ABSTRACT
BACKGROUND: The Roux-en-Y gastric bypass (RYGB) is considered as one of the most effective treatments for people with obesity. A variant of this procedure, the banded-RYGB, may present several advantages over the standard technique. These potential benefits include enhanced weight loss, decreased recurrent weight gain, a lower incidence of dumping syndrome, and less distention of the jejunum below the gastrojejunostomy. OBJECTIVES: The objective of this meta-analysis is to compare the surgical outcomes of RYGB procedures with a band (banded-RYGB) and without a band (RYGB) in the management of individuals with obesity. SETTING: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane protocol (PROSPERO ID: CRD42023439874). METHOD: The systematic review process led to the identification of 13 comparative studies involving 3230 patients who underwent banded-RYGB and 5302 who received RYGB, all of which were eligible for inclusion and meta-analysis. RESULTS: Four studies reported data on 1-year postoperative percent excess weight loss (%EWL), demonstrating a significant increase of 6.03 %EWL in patients who underwent banded-RYGB. Four studies reported the 2-year postoperative %EWL, showing that patients who had banded-RYGB experienced a 5.32 greater %EWL compared to those who received RYGB, even if this was not statistically significant. For 5-year %EWL after bariatric surgery, 5 studies were included for continuous outcome meta-analysis. The average 5-years %EWL difference was 7.6 in favor of banded-RYGB. Patients who had banded-RYGB presented a nonsignificant 1.45 OR of developing postoperative complications compared to patients receiving RYGB. CONCLUSION: This meta-analysis demonstrates that, compared to RYGB, patients who underwent banded-RYGB surgery showed a statistically significant increase in the %EWL at 1, 2, and 5 years postoperatively. Moreover, the banding procedure does not significantly increase the risk of postoperative complications.
ABSTRACT
BACKGROUND: Huge (>10 cm) hepatocellular carcinoma is burdened by elevated mortality due to its peculiar characteristics and delayed diagnosis. Liver resection is considered the gold standard although survival is poor. Recently, some different strategies have been evaluated to improve results in tumor recurrence and survival. The aim of this research is to identify which strategy offers the best results in terms of overall survival for resectable huge hepatocellular carcinoma. METHODS: A systematic review and network meta-analysis of 13 studies was conducted from PubMed, Embase, Scopus, Cochrane Library, and Web of Science databases including research comparing two or more treatments to manage huge hepatocellular carcinoma. Results were synthesized through forest plots and risk of bias assessed with the CINeMA framework as recommended. RESULTS: The association of liver resection and transcatheter arterial chemoembolization confers a significant improvement in survival compared to liver resection alone (HR: 0.55) while transcatheter arterial chemoembolization, radioembolization, and ethanol ablation alone were associated to decreased overall survival. Within-study bias, indirectness and incoherence were the domains mainly affected by concerns in risk of bias analysis. CONCLUSION: Multimodal treatment including liver resection and transcatheter arterial chemoembolization increases survival in patients with resectable huge hepatocellular carcinoma.
Subject(s)
Carcinoma, Hepatocellular , Chemoembolization, Therapeutic , Hepatectomy , Liver Neoplasms , Network Meta-Analysis , Humans , Carcinoma, Hepatocellular/therapy , Carcinoma, Hepatocellular/mortality , Carcinoma, Hepatocellular/pathology , Combined Modality Therapy , Liver Neoplasms/therapy , Liver Neoplasms/mortality , Liver Neoplasms/pathology , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: The impact of cirrhosis on the postoperative outcomes of distal pancreatectomy is yet to be reported. We aimed to evaluate the outcomes of distal pancreatectomy in patients with cirrhosis. METHODS: We conducted a retrospective, multicentric study patients with cirrhosis who underwent planned distal pancreatectomy between 2008 and 2020 in French high volume centers. Patients with cirrhosis were matched 1:4 for demographic, surgical, and histologic criteria with patients without cirrhosis. The primary endpoint was severe morbidity (Clavien-Dindo grade ≥III). The secondary endpoints were postoperative complications, specifically related to cirrhosis and pancreatic surgery, and survival for patients with pancreatic adenocarcinoma. RESULTS: Overall, 32 patients with cirrhosis were matched with 128 patients without cirrhosis. Most patients (93.5%) had Child-Pugh A cirrhosis. The severe morbidity rate after distal pancreatectomy was higher in patients with cirrhosis than in those without cirrhosis (28.13% vs 25.75%, P = .11. The operative time was significantly longer in the cirrhotic group compared with controls (P = .01). However, patients with and without cirrhosis had comparable blood loss and conversion rates. Postoperatively, the two groups had similar rates of pancreatic fistula, hemorrhage, reoperation, postoperative mortality, and survival rates at 1, 3, and 5 years. CONCLUSION: The current study suggests that distal pancreatectomy in high-volume centers is feasible for patients with compensated cirrhosis.
