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1.
Surg Endosc ; 37(5): 3340-3353, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36542137

RESUMO

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm. METHODS: A systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data. RESULTS: From 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm. CONCLUSION: The available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM.


Assuntos
Carcinoma Hepatocelular , Ablação por Cateter , Neoplasias Colorretais , Neoplasias Hepáticas , Ablação por Radiofrequência , Humanos , Neoplasias Hepáticas/secundário , Carcinoma Hepatocelular/cirurgia , Carcinoma Hepatocelular/patologia , Micro-Ondas/uso terapêutico , Resultado do Tratamento , Neoplasias Colorretais/cirurgia
2.
Surg Endosc ; 37(4): 2508-2516, 2023 04.
Artigo em Inglês | MEDLINE | ID: mdl-36810687

RESUMO

BACKGROUND: Colorectal liver metastases (CRLM) occur in roughly half of patients with colorectal cancer. Minimally invasive surgery (MIS) has become an increasingly acceptable and utilized technique for resection in these patients, but there is a lack of specific guidelines on the use of MIS hepatectomy in this setting. A multidisciplinary expert panel was convened to develop evidence-based recommendations regarding the decision between MIS and open techniques for the resection of CRLM. METHODS: Systematic review was conducted for two key questions (KQ) regarding the use of MIS versus open surgery for the resection of isolated liver metastases from colon and rectal cancer. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Additionally, the panel developed recommendations for future research. RESULTS: The panel addressed two KQs, which pertained to staged or simultaneous resection of resectable colon or rectal metastases. The panel made conditional recommendations for the use of MIS hepatectomy for both staged and simultaneous resection when deemed safe, feasible, and oncologically effective by the surgeon based on the individual patient characteristics. These recommendations were based on low and very low certainty of evidence. CONCLUSIONS: These evidence-based recommendations should provide guidance regarding surgical decision-making in the treatment of CRLM and highlight the importance of individual considerations of each case. Pursuing the identified research needs may help further refine the evidence and improve future versions of guidelines for the use of MIS techniques in the treatment of CRLM.


Assuntos
Neoplasias Colorretais , Neoplasias Hepáticas , Neoplasias Retais , Humanos , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/secundário , Hepatectomia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias Retais/cirurgia
3.
Surg Endosc ; 37(12): 8991-9000, 2023 12.
Artigo em Inglês | MEDLINE | ID: mdl-37957297

RESUMO

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies. METHODS: A systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations. RESULTS: The panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence). CONCLUSION: Given the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.


Assuntos
Carcinoma Hepatocelular , Ablação por Cateter , Neoplasias Colorretais , Neoplasias Hepáticas , Ablação por Radiofrequência , Humanos , Neoplasias Hepáticas/cirurgia , Neoplasias Hepáticas/patologia , Carcinoma Hepatocelular/cirurgia , Micro-Ondas/uso terapêutico , Ablação por Cateter/métodos , Resultado do Tratamento , Ablação por Radiofrequência/métodos , Neoplasias Colorretais/cirurgia , Estudos Retrospectivos
4.
Surg Endosc ; 36(11): 7915-7937, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-36138246

RESUMO

BACKGROUND: While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor. METHODS: PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD). RESULTS: From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17). CONCLUSIONS: Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.


Assuntos
Neoplasias Colorretais , Laparoscopia , Neoplasias Hepáticas , Humanos , Hepatectomia/métodos , Neoplasias Hepáticas/secundário , Tempo de Internação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Neoplasias Colorretais/patologia , Laparoscopia/métodos
5.
HPB (Oxford) ; 23(6): 927-936, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33189566

RESUMO

BACKGROUND: We assessed if the risk of post-liver transplant mortality within 24 h could be stratified at the time of listing using the liver transplant risk score (LTRS). Secondary aims were to assess if the LTRS could stratify the risk of 30-day, 1-year mortality, and survival beyond the first year. METHODS: MELD, BMI, age, diabetes, and the need for dialysis were the five variables used to calculate the LTRS during patients' evaluation for liver transplantation. Mortality rates at 24 h, 30 days, and 1-year were compared among groups of patients with different LTRS. Patients with ABO-incompatibility, redo, multivisceral, partial graft and malignancies except for hepatocellular carcinoma were excluded. Data of 48,616 adult liver transplant recipients were extracted from the Scientific Registry of Transplant Recipients between 2002 and 2017. RESULTS: 24-h mortality was 0.9%, 1.0%, 1.1%, 1.7%, 2.3%, 2.0% and 3.5% for patients with LTRS of 0,1,2,3,4, 5 and ≥ 6, respectively (P < 0.001). 30-day mortality was 3.5%, 4.2%, 4.9%, 6.2%, 7.6%, 7.2% and 10.1% respectively (P < 0.001). 1-year mortality was 8.6%, 10.8%, 12.9%, 13.9%, 18.5%, 20.3% and 28.6% respectively (P < 0.001). 10-year survival was 61%, 56%, 57%, 54%, 47%, and 31% for patients with 0, 1, 2, 3, 4, 5 and ≥ 6 points respectively (P < 0.001). CONCLUSION: Perioperative mortality and long-term survival of patients undergoing LT can be accurately estimated at the time of listing by the LTRS.


Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Transplante de Fígado , Adulto , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Transplantados
6.
HPB (Oxford) ; 21(1): 67-76, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30691592

RESUMO

BACKGROUND: The oncological effects of obesity on liver transplant (LT) patients with hepatocellular carcinoma (HCC) remains unclear. We investigated patient overall survival and tested two-way interactions between donor and recipient obesity status. METHODS: Using the UNOS database, a total of 8352 LT recipients with HCC were included. Donors and recipients were stratified in normal weight (NW), overweight (OW) and obese (OB). Hazard ratios (HR) for any cause of death and interactions between recipient and donor BMI were estimated by multivariate flexible parametric models. RESULTS: Five-year overall survival was 66% for NW, 67% for OW and 68% for OB recipients. The HRs of death from all causes were 0.96 (95% CI: 0.86-1.08) for OW and 0.93 (95% CI: 0.82-1.05) for OB recipients when compared to NW patients. At multivariate analysis, predictors of inferior survival were recipient age (≥65 years), donor age (≥45 years), need for pre-operative dialysis, HCV infection, transplants performed before 2007, and UNOS regions 2,3,9,10, and 11. The lowest adjusted HR was measured for recipients with BMI between 25 and 35 and there were no interactions between recipient and donor BMI. CONCLUSIONS: the overall survival of LT recipients with HCC was not affected by donor or recipient obesity.


Assuntos
Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/cirurgia , Transplante de Fígado , Obesidade/epidemiologia , Adulto , Idoso , Índice de Massa Corporal , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Seleção do Doador , Feminino , Humanos , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
8.
Surg Endosc ; 28(5): 1629-33, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24385247

RESUMO

BACKGROUND: The robotic platform might offer superior ergonomics over other minimally invasive approaches. However, the increased time required for instrument set-up, operations, and surgical training are perceived as major drawbacks. There is limited literature on this topic, therefore we report our experience at an academic tertiary medical center in the USA. The primary aim of this study was to analyze the learning curve and the times for necessary steps for singly docked totally robotic Roux-en-Y gastric bypass (RREYGB). MATERIALS AND METHODS: From November 2010 to April 2013, all consecutive patients who underwent RREYGB were retrospectively analyzed from a prospectively maintained database. Variables of interest for this study were patient demographics, preoperative body mass index, previous surgical history, clinically relevant perioperative events, and operative times for various steps in the procedure. RESULTS: During the study period, a total of 32 patients were enrolled. The mean age was 39.9 ± 9.7 years (range 25-60), preoperative weight was 120.9 ± 21.5 kg (range 76.7-184.6), and body mass index (BMI) was 44.7 ± 5.3 kg/m(2) (range 36.1-61). The mean total operative time was 187.3 ± 36.4 min (range 130-261). The time necessary for trocar placement was 11.9 ± 4.5 min (range 4-23), robot set-up was 8.5 ± 3.6 min (range 3-20), pouch creation was 32 ± 10.11 min (range 16-56), gastrojejunal anastomosis was 59.5 ± 12.3 min (range 39-90), jejunojejunal anastomosis was 33.5 ± 9.6 min (range 18-65), and endoscopy/hemostasis was 12.9 ± 7.2 min (range 2-34). Operative time significantly improved after eight cases. CONCLUSION: In a high-volume established robotic bariatric center, robot set-up, operative times, and learning curve are shorter than previously reported.


