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1.
Br J Surg ; 110(10): 1331-1347, 2023 09 06.
Artículo en Inglés | MEDLINE | ID: mdl-37572099

RESUMEN

BACKGROUND: Posthepatectomy liver failure (PHLF) contributes significantly to morbidity and mortality after liver surgery. Standardized assessment of preoperative liver function is crucial to identify patients at risk. These European consensus guidelines provide guidance for preoperative patient assessment. METHODS: A modified Delphi approach was used to achieve consensus. The expert panel consisted of hepatobiliary surgeons, radiologists, nuclear medicine specialists, and hepatologists. The guideline process was supervised by a methodologist and reviewed by a patient representative. A systematic literature search was performed in PubMed/MEDLINE, the Cochrane library, and the WHO International Clinical Trials Registry. Evidence assessment and statement development followed Scottish Intercollegiate Guidelines Network methodology. RESULTS: Based on 271 publications covering 4 key areas, 21 statements (at least 85 per cent agreement) were produced (median level of evidence 2- to 2+). Only a few systematic reviews (2++) and one RCT (1+) were identified. Preoperative liver function assessment should be considered before complex resections, and in patients with suspected or known underlying liver disease, or chemotherapy-associated or drug-induced liver injury. Clinical assessment and blood-based scores reflecting liver function or portal hypertension (for example albumin/bilirubin, platelet count) aid in identifying risk of PHLF. Volumetry of the future liver remnant represents the foundation for assessment, and can be combined with indocyanine green clearance or LiMAx® according to local expertise and availability. Functional MRI and liver scintigraphy are alternatives, combining FLR volume and function in one examination. CONCLUSION: These guidelines reflect established methods to assess preoperative liver function and PHLF risk, and have uncovered evidence gaps of interest for future research.


Liver surgery is an effective treatment for liver tumours. Liver failure is a major problem in patients with a poor liver quality or having large operations. The treatment options for liver failure are limited, with high death rates. To estimate patient risk, assessing liver function before surgery is important. Many methods exist for this purpose, including functional, blood, and imaging tests. This guideline summarizes the available literature and expert opinions, and aids clinicians in planning safe liver surgery.


Asunto(s)
Fallo Hepático , Neoplasias Hepáticas , Humanos , Hepatectomía/métodos , Neoplasias Hepáticas/cirugía , Hígado , Verde de Indocianina , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología
2.
Ann Surg ; 274(5): 713-720, 2021 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-34334656

RESUMEN

OBJECTIVE: The aim of this study was to pool data from randomized controlled trials (RCT) limited to resectable pancreatic ductal adenocarcinoma (PDAC) to determine whether a neoadjuvant therapy impacts on disease-free survival (DFS) and surgical outcome. SUMMARY BACKGROUND DATA: Few underpowered studies have suggested benefits from neoadjuvant chemo (± radiation) for strictly resectable PDAC without offering conclusive recommendations. METHODS: Three RCTs were identified comparing neoadjuvant chemo (± radio) therapy vs. upfront surgery followed by adjuvant therapy in all cases. Data were pooled targeting DFS as primary endpoint, whereas overall survival (OS), postoperative morbidity, and mortality were investigated as secondary endpoints. Survival endpoints DFS and OS were compared using Cox proportional hazards regression with study-specific baseline hazards. RESULTS: A total of 130 patients were randomized (56 in the neoadjuvant and 74 in the control group). DFS was significantly longer in the neoadjuvant treatment group compared to surgery only [hazard ratio (HR) 0.6, 95% confidence interval (CI) 0.4-0.9] (P = 0.01). Furthermore, DFS for the subgroup of R0 resections was similarly longer in the neoadjuvant treated group (HR 0.6, 95% CI 0.35-0.9, P = 0.045). Although postoperative complications (Comprehensive Complication Index, CCI®) occurred less frequently (P = 0.008), patients after neoadjuvant therapy experienced a higher toxicity, but without negative impact on oncological or surgical outcome parameters. CONCLUSION: Neoadjuvant therapy can be offered as an acceptable standard of care for patients with purely resectable PDAC. Future research with the advances of precision oncology should now focus on the definition of the optimal regimen.


