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Spitzner A, Mieth M, Langan EA, Büchler MW, Michalski C, Billmann F. Influence of dental status on postoperative complications in major visceral surgical and organ transplantation procedures-the bellydent retrospective observational study. Langenbecks Arch Surg 2024; 409:284. [PMID: 39297959 PMCID: PMC11413042 DOI: 10.1007/s00423-024-03448-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Accepted: 08/14/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE The significance of dental status and oral hygiene on a range of medical conditions is well-recognised. However, the correlation between periodontitis, oral bacterial dysbiosis and visceral surgical outcomes is less well established. To this end, we study sought to determine the influence of dental health and oral hygiene on the rates of postoperative complications following major visceral and transplant surgery in an exploratory, single-center, retrospective, non-interventional study. METHODS Our retrospective non-interventional study was conducted at the Department of General, Visceral, and Transplant Surgery, University Hospital Heidelberg, Germany. Patients operated on between January 2018 and December 2019 were retrospectively enrolled in the study based on inclusion (minimum age of 18 years, surgery at our Department, intensive care / IMC treatment after major surgery, availability of patient-specific preoperative dental status assessment, documentation of postoperative complications) and exclusion criteria (minor patients or legally incapacitated patients, lack of intensive care or intermediate care (IMC) monitoring, incomplete documentation of preoperative dental status, intestinal surgery with potential intraoperative contamination of the site by intestinal microbes, pre-existing preoperative infection, absence of data regarding the primary endpoints of the study). The primary study endpoint was the incidence of postoperative complications. Secondary study endpoints were: 30-day mortality, length of hospital stay, duration of intensive care stay, Incidence of infectious complications, the microbial spectrum of infectious complication. A bacteriology examination was added whenever possible (if and only if the examination was safe for the patient)for infectious complications. RESULTS The final patient cohort consisted of 417 patients. While dental status did not show an influence (p = 0.73) on postoperative complications, BMI (p = 0.035), age (p = 0.049) and quick (p = 0.033) were shown to be significant prognostic factors. There was significant association between oral health and the rate of infectious complications for all surgical procedures (p = 0.034), excluding transplant surgery. However, this did not result in increased 30-day mortality rates, prolonged intensive care unit treatment or an increase in the length of hospital stay (LOS) for the cohort as a whole. In contrast there was a significant correlation between the presence of oral pathogens and postoperative complications for a group as a whole (p < 0.001) and the visceral surgery subgroup (p < 0.001). Whilst this was not the case in the cohort who underwent transplant surgery, there was a correlation between oral health and LOS in this subgroup (p = 0.040). Bacterial swabs supports the link between poor oral health and infectious morbidity. CONCLUSIONS Dental status was a significant predictor of postoperative infectious complications in this visceral surgery cohort. This study highlights the importance preoperative dental assessment and treatment prior to major surgery, particularly in the case of elective surgical procedures. Further research is required to determine the effect of oral health on surgical outcomes in order to inform future practice. TRIAL REGISTRATION Trial registered under the ethics-number S-082/2022 (Ethic Committee of the University Heidelberg).
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Affiliation(s)
- Anastasia Spitzner
- Praxis Dr. Dietmar Czech, Marktplatz 15, 16, 89073, Ulm, Germany
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ewan A Langan
- Department of Dermatology and Venerology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Dermatological Sciences, University of Manchester, Manchester, UK
| | - Markus W Büchler
- Botton-Champalimaud Pancreatic Cancer Center, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisboa, Portugal
| | - Christoph Michalski
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Franck Billmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Verloh N, Rio Bartulos C, Utpatel K, Brennfleck F, Goetz A, Schicho A, Fellner C, Nickel D, Zeman F, Steinmann JF, Uller W, Stroszczynski C, Schlitt HJ, Wiggermann P, Haimerl M. Volume-Assisted Estimation of Remnant Liver Function Based on Gd-EOB-DTPA Enhanced MR Relaxometry: A Prospective Observational Trial. Diagnostics (Basel) 2023; 13:3014. [PMID: 37761381 PMCID: PMC10529888 DOI: 10.3390/diagnostics13183014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
In the context of liver surgery, predicting postoperative liver dysfunction is essential. This study explored the potential of preoperative liver function assessment by MRI for predicting postoperative liver dysfunction and compared these results with the established indocyanine green (ICG) clearance test. This prospective study included patients undergoing liver resection with preoperative MRI planning. Liver function was quantified using T1 relaxometry and correlated with established liver function scores. The analysis revealed an improved model for predicting postoperative liver dysfunction, exhibiting an accuracy (ACC) of 0.79, surpassing the 0.70 of the preoperative ICG test, alongside a higher area under the curve (0.75). Notably, the proposed model also successfully predicted all cases of liver failure and showed potential in predicting liver synthesis dysfunction (ACC 0.78). This model showed promise in patient survival rates with a Hazard ratio of 0.87, underscoring its potential as a valuable tool for preoperative evaluation. The findings imply that MRI-based assessment of liver function can provide significant benefits in the early identification and management of patients at risk for postoperative liver dysfunction.
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Affiliation(s)
- Niklas Verloh
- Department of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany (M.H.)
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Carolina Rio Bartulos
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig gGmbH, 38114 Braunschweig, Germany
| | - Kirsten Utpatel
- Department of Pathology, University Regensburg, 95053 Regensburg, Germany
| | - Frank Brennfleck
- Department of Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Andrea Goetz
- Department of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany (M.H.)
| | - Andreas Schicho
- Department of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany (M.H.)
| | - Claudia Fellner
- Department of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany (M.H.)
| | - Dominik Nickel
- MR Applications Predevelopment, Siemens Healthcare GmbH, 91052 Erlangen, Germany
| | - Florian Zeman
- Center for Clinical Trials, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Johannes F. Steinmann
- Department of Anesthesiology, University Medical Center Regensburg, 93053 Regensburg, Germany
| | - Wibke Uller
- Department of Diagnostic and Interventional Radiology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | | | - Hans-Jürgen Schlitt
- Department of Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Phillip Wiggermann
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig gGmbH, 38114 Braunschweig, Germany
| | - Michael Haimerl
- Department of Radiology, University Hospital Regensburg, 93053 Regensburg, Germany (M.H.)
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Faraji S, Hosseini Azar MRM, Alizadeh M. Brewed chicory leaf consumption has unexpected side effects along beneficial effects on liver enzymes in non-alcoholic fatty liver disease patients. J Herb Med 2022. [DOI: 10.1016/j.hermed.2022.100572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Tariba Lovaković B, Barbir R, Pem B, Goessler W, Ćurlin M, Micek V, Debeljak Ž, Božičević L, Ilić K, Pavičić I, Gorup D, Vinković Vrček I. Sex-related response in mice after sub-acute intraperitoneal exposure to silver nanoparticles. NANOIMPACT 2021; 23:100340. [PMID: 35559841 DOI: 10.1016/j.impact.2021.100340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 06/15/2023]
Abstract
Silver nanoparticles (AgNPs) are among the most commercialized nanomaterials in biomedicine due to their antimicrobial and anti-inflammatory properties. Nevertheless, possible health hazards of exposure to AgNPs are yet to be understood and therefore raise public concern in regards of their safety. In this study, sex-related differences, role of steroidal hormones and influence of two different surface stabilizing agents (polymer vs. protein) on distribution and adverse effects of AgNPs were investigated in vivo. Intact and gonadectomised male and female mice were treated with seven AgNPs doses administered intraperitoneally during 21 days. After treatment, steroid hormone levels in serum, accumulation of Ag levels and oxidative stress biomarkers in liver, kidneys, brain and lungs were determined. Sex-related differences were observed in almost all tissues. Concentration of Ag was significantly higher in the liver of females compared to males. No significant difference was found for AgNP accumulation in lungs between females and males, while the lungs of intact males showed significantly higher Ag accumulation compared to gonadectomised group. Effect of surface coating was also observed, as Ag accumulation was significantly higher in kidneys and liver of intact females, as well as in kidneys and brain of intact males treated with protein-coated AgNPs compared to polymeric AgNPs. Oxidative stress response to AgNPs was the most pronounced in kidneys where protein-coated AgNPs induced stronger effects compared to polymeric AgNPs. Interestingly, protein-coated AgNPs reduced generation of reactive oxygen species in brains of females and gonadectomised males. Although there were no significant differences in levels of hormones in the AgNP-exposed animals compared to controls, sex-related differences in oxidative stress parameters were observed in all organs. Results of this study highlight the importance of including the sex-related differences and effects of protein corona in biosafety evaluation of AgNPs exposure.
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Affiliation(s)
- Blanka Tariba Lovaković
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia.
| | - Rinea Barbir
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia
| | - Barbara Pem
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia
| | - Walter Goessler
- Institute of Chemistry, University of Graz, Universitätsplatz 1/1, 8 010 Graz, Austria
| | - Marija Ćurlin
- School of Medicine, University of Zagreb, Šalata 2, 10 000 Zagreb, Croatia
| | - Vedran Micek
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia
| | - Željko Debeljak
- Department for Clinical Laboratory Diagnostics, Clinical Hospital Osijek, Josipa Huttlera 4, 31 000 Osijek, Croatia; Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, 31 000 Osijek, Croatia
| | - Lucija Božičević
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia
| | - Krunoslav Ilić
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia
| | - Ivan Pavičić
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia
| | - Dunja Gorup
- School of Medicine, University of Zagreb, Šalata 2, 10 000 Zagreb, Croatia
| | - Ivana Vinković Vrček
- Institute for Medical Research and Occupational Health, Ksaverska cesta 2, 10 000 Zagreb, Croatia.
