Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies.

BACKGROUND: Spleen preserving distal pancreatectomy (SPDP) represents a widely adopted procedure in the presence of benign or low-grade malignant tumors. Splenic vessels preservation and resection (Kimura and Warshaw techniques respectively) represent the two main surgical modalities to avoid splenic resection. Each one is characterized by strengths and drawbacks. The aim of the present study is to systematically review the current high-quality evidence regarding these two techniques and analyze their short-term outcomes. METHODS: A systematic review was conducted according to PRISMA, AMSTAR II and MOOSE guidelines. The primary endpoint was to assess the incidence of splenic infarction and splenic infarction leading to splenectomy. As secondary endpoints, specific intraoperative variables and postoperative complications were explored. Metaregression analysis was conducted to evaluate the effect of general variables on specific outcomes. RESULTS: Seventeen high-quality studies were included in quantitative analysis. A significantly lower risk of splenic infarction for patients undergoing Kimura SPDP (OR = 0.14; p < 0.0001). Similarly, splenic vessel preservation was associated with a reduced risk of gastric varices (OR = 0.1; 95% p < 0.0001). Regarding all secondary outcome variables, no differences between the two techniques were noticed. Metaregression analysis failed to identify independent predictors of splenic infarction, blood loss, and operative time among general variables. CONCLUSIONS: Although Kimura and Warshaw SPDP have been demonstrated comparable for most of postoperative outcomes, the former resulted superior compared to the latter in reducing the risk of splenic infarction and gastric varices. For benign pancreatic tumors and low-grade malignancies Kimura SPDP may be preferred.

Preoperative indocyanine green (ICG) clearance test: Can we really trust it to predict post hepatectomy liver failure? A systematic review of the literature and meta-analysis of diagnostic test accuracy.

INTRODUCTION: Post hepatectomy liver failure (PHFL) still represents a potentially fatal complication after major liver resection. Indocyanine green (ICG) clearance test represents one of the most widely adopted examinations in the preoperative workup. Despite a copious body of evidence which has been published on this topic, the role of ICG in predicting PHLF is still a matter of debate. METHODS: A systematic review of the literature was conducted according to PRISMA-DTA guidelines. The primary outcome was the assessment of diagnostic performance of ICG in predicting PHLF. The secondary outcome was the mean ICGR15 and ICGPDR in patients experiencing PHLF. RESULTS: Seventeen studies, for a total of 4852 patients, were deemed eligible. Sensitivity ranged from 25% to 83%; Specificity ranged from 66.1% to 93.8%. ICG clearance test pooled AUC was 0.673 (95% CI: 0.632-0.713). The weighted mean ICGR15 was 11 (95%CI: 8.3-13.7). The weighted mean ICGPDR was 16.5 (95%CI: 13.3-19.8). High risk of bias was detected in all examined domains. CONCLUSIONS: Preoperative ICG clearance test alone may not represent a reliable method to predict post hepatectomy liver failure. Its diagnostic significance should be framed within multiparametric models involving clinical and imaging features.

Impact of resuscitative endovascular balloon occlusion of the aorta (REBOA) in traumatic abdominal and pelvic exsanguination: a systematic review and meta-analysis.

PURPOSE: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) represents a minimally invasive technique of aortic occlusion (AO). It has been demonstrated to be safe and effective with appropriate training in traumatic hemorrhage with hemodynamic instability; however, its indications are still debated. The aim of this systematic review and meta-analysis is to assess the impact of REBOA on mortality in torso trauma patient with severe non-compressible hemorrhage compared to other temporizing hemostatic techniques. STUDY DESIGN: The primary outcome is represented by 24-h, and in-hospital mortality. Secondary outcomes are post-procedural hemodynamic improvement (systolic blood pressure-SBP), mean injury severity score (ISS) differences, treatment-related morbidity, transfusional requirements and identification of prognostic factors. RESULTS: A significant survival benefit at 24 h (RR 0.46; 95% CI 0.27-0.79; I2: 55%; p = 0.005) was highlighted in patients undergoing REBOA. Regarding in-hospital mortality (RR 0.99; 95% CI 0.75-1.32; I2: 73%; p = 0.98) no differences in risk of death were noticed. A hemodynamic improvement-although not significant-was highlighted, with 55.8 mmHg post-AO SBP mean difference between REBOA and control groups. A significantly lower mean number of packed Red Blood Cells (pRBCs) was noticed for REBOA patients (mean difference: - 3.02; 95% CI - 5.79 to - 0.25; p = 0.033). Nevertheless, an increased risk of post-procedural complications (RR 1.66; 95% CI 0.39-7.14; p = 0.496) was noticed in the REBOA group. CONCLUSIONS: REBOA may represent a valid tool in the initial treatment of multiple sites subdiaphragmatic hemorrhage with refractory hemodynamic instability. However, due to several important limitations of the present study, our findings should be interpreted with caution. LEVEL OF EVIDENCE: Level III according to ELIS (SR/MA with up to two negative criteria).