Asunto(s)
Pancreatectomía/métodos , Neoplasias Pancreáticas/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto , Terapia Combinada , Supervivencia sin Enfermedad , Humanos , Terapia Neoadyuvante
3.
Ann Surg ; 272(5): 715-722, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32833764

RESUMEN

OBJECTIVE: To test the degree of agreement in selecting therapeutic options for patients suffering from colorectal liver metastasis (CRLM) among surgical experts around the globe. SUMMARY/BACKGROUND: Only few areas in medicine have seen so many novel therapeutic options over the past decades as for liver tumors. Significant variations may therefore exist regarding the choices of treatment, even among experts, which may confuse both the medical community and patients. METHODS: Ten cases of CRLM with different levels of complexity were presented to 43 expert liver surgeons from 23 countries and 4 continents. Experts were defined as experienced surgeons with academic contributions to the field of liver tumors. Experts provided information on their medical education and current practice in liver surgery and transplantation. Using an online platform, they chose their strategy in treating each case from defined multiple choices with added comments. Inter-rater agreement among experts and cases was calculated using free-marginal multirater kappa methodology. A similar, but adjusted survey was presented to 60 general surgeons from Asia, Europe, and North America to test their attitude in treating or referring complex patients to expert centers. RESULTS: Thirty-eight (88%) experts completed the evaluation. Most of them are in leading positions (92%) with a median clinical experience of 25 years. Agreement on therapeutic strategies among them was none to minimal in more than half of the cases with kappa varying from 0.00 to 0.39. Many general surgeons may not refer the complex cases to expert centers, including in Europe, where they also engage in complex liver surgeries. CONCLUSIONS: Considerable inconsistencies of decision-making exist among expert surgeons when choosing a therapeutic strategy for CRLM. This might confuse both patients and referring physicians and indicate that an international high-level consensus statements and widely accepted guidelines are needed.


Asunto(s)
Neoplasias Colorrectales/patología , Toma de Decisiones , Hepatectomía/métodos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Consenso , Femenino , Humanos , Masculino , Persona de Mediana Edad
4.
Ann Surg ; 270(2): 211-218, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-30829701

RESUMEN

OBJECTIVE: To use the concept of benchmarking to establish robust and standardized outcome references after pancreatico-duodenectomy (PD). BACKGROUND: Best achievable results after PD are unknown. Consequently, outcome comparisons among different cohorts, centers or with novel surgical techniques remain speculative. METHODS: This multicenter study analyzes consecutive patients (2012-2015) undergoing PD in 23 international expert centers in pancreas surgery. Outcomes in patients without significant comorbidities and major vascular resection (benchmark cases) were analyzed to establish 20 outcome benchmarks for PD. These benchmarks were tested in a cohort with a poorer preoperative physical status (ASA class ≥3) and a cohort treated by minimally invasive approaches. RESULTS: Two thousand three hundred seventy-five (38%) low-risk cases out of a total of 6186 PDs were analyzed, disclosing low in-hospital mortality (≤1.6%) but high morbidity, with a 73% benchmark morbidity rate cumulated within 6 months following surgery. Benchmark cutoffs for pancreatic fistulas (B-C), severe complications (≥ grade 3), and failure-to-rescue rate were 19%, 30%, and 9%, respectively. The ASA ≥3 cohort showed comparable morbidity but a higher in hospital-mortality (3% vs 1.6%) and failure-to-rescue rate (16% vs 9%) than the benchmarks. The proportion of benchmark cases performed varied greatly across centers and continents for both open (9%-93%) and minimally invasive (11%-62%) PD. Centers operating mostly on complex PD cases disclosed better results than those with a majority of low-risk cases. CONCLUSION: The proposed outcome benchmarks for PD, established in a large-scale international patient cohort and tested in 2 different cohorts, may allow for meaningful comparisons between different patient cohorts, centers, countries, and surgical techniques.