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Shen YN, Tang TY, Yao WY, Guo CX, Yi-Zong, Song W, Liang TB, Bai XL. A nomogram for prediction of posthepatectomy liver failure in patients with hepatocellular carcinoma: A retrospective study. Medicine (Baltimore) 2019; 98:e18490. [PMID: 31861033 PMCID: PMC6940184 DOI: 10.1097/md.0000000000018490] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To generate a nomogram to predict posthepatectomy liver failure (PHLF), we attempted to elucidate salient risk factors in patients with hepatocellular carcinoma (HCC).We performed a retrospective review of 665 patients with HCC who received hepatectomy in 2 academic institutions in China. Independent risk factors for PHLF were identified from putative demographic, intrinsic, biochemical, surgery-related, and volumetric data. A predictive nomogram was formulated based on relevant risk factors, and we compared this with existing models.We identified clinical signs of portal hypertension (P = .023), serum total bilirubin (P = .001), serum creatinine (P = .039), and intraoperative hemorrhage (P = .015) as being important risk factors in predicting PHLF. The nomogram had a C-index of 0.906 for the externally validated data. The nomogram displayed better predictive value than 2 of the other most cited models (C-indices of 0.641 and 0.616, respectively) in the current cohort. Additionally, we were able to patients into low- (<10%), intermediate- (10-30%), and high-risk (≥30%) groups based on the nomogram. This allows us to facilitate person-specific management.Here, we constructed a simple nomogram for prediction of PHLF in patients with HCC weighted by independent risk factors. Further prospective studies are required to confirm the predictive ability of our nomogram.
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Affiliation(s)
- Yi-Nan Shen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Tian-Yu Tang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Wei-Yun Yao
- Department of General Surgery, The People's Hospital of Changxing County, Huzhou
| | - Cheng-Xiang Guo
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Yi-Zong
- The 5th Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Wei Song
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Xue-Li Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
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Stutchfield BM, Bodingbauer MW, Adair A, Wakelin S, Schindl M, Forbes SJ, Wigmore SJ. Quantifying changes in innate immune function following liver transplantation for chronic liver disease. HPB (Oxford) 2019; 21:1322-1326. [PMID: 30850189 DOI: 10.1016/j.hpb.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/26/2019] [Accepted: 02/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LT) offers patients with cirrhosis long-term survival, however many die from sepsis whilst awaiting LT. The liver's role in innate immunity may be key to improving outcomes, but the immune effects of LT have not been quantified. METHODS Innate immune capacity was assessed by clearance of 99mTc-Albumin nanospheres in patients with chronic liver failure before and after LT. RESULTS Twenty-eight patients with chronic liver disease on the LT waiting list entered the study during the twelve-month study period and nine patients underwent LT and completed the study protocol. One patient developed hepatic artery thrombosis in <7 days and was excluded from the study. Innate immune function was significantly impaired in patients with chronic liver disease on the LT waiting list and this was directly correlated with MELD score. LT normalised innate immune function by day 1 post LT with further improvement occurring by day 7 post LT. Donor liver weight was the only factor correlated with innate immune function at day 1 post LT but this effect was negated by day 7 post LT. CONCLUSION Recognising the immune effects of LT may facilitate treatment of cirrhosis and inform development of extracorporeal liver support systems.
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Affiliation(s)
- Benjamin M Stutchfield
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | | | - Anya Adair
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Sonia Wakelin
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Martin Schindl
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stuart J Forbes
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Stephen J Wigmore
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK.
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Early Morbidity and Mortality after Minimally Invasive Liver Resection for Hepatocellular Carcinoma: a Propensity-Score Matched Comparison with Open Resection. J Gastrointest Surg 2019; 23:1435-1442. [PMID: 30377911 DOI: 10.1007/s11605-018-4016-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/12/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of minimally invasive surgery on the short-term outcomes of patients with hepatocellular carcinoma (HCC) undergoing liver resection remains poorly defined. METHODS The ACS-NSQIP-targeted hepatectomy database was used to identify patients who underwent liver resection for HCC during 2014-2016. A 1:1 propensity score matching was created between patients who underwent open (OLR) vs. minimally invasive liver resection (MILR) based on age, ASA score, liver resection type, liver texture, and stage of disease. The short-term outcomes of patients undergoing OLR vs. MILR were compared. RESULTS Among a total cohort of 1816 patients, propensity score matching resulted in 728 liver resections: 364 (50%) OLR and 364 (50%) MILR. Overall morbidity (29% vs. 23%, P = 0.04) was greater among patients undergoing OLR compared with MILR, whereas mortality did not differ between the two approaches (2% vs 1%, P = 0.57). MILR was associated with significant reductions in hospital LOS (6 vs. 4 days, P < 0.0001) but no difference in operative time (188 vs. 171 min, P = 0.13). On multivariate logistic regression analysis, age ≥ 65 (OR:1.6, 95%CI: 1.1-2.3, P = 0.0065), ASA class ≥ 3 (OR:2.7, 95%CI: 1.5-4.7, P = 0.0003), preoperative blood transfusion (OR:9.7, 95%CI: 1.06-90.3, P = 0.04), T ≥ 3 (OR:1.9, 95%CI: 1.09-3.4, P = 0.02), operative time > 200 min (OR:1.8, 95%CI: 1.2-2.5, P = 0.0011), and OLR (OR:1.4, 95%CI: 1.002-2.03, P = 0.04) were associated with increased odds of overall morbidity. CONCLUSIONS MILR for HCC is associated with a shorter hospital LOS and reduced postoperative complication rates, even after controlling for important patient and clinicopathologic confounders, compared to OLR. Efforts to expand the use of MILR for hepatobiliary surgery are warranted.
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Kruepunga N, Hakvoort TB, Hikspoors JP, Köhler SE, Lamers WH. Anatomy of rodent and human livers: What are the differences? Biochim Biophys Acta Mol Basis Dis 2019; 1865:869-878. [DOI: 10.1016/j.bbadis.2018.05.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/30/2018] [Accepted: 05/22/2018] [Indexed: 12/17/2022]
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Nomogram for individualised prediction of liver failure risk after hepatectomy in patients with resectable hepatocellular carcinoma: the evidence from ultrasound data. Eur Radiol 2017; 28:877-885. [DOI: 10.1007/s00330-017-4900-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 04/05/2017] [Accepted: 05/16/2017] [Indexed: 12/17/2022]
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van Mierlo KMC, Schaap FG, Dejong CHC, Olde Damink SWM. Liver resection for cancer: New developments in prediction, prevention and management of postresectional liver failure. J Hepatol 2016; 65:1217-1231. [PMID: 27312944 DOI: 10.1016/j.jhep.2016.06.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/03/2016] [Accepted: 06/07/2016] [Indexed: 12/11/2022]
Abstract
UNLABELLED Hepatic failure is a feared complication that accounts for up to 75% of mortality after extensive liver resection. Despite improved perioperative care, the increasing complexity and extensiveness of surgical interventions, in combination with an expanding number of resections in patients with compromised liver function, still results in an incidence of postresectional liver failure (PLF) of 1-9%. Preventive measures aim to enhance future remnant liver size and function. Numerous non-invasive techniques to assess liver function and predict remnant liver volume are being developed, along with introduction of novel surgical strategies that augment growth of the future remnant liver. Detection of PLF is often too late and treatment is primarily symptomatic. Current therapeutic research focuses on ([bio]artificial) liver function support and regenerative medicine. In this review we discuss the current state and new developments in prediction, prevention and management of PLF, in light of novel insights into the aetiology of this complex syndrome. LAY SUMMARY Liver failure is the main cause of death after partial liver resection for cancer, and is presumably caused by an insufficient quantity and function of the liver remnant. Detection of liver failure is often too late, and current treatment focuses on relieve of symptoms. New research initiatives explore artificial support of liver function and stimulation of regrowth of the remnant liver.
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Affiliation(s)
- Kim M C van Mierlo
- Department of Surgery, Maastricht University Medical Centre & NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Frank G Schaap
- Department of Surgery, Maastricht University Medical Centre & NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre & NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre & NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands; Department of Surgery, Institute of Liver and Digestive Health, Royal Free Hospital, University College London, London, United Kingdom.
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Han H, Hu H, Xu YD, Wang WP, Ding H, Lu Q. Liver failure after hepatectomy: A risk assessment using the pre-hepatectomy shear wave elastography technique. Eur J Radiol 2016; 86:234-240. [PMID: 28027753 DOI: 10.1016/j.ejrad.2016.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the efficacy of liver stiffness (LS) measurements utilizing the Shear Wave Elastography (SWE) technique for predicting post-hepatectomy liver failure (PHLF) among patients with hepatocellular carcinoma (HCC). METHODS Data from eighty consecutive patients who were undergoing hepatectomy for HCC were prospectively identified and evaluated with preoperative SWE. The SWE was measured with advanced ultrasound equipment (Philips EPIQ7; Philips Healthcare, Seattle, WA, USA). PHLF classification was defined according to the International Study Group of Liver Surgery Recommendations (ISGLS). RESULTS SWE was successfully performed in 77 patients. According to the ISGLS criteria, PHLF occurred in 35.1% of patients (27 patients), including 2/25 patients with Grade A/B, respectively. Elevated SWE values (P=0.002) and histological cirrhosis (P=0.003) were independent predictors of PHLF according to the multivariate analysis. Patients with SWE values higher than or equal to 6.9kPa were identified at higher risk of PHLF (area under the curve: 0.843, sensitivity: 77.8% and specificity: 78.0%). Postoperative dynamic course of the median the Model For End-stage Liver Disease (MELD) score showed irregular changes among patients with an SWE >6.9kPa. Patients with an SWE <6.9kPa, postoperative dynamic course of the median MELD score gradually decreased. CONCLUSION LS measured with SWE is a valid and reliable method for the prediction of PHLF grade A/B among patients with HCC. SWE could become a routine examination for the preoperative evaluation of PHLF.
