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BackgroundLaparoscopic liver resection for perihilar cholangiocarcinoma (pCCA) is still in its infancy. The biliary-enteric reconstruction represents one of the most delicate parts of this minimally invasive procedure.MethodsIn this study, a 78-year old woman with perihilar cholangiocarcinoma (pCCA) type 3b underwent a hepaticojejunostomy performed by a parachute technique.ResultsThe operation, performed totally by minimally invasive resections, was completed in 386 min, with a blood loss of less than 400 ml and no transfusion requirements. Two intraluminal stents were placed during the hepaticojenunostomy for splinting of the biliary-enteric anastomosis. The patient required prolonged antibiotic treatment for postoperative cholangitis and finally was discharged on postoperative day 15. The histopathologic grading displayed a G 2–3 adenocarcinoma, pT3 pN0, M0, L1, V1, pN1, UICC IIIc R0, and the patient was referred to adjuvant chemotherapy.ConclusionResections of pCCAs, performed totally by minimally invasive techniques, may be feasible and safe for a selected group of patients. With this approach, a running-suture hepaticojejunostomy using the parachute technique represents a worthwhile strategy for biliary-enteric reconstruction.

Background Transabdominal Preperitoneal (TAPP) and Lichtenstein operation are established methods for inguinal hernia repair in clinical practice. Meta-analyses of randomized controlled studies, comparing those two methods for repair of primary inguinal hernia, are still missing. In this study, a systematic review and meta-analysis of published randomized controlled trials was performed to compare early and long term outcomes of the two methods. Methods A literature search was carried out to identify randomized controlled trials, which compared TAPP and Lichtenstein repair for primary inguinal hernia. Outcome measures included duration of operation, length of hospital stay, acute postoperative and chronic pain, time to return to work, hematoma, wound infection, neuralgia, numbness, scrotal swelling, seroma and hernia recurrence. A quantitative meta-analysis was performed, using Odds Ratios (OR) or Standardized Mean Difference (SMD), and Confidence Interval (CI). Results Eight controlled randomized studies were identified suitable for the analysis. The mean duration of the operation was shorter in Lichtenstein repair (SMD = 6.79 min, 95% CI, −0.68 – 14.25), without significant difference. Comparing both techniques, patients of the laparoscopic group showed postoperatively significantly less chronic inguinal pain (OR = 0.42; 95% CI, 0.23–0.78). Analyses of the remaining outcome measures did not show any significant differences between the two techniques. Conclusion The results of this analysis indicate that complication rate and outcome of both procedures are comparable. TAPP operation demonstrated only one advantage over Lichtenstein operation with significantly less chronic inguinal pain postoperatively.

Background The aim of the study was to investigate the effect of recipient obesity on the short- and long-term outcomes of patients undergoing primary kidney transplantation (KT). Patients and methods A total of 578 patients receiving primary KT in our department between 1993 and 2017 were included in the study. Patients were divided according to their body mass index (BMI) into normal weight (BMI 18.5–24.9 kg/m 2 ; N = 304), overweight (BMI 25–29.9 kg/m 2 ; N = 205) and obese (BMI ≥ 30 kg/m 2 ; N = 69) groups. Their clinicopathological characteristics, outcomes, and survival rates were analyzed retrospectively. Results Obesity was associated with an increased rate of surgical complications such as wound infection ( P  < 0.001), fascial dehiscence ( P  = 0.023), and lymphoceles ( P  = 0.010). Furthermore, the hospital stay duration was significantly longer in the groups with obese patients compared to normal weight and overweight patients (normal weight: 22 days, overweight: 25 days, and obese: 33 days, respectively; P  < 0.001). Multivariate analysis showed that recipient obesity (BMI ≥ 30) was an independent prognostic factor for delayed graft function (DGF) (OR 2.400; 95% CI, 1.365–4.219; P  = 0.002) and postoperative surgical complications (OR 2.514; 95% CI, 1.230–5.136; P  = 0.011). The mean death-censored graft survival was significantly lower in obese patients (normal weight: 16.3 ± 0.6 years, overweight: 16.3 ± 0.8 years, obese 10.8 ± 1.5 years, respectively; P  = 0.001). However, when using the Cox proportional hazards model, the association between recipient obesity and death-censored renal graft failure disappeared, after adjustment for important covariates, whereas the principal independent predictors of graft loss were recipient diabetes mellitus and hypertension and kidneys from donors with expanded donor criteria. Conclusion In conclusion, obesity increases the risk of DGF and post-operative surgical complications after primary KT. Appropriate risk-adapted information concerning this must be provided to such patients before KT. Furthermore, obesity-typical concomitant diseases seem to negatively influence graft survival and need to be considered after the transplantation of obese patients.

