RESUMEN
BACKGROUND & AIM: We aimed to assess long-term outcome after transplantation of HOPE-treated donor livers based on real-world data (i.e., IDEAL-D stage 4). METHODS: In this international, multicentre, observational cohort study, we collected data from adult recipients of a HOPE-treated liver transplanted between January 2012 and December 2021. Analyses were stratified for brain-dead (DBD) and circulatory-dead (DCD) donor livers, sub-divided by their respective risk categories. The primary outcome was death-censored graft survival. Secondary outcomes included the incidence of primary non-function (PNF) and ischemic cholangiopathy (IC). RESULTS: We report on 1202 liver transplantations (64% DBD) performed at 22 European centres. For DBD, a total number of 99 benchmark (8%), 176 standard (15%), and 493 extended-criteria (41%) cases were included. For DCD, 117 transplants were classified as low-risk (10%), 186 as high-risk (16%), and 131 as futile (11%), with significant risk profile variations among centres. Actuarial 1-, 3-, and 5-year death-censored graft survival for DBD and DCD was 95%, 92%, and 91%, vs. 92%, 87%, and 81%, respectively (logrank p=0.003). Within DBD and DCD-strata, death-censored graft survival was similar among risk groups (logrank p=0.26, p=0.99). Graft loss due to PNF or IC was 2.3% and 0.4% (DBD), and 5% and 4.1% (DCD). CONCLUSIONS: This study shows excellent 5-year survival after transplantation of HOPE-treated DBD and DCD livers with low rates of graft loss due to PNF or IC, irrespective of their individual risk profile. HOPE-treatment has now reached IDEAL-D stage 4, which further supports the implementation of HOPE in routine clinical practice. IMPACT AND IMPLICATIONS: This study demonstrates the excellent long-term performance of HOPE-treatment of DCD and DBD liver grafts irrespective of their individual risk profile in a real-world setting, outside the evaluation of randomized controlled trials. While previous studies have established safety, feasibility, and efficacy against the current standard, according to the IDEAL-D evaluation framework, HOPE-treatment has now reached the final IDEAL-D Stage 4, which further supports the implementation of HOPE in routine clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05520320.
RESUMEN
BACKGROUND: In June 2021, the first robot-assisted donor nephrectomy (RADN) was performed at the Leiden University Medical Center (LUMC), the Netherlands. The goal of this study was to investigate whether this procedure has been implemented safely and efficiently. METHODS: RADN was retrospectively compared to laparoscopic donor nephrectomy (LDN) performed during the same time period (June 2021 until November 2022). Patients were assigned to RADN depending on the availability of the da Vinci robot and surgical team. The studied endpoints were postoperative complications, operative time, estimated blood loss, warm ischemic time (WIT), and postoperative pain experience. For analysis, the Student's t-test and Chi-squared test were used for, respectively, continuous and categorical data. RESULTS: Forty RADN were compared to 63 LDN. Total insufflation time was significantly longer in RADN compared to LDN (188 min (169-214) versus 172 min (144-194); p = 0.02). Additionally, WIT was also found to be significantly higher in the robot-assisted group (04:54 min vs. 04:07 min; p < 0.01). No statistical differences were found in postoperative outcomes (eGFR of the recipient at 3-month follow-up, RADN 54.08 mL/min ±18.79 vs. LDN 56.41 mL/min ±16.82; p = 0.52), pain experience, and complication rate. CONCLUSION: RADN was safely and efficiently implemented at the LUMC. It's results were not inferior to laparoscopic donor nephrectomy. Operative time and warm ischemic times were longer in RADN. This may relate to a learning curve effect. No clinically relevant effect on postoperative outcomes was observed.