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Affiliation(s)
- Hong Han
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China.
| | - Hao Hu
- Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Ya Dan Xu
- Zhongshan Hospital, Fudan University, Shanghai Institute of Medical Imaging, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Wen Ping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China.
| | - Hong Ding
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Qing Lu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai 200032, China
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Klemencsics I, Lazary A, Szoverfi Z, Bozsodi A, Eltes P, Varga PP. Risk factors for surgical site infection in elective routine degenerative lumbar surgeries. Spine J 2016; 16:1377-1383. [PMID: 27520077 DOI: 10.1016/j.spinee.2016.08.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 06/11/2016] [Accepted: 08/02/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical site infection (SSI) is one of the most serious complications of spine surgery. Its predisposing factors, especially in routine surgeries, are less reported. However, a number of patient- and procedure-related risk factors could be avoided or at least determined preoperatively. Moreover, the patient-specific risk for SSI could be estimated before the elective surgery. PURPOSE The aim of the present study was to analyze the preoperatively determinable risk factors for SSI in patients who require elective routine surgery related to lumbar disc degeneration and to build a multivariable model for the individual risk prediction. STUDY DESIGN Analysis of prospectively collected standardized clinical data and the validation of the results on an independent prospective cohort were performed. PATIENT SAMPLE One thousand thirty (N=1,030) patients were included in the study. All subjects underwent primary lumbar single- or two-level decompression, microdiscectomy, or instrumented fusion. OUTCOME MEASURES Occurrence of an SSI defined according to the current Centers for Disease Control and Prevention guidelines that required surgical or nonsurgical therapy. METHODS The effect of preoperative patient characteristics, comorbidities, disease history, and invasiveness of the elective surgery on the risk of SSI was determined in uni- and multivariate logistic regression models in the test cohort (N=723). The performance of the final multivariable regression model was assessed by measuring its discriminative ability (c-index) in receiver operating characteristic analysis. Performance of the multivariable risk estimation model was tested on the validation (N=307) cohort. RESULTS The prevalence of SSI was 3.5% and 3.9% in the test and in the validation cohorts, respectively. The final multivariable regression model predictive (p=.003) for SSI contained the patient's age, body mass index (BMI), and the presence of 5 comorbidities, such as diabetes, ischemic heart disease, arrhythmia, chronic liver disease, and autoimmune disease as risk factors. The c-index of the model was 0.71, showing good discriminative ability, and it was confirmed by the data of the independent validation cohort (c=0.72). CONCLUSIONS Predisposing factors for SSI were older age, higher BMI, and the presence of certain comorbidities in the present study. The cumulative number of risk factors significantly associated with the increasing risk for an SSI (p<.0001). Our model needs further validation but it may be used for individual risk assessment and reduction in the future.
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Affiliation(s)
- Istvan Klemencsics
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary; School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Aron Lazary
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary.
| | - Zsolt Szoverfi
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary; School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Arpad Bozsodi
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary; School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Peter Eltes
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary; School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Peter Pal Varga
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
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Ascha MS, Ascha ML, Hanouneh IA. Management of immunosuppressant agents following liver transplantation: Less is more. World J Hepatol 2016; 8:148-161. [PMID: 26839639 PMCID: PMC4724578 DOI: 10.4254/wjh.v8.i3.148] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/12/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Immunosuppression in organ transplantation was revolutionary for its time, but technological and population changes cast new light on its use. First, metabolic syndrome (MS) is increasing as a public health issue, concomitantly increasing as an issue for post-orthotopic liver transplantation patients; yet the medications regularly used for immunosuppression contribute to dysfunctional metabolism. Current mainstay immunosuppression involves the use of calcineurin inhibitors; these are potent, but nonspecifically disrupt intracellular signaling in such a way as to exacerbate the impact of MS on the liver. Second, the impacts of acute cellular rejection and malignancy are reviewed in terms of their severity and possible interactions with immunosuppressive medications. Finally, immunosuppressive agents must be considered in terms of new developments in hepatitis C virus treatment, which undercut what used to be inevitable viral recurrence. Overall, while traditional immunosuppressive agents remain the most used, the specific side-effect profiles of all immunosuppressants must be weighed in light of the individual patient.
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Stutchfield BM, Antoine DJ, Mackinnon AC, Gow DJ, Bain CC, Hawley CA, Hughes MJ, Francis B, Wojtacha D, Man TY, Dear JW, Devey LR, Mowat AM, Pollard JW, Park BK, Jenkins SJ, Simpson KJ, Hume DA, Wigmore SJ, Forbes SJ. CSF1 Restores Innate Immunity After Liver Injury in Mice and Serum Levels Indicate Outcomes of Patients With Acute Liver Failure. Gastroenterology 2015; 149:1896-1909.e14. [PMID: 26344055 PMCID: PMC4672154 DOI: 10.1053/j.gastro.2015.08.053] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 08/01/2015] [Accepted: 08/27/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Liver regeneration requires functional liver macrophages, which provide an immune barrier that is compromised after liver injury. The numbers of liver macrophages are controlled by macrophage colony-stimulating factor (CSF1). We examined the prognostic significance of the serum level of CSF1 in patients with acute liver injury and studied its effects in mice. METHODS We measured levels of CSF1 in serum samples collected from 55 patients who underwent partial hepatectomy at the Royal Infirmary Edinburgh between December 2012 and October 2013, as well as from 78 patients with acetaminophen-induced acute liver failure admitted to the Royal Infirmary Edinburgh or the University of Kansas Medical Centre. We studied the effects of increased levels of CSF1 in uninjured mice that express wild-type CSF1 receptor or a constitutive or inducible CSF1-receptor reporter, as well as in chemokine receptor 2 (Ccr2)-/- mice; we performed fate-tracing experiments using bone marrow chimeras. We administered CSF1-Fc (fragment, crystallizable) to mice after partial hepatectomy and acetaminophen intoxication, and measured regenerative parameters and innate immunity by clearance of fluorescent microbeads and bacterial particles. RESULTS Serum levels of CSF1 increased in patients undergoing liver surgery in proportion to the extent of liver resected. In patients with acetaminophen-induced acute liver failure, a low serum level of CSF1 was associated with increased mortality. In mice, administration of CSF1-Fc promoted hepatic macrophage accumulation via proliferation of resident macrophages and recruitment of monocytes. CSF1-Fc also promoted transdifferentiation of infiltrating monocytes into cells with a hepatic macrophage phenotype. CSF1-Fc increased innate immunity in mice after partial hepatectomy or acetaminophen-induced injury, with resident hepatic macrophage as the main effector cells. CONCLUSIONS Serum CSF1 appears to be a prognostic marker for patients with acute liver injury. CSF1 might be developed as a therapeutic agent to restore innate immune function after liver injury.
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Affiliation(s)
- Benjamin M. Stutchfield
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom,Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel J. Antoine
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Edinburgh, Edinburgh, United Kingdom
| | - Alison C. Mackinnon
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Deborah J. Gow
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, United Kingdom
| | - Calum C. Bain
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Catherine A. Hawley
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael J. Hughes
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Benjamin Francis
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Davina Wojtacha
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Tak Y. Man
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - James W. Dear
- National Poisons Information Service Edinburgh, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, United Kingdom
| | - Luke R. Devey
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Alan M. Mowat
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Jeffrey W. Pollard
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - B. Kevin Park
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen J. Jenkins
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom
| | - Kenneth J. Simpson
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - David A. Hume
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, University of Edinburgh, Edinburgh, United Kingdom
| | - Stephen J. Wigmore
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Stuart J. Forbes
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom,Reprint requests Address requests for reprints to: S. J. Forbes, MD, Scottish Centre for Regenerative Medicine, 5 Little France Drive, Edinburgh BioQuarter, Edinburgh EH16 4UU, United Kingdom. fax: (44) (0)131-651-9501.
