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BACKGROUND: Laparoscopic liver resections (LLR) have been shown a treatment approach comparable to open liver resections (OLR) in hepatocellular carcinoma (HCC). However, the influence of procedural type on body composition has not been investigated. The aim of the current study was to compare the degree of skeletal muscle loss between LLR and OLR for HCC. METHODS: By using propensity score matching (PSM) analysis, 64 pairs of patients were enrolled. The change of psoas muscle index (PMI) after the operation was compared between the matched patients in the LLR and OLR. Risk factors for significant muscle loss (defined as change in PMI > mean change minus one standard deviation) were further investigated by multivariate analysis. RESULTS: Among patients enrolled, there was no significant difference in baseline characteristics between the two groups. The PMI was significantly decreased in the OLR group (P = 0.003). There were also more patients in the OLR group who developed significant muscle loss after the operations (P = 0.008). Multivariate analysis revealed OLR (P = 0.023), type 2 diabetes mellitus, indocyanine green retention rate at 15 min (ICG-15) > 10%, and cancer stage ⧠3 were independent risk factors for significant muscle loss. In addition, significant muscle loss was associated with early HCC recurrence (P = 0.006). Metabolomic analysis demonstrated that the urea cycle may be decreased in patients with significant muscle loss. CONCLUSION: LLR for HCC was associated with less significant muscle loss than OLR. Since significant muscle loss was a predictive factor for early tumor recurrence and associated with impaired liver metabolism, LLR may subsequently result in a more favorable outcome.
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Carcinoma Hepatocelular , Diabetes Mellitus Tipo 2 , Laparoscopía , Neoplasias Hepáticas , Humanos , Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Laparoscopía/efectos adversos , Músculo EsqueléticoRESUMEN
BACKGROUND: Laparoscopic procedure has inherent merits of smaller incisions, better cosmesis, less postoperative pain, and earlier recovery. In the current study, we presented our method of purely laparoscopic feeding jejunostomy and compared its results with that of conventional open approach. METHODS: We retrospectively reviewed our patients from 2012 to 2019 who had received either laparoscopic jejunostomy (LJ, n = 29) or open ones (OJ, n = 94) in Chang Gung Memorial Hospital, Linkou. Peri-operative data and postoperative outcomes were analyzed. RESULTS: In the current study, we employed 3-0 Vicryl, instead of V-loc barbed sutures, for laparoscopic jejunostomy. The mean operative duration of LJ group was about 30 min longer than the OJ group (159 ± 57.2 mins vs 128 ± 34.6 mins; P = 0.001). There were no intraoperative complications reported in both groups. The patients in the LJ group suffered significantly less postoperative pain than in the OJ group (mean NRS 2.03 ± 0.9 vs. 2.79 ± 1.2; P = 0.002). The majority of patients in both groups received early enteral nutrition (< 48 h) after the operation (86.2% vs. 74.5%; P = 0.143). CONCLUSIONS: Our study demonstrated that purely laparoscopic feeding jejunostomy is a safe and feasible procedure with less postoperative pain and excellent postoperative outcome. It also provides surgeons opportunities to enhance intracorporeal suture techniques.
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Nutrición Enteral/métodos , Yeyunostomía/métodos , Laparoscopía , Femenino , Humanos , Yeyunostomía/efectos adversos , Yeyunostomía/instrumentación , Laparoscopía/efectos adversos , Masculino , Estudios Retrospectivos , Suturas , Técnicas de Cierre de HeridasRESUMEN
PURPOSE: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver with a dismal prognosis. Vascular invasion, among others, is the most robust indicator of postoperative recurrence and overall survival after liver resection for HCC. Few studies to date have attempted to search for effective markers to predict vascular invasion before the operation. The current study would examine the plasma metabolic profiling via 1H-NMR of HCC patients undergoing liver resection and aim to search for potential biomarkers in the early detection of HCC with normal alpha-fetoprotein (AFP) and the diagnosis of vascular invasion preoperatively. MATERIALS AND METHODS: HCC patients scheduled to receive liver resections for their HCC were recruited and divided into two separate groups, investigation cohort and validation cohort. Their preoperative blood samples were collected and subjected to a comprehensive metabolomic profiling using 1H-nuclear magnetic resonance spectroscopy (NMR). RESULTS: There were 35 HCC patients in the investigation group and 22 patients in the validation group. Chronic hepatitis B remained the most common etiology of HCC, followed by chronic HCV infection. The two study cohorts were essentially comparable in terms of major clinicopathological variables. After 1H-nuclear NMR analysis, we found in the investigation cohort that HCC with normal alpha-fetoprotein (AFP < 15 ng/mL) had significantly higher serum level of O-acetylcarnitine than those with higher AFP (AFP ≥ 15 ng/mL, P = 0.025). In addition, HCC with microscopic vascular invasion (VI) had significantly higher preoperative serum level of formate than HCC without microscopic VI (P = 0.023). These findings were similar in the validation cohort. CONCLUSION: A comprehensive metabolomic profiling of HCC demonstrated that serum metabolites may be utilized to assist the early diagnosis of AFP-negative HCC patients and recognition of microvascular invasion in order to facilitate preoperative surgical planning and postoperative follow-up. Further, larger scale prospective studies are warranted to consolidate our findings.