Asunto(s)
Laparoscopía , Donadores Vivos , Nefrectomía , Procedimientos Quirúrgicos Robotizados , Humanos , Nefrectomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Femenino , Masculino , Laparoscopía/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Adulto , Trasplante de Riñón/métodos , Recolección de Tejidos y Órganos/métodos , Tempo Operativo , Competencia Clínica , Resultado del Tratamiento , Países Bajos , AncianoRESUMEN
BACKGROUND: The aim of this study was to analyze the value of the unadjusted CUSUM graph of liver surgical injury and discard rates in organ procurement in the Netherlands. METHODS: Unadjusted CUSUM graphs were plotted for surgical injury (C event) and discard rate (C2 event) from procured livers accepted for transplantation for each local procurement team compared with the total national cohort. The average incidence for each outcome was used as benchmark based on procurement quality forms (Sep 2010-Oct 2018). The data from the five Dutch procuring teams were blind-coded. RESULTS: The C and C2 event rate were 17% and 1.9%, respectively (n = 1265). A total of 12 CUSUM charts were plotted for the national cohort and the five local teams. National CUSUM charts showed an overlapping "alarm signal." This overlapping signal for both C and C2, albeit a different time period, was only found in one local team. The other CUSUM alarm signal went off for two separate local teams, but only for C events or C2 events respectively, and at different points in time. The other remaining CUSUM charts showed no alarm signaling. CONCLUSION: The unadjusted CUSUM chart is a simple and effective monitoring tool in following performance quality of organ procurement for liver transplantation. Both national and local recorded CUSUMs are useful to see the implication of national and local effects on organ procurement injury. Both procurement injury and organ discard are equally important in this analysis and need to be separately CUSUM charted.
Asunto(s)
Trasplante de Hígado , Obtención de Tejidos y Órganos , Humanos , Donadores Vivos , Benchmarking , Hígado/cirugíaRESUMEN
BACKGROUND: Liver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients. METHODS: In this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed. RESULTS: In total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02-1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression. CONCLUSION: Thirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.
Asunto(s)
Hígado , Octogenarios , Factores de Edad , Anciano , Anciano de 80 o más Años , Humanos , Países Bajos , Complicaciones Posoperatorias/etiología , Estudios RetrospectivosRESUMEN
The use of a temporary portocaval shunt (TPCS) as well as the order of reperfusion (initial arterial reperfusion [IAR] versus initial portal reperfusion) in orthotopic liver transplantation (OLT) is controversial and, therefore, still under debate. The aim of this study was to evaluate outcome for the 4 possible combinations (temporary portocaval shunt with initial arterial reperfusion [A+S+], temporary portocaval shunt with initial portal reperfusion, no temporary portocaval shunt with initial arterial reperfusion, and no temporary portocaval shunt with initial portal reperfusion) in a center-based cohort study, including liver transplantations (LTs) from both donation after brain death and donation after circulatory death (DCD) donors. The primary outcome was the perioperative transfusion of red blood cells (RBCs), and the secondary outcomes were operative time and patient and graft survival. Between January 2005 and May 2017, all first OLTs performed in our institution were included in the 4 groups mentioned. With IAR and TPCS, a significantly lower perioperative transfusion of RBCs was seen (P < 0.001) as well as a higher number of recipients without any transfusion of RBCs (P < 0.001). A multivariate analysis showed laboratory Model for End-Stage Liver Disease (MELD) score (P < 0.001) and IAR (P = 0.01) to be independent determinants of the transfusion of RBCs. When comparing all groups, no statistical difference was seen in operative time or in 1-year patient and graft survival rates despite more LTs with a liver from a DCD donor in the A+S+ group (P = 0.005). In conclusion, next to a lower laboratory MELD score, the use of IAR leads to a significantly lower need for perioperative blood transfusion. There was no significant interaction between IAR and TPCS. Furthermore, the use of a TPCS and/or IAR does not lead to increased operative time and is therefore a reasonable alternative surgical strategy.
Asunto(s)
Pérdida de Sangre Quirúrgica/prevención & control , Enfermedad Hepática en Estado Terminal/cirugía , Trasplante de Hígado/efectos adversos , Derivación Portocava Quirúrgica/métodos , Daño por Reperfusión/prevención & control , Reperfusión/métodos , Adulto , Anciano , Aloinjertos/irrigación sanguínea , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Transfusión Sanguínea/estadística & datos numéricos , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/mortalidad , Femenino , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Hígado/irrigación sanguínea , Trasplante de Hígado/métodos , Masculino , Persona de Mediana Edad , Tempo Operativo , Periodo Perioperatorio/estadística & datos numéricos , Derivación Portocava Quirúrgica/efectos adversos , Reperfusión/efectos adversos , Daño por Reperfusión/epidemiología , Daño por Reperfusión/etiología , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Professional abdominal organ recovery with certification has been mandatory in the Netherlands since 2010. This study analyses the effects of certification (January 2010-September 2015) on pancreas transplantation and compares it to an era before certification (February 2002-May 2008) for surgical injuries and the number of pancreases transplanted. A total of 264 cases were analysed. Eighty-four recovered pancreases (31.8%) with surgically injuries were encountered. Forty-six of those were surgically salvaged for transplantation, resulting in a total of 226 (85.6%) being transplanted. It was found that certified surgeons recovered grafts from older donors (36.8 vs. 33.3; P = 0.021), more often from donation after circulatory death (DCD) donors (18% vs. 0%; P < 0.001) and had less surgical injuries (21.6% vs. 41.0%; P < 0.001). Certification (OR: 0.285; P < 0.001) and surgeons from a pancreas transplant centre (OR: 0.420; P = 0.002) were independent risk factors for surgical organ injury. Predictors for proceeding to the actual pancreas transplantation were a recovering surgeon from a pancreas transplantation centre (OR: 3.230; P = 0.003), certification (OR: 3.750; P = 0.004), donation after brain death (DBD) (OR: 8.313; P = 0.002) and donor body mass index (BMI) (OR: 0.851; P = 0.023). It is concluded that certification in abdominal organ recovery will limit the number of surgical injuries in pancreas grafts which will translate in more pancreases available for transplantation.