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Asialoglycoprotein receptor mediated hepatocyte targeting — Strategies and applications. J Control Release 2015; 203:126-39. [DOI: 10.1016/j.jconrel.2015.02.022] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 02/14/2015] [Accepted: 02/16/2015] [Indexed: 02/07/2023]
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Liu T, Choi H, Zhou R, Chen IW. Quantitative evaluation of the reticuloendothelial system function with dynamic MRI. PLoS One 2014; 9:e103576. [PMID: 25090653 PMCID: PMC4121285 DOI: 10.1371/journal.pone.0103576] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 07/03/2014] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To evaluate the reticuloendothelial system (RES) function by real-time imaging blood clearance as well as hepatic uptake of superparamagnetic iron oxide nanoparticle (SPIO) using dynamic magnetic resonance imaging (MRI) with two-compartment pharmacokinetic modeling. MATERIALS AND METHODS Kinetics of blood clearance and hepatic accumulation were recorded in young adult male 01b74 athymic nude mice by dynamic T2* weighted MRI after the injection of different doses of SPIO nanoparticles (0.5, 3 or 10 mg Fe/kg). Association parameter, Kin, dissociation parameter, Kout, and elimination constant, Ke, derived from dynamic data with two-compartment model, were used to describe active binding to Kupffer cells and extrahepatic clearance. The clodrosome and liposome were utilized to deplete macrophages and block the RES function to evaluate the capability of the kinetic parameters for investigation of macrophage function and density. RESULTS The two-compartment model provided a good description for all data and showed a low sum squared residual for all mice (0.27±0.03). A lower Kin, a lower Kout and a lower Ke were found after clodrosome treatment, whereas a lower Kin, a higher Kout and a lower Ke were observed after liposome treatment in comparison to saline treatment (P<0.005). CONCLUSION Dynamic SPIO-enhanced MR imaging with two-compartment modeling can provide information on RES function on both a cell number and receptor function level.
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Affiliation(s)
- Ting Liu
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Hoon Choi
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Rong Zhou
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - I-Wei Chen
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Pulitano C, Crawford M, Joseph D, Aldrighetti L, Sandroussi C. Preoperative assessment of postoperative liver function: the importance of residual liver volume. J Surg Oncol 2014; 110:445-50. [PMID: 24962104 DOI: 10.1002/jso.23671] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 04/26/2014] [Indexed: 12/15/2022]
Abstract
An inadequate volume of future liver remnant (FLR) remains an absolute contraindication to liver resection. FLR measurement correlates with surgical outcome and is fundamental to identify those patients that may benefit from portal vein embolization (PVE) and to assess the liver volume change following embolization. In order to minimize the risk of postoperative liver failure, preoperative analysis of FLR must be included in the surgical planning of every major liver resection. The aims of this review are to describe the use of preoperative volumetric analysis in modern liver surgery and indications for PVE.
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Affiliation(s)
- Carlo Pulitano
- Department of Hepatobiliary and Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Siu J, McCall J, Connor S. Systematic review of pathophysiological changes following hepatic resection. HPB (Oxford) 2014; 16:407-21. [PMID: 23991862 PMCID: PMC4008159 DOI: 10.1111/hpb.12164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection. METHODS The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were 'hepatectomy/', 'liver function/', 'liver failure/' and 'physiology/'. RESULTS Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure. CONCLUSIONS The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.
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Affiliation(s)
- Joey Siu
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - John McCall
- Department of Surgery, Dunedin HospitalDunedin, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand,Correspondence Saxon Connor, Department of Surgery, Christchurch Hospital, Christchurch 8011, New Zealand. Tel: + 64 3 364 0640. Fax: + 64 3 364 0352. E-mail:
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Yang T, Tu PA, Zhang H, Lu JH, Shen YN, Yuan SX, Lau WY, Lai ECH, Lu CD, Wu MC, Li JW, Shen F. Risk factors of surgical site infection after hepatic resection. Infect Control Hosp Epidemiol 2014; 35:317-20. [PMID: 24521601 DOI: 10.1086/675278] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A study of 7,388 consecutive patients after hepatic resection between 2011 and 2012 identified hepatolithiasis, cirrhosis, and intraoperative blood transfusion as the only independent risk factors of both incisional and organ/space surgical site infection (SSI). Patients with these conditions should be cared for with caution to lower SSI rates.
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Affiliation(s)
- Tian Yang
- Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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Petrovai G, Truant S, Langlois C, Bouras AF, Lemaire S, Buob D, Leteurtre E, Boleslawski E, Pruvot FR. Mechanisms of splenic hypertrophy following hepatic resection. HPB (Oxford) 2013; 15:919-27. [PMID: 23458075 PMCID: PMC3843609 DOI: 10.1111/hpb.12056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 12/20/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Following hepatic resection, liver regeneration has been associated with concurrent splenic hypertrophy. The mechanisms of this phenomenon are unknown, may be multiple and include: splanchnic sequestration caused by a reduction in the hepatic mass; hepatic growth factors that may indirectly act on the spleen, and the redistribution of the total reticuloendothelial system. METHODS Seventy-five patients (40 males; median age: 60 years) who underwent minor (16%) or major (84%) hepatectomy between September 2004 and October 2009 were included. Prospective measurements of liver and spleen volumes were obtained preoperatively and postoperatively 1 month after hepatectomy using computed tomography (CT). The future remnant liver volume (RLV) was calculated on preoperative CT and the extent of resection was expressed as the RLV divided by total liver volume (TLV). Liver and spleen hypertrophy were expressed according to the absolute gain or relative increase in the initial volumes (%).The presence of fibrosis >F1, associated extrahepatic resection (except minor resections), and previous hepatectomy (major or minor) within 3 months represented exclusion criteria. RESULTS Mean ± standard deviation (SD) liver volume at 1 month was higher than RLV (1187 ± 286 cm(3) versus 764 ± 421 cm(3) ; P < 0.001). Mean ± SD splenic volume increased from 252 ± 100 cm(3) preoperatively to 300 ± 111 cm(3) at 1 month (P < 0.001). Liver and splenic hypertrophy were significant after major hepatectomies (+100% and +26%, respectively; P < 0.001), but not after minor hepatectomies. Liver hypertrophy was inversely correlated to RLV/TLV (r = -0.687, P < 0.001). Splenic hypertrophy was not correlated to RLV/TLV. Liver and splenic hypertrophy were linearly correlated (r = 0.495, P < 0.001). Neoadjuvant chemotherapy (n = 37), preoperative portal vein embolization (n = 10) and postoperative complications (overall: n = 25; major: n = 10; infectious: n = 6) had no impact on hepatic or splenic hypertrophy. CONCLUSIONS Splenic hypertrophy occurred after major hepatectomy, but was not correlated to the extent of resection, by contrast with liver hypertrophy. Nevertheless, there was a linear correlation between splenic and liver hypertrophy. This correlation suggests the hypothesis of a splenic action of hepatic growth factors or a redistribution of the total reticuloendothelial system rather than an effect of reduction of the portal bed or hepatic outflow.
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Affiliation(s)
- Gheorghe Petrovai
- Department of Digestive Surgery and Transplantation, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - Carole Langlois
- Department of Biostatistics, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - Ahmed F Bouras
- Department of Digestive Surgery and Transplantation, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - Stéphanie Lemaire
- Department of Digestive Radiology, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - David Buob
- Department of Pathology, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - Emmanuelle Leteurtre
- Department of Pathology, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - Emmanuel Boleslawski
- Department of Digestive Surgery and Transplantation, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
| | - François-René Pruvot
- Department of Digestive Surgery and Transplantation, University Hospital Centre [Centre Hospitalier Universitaire (CHU)], University of Lille Nord de FranceLille, France
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Pessaux P, van den Broek MAJ, Wu T, Olde Damink SWM, Piardi T, Dejong CHC, Ntourakis D, van Dam RM. Identification and validation of risk factors for postoperative infectious complications following hepatectomy. J Gastrointest Surg 2013; 17:1907-16. [PMID: 23661000 DOI: 10.1007/s11605-013-2226-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 04/29/2013] [Indexed: 02/07/2023]
Abstract
UNLABELLED Postoperative infectious complications (PICs) are associated with significant morbidity after abdominal surgery. Using multivariate analysis of data from a prospective database, our study focused on the risk factors for PICs and the prevention of these complications after hepatectomy, with the goal of improving outcomes and reducing the length of hospital stays. BACKGROUND PICs following surgery are associated with significant morbidity, increase the length of hospital stays, and have a negative impact on long-term oncological outcome. The aim of this study was to determine the risk factors for PICs following partial hepatectomy and to validate these results with an external database. METHODS Between January 2006 and December 2009, 555 patients underwent elective partial hepatectomy. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. The dependent variables studied were the occurrence of PICs, defined as development of one or more of the following conditions: pneumonia, sepsis, Central line-associated bloodstream infection, urinary tract infection, wound infection, and infected intra-abdominal fluid collection. PICs were devised in medical (PIMCs) and surgical (PISCs) complications. The incidence of PICs and validation of the predictive score were determined using an external prospective database of 342 patients. RESULTS The multivariate analysis identified three independent risk factors for PICs: the presence of a nasogastric tube (OR = 1.8), blood transfusion (OR = 1.9), and diabetes (OR = 2.4). The multivariate analysis identified only one independent risk factor for PISCs: an associated portal venous resection (OR = 5.5). The multivariate analysis identified four independent risk factors for PIMCs: presence of a biliary drainage (OR = 1.9), blood transfusion (OR = 2.1), diabetes (OR = 2.9), and presence of atrial fibrillation (OR = 3.6). According to the three predictive factors, the observed rates of PICs ranged from 18.8 % to 77.8 % and ranged from 24.2 % to 100 % in the external database. Predicted and observed risks of PICs were not statistically different. CONCLUSIONS The correction of modifiable risk factors among the identified factors could reduce the incidence of PICs and, as a consequence, improve patient outcomes and reduce the length of hospital stays.