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Carcinoma Hepatocelular/sangre , Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/sangre , Neoplasias Hepáticas/cirugía , Recurrencia Local de Neoplasia/sangre , Recurrencia Local de Neoplasia/cirugía , alfa-Fetoproteínas/metabolismo , Anciano , Biomarcadores de Tumor/sangre , Carcinoma Hepatocelular/irrigación sanguínea , Carcinoma Hepatocelular/patología , Femenino , Hepatectomía , Humanos , Neoplasias Hepáticas/irrigación sanguínea , Neoplasias Hepáticas/patología , Masculino , Invasividad Neoplásica , Recurrencia Local de Neoplasia/irrigación sanguínea , Recurrencia Local de Neoplasia/patología , Proyectos Piloto , Pronóstico , Estudios Prospectivos , Curva ROC , Factores de RiesgoRESUMEN
BACKGROUND: Laparoscopic liver resection has been regarded as the standard treatment for liver tumors located at the left lateral liver sector. However, few studies have reported the results of laparoscopic left lateral sectionectomy (LLS) for HCC, not to mention the feasibility of this emerging technique for the less experienced liver surgeons. The current study would reappraise the Louisville statement by examining the outcome of LLS performed by a young liver surgeon. METHODS: We retrospectively reviewed two separate groups of patients who underwent open or laparoscopic left lateral sectionectomies at Chung Gung Memorial Hospital, Linkou. All laparoscopic hepatectomies were performed by the index young surgeon following a stepwise stapleless LLS. The surgical results and oncological outcomes of laparoscopic vs. open hepatectomies (LH and OH, respectively) with the surgical indication of HCC at left lateral liver sector were further compared and analyzed. RESULTS: 18 of 29 patients in the laparoscopic group and 75 patients in the conventional open group had primary HCC. The demographic data was essentially the same for the two groups. Statistical analysis revealed that the LH group had smaller tumor size, higher blood transfusion requirement, longer duration of inflow control and parenchymal transection, and longer operation time. However, no significant difference was observed in terms of complication rate, mortality rate, and hospital stay between the two groups. After adjusting for tumor size, LH and OH showed no statistical difference in the amount of blood transfusion, operation time and patient survival. CONCLUSIONS: This study demonstrated that stapleless LLS is a safe and feasible procedure for less experienced liver surgeons to resect HCC located at the left lateral liver sector. This stepwise stapleless LSS can not only achieve surgical results comparable to OH but also can provide a platform for liver surgeons to apply laparoscopic technique before conducting more complicated liver resections.
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Carcinoma Hepatocelular/cirugía , Competencia Clínica , Hepatectomía/métodos , Laparoscopía/métodos , Neoplasias Hepáticas/cirugía , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Femenino , Hepatectomía/efectos adversos , Mortalidad Hospitalaria , Humanos , Laparoscopía/efectos adversos , Tiempo de Internación , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias , Estudios Retrospectivos , Grapado Quirúrgico , Resultado del TratamientoRESUMEN
BACKGROUND: The goal of this study was to evaluate the accuracy and interchangeability between continuous cardiac output (CO) measured by electrical velocimetry (COEv) and continuous cardiac output obtained using the pulmonary thermodilution method (COPAC) during living donor liver transplantation (LDLT). METHOD: Twenty-three patients were enrolled in this prospective observational study. CO was recorded by both two methods and compared at nine specific time points. The data were analyzed using correlation coefficients, Bland-Altman analysis for the percentage errors, and the concordance rate for trend analysis using a four-quadrant plot. RESULTS: In total, 207 paired datasets were recorded during LDLT. CO data were in the range of 2.8-12.7 L/min measured by PAC and 3.4-14.9 L/min derived from the EV machine. The correction coefficient between COPAC and COEv was 0.415 with p < 0.01. The 95% limitation agreement was - 5.9 to 3.4 L/min and the percentage error was 60%. The concordance rate was 56.5%. CONCLUSIONS: The Aesculon™ monitor is not yet interchangeable with continuous thermodilution CO monitoring during LDLT. TRIAL REGISTRATION: The study was approved by the Institutional Review Board of Chang Gung Medical Foundation in Taiwan (registration number: 201600264B0 ).
