Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 62
Filtrar
1.
Artigo em Inglês | MEDLINE | ID: mdl-32753333

RESUMO

BACKGROUND: There is an ongoing debate on the feasibility, safety, and oncological efficacy of the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) technique. The aim of this study was to compare ALPPS, two-staged hepatectomy (TSH), and portal vein embolization (PVE)/ligation (PVL) using updated traditional meta-analysis and network meta-analysis (NMA). DATA SOURCES: Electronic databases were used in a systematic literature search. Updated traditional meta-analysis and NMA were performed and compared. Mortality and major morbidity were selected as primary outcomes. RESULTS: Nineteen studies including 1200 patients were selected from the pool of 436 studies. Of these patients, 315 (31%) and 702 (69%) underwent ALPPS and portal vein occlusion (PVO), respectively. Ninety-day mortality based on updated traditional meta-analysis, subgroup analysis of the randomized controlled trials (RCTs), and both Bayesian and frequentist NMA did not demonstrate significant differences between the ALPPS cohort and the PVE, PVL, and TSH cohorts. Moreover, analysis of RCTs did not demonstrate significant differences of major morbidity between the ALPPS and PVO cohorts. The ALPPS cohort demonstrated significantly more favorable outcomes in hypertrophy parameters, time to operation, definitive hepatectomy, and R0 margins rates compared with the PVO cohort. In contrast, 1-year disease-free survival was significantly higher in the PVO cohort compared to the ALPPS cohort. CONCLUSIONS: This study is the first to use updated traditional meta-analysis and both Bayesian and frequentist NMA and demonstrated no significant differences in 90-day mortality between the ALPPS and other hepatic hypertrophy approaches. Furthermore, two high quality RCTs including 147 patients demonstrated no significant differences in major morbidity between the ALPPS and PVO cohorts.

2.
Lancet Diabetes Endocrinol ; 8(9): 773-781, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32711725

RESUMO

BACKGROUND: Cross-sectional imaging regularly results in incidental discovery of adrenal tumours, requiring exclusion of adrenocortical carcinoma (ACC). However, differentiation is hampered by poor specificity of imaging characteristics. We aimed to validate a urine steroid metabolomics approach, using steroid profiling as the diagnostic basis for ACC. METHODS: We did a prospective multicentre study in adult participants (age ≥18 years) with newly diagnosed adrenal masses. We assessed the accuracy of diagnostic imaging strategies based on maximum tumour diameter (≥4 cm vs <4 cm), imaging characteristics (positive vs negative), and urine steroid metabolomics (low, medium, or high risk of ACC), separately and in combination, using a reference standard of histopathology and follow-up investigations. With respect to imaging characteristics, we also assessed the diagnostic utility of increasing the unenhanced CT tumour attenuation threshold from the recommended 10 Hounsfield units (HU) to 20 HU. FINDINGS: Of 2169 participants recruited between Jan 17, 2011, and July 15, 2016, we included 2017 from 14 specialist centres in 11 countries in the final analysis. 98 (4·9%) had histopathologically or clinically and biochemically confirmed ACC. Tumours with diameters of 4 cm or larger were identified in 488 participants (24·2%), including 96 of the 98 with ACC (positive predictive value [PPV] 19·7%, 95% CI 16·2-23·5). For imaging characteristics, increasing the unenhanced CT tumour attenuation threshold to 20 HU from the recommended 10 HU increased specificity for ACC (80·0% [95% CI 77·9-82·0] vs 64·0% [61·4-66.4]) while maintaining sensitivity (99·0% [94·4-100·0] vs 100·0% [96·3-100·0]; PPV 19·7%, 16·3-23·5). A urine steroid metabolomics result indicating high risk of ACC had a PPV of 34·6% (95% CI 28·6-41·0). When the three tests were combined, in the order of tumour diameter, positive imaging characteristics, and urine steroid metabolomics, 106 (5·3%) participants had the result maximum tumour diameter of 4 cm or larger, positive imaging characteristics (with the 20 HU cutoff), and urine steroid metabolomics indicating high risk of ACC, for which the PPV was 76·4% (95% CI 67·2-84·1). 70 (3·5%) were classified as being at moderate risk of ACC and 1841 (91·3%) at low risk (negative predictive value 99·7%, 99·4-100·0). INTERPRETATION: An unenhanced CT tumour attenuation cutoff of 20 HU should replace that of 10 HU for exclusion of ACC. A triple test strategy of tumour diameter, imaging characteristics, and urine steroid metabolomics improves detection of ACC, which could shorten time to surgery for patients with ACC and help to avoid unnecessary surgery in patients with benign tumours. FUNDING: European Commission, UK Medical Research Council, Wellcome Trust, and UK National Institute for Health Research, US National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.