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Affiliation(s)
- Patrick Pessaux
- Department of Hepato-Biliary and Pancreatic Surgery, Nouvel Hopital Civil, Université de Strasbourg, IHU MixSurg, IRCAD, 1 place de l'hôpital, 67091, Strasbourg, France,
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Wibmer A, Prusa AM, Nolz R, Gruenberger T, Schindl M, Ba-Ssalamah A. Liver Failure after Major Liver Resection: Risk Assessment by Using Preoperative Gadoxetic Acid–enhanced 3-T MR Imaging. Radiology 2013. [DOI: 10.1148/radiology.13130210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wibmer A, Prusa AM, Nolz R, Gruenberger T, Schindl M, Ba-Ssalamah A. Liver failure after major liver resection: risk assessment by using preoperative Gadoxetic acid-enhanced 3-T MR imaging. Radiology 2013; 269:777-86. [PMID: 23942606 DOI: 10.1148/radiol.13130210] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine if gadoxetic acid-enhanced magnetic resonance (MR) imaging with measurement of relative liver enhancement (RLE) on hepatobiliary phase images can allow preoperative assessment of the risk of liver failure after major liver resection. MATERIALS AND METHODS The local institutional review committee approved this retrospective analysis and waived written informed consent. The study included 73 patients (39 men; median age, 64.4 years) who underwent gadoxetic acid-enhanced 3-T MR imaging before resection of three or more liver segments. RLE was calculated as the ratio of signal intensity measurements of the liver parenchyma before and 20 minutes after intravenous administration of gadoxetic acid. RLE was assessed in each liver segment and the mean value of all segments was used for analysis. Posthepatectomy liver failure was defined according to the "50-50 criteria" (ie, prothrombin time <50% and serum bilirubin >50 µmol/L on postoperative day 5) and the International Study Group of Liver Surgery (ISGLS) classification. The association of RLE and liver failure was tested with univariate and multivariate logistic regression analysis. In addition to RLE, the latter also included demographic, clinical, operative, and histologic variables. RESULTS Patients with liver failure according to the 50-50 criteria (n = 3) had significantly lower RLE (54.5%) than those without (125.6%) (P = .009). According to ISGLS criteria, RLE was 112.5% in patients with grade A liver failure (n = 20), 88.4% in patients with grade B (n = 7), 41.7% (n = 2) in patients with grade C, and 136.5% (P < .001) in those without liver failure. In a logistic regression analysis, RLE was inversely related to the probability of liver failure according to the 50-50 (P = .02) and ISGLS (P < .001) criteria. In a multivariate analysis, RLE was independently associated with a higher probability of liver failure according to ISGLS classification (P = .003). CONCLUSION Gadoxetic acid-enhanced MR imaging can help with the assessment of the risk for liver failure after major liver resection.
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Affiliation(s)
- Andreas Wibmer
- From the Departments of Radiology (A.W., R.N., A.B.S.) and Surgery (A.M.P., T.G., M.S.), Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Hirokawa F, Hayashi M, Miyamoto Y, Asakuma M, Shimizu T, Komeda K, Inoue Y, Uchiyama K, Nishimura Y. Evaluation of postoperative antibiotic prophylaxis after liver resection: a randomized controlled trial. Am J Surg 2013; 206:8-15. [DOI: 10.1016/j.amjsurg.2012.08.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 08/09/2012] [Accepted: 08/19/2012] [Indexed: 10/26/2022]
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Hoekstra LT, de Graaf W, Nibourg GAA, Heger M, Bennink RJ, Stieger B, van Gulik TM. Physiological and biochemical basis of clinical liver function tests: a review. Ann Surg 2013; 257:27-36. [PMID: 22836216 DOI: 10.1097/sla.0b013e31825d5d47] [Citation(s) in RCA: 244] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review the literature on the most clinically relevant and novel liver function tests used for the assessment of hepatic function before liver surgery. BACKGROUND Postoperative liver failure is the major cause of mortality and morbidity after partial liver resection and develops as a result of insufficient remnant liver function. Therefore, accurate preoperative assessment of the future remnant liver function is mandatory in the selection of candidates for safe partial liver resection. METHODS A MEDLINE search was performed using the key words "liver function tests," "functional studies in the liver," "compromised liver," "physiological basis," and "mechanistic background," with and without Boolean operators. RESULTS Passive liver function tests, including biochemical parameters and clinical grading systems, are not accurate enough in predicting outcome after liver surgery. Dynamic quantitative liver function tests, such as the indocyanine green test and galactose elimination capacity, are more accurate as they measure the elimination process of a substance that is cleared and/or metabolized almost exclusively by the liver. However, these tests only measure global liver function. Nuclear imaging techniques ((99m)Tc-galactosyl serum albumin scintigraphy and (99m)Tc-mebrofenin hepatobiliary scintigraphy) can measure both total and future remnant liver function and potentially identify patients at risk for postresectional liver failure. CONCLUSIONS Because of the complexity of liver function, one single test does not represent overall liver function. In addition to computed tomography volumetry, quantitative liver function tests should be used to determine whether a safe resection can be performed. Presently, (99m)Tc-mebrofenin hepatobiliary scintigraphy seems to be the most valuable quantitative liver function test, as it can measure multiple aspects of liver function in, specifically, the future remnant liver.
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Hassanain M, Metrakos P, Fisette A, Doi SAR, Schricker T, Lattermann R, Carvalho G, Wykes L, Molla H, Cianflone K. Randomized clinical trial of the impact of insulin therapy on liver function in patients undergoing major liver resection. Br J Surg 2013; 100:610-8. [PMID: 23339047 DOI: 10.1002/bjs.9034] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative liver dysfunction is the major source of morbidity and mortality in patients undergoing partial hepatectomy. This study tested the benefits of a metabolic support protocol based on insulin infusion, for reducing liver dysfunction following hepatic resection. METHODS Consecutive consenting patients scheduled for liver resection were randomized to receive preoperative dextrose infusion followed by insulin therapy using the hyperinsulinaemic normoglycaemic clamp protocol (n = 29) or standard therapy (control group, n = 27). Patients in the insulin therapy group followed a strict dietary regimen for 24 h before surgery. Intravenous dextrose was started at 2 mg per kg per min the night before and continued until surgery. Hyperinsulinaemic therapy for a total of 24 h was initiated at 2 munits per kg per min at induction of anaesthesia, and continued at 1 munit per kg per min after surgery. Normoglycaemia was maintained (3.5-6.0 mmol/l). Control subjects received no additional dietary supplement and a conventional insulin sliding scale during fasting. All patients were tested serially to evaluate liver function using the Schindl score. Liver tissue samples were collected at two time points during surgery to measure glycogen levels. RESULTS Demographics were similar in the two groups. More liver dysfunction occurred in the control cohort (liver dysfunction score range 0-8 versus 0-4 with insulin therapy; P = 0.031). Median (interquartile range) liver glycogen content was 278 (153-312) and 431 (334-459) µmol/g respectively (P = 0.011). The number of complications rose with increasing severity of postoperative liver dysfunction (P = 0.032) CONCLUSION: The glucose-insulin protocol reduced postoperative liver dysfunction and improved liver glycogen content. REGISTRATION NUMBER NCT00774098 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Hassanain
- Department of Surgery, Royal Victoria Hospital, McGill University Health Centre, Canada
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Sadamori H, Yagi T, Shinoura S, Umeda Y, Yoshida R, Satoh D, Nobuoka D, Utsumi M, Yoshida K, Fujiwara T. Risk factors for organ/space surgical site infection after hepatectomy for hepatocellular carcinoma in 359 recent cases. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 20:186-96. [DOI: 10.1007/s00534-011-0503-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Hiroshi Sadamori
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Takahito Yagi
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Susumu Shinoura
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Yuzo Umeda
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Ryuichi Yoshida
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Daisuke Satoh
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Daisuke Nobuoka
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Masashi Utsumi
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Kazuhiro Yoshida
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; 2-5-1 Shikata Okayama 700-8558 Japan
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Millar AM, Bodingbauer M, O'Brien LM, Beattie LA, Duffin R, Wigmore SJ. Preparation of technetium-99 m human albumin nanospheres for use in the measurement of reticuloendothelial clearance capacity. J Labelled Comp Radiopharm 2011. [DOI: 10.1002/jlcr.1861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Risk factors for postoperative infectious complications after hepatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 18:67-73. [DOI: 10.1007/s00534-010-0313-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Chaudhury P, Hassanain M, Bouganim N, Salman A, Kavan P, Metrakos P. Perioperative chemotherapy with bevacizumab and liver resection for colorectal cancer liver metastasis. HPB (Oxford) 2010; 12:37-42. [PMID: 20495643 PMCID: PMC2814402 DOI: 10.1111/j.1477-2574.2009.00119.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 06/30/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery remains the only curative option for patients with colorectal cancer liver metastases (CRLM). Perioperative chemotherapeutic strategies have become increasingly popular in the treatment of CRLM. Although the role of bevacizumab (Bev) in this setting remains unclear, its widespread use has raised concerns about the use of Bev as part of perioperative chemotherapy. METHODS We retrospectively reviewed all patients who received Bev and underwent liver resection between July 2004 and July 2008 at the McGill University Health Center. Chemotherapy-related toxicity, response to chemotherapy, surgical morbidity and mortality, liver function and survival data were assessed. RESULTS A total of 35 patients were identified. Of these, 26 (74.3%) patients received oxaliplatin-based cytotoxic chemotherapy, six (17.1%) received irinotecan-based therapy and the remainder received both agents. A total of 17 patients (48.6%) underwent portal vein embolization prior to resection and 12 (34.3%) underwent staged resection for extensive bilobar disease. A median of six cycles of preoperative Bev were administered. Nine patients (25.7%) experienced grade 3 or higher chemotherapy-related toxicities. Four events were deemed to be related to Bev. The overall response rate was 65.7% (complete and partial response). One patient progressed on therapy, but this did not prevent R0 resection. The incidence of postoperative morbidity was 42.3%. A total of 21.7% of complications were Clavien grade 3 or higher. There were no perioperative mortalities. There were no cases of severe sinusoidal injury or steatohepatitis. The Kaplan-Meier estimate of 4-year survival was 52.5%. CONCLUSIONS These data confirm the safety of chemotherapy regimens which include Bev in the perioperative setting and demonstrate that such perioperative chemotherapy in patients with CRLM does not adversely affect patient outcome. There was no increase in perioperative morbidity compared with published rates. The addition of Bev to standard chemotherapy may improve response rates, which may, in turn, impact favourably on patient survival.
