Multimodal prehabilitation in older adults before major abdominal surgery: a systematic review and meta-analysis.

PURPOSE: Multimodal prehabilitation aims to prepare frail older patients for major surgery. The objective of this review is to determine the benefits of pre-operative multimodal prehabilitation compared to standard care in older patients. METHODS: Data sources included MEDLINE, EMBASE, CENTRAL, CINAHL and PsychINFO. They were searched from inception to September 2021. Only randomized controlled trials (RCT) with an average study population age ≥ 65 that had undergone major abdominal operation with at least two components (physical, nutritional, psychological) of prehabilitation programs were included. RESULTS: Nine RCTs were included with a total of 823 patients, of whom 705 completed the study with 358 undergoing prehabilitation and 347 were controls. Significantly lower complications were observed in the prehabilitation group compared to control (OR 0.67; 95% CI 0.46 to 0.99; p = 0.04; I2 = 32%). A significant increase in 6-min walking distance (6MWD) from baseline to immediately prior to surgery (mean difference 35.1 m; 95%CI 11.6-58.4; p = 0.003; I2 = 67%) and 8 weeks post-surgery (mean difference 44.9 m; 95%CI 6.0-83.8; p = 0.02; I2 = 75%) was noted in the prehabilitation group. No difference was observed in length of stay (OR 0.59; 95% CI - 0.23 to 1.40; p = 0.16; I2 = 91%) or 30-day emergency department visit (OR 0.72; 95% CI 0.41 to 1.26; p = 0.25; I2 = 0%). Patient reported outcome measures were not significantly different. CONCLUSIONS: Amongst older patients, multimodal prehabilitation increases peri-operative functional capacity and may potentially decrease post-operative complications. Future studies should continue to focus on older patients who are frail as this is the group that prehabilitation would likely have a clinically significant impact on.

Living donor hepatectomy in medium volume liver transplant centre has comparable outcomes to high volume centres: validation of donabedian quality assurance framework.

BACKGROUND: Given the complexity of living donor hepatectomy, it is expected that high hospital volume will better outcomes. This study aims to evaluate post-operative outcomes for living donor hepatectomy in a medium volume liver transplant centre and compare to outcomes in high volume centres. Also, it serves as a validation tool for framework of structure-process-outcome model for safe living donor hepatectomy program. METHODS: 204 donors who underwent donor hepatectomy between June 1996 to September 2019 were reviewed retrospectively and compared to outcomes in high volume centres. RESULTS: At 6 months, overall donor morbidity rate was 20/204 (9.8%). Wound complications were most common at 5/204 (2.5%). Majority of complications were either Clavien grade 1 or 2 and only 3 donors had Clavien grade 3 complications. There was zero donor mortality. DISCUSSION: Our centre's donor morbidity rate of 9.8% is the one of the lowest reported in the published literature. With increased experience, stringent donor selection and enhanced perioperative care by a multi-disciplinary team, outcomes in a medium volume centre can match the outcomes reported in high volume centres. The framework for quality in terms of structure, process and outcomes is presented which can be adopted for developing programs.

The influence of the middle hepatic vein and its impact on outcomes in right lobe living donor liver transplantation.

BACKGROUND: In adult right lobe living donor liver transplantation, the decision to include the middle hepatic vein (MHV) remains controversial. METHODS: A retrospective analysis of 50 R-LDLTs between January 2008 and June 2016 was performed. RESULTS: Twenty-one procedures were performed using a MHV+ graft (42.0%) and 29 procedures using a MHV- graft (58%). MHV- donors were taller (173 vs 166 cm, p = 0.004) with a larger standard liver volume (1351 vs 1245 mls, p = 0.014) compared to MHV+ donors. The duration of operation for donors was significantly longer in the MHV+ group (530 (313-975) mins) compared to the MHV- group (489 (336-708) mins) (p = 0.029). Similarly, the operative time for recipients was longer in the MHV+ group (660 (428-831) mins) compared to MHV- (579 (359-1214) mins) (p = 0.023). MHV- grafts were heavier compared to MHV+ grafts (918 vs 711 g, p = 0.017). Recipient mortality rates and Kaplan-Meier survival analysis were comparable (p = 0.411). All donors were well at last review. CONCLUSION: Both MHV+ and MHV- grafts are safe for the donor and recipient. The decision to take the MHV should be based on specific donor-recipient characteristics.

Does persistent anti-HBc positivity influence the prognosis of HBsAg-negative hepatocellular carcinoma? comparative outcomes of anti-Hbc positive versus anti-Hbc negative non-B non-C HCC.