Asunto(s)
Aloinjertos/normas , Trasplante de Páncreas , Recolección de Tejidos y Órganos/normas , Adulto , Certificación , Humanos , Persona de Mediana Edad , Países Bajos , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Tumor recurrence after radical resection of hepatic tumors is not uncommon, suggesting that malignant lesions are missed during surgery. Intraoperative navigation using fluorescence guidance is an innovative technique enabling real-time identification of (sub)capsular liver tumors. The objective of the current study was to compare fluorescence imaging (FI) and conventional imaging modalities for laparoscopic detection of both primary and metastatic tumors in the liver. METHODS: Patients undergoing laparoscopic resection of a malignant hepatic tumor were eligible for inclusion. Patients received standard of care, including preoperative CT and/or MRI. In addition, 10 mg indocyanine green was intravenously administered 1 day prior to surgery. After introduction of the laparoscope, inspection, FI, and laparoscopic ultrasonography (LUS) were performed. Histopathological examination of resected suspect tissue was considered the gold standard. RESULTS: Twenty-two patients suspected of having hepatocellular carcinoma (n = 4), cholangiocarcinoma (n = 2) or liver metastases from colorectal carcinoma (n = 12), uveal melanoma (n = 2), and breast cancer (n = 2) were included. Two patients were excluded because their surgery was unexpectedly postponed several days. Twenty-six malignancies were resected in the remaining 20 patients. Sensitivity for various modalities was 80 % (CT), 84 % (MRI), 62 % (inspection), 86 % (LUS), and 92 % (FI), respectively. Three metastases (12 %) were identified solely by FI. All 26 malignancies could be detected by combining LUS and FI (100 % sensitivity). CONCLUSION: This study demonstrates added value of FI during laparoscopic resections of several hepatic tumors. Although larger series will be needed to confirm long-term patient outcome, the technology already aids the surgeon by providing real-time fluorescence guidance.
Asunto(s)
Carcinoma Hepatocelular/diagnóstico , Neoplasias Hepáticas/diagnóstico , Recurrencia Local de Neoplasia/diagnóstico , Adulto , Anciano , Carcinoma Hepatocelular/secundario , Carcinoma Hepatocelular/cirugía , Colangiocarcinoma/diagnóstico , Colangiocarcinoma/secundario , Colangiocarcinoma/cirugía , Femenino , Fluorescencia , Humanos , Verde de Indocianina/metabolismo , Laparoscopía/métodos , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Sensibilidad y Especificidad , Espectroscopía Infrarroja Corta , Cirugía Asistida por ComputadorRESUMEN
BACKGROUND: Fluorescence cholangiography using indocyanine green (ICG) can enhance orientation of bile duct anatomy during laparoscopic cholecystectomy. To ensure clear discrimination between bile ducts and liver, the fluorescence ratio between both should be sufficient. This ratio is influenced by the ICG dose and timing of fluorescence imaging. We first systematically identified all strategies for fluorescence cholangiography. Second, we aimed to optimize the dose of ICG and dosing time in a prospective clinical trial. METHODS: PubMed was searched for clinical trials studying fluorescence cholangiography. Furthermore, 28 patients planned to undergo laparoscopic cholecystectomy were divided into 7 groups, receiving different intravenous doses (5 or 10 mg ICG) at different time points (0.5, 2, 4, 6, or 24 hours prior to surgery). RESULTS: The systematic review revealed 27 trials including 1057 patients. The majority of studies used 2.5 mg administered within 1 hour before imaging. Imaging 3 to 24 hours after ICG administration was never studied. The clinical trial demonstrated that the highest bile duct-to-liver ratio was achieved 3 to 7 hours after administration of 5 mg and 5 to 25 hours after administration of 10 mg ICG. Up to 3 hours after administration of 5 mg and up to 5 hours after administration of 10 mg ICG, the liver was equally or more fluorescent than the cystic duct, resulting in a ratio ≤1.0. CONCLUSION: This study shows for the first time that the interval between ICG administration and intraoperative fluorescence cholangiography should be extended. Administering 5 mg ICG at least 3 hours before imaging is easy to implement in everyday clinical practice and results in bile duct-to-liver ratios >1.0.