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Affiliation(s)
- Prosanto Chaudhury
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Mazen Hassanain
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Nathaniel Bouganim
- Department of Oncology, Jewish General Hospital Segal Cancer CenterMontreal, QC, Canada
| | - Ayat Salman
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
| | - Petr Kavan
- Department of Oncology, Jewish General Hospital Segal Cancer CenterMontreal, QC, Canada
| | - Peter Metrakos
- Department of Surgery, McGill University Health CenterMontreal, QC, Canada
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Chiarla C, Giovannini I, Giuliante F, Vellone M, Ardito F, Masi A, Nuzzo G. Plasma bilirubin correlations in non-obstructive cholestasis after partial hepatectomy. Clin Chem Lab Med 2009; 46:1598-601. [PMID: 19012524 DOI: 10.1515/cclm.2008.321] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study was to provide an improved outline of the patterns and correlates of changes in plasma bilirubin after partial hepatectomy. METHODS A large series of blood measurements and complementary variables were prospectively collected from 85 patients undergoing liver resection, and bilirubin correlations were assessed by regression analysis. RESULTS Early postoperatively, the best simultaneous correlates of increasing bilirubin were the preoperative value, the duration of surgery, and the number of blood transfusions (r2 = 0.74, p < 0.001). Subsequently, increasing bilirubin became related to the number of resected liver segments, the duration of intraoperative liver ischemia, the use of continuous vs. intermittent ischemia, and the presence of sepsis (r2 = 0.82, p < 0.001); these were also the best simultaneous correlates of peak bilirubin. This pattern was characterized by prominently conjugated hyperbilirubinemia, hypocholesterolemia, and moderately increased alkaline phosphatase, and occurred in the absence of obstructive cholestasis. CONCLUSIONS Major hepatectomy, parenchymal ischemia, and sepsis have similar and synergistic impacts as determinants of prominently conjugated hyperbilirubinemia after liver resection. This is likely related to impaired hepatocellular bilirubin transport and occurs in the absence of obstructive components.
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Affiliation(s)
- Carlo Chiarla
- Department of Surgery, Hepatobiliary Unit and CNR-IASI Shock Center, Catholic University of the Sacred Heart School of Medicine, Rome, Italy
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Capussotti L, Viganò L, Giuliante F, Ferrero A, Giovannini I, Nuzzo G. Liver dysfunction and sepsis determine operative mortality after liver resection. Br J Surg 2009; 96:88-94. [PMID: 19109799 DOI: 10.1002/bjs.6429] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver failure is the principal cause of death after hepatectomy. Its progression towards death and its relationship with sepsis are unclear. This study analysed predictors of mortality in patients with liver dysfunction and the role of sepsis in the death of these patients. METHODS The study focused on patients with liver dysfunction, excluding those with vascular thrombosis, after liver resection at one of two centres between 1998 and 2006. RESULTS Liver dysfunction occurred after 57 (4.5 per cent) of 1271 hepatectomies. Fifty-three patients without vascular thrombosis were included in the analysis, with a mortality rate of 23 per cent. Independent predictors of death were age (odds ratio (OR) 1.18 per year increase; P = 0.017), cirrhosis (OR 54.09; P = 0.004) and postoperative sepsis (OR 37.58; P = 0.005). Sepsis occurred in 15 patients (28 per cent), seven of whom died. Intestinal pathogens were isolated in 12 patients with sepsis. The risk of sepsis was significantly increased in those with surgical complications (11 of 16 versus four of 37; P < 0.001). CONCLUSION Sepsis plays a key role in the death of patients with liver dysfunction after hepatectomy. Early recognition and aggressive treatment of sepsis may reduce mortality.
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Affiliation(s)
- L Capussotti
- Department of Hepatopancreatobiliary and Digestive Surgery, Ospedale Mauriziano Umberto I, Largo Turati 62, Turin, Italy.
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van de Poll MCG, Ligthart-Melis GC, Olde Damink SWM, van Leeuwen PAM, Beets-Tan RGH, Deutz NEP, Wigmore SJ, Soeters PB, Dejong CHC. The gut does not contribute to systemic ammonia release in humans without portosystemic shunting. Am J Physiol Gastrointest Liver Physiol 2008; 295:G760-5. [PMID: 18703642 DOI: 10.1152/ajpgi.00333.2007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The gut is classically seen as the main source of circulating ammonia. However, the contribution of the intestines to systemic ammonia production may be limited by hepatic extraction of portal-derived ammonia. Recent data suggest that the kidney may be more important than the gut for systemic ammonia production. The aim of this study was to quantify the role of the kidney, intestines, and liver in interorgan ammonia trafficking in humans with normal liver function. In addition, we studied changes in interorgan nitrogen metabolism caused by major hepatectomy. From 21 patients undergoing surgery, blood was sampled from the portal, hepatic, and renal veins to assess intestinal, hepatic, and renal ammonia metabolism. In seven cases, blood sampling was repeated after major hepatectomy. At steady state during surgery, intestinal ammonia release was equaled by hepatic ammonia uptake, precluding significant systemic release of intestinal-derived ammonia. In contrast, the kidneys released ammonia to the systemic circulation. Major hepatectomy led to increased concentrations of ammonia and amino acids in the systemic circulation. However, transsplanchnic concentration gradients after major hepatectomy were similar to baseline values, indicating the rapid institution of a new metabolic equilibrium. In conclusion, since hepatic ammonia uptake exactly equals intestinal ammonia release, the splanchnic area, and hence the gut, probably does not contribute significantly to systemic ammonia release. After major hepatectomy, hepatic ammonia clearance is well preserved, probably related to higher circulating ammonia concentrations.
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Affiliation(s)
- Marcel C G van de Poll
- Univ. Hospital Maastricht, Dept. of Surgery, PO Box 5800, 6200 AZ Maastricht, the Netherlands
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Slotta JE, Laschke MW, Menger MD, Thorlacius H. Rho-kinase signalling mediates endotoxin hypersensitivity after partial hepatectomy. Br J Surg 2008; 95:976-84. [PMID: 18563790 DOI: 10.1002/bjs.6082] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Excessive loss of functional liver mass results in hepatic dysfunction and is associated with an increased sensitivity to infection. This experimental study investigated the role of Rho-kinase in hepatectomy-induced sensitization to endotoxin. METHODS Male C57BL/6J mice underwent 68 per cent hepatectomy and were injected 24 h later with 100 microg Escherichia coli lipopolysaccharide (LPS). Simultaneously, animals received either fasudil or Y-27632 for Rho-kinase inhibition, or phosphate-buffered saline. Untreated hepatectomized animals served as positive controls and sham-operated animals as negative controls. Liver injury and inflammatory parameters were assessed 6 h after LPS challenge by serum alanine aminotransferase (ALT) levels, histomorphology and enzyme-linked immunosorbent assay. RESULTS Hepatectomy resulted in a significant susceptibility to LPS, as indicated by inflammatory leucocyte recruitment (mean(s.e.m.) 10(1) leucocytes per high-power field), hepatocellular disintegration (ALT 22.4(3.1) microkat/l) and apoptotic cell death (3.8(0.2) per cent). Rho-kinase inhibition reduced leucocytic infiltration by more than 33 per cent, abolished hepatocellular apoptosis entirely, and reduced tumour necrosis factor alpha expression by more than 48 per cent and CXC chemokine expression by more than 36 per cent. CONCLUSION Hepatectomy increased susceptibility to LPS by Rho-kinase-dependent mechanisms. Blocking Rho-kinase signalling decreased LPS-induced liver injury in hepatectomized mice.
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Affiliation(s)
- J E Slotta
- Department of Surgery, Malmö University Hospital, Lund University, Malmö, Sweden
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Pulmonary and blood stream infections in adult living donor and cadaveric liver transplant patients. Transplantation 2008; 85:1564-8. [PMID: 18551060 DOI: 10.1097/tp.0b013e31816f61a6] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Infectious complications occur in approximately 50% of cadaveric liver transplant (CDLT) recipients. Living-donor liver transplantation (LDLT) is an established alternative to shorten the waiting time. Currently, the incidence of pulmonary infections after LDLT and the microbiologic causes are unknown. In the present cohort study, we compared the incidence and profiles of pulmonary and blood stream infections (BSI) between LDLT and CDLT recipients. We hypothesized a lower incidence in LDLT recipients. METHODS The clinical course of 55 LDLT recipients consecutively transplanted between January 2003 and December 2006 was analyzed. The 173 CDLT recipients who were transplanted in the same period served as a control group. Patients were treated in a single Intensive Care Unit, applying standardized postoperative care. RESULTS Mean model for end-stage liver disease score did not differ between LDLT and CDLT recipients (14.2 vs. 13.3). The overall incidence of pulmonary and BSI for both groups was 8% and 24%, respectively. Pulmonary infections were experienced by 18% of LDLT versus 5% of CDLT recipients (P=0.005) and BSI occurred in 33% of LDLT versus 21% of CDLT recipients (P=0.1). CONCLUSIONS In contrast to our hypothesis, LDLT recipients experienced significantly more pulmonary infections and a trend toward increased higher incidence of BSI. These findings emphasize the need for future research on the causative agents and prevention of infection in LDLT recipients. The observation that patients with pulmonary infection had a significantly reduced 1-year survival rate underscores the importance of our observations.
