Surgical resection is the only potentially curative treatment for patients with cholangiocarcinoma. For both perihilar cholangiocarcinoma (pCCA) and intrahepatic cholangiocarcinoma (iCCA), 5‐year overall survival of about 30% has been reported in large series. This review addresses several challenges in surgical management of cholangiocarcinoma. The first challenge is diagnosis: a biopsy is typically avoided because of the risk of seeding metastases and the low yield of a brush of the bile duct. However, about 15% of patients with suspected pCCA are found to have a benign diagnosis after resection. The second challenge is staging; even with the best preoperative imaging, a substantial percentage of patients has occult metastatic disease detected at staging laparoscopy or early recurrence after resection. The third challenge is an adequate volume and function of the future liver remnant, which may require preoperative biliary drainage and portal vein embolization. The fourth challenge is a complete resection: a positive bile duct margin is not uncommon because the microscopic biliary extent of disease may be more extensive than perceived on imaging. The fifth challenge is the high post‐operative mortality that has decreased in very high volume Asian centres, but remains about 10% in many Western referral centres. The sixth challenge is that even after a complete resection most patients develop recurrent disease. Recent randomized controlled trials found conflicting results regarding the benefit of adjuvant chemotherapy. The final challenge is to determine which patients with cholangiocarcinoma should undergo liver transplantation rather than resection.

We investigated the efficacy of LL-37, the C-terminal part of the only cathelicidin in humans identified to date (termed human cationic antimicrobial protein), in three experimental rat models of gram-negative sepsis. Adult male Wistar rats (i) were given an intraperitoneal injection of 1 mg Escherichia coli 0111:B4 LPS, (ii) were given 2 ؋ 10 10 CFU of Escherichia coli ATCC 25922, or (iii) had intra-abdominal sepsis induced via cecal ligation and puncture. For each model, all animals were randomized to receive intravenously isotonic sodium chloride solution, 1-mg/kg LL-37, 1-mg/kg polymyxin B, 20-mg/kg imipenem, or 60-mg/kg piperacillin. Lethality; growth of bacteria in blood, peritoneum, spleen, liver, and mesenteric lymph nodes; and endotoxin and tumor necrosis factor alpha (TNF-␣) concentrations in plasma were evaluated. All compounds reduced lethality compared to levels in controls. Endotoxin and TNF-␣ plasma levels were significantly higher in conventional antibiotic-treated rats than in LL-37-and polymyxin B-treated animals. All drugs tested significantly reduced bacterial growth compared to saline treatment. No statistically significant differences between LL-37 and polymyxin B were noted for antimicrobial and antiendotoxin activities. LL-37 and imipenem proved to be the most effective treatments in reducing all variables measured. Due to its multifunctional properties, LL-37 may become an important future consideration for the treatment of sepsis.

IMPORTANCE Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR).OBJECTIVE To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis.DESIGN, SETTING, AND PARTICIPANTS Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated.MAIN OUTCOMES AND MEASURES Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin.RESULTS A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a worse TOLS rate. CONCLUSIONS AND RELEVANCEIn this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

The quorum-sensing inhibitor RIP inhibits staphylococcal TRAP/agr systems and both TRAP-and agrnegative strains are deficient in biofilm formation in vivo, indicating the importance of quorum sensing to biofilms in the host. RIP injected systemically into rats has been found to have strong activity in preventing methicillin-resistant Staphylococcus aureus graft infections, suggesting that RIP can be used as a therapeutic agent.Millions of indwelling medical devices are implanted annually and are at risk of persistent infections caused by bacteria organized as a biofilm. Such biofilms are resistant to antibiotics, are difficult to treat, and are common causes of morbidity and mortality (1,14,17,26,29,13,34,35). Staphylococcus aureus and S. epidermidis are common causes of device-associated infections. S. aureus (like Pseudomonas aeruginosa) regulates virulence through two quorum-sensing (QS) systems that regulate one another (4,23,33,28,41). One QS uses the 33-kDa autoinducer RNAIII-activating protein (RAP), which induces the phosphorylation of the target of RAP (TRAP) (4,5,8,22,23,24). The other QS uses the autoinducing peptide AIP, which phosphorylates AgrC, resulting in the production of RNAIII and toxins (10,18,25,27,30,31,32,37,38).TRAP is a 21-kDa protein that was shown to regulate the expression of the many toxins and their regulator, agr (9, 23). In the absence of TRAP expression or phosphorylation, the bacteria do not produce toxins and do not cause disease (as determined from tests with multiple strains and species of S. aureus and S. epidermidis) (9,22,39,40). To directly test the biofilm formation by TRAP and agr mutants in vivo, TRAP-and agr-negative mutants and their parent strains were injected onto a graft (n ϭ 10) by using the rat graft model. The bacteria used were S. aureus 8325-4, a wild-type (WT) laboratory strain, and its isogenic derivative with an inactivated TRAP gene (the TRAP-negative strain) (22) and WT laboratory strain S. aureus RN6390 and its agrnegative isogenic derivative, strain RN6911 (30, 31). The results (Fig. 1) show that the TRAP-negative mutants formed very little biofilm (27 Ϯ 5 CFU/ml) compared to the amount formed by control parent strain S. aureus 8325-4 (5.0 ϫ 10 5 Ϯ 1

