The Change in the Fibrosis-4 Index for the Assessment of Liver Fibrosis After Pancreaticoduodenectomy.

OBJECTIVES: Nonalcoholic fatty liver is a complication of pancreaticoduodenectomy (PD); however, liver fibrosis after PD is not well documented. Therefore, we estimated the hepatic fibrotic index of nonalcoholic fatty liver after PD. METHODS: We retrospectively examined the electronic medical records of patients who had underwent PD and had computed tomography (CT) records preoperatively and 6 months postoperatively between 2011 and 2019 at the Shiga University of Medical Science Hospital. RESULTS: Overall, 115 patients were enrolled. After 6 months from PD, body mass index significantly decreased from 21.90 to 19.57 kg/m2 (-10.6%). The Fibrosis-4 (FIB-4) index significantly increased from 1.756 to 2.384 (P < 0.001). The FIB-4 grade significantly worsened. Contrarily, neither the albumin-bilirubin (ALBI) score nor the ALBI grade demonstrated significant differences. The CT attenuation value significantly decreased (P < 0.001) from 57.6 to 49.5. Multivariate analysis predicted a high preoperative FIB-4 index, high ALBI index, and hypo-CT attenuation value (<30 HU) as risk factors for a high postoperative FIB-4 index. CONCLUSIONS: The FIB-4 index worsened when the follow-up period was only 6 months, regardless of the eternalness in the ALBI score. Liver fibrosis should be assessed using the FIB-4 index for a long-term survivorship after PD.

Risk factors for and management of morbidity in pure laparoscopic resection of the right posterosuperior segments of the liver: A multicenter retrospective study.

BACKGROUND: This study aimed to determine the risk factors for severe postoperative complications in patients undergoing pure laparoscopic liver resection (LLR) for tumors in the right posterosuperior (PS) segments. METHODS: The study included 289 patients who underwent parenchyma-sparing pure LLR for tumors in the right PS segments at eight treatment centers between January 2009 and December 2019. RESULTS: Multivariate analysis revealed tumor size ≥3 cm (P = .016), segmentectomy (P = .044), and liver cirrhosis (P = .029) as independent risk factors for severe postoperative complications. The severe complication rates (2.7% vs 12.1%, P = .0025), median intraoperative blood loss (100 mL vs 150 mL, P = .001), and median operation time (248 minutes vs 299.5 minutes, P = .0013) were lower in the patients without all these three risk factors than those with at least one risk factor. The median length of postoperative hospital stay was shorter in patients with no risk factors than those with at least one risk factor (9 days vs. 10 days, P = .001). CONCLUSIONS: Tumor size ≥3 cm, segmentectomy, and liver cirrhosis were the risk factors for severe postoperative complications after parenchyma-sparing pure LLR for tumors in the right PS segments. Patients without these three risk factors would be appropriate candidates for safely performing parenchyma-sparing pure LLR in the right PS segments at the outset.

Preoperative Risk Assessment for Loss of Independence Following Hepatic Resection in Elderly Patients: A Prospective Multicenter Study.

OBJECTIVE: To establish a preoperative risk assessment method for loss of independence after hepatic resection. SUMMARY BACKGROUND DATA: Hepatic resection often results in loss of independence in preoperatively self-sufficient elderly people. Elderly patients should therefore be carefully selected for surgery. METHODS: In this prospective, multicenter study, 347 independently-living patients aged ≥65 years, scheduled for hepatic resection, were divided into study (n = 232) and validation (n = 115) cohorts. We investigated the risk factors for postoperative loss of independence in the study cohort and verified our findings with the validation cohort. Loss of independence was defined as transfer to a rehabilitation facility, discharge to residence with home-based healthcare, 30-day readmission for poor functionality, and 90-day mortality (except for cancer-related deaths). RESULTS: In the study cohort, univariate and multivariate analyses indicated that frailty, age ≥ 76 years, and open surgery were independent risk factors for postoperative loss of independence. Proportions of patients with postoperative loss of independence in the study and validation cohorts were respectively 3.0% and 0% among those with no applicable risk factors, 8.1% and 12.5% among those with 1 applicable risk factor, 25.5% and 25.0% among those with 2 applicable risk factors, and 56.3% and 50.0% among those with all 3 factors applicable (P < 0.001 for both cohorts). Areas under the receiver operating characteristic curves for the study and validation groups were 0.777 and 0.783, respectively. CONCLUSIONS: Preoperative risk assessments using these 3 factors may be effective in predicting and planning for postoperative loss of independence after hepatic resection in elderly patients.