Asunto(s)
Benchmarking , Enfermedades Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Complicaciones Posoperatorias/epidemiología , Asia/epidemiología , Europa (Continente)/epidemiología , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiología
6.
Gastroenterology ; 148(2): 307-23, 2015 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-25224524

RESUMEN

Liver transplantation (LT) is a highly successful treatment for many patients with nonmalignant and malignant liver diseases. However, there is a worldwide shortage of available organs; many patients deteriorate or die while on waiting lists. We review the important clinical challenges to LT and the best use of the scarce organs. We focus on changes in indications for LT and discuss scoring systems to best match donors with recipients and optimize outcomes, particularly for the sickest patients. We also cover controversial guidelines for the use of LT in patients with hepatocellular carcinoma and cholangiocarcinoma. Strategies to increase the number of functional donor organs involve techniques to perfuse the organs before implantation. Partial LT (living donor and split liver transplantation) techniques might help to overcome organ shortages, and we discuss small-for-size syndrome. Many new developments could increase the success of this procedure, which is already one of the major achievements in medicine during the second part of the 20th century.


Asunto(s)
Trasplante de Hígado/métodos , Carcinoma Hepatocelular/cirugía , Colangiocarcinoma/cirugía , Hepatitis C/cirugía , Humanos , Hepatopatías Alcohólicas/cirugía , Neoplasias Hepáticas/cirugía , Regeneración Hepática , Enfermedad del Hígado Graso no Alcohólico/cirugía , Perfusión
7.
Dig Surg ; 33(4): 351-9, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27216160

RESUMEN

With the advent of novel and somewhat effective chemotherapy against pancreas cancer, several groups developed a new interest on locally advanced pancreatic cancer (LAPC). Unresectable tumors constitute up to 80% of pancreatic cancer (PC) at the time of diagnosis and are associated with a 5-year overall survival of less than 5%. To control those tumors locally, with perhaps improved patients survival, significant advances were made over the last 2 decades in the development of ablation methods including cryoablation, radiofrequency ablation, microwave ablation, high intensity focused ultrasound and irreversible electroporation (IRE). Many suggested a call for caution for possible severe or lethal complications in using such techniques on the pancreas. Most fears were on the heating or freezing of the pancreas, while non-thermal ablation (IRE) could offer safer approaches. The multimodal therapies along with high-resolution imaging guidance have created some enthusiasm toward ablation for LAPC. The impact of ablation techniques on primarily non-resectable PC remains, however, unclear.


Asunto(s)
Ablación por Catéter/métodos , Criocirugía , Neoplasias Pancreáticas/terapia , Quimioradioterapia Adyuvante , Electroporación , Humanos , Microondas/uso terapéutico
8.
Ann Surg ; 262(5): 764-70; discussion 770-1, 2015 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-26583664

RESUMEN

BACKGROUND: Exposure of donor liver grafts to prolonged periods of warm ischemia before procurement causes injuries including intrahepatic cholangiopathy, which may lead to graft loss. Due to unavoidable prolonged ischemic time before procurement in donation after cardiac death (DCD) donation in 1 participating center, each liver graft of this center was pretreated with the new machine perfusion "Hypothermic Oxygenated PErfusion" (HOPE) in an attempt to improve graft quality before implantation. METHODS: HOPE-treated DCD livers (n = 25) were matched and compared with normally preserved (static cold preservation) DCD liver grafts (n = 50) from 2 well-established European programs. Criteria for matching included duration of warm ischemia and key confounders summarized in the balance of risk score. In a second step, perfused and unperfused DCD livers were compared with liver grafts from standard brain dead donors (n = 50), also matched to the balance of risk score, serving as baseline controls. RESULTS: HOPE treatment of DCD livers significantly decreased graft injury compared with matched cold-stored DCD livers regarding peak alanine-aminotransferase (1239 vs 2065 U/L, P = 0.02), intrahepatic cholangiopathy (0% vs 22%, P = 0.015), biliary complications (20% vs 46%, P = 0.042), and 1-year graft survival (90% vs 69%, P = 0.035). No graft failure due to intrahepatic cholangiopathy or nonfunction occurred in HOPE-treated livers, whereas 18% of unperfused DCD livers needed retransplantation. In addition, HOPE-perfused DCD livers achieved similar results as control donation after brain death livers in all investigated endpoints. CONCLUSIONS: HOPE seems to offer important benefits in preserving higher-risk DCD liver grafts.