ERAS Protocol for Perioperative Care of Patients Treated with Laparoscopic Nonanatomic Liver Resection for Hepatocellular Carcinoma: The ISMETT Experience.

Background: Liver resection (LR) remains the best therapeutic option for patients with early-stage hepatocellular carcinoma (HCC) with preserved hepatic function and who are not eligible for liver transplantation. After its inception, the enhanced recovery after surgery (ERAS) protocol was widely used for treating patients with liver cancer, although there are still no clear indications for improving upon it in both open and laparoscopic surgery. Objective: This study aims to describe our institute's experience in the application of the ERAS protocol in a cohort of HCC patients, and to explore possible factors that could have an impact on postoperative outcomes. Materials and Methods: We retrospectively analyzed our experience with LR performed from September 2017 to January 2020 in patients treated with ERAS protocol, focusing on describing impact on postoperative nutrition, analgesic requirements, and length of hospitalization. Demographics, operative factors, and postoperative complications of patients were reviewed. Results: During the study period, 89 HCC patients were eligible for LR, and 75% of patients presented with liver cirrhosis. The most prevalent among etiologic factors was hepatitis C virus infection (53 patients out of 89, 60%), followed by nonalcoholic steatohepatitis (18 patients, 20%). The median age was 70 years. Liver cirrhosis did not have an impact on postoperative course of patients. Patients who underwent laparoscopic surgery and nonanatomic LR experienced low complication rates, shorter length of stay, and shorter time of intravenous analgesic requirements. Conclusions: Continual refinement with ERAS protocol for treating HCC patients based on perioperative counseling and surgical decision-making is crucial to guarantee low complication rates, and reduce patient morbidity and time for recovery.

Laparoscopic Microwave Thermal Ablation for the Treatment of Hepatocellular Carcinoma in Chronic Hepatic Patients.

Background: Laparoscopic microwave thermal ablation (LMWTA) is a well-established alternative treatment to liver resection for treatment of liver tumors. The aim of this study was to describe our experience in LMWTA for hepatocellular carcinoma (HCC) in chronic hepatic patients. Materials and Methods: A study group of 61 consecutive HCC patients treated with LMWTA from January, 2013 to May, 2020 were considered for this study. Patient characteristics, liver function test, operational characteristics, and complications were recorded. Results: Of the 61 patients who underwent LMWTA, median age was 64 (interquartile range [IQR]: 58-71) years, mean body mass index was 26.2 (IQR: 23.2-29.4); 44 patients (72%) presented with an hepatitis C virus etiology, 46 (75%) were Child-Pugh Class A, median model for end-stage liver disease (MELD) score was 8.0 (IQR: 7.0-9.4). Viral infection was confirmed to be the most important risk factor in determining progressive cirrhotic evolution with HCC expression. Conclusions: LMWTA is a safe alternative treatment to traditional surgery, and can be combined with surgery.

Ex Situ Liver Machine Perfusion: The Impact of Fresh Frozen Plasma.