BACKGROUND: To compare the presentations and outcomes of anti-HBc seropositive Hepatocellular Carcinoma (HBc-HCC) with anti-HBc seronegative (NHBc-HCC) patients in HBsAg negative Non-HBV Non-HCV (NBNC-HCC) HCC population. METHODS: 515 newly diagnosed HCC patients from January 2011 to September 2016 were retrospectively reviewed. 145 (66.5%) NHBc-HCC and 73 (33.5%) HBc-HCC patients were identified. Patient demographics, disease characteristics, details of treatments, recurrence and survival outcomes were analysed. RESULTS: A significantly lower proportion of HBc-HCC patients were diagnosed through surveillence (6.8% vs 26.2%, p = 0.001). HBc-HCC patients were less likely cirrhotic (p < 0.001), portal hypertensive (p < 0.001), ascitic (p = 0.008) and thrombocytopenic (p = 0.003). A higher proportion of HBc-HCC patients had treatment with curative intent (46.6% vs 30.3%, p = 0.018) and surgery (39.7% vs 16.6%, p < 0.001). Although HBc-HCC patients had larger median tumor size (74.0 mm vs 55.0 mm, p = 0.016) with a greater proportion of patients having tumors ≥5 cm, there was no difference in the overall median survival (19.0 months vs 22.0 months, p = 0.919) and recurrence rates (38.2% vs 40.9%). CONCLUSION: Isolated anti-HBc seropositivity in HbsAg negative patients tend to present incidentally with delayed diagnoses resulting in larger tumors, but their long-term survival remain comparable.

Outcomes of Percutaneous Cholecystostomy for Acute Cholecystitis.

BACKGROUND: Acute cholecystitis (AC) is an important cause of emergency admissions among the elderly. The use of percutaneous cholecystostomy (PC) as bridging therapy among high-risk patients is widely accepted. However, the use of PC as definitive treatment is controversial. AIM: To determine the characteristics, clinical outcomes and predictors of recurrence of AC among patients who underwent PC. METHODS: A retrospective case series of 71 consecutive patients [73 (38-96) years, 43/71 males] treated with PC for AC at a tertiary hospital from 2007 to 2013, with data collected from case records. RESULTS: Patients were followed up for 37.0 (0.1-110.8) months after PC. Mortality rate was 8.5 % (6/71) during the index admission and 32.4 % (23/71) at the end of follow-up. Recurrence rate for AC was 11.9 % (7/59). Median time to recurrence was 62 (13-464) days. PC was definitive treatment in 33/59. Predictors of recurrence were higher serum alkaline phosphatase (ALP) at diagnosis (OR = 1.01, 95 % CI 1.00-1.02, p = 0.021) and acute myocardial infarction (AMI) during index admission (OR = 8.00, 95 % CI 1.19-54.0, p = 0.033). Fifteen patients (26.3 %, 15/71) had post-procedural complications including dislodgement (14 %, 10/71), tube obstruction (7.0 %, 5/71), bile leaks (2.8 %, 2/71), gallbladder perforation (1.4 %, 1/71), bowels perforation (1.4 %, 1/71) and severe post-procedural haemorrhage (1.4 %, 1/71). CONCLUSION: PC is effective and relatively safe in high-risk patients with AC. However, patients with higher ALP or AMI during index admission have higher risk of recurrence and might benefit from definitive cholecystectomy.

Safely Implementing a Program of Pure Laparoscopic Donor Right Hepatectomy: The Experience From a Southeast Asian Center.

Laparoscopic donor right hepatectomy (LDRH) is a technically challenging procedure. There is increasing evidence demonstrating the safety of LDRH in high-volume expert centers. We report our center's experience in implementing an LDRH program in a small- to medium-sized transplantation program. Methods: Our center systematically introduced a laparoscopic hepatectomy program in 2006. We started with minor wedge resections followed by major hepatectomies with increasing complexities. In 2017, we performed our first laparoscopic living donor left lateral sectionectomy. Since 2018, we have performed 8 cases of right lobe living donor hepatectomy (laparoscopy-assisted: 4 and pure laparoscopic: 4). Results: The median operative time was 418 (298-540) min, whereas the median blood loss was 300 (150-900) mL. Two patients (25%) had surgical drain placed intraoperatively. The median length of stay was 5 (3-8) d, and the median time to return to work was 55 (24-90) d. None of the donors sustained any long-term morbidity or mortality. Conclusions: Small- to medium-sized transplant programs face unique challenges in adopting LDRH. Progressive introduction of complex laparoscopic surgery, a mature living donor liver transplantation program, appropriate patient selection, and the invitation of an expert to proctor the LDRH are necessary to ensure success.