Asunto(s)
Enfermedad Hepática en Estado Terminal/cirugía , Trasplante de Hígado/métodos , Preservación de Órganos/métodos , Perfusión/métodos , Donantes de Tejidos , Obtención de Tejidos y Órganos/métodos , Criopreservación , Muerte , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo
9.
Curr Opin Organ Transplant ; 19(3): 245-52, 2014 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-24811436

RESUMEN

PURPOSE OF REVIEW: Cholangiocarcinoma is a rare tumour with dismal prognosis. Only radical resection offers a chance for cure with reported survivals ranging from 25 to 45% at 5 years. Considering the low rate of resectability and lack of efficacy of other treatments, liver transplantation has emerged as a reasonable approach to cure selective patients with unresectable diseases. The use of liver transplantation, however, is associated with the inherent risk of early tumour recurrence due to the need for immunosuppression and the poor survival rate. This review will focus on the role of liver transplantation in treating patients with cholangiocellular cancer. RECENT FINDINGS: The indication of liver transplantation for cholangiocarcinoma has evolved over time moving from an absolute to a relative contraindication until eventually becoming the best indication for a small group of patients presenting with unresectable perihilar cholangiocarcinoma, when associated with a neoadjuvant chemoradiotherapy. In contrast, the indication of liver transplantation for intrahepatic cholangiocarcinoma is far from being established and should be offered only under protocol, mainly for small tumours in the setting of cirrhosis. SUMMARY: The poor outcome of cholangiocarcinoma, irrespective of the therapy, justifies the search for novel approaches. Only selective patients with perihilar cholangiocarcinoma subjected to a neoadjuvant protocol may qualify for liver transplantation.


Asunto(s)
Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos/cirugía , Colangiocarcinoma/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado , Neoplasias de los Conductos Biliares/patología , Conductos Biliares Intrahepáticos/patología , Colangiocarcinoma/patología , Humanos , Neoplasias Hepáticas/patología , Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Pronóstico
10.
Curr Opin Gastroenterol ; 29(3): 293-8, 2013 May.
Artículo en Inglés | MEDLINE | ID: mdl-23563982

RESUMEN

PURPOSE OF REVIEW: The purpose of this review is to evaluate the most current strategies of surgical treatment for cholangiocarcinoma including liver resection and transplantation. RECENT FINDINGS: More aggressive surgical approaches have emerged over the past decade to treat patients previously considered to have unresectable lesions, which include combined hepatectomy with vascular resection, liver mass manipulation, oncological nontouch technique and liver transplantation. SUMMARY: Cholangiocarcinoma can occur anywhere along the biliary system. Its detection rate, and consequently its incidence, has risen possibly because of improvements in diagnostic imaging. Cholangiocarcinomas are presently understood within three distinct categories: intrahepatic, perihilar and distal tumors. The perihilar type is the most common, followed by the distal and intrahepatic types. This division has therapeutic relevance because the type of surgery depends on the anatomical location and extension of the tumor. This review will primarily focus on those circumstances in which a hepatectomy is required, which provides the greatest chance of cure. In this setting, liver transplantation for perihilar cholangiocarcinoma has resurged as an excellent option for a selective group of patients, when associated with a neoadjuvant chemoradiation protocol. Despite more aggressive surgical approaches, many cases remain unresectable with a poor prognosis.


Asunto(s)
Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos , Colangiocarcinoma/cirugía , Hepatectomía/métodos , Trasplante de Hígado/métodos , Humanos , Pronóstico
11.
World J Surg ; 37(8): 1782-8, 2013 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-23674251

RESUMEN

Lymph node staging is one of the most important factors in determining the prognosis after resection of pancreatic ductal adenocarcinoma. Despite ongoing efforts to further refine lymph node staging, the debate on the extent of lymphadenectomy during pancreaticoduodenectomy is still open. The purpose of this review was to summarize the evidence about performing standard lymphadenectomy during curative resection of pancreatic cancer. All four prospective randomized controlled trials published concluded that extended lymphadenectomy does not contribute to better oncologic outcome for patients with adenocarcinoma of the pancreatic head. Indeed, one major drawback of extended lymphadenectomy is the higher risk of persistent postoperative diarrhea. No prospective randomized studies could be found on the role of extended lymphadenectomy in patients with adenocarcinoma of the corpus and tail. Based on current evidence there is no indication that extended lymphadenectomy should be performed routinely during resection of pancreatic cancer.


