value of Angs and TIE2‐expressing monocytes (TEMs) in cholangiocarcinoma.

FROM COMPLEX EVOLVING TO SIMPLE: CURRENT REVISIONAL AND ENDOSCOPIC PROCEDURES FOLLOWING BARIATRIC SURGERY

ABSTRACT Background: Roux-en-Y gastric bypass (RYGB) is a standard therapy in bariatric surgery. Sleeve gastrectomy and gastric banding, although with good results in the literature, are showing higher rates of treatment failure to reduce obesity-associated morbidity and body weight. Other problems after bariatric may occur, as band erosion, gastroesophageal reflux disease and might be refractory to medication. Therefore, a laparoscopic conversion to a RYGB can be an effective alternative, as long as specific indications for revision are fulfilled. Objective: The objective of this study was to analyse own and literature data on revisional bariatric procedures to evaluate best alternatives to current practice. Methods: Institutional experience and systematic review from the literature on revisional bariatric surgery. Results: Endoscopic procedures are recently applied to ameliorate failure and complications of bariatric procedures. Therapy failure following RYGB occurs in up to 20%. Transoral outlet reduction is currently an alternative method to reduce the gastrojejunal anastomosis. The diameter and volume of sleeve gastrectomy can enlarge as well, which can be reduced by endoscopic full-thickness sutures longitudinally. Dumping syndrome and severe hypoglycemic episodes (neuroglycopenia) can be present in patients following RYGB. The hypoglycemic episodes have to be evaluated and usually can be treated conventionally. To avoid partial pancreatectomy or conversion to normal anatomy, a new laparoscopic approach with remnant gastric resection and jejunal interposition can be applied in non-responders alternatively. Hypoglycemic episodes are ameliorated while weight loss is sustained. Conclusion: Revisional and endoscopic procedures following bariatric surgery in patients with collateral symptomatic or treatment failure can be applied. Conventional non-surgical approaches should have been applied intensively before a revisional surgery will be indicated. Former complex surgical revisional procedures are evolving to less complicated endoscopic solutions.

EVOLUÇÃO DO COMPLEXO PARA O SIMPLES: PROCEDIMENTOS REVISIONAIS E ENDOSCÓPICOS APÓS CIRURGIA BARIÁTRICA

Racional: Bypass gastrico em Y-de-Roux (BGYR) e procedimento padrao em cirurgia bariatrica. Gastrectomia vertical e banda gastrica, embora com bons resultados na literatura, estao mostrando taxas mais elevadas de insucesso no tratamento para reduzir a morbidade associada a obesidade e peso corporal. Outros problemas pos-operatorios podem ocorrer, como a erosao da banda, e doenca do refluxo gastroesofagico refrataria a medicacao. Portanto, conversao laparoscopica para BGYR pode ser alternativa eficaz, desde que indicacoes especificas para a revisao sejam cumpridas. Objetivo: Analisar os nossos dados e os da literatura sobre procedimentos bariatricos revisionais para avaliar melhores alternativas para a pratica atual. Metodos: Foram efetuados experiencia institucional e revisao sistematica da literatura sobre cirurgia bariatrica revisional. Resultados: Procedimentos endoscopicos estao sendo aplicados recentemente para melhorar a falha e complicacoes de procedimentos bariatricos. Falha terapeutica apos BGYR ocorre em ate 20%. A reducao transoral e atualmente um metodo alternativo para reduzir a anastomose gastrojejunal. A gastrectomia vertical pode apresentar aumento de volume e do diâmetro do pouch , o qual podem ser reduzidos por meio de sutura total endoscopica longitudinal. Sindrome de dumping e episodios de hipoglicemia grave (neuroglicopenia) podem estar presentes nos pacientes com BGYR. Os episodios hipoglicemicos devem ser avaliados e geralmente podem ser tratados convencionalmente. Para evitar pancreatectomia parcial ou conversao a anatomia normal, uma nova abordagem laparoscopica com resseccao do remanescente gastrico e interposicao de jejuno, pode ser aplicada como alternativa em nao-respondedores. Episodios de hipoglicemia melhoram, enquanto a perda de peso e mantida. Conclusao: Procedimentos revisionais endoscopicos podem ser aplicados apos cirurgia bariatrica em pacientes com sintomas colaterais ou na falha do tratamento. Abordagens convencionais nao-cirurgicas devem ser aplicadas intensivamente antes que uma operacao revisional seja indicada. Antigos procedimentos cirurgicos revisionais complexos estao evoluindo para solucoes endoscopicas menos complicadas.

Validity of the Iwate criteria for patients with hepatocellular carcinoma undergoing minimally invasive liver resection

Recently proposed by the International Consensus Conference on Laparoscopic Liver Resection, the Iwate criteria (IC) can be used by surgeons to predict the operative difficulty of laparoscopic liver resection (LLR) and were validated in patients with hepatocellular carcinoma (HCC), the most common indication for LLR.