Staphylococcus epidermidis is a frequent cause of infections associated with foreign bodies and indwelling medical devices. The bacteria are capable of surviving antibiotic treatment through encapsulation into biofilms. RNAIII-inhibiting peptide (RIP) is a heptapeptide that inhibits S. aureus pathogenesis by disrupting quorum-sensing mechanisms. In this study, RIP inhibited drug-resistant S. epidermidis biofilm formation through a mechanism similar to that evidenced for S. aureus. RIP is synergistic with antibiotics in eliminating 100% of graft-associated in vivo S. epidermidis infections, which suggests that RIP may be used to coat medical devices to prevent staphylococcal infections. Disruption of cell-cell communication can prevent infections associated with antibiotic-resistant strains.

Staphylococcus aureus is a prevalent cause of bacterial infections associated with indwelling medical devices. RNA III inhibiting peptide (RIP) is known to inhibit S. aureus pathogenesis by disrupting quorum-sensing mechanisms. RIP was tested in the present study for its ability to inhibit S. aureus biofilm formation in a rat Dacron graft model. The activity of RIP was synergistic with those of antibiotics for the complete prevention of drug-resistant S. aureus infections.Staphylococci are a common cause of nosocomial infections related to bacterial biofilm formation on implanted devices (17). Central venous catheters, urinary catheters, prosthetic heart valves, orthopedic implants, and dialysis catheters are among the most common targets of infection (21, 28). Staphylococcus aureus and Staphylococcus epidermidis are often the predominant species found on biofilms after the removal of devices (20,28). Infections related to bacterial biofilm formation may result in longer hospitalizations, a need for surgery, and even death (6). In hemodialysis patients, S. aureus is the leading cause of bacteremia, with an attributable mortality rate of 5 to 19%, often due to endocarditis (20). Peritoneal catheter-related infections (exit site and tunnel) are also often caused by S. aureus isolates and, as in hemodialysis patients, can be difficult to eradicate.Infections characterized by bacterial biofilm formation can be described as follows. The biofilm structure is highly resistant to antibiotic treatment. Several explanations for the mechanism of biofilm resistance have been given, such as the failure of antimicrobial agents to penetrate the biofilm; the different metabolic states of the cells in the biofilm, which results in reduced susceptibilities to antimicrobial agents; and the expression of different genes by bacteria on a surface compared with those expressed by the planktonic counterparts (7, 10). One of the most intriguing explanations, however, is the possibility that antimicrobial resistance in the biofilm is acquired as a multicellular strategy, in which a "multicellular organism" collectively withstands antimicrobial treatments that would kill a lone cell (11,12,28). A novel way to prevent biofilm formation is to interfere with the bacterial cell-cell communication that leads to the virulence phenotype (4, 11, 27). The organization of the biofilm into complex structures is regulated by the exchange of chemical signals between cells in a process known as quorum sensing. Until now, two quorum-sensing mechanisms have been described in S. aureus. The first one is composed of the autoinducer RNA III-activating peptide (RAP) and its target protein, TRAP (3, 4). The second is composed of the peptide AIP and its receptor, AgrC (18,19). When the amount of RAP reaches a threshold concentration, it induces the phosphorylation of TRAP, which, through an unknown mechanism, leads to increased cell adhesion and to the activation of the regulatory system agr, which encodes AIP and AgrC. AIP downregulates TRAP phosphorylation, ...

Sepsis remains a major cause of morbidity and mortality in hospitalized patients, despite intense efforts to improve survival. The primary lead for septic shock results from activation of host effector cells by endotoxin, the lipopolysaccharide (LPS) associated with cell membranes of gram-negative bacteria. For these reasons, the quest for compounds with antiendotoxin properties is actively pursued. We investigated the efficacy of the amphibian skin antimicrobial peptide temporin L in binding Escherichia coli LPS in vitro and counteracting its effects in vivo. Temporin L strongly bound to purified E. coli LPS and lipid A in vitro, as proven by fluorescent displacement assay, and readily penetrated into E. coli LPS monolayers. Furthermore, the killing activity of temporin L against E. coli was progressively inhibited by increasing concentrations of LPS added to the medium, further confirming the peptide's affinity for endotoxin. Antimicrobial assays showed that temporin L interacted synergistically with the clinically used ␤-lactam antibiotics piperacillin and imipenem. Therefore, we characterized the activity of temporin L when combined with imipenem and piperacillin in the prevention of lethality in two rat models of septic shock, measuring bacterial growth in blood and intra-abdominal fluid, endotoxin and tumor necrosis factor alpha (TNF-␣) concentrations in plasma, and lethality. With respect to controls and single-drug treatments, the simultaneous administration of temporin L and ␤-lactams produced the highest antimicrobial activities and the strongest reduction in plasma endotoxin and TNF-␣ levels, resulting in the highest survival rates.

RIP significantly reduces bacterial load and enhances the effect of antibiotics in the treatment of CVC-associated S. aureus infections.