Prospective study to evaluate the prognostic value of different nutritional assessment scores in liver surgery: NURIMAS Liver (DRKS00006340).

BACKGROUND: Malnutrition is recognised as a preoperative risk factor for patients undergoing hepatic resection. It is important to identify malnourished patients and take preventive therapeutic action before surgery. However, there is no evidence regarding which existing nutritional assessment score (NAS) is best suited to predict outcomes of liver surgery. METHODS: All patients scheduled for elective liver resection at the surgical department of the University Hospital of Heidelberg and the Municipal Hospital of Karlsruhe were screened for eligibility. Twelve NASs were calculated before operation, and patients were categorised according to each score as being either at risk or not at risk for malnutrition. The association of malnutrition according to each score and occurrence of at least one major complication was the primary endpoint, which was achieved using a multivariate logistic regression analysis including established risk factors in liver surgery as covariates. RESULTS: The population consisted of 182 patients. The percentage of patients deemed malnourished by the NAS varied among the different scores, with the lowest being 2.20% (Mini Nutritional Assessment) and the highest 52.20% (Nutritional Risk Classification). Forty patients (22.0%) had a major complication. None of the scores were significantly associated with major complications. CONCLUSIONS: None of the twelve investigated NAS defined a state of malnutrition that was independently associated with postoperative complications. Other means of measuring malnutrition in liver surgery should be investigated prospectively.

Risk assessment for liver resection.

BACKGROUND: In recent years, the profile for patients undergoing complex liver resections has changed, with mortality rates remaining generally stable. With these factors in mind, the objective of this study was to evaluate the variables associated with surgical outcomes after hepatectomy and identify groups at high risk for postoperative mortality. METHODS: The records of 1,796 patients who underwent liver resection of more than one liver segment at the Department of General and Transplantation Surgery, University Hospital Heidelberg, Germany, were analyzed. The primary end point was a 90-day in-hospital mortality. Logistic regression analyses were performed to identify risk factors associated with mortality. A risk score was created in accordance with weighted points based on the odds ratios obtained from multivariate logistic regression analyses. External validation of the score was performed, using data derived from 281 patients at the board-certified center for liver surgery in Karlsruhe, Germany. RESULTS: The overall patient morbidity rate (Clavien-Dindo Grade II or greater) was 32%. The 30- and 90-day mortality rates were 3.0% and 4.5%, respectively. In multivariate analysis, factors independently associated with risk for 90-day in-hospital mortality were age ≥60 years (OR 3.71), ASA classification III (OR 2.94), ASA IV (15.66), perihilar cholangiocarcinoma (OR 5.65), intrahepatic cholangiocarcinoma (OR 3.08), INR ≥ 1.1 (OR 2.43), g-GT ≥ 60 U/L (OR 2.86), platelet count ≤ 120/nL (OR 5.52), creatinine ≥ 2 mg/dL (OR 9.85), and right trisectionectomy (OR 2.88). The 90-day mortality-risk score that was created based on these factors effectively stratified patients into very low risk (0-1 points, 0.2% mortality rate in 662 patients), low risk (2-3 points, 2.9% mortality rate in 769 patients), medium risk (4-5 points, 14.7% mortality rate in 232 patients), and high risk (≥6 points, 33% mortality rate in 57 patients) groups (P < .0001). As a performance metric, the C-index for the proposed risk score for 90-day mortality was 0.86; whereas external validation revealed that this C-index was 0.89 (P = .0002). CONCLUSION: Based on patient-related factors and procedure-specific variables, the proposed preoperative-risk score can be used to identify high-risk patients to determine 90-day mortality after liver resection.

Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304).

OBJECTIVE: Acute cholecystitis is a common disease, and laparoscopic surgery is the standard of care. BACKGROUND: Optimal timing of surgery for acute cholecystitis remains controversial: either early surgery shortly after hospital admission or delayed elective surgery after a conservative treatment with antibiotics. METHODS: The ACDC ("Acute Cholecystitis-early laparoscopic surgery versus antibiotic therapy and Delayed elective Cholecystectomy") study is a randomized, prospective, open-label, parallel group trial. Patients were randomly assigned to receive immediate surgery within 24 hours of hospital admission (group ILC) or initial antibiotic treatment, followed by delayed laparoscopic cholecystectomy at days 7 to 45 (group DLC). For infection, all patients were treated with moxifloxacin for at least 48 hours. Primary endpoint was occurrence of predefined relevant morbidity within 75 days. Secondary endpoints were as follows: (1) 75-day morbidity using a scoring system; (2) conversion rate; (3) change of antibiotic therapy; (4) mortality; (5) costs; and (6) length of hospital stay. RESULTS: Morbidity rate was significantly lower in group ILC (304 patients) than in group DLC (314 patients): 11.8% versus 34.4%. Conversion rate to open surgery and mortality did not differ significantly between groups. Mean length of hospital stay (5.4 days vs 10.0 days; P < 0.001) and total hospital costs (€2919 vs €4262; P < 0.001) were significantly lower in group ILC. CONCLUSIONS: In this large, randomized trial, laparoscopic cholecystectomy within 24 hours of hospital admission was shown to be superior to the conservative approach concerning morbidity and costs. Therefore, we believe that immediate laparoscopic cholecystectomy should become therapy of choice for acute cholecystitis in operable patients. (NCT00447304).