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Gasto Cardíaco/fisiología , Trasplante de Hígado/métodos , Pulmón/fisiología , Monitoreo Intraoperatorio/métodos , Reología/métodos , Adulto , Anciano , Femenino , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/normas , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/normas , Estudios Prospectivos , Reología/normas , Termodilución/métodos , Termodilución/normasRESUMEN
BACKGROUND: Liver resection had been regarded as a standard treatment for primary hepatocellular carcinoma (HCC). However, early mortality and recurrence after surgery were still of major concern. RAM (Risk Assessment for early Mortality) scoring system is a newly developed tool for assessing early mortality after hepatectomy for HCC. In this study, we compared RAM scoring system with ALBI and MELD scores for their capability of predicting short-term outcome. METHODS: We retrospectively reviewed patients with hepatocellular carcinoma who were treated with hepatectomy at Chang Gung Memorial Hospital between 1986 and 2015. Their clinical characteristics and perioperative variables were collected. We applied RAM, albumin-bilirubin (ALBI), and model for end-stage liver disease (MELD) scoring systems to predict early mortality and early recurrence in HCC patients after surgery. We investigated the discriminative power of each scoring system by receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). RESULTS: A total of 1935 patients (78% male) who underwent liver resection for HCC were included in this study. The median follow-up period was 41.9 months. One hundred and forty-nine patients (7.7%) died within 6 months after hepatectomy (early mortality). All the three scoring systems were effective predictor for early mortality, with higher score indicating higher risk of early mortality (AUC of RAM = 0.723, p < 0.001; AUC of ALBI = 0.682, p < 0.001; AUC of MELD = 0.590, p = 0.002). Cox regression multivariate analysis demonstrated that the RAM class was the most significant independent predictor of early mortality after surgery, while MELD grade failed to discriminatively predict early mortality. In addition to early mortality, the RAM score was also predictive of early recurrence in HCC after surgery. CONCLUSIONS: This study demonstrated that RAM score is an effective and user-friendly bedside scoring system to predict early mortality and early recurrence after hepatectomy for HCC. In addition, the predictive capability of RAM score is superior to ALBI and MELD scores. Further study is warranted to validate our findings.
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Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/mortalidad , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidad , Recurrencia Local de Neoplasia/diagnóstico , Recurrencia Local de Neoplasia/mortalidad , Anciano , Carcinoma Hepatocelular/cirugía , Femenino , Hepatectomía/mortalidad , Hepatectomía/tendencias , Humanos , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , Recurrencia Local de Neoplasia/cirugía , Pronóstico , Estudios Retrospectivos , Medición de Riesgo/métodosRESUMEN
Although organ transplantation is the definitive treatment for end-stage organ failure, the post-transplant outcomes can be substantially influenced by cardiovascular complications. A national cohort study was performed to estimate risks of cardiovascular diseases in those with heart, lung, kidney, and liver transplantation. This cohort study consisted of 5978 solid organ transplantations identified using the Taiwan National Health Insurance Database. Cardiovascular and mortality risks in transplant recipients were evaluated using standardized incidence ratios, excess absolute risks, and standardized mortality ratios as compared to those in the general population. In heart, kidney, and liver recipients, the standardized incidence ratios of overall cardiovascular diseases were 9.41 (7.75-11.44), 3.32 (2.29-3.77), and 1.4 (1.15-1.7) and the overall standardized mortality ratios were 5.23 (4.54-6.03), 1.48 (1.34-1.63), and 3.95 (3.64-4.28), respectively. Except for heart organ recipients who were at highest risk for coronary artery disease with a standardized incidence ratio of 13.12 (10.57-16.29), kidney and liver organ recipients had a ninefold increased risk in developing deep vein thrombosis post-transplant. In conclusion, solid organ transplant patients are at risk of cardiovascular disease, in particular, deep vein thrombosis, which may warrant early identification of high-risk patients in addition to prompt and adequate thromboprophylaxis perioperatively.