Impact of donor age on recipient morbidity and mortality after living donor liver transplantation.

BACKGROUND: Evidence for use of graft from older donors in living donor liver transplantation (LDLT) has been conflicting. This study aims to clarify the impact of donor age on recipient morbidity and mortality after adult LDLT. METHODS: A total of 90 live liver donors and recipients who underwent primary adult-to-adult LDLT were divided into three groups according to donor age: donors in 20s (D-20s) group, donors in 30s and 40s (D-30s and 40s) group and donors in 50s & 60s (D-50s and 60s) group. Multivariate analyses were conducted to look for independent risk/prognostic factors. Donor age was analysed as a continuous variable to determine an optimal cut off. RESULTS: Overall donor morbidity was 4/90 (4.44%), major donor morbidity was 1/90 (1.11%) and there was no donor mortality. Recipients in the D-20s group had better 1-, 3- and 5-year recipient survival than recipients in the D-50s and 60s group (96%, 91%, 91% versus 73%, 58%, 58%, respectively) (P = 0.020). Donor age was identified to be an independently significant risk factor for increased major complications (P = 0.007) and prognostic factor for reduced overall survival (P = 0.014). The optimal donor age cut off was determined to be 46.5 years old. CONCLUSION: Older donors are associated with poorer recipient outcomes after adult-to-adult LDLT. Usage of liver grafts from older donors should be carefully considered when choosing liver grafts for patients undergoing LDLT.

Evaluation of Adult Living Donor Liver Transplantation in Largest Southeast Asian Transplantation Center: Benchmarking With Adult-to-Adult Living Donor Liver Transplantation (A2ALL) Experience.

BACKGROUND: The volume-outcome relation for complex surgical procedures such as living donor liver transplantation (LDLT) generally favors high volume (HV) centers. It is important for low to medium volume (MV) centers to evaluate their centers' performance against HV centers to allow early detection and correction of potential systemic issues. There is a dearth of national and international comprehensive registries for LDLT that may allow reasonable risk-adjusted comparisons for benchmarking. This study aims to evaluate the LDLT program by comparing our center's performance against HV centers of the Adult-to-Adult Living Donor Liver Transplantation cohort. STUDY DESIGN: Patient outcomes from a MV transplant center were compared with 11 HV transplant centers from the Adult-to-Adult Living Donor Liver Transplantation cohort. Outcomes evaluated included length of hospital stay, same admission mortality, 90-day mortality, and overall survival. RESULTS: A total of 1381 patients were analzyed. HV 1 to 4, 6, 8, 9, and 11 centers had a shorter median length of hospital stay compared with the MV center (All Dunnett corrected P values all less than .05). HV 9 and 11 centers had lower same admission mortality compared with the MV center (Dunnett corrected P = .023 and .015). After adjusting for other significant predictors, the MV center had comparable 90-day mortality rates and overall survival rates to all HV centers. CONCLUSION: This benchmarking exercise has demonstrated that the limitation of low institutional case volume can be overcome with a protocol-based framework to implement a safe LDLT program. This framework presented can be adopted for developing programs.

Liver lesions detected in a hepatitis B core total antibody-positive patient masquerading as hepatocellular carcinoma: a rare case of peliosis hepatis and a review of the literature.

Peliosis Hepatis (PH) is a rare vascular disorder of the liver, characterized by the presence of cystic blood-filled cavities distributed throughout the hepatic parenchyma. The pathogenesis of PH remains controversial. The preoperative diagnosis of PH is difficult, due to the non-specific imaging characteristics of PH and almost all cases are diagnosed on histology post resection. This study presents a case of PH masquerading as hepatocellular carcinoma (HCC). The patient is a 45-year old Chinese lady, who presented with transaminitis. She was found to be hepatitis B virus core total antibody-positive with an alpha-fetoprotein (AFP) of 29.4 ng/ml. Triphasic liver computed tomography showed several arterial hypervascular lesions and hypoenhancing lesions on the venous phase, particularly in the segments 6/7. Subsequently, a magnetic resonance imaging scan showed multiple lesions in the right hemiliver with an indeterminate enhancement patterns. Subsequently, she decided to undergo a resection procedure. Histopathology revealed findings consistent with PH with some unusual features. This case demonstrates a clinical conundrum, in which PH presented with a raised AFP, in a patient with risk factors for the development of HCC. The clinical suspicion of PH should be high in patients, who present with multiple hepatic lesions with variable enhancement patterns.