Assuntos
Educação Médica Continuada/normas , Derivação Gástrica/educação , Curva de Aprendizado , Obesidade Mórbida/cirurgia , Duração da Cirurgia , Robótica/educação , Robótica/instrumentação , Adulto , Feminino , Seguimentos , Derivação Gástrica/métodos , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo
9.
World J Surg ; 35(12): 2739-46, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21947494

RESUMO

BACKGROUND: Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures, and its application is poorly reported in the literature so far. To date, few data are available comparing a minimally invasive approach to open PD. The aim of the present study is to compare the robotic and open approaches for PD at a single institution. METHODS: Data from 83 consecutive PD procedures performed between January 2002 and May 2010 at a single institution were retrospectively reviewed. Patients were stratified into two groups: the open group (n = 39; 47%) and the robotic group (n = 44; 53%). RESULTS: Patients in the robotic group were statistically older (63 years of age versus 56 years; p = 0.04) and heavier (body mass index: 27.7 vs. 24.8; p = 0.01); and had a higher American Society of Anesthesiologists (ASA) score (2.5 vs. 2.15; p = 0.01) when compared to the open group. Indications for surgery were the same in both groups. The robotic group had a significantly shorter operative time (444 vs. 559 min; p = 0.0001), reduced blood loss (387 vs. 827 ml; p = 0.0001), and a higher number of lymph nodes harvested (16.8 vs. 11; p = 0.02) compared to the open group. There was no significant difference between the two groups in terms of complication rates, mortality rates, and hospital stay. CONCLUSIONS: The authors present one of the first studies comparing open and robotic PD. While it is too early to draw definitive conclusions concerning the long-term outcomes, short-term results show a positive trend in favor of the robotic approach without compromising the oncological principles associated with the open approach.


Assuntos
Pancreaticoduodenectomia/métodos , Robótica , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
10.
World J Surg ; 35(3): 637-42, 2011 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21190108

RESUMO

BACKGROUND: Application of the robot for Roux-en-Y gastric bypass has been slow to evolve, despite its rapid acceptance in other fields. This is largely due to associated costs of technology, reports of increased operative time, and inadequate data available to correlate the benefits of robotics to a clinical outcome. The authors present a comparative study between laparoscopic and robot-assisted Roux-en-Y gastric bypass performed at a specialized institution for robotic surgery. MATERIALS AND METHOD: A total of 135 consecutive Roux-en-Y gastric bypass procedures were performed from January 2006 to December 2009 by a single surgeon. The first 45 were performed laparoscopically and the remaining 90 were robot-assisted. Patient demographics, operative time, complication rate, length of stay, long-term weight loss, and follow-up for the two groups were gathered from a prospectively maintained database and statistically analyzed. RESULTS: The overall operative time was significantly shorter for the robot-assisted procedures than for the laparoscopic procedures (207 ± 31 vs. 227 ± 31 min) (P = 0.0006). The robotic set-up time remained constant at 13 ± 4 min. 30 robotic cases were necessary in order to perform the procedure in less time than with the laparoscopic approach (P = 0.047). Mortality was 0% in both groups, with no conversions to open surgery and no transfusions. Early morbidities and percentage of excess weight loss at 1 year were comparable for the two groups. CONCLUSIONS: The use of the robot for performing the gastrojejunostomy during laparoscopic Roux-en-Y gastric bypass does not increase the operative time or the rate of specific complications. The short-term outcomes of the robot-assisted procedure are comparable to those found with the conventional laparoscopic method.


Assuntos
Derivação Gástrica/métodos , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Robótica/métodos , Adulto , Índice de Massa Corporal , Estudos de Coortes , Feminino , Seguimentos , Derivação Gástrica/efeitos adversos , Humanos , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Obesidade Mórbida/diagnóstico , Dor Pós-Operatória/fisiopatologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos , Redução de Peso
11.
Transplant Proc ; 53(10): 2971-2982, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34740448

RESUMO

BACKGROUND: Because of the rising prevalence of obesity, the use of steatotic grafts in orthotopic liver transplantation is becoming increasingly obligatory. The purpose of this study was to determine the relative distribution of microvesicular steatosis (MiS) burden across categories of macrovesicular steatosis (MaS) and the effect of biopsy-sourced MaS and MiS on graft failure, recipient death, and retransplantation. METHODS: We performed a retrospective analysis of 13,889 adults with deceased donor liver transplantations from the Scientific Registry of Transplant Recipients between 2010 and 2018. Multivariable Cox proportional hazards models were run to examine the independent and combined effects of MaS and MiS on major transplantation outcomes. RESULTS: Recipients had a mean age of 56.5 years and a body mass index (BMI) of 29.2 kg/m2; 70% were men, and 74% were non-Hispanic white. Considering the independent effect of MaS, recipients of livers with 30% to 60% MaS had 97% and 129%, 71% and 81%, 39% and 43%, and 40% and 19% increased risks of graft failure and death at 1 month, 3 months, 1 year, and 3 years post-transplantation, respectively. Considering the combined effects of MaS and MiS, 16% to 60% MaS increased the risk of graft failure and recipient death regardless of MiS burden within the first 3 months post-transplantation. These risks were also increased among recipients of livers with 5% to 15% MaS and the additional burden of 16% to 60% MiS. CONCLUSIONS: Our findings suggest that risk threshold of adverse transplantation outcomes owing to steatosis appears to be lower than previously recognized and currently practiced. These risks must be weighed and mitigated against the duress of organ shortage and saving lives.