Subject(s)
Liver Cirrhosis , Pancreatectomy , Pancreatic Neoplasms , Postoperative Complications , Humans , Pancreatectomy/adverse effects , Male , Female , Retrospective Studies , Middle Aged , Aged , Liver Cirrhosis/complications , Liver Cirrhosis/surgery , Liver Cirrhosis/mortality , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Pancreatic Neoplasms/surgery , Pancreatic Neoplasms/mortality , Pancreatic Neoplasms/complications , Treatment Outcome , Operative Time , Survival Rate , Adenocarcinoma/surgery , Adenocarcinoma/mortality , Adenocarcinoma/complicationsABSTRACT
BACKGROUND: Obesity is associated with nonalcoholic steatohepatitis (NASH), which leads to an increased rate of primary liver cancers, cirrhosis, and decreased life expectancy. Metabolic/bariatric surgery (MBS) determines long-term weight loss and the resolution of obesity-related medical problems. OBJECTIVE: The aim of this study was to evaluate the impact of MBS on liver histologic features in individuals with obesity. SETTING: Tertiary referral university hospital. METHODS: We retrospectively analyzed data on 37 patients undergoing MBS from a prospectively held database. All patients had a liver biopsy at the time of MBS and a second liver biopsy in case of further surgery or for NASH follow-up. Eighteen patients had NASH on the first liver biopsy. The primary endpoint was the resolution of steatohepatitis without worsening of fibrosis on the second liver biopsy. Secondary endpoints were the evolution of liver steatosis, hepatocyte ballooning, nonalcoholic fatty liver disease activity score, and biochemical parameters from the time of the first to the second liver biopsy. RESULTS: Fifteen (83.3%) patients had significant resolution of steatohepatitis (P < .001) without fibrosis worsening. There was a statistically significant improvement of all blood tests except for low-density lipoprotein, alkaline phosphatases, and bilirubinemia. The Homeostatic Model Assessment (HOMA) index was significantly improved after MBS (P < .001), and circulating insulin and leptin concentrations were significantly reduced. Mean weight loss was 47 kg, with a 16.6 kg/m2 body mass index reduction and a % of total weight loss (%TWL) of 40.3 ±14% from the moment of MBS to the last follow-up. CONCLUSION: MBS is effective in determining NASH regression without fibrosis worsening and in reducing HOMA index and leptin and insulin concentrations.
Subject(s)
Bariatric Surgery , Non-alcoholic Fatty Liver Disease , Obesity, Morbid , Weight Loss , Humans , Non-alcoholic Fatty Liver Disease/surgery , Non-alcoholic Fatty Liver Disease/etiology , Female , Male , Retrospective Studies , Middle Aged , Adult , Obesity, Morbid/surgery , Obesity, Morbid/complications , Treatment Outcome , Remission Induction , BiopsyABSTRACT
BACKGROUND: Laparoscopic liver resection (LLR) is the gold standard for liver resections. Despite its feasibility and safety in high-volume centers (HVC), its performance is controversial in low-volume centers (LVCs). We aimed to evaluate the results of LLR performed in LVC. METHODS: Patients who underwent LLR between 2013 and 2019 in three LVCs were compared after case-matching with those in an HVC using the Institut Mutualiste Montsouris LLR Difficulty Score (IMMLDS). RESULTS: Seventy-six patients treated in three LVCs were matched to 152 in HVCs for age, body mass index, and resection type. The incidence of LLR significantly increased in LVCs over time (2013-2016 vs. 2017-2019) (21.2% vs. 39.3%; p = 0.002 and) while abdominal drainage rate decreased (77.4% vs. 51.1%; p = 0.003). In IMMLDS group I (60 vs. 120 patients), higher Pringle maneuver (43.3% vs. 2.5%; p < 0.0001), median blood loss (175 ml vs. 50 ml; p < 0.0001), abdominal drainage (58.3% vs. 6.6%; p < 0.0001), and conversion rate (8.3% vs. 1.6%, p = 0.04) were observed in LVCs. The overall postoperative morbidity was comparable (Clavien I-II: p = 0.54; Clavien > II: p = 0.71). In IMMLDS groups II-III, Pringle maneuver (56.5% vs. 3.1%; p < 0.0001), blood loss (350 ml vs. 175 ml; p = 0.02), and abdominal drainage (75% vs. 28.3%; p = 0.004) were different; however, postoperative morbidity was not. The surgical difficulty notwithstanding, length of stay (group I: p = 0.13; group II-III: p = 0.93) and R0 surgical margin (group I: p = 0.3; group II-III p = 0.39) were not different between LVCs and HVCs. CONCLUSIONS: LLR performed at an LVC can be feasible and safe with acceptable morbidity.