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Enfermedades Cardiovasculares/epidemiología , Trasplante de Órganos/mortalidad , Complicaciones Posoperatorias/epidemiología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Taiwán/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Intrahepatic biliary mucinous cystic neoplasms are rare hepatic tumors and account for less than 5% of intrahepatic cystic lesions. Accurate preoperative diagnosis is difficult and the outcome differs among various treatment modalities.The aim of this study is to investigate the clinico-radiological characteristics of intrahepatic biliary mucinous cystic neoplasms and to establish eligible diagnostic and treatment suggestions. METHODS: Nineteen patients with intrahepatic biliary cystadenomas and two patients with biliary cystadenocarcinomas were retrospectively reviewed. Their clinico-radiological variables and survival outcome were analyzed. RESULTS: Of the 19 patients with biliary cystadenoma, 16 (84.2 %) were female. 11 (57.9 %) patients had symptoms before operation with the most common presenting symptom being abdominal pain. Among the patients with available data, serum and cystic fluid CA 19-9 levels were invariably elevated and the CA 19-9 level in the cystic fluid was significantly higher than that in the serum. Loculations (84.2 %) and septations (63.2 %) were the most common radiologic findings. For treatment, 11 (57.9 %) patients received radical resection by either enucleation or hepatic resection, while the remaining 8 (42.1 %) patients underwent only fenestration of liver cysts. Radical resection provided a significantly better clinical outcome than fenestration in terms of tumor recurrence (p = 0.018). The only two male patients with biliary cystadenocarcinoma received radical hepatic resection and achieved a disease-free survival of 16.5 months and 33 months, respectively. CONCLUSION: Intrahepatic biliary mucinous cystic neoplasms are rare and preoperative diagnosis is difficult. Internal septations and loculations on radiologic examinations should raise some suspicion of this diagnosis. Complete tumor excision is the standard treatment that may provide patients with better long term results after the operation.
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Neoplasias de los Conductos Biliares/diagnóstico , Conductos Biliares Intrahepáticos , Cistadenocarcinoma/diagnóstico , Cistoadenoma/diagnóstico , Hepatectomía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Conductos Biliares/diagnóstico por imagen , Neoplasias de los Conductos Biliares/mortalidad , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos/diagnóstico por imagen , Conductos Biliares Intrahepáticos/cirugía , Cistadenocarcinoma/diagnóstico por imagen , Cistadenocarcinoma/mortalidad , Cistadenocarcinoma/cirugía , Cistoadenoma/diagnóstico por imagen , Cistoadenoma/mortalidad , Cistoadenoma/cirugía , Femenino , Estudios de Seguimiento , Hepatectomía/métodos , Humanos , Masculino , Persona de Mediana Edad , Periodo Preoperatorio , Radiografía , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
Resveratrol, a natural polyphenolic compound of grape and red wine, owns potential anti-inflammatory effects, which results in the reduction of cytokines overproduction, the inhibition of neutrophil activity, and the alteration of adhesion molecules expression. Resveratrol also possesses antioxidant, anti-coagulation and anti-aging properties, and it may control of cell cycle and apoptosis. Resveratrol has been shown to reduce organ damage following traumatic and shock-like states. Such protective phenomenon is reported to be implicated in a variety of intracellular signaling pathways including the activation of estrogen receptor, the regulation of the sirtuin 1/nuclear factor-kappa B and mitogen-activated protein kinases/hemeoxygenase-1 pathway, and the mediation of proinflammatory cytokines and reactive oxygen species formation and reaction. In the recent studies, resveratrol attenuates hepatocyte injury and improves cardiac contractility due to reduction of proinflammatory mediator expression and ameliorates hypoxia-induced liver and kidney mitochondrial dysfunction following trauma and hemorrhagic injuries. Moreover, through anti-inflammatory effects and antioxidant properties, the resveratrol is believed to protect organ function in trauma-hemorrhagic injury. In this review, the organ-protective and anti-inflammatory effects of resveratrol in trauma-hemorrhagic injury will be discussed.