Asunto(s)
Escisión del Ganglio Linfático/métodos , Neoplasias Pancreáticas/cirugía , Ensayos Clínicos como Asunto , Humanos , Metástasis Linfática , Recurrencia Local de Neoplasia , Neoplasias Pancreáticas/patología
12.
Hepatology ; 53(4): 1363-71, 2011 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-21480336

RESUMEN

Perihilar cholangiocarcinoma is one of the most challenging diseases with poor overall survival. The major problem for anyone trying to convincingly compare studies among centers or over time is the lack of a reliable staging system. The most commonly used system is the Bismuth-Corlette classification of bile duct involvement, which, however, does not include crucial information such as vascular encasement and distant metastases. Other systems are rarely used because they do not provide several key pieces of information guiding therapy. Therefore, we have designed a new system reporting the size of the tumor, the extent of the disease in the biliary system, the involvement of the hepatic artery and portal vein, the involvement of lymph nodes, distant metastases, and the volume of the putative remnant liver after resection. The aim of this system is the standardization of the reporting of perihilar cholangiocarcinoma so that relevant information regarding resectability, indications for liver transplantation, and prognosis can be provided. With this tool, we have created a new registry enabling every center to prospectively enter data on their patients with hilar cholangiocarcinoma (www.cholangioca.org). The availability of such standardized and multicenter data will enable us to identify the critical criteria guiding therapy.


Asunto(s)
Neoplasias de los Conductos Biliares/clasificación , Neoplasias de los Conductos Biliares/patología , Conductos Biliares Intrahepáticos/patología , Colangiocarcinoma/clasificación , Colangiocarcinoma/patología , Estadificación de Neoplasias/métodos , Humanos , Tumor de Klatskin/patología , Sistema de Registros
13.
Ann Surg ; 254(5): 716-22; discussion 722-3, 2011 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-22042467

RESUMEN

OBJECTIVE: To assess the incidence and impact of biliary complications in recipients transplanted from donors after cardiac death (DCD) at one single large institution. BACKGROUND: Shortage of available cadaveric organs is a significant limiting factor in liver transplantation (LT). The use of DCD offers the potential to increase the organ pool. However, early results with DCD liver grafts were associated with a greater incidence of ischemic cholangiopathy (IC), leading to several programs to abandoning this source of organs. METHODS: A retrospective analysis of a prospective database from April 2001 to 2010 focused on 167 consecutive DCD-LT. Each DCD transplant was matched with 2 brain death donors (DBD) grafts (n = 333) according to the period of transplantation. Primary outcome measures were biliary complications including the severity of complications, graft survival and patient survival. Minimum follow-up was 3 months. RESULTS: Anastomotic stricture was the most common biliary complication (DCD = 30, 19% vs. DBD = 41, 13%). Most were treated endocoscopically (grade IIIa = 72%), whereas hepatico-jejunostomy (grade IIIb) was performed in 22%. Primary IC occurred in 4 (2.5%) recipients from the DCD group and was absent in the DBD group (P = 0.005). However, none of these patients required retransplantation. Patient and graft survival at 1, 3, and 5 years were similar between DCD and DBD groups (P = 0.106, P = 0.138, P = 0.113, respectively). CONCLUSIONS: The encouraging results with DCD-LT are probably due to the selection of DCD grafts and clear definition of warm ischemia.


