Peter Nørgaard Larsen

Evaluation of a fast-track programme for patients undergoing liver resection.

Recent developments in perioperative pathophysiology and care have documented evidence‐based, multimodal rehabilitation (fast‐track) to hasten recovery and to decrease morbidity and hospital stay for several major surgical procedures. The aim of this study was to investigate the effect of introducing fast‐track principles for perioperative care in unselected patients undergoing open or laparoscopic liver resection.

Intraincisional antibiotic in addition to systemic antibiotic treatment fails to reduce wound infection rates in contaminated abdominal surgery. A controlled clinical trial.

One hundred ninety patients with peritonitis at the time of abdominal surgery were allocated at random to systemic antibiotic treatment alone or systemic antibiotic treatment combined with topical application of antibiotics in the wound at the time of wound closure. The overall wound infection rate was 17 percent without significant difference between the two treatment groups (P>0.80).

Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

BACKGROUND Right or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction. METHODS In patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed. RESULTS In six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery. SUMMARY After pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.

Alpps Improves Resectability Compared With Conventional Two-stage Hepatectomy in Patients With Advanced Colorectal Liver Metastasis: Results From a Scandinavian Multicenter Randomized Controlled Trial (ligro Trial)

Objective: The aim of the study was to evaluate if associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) could increase resection rates (RRs) compared with two-stage hepatectomy (TSH) in a randomized controlled trial (RCT). Background: Radical liver metastasis resection offers the only chance of a cure for patients with metastatic colorectal cancer. Patients with colorectal liver metastasis (CRLM) and an insufficient future liver remnant (FLR) volume are traditionally treated with chemotherapy with portal vein embolization or ligation followed by hepatectomy (TSH). This treatment sometimes fails due to insufficient liver growth or tumor progression. Methods: A prospective, multicenter RCT was conducted between June 2014 and August 2016. It included 97 patients with CRLM and a standardized FLR (sFLR) of less than 30%. Primary outcome—RRs were measured as the percentages of patients completing both stages of the treatment. Secondary outcomes were complications, radicality, and 90-day mortality measured from the final intervention. Results: Baseline characteristics, besides body mass index, did not differ between the groups. The RR was 92% [95% confidence interval (CI) 84%–100%] (44/48) in the ALPPS arm compared with 57% (95% CI 43%–72%) (28/49) in the TSH arm [rate ratio 8.25 (95% CI 2.6–26.6); P < 0.0001]. No differences in complications (Clavien–Dindo ≥3a) [43% (19/44) vs 43% (12/28)] [1.01 (95% CI 0.4–2.6); P = 0.99], 90-day mortality [8.3% (4/48) vs 6.1% (3/49)] [1.39 [95% CI 0.3–6.6]; P = 0.68] or R0 RRs [77% (34/44) vs 57% (16/28)] [2.55 [95% CI 0.9–7.1]; P = 0.11)] were observed. Of the patients in the TSH arm that failed to reach an sFLR of 30%, 12 were successfully treated with ALPPS. Conclusion: ALPPS is superior to TSH in terms of RR, with comparable surgical margins, complications, and short-term mortality.

New approach to treatment of severe incisional abscesses following laparotomy. Wound closure under systemic antibiotic cover four days after drainage.

Forty consecutive patients who developed subcutaneous abscesses after intraperitoneal operations were treated by incision and drainage followed by suture of the wound four days later under antibiotic cover. The wound was closed by means of interrupted Prolene® sutures. No sutures were placed in the wound cavity, and no drain was applied. The antibiotic used was clindamycin 600 mg intravenously peroperatively and 150 mg every six hours for four days.