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Antiinflamatorios/uso terapéutico , Antioxidantes/uso terapéutico , Choque Hemorrágico/tratamiento farmacológico , Estilbenos/uso terapéutico , Heridas y Lesiones/tratamiento farmacológico , Animales , Humanos , Resveratrol , Choque Hemorrágico/metabolismo , Sirtuina 1/metabolismo , Heridas y Lesiones/metabolismoRESUMEN
BACKGROUND: Liver transplantation is treatment option for patients with end-stage liver disease and hepatocellular carcinoma. Renal function deterioration significantly impacts the survival rates of liver recipients, and serum uric acid (SUA) is associated with both acute and chronic renal function disorders. Thus, our study aimed to assess the relationship and predictive value of preoperative SUA level and postoperative acute kidney injury (AKI) in living donor liver transplantation (LDLT). METHODS: We conducted a prospective observational study on 87 patients undergoing LDLT. Blood samples were collected immediately before LDLT, and renal function status was followed up for 3 consecutive days postoperatively. RESULTS: Low SUA levels (cutoff value 4.15 mg/dL) were associated with a high risk of early posttransplantation AKI. The area under the curve was 0.73 (sensitivity, 79.2%; specificity, 59.4%). Although not statistically significant, there were no deaths in the non-AKI group but two in the early AKI group secondary to liver graft dysfunction in addition to early AKI within the first month after LDLT. CONCLUSION: AKI after liver transplantation may lead to a deterioration of patient status and increased mortality rates. We determined low preoperative SUA levels as a possible risk factor for early postoperative AKI.
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Lesión Renal Aguda , Trasplante de Hígado , Donadores Vivos , Ácido Úrico , Humanos , Trasplante de Hígado/efectos adversos , Ácido Úrico/sangre , Lesión Renal Aguda/etiología , Lesión Renal Aguda/sangre , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Adulto , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: Patients with autoimmune diseases (AD) generally carry an increased risk of developing cancer. However, the effect of AD in hepatocellular carcinoma (HCC) patients receiving surgical treatment is uncertain. The present study aimed to investigate the potential influence of AD on the survival of HCC patients undergoing hepatectomies. METHODS: Operated HCC patients were identified from the Chang Gung Research Database, and the survival outcomes of HCC patients with or without AD were analyzed ad compared. Cox regression model was performed to identify significant risk factors associated with disease recurrence and mortality. RESULTS: From 2002 to 2018, a total of 5532 patients underwent hepatectomy for their HCC. Among them, 229 patients were identified to have AD and 5303 were not. After excluding cases who died within 30 days of surgery, the estimated median overall survival (OS) was 43.8 months in the AD (+) group and 47.4 months in the AD (-) group (P = 0.367). The median liver-specific survival and disease-free survival (DFS) were also comparable between the two groups. After Cox regression multivariate analysis, the presence of AD did not lead to a higher risk of all-cause mortality, liver-specific mortality, or disease recurrence. CONCLUSION: Our study demonstrated that autoimmune disease does not impair the OS and DFS of HCC patients undergoing liver resections. AD itself is not a risk factor for tumor recurrence after surgery. Patients eligible for liver resections, as a result, should be considered for surgery irrespective of the presence of AD. Further studies are mandatory to validate our findings.
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Enfermedades Autoinmunes , Carcinoma Hepatocelular , Hepatectomía , Neoplasias Hepáticas , Humanos , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Carcinoma Hepatocelular/cirugía , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Masculino , Femenino , Hepatectomía/mortalidad , Enfermedades Autoinmunes/complicaciones , Enfermedades Autoinmunes/mortalidad , Enfermedades Autoinmunes/cirugía , Persona de Mediana Edad , Anciano , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estudios Retrospectivos , Factores de Riesgo , Adulto , Tasa de Supervivencia , PronósticoRESUMEN
INTRODUCTION: The influence of deranged body composition on stage I/II HCC after surgery remains undetermined. The current study aimed to investigate the impact of low skeletal muscle bulk and disturbed body fat mass on the recurrence outcome of stage I/II HCC patients undergoing liver resection. The associated metabolomic alterations were also assessed. METHODS: From 2012 to 2021, stage I and II HCC patients who underwent liver resection at our institute were retrospectively reviewed. Their preoperative body composition including skeletal muscle mass and body fat volume was measured by computed tomography (CT). The recurrence outcome was recorded and analyzed. The preoperative serum was collected and subjected to metabolomic analysis. RESULTS: A total of 450 stage I and II HCC patients were included in the current study. Among them, 76% were male and around 60% had HBV infection. After stratified by normal cutoff values obtained from a healthy cohort, 6.4% of stage I/II HCC patients were found to have a low psoas muscle index (PMI), 17.8% a high subcutaneous adipose tissue (SAT) index, and 27.8% a high visceral adipose tissue (VAT) index. Cox regression multivariate analysis further demonstrated that low PMI and high SAT index were independent prognostic factors for time-to-recurrence (TTR) after surgery. Metabolomic analysis discovered that free fatty acid ß-oxidation was enhanced in with low PMI or high SAT index. CONCLUSION: The current study demonstrated that reduced psoas muscle mass may impair while elevated SAT may prolong the TTR of stage I/II HCC patients undergoing liver resections. VAT, on the other hand, was not associated with recurrence outcome after surgery. Further studies are warranted to validate our findings.