Asunto(s)
Enfermedades de las Vías Biliares/epidemiología , Trasplante de Hígado , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Niño , Preescolar , Muerte , Femenino , Supervivencia de Injerto , Humanos , Lactante , Tiempo de Internación , Masculino , Persona de Mediana Edad , Donantes de Tejidos , Adulto Joven
14.
Liver Int ; 31(3): 313-21, 2011 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-21281431

RESUMEN

BACKGROUND: New chemotherapy regimens are increasingly used in metastatic colorectal cancer to the liver before surgery. Some clinical observations have suggested that chemotherapy may affect liver regeneration. AIMS: The aim of this study was to evaluate liver damage and liver regeneration after chemotherapy treatment in a model of partial hepatectomy. METHODS: C57BL/6 mice were repeatedly treated with intraperitoneal injections of either saline or different chemotherapy regimens including the drugs 5-fluorouracyl (5-FU), irinotecan, oxaliplatin, gemcitabine and combined treatments with 5-FU/irinotecan, 5-FU/oxaliplatin. A 70% partial hepatectomy was performed 1 week after the last injection. Ki-67 and PCNA immunohistochemistry were performed to assess liver regeneration, serum liver enzymes and histology analysis to evaluate injury. RESULTS: A variety of chemotherapeutic agents used at maximum tolerated doses compatible with survival affected body weight and blood cell levels. However, these regimens did not affect liver injury before and after hepatectomy nor did they impair liver regeneration. Liver histology showed no steatosis, fibrosis or inflammation before hepatectomy. We therefore tested whether chemotherapy in presence of diet-induced steatosis may trigger injury. Even under these conditions, we did not observe histological signs of inflammation or sinusoidal injury. CONCLUSIONS: Liver injury and liver regeneration are not impaired after neoadjuvant chemotherapy with 5-FU, irinotecan, oxaliplatin and gemcitabine in non-tumoural liver parenchyma. In addition, combined treatments disclose no adverse effects on liver regeneration. Chemotherapy alone induces no histological alterations even in the presence of steatosis.


Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/toxicidad , Enfermedad Hepática Inducida por Sustancias y Drogas/etiología , Modelos Animales de Enfermedad , Hepatectomía , Regeneración Hepática/efectos de los fármacos , Hígado/efectos de los fármacos , Alanina Transaminasa/sangre , Animales , Aspartato Aminotransferasas/sangre , Enfermedad Hepática Inducida por Sustancias y Drogas/metabolismo , Enfermedad Hepática Inducida por Sustancias y Drogas/patología , Hígado Graso/complicaciones , Hígado Graso/patología , Antígeno Ki-67/metabolismo , Hígado/metabolismo , Hígado/patología , Regeneración Hepática/fisiología , Ratones , Ratones Endogámicos C57BL , Antígeno Nuclear de Célula en Proliferación/metabolismo
15.
Ann Surg ; 252(5): 726-34, 2010 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-21037427

RESUMEN

OBJECTIVE: To develop and validate a simple score to predict postoperative complications by severity after liver resection, using readily available preoperative risk factors. BACKGROUND: Although liver surgery has enjoyed major development with dramatic reduction in mortality rates, the incidence of serious yet nonlethal complications remains high. No scoring system is currently available to identify those patients at higher risk for a complicated course. METHODS: Complications were prospectively assessed in 615 consecutive noncirrhotic patients undergoing liver resection at the same institution. In randomly selected 60% of the population, multivariate-logistic-regression analysis was used to develop a score to predict severe complications defined as complications grades III, IV, and mortality (grade V) (Clavien-Dindo classification). The score was validated by calibration within the remaining 40% of the patients. RESULTS: Grades III to V complications occurred in 159 (26%) of the 615 patients after liver resection, 90 (15%) were grade III, 48 (8%) grade IV, and 21 (3%) grade V. Four preoperative parameters were identified as independent predictors including American Society of Anesthesiologists category, transaminases levels (aspartate aminotransferase), extent of liver resection (>3 vs <3 segments), and the need for an additional hepaticojejunostomy or colon resection. A prediction score was calculated on the basis of 60% of the population (369 patients) using the 4 independent predictors ranging from 0 to 10 points. The risk to develop serious postoperative complications was 16% in "low risk" patients (0-2 points), 37% in "intermediate risk" patients (3-5 points) and 60% in "high risk" patients (6-10 points). The predicted mean for absolute risk for grades III to V complications was 27% in the validation population including 40% of the patients (n = 246), whereas the observed risk was 24%. Predicted and observed risks were similar throughout the different risk categories (P = 0.8). The score was significantly associated with hospital and intensive care unit stays. Costs of the entire procedure doubled among the 3 risk groups. CONCLUSIONS: This novel and simple score accurately predicts postoperative complications and cost in patients undergoing liver resection. This score allows early identification of patients at risk and may impact not only decision making for surgical intervention but also quality assessment and reimbursement.