Assuntos
Fígado Gorduroso , Transplante de Fígado , Adulto , Sobrevivência de Enxerto , Humanos , Fígado , Transplante de Fígado/efeitos adversos , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Doadores de Tecidos
12.
World J Surg ; 34(9): 2109-14, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20526598

RESUMO

BACKGROUND: Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures and its application in the elderly population is poorly reported in the literature so far. The goal of this study was to demonstrate that robot-assisted PD can be safely performed in patients aged 70 years and older. METHODS: Forty-one consecutive robot-assisted PD performed between April 2007 and January 2010 were prospectively entered in a dedicated database. Patients were stratified into two groups: group 1, aged > or =70 years (n = 15, 36.6%); and group 2, aged <70 years (n = 26, 63.4%). The data were reviewed retrospectively. RESULTS: Indications for surgery and patient characteristics were the same in both groups, with the exception of age. There was no statistical difference in terms of operative time (P = 0.376), blood loss (P = 0.989), conversion rate (P = 0.52), mortality (P = 0.36), or overall morbidity rate (P = 0.74). The mean hospital stay was 14.3 days in group 1 and 11.2 days in group 2. This was not statistically significant (P = 0.136). CONCLUSIONS: Robot-assisted pancreaticoduodenectomy can be performed safely in elderly patients with comparable mortality, morbidity, and outcomes compared with a younger population. Age alone should not be a contraindication for robotic pancreatic resection.


Assuntos
Pancreatopatias/cirurgia , Pancreaticoduodenectomia/métodos , Robótica , Adulto , Idoso , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatopatias/epidemiologia , Neoplasias Pancreáticas/epidemiologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/mortalidade , Resultado do Tratamento , Adulto Jovem
13.
Transplant Proc ; 52(1): 276-283, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31889539

RESUMO

BACKGROUND: Obesity is a major public health burden that affects the transplant community because of its key role in fatty liver disease and transplantation outcomes. OBJECTIVES: To evaluate the role of sleeve gastrectomy in treating recurrent and de novo nonalcoholic fatty liver disease (NAFLD) in liver transplant recipients. SETTING: A university hospital. METHODS: We describe 2 obese liver transplant recipients with recurrent and de novo NAFLD who underwent minimally invasive metabolic and bariatric surgery. RESULTS: The surgery was performed successfully, with much of the operative time consumed by enterolysis. There were no intraoperative or postoperative complications. At last follow-up appointment (16 months postoperatively), there was a mean reduction in weight (31.98 kg), body mass index (10.2 kg/m2), glycosylated hemoglobin (1.05%), alanine aminotransferase (38 IU/L), steatosis score (0.34), and fibrosis score (0.05). The mean decrease in 6-month postoperative hepatic fat quantification was 6%. CONCLUSIONS: These cases show that metabolic and bariatric surgery in obese, posttransplant recipients with recurrent and de novo nonalcoholic steatohepatitis lead to improved steatosis and reduced obesity and obesity-associated comorbidities.


Assuntos
Cirurgia Bariátrica/métodos , Gastrectomia/métodos , Transplante de Fígado , Hepatopatia Gordurosa não Alcoólica/cirurgia , Obesidade Mórbida/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Hepatopatia Gordurosa não Alcoólica/complicações , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/cirurgia , Transplantados
14.
Transplantation ; 104(12): e332-e341, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32675743