Children with end-stage renal disease (ESRD) frequently require more than one kidney transplantation (KT) during their lifetime due to limited graft longevity. Despite this clinical reality, few studies have evaluated long-term outcomes following repeat pediatric KT. We conducted a retrospective single-center study analyzing 120 KTs performed in 89 pediatric recipients between 1993 and 2024. Outcomes included graft function, postoperative complications, and long-term graft and patient survival. Recipients were stratified into primary (1KT), second (2KT), and third (3KT) transplantation groups. At the time of 1KT, median recipient age was 11.0 years (IQR 7.0, 14.5). Living donation accounted for 16.7% of procedures. Graft failure within five years occurred in approximately 20% of 1KT cases. Half of these patients received a 2KT after a median waiting time of 4.6 years (IQR 2.1, 9.0). Rates of early postoperative complications and kidney function were comparable across groups. Kaplan–Meier analysis revealed significantly improved long-term survival following 2KT compared to failed 1KT ( p  = 0.023). Repeat kidney transplantation is a feasible and effective strategy for pediatric ESRD patients. Second transplants provide long-term outcomes comparable to, or better than, initial grafts. Multicenter prospective studies are warranted to confirm these findings.

There are complex associations between the imaging phenotype and underlying histopathology of hepatocellular carcinomas (HCC). The recently proposed SMARS score (acronym comprising S hape of tumour, M osaic architecture, A FP level, R im APHE, and S atellite lesion) could discriminate proliferative and non-proliferative HCC tumours in a non-invasive way and was associated with treatment outcomes. However, a systematic validation of this score is needed and it is unclear whether associations with histopathology features exist. The present study elucidates possible correlations between the SMARS score defined by CT and MRI images with immunohistochemistry features of the pathological specimens in a curatively treated HCC cohort. A total of 44 patients (mean age: 59.6 ± 10.7 years) with histologically confirmed HCC, who underwent curative surgical resection, were included in the present analysis. Contrast enhanced MRI and CT images were performed before surgery and the SMARS score was calculated. The pathological specimens were analyzed for programmed death ligand 1 (PD-L1), Glypican-3, CD3-tumour infiltrating lymphocyte, CD68 positive cells, CD34 positive microvessel density (MVD). The median SMARS score derived from MRI images was 1.4 (interquartile range: -0.32; 2.18) and from CT images it was − 0.32 (interquartile range: -1.08; 0.56). According to the proposed threshold, 29 tumours were categorized as proliferative HCC (82.9%) and six tumours as nonproliferative HCC (17.1%) accordingly to the MRI SMARS score. According to the CT SMARS score 24 tumours were categorized as proliferative HCC (61.5%) and 15 as nonproliferative HCC (38.5%). The SMARS score derived from MRI images showed no correlations with the PD-L1, CD68, CD3 and MVD parameters. However, a moderate association was shown between the SMARS score with the Glypican-3 expression ( r  = 0.37, p  = 0.03). The SMARS score derived from CT images, instead, showed correlations with two of the PD-L1 parameters (for PD-L1 tumour positive score r =-0.37, p  = 0.02 and for PD-L1 combined positive score r =-0.35, p  = 0.03) while no other association with the remaining parameters was detected. The SMARS score as a promising novel imaging score is associated with the Glypican-3 and PD-L1 expression in curatively treated HCC patients. Differences between the CT and MRI defined score needs to be investigated in further trials on larger patient cohorts.