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van den Broek MAJ, Olde Damink SWM, Dejong CHC, Lang H, Malagó M, Jalan R, Saner FH. Liver failure after partial hepatic resection: definition, pathophysiology, risk factors and treatment. Liver Int 2008; 28:767-80. [PMID: 18647141 DOI: 10.1111/j.1478-3231.2008.01777.x] [Citation(s) in RCA: 298] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Liver failure is a dreaded and often fatal complication that sometimes follows a partial hepatic resection. This article reviews the definition, incidence, pathogenesis, risk factors, risk assessment, prevention, clinical features and treatment of post-resectional liver failure (PLF). A systematic, computerized search was performed using key words related to 'partial hepatic resection' and 'liver failure' to review most relevant literature about PLF published in the last 20 years. The reported incidence of PLF ranges between 0.7 and 9.1%. An inadequate quantity or quality of residual liver mass are key events in its pathogenesis. Major risk factors are the presence of comorbid conditions, pre-existent liver disease and small remnant liver volume (RLV). It is essential to identify these risk factors during the pre-operative assessment that includes evaluation of liver volume, anatomy and function. Preventive measures should be applied whenever possible as curative treatment options for PLF are limited. These preventive measures intend to increase RLV and protect remnant liver function. Management principles focus on support of end-organ and liver function. Further research is needed to elucidate the exact pathogenesis of PLF and to develop and validate adequate treatment options.
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Dello SAWG, van Dam RM, Slangen JJG, van de Poll MCG, Bemelmans MHA, Greve JWWM, Beets-Tan RGH, Wigmore SJ, Dejong CHC. Liver volumetry plug and play: do it yourself with ImageJ. World J Surg 2008; 31:2215-21. [PMID: 17726630 PMCID: PMC2039862 DOI: 10.1007/s00268-007-9197-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background A small remnant liver volume is an important risk factor for posthepatectomy liver failure and can be predicted accurately by computed tomography (CT) volumetry using radiologic image analysis software. Unfortunately, this software is expensive and usually requires support by a radiologist. ImageJ is a freely downloadable image analysis software package developed by the National Institute of Health (NIH) and brings liver volumetry to the surgeon’s desktop. We aimed to assess the accuracy of ImageJ for hepatic CT volumetry.
Methods ImageJ was downloaded from http://www.rsb.info.nih.gov/ij/. Preoperative CT scans of 15 patients who underwent liver resection for colorectal cancer liver metastases were retrospectively analyzed. Scans were opened in ImageJ; and the liver, all metastases, and the intended parenchymal transection line were manually outlined on each slice. The area of each selected region, metastasis, resection specimen, and remnant liver was multiplied by the slice thickness to calculate volume. Volumes of virtual liver resection specimens measured with ImageJ were compared with specimen weights and calculated volumes obtained during pathology examination after resection.
Results There was an excellent correlation between the volumes calculated with ImageJ and the actual measured weights of the resection specimens (r² = 0.98, p < 0.0001). The weight/volume ratio amounted to 0.88 ± 0.04 (standard error) and was in agreement with our earlier findings using CT-linked radiologic software.
Conclusion ImageJ can be used for accurate hepatic CT volumetry on a personal computer. This application brings CT volumetry to the surgeon’s desktop at no expense and is particularly useful in cases of tertiary referred patients, who already have a proper CT scan on CD-ROM from the referring institution. Most likely the discrepancy between volume and weight results from exsanguination of the liver after resection.
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Affiliation(s)
| | - Ronald M. van Dam
- Department of Surgery, University Hospital, Maastricht, The Netherlands
| | | | - Marcel C. G. van de Poll
- Department of Surgery, University Hospital, Maastricht, The Netherlands
- Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | | | - Jan Willem W. M. Greve
- Department of Surgery, University Hospital, Maastricht, The Netherlands
- Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | | | | | - Cornelis H. C. Dejong
- Department of Surgery, University Hospital, Maastricht, The Netherlands
- Nutrition and Toxicology Research Institute (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
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Ferrero A, Viganò L, Polastri R, Muratore A, Eminefendic H, Regge D, Capussotti L. Postoperative liver dysfunction and future remnant liver: where is the limit? Results of a prospective study. World J Surg 2008; 31:1643-51. [PMID: 17551779 DOI: 10.1007/s00268-007-9123-2] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The future remnant liver (FRL) limit for safe major hepatectomy with low risk of postoperative liver failure has not yet been well defined. METHODS Between April 2000 and September 2004, every patient scheduled for major hepatectomy in our institution underwent CT-volumetry of FRL. Patients with FRL <25% underwent portal vein embolization (PVE). Exclusion criteria were PVE, associated vascular resection and liver cirrhosis. The FRL was correlated with short-term results in patients with normal liver (group A) and those with impaired liver function secondary to neoadjuvant chemotherapy or cholestasis (bilirubin >2 mg/100 ml) (group B). Liver dysfunction was defined as both PT <50% and serum bilirubin level >5 mg/100 ml for three or more consecutive days. RESULTS A total of 119 patients were analyzed, 72 in group A and 47 in group B. The FRL value was the only significant risk factor for postoperative liver dysfunction in the univariate and multivariate analysis (p = 0.009). The FRL did not correlate with postoperative mortality and morbidity. Bilirubin and prothrombin time (PT) on days 3 and 7 were significantly correlated to FRL in both groups. In group A, patients with postoperative liver dysfunction had a FRL<30% (3 versus 0; p = 0.005). According to receiving operator characteristic (ROC) curve analysis, a FRL value of 26.5% predicted postoperative liver dysfunction with 66.7% sensitivity, 97.1% specificity, 50% positive predictive value (PPV), and 98.5% negative predictive value (NPV). In group B, patients with postoperative liver dysfunction had a FRL <35% (4 versus 0; p = 0.027). According to ROC curve analysis, a FRL value of 31.05% predicted postoperative liver dysfunction with 75% sensitivity, 79.1% specificity, 25% PPV, and 97.1% NPV. CONCLUSIONS Hepatectomy can be considered safe when FRL is >26.5% in patients with healthy liver and >31% in patients with impaired liver function.
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Affiliation(s)
- Alessandro Ferrero
- Unit of Surgical Oncology, Institute for Cancer Research and Treatment, Candiolo, Italy.
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van de Poll MCG, Wigmore SJ, Redhead DN, Beets-Tan RGH, Garden OJ, Greve JWM, Soeters PB, Deutz NEP, Fearon KCH, Dejong CHC. Effect of major liver resection on hepatic ureagenesis in humans. Am J Physiol Gastrointest Liver Physiol 2007; 293:G956-62. [PMID: 17717046 DOI: 10.1152/ajpgi.00366.2006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Changes in hepatic ureagenesis following major hepatectomy are not well characterized. We studied the relation between urea synthesis and liver mass before and after major hepatectomy in humans. Fifteen patients scheduled for resection of malignancies in otherwise healthy livers were studied. Pre- and postoperative liver volume was assessed by computerized tomography-volumetry. During surgery, a primed, continuous infusion of [(13)C]urea was administered intravenously, and arterial blood samples were obtained hourly. Indocyanine green clearance was determined before and after resection. Seven patients underwent major hepatectomy, and eight patients underwent minor [<5% functional liver volume (total volume -- tumor volume)] or no resection, serving as controls. Resected functional liver volume in the major hepatectomy group averaged 60%. Urea synthesis per gram of functional liver tissue increased 2.6-fold following major hepatectomy, maintaining whole body urea synthesis. Arterial ammonia remained unchanged throughout the study, whereas following hepatectomy a hyperaminoacidemia occurred. In conclusion, immediately following major hepatectomy, urea synthesis per gram of functional liver tissue increases rapidly and proportionately to the amount of liver tissue resected, maintaining whole body urea synthesis at preoperative levels. This rapid and complete adaptation suggests that the capacity of urea synthesis is not limiting the maximum resectable volume in otherwise healthy livers.
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Affiliation(s)
- Marcel C G van de Poll
- Department of Surgery, University Hospital Maastricht, 6202 AZ, Maastricht, the Netherlands.