Asunto(s)
Conductos Biliares/diagnóstico por imagen , Colangiografía/métodos , Colorantes Fluorescentes , Laparoscopía/métodos , Imagen Óptica/métodos , Adulto , Anciano , Femenino , Colorantes Fluorescentes/administración & dosificación , Colorantes Fluorescentes/uso terapéutico , Humanos , Verde de Indocianina/administración & dosificación , Verde de Indocianina/uso terapéutico , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ensayos Clínicos Controlados Aleatorios como Asunto , Adulto JovenRESUMEN
AIM: We retrospectively analyzed incisional hernia (IH) outcomes of liver transplant (LT) vs. hepatopancreaticobiliary (HPB) cases sharing the same incision. METHODS: IH repair patients with a history of LT were compared with those with HPB surgical history sharing the same type of incision and using the European Hernia Society classification and nomenclature for reporting outcome. RESULTS: Eighty-two patients (27 HPB and 55 LT) between February 2001 and February 2014 were analyzed. Baseline demographics showed that the LT group had more diabetes and steroid use, but were less physical active. Outcomes showed no differences in wound complication, SSI rate, and recurrence rate (recurrence rate of 11.1% and 16.4% for HPB and LT, respectively). Multivariate analysis showed longer operating time to be a risk factor for both wound complication and SSI. M-tor inhibitor use was an additional risk factor for SSI. Interval to recurrence was significant longer in the LT group (35 vs. 61 months). Cox analysis showed steroid use, immunosuppression and not using a synthetic mesh as risk factors for recurrence. CONCLUSION: Incisional hernia repair with synthetic mesh after liver transplantation does not result in more wound complications, SSI, and recurrences, when compared to patients without immunosuppression.
Asunto(s)
Enfermedades de las Vías Biliares/cirugía , Procedimientos Quirúrgicos del Sistema Biliar/efectos adversos , Hernia Incisional/prevención & control , Hepatopatías/cirugía , Trasplante de Hígado/efectos adversos , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias , Cicatrización de Heridas , Enfermedades de las Vías Biliares/complicaciones , Femenino , Estudios de Seguimiento , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Hernia Incisional/etiología , Hepatopatías/complicaciones , Masculino , Persona de Mediana Edad , Enfermedades Pancreáticas/complicaciones , Enfermedades Pancreáticas/cirugía , Pronóstico , Recurrencia , Factores de Riesgo , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
AIM: Organ procurement errors account for almost 20% of discarded pancreatic allografts. For this reason, the anatomical significance of the dorsal pancreatic artery (DPA) was reviewed. METHODS: A strategy on dealing with an often overlooked DPA is evaluated. RESULTS: The DPA provides together with the splenic artery the main blood supply to the pancreatic tail. Three different arterial variations have been described. In the rare instances when the DPA arises from the common hepatic artery or the celiac trunk, instead of the splenic origin, the DPA can easily be overlooked by surgeons not familiar with this artery. This may result in an unintentional damage to the pancreatic tail blood supply. If unrecognized during the back-table inspection, it could potentially jeopardize the pancreatic graft after reperfusion. When a cut DPA is encountered during inspection, efforts should be attempted to revascularize the graft, especially if there is no backflow from the splenic artery as sign of absent collateral circulation. CONCLUSION: The DPA may play a more prominent role in the vascularization of pancreas transplants than currently assumed. Better understanding of the vascular anatomy may lead to improved results in pancreas transplantation.