Subject(s)
Laparoscopy , Liver Neoplasms , Hepatectomy/adverse effects , Humans , Length of Stay , Liver , Liver Neoplasms/surgery , Postoperative Complications/epidemiology , Postoperative Period , Retrospective StudiesABSTRACT
Endometriosis is a dissemination of endometrial-like tissue outside the uterine cavity, responsible for pain and impaired fertility in women of childbearing age. Although endometriosis generally occurs in the pelvis, it can be located further away. We describe the case of a 35-year-old woman who was admitted for further evaluation of a cystic mass of the liver that had invaded the right ventricle and caused pain. Serum levels of the tumor markers CA 125, CA 15-3 and CA 19-9 were elevated. The tumor was resected with a small part of the right ventricle free wall, the diaphragm and the left liver lobe. A histological analysis confirmed that the mass was a benign endometrial cyst. The postoperative course was uneventful and the patient remains asymptomatic with 5 year follow-up. A diagnosis of endometriosis should be considered for thoraco-abdominal cystic masses associated with menses-related pain in women of childbearing age.
Subject(s)
Biomarkers, Tumor/blood , Endometriosis/diagnosis , Liver Diseases/diagnosis , Abdominal Pain/etiology , Adult , CA-125 Antigen/blood , CA-19-9 Antigen/blood , Diaphragm/surgery , Endometriosis/blood , Endometriosis/surgery , Female , Heart Diseases/blood , Heart Diseases/surgery , Heart Ventricles/surgery , Humans , Liver Diseases/blood , Liver Diseases/surgery , Mucin-1/bloodABSTRACT
OBJECTIVE: The aim of this study was to identify "inherent limitations" in healthy donors who are responsible for donor morbidity after right hepatectomy (RH) for adult-to-adult living donor liver transplantation (ALDLT). BACKGROUND: Right hepatectomy for ALDLT remains a challenging procedure without significant improvement in morbidity over time. This suggests some "inherent limitations" in healthy individuals, which are beyond the recent improvements in the donor evaluation and selection process and refinements in surgical technique during the learning curve. METHODS: To identify response of RH in ALDLT, we prospectively studied 32 patients requiring an RH for benign liver lesions (BL), matched with 32 living donors (LD) operated by same team. All patients underwent liver volume evaluation by computed tomographic (CT) volumetry preoperatively and 1 week after RH, postoperative complications graded with Clavien's system. RESULTS: The comparison (LD vs BL) showed that remnant liver volume (RLV) on preoperative CT volumetry was higher in the BL group (450 ± 150 vs 646 ± 200 mL, P < 0.001) representing 31% ± 7% in LD group versus 36% ± 7% of the total liver volume in BL group (P = 0.03). On postoperative day 7, the RLV was similar in the 2 groups (866 ± 162 vs 941 ± 153 mL) resulting from a significantly higher regeneration rate in the LD group (89% vs 55%, P = 0.009). Overall complications rate was lower in the BL group (46% vs 21%, P = 0.035). CONCLUSIONS: Right hepatectomy in LDLT induces a more severe deprivation of liver volume than in BL, which induce an accelerated regeneration. Accelerated regeneration could represent "inherent limitation" in healthy donors that makes them more vulnerable for postoperative complications.