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Purpose Intravenous sedation has been well accepted to allow dental restoration in uncooperative children while avoiding aspiration and laryngospasm; however, intravenous anesthetics such as propofol may lead to undesired effects such as respiratory depression and delayed recovery. The use of the bispectral index system (BIS), a monitoring system reflective of the hypnotic state, is con-troversial in the reduction in the risk of respiratory adverse events (RAEs), recovery time, the in-travenous drug dosage, and post-procedural events. The aim of the study is to evaluate whether BIS is advantageous in pediatric dental procedures. Methods A total of 206 cases, aged 2-8 years, receiving dental procedures under deep sedation with propofol using target-controlled infusion (TCI) technique were enrolled in the study. BIS level was not monitored in 93 children whereas it was for 113 children, among which BIS values were maintained between 50-65. Physiological variables and adverse events were recorded. Statistical analysis was conducted using Chi-square, Mann Whitney U, Independent Samples t and Wilcoxon signed tests, with a p value of <0.05 considered to be statistically significant. Results Although no statistical significance in the post-discharge events and total amount of propofol used was observed, a clear significance was identified in periprocedural adverse events (hypoxia, apnea, and recurrent cough, all p value < 0.05) and discharge time (63.4 ± 23.2 vs. 74.5 ± 24.0 min, p value < 0.001) between these two groups. Conclusions The application of BIS in combination with TCI may be beneficial for young children undergoing deep sedation for dental procedures.
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BACKGROUND: In periarterial sympathectomy for intractable Raynaud's phenomenon, the extent of adventitiectomy as well as postoperative outcomes and hand perfusion assessment tools remain debatable. We evaluated the outcome of neurectomy of the nerve of Henle combined with ulnar tunnel release and periarterial adventitiectomy in the treatment of refractory Raynaud's phenomenon using objective measurements and patient-reported outcomes. METHODS: Nineteen patients with 20 affected hands were prospectively enrolled and underwent the proposed procedures from 2015 to 2021. Relevant data, including Michigan Hand Outcomes Questionnaire and 36-Item Short Form health questionnaire scores, were documented for analysis during a 3-year follow-up. RESULTS: The average ingress value of the three measured fingers (index, long, and ring) on indocyanine green angiography increased after surgery (p=0.02). The median number of ulcers decreased (p<0.001) and the median digital skin temperature increased (p<0.001). Questionnaire scores showed improvement in physical aspects, such as overall hand function (p≤0.001), activities of daily living (p=0.001), work performance (p=0.02), pain (p<0.001), physical function (p=0.053), and general health (p=0.048), as well as mental aspects, such as patient satisfaction (p<0.001) and mental health (p=0.001). The average indocyanine green ingress value of the three measured fingers significantly correlated with the patient-reported outcomes, including overall hand function (r=0.46, p=0.04), work performance (r=0.68, p=0.001), physical function (r=0.51, p=0.02), and patient satisfaction (r=0.35, p=0.03). CONCLUSIONS: The proposed surgical procedures provided satisfactory outcomes, both subjectively and objectively, over a follow-up period of up to 3 years. Indocyanine green angiography may provide rapid and quantitative measurements for perioperative hand perfusion assessment.