RESUMO

BACKGROUND: The liver transplant risk score (LTRS) was developed to stratify 90-day mortality of patients referred for liver transplantation (LT). We aimed to validate the LTRS using a new cohort of patients. METHODS: The LTRS stratifies the risk of 90-day mortality of LT recipients based on their age, body mass index, diabetes, model for end-stage liver disease (MELD) score, and need for dialysis. We assessed the performance of the LTRS using a new cohort of patients transplanted in the United States between July 2013 and June 2017. Exclusion criteria were age <18 years, ABO incompatibility, redo or multivisceral transplants, partial grafts, malignancies other than hepatocellular carcinoma and fulminant hepatitis. RESULTS: We found a linear correlation between the number of points of the LTRS and 90-day mortality. Among 18 635 recipients, 90-day mortality was 2.7%, 3.8%, 5.2%, 4.8%, 6.7%, and 9.3% for recipients with 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). The LTRS also stratified 1-year mortality that was 5.5%, 7.7%, 9.9%, 9.3%, 10.8%, and 15.4% for 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). An inverse correlation was found between the LTRS and 4-year survival that was 82%, 79%, 78%, 82%, 78%, and 66% for patients with 0, 1, 2, 3, 4, and ≥5 points (P < 0.001). The LTRS remained an independent predictor after accounting for recipient sex, ethnicity, cause of liver disease, donor age, cold ischemia time, and waiting time. CONCLUSIONS: The LTRS can stratify the short- and long-term outcomes of LT recipients at the time of their evaluations irrespective of their gender, ethnicity, and primary cause of liver disease.


Assuntos
Técnicas de Apoio para a Decisão , Indicadores Básicos de Saúde , Hepatopatias/cirurgia , Transplante de Fígado/mortalidade , Idoso , Feminino , Humanos , Hepatopatias/diagnóstico , Hepatopatias/mortalidade , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
Surg Endosc ; 23(3): 657-8, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-19057961

RESUMO

Laparoscopic gastric banding is in the category of purely restrictive gastric procedures. It offers the advantage of being minimally invasive, adjustable, and reversible. The incidence of band erosion with penetration into stomach is well documented in literature. We present a case of band erosion and simultaneous laparoscopic removal of lap-band through the same incisions used for its placement. The stomach was repaired with laparoscopic suture placement and an omental patch was placed on top of the repair along with fibrin glue and a JP drain. An upper gastrointestinal study demonstrated no extravasation of contrast and the patient was discharged postoperative day 1.


Assuntos
Remoção de Dispositivo , Gastroplastia/instrumentação , Laparoscopia/métodos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/cirurgia , Meios de Contraste , Feminino , Humanos , Pessoa de Meia-Idade
16.
Surg Clin North Am ; 99(2): 259-282, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30846034

RESUMO

Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.


Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Doenças do Ducto Colédoco/diagnóstico , Doenças do Ducto Colédoco/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Colangiografia , Humanos
17.
J Laparoendosc Adv Surg Tech A ; 29(6): 817-819, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30556764

RESUMO

Background: Common bile duct (CBD) injury is a serious complication of laparoscopic and open cholecystectomy. Early identification and minimally invasive repair, when possible, can prevent much of the morbidity associated with this injury. Materials and Methods: A 36-year-old woman referred in the immediate perioperative period for CBD injury at the time of laparoscopic cholecystectomy. We present a case of early robot-assisted repair of a Strasberg class E1 bile duct injury with Roux-en-Y hepaticojejunostomy. Results: Total console time of 4 hours with minimal blood loss and no requirement for transfusion with length of stay of 3 days. No intra- or perioperative complications of the surgery were noted. Conclusion: The degrees of freedom and stability of the robotic platform were instrumental during several key steps, including exposure of the hepatic hilum, positioning of the Roux limb, and suturing of the CBD. Successful minimally invasive repair of this patient's CBD injury minimized the morbidity of the index operation, blood loss, hospital length of stay, and potential legal consequences.


Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Ducto Colédoco/lesões , Jejuno/cirurgia , Fígado/cirurgia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Anastomose em-Y de Roux , Ducto Colédoco/cirurgia , Feminino , Humanos
18.
Surg Clin North Am ; 99(2): 231-244, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30846032

RESUMO

Gallstone disease is a leading cause of morbidity in the United States and usually requires surgical or endoscopic interventions for diagnosis and/or treatment. Although gallstone disease is classically associated with the inflammatory sequela of cholecystitis, gallstones can also contribute to other clinical presentations such as gallstone ileus, Mirizzi syndrome, and Bouveret syndrome. This article explores the common-and uncommon-causes of surgical pathology owing to gallstones with an emphasis on clinical identification, diagnostics, and management options.