Asunto(s)
Hepatectomía , Complicaciones Posoperatorias , Medición de Riesgo , Anciano , Análisis de Varianza , Costos y Análisis de Costo , Femenino , Hepatectomía/economía , Hepatectomía/mortalidad , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/mortalidad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Suiza/epidemiología
16.
Ann Surg ; 252(5): 813-22, 2010 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-21037437

RESUMEN

OBJECTIVES: To evaluate the effects of pentoxifylline (PTX) on liver regeneration in patients undergoing major liver resection. BACKGROUND: Recent experimental data suggest that PTX, a tumor necrosis factor (TNF) α inhibitor, enhances liver regeneration and reduces ischemic injury through activation of the interleukin-6 (IL-6) signaling pathway. However, the clinical impact of PTX in patients undergoing major liver surgery is unknown. METHODS: One hundred one consecutive noncirrhotic patients undergoing major liver surgery with inflow occlusion were included in a double-blinded, randomized, controlled trial (RCT) at a single tertiary care center (2006-2009). Fifty-one patients received intravenous administration of PTX starting 12 hours before and ending 72 hours after surgery, whereas 50 control patients received a placebo infusion. Primary endpoint was liver regeneration as assessed by three-dimensional volumetry based on magnetic resonance (MR) tomography at postoperative day 8 compared with preoperative images. Secondary endpoints were transaminases, cytokines, and postoperative complications. RESULTS: Both groups were comparable regarding demographics, risk score, preoperative laboratory tests, and type and extent of liver resection. Treatment with PTX resulted in significantly better volume regeneration for small remnant livers [remnant liver to body weight (RLBW) ratio ≤ 1.2%], whereas no beneficial effect was observed for RLBW ratio of more than 1.2%. There was a 3.6-fold stronger induction of IL-6 mRNA for the PTX group (P < 0.001). Postoperative alanine aminotransferase (AST) levels were significantly decreased for the PTX group on the second postoperative day (442 vs 585 U/L, P = 0.025). No significant benefit could be identified regarding the number and severity of postoperative complications and median ICU (1 vs 1 day) and hospital stay (10 vs 10 days). However, the PTX group had significantly more drug-related adverse events (23 vs 8, P = 0.007). CONCLUSIONS: This is the first RCT evaluating the effects of PTX on liver regeneration after major liver resection. The study demonstrates beneficial effects of PTX on regeneration of small remnant livers (RLBW ratio ≤ 1.2%) that seems to be mediated by IL-6.


Asunto(s)
Hepatopatías/cirugía , Regeneración Hepática/efectos de los fármacos , Pentoxifilina/farmacología , Inhibidores de Fosfodiesterasa/farmacología , Biopsia , Método Doble Ciego , Femenino , Hepatectomía , Humanos , Infusiones Intravenosas , Interleucina-6/metabolismo , Pruebas de Función Hepática , Masculino , Persona de Mediana Edad , Pentoxifilina/administración & dosificación , Inhibidores de Fosfodiesterasa/administración & dosificación , Complicaciones Posoperatorias , Factores de Riesgo , Factor de Necrosis Tumoral alfa/metabolismo
17.
J Gastrointest Surg ; 11(8): 970-6; discussion 976, 2007 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-17623266