Preoperative Risk Assessment for Delirium After Hepatic Resection in the Elderly: a Prospective Multicenter Study.

BACKGROUND: Hepatic resection often results in delirium in preoperatively self-sufficient elderly people. The association of frailty with postoperative delirium remains unclear, and preoperative risk assessment, including frailty, of postoperative delirium has not been established. METHODS: This prospective multicenter study included 295 independently living patients aged ≥ 65 years scheduled for initial hepatic resection. All patients answered the phenotypic frailty index Kihon Checklist, which is a self-reporting list of 25 questions, within a week before surgery. The risk factors for postoperative delirium were investigated. Patients who scored ≥ 4 in the Intensive Care Delirium Screening Checklist were designated as having postoperative delirium. RESULTS: Delirium developed after liver resection in 22 of 295 patients (7.5%). Total Kihon Checklist score (≥ 6 points), age (≥ 75 years), and serum albumin concentration (≤ 3.7 g/dL) were the independent risk factors for postoperative delirium. The proportion of patients with postoperative delirium was 0% in those with no applicable risk factors, 3.2% in those with one applicable risk factor, 12.0% in those with two applicable risk factors, and 40.9% in those with all three factors (p < 0.001). The area under the receiver operating characteristic curve for this risk assessment for predicting postoperative delirium was 0.842. CONCLUSION: The use of these three factors for preoperative risk assessment may be effective in predicting and preparing for delirium after hepatic resection in elderly patients.

Assessment of Body Composition From CT Images at the Level of the Third Lumbar Vertebra in Inflammatory Bowel Disease.

BACKGROUND: Although there are several reports of associations between body composition parameters and outcomes in patients with inflammatory bowel disease (IBD), it is not clear which muscle tissue parameters and/or adipose tissue parameters most strongly affect outcomes. Therefore, this study sought to determine the associations of such parameters determined at the level of the third lumbar vertebra (L3) on computed tomography (CT) images with outcomes in IBD patients. METHODS: Subjects were IBD patients who were admitted to our hospital and underwent abdominal CT. The following parameters were assessed: skeletal muscle index, psoas muscle index, visceral adipose tissue/height index, visceral to subcutaneous adipose tissue area ratio, and intramuscular adipose tissue content. In this study, short- and long-term outcomes were defined as prolonged length of stay (≥30 days) and intestinal resection during the overall period of observation, respectively. RESULTS: In total, 187 patients were enrolled, 99 with Crohn's disease and 88 with ulcerative colitis. For all IBD patients, multivariate logistic regression analysis revealed that low albumin level and low psoas muscle index on admission were associated with prolonged length of stay. Multivariate Cox regression analysis revealed that male sex, Crohn's disease (not ulcerative colitis), low psoas muscle index, and high visceral to subcutaneous adipose tissue area ratio were associated with intestinal resection. CONCLUSIONS: This study revealed that muscle volume is associated with the short-term outcome of prolonged length of stay, whereas muscle volume and visceral adipose tissue volume (relative to subcutaneous adipose tissue volume) are associated with the long-term outcome of intestinal resection.

Preoperative assessment of frailty predicts age-related events after hepatic resection: a prospective multicenter study.