Background Thoracic stab injuries (TSI) are rare but potentially life-threatening emergencies. In Germany, their incidence in emergency departments remains low. The cardiac box (CB) concept has been proposed to identify cardiac involvement in penetrating thoracic trauma, although its clinical relevance remains uncertain. This study aimed to evaluate the in-hospital management of TSI and to assess the predictive value of the cardiac box for major intrathoracic injuries. Methods A retrospective and exploratory analysis was conducted of all patients with TSI resulting from assault or self-harm who were admitted to a certified Level 1 trauma centre between January 2020 and June 2024. Prehospital and in-hospital variables were descriptively analysed. Results Fifty-six male patients were included (median age 28.5 years). Sixteen patients sustained injuries within the cardiac box (CB), and thirty-nine outside this area (NCB). All CB patients (100%) and 95% of NCB patients were admitted via the emergency department. The annual proportion of thoracic stab injuries among all emergency presentations ranged from 1.4% to 2.4%. The median Injury Severity Score (ISS) was significantly higher in the CB group (9.5 vs 3; p  = 0.045), whereas the distribution of intrathoracic injury types and initial haemodynamic parameters (MAP CB: 93 mmHg vs NCB: 97 mmHg; p  = 0.925) did not differ significantly. Two patients in the CB group had a cardiac and/or great vessel injury. Two NCB patients received prehospital chest tubes. In the emergency department, chest tubes were placed in 23.2% of patients, with no significant group difference. Median intrahospital transfer time to the target department was shorter in CB patients (38 vs 67 min). Video-assisted thoracic surgery (VATS) was performed in eight patients (CB: 25%; NCB: 10.3%; p  = 0.241), and one open procedure was undertaken in each group. Major complications (Clavien–Dindo ≥ II) occurred more frequently among CB patients (50.1% vs 25.7%; p  = 0.018). The overall mortality rate was 3.6% (two CB patients). Conclusions TSI are rare but serious injuries requiring structured, multidisciplinary in-hospital management. Minimally invasive approaches are feasible in haemodynamically stable patients. The low rate of prehospital chest tube placement warrants further evaluation. The cardiac box concept appears overly simplistic, as clinically significant injuries may also occur outside this anatomical region.

Background Superficial surgical site infections (SSSIs) are a major reason for morbidity after abdominal surgery. Microbiologic isolates of SSSIs vary widely geographically. Therefore, knowledge about the specific bacterial profile is of paramount importance to prevent SSSI. Methods We performed a subgroup analysis of the microbiological isolates from patients with SSSI after abdominal surgery that were included in our institutional wound register. We aimed at identifying predominant strains as well as risk factors that would predispose for SSSI with certain bacteria. Results A total of 494 patients were eligible for analysis. Of those 313 had received wound swaps, with 268 patients yielding a bacterial isolate. Enterobacterales (31.7%) and Enterococcus spp. (29.5%) were found as main bacteria in SSSI, with 62.3% of the wounds being polymicrobial. As risk factors for changes in bacterial isolates, we identified operative revision (OR 3.032; 95%CI 1.734–5.303) in multivariate analysis. Enterococcus spp. showed a significant increase in patients after revision surgery ( p <0.001). Antibiotic therapy was neither influential on bacterial changes nor on the presence of Enterococcus spp. in SSSI. Conclusion Our study accentuates the high frequency of Enterococcus spp. in SSSI after abdominal surgery, while identifying surgical revision as major risk factor. The results urge vigilance in the treatment of patients with surgical revisions to include Enterococcus spp. in the prevention and treatment strategies.

Background Simultaneous pancreas-kidney transplantation (SPKT) profoundly improves the health-related quality of life (HRQoL) of recipients. However, the influence of the pre-transplant dialysis modality on the success of the SPKT and post-transplant HRQoL remains unknown. Methods We analyzed the surgical outcome, long-term survival, as well as HRQoL of 83 SPKTs that were performed in our hospital between 2000 and 2016. Prior to transplant, 64 patients received hemodialysis (HD) and nineteen patients received peritoneal dialysis (PD). Physical and mental quality of life results from eight basic scales and the physical and mental component summaries (PCS and MCS) were measured using the Short Form 36 (SF-36) survey. Results Peri- and postoperative complications, as well as patient and graft survival were similar between the two groups. Both groups showed an improvement of HRQoL in all SF-36 domains after transplantation. Compared with patients who received HD before transplantation, PD patients showed significantly better results in four of the eight SF-36 domains: physical functioning (mean difference HD - PD: − 12.4 ± 4.9, P = < 0.01), bodily pain (− 14.2 ± 6.3, P  < 0.01), general health (− 6.3 ± 2.8, P  = 0.04), vitality (− 6.8 ± 2.6, P = 0.04), and PCS (− 5.2 ± 1.5, P  < 0.01) after SPKT. In the overall study population, graft loss was associated with significant worsening of the HRQoL in all physical components (each P < 0.01). Conclusions The results of this analysis show that pre-transplant dialysis modality has no influence on the outcome and survival rate after SPKT. Regarding HRQoL, patients receiving PD prior to SPKT seem to have a slight advantage compared with patients with HD before transplantation.