RESUMEN

Survival after resection of colorectal liver metastases has traditionally been associated with clinicopathologic factors. We sought to investigate whether echogenicity of colorectal liver metastasis as assessed by intraoperative ultrasound (IOUS) was a prognostic factor after hepatic resection. Prospective data on tumor IOUS appearance were collected in 84 patients who underwent hepatic resection for colorectal liver metastasis. Images were digitally recorded, blindly reviewed, and scored for echogenicity (hypo-, iso-, or hyperechoic). The median tumor number was 1 and the median tumor size was 5.0 cm. At the time of surgery, the IOUS appearance of the colorectal liver metastases were hypoechoic in 35 (41.7%) patients, isoechoic in 37 (44.0%) patients, and hyperechoic in 12 (14.3%) patients. Traditional clinicopathologic prognostic factors were similarly distributed among the three echogenicity groups (all p > 0.05). Patients with a hypoechoic lesion had a significantly shorter median survival (30.2 months) compared with patients who had either an isoechoic (53.2 months) or hyperechoic (42.3 months) lesion (p = 0.005). The 5-year survival after hepatic resection of colorectal liver metastasis was also associated with the echogenic appearance of the lesion (hypoechoic 14.4 vs isoechoic 37.4 vs hyperechoic 46.2%) (p < 0.05). Intraoperative ultrasound echogenicity should be considered a prognostic factor after hepatic resection of metastatic colorectal cancer.


Asunto(s)
Neoplasias Colorrectales/patología , Hepatectomía , Cuidados Intraoperatorios , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/cirugía , Ultrasonografía Intervencional , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tasa de Supervivencia
18.
J Gastrointest Surg ; 10(8): 1140-3, 2006.
Artículo en Inglés | MEDLINE | ID: mdl-16966033

RESUMEN

Carcinoma of the papilla of Vater is classified as periampullary cancer representing 5% of all gastrointestinal tract malignancies. Early and accurate diagnosis is important for those patients with a tumor of the papilla, as the prognosis is more favorable than in other periampullary neoplasms. Endoscopically obtained biopsies from suspicious papillae can detect an early tumor, although even for skilled pathologists it is often difficult to differentiate carcinomas from noninvasive lesions on the basis of forceps biopsies. The purpose of this study was to assess the preoperative diagnostic accuracy of duodenoscopy appearance and biopsy in all cases with suspicion of tumor. Thirty patients with suspicion of carcinoma of the papilla of Vater and with final diagnosis established by pancreatoduodenectomy were included in this retrospective study. In each case, a comparison was made between endoscopic biopsy and duodenoscopic appearance. Duodenoscopic appearance sensitivity and accuracy for malignancy were 86% and 83%, respectively, whereas endoscopic biopsy sensitivity and accuracy were 65% and 67%, respectively. Although preoperative diagnosis of carcinoma of the papilla of Vater is useful for making therapeutic decisions, the diagnostic value of the endoscopic appearance was superior to endoscopic biopsy in this series.


Asunto(s)
Ampolla Hepatopancreática/patología , Neoplasias del Conducto Colédoco/patología , Duodenoscopía , Biopsia/métodos , Diagnóstico Diferencial , Humanos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad
19.
Am J Surg ; 212(4): 715-721, 2016 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-27712669

RESUMEN

BACKGROUND: Irreversible electroporation is increasingly used for treatment of solid tumors, but safety data remain scarce. This study aimed to describe intraoperative adverse events associated with irreversible electroporation in patients undergoing solid tumor ablation. METHODS: We analyzed demographic and intraoperative data for patients (n = 43) undergoing irreversible electroporation for hepato-pancreato-biliary and retroperitoneal malignancies (2012 to 2015). Adverse events were defined as cardiac, surgical, or equipment-related. RESULTS: Adverse events (n = 20, 47%) were primarily cardiac (90%, n = 18), including blood pressure elevation (77%, n = 14/18) and arrhythmia (16%, n = 7/43). All but one was managed medically, 1 patient with arrhythmia required termination of ablation. Bleeding and technical problems with the equipment occurred in 1 patient each. Multivariable analysis revealed previous cardiovascular disease and needle placement close to the celiac trunk associated with increased likelihood for cardiac events. CONCLUSIONS: Intraoperative cardiac adverse events are common during irreversible electroporation but rarely impair completion of the procedure.


Asunto(s)
Neoplasias del Sistema Digestivo/cirugía , Electroporación , Complicaciones Intraoperatorias , Neoplasias Retroperitoneales/cirugía , Anciano , Arritmias Cardíacas/etiología , Enfermedades Cardiovasculares/complicaciones , Arteria Celíaca , Electroporación/instrumentación , Femenino , Humanos , Hiperpotasemia/etiología , Hipertensión/etiología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Factores de Riesgo
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