Subject(s)
Donor Selection/standards , Hepatectomy/methods , Liver Diseases/surgery , Liver Transplantation , Living Donors , Adolescent , Adult , Contraindications , Female , Hepatectomy/adverse effects , Humans , Male , Middle Aged , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Prospective Studies , Young AdultABSTRACT
Hepatectomy remains the only curative treatment for many primary and secondary liver cancers. Portal vein embolization (PVE) has been used to increase the volume of the future liver remnant and thus lower the risk of small-for-size syndrome and postoperative liver failure. This technique has proven its safety, with a low post-procedure morbidity rate. Here, we describe a very rare case in which a young patient suffered a glue embolism to the right atrial cavity following PVE in preparation for a major hepatectomy for colorectal metastasis. The foreign body was withdrawn from the heart with a femoral, percutaneous device and trapped against the wall of the femoral vein with a self-expanding metal stent. Our report shows that this previously unknown complication of PVE can be resolved without recourse to sternotomy and open heart surgery.
ABSTRACT
BACKGROUND: Excellent survival obtained with liver transplantation (LT) for limited hepatocellular carcinoma (HCC) in patients with chronic liver disease is still challenged by the increasing discrepancy between candidates and grafts available. We review the current strategy of LT for HCC in our country highlighting the tendency: (1) to expand recipient selection beyond the Milan criteria, (2) to use systematic pre-LT treatments with a greater number of resections and (3) new rules for graft attribution. RESULTS: Although the vast majority of cirrhotic patients with HCC are transplanted within the Milan criteria; the number of candidates is continually rising, while the number of grafts available is stable with a disappearance of adult LDLTs. Moreover, the new rules for organ allocations, mainly based on the MELD score, minimize the accessibility to liver grafts for patients with HCC and compensated liver disease. For these reasons, in France we have observed an increase in waiting time for HCC patients, leading to the extensive use of pre-LT treatments in order to limit the list dropouts. Many studies have been performed on transarterial chemo-embolization (TACE) and supraselective TACE. Moreover, the use of liver resection (LR) as a bridge therapy, showing that initial resection does not impair short- and long-term survival, led French surgeons to develop the concept of LR as a way to select patients who might benefit from LT and to use it, in selected cases, as a primary therapy, considering LT as salvage treatment in case of recurrence. CONCLUSIONS: The number of HCC candidates who cannot benefit from a LT is increasing worldwide. The French answer to this situation involves pre-LT treatments, particularly partial LR, based mainly on the excellent Japanese results in this field. Moreover, the country of égalité is actually modifying the rules of graft attribution in order to reduce the inequality between the HCC patients with poor and good liver function.
Subject(s)
Carcinoma, Hepatocellular/surgery , Liver Neoplasms/surgery , Liver Transplantation , Adult , Aged , Carcinoma, Hepatocellular/diagnosis , Carcinoma, Hepatocellular/epidemiology , Female , Follow-Up Studies , France/epidemiology , Humans , Incidence , Liver Neoplasms/diagnosis , Liver Neoplasms/epidemiology , Magnetic Resonance Imaging , Male , Middle Aged , Neoplasm Recurrence, Local/epidemiology , Neoplasm Staging , Retrospective Studies , Survival Rate , Tomography, X-Ray Computed , Treatment Outcome , Young AdultABSTRACT
The liver hanging manoeuvre (LHM) facilitates the anterior approach (AA), which is one of the most important innovations in the field of major hepatic resections. The AA confers some definite advantages over the classical approach, in that it provides for: less haemorrhage; less tumoral manipulation and rupture; better haemodynamic stability by avoiding any twisting of the inferior vena cava; reduced ischaemic damage of the liver remnant, and better survival for patients with hepatocellular carcinoma (HCC). The LHM makes the AA easier because it serves as a guide to the correct anatomical transection plane and elevates the deep parenchymal plane. The LHM is a safe technique, in which minor complications have been reported in < or = 7% of patients and >90% feasibility has been demonstrated in experienced centres. Over the years, different variants of the LHM have been developed to facilitate almost all anatomical liver resections. In view of its advantages, feasibility and safety, the LHM should be considered for most anatomical hepatectomies.