Asunto(s)
Arterias/anatomía & histología , Trasplante de Páncreas/métodos , Páncreas/irrigación sanguínea , Recolección de Tejidos y Órganos/métodos , Arterias/cirugía , Humanos , Páncreas/cirugía , Arteria Esplénica/anatomía & histología , Arteria Esplénica/cirugíaRESUMEN
BACKGROUND: This study investigates the impact of certification training and liver transplant experience on procurement outcomes of deceased donor liver procurement in the Netherlands. METHODS: Three groups (trainee, certified, and master) were formed, with further subdivision based on liver transplant experience. Three key outcomes-surgical injury, graft discard after injury, and donor hepatectomy duration-were analyzed. RESULTS: There were no significant differences in surgical graft injury in the three groups (trainee, 16.9%; certified, 14.8%; master, 18.2%; Pâ =â 0.357; 2011 to 2018). The only predictor for surgical graft injury was donation after cardiac death (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.10-2.02). Of the three groups, the master group had the highest discard rate after surgical injury (trainee, 0%; certified, 1.3%; master, 2.8%; Pâ =â 0.013). Master group without liver transplant experience (OR, 3.16; 95% CI, 1.21-8.27) and male donor sex (OR, 3.58; 95% CI, 1.32-9.73) were independent risk factors for discarding livers after surgical injury. Independent predictors for shorter hepatectomy durations included donors older than 50 years (coefficient [Coeff], -7.04; 95% CI, -8.03 to -3.29; Pâ <â 0.001), and master group (Coeff, -9.84; 95% CI, -14.37 to -5.31; Pâ <â 0.001) and certified group with liver transplant experience (Coeff, -6.54; 95% CI, -10.83 to -2.26; Pâ =â 0.003). On the other hand, master group without liver transplant experience (Coeff, 5.00; 95% CI, 1.03-8.96; Pâ =â 0.014) and donation after cardiac death (Coeff, 10.81; 95% CI, 8.32-13.3; Pâ <â 0.001) were associated with longer hepatectomy durations. CONCLUSIONS: Training and certification in abdominal organ procurement surgery were associated with a reduced discard rate for surgical injured livers and shorter hepatectomy times. The contrast between master group with and without liver transplant experience underscores the need for specialized training in this field.
RESUMEN
Diaphragmatic hernias (DH) are an unusual complication after pediatric liver transplantation; however, they have been reported with increased frequency in the past few years. DHs are responsible for nearly half of the small bowel obstructions requiring surgical intervention in this patient population. It has been suggested that the use of a left lobe liver graft, surgical trauma, malnourishment, elevated intra-abdominal pressures, and mTor inhibitors may predispose to development of DH. The use of a segmental graft may increase the recognition of diaphragmatic hernia because the surgically damaged right hemi-diaphragm often remains exposed to underlying viscera, instead of being covered by the right hepatic lobe. Treatment is surgical reduction, with up to 20% of the patients requiring resection of the herniated intestine. Herein we describe a case of DH after left segmental liver transplant in a two- yr-old boy that presented one month post left lobe split liver transplant with abdominal pain, anorexia, and respiratory distress. Just like in the majority of the reported cases, an urgent laparotomy with primary repair was performed. No resection of the herniated segment of intestine was required. For pediatric patients with otherwise unexplained respiratory or gastrointestinal symptoms after a left lateral segment liver transplant, right-sided diaphragmatic hernias should always be high in the differential diagnosis.
Asunto(s)
Hernia Diafragmática/complicaciones , Hernia Diafragmática/diagnóstico , Fallo Hepático/terapia , Trasplante de Hígado/efectos adversos , Dolor Abdominal/diagnóstico , Preescolar , Hernia Diafragmática/cirugía , Humanos , Obstrucción Intestinal/diagnóstico , Laparotomía , Fallo Hepático/complicaciones , Masculino , Complicaciones Posoperatorias , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Currently, no practical definition of potentially resectable, borderline or unresectable perihilar cholangiocarcinoma (pCCA) is available. Aim of this study was to define criteria to categorize patients for use in a future neoadjuvant or induction therapy study. METHOD: Using the modified DELPHI method, hepatobiliary surgeons from all tertiary referral centers in the Netherlands were invited to participate in this study. During five online meetings, predefined factors determining resectability and additional factors regarding surgical resectability and operability were discussed. RESULTS: The five online meetings resulted in 52 statements. After two surveys, consensus was reached in 63% of the questions. The main consensus included a definition regarding potential resectability. 1) Clearly resectable: no vascular involvement (≤90°) of the future liver remnant (FLR) and expected feasibility of radical biliary resection. 2) Clearly unresectable: non-reconstructable venous and/or arterial involvement of the FLR or no feasible radical biliary resection. 3) Borderline resectable: all patients between clearly resectable and clearly unresectable disease. CONCLUSION: This DELPHI study resulted in a practical and applicable resectability, or more accurate, an explorability classification, which can be used to categorize patients for use in future neoadjuvant therapy studies.