BACKGROUND: Age-related events, such as cardiopulmonary complications, delirium, transfer to a rehabilitation facility, and dependency are a major problem after hepatic resection in the elderly. This prospective multicenter study aimed to preoperatively evaluate frailty in the elderly according to a phenotypic frail index, named the "Kihon Checklist (KCL)," to predict "age-related events" after hepatic resection. METHODS: Between May 2016 and September 2017, 217 independently living patients who consented among all patients aged ≥65 years who planned to undergo hepatic resection were included in the study. Preoperative frailty was defined as a total KCL score ≥8. We analyzed clinical characteristics and outcomes, including age-related events (major respiratory and cardiac complications, delirium medication needed, transfer to rehabilitation facility, and dependency) between patients with and without frailty. RESULTS: Of the 217 patients, 63 and 154 were classified into the frail and non-frail groups, respectively. The incidences of age-related events (31.7% vs. 7.8%, P < 0.001) were higher in the frail group. Multivariate analysis indicated that frailty (P < 0.001, hazard ratio 5.16) and resection of ≥2 sectors (P = 0.014, hazard ratio 2.98) were independent risk factors for age-related events. CONCLUSIONS: Frailty evaluated by KCL in the elderly can predict postoperative age-related events after hepatic resection.

Geriatric assessment as a predictor of postoperative complications in elderly patients with hepatocellular carcinoma.

BACKGROUND: Older patients are considered to have increased risk for complications after major surgery, but age alone is not a reliable predictor of postoperative complications. However, no universal screening test adequately predicts postoperative complications in older patients. This prospective study recorded pertinent baseline geriatric assessment variables to identify risk factors for postoperative complications in hepatocellular carcinoma (HCC) for patients aged ≥70 years who undergo hepatectomy. METHODS: We retrospectively analyzed 71 consecutive patients ≥70 years of age. Patients had geriatric assessments of baseline and later cognition, nutritional and functional status, and burden of comorbidities, completed preoperatively and at 1, 3, and 6 months postoperatively. Postoperative morbidities were recorded. RESULTS: Postoperative morbidities developed in 18 patients (25 %). Univariate analysis identified serum albumin, operating time and blood loss, cirrhosis, geriatric 8 (G8), and Mini Nutritional Assessment as possible risk factors for postoperative complications, but only G8 < 14 survived multivariate analysis as an independent predictor of complications. CONCLUSIONS: Our findings indicate that the G8 score, based on patients' nutritional assessments, is a useful screening method for older HCC patients who qualify for elective liver resection. Preoperative G8 scores can help forecast postoperative complications in older HCC patients. Future studies with larger numbers of patients, limited to HCC and liver resections, are needed to verify our results.

[OBJECTIVE ASSESSMENT OF POSTOPERATIVE PAIN AFTER DIGESTIVE TRACT SURGERY].

Pain is a sensation associated with subjective factors, making it difficult to measure and assess. Currently, there is no widely accepted method of objectively assessing pain, and therefore subjective assessments such as the Visual Analogue Scale (VAS) are generally used. The PainVision system has been developed for the quantitative analysis of pain and comparison of postoperative pain intensity. In this study, we investigated whether postoperative pain could be objectively assessed using this system in digestive tract surgery patients. Pain scores were measured with the VAS, the PainVision system, and the short-form McGill Pain Questionnaire in patients undergoing open or laparoscopic hepatectomy, open or laparoscopic gastrectomy, and laparoscopic cholecystectomy. As measured using the PainVision system, postoperative pain intensity was lower in patients who underwent laparoscopic surgery compared with open hepatectomy. In open hepatectomy patients, pain intensity measured by the PainVision system was significantly lower on postoperative days (POD) 7 and 10 than on POD 1. Preemptive use of nonsteroidal antiinflammatory drugs significantly reduced postoperative pain in open hepatectomy patients. The results showed that PainVision effectively quantifies pain intensity after digestive tract surgery. Objective assessment of postoperative pain may lead to earlier mobility and improved quality of life.