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Surgical resection remains one of the most effective curative therapies for HCC. However, the majority of patients have advanced unresectable diseases upon presentation. It is of paramount importance to raise the resectability of patients with HCC. The remarkable objective response rate reported by Phase III IMbrave150 trial has led to the concept of "Atezo/Bev followed by curative conversion (ABC conversion)" for initially unresectable HCC. With this revolutionary treatment strategy, the concept of surgical resection for HCC should be amended. The current opinion illustrated three extended surgical concepts, which could be integrated into clinical practice in the era of immune checkpoint inhibitors (ICI).
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BACKGROUND: Opioids provide good analgesic effect in burn patients during acute phase, but these patients may develop tolerance after prolonged exposure. Alternative analgesic strategies such as peripheral nerve blocks appear to provide adequate pain control while sparing opioid-related side effects. The purpose of this study was to evaluate intravenous patient-controlled analgesia (IV-PCA) and continuous peripheral nerve block (CPNB-PCA) in severe burn patients with relatively young age undergoing repeated debridement and large-area full thickness skin graft (FTSG). METHODS: The records of victims in dust explosion in Taiwan in 2016 from Chang Gung Memorial Hospital Pain Service Database between 2016 June and 2017 December were evaluated. The patients' demographic data including age, gender, weight, burn area, degree of burn, type of PCA regimen (IV-PCA versus CPNB-PCA), size of FTSG, and adverse effects were collected. RESULTS: The total in-hospital morphine consumption was significantly lower in CPNB-PCA than IV-PCA group. A trend of decrease in numerical rating scores (NRS) was observed for both groups and CPNB group had comparable NRS than IV-PCA group at rest. On movement, CPNB grouped had significantly lower NRS than IV-PCA on post-operative day 3. CONCLUSION: Our study demonstrated that in patients requiring high dosage of opioid, CPNB may be a suitable alternative for pain control.
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Analgésicos Opioides , Quemaduras , Humanos , Analgésicos Opioides/uso terapéutico , Analgesia Controlada por el Paciente , Dolor Postoperatorio/tratamiento farmacológico , Analgésicos/uso terapéutico , Quemaduras/cirugía , Quemaduras/tratamiento farmacológico , Extremidad SuperiorRESUMEN
BACKGROUND: Topical pharyngeal anesthesia as an adjunct to intravenous sedation to facilitate gastroscopy has been widely acknowledged; however, its efficacy has not been established when it is used in patients under deep sedation with propofol. AIMS: To demonstrate the limited value of topical pharyngeal anesthesia in patients under moderate to deep sedation with propofol. METHODS: One hundred and twenty-nine patients undergoing gastroscopy were prospectively randomized to receive 10 % lidocaine or distilled water topical spray as an adjunct to intravenous propofol via target-controlled infusion. Verbal and somatic responsiveness, presence of gag reflex and hiccup to esophageal intubation, and the overall ease of the procedure were evaluated by the anaesthetists and gastroenterologists. Hemodynamic parameters including peripheral oxygen saturation, systolic/diastolic blood pressure (SBP/DBP), heart rate (HR), bispectral index, and SBP × HR were compared at 5 time points: on arrival, after 5 spontaneous breaths, when estimated brain concentration of propofol, Ce, reached 3.5 µg/ml, on esophageal intubation, and on awakening. RESULTS: No statistical difference was observed between the lidocaine and distilled water group in verbal or somatic responses, gag reflex or hiccups on esophageal intubation. Similarly, BIS, SBP, DBP, and HR showed no significant difference between the groups. CONCLUSIONS: The use of topical pharyngeal anesthesia in combination with target-controlled infusion with propofol in the performance of diagnostic gastroscopy might be eliminated without adversely affecting patient care or outcomes.