Assuntos
Neoplasias das Glândulas Suprarrenais/epidemiologia , Neoplasias das Glândulas Suprarrenais/urina , Metabolômica/métodos , Esteroides/urina , Neoplasias das Glândulas Suprarrenais/diagnóstico , Adulto , Idoso , Diagnóstico Diferencial , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
3.
HPB (Oxford) ; 2020 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-32417170

RESUMO

BACKGROUND: The aim of this study was to investigate the influence of resection margin status in patients with KRAS mutations (mt-KRAS) when compared to those with wild-type KRAS (wt-KRAS) on long-term outcomes in patients with resected CRLM. METHODS: All patients who underwent resection of CRLM with curative intent between January 2011 and December 2016 and had a KRAS type recorded were included in the study. Overall survival (OS), as well as death-censored overall (RFS) and liver-specific (LS-RFS) recurrence-free survival between KRAS types and the margin status within KRAS subgroups were compared using Cox regression models. RESULTS: Data were available for N = 500 patients (30.4% mt-KRAS). mt-KRAS status was independently associated with significantly shorter OS. Within the wt-KRAS subgroup, smaller margins were found to be associated with significantly shorter death-censored LS-RFS (p < 0.001), with HRs of 1.93 (p = 0.005) for 1-4 mm margins and 2.83 (p < 0.001) for <1 mm margins, relative to those with clear margins. No such association was observed in the mt-KRAS subgroup (p = 0.721). CONCLUSION: The resection margin status is of greater importance in patients with wt-KRAS. Such information could be useful in the operative planning, especially for those with multiple metastatic deposits, and also in the post-operative counselling and surveillance based on the margin and KRAS status.

4.
Eur J Surg Oncol ; 46(7): 1214-1224, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32312592

RESUMO

BACKGROUND: The evidence of pairwise meta-analysis of Robotic Hepatectomy (RH) vs Laparoscopic Hepatectomy (LH) and RH vs Open Hepatectomy (OH) is inconclusive. Therefore, the aim of this study, was to compare the outcomes of RH, LH and OH by performing a network meta-analysis. METHODS: A systematic literature search was performed in the following databases: Pubmed, Google scholar, EMBASE and Cochrane library. Cost-effectiveness and survival benefits were selected as primary outcomes. RESULTS: The cost was less in OH compared to both minimally invasive procedures, LH demonstrated lower cost compared to RH, but the differences were not statistically significant. Both the RH and LH cohorts demonstrated significantly lower estimated blood loss, reduced major morbidity rate and shorter length of stay compared to OH cohort. The LH and OH cohorts demonstrated significantly shorter operative time and duration of clamping compared to the RH cohort. The LH cohort included significantly smaller tumours compared to the OH cohort. CONCLUSION: The present network meta-analysis, demonstrated that both RH and LH in malignant and benign conditions were associated with lower morbidity rates, shorter hospital stay and the procedure related costs were statistically nonsignificant between RH, LH and OH.