Cystic Echinococcosis of the Liver: Experience From a Danish Tertiary Reference Center (2002–2010)

BACKGROUND Cystic echinococcosis (CE) of the liver can be treated with ultrasound-guided puncture, aspiration, injection, and re-aspiration (PAIR), with surgery and with benzimidazole derivatives. The aim of this study was to review available data concerning treatment modality and outcome for patients treated for CE of the liver in a Danish tertiary reference center. METHODS A search was made for patients treated for CE infection between January 1, 2002 and January 1, 2010. All relevant patient records and radiology exams were scrutinized and all cysts were re-classified according to the WHO-IWGE, blinded as to which treatment the patient had received. PAIR was performed as a first choice treatment and surgery was reserved for cases where PAIR was impossible. Inactive cyst stages received medical treatment only. RESULTS The search revealed 26 cases with confirmed CE of the liver. Nine patients underwent PAIR and nine patients surgery as a first choice treatment. Three patients were treated with PAIR secondary to surgery and one patient was treated with surgery secondary to PAIR. For all PAIR treatments, the success rate was 58% regardless of cyst stage and for surgery the success rate was 70%. The difference between the rates was not statistically significant (p = 0.67). CONCLUSION CE is a rare disease in Denmark and our study is the first describing clinical management of CE in our institution.

Long-Term Graft Outcome of Pediatric Liver Transplantation in Copenhagen: Analysis of the First 51 Cases

Background: Graft loss after liver transplantation remains a significant problem, especially in pediatric patients. The aim of this study was to assess our initial series of pediatric liver transplantation and to identify the risk factors that influence graft outcome. Methods: The first 51 transplantations were analyzed retrospectively. All transplantations were stratified into three groups according to graft type (full-size, reduced-size, and living-related-donor graft). Survival data of the grafts were stratified and multivariate analysis conducted with respect to preoperative and surgical factors. Results: Seventeen of all the transplants were full-size grafts and 34 technical-variant grafts (27 reduced-size grafts from cadavers and 7 living-related-donor grafts). The overall graft survival rates were 65, 62 and 53% at 1, 3 and 5 years, respectively. Twenty-three of 51 grafts (45%) were lost. Poor status of the recipients (hospitalization or intensive care unit care before surgery), a retransplanted graft, and a reduced-size graft were independent risk factors for graft failure. With experience, overall graft survival has improved significantly and the differences in graft survival between graft types have disappeared. Conclusions: To improve graft survival after pediatric liver transplantation, the timely referral of potential recipients to the transplant team and employing a meticulous technique during the operation, particularly for the technical-variant graft, are required.

Concurrent biliary drainage and portal vein embolization in preparation for extended hepatectomy in patients with biliary cancer.

Background Patients with perihilar cholangiocarcinoma and gallbladder cancer extending into the hilum often present with jaundice and a small future liver remnant (FLR). If resectable, preoperative biliary drainage and portal vein embolization (PVE) are indicated. Classically, these measures have been performed sequentially, separated by 4–6 weeks. Purpose To report on a new regime where percutaneous transhepatic biliary drainage (PTBD) and PVE are performed simultaneously, shortening the preoperative process. Material and Methods Six patients were treated with concurrent PTBD and PVE under general anesthesia. Results Surgical exploration followed the combined procedure after 35 days (range, 28–51 days). The FLR ratio increased from 22% to 32%. Three patients developed cholangitis after the procedure. Conclusion The combined approach of PTBD and PVE seems feasible, but more studies on morbidity are warranted.

Treatment of Abscesses in the Vulva: Conventional Open Treatment Versus Primary Suture Under Antibiotic Cover

Seventy patients were treated for a subcutaneous abscess in the vulva. in 35 consecutive patients the abscess was treated conventionally with deroofing of the abscess and wet dressings. in the other 35 consecutive patients the abscess was treated by incision, curettage and primary suture under antibiotic cover with a single dose of clindamycin. in the conventionally treated group the median stay in hospital was 7 days and the median healing time 18 days. in the group treated by primary suture the median stay in hospital was 2 days and the median healing time 7 days (P<0.0001). Recurrence of abscess was observed in one patient in each group. No other complications were observed in either group. It is concluded that vulvar abscesses may be treated safely and advantageously by primary suture under antibiotic cover.