Assuntos
Colecistite/diagnóstico , Cálculos Biliares/diagnóstico , Cálculos Biliares/terapia , Íleus/diagnóstico , Síndrome de Mirizzi/diagnóstico , Colecistite/etiologia , Colecistite/terapia , Cálculos Biliares/etiologia , Humanos , Íleus/etiologia , Íleus/terapia , Síndrome de Mirizzi/etiologia , Síndrome de Mirizzi/terapia
19.
Transplantation ; 103(10): e297-e307, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31283673

RESUMO

BACKGROUND: There are no instruments that can identify patients at an increased risk of poor outcomes after liver transplantation (LT) based only on their preoperative characteristics. The primary aim of this study was to develop such a scoring system. Secondary outcomes were to assess the discriminative performance of the predictive model for 90-day mortality, 1-year mortality, and 5-year patient survival. METHODS: The study population was represented by 30 458 adults who underwent LT in the United States between January 2002 and June 2013. Machine learning techniques identified recipient age, Model for End-Stage Liver Disease score, body mass index, diabetes, and dialysis before LT as the strongest predictors for 90-day postoperative mortality. A weighted scoring system (minimum of 0 to a maximum of 6 points) was subsequently developed. RESULTS: Recipients with 0, 1, 2, 3, 4, 5, and 6 points had an observed 90-day mortality of 6.0%, 8.7%, 10.4%, 11.9%, 15.7%, 16.0%, and 19.7%, respectively (P ≤ 0.001). One-year mortality was 9.8%, 13.4%, 15.8%, 17.2%, 23.0%, 25.2%, and 35.8% (P ≤ 0.001) and five-year survival was 78%, 73%, 72%, 71%, 65%, 59%, and 48%, respectively (P = 0.001). The mean 90-day mortality for the cohort was 9%. The area under the curve of the model was 0.952 for the discrimination of patients with 90-day mortality risk ≥10%. CONCLUSIONS: Short- and long-term outcomes of patients undergoing cadaveric LT can be predicted using a scoring system based on recipients' preoperative characteristics. This tool could assist clinicians and researchers in identifying patients at increased risks of postoperative death.


Assuntos
Tomada de Decisão Clínica/métodos , Doença Hepática Terminal/mortalidade , Transplante de Fígado/estatística & dados numéricos , Modelos Estatísticos , Seleção de Pacientes , Adulto , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/cirurgia , Estudos de Viabilidade , Feminino , Sobrevivência de Enxerto , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Redes Neurais de Computação , Período Perioperatório , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Índice de Gravidade de Doença , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia
20.
World J Transplant ; 8(5): 167-177, 2018 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-30211025

RESUMO

AIM: To compare trends in donor/recipient characteristics and outcomes using four period cohorts of liver transplant recipients from 1990 to 2009. METHODS: Seventy thousand three hundred and seventy-seven adult first-time recipients of whole-organ deceased-donor liver grafts from 1990 to 2009 were followed up until September 2013. Four periods based on transplantation dates were considered to account for developments in transplantation. Descriptive statistics were used to describe donor/recipient characteristics and transplant outcomes. Statistical comparisons between periods were performed using χ2/Fischer's exact test (categorical variables) and t-tests/Mann-Whitney U test (continuous variables). Univariate descriptive statistics/survival data were generated using Kaplan-Meier curves. Cox Proportional Hazards models were used for regression analyses of patient and graft survival. RESULTS: Mean age (years), body mass index (kg/m2), and the proportion of males were, respectively, 39.1 (± 17.4), 25.9 (± 5.7) and 60.3 for donors, and 51.3 (± 10.5), 27.7 (± 5.6), and 64.4 for recipients. Donor and transplantation rates differed between racial/ethnic groups. Median (Q1-Q3) cold and warm ischemia, waitlist, and hospital stay times were 8 (6.0-10.0) h and 45 (35-59) min, 93 (21-278) d, and 12 (8-20) d. Total functional assistance was required by 8% of recipients at wait-listing and 13.4% at transplantation. Overall survival at 1, 3, 5, 10, 15, and 20 years was 87.3%, 79.4%, 73.6%, 59.8%, 46.7%, and 35.9%, respectively. The 2005-2009 cohort had better patient and graft survival than the 1990-1994 cohort overall [HR 0.67 (0.62-0.72) and 0.66 (0.62-0.71)] and at five years [HR 0.73 (0.66-0.80) and 0.71 (0.65-0.77)]. CONCLUSION: Despite changes in donor quality, recipient characteristics, and declining functional status among transplant recipients, overall patient survival is superior and post-transplant outcomes continue to improve.

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