5.
Surgery ; 167(6): 942-949, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32183995

RESUMO

BACKGROUND: Outcomes after Strasberg grade E bile duct injury have been widely reported. However, there are comparatively few reports of outcomes after Strasberg A to D bile duct injury. Therefore, the aim of this study was to comprehensively evaluate the long-term clinical and economic impact of Strasberg A to D bile duct injury. METHODS: Patients with Strasberg A to D bile duct injury were identified from a prospectively collected and maintained database. Long-term biliary complication rates, as well as treatment costs were then estimated, and compared across Strasberg injury grades. RESULTS: A total of N = 120 patients were identified, of whom N = 49, 13, 20, and 38 had Strasberg grade A, B, C, and D bile duct injury, respectively. Surgical repair was most commonly performed in Strasberg grade D injuries (74% vs 8%-20% in lower grades, P < .001). By 5 years post bile duct injury, the estimated long-term biliary complication rate was 40% in Strasberg grade D injuries, compared with 15% in Strasberg grade A (P = .022). A significant difference in total treatment and follow-up costs was also detected (P < .001), being highest in Strasberg grade D injuries (mean £11,048/US$14,252 per patient) followed by the Strasberg grade B group (mean £10,612/US$13,689 per patient). DISCUSSION: Strasberg grade A to D injuries lead to considerable long-term morbidity and cost. Strasberg grade D injuries are typically managed surgically and result in the highest complication rate and treatment costs. Strasberg grade B injuries lead to a similar complication rate and treatment cost but are often managed without surgery.


Assuntos
Ductos Biliares/lesões , Doença Iatrogênica/economia , Complicações Intraoperatórias/cirurgia , Anastomose em-Y de Roux/economia , Ductos Biliares/cirurgia , Colecistectomia Laparoscópica/efeitos adversos , Custos e Análise de Custo , Feminino , Seguimentos , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Reino Unido , Ferimentos e Lesões/classificação
6.
HPB (Oxford) ; 22(3): 383-390, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31416786

RESUMO

BACKGROUND: The aim of this study was to develop and validate a risk score to predict overall survival (OS) in patients undergoing surgical resection for hepatocellular carcinoma in non-cirrhotic liver (NC-HCC). METHODS: Patients who underwent resection for NC-HCC between 2004 and 2013 were identified from the SEER database. A derivation set of 75% of this cohort was used to develop a risk score. This was then internally validated on the remaining patients, and externally validated using a cohort of patients from The HPB Unit, Birmingham, UK. RESULTS: A total of 3897 patients were included from the SEER database, with a median post-diagnosis survival of 59 months. In the derivation set, multivariable analyses identified male sex, increasing tumour size, the presence of multiple tumours, bilobar tumours and major vascular invasion as adverse prognostic factors. A risk score generated from these factors was significantly predictive of OS, and was used to classify patients into low, medium and high-risk groups. These groups had a five-year OS of 69%, 51% and 19% in the internal, and 73%, 50% and 45% in the external validation sets. CONCLUSION: The proposed risk score is useful in the selection, pre-operative consenting and counselling of patients for surgery and to allow patients to make an informed decision regarding treatment.

7.
HPB (Oxford) ; 22(3): 452-460, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31445781

RESUMO

BACKGROUND: Post-operative pancreatic fistula (POPF) is a major cause of morbidity following pancreatoduodenectomy. The risk of POPF varies between individuals and thus assessment without risk adjustment is crude. However, despite the availability of numerous scores to determine risk, no study has provided a risk adjusted assessment of POPF outcomes. METHODS: The observed and risk adjusted occurrence of POPF from consecutive patients operated upon by eight surgeons were recorded. Surgeons varied in experience from newly appointed (n = 5) to established (n = 3). CUSUM (cumulative sum) analysis was used to assess performance. RESULTS: 104 POPF occurred among 519 patients (20.0%). The occurrence of POPF was significantly lower among experienced surgeons (20/186, 10.7% vs 84/333, 25.2%; p < 0.001). Following risk adjustment surgeons observed 16.6 fewer to 6.5 excess POPF per 100 patients than predicted. Analysis of the CUSUM plots demonstrated the experienced surgeons performed steadily with a gradual reduction in observed POPF compared to what was predicted. The new surgeon's performance was less consistent and evidence of a learning curve was observed with steady improvement occurring after 50-70 patients. CONCLUSIONS: Risk adjusted assessment of POPF demonstrates differences between experienced and less experienced surgeons. This method could be used to audit practice and observe effects of changes to technique.