Objective and background Hyperspectral imaging (HSI) is an innovative, noninvasive technique that assesses tissue and organ perfusion and oxygenation. This study aimed to evaluate HSI as a predictive tool for early postoperative graft function and long-term outcomes in living donor (LD) and deceased donor (DD) kidney transplantation (KT). Patients and methods HSI of kidney allograft parenchyma from 19 LD and 51 DD kidneys was obtained intraoperatively 15 minutes after reperfusion. Using the dedicated HSI TIVITA Tissue System, indices of tissue oxygenation (StO 2 ), perfusion (near-infrared [NIR]), organ hemoglobin (OHI), and tissue water (TWI) were calculated and then analyzed retrospectively. Results LD kidneys had superior intraoperative HSI values of StO 2 (0.78 ± 0.13 versus 0.63 ± 0.24; P  = 0.001) and NIR (0.67 ± 0.10 versus 0.56 ± 0.27; P  = 0.016) compared to DD kidneys. Delayed graft function (DGF) was observed in 18 cases (26%), in which intraoperative HSI showed significantly lower values of StO 2 (0.78 ± 0.07 versus 0.35 ± 0.21; P  < 0.001) and NIR (0.67 ± 0.11 versus 0.34 ± 0.32; P  < 0.001). Receiver operating characteristic curve analysis demonstrated an excellent predictive value of HSI for the development of DGF, with an area under the curve of 0.967 for StO 2 and 0.801 for NIR. Kidney grafts with low StO 2 values (cut-off point 0.6) showed reduced renal function with a low glomerular filtration rate and elevated urea levels in the first two weeks after KT. Three years after KT, graft survival was also inferior in the group with initially low StO 2 values. Conclusion HSI is a useful tool for predicting DGF in living and deceased KT and may assist in estimating short-term allograft function. However, further studies with expanded cohorts are needed to evaluate the association between HSI and long-term graft outcomes.

Background The inferior vena cava (IVC) parameters are associated with prognostic significance in emergency patients, but there is a lack of data using this parameter in patients with active bleeding. Objectives To investigate the prognostic relevance of IVC parameters in patients with active bleeding. Patients and methods A retrospective analysis was conducted on consecutive patients who underwent transarterial embolization due to bleeding from different anatomical sites following computed tomography (CT) imaging at a university medical center over a five-year period (2018–2022). The initial CT scan was used to determine the IVC volume and IVC flatness index, which were then incorporated into multivariable regression analyses that included demographic, hemodynamic, and laboratory data. Results The analysis included 188 patients (75.3% male) with a median age of 50 years, and a massive transfusion rate and an all-cause 30-day mortality rate of 26.6% each. Compared with female patients, male patients had a significantly higher median IVC volume (25.45 vs. 15.8 cm³, p  < 0.001), whereas the median IVC flatness index was similar for both sexes (14 vs. 14, p  = 0.414). Median IVC volumes were similar between 30-day survivors and nonsurvivors (21.6 vs. 20.2 cm³, p  = 0.382) and between patients who underwent massive transfusion and those who did not (21.2 vs. 21.5 cm³, p  = 0.567). A multivariable Cox proportional hazards model revealed a statistically significant association between the IVC flatness index and 30-day mortality (hazard ratio, 1.27; 95% confidence interval, 1.01–1.59; p  = 0.038). Additionally, logistic regression analysis revealed no significant association between the IVC flatness index and massive transfusion (univariable odds ratio, 1.01; 95% confidence interval, 0.75–1.34; p  = 0.972). Conclusions A higher IVC flatness index was associated with 30-day mortality in patients undergoing transarterial embolization for active bleeding. Further studies are needed to determine the prognostic value of CT-derived IVC parameters.