RESUMEN
Hepatocellular adenomas (HCAs) are benign liver tumors associated with bleeding or malignant transformation. Data on the indication for surgery are scarce. We analyzed indications and outcome of patients operated for HCAs < 50 mm compared to HCAs ≥ 50 mm. Changes in final postoperative diagnosis were assessed. We performed a retrospective study that included patients who underwent resection for (suspected) HCAs in the Netherlands from 2014 to 2019. Indication for resection was analyzed and stratified for small (<50 mm) and large (≥50 mm) tumors. Logistic regression analysis was performed on factors influencing change in tumor diagnosis. Out of 222 patients who underwent surgery, 44 (20%) patients had a tumor <50 mm. Median age was 46 (interquartile range [IQR], 33-56) years in patients with small tumors and 37 (IQR, 31-46) years in patients with large tumors ( p = 0.016). Patients with small tumors were more frequently men (21% vs. 5%, p = 0.002). Main indications for resection in patients with small tumors were suspicion of (pre)malignancy (55%), (previous) bleeding (14%), and male sex (11%). Patients with large tumors received operations because of tumor size >50 mm (52%), suspicion of (pre)malignancy (28%), and (previous) bleeding (5.1%). No difference was observed in HCA-subtype distribution between small and large tumors. Ninety-six (43%) patients had a postoperative change in diagnosis. Independent risk factors for change in diagnosis were tumor size <50 mm (adjusted odds ratio [aOR], 3.4; p < 0.01), male sex (aOR, 3.7; p = 0.03), and lack of hepatobiliary contrast-enhanced magnetic resonance imaging (CE-MRI) (aOR, 1.8; p = 0.04). Resection for small (suspected) HCAs was mainly indicated by suspicion of (pre)malignancy, whereas for large (suspected) HCAs, tumor size was the most prevalent indication. Male sex, tumor size <50 mm, and lack of hepatobiliary CE-MRI were independent risk factors for postoperative change in tumor diagnosis.
Asunto(s)
Adenoma de Células Hepáticas , Carcinoma Hepatocelular , Neoplasias Hepáticas , Humanos , Masculino , Adulto , Persona de Mediana Edad , Adenoma de Células Hepáticas/diagnóstico por imagen , Adenoma de Células Hepáticas/cirugía , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/cirugía , Carcinoma Hepatocelular/patología , Estudios Retrospectivos , Imagen por Resonancia Magnética/métodosRESUMEN
BACKGROUND: There are few reports that show that laparoscopic rectal surgery for rectal cancer had similar oncological results based on short-term benefits. The purpose of this study was to analyze our institutional short- and long-term results in laparoscopic rectal surgery and to compare these results with that reported in the literature. METHODS: The records of 121 patients who underwent sphincter-saving procedure for rectal cancer were reviewed. The variables analyzed included possible factors causing morbidity, anastomotic leak, and recurrence rate in the laparoscopic and open techniques. Multivariable analyses were used to determine relationship between variables. Survival curves were determined by using the Kaplan-Meier method. RESULTS: Laparoscopic sphincter-saving total mesorectal excision or partial mesorectal excision was performed in 97 patients (group 1). Twenty-four patients had open procedure (group 2). The conversion rate from laparoscopic to open technique was 10.3% (n=10). The overall postoperative morbidity and anastomotic leak rates were 33.4% and 14.8%, respectively. There was no statistical difference in terms of postoperative morbidity (p=0.177) and anastomotic leak (p=0.216) between the two groups. Old age was an independent predictor for postoperative morbidity, and downstaging was an independent predictor for anastomotic leak with a sixfold increased risk. Complete downstaging to stage 0 showed a lower overall 5-year survival rate compared with non-downstaged stage I patients (79% vs. 100%). The overall local recurrence rate was 6%. There was one port site metastasis (0.8%). There were two (1.7%) postoperative deaths in group 1. The overall 5-year patient and disease-free survivals were 64% and 74%, respectively, and there was no difference between groups 1 and 2 (p=0.801). CONCLUSIONS: Laparoscopic sphincter-saving rectal resection for rectal cancer shows good long-term results. However, it has no advantage in terms of short-term benefits compared with the open procedure. Further studies are needed to validate the effect of downstaging on anastomotic leaks.