The primary aim of this single-center, phase 1 exploratory study was to investigate the safety, feasibility, and impact on intrahepatic hemodynamics of a fresh frozen plasma (FFP)-based perfusate in ex situ liver normothermic machine perfusion (NMP) preservation. Using an institutionally developed perfusion device, 21 livers (13 donations after brain death and 8 donations after circulatory death) were perfused for 3 hours 21 minutes to 7 hours 52 minutes and successfully transplanted. Outcomes were compared in a 1:4 ratio to historical control patients matched according to donor and recipient characteristics and preservation time. Perfused livers presented a very low resistance state with high flow during ex situ perfusion (arterial and portal flows 340 ± 150 and 890 ± 70 mL/minute/kg liver, respectively). This hemodynamic state was maintained even after reperfusion as demonstrated by higher arterial flow observed in the NMP group compared with control patients (220 ± 120 versus 160 ± 80 mL/minute/kg liver, P = 0.03). The early allograft dysfunction (EAD) rate, peak alanine aminotransferase (ALT), and peak aspartate aminotransferase (AST) levels within 7 days after transplantation were lower in the NMP group compared with the control patients (EAD 19% versus 46%, P = 0.02; peak ALT 363 ± 318 versus 1021 ± 999 U/L, P = 0.001; peak AST 1357 ± 1492 versus 2615 ± 2541 U/L, P = 0.001 of the NMP and control groups, respectively). No patient developed ischemic type biliary stricture. One patient died, and all other patients are alive and well at a follow-up of 12-35 months. No device-related adverse events were recorded. In conclusion, with this study, we showed that ex situ NMP of human livers can be performed safely and effectively using a noncommercial device and an FFP-based preservation solution. Future studies should further investigate the impact of an FFP-based perfusion solution on liver hemodynamics during ex situ normothermic machine preservation.

Stenting for Inferior Vena Cava Stenosis After Liver Transplant.

OBJECTIVE. A case series analysis and meta-analysis were performed to assess the efficacy of stenting for inferior vena cava (IVC) stenosis after liver transplant; a secondary analysis assessed demographic factors as potential predictors of all-cause mortality. MATERIALS AND METHODS. Liver transplant recipients treated for symptomatic IVC stenosis at a major medical center from 1996 to 2017 were assessed. The main medical databases were searched for studies evaluating stenting in liver transplant recipients with IVC stenosis. Cox proportional hazards regression analysis was used to determine predictors of survival (age, sex, reason for transplant, stent size and number, publication year). Univariate and multivariable models were constructed. Because patients in the case series and meta-analysis had similar demographics and outcomes, the results were pooled. RESULTS. The case series included 40 patients (31 treated with stents; nine, without stents). Meta-analysis of 5277 records identified 17 eligible studies involving 73 patients. Stenting was effective in resolving the gradient in 100% of patients and in relieving symptoms in 85% of patients. Primary stent patency at latest follow-up (median, 556 days) was seen in 113 of 118 stents (96%; some patients had multiple stents). Reason for transplant was the only significant predictor of all-cause mortality; patients with hepatocellular carcinoma had a higher hazard of death than those undergoing transplant for other reasons (hazard ratio = 3.23; 95% CI, 1.40-7.42; p = 0.006). CONCLUSION. Stenting for IVC stenosis after liver transplant is clinically effective and durable, with 96% of stents showing long-term patency and 85% of patients experiencing symptom relief.

Is Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy Related to Short-Course Prophylaxis of Thromboembolism? A Monocentric Retrospective Analysis About an Infrequent but Not Rare Complication and Review of the Literature.

BACKGROUND: Portomesenteric vein thrombosis (PMVT) is considered a rare and potentially fatal complication of bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) is one of the most performed bariatric procedures in the world. PMVT in LSG was first reported in 2009 by Berthet et al. in a thrombophilic patient. No data exist regarding the real prevalence of this complication specifically after LSG. METHODS: We examined retrospectively all the clinical records of patients who underwent LSG for morbid obesity from January 2011 to December 2016. Moreover, we performed a literature search of PubMed, Medscape, and EMBASE databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: 2854 patients underwent LSG for morbid obesity from January 2011 to December 2016. The retrospective analysis of our records revealed only 1 case of PMVT. The 18 studies selected include 62 cases of PMVT after LSG with a prevalence of 0.52% (ranging from 0.2% to 1.81%) and a mortality rate of 1.61%. CONCLUSIONS: PMVT is an infrequent but not rare complication in patients who undergo LSG. Short-course antithrombotic prophylaxis (<10 days) could increase the risk of this complication. The authors recommend a postoperative prophylaxis with sodium enoxaparin 40 mg sc once a day for 4 weeks. PMVT mortality in patients who undergo LSG is lower than other causes of portal vein thrombosis (hepatic cirrhosis, tumors, myeloproliferative disorders, etc.) If risk factors for PMVT are present preoperatively, the authors recommend a prophylaxis with sodium enoxaparin 40 mg sc twice daily for 4 weeks.