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Anestésicos Intravenosos , Anestésicos Locales/administración & dosificación , Gastroscopía , Lidocaína/administración & dosificación , Faringe/efectos de los fármacos , Propofol , Adulto , Aerosoles , Anciano , Anestesia Local , Presión Sanguínea , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Background: Adequate pain control is of crucial importance to patient recovery and satisfaction following abdominal surgeries. The optimal analgesia regimen remains controversial in liver resections. Methods: Three groups of patients undergoing open hepatectomies were retrospectively analyzed, reviewing intravenous patient-controlled analgesia (IV-PCA) versus IV-PCA in addition to bilateral rectus sheath and subcostal transversus abdominis plane nerve blocks (IV-PCA + NBs) versus patient-controlled thoracic epidural analgesia (TEA). Patient-reported pain scores and clinical data were extracted and correlated with the method of analgesia. Outcomes included total morphine consumption and numerical rating scale (NRS) at rest and on movement over the first three postoperative days, time to remove the nasogastric tube and urinary catheter, time to commence on fluid and soft diet, and length of hospital stay. Results: The TEA group required less morphine over the first three postoperative days than IV-PCA and IV-PCA + NBs groups (9.21 ± 4.91 mg, 83.53 ± 49.51 mg, and 64.17 ± 31.96 mg, respectively, p < 0.001). Even though no statistical difference was demonstrated in NRS scores on the first three postoperative days at rest and on movement, the IV-PCA group showed delayed removal of urinary catheter (removal on postoperative day 4.93 ± 5.08, 3.87 ± 1.31, and 3.70 ± 1.30, respectively) and prolonged length of hospital stay (discharged on postoperative day 12.71 ± 7.26, 11.79 ± 5.71, and 10.02 ± 4.52, respectively) as compared to IV-PCA + NBs and TEA groups. Conclusions: For postoperative pain management, it is expected that the TEA group required the least amount of opioid; however, IV-PCA + NBs and TEA demonstrated comparable postoperative outcomes, namely, the time to remove nasogastric tube/urinary catheter, to start the diet, and the length of hospital stay. IV-PCA with NBs could thus be a reliable analgesic modality for patients undergoing open liver resections.
RESUMEN
Background: Transarterial chemoembolization(TACE) is the suggested treatment for hepatocellular carcinoma (HCC) not amenable to curative treatments. We investigated the role of sarcopenia on overall survival in HCC patients receiving TACE and proposed a new prognostic scoring system incorporating sarcopenia. Materials and methods: We retrospectively analyzed 260 HCC patients who received TACE between 2010 and 2015. Total psoas muscle was measured on a cross-sectional CT image before the first TACE session. Sarcopenia was defined by the pre-determined sex-specific cutoff value. We assessed the impact of sarcopenia and other biochemical factors on the overall survival and compared the new scoring system with other prognostic scoring systems. Results: One hundred and thirty patients (50%) were classified as sarcopenia before the first TACE. They were older with a higher male tendency and a significantly lower body mass index (BMI). Cox regression multivariate analysis demonstrated that sarcopenia, multiple tumors, maximal tumor diameter≥ 5cm, major venous thrombosis, sarcopenia, AFP ≥ 200 ng/ml, and albumin<3.5mg/dL were independent poor prognostic factors for overall survival in HCC patients receiving TACE. Our scoring system comprising these factors outperformed other major scoring systems in terms of predicting survival after TACE. Conclusion: The current study demonstrated that sarcopenia was an independent prognostic factor for HCC undergoing TACE therapy. Our newly developed scoring system could effectively predict patient survival after TACE. Physicians could, based on the current score model, carefully select candidate patients for TACE treatment in order to optimize their survival. Further studies are warranted to validate our findings.
RESUMEN
BACKGROUND: In the 8th edition of American Joint Committee on Cancer (AJCC) staging system for hepatocellular carcinoma (HCC), tumor size is not considered in T1 stage. The present study aimed to find out the optimal cutoff for tumor size to further stratify patients with T1 HCC. METHODS: Operated HCC patients were identified from the Chang Gung Research Database (CGRD), and the patients with T1bN0M0 tumors were further divided into two groups based on the tumor size. The resulting subgroups were denoted as T1b (≤ cutoff) and T1c (> cutoff). The survivals were compared between T1a/b and T1c as well as T1c and T2. RESULTS: From 2002 to 2018, a total of 2893 patients who underwent surgery for T1N0M0 HCC were identified from the CGRD. After excluding cases who died within 30 days of surgery, Kaplan-Meier survival analysis discovered that T1 tumors > 65 mm (T1c) had survivals similar to those of T2N0M0 tumors. Cox regression multivariate analysis further demonstrated that tumor size > 6.5 cm was an independent poor prognostic indicator for T1 HCC. Sensitivity tests also confirmed that tumors lager than 6.5 cm were significantly more likely to develop both tumor recurrence and liver-specific death after surgery. CONCLUSIONS: Our study demonstrated that tumor size would significantly impact the survival outcome of T1 HCC after surgery. Due to significantly worse survival, we proposed a subclassification within T1 HCC, T1c: solitary tumor > 6.5 cm without vascular invasion, to further stratify those patients at risk. Further studies are mandatory to validate our findings.