8.
J Clin Med Res ; 11(8): 572-582, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31413769

RESUMO

Background: Systematic reviews and meta-analyses that compare simultaneous, delayed and liver-first approach for synchronous colorectal liver metastases have found no significant differences. The aim of this study was to determine the best treatment strategy on the basis of effect sizes and the probabilities of treatment ranking by using a network meta-analysis. Moreover, first-time pairwise and network meta-analyses were used to estimate the existing evidence, and their results were compared to detect any discrepancies between them. Methods: Systematic review, pairwise meta-analysis and network meta-analysis were performed. The primary and secondary outcomes were 5-year overall survival and postoperative major morbidity, respectively. Results: No significant differences in long-term survival and major morbidity were found amongst the three approaches. The hazard ratios (95% confidence interval) for 5-year overall survival for the simultaneous, delayed and liver-first approaches were 0.93 (0.69 - 1.24, P = 0.613), 0.97 (0.87 - 1.07, P = 0.596) and 0.90 (0.67 - 1.22, P = 0.499), respectively. Moreover, the liver-first approach with a surface under the cumulative ranking area score of 89% was ranked as the potentially best treatment option based on probabilities of treatment ranking. Conclusions: On the basis of the relative ranking of treatments, the liver-first approach ranked first, followed by the delayed and simultaneous approaches. Therefore, a three-arm randomized controlled trial that compares the liver-first, simultaneous and delayed approaches needs to shed further light as to which is the best treatment option.

9.
J Clin Med Res ; 11(8): 600-608, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31413772

RESUMO

Background: Recent studies have demonstrated that hepatectomy in patients with synchronous hepatic gastric metastases may improve survival in certain patients. This study aimed to evaluate survival benefits of gastrectomy plus hepatectomy versus gastrectomy alone in patients with hepatic gastric metastases. Methods: Studies were identified by a systematic search of Embase, PubMed, Cochrane Library, and Google Scholar databases. Traditional and cumulative meta-analyses were used to monitor the evidence over time. Results: Eleven studies which included 861 patients compared gastrectomy plus hepatic resection in 349 patients with gastrectomy alone in 512 patients. Overall significantly better survival rates of 1, 2, 3, and 5 years were demonstrated for patients who underwent gastrectomy plus hepatic resection compared to patients who under underwent gastrectomy alone ((hazard ratio (HR) = 0.52 (0.39, 0.69), P < 0.001), (HR = 0.85 (0.74, 0.97), P = 0.01), (HR = 0.80 (0.72, 0.90), P = 0.003), (HR = 0.83 (0.78, 0.90), P < 0.001), respectively). Conclusions: Carefully selected patients with hepatic gastric metastases may benefit from hepatic resection.

10.
Hepatobiliary Pancreat Dis Int ; 18(4): 379-388, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31122750

RESUMO

BACKGROUND: Pre-operative risk factors for post-operative ventilation and their influence on survival after pancreaticoduodenectomy for malignancy are unknown. METHODS: Totally 391 patients operated in Hannover, Germany were investigated with multivariable logistic regression and Cox regression modeling to identify independent risk factors for post-operative ventilation ≥6 h, patient survival and 90-day mortality. And 84 patients operated in Birmingham, United Kingdom were analyzed to assess the external relevance of findings. RESULTS: Longer operations, history of thrombosis, intra-operative blood transfusion, lower estimated glomerular filtration rates (eGFR) and higher values of the age at operation divided by the Horovitz Quotient independently increased the risk of post-operative ventilation ≥ 6 h in German patients (n = 108; 27.6%) (P<0.050). Blood transfusion and lower pre-operative eGFR levels increased the risk of early death in German patients significantly and independently of established prognostic factors. A history of thrombosis and lower eGFR levels were also independent significant risk factors for 90-day mortality in German patients but not in English patients. None of the English patients received post-operative ventilation. Significantly more German patients were >75 years, had a history of thrombosis, received blood transfusions, and had significantly worse lung function parameters. pT4 tumors were detected in 18 German patients (4.6%), but not in the English patients. CONCLUSIONS: Identified risk factors for post-operative ventilation are clinically relevant in Germany but not in England and may be used to lower mortality risk. The German and the English cohorts displayed significant differences in the approach to patient selection and early post-operative extubation.