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Yamanaka J, Saito S, Fujimoto J. Impact of preoperative planning using virtual segmental volumetry on liver resection for hepatocellular carcinoma. World J Surg 2007; 31:1249-55. [PMID: 17440774 DOI: 10.1007/s00268-007-9020-8] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Accurate assessment of resection volume and vascular anatomy is mandatory in preoperative planning for safe and curative hepatectomy to treat cancer. Accordingly, we examined feasibility and accuracy of a preoperative three-dimensional (3D) computed tomography (CT) scan based simulation in patients with impaired liver function undergoing hepatectomy for hepatocellular carcinoma (HCC). METHODS Hepatectomy simulation software was programmed to reconstruct detailed 3D vascular structure and calculate liver volume based on hepatic circulation. In 113 patients with HCC, liver resection volume was estimated preoperatively by both simulation and conventional planimetry. For validation, predicted resection volumes were compared with actual resected specimen weights. The resection margin as estimated by the simulation was compared with the margin in the specimen. RESULTS Simulation showed higher correlation and smaller discrepancy (r = 0.96; 9.3 ml) between predicted and actual liver resection volume than conventional planimetry (r = 0.74; 174 ml). Simulation showed correlation (p < 0.01) between estimated and actual segmental volume, which was not measurable by planimetry. Simulation showed a correlation (r = 0.84) between predicted and actual margin, with a difference of 1.6 mm. CONCLUSIONS Hepatectomy simulation in 3D predicted segmental liver volume and the resection margin accurately. This virtual method should contribute to preoperative planning to achieve safe, curative resection in HCC patients, whose hepatic function is compromised.
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Affiliation(s)
- Junichi Yamanaka
- First Department of Surgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Dejong CHC, van de Poll MCG, Soeters PB, Jalan R, Olde Damink SWM. Aromatic amino acid metabolism during liver failure. J Nutr 2007; 137:1579S-1585S; discussion 1597S-1598S. [PMID: 17513430 DOI: 10.1093/jn/137.6.1579s] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Liver failure is associated with hepatic encephalopathy (HE). An imbalance in plasma levels of aromatic amino acids (AAA) phenylalanine, tyrosine, and tryptophan and branched chain amino acids (BCAA) and their BCAA/AAA ratio has been suggested to play a causal role in HE by enhanced brain AAA uptake and subsequently disturbed neurotransmission. Until recently, data on this subject and the role of the liver and splanchnic bed were scarce, particularly in humans, due to inaccessibility of portal and hepatic veins. Here, we discuss, against a background of relevant literature, data obtained in patients undergoing liver resection or with a transjugular intrahepatic portasystemic stent shunt (TIPSS), where these veins are accessible. The BCAA/AAA ratio remained unchanged after major liver resection, but plasma AAA levels were inversely correlated (P < 0.001) with residual liver volume, in keeping with the observed hepatic AAA uptake. In patients with stable cirrhosis and a TIPSS, the plasma BCAA/AAA ratio was lower than in controls (1.19 +/- 0.09 vs. controls: 3.63 +/- 0.34). Gastrointestinal bleeding in cirrhotics with a TIPSS induced disturbances in BCAA levels and the BCAA/AAA ratio and induced catabolism, which could partly be corrected by isoleucine administration. AAA may be important in the pathogenesis of HE, but it is unlikely that they are the sole factors. HE most likely is a syndrome with multifactorial pathogenesis, where hyperammonemia, AAA/BCAA imbalances, inflammation, brain edema, and neurotransmitter changes interact. Novel therapies to normalize AAA levels in patients with liver failure (such as the molecular adsorbent recirculating system dialysis device) should probably be combined with supplementation of e.g. isoleucine and enhancing ammonia excretion by the kidneys.
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Affiliation(s)
- Cornelis H C Dejong
- Department of Surgery, Nutrition and Toxicology Institute Maastricht, Maastricht University, the Netherlands.
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Devey LR, Wigmore SJ. Attenuation of Kupffer Cell Function in Acute on Chronic Liver Injury Enhanced the Engraftment of Transplanted Hepatocytes. World J Surg 2007. [PMID: 17446990 DOI: 10.1007/s00268-007-9052-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Arikan Y, Akbulut G, Sahin DA, Dilek FH, Saykol V, Dilek ON. Effects of octenidine HCl on liver tissue: could it be an alternative scolicidal for Hidatid disease? World J Surg 2007; 31:1280-3. [PMID: 17446990 DOI: 10.1007/s00268-007-9022-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Octenidine HCl is new topical antiseptic solution for wounds and abdominal washing that has been found to be highly effective for inactivating scolices in an in vitro study. However, the effects of octenidine HCl on the liver are not yet known. The aim of this study was to determine if there are any histopathologic changes after injecting octenidine HCl into the liver. A group of 50 male Sprague-Dawley rats were included in the study and randomly divided into five groups of 10 rats each, as follows: sham group; 0.09% NaCl group; 20% NaCl group; undiluted octenidine HCl group; 1% octenidine HCl group. The scolicidal agents (0.3 ml) were directly injected into the left lobe of the liver (except in the sham group). At 3 and 7 days after the injection, the rats were sacrificed, and the left lobe of the liver was harvested. Liver tissue was scored for degree of necrosis and the diameter of the necrosis examined under light microscopy. The highest scores were found in the undiluted octenidine HCl group, although a similar effect was observed in the 20% NaCl group. There was no necrosis in the sham group, the 0.09% NaCl group, or the 1% octenidine HCl group. All of the injury was coagulation-type necrosis. No mortality was observed throughout the study. The 1% octenidine HCl solution could thus be used as a scolicidal agent in liver tissue, whereas the undiluted form of octenidine and 20% NaCl solutions were shown to cause necrosis when directly injected into liver tissue in our animal model.
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Affiliation(s)
- Yüksel Arikan
- Department of General Surgery, Afyonkarahisar Kocatepe University, School of Medicine, Tip Fakültesi, Genel Cerrahi AD, Ali Cetinkaya Kampüsü, 03200, Afyon Karahisar, Turkey
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van de Poll MCG, Ligthart-Melis GC, Boelens PG, Deutz NEP, van Leeuwen PAM, Dejong CHC. Intestinal and hepatic metabolism of glutamine and citrulline in humans. J Physiol 2007; 581:819-27. [PMID: 17347276 PMCID: PMC2075174 DOI: 10.1113/jphysiol.2006.126029] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Glutamine plays an important role in nitrogen homeostasis and intestinal substrate supply. It has been suggested that glutamine is a precursor for arginine through an intestinal-renal pathway involving inter-organ transport of citrulline. The importance of intestinal glutamine metabolism for endogenous arginine synthesis in humans, however, has remained unaddressed. The aim of this study was to investigate the intestinal conversion of glutamine to citrulline and the effect of the liver on splanchnic citrulline metabolism in humans. Eight patients undergoing upper gastrointestinal surgery received a primed continuous intravenous infusion of [2-(15)N]glutamine and [ureido-(13)C-(2)H(2)]citrulline. Arterial, portal venous and hepatic venous blood were sampled and portal and hepatic blood flows were measured. Organ specific amino acid uptake (disposal), production and net balance, as well as whole body rates of plasma appearance were calculated according to established methods. The intestines consumed glutamine at a rate that was dependent on glutamine supply. Approximately 13% of glutamine taken up by the intestines was converted to citrulline. Quantitatively glutamine was the only important precursor for intestinal citrulline release. Both glutamine and citrulline were consumed and produced by the liver, but net hepatic flux of both amino acids was not significantly different from zero. Plasma glutamine was the precursor of 80% of plasma citrulline and plasma citrulline in turn was the precursor of 10% of plasma arginine. In conclusion, glutamine is an important precursor for the synthesis of arginine after intestinal conversion to citrulline in humans.
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Affiliation(s)
- Marcel C G van de Poll
- Department of Surgery, University Hospital Maastricht and Nutrition and Toxicology Research Institute Maastricht (NUTRIM), Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
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Nuzzo G, Giuliante F, Gauzolino R, Vellone M, Ardito F, Giovannini I. Liver resections for hepatocellular carcinoma in chronic liver disease: experience in an Italian centre. Eur J Surg Oncol 2007; 33:1014-8. [PMID: 17207957 DOI: 10.1016/j.ejso.2006.11.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Accepted: 11/27/2006] [Indexed: 12/12/2022] Open
Abstract
AIM Liver resection (LR) and transplantation are the best options for treatment of hepatocellular carcinoma (HCC). We retrospectively analysed the experience obtained with LR for HCC in chronic liver disease patients. METHODS Up until May 2005, 248 patients with HCC were evaluated, and 113 resected. Of these, 97 with chronic liver disease, who underwent a total of 100 resections, form the basis of this study. Age of the patients was 65.6+/-9.2 years (range 32-81, male/female 76/21). In 77 cases there was unifocal and in 23 multinodular tumour; in 61 the size of the tumours was < or =5 cm and in 39>5 cm. Limited resections were performed in 15 cases, resections of 1-2 segments in 51, and major hepatectomies in 34. RESULTS Blood transfusions were required in 28 cases. Three patients died postoperatively, from liver failure and/or sepsis. Seventeen patients had nonlethal complications (mostly liver dysfunction, often with signs of amplified inflammatory response, including ARDS, without evident sources of sepsis). The 5- and 10-year survival rates were 44% and 24%, respectively. Decreased survival was significantly related to increasing number of tumour nodules and degree of liver fibrosis/presence of cirrhosis, and with the expression of markers of carcinogenesis in a sub-group who received this assessment. At 5 years the rate of liver HCC recurrence was 46%, however, death was unrelated to recurrence in 41% of non-survivors. CONCLUSIONS Surgery for HCC achieves acceptable early and long-term results. However, the patterns affecting perioperative outcome must be better understood, and the high recurrence rate warrants further trials to assess preventive treatments after LR.
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Affiliation(s)
- G Nuzzo
- Department of Surgical Sciences, Unit of Hepato-Biliary and Digestive Surgery, Catholic University of the Sacred Heart School of Medicine, Largo A Gemelli 8, I-00168, Rome, Italy
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