ABSTRACT
OBJECTIVE: To compare the specific features and outcomes of laparoscopic cholecystectomy in two university hospitals, one in a developing country, Bosnia-Herzegovina, and the other in a well developed country, Italy. METHODS: Between January 1996 and December 2005, a total of 2018 patients underwent laparoscopic cholecystectomy in Mostar Clinical Hospital, Bosnia-Herzegovina (1066) and in Chieti University Hospital, Chieti, Italy (952). Differences in patients' presentations, diagnostic protocols, medication, surgical treatment, complications and outcomes were analyzed. RESULTS: The number of patients with life-threatening conditions was lower in Italy (15 or 1.5% vs. 53 or 4.9%; P<0.001), as was the use of analgesia and antibiotics (131 or 13.96% vs. 873 or 81.97%; P<0.001). Open-access biliary surgery was rare in Italy, where the vast majority of patients were operated laparoscopically; only 44 (4.41%) patients had open-access surgery, including 35 (3.61%) conversion patients. In comparison, 1669 (61%) patients in Bosnia-Herzegovina underwent open-access operations. There was a significant difference, in favor of the Italian hospital, in the number of surgical complications (8 or 0.84% vs. 40 or 3.75%; P<0.002) and also in the number of postoperative infections following surgical incision (0 or 0.0% vs. 6 or 0.56%; P<0.033). CONCLUSIONS: It is encouraging for surgeons in Bosnia-Herzegovina to find that satisfactory results can be achieved in a developing country. However, the number of complications encountered in the Mostar hospital emphasizes the need for further improvement of surgical technique through better structured training combined with strict supervision of junior staff. The finding of postoperative infections in the Bosnia-Herzegovina hospital, despite that their occurrence was relatively rare, highlights the necessity for further improvement of hospital infection control.
Subject(s)
Cholecystectomy, Laparoscopic/statistics & numerical data , Developed Countries/statistics & numerical data , Developing Countries/statistics & numerical data , Postoperative Complications/epidemiology , Risk Assessment/methods , Bosnia and Herzegovina/epidemiology , Humans , Incidence , Italy/epidemiology , Longitudinal Studies , Risk FactorsABSTRACT
OBJECTIVES: To report our experience with endovascular repair of descending thoracic aorta in patients with acute and chronic traumatic lesions due to blunt chest trauma in last 4 years. MATERIAL AND METHODS: From January 2002 to September 2006, 5 patients underwent endovascular repair of descending thoracic aorta for acute (3 cases) and chronic (2 cases) traumatic lesions due to road traffic accidents (motorcycle crash: 1; car crash: 4). RESULTS: Stent-graft placement was successful in all cases with good early outcomes and without late complications (follow up 3-48 months). CONCLUSION: Endovascular repair of descending thoracic aorta lesions, due to blunt chest trauma, is a feasible and valid alternative to conventional open operation.
Subject(s)
Aorta, Thoracic/injuries , Aorta, Thoracic/surgery , Blood Vessel Prosthesis , Stents , Thoracic Injuries/complications , Wounds, Nonpenetrating/complications , Adult , Aged , Female , Humans , Male , Middle AgedABSTRACT
In the field of transplants, the practice of using marginal donor livers has become widely accepted, yielding good clinical results. This study investigated and compared the pharmacokinetics of cyclosporine in marginal and standard liver transplant recipients. Twenty-four de novo liver transplant patients, 12 with marginal and 12 with standard (normal) grafts, were treated with a microemulsion formulation of cyclosporine (capsules 100 mg) as immunosuppressive therapy. Blood concentration profiles were measured, and pharmacokinetic calculations performed at days 3 and 10 after transplantation. Different sampling strategies to predict drug exposure (AUC(0-12 h)) were compared, and the best limited-sampling strategies to monitor the desired blood levels were determined. Marginal and standard patients showed a significant difference in blood concentration and pharmacokinetic profiles of cyclosporine at the day 10 post-transplantation. Blood concentration at 4h (C(4 h)) was the single best timepoint to estimate AUC(0-12 h) in marginal liver transplant (r(2)=0.700), while C(2h) was confirmed to be the optimal choice with standard graft (r2=0.720). Two blood samples at 2 and 6 h significantly improved the prediction model in both groups (r2=0.920). Our data suggest that patients receiving a marginal liver transplant present a different pharmacokinetic profile of cyclosporine from those receiving standard graft, which should be taken into account in dosing the patient to avoid subtherapeutic blood concentrations or toxic effects.