Major coronary artery calcifications as predictors of postoperative complications in Ivor Lewis esophagectomies: a five-year retrospective analysis.

BACKGROUND: This study aimed to determine the relationship between preoperative arterial calcifications and postoperative outcomes after Ivor Lewis esophagectomies. METHODS: This was a single-center retrospective review of Ivor Lewis esophagectomies from 2013 to 2018. Preoperative CT imaging was reviewed, and arterial calcifications were graded (absent, minor, or major) in various locations. The primary outcome included major complications (defined by the Clavien-Dindo classification III-V) and the secondary outcomes were 90-day reoperations, readmissions, and mortality. Significant associations (p < 0.05) between calcifications and outcomes on univariable analysis were evaluated using a multivariable logistic regression model (odds ratios, OR; 95% confidence intervals, CI). RESULTS: One hundred patients underwent esophagectomies from 2013 to 2018 (79% male, 90% White, median age 68 years), and 85% were classified as ASA III. Ninety-four patients had accessible preoperative imaging. Arterial calcifications in specific areas were observed: 82 in coronary arteries (major in 33 patients), 54 in the aortic valve, 78 in supra-aortic arteries, 79 in the thoracic aorta, 82 in the abdominal aorta, and 71 in common iliac. Furthermore, 60 patients exhibited celiac axis calcifications, with 40 patients classified as major. Twenty-five patients experienced major complications. Anastomotic leak occurred in two patients, and graft necrosis occurred in one patient. Ninety-day readmission was 10%, reoperation was 12%, and mortality was 4%. On univariable analysis, major coronary artery calcifications were significantly associated with major complications (OR 4.04; 95% CI 1.34-12.16; p = 0.02) and 90-day readmissions (OR 8.20; 95% CI 1.01-68.47; p = 0.04). However, no significant associations were identified between 90-day reoperations or mortality and arterial calcifications. CONCLUSIONS: This study demonstrated that preoperative coronary calcifications increase the risk of postoperative complications, as this may be a surrogate of overall health. Nonetheless, the correlation between splanchnic calcifications and postoperative outcomes needs further exploration.

Post-COVID-19 Secondary Sclerosing Cholangitis: A Rare but Severe Condition with no Treatment Besides Liver Transplantation.

BACKGROUND The incidence of abnormal liver function, mainly aspartate aminotransferase and alanine aminotransferase elevations, in patients with COVID-19 is not uncommon, but persistent liver damage after the acute phase of the disease is uncommon and has been recently recognized as a new entity named post-COVID-19 cholangiopathy. CASE REPORT We report a clinical case with progressive cholestatic disease following severe COVID-19. AST and ALT peaked at hospital admission and while its serum concentration went down, bilirubin and cholestatic liver enzymes started to increase, reaching the maximum at day 122. Magnetic resonance imaging (MRI) revealed a diffuse irregularity of intra- and extrahepatic bile ducts, with multiple focal strictures alternating with mild focal dilations of the biliary tree, suggesting a sclerosing cholangiopathy. A transjugular liver biopsy showed a prominent bile ductular reaction, cholangiocyte injury, inflammatory infiltrate rich in neutrophils, biliary infarctions, marked cholestasis, and portal fibrosis, suggesting the diagnosis of post-Covid-19 secondary sclerosing cholangitis. The patient evolved with a continuous deterioration of liver functions, but liver transplantation was not performed due to his poor clinical condition. CONCLUSIONS Post-COVID-19 SSC is a severe disease with no effective clinical treatment and has liver transplantation as the only treatment for a few selected patients.

Association between Metabolic Disorders and Cholangiocarcinoma: Impact of a Postulated Risk Factor with Rising Incidence.

Introduction and objectives: The incidence of cholangiocarcinoma (CCA) has been increasing globally. Although a concomitant increase in the incidence of metabolic disorders might suggest a causal relationship, the data are scarce. We aimed to describe the prevalence of metabolic disorders in patients with CCA and report the clinical features and outcomes. Patients and Methods: Retrospective study including patients with CCA. Patients were divided into: (1) past history of diabetes or/and overweight/obesity ("metabolic disorder group") and (2) without any of these features ("non-metabolic-disorder group"). A Cox regression model was used to determine the prognostic factors. Results: 122 patients were included. In total, 36 (29.5%) had overweight/obesity, 24 (19.7%) had diabetes, and 8 (6.6%) had both. A total of 29 (23.8%) patients had resectable disease and received upfront surgery. A total of 104 (85.2%) received chemotherapy for advanced/recurrent disease. The overall survival of the cohort was 14.3 months (95% CI: 10.1−17.3). ECOG-PS 0 (p < 0.0001), resectable disease (p = 0.018) and absence of vascular invasion (p = 0.048) were independently associated with better prognosis. The "metabolic disorder group" (n = 52) had a median survival of 15.5 months (95% CI 10.9−33.9) vs. 11.5 months (95% CI 8.4−16.5) in the "non-metabolic-disorder group" (n = 70) (HR: 1.10; 95% CI 0.62−1.94). Patients with resectable disease in the "metabolic group" had longer survival than patients in the "non-metabolic group" (43.4 months (95% CI 33.9-NR) vs. 21.8 months (95% CI 8.6−26.9); HR = 0.12, 95% CI 0.03−0.59). Conclusion: Metabolic disorders are frequent among CCA patients. Underlying metabolic comorbidities may be associated with prognosis in resectable CCA. There is a need to explore the mechanism that drives CCA carcinogenesis in a metabolic background.

Liver Surgery: Important Considerations for Pre- and Postoperative Imaging.

Liver surgery may be a curative treatment option not only for primary liver neoplasms but also for liver metastases in selected patients. The number of liver surgeries performed worldwide has increased, but surgical morbidity associated with these surgeries remains significant. Therefore, radiologists need to understand the terminology, surgical techniques, resectability and unresectability criteria, and possible postoperative complications as these are part of the decision-making process. Because vascular and biliary variations are common, an adequate preoperative anatomic evaluation determines the best surgical technique, helps identify patients in whom additional surgical steps will be required, and reduces the risk of inadvertent injury. The surgeon must ensure that the future liver remnant is sufficient to maintain adequate function, aided by the radiologist who can provide valuable information such as the presence of steatosis, biliary dilatation, signs of cirrhosis, and portal hypertension, in addition to the volume of the future liver remnant. Postoperative complications must also be understood and evaluated. The most common postoperative complications are vascular (bleeding, thrombosis, and ischemia), biliary (fistulas, bilomas, and strictures), infectious (incisional or deep), those related to liver failure, and even tumor recurrence. An invited commentary by Winslow is available online. Online supplemental material is available for this article. ©RSNA, 2022.