Assuntos
Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/mortalidade , Respiração Artificial/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/mortalidade , Comorbidade , Inglaterra/epidemiologia , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia/efeitos adversos , Seleção de Pacientes , Respiração Artificial/efeitos adversos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
11.
HPB (Oxford) ; 21(10): 1268-1276, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31080086

RESUMO

INTRODUCTION: The current evidence comparing oncological adequacy and effectiveness of robotic and laparoscopic distal pancreatectomy to open distal pancreatectomy for pancreatic adenocarcinoma is inconclusive. Recent pairwise meta-analyses demonstrated reduced blood loss and length of stay as the principal advantages of RDP and LDP compared to ODP. The aim of this study was to compare the three approaches to distal pancreatectomy conducting a pairwise meta-analysis and consequently network meta-analysis. METHODS: A systematic literature search was performed using the databases, EMBASE, Pubmed, the Cochrane library, and Google Scholar. Meta-analyses were performed using both fixed-effect and random-effect models. RESULTS: RDP cohort represented only 11% of the total sample; significantly younger patients with smaller size tumours were included in the RDP and LDP cohorts compared to ODP cohort. Significantly less blood loss and shorter length of stay were the advantages of both RDP and LDP compared to ODP. The ODP cohort included significantly more specimens with positive resection margins compared to RDP and LDP cohorts. DISCUSSION: The results of the present study demonstrate that reduced blood losses and shorter length of stay are the advantages of RDP and LDP compared to ODP. However, demographic discrepancies, underpowered RDP sample and differences in oncological burden do not permit certain conclusions regarding the oncological safety of RDP and LDP for pancreatic adenocarcinoma.

12.
HPB (Oxford) ; 21(11): 1505-1512, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-30992198

RESUMO

BACKGROUND: Laparoscopic liver resection (LLR) requires training in both hepatobiliary surgery and advanced laparoscopy. Available data on LLR learning curves are derived from pioneer surgeons. The aims of this study were to evaluate the LLR learning curve for second generation surgeons, and to compare different CUSUM methodology with and without risk adjustment. METHODS: Retrospective analysis of a prospective database of 111 consecutive patients who underwent LLR by two surgeons at a single centre between 2011 and 2016. The LLR learning curve for minor hepatectomy (MH) was evaluated for each surgeon using standard CUSUM before and after risk-adjusting for operative difficulty using the Iwate index, and compared with Learning Curve (LC) CUSUM. The end points were operative time and conversion rate. RESULTS: Standard CUSUM analysis identified a learning curve of 50-60 MH procedures. The corresponding learning curve reduced to 25-30 after risk-adjusting for operative difficulty, whilst LC-CUSUM identified a learning curve of 17-25 procedures. CONCLUSIONS: The learning curve for laparoscopic minor liver resection by second generation surgeons is shorter than that for pioneer surgeons. Laparoscopic HPB fellowship programmes may further shorten the learning curve, facilitating safe expansion of LLR. The LC-CUSUM method is an alternative technique that warrants further study.

13.
HPB (Oxford) ; 21(8): 945-952, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30879991

RESUMO

BACKGROUND: Although epidural analgesia (EA) provides effective pain control after open hepatectomy, postoperative hypotension is a common problem that limits ambulation. There is growing interest in alternative methods of pain control after open abdominal surgery, including a potential role for local anaesthetic infusion via wound catheter (WC). The aim of this study was to evaluate the available evidence for WC in open hepatectomy by conducting a meta-analysis of randomised trials. METHODS: A systematic database search of literature published in the last 20 years was performed. Only randomised controlled trials (RCTs) were included in the study. Meta-analyses were performed using both fixed-effects and random-effects models. RESULTS: WC patients had significantly faster functional recovery (WMD = -0.73 (-1.13, -0.32), I2 = 0%, p = 0.004). There was no significant difference in pain scores on the first postoperative day (POD1). On POD2, WC patients had higher pain scores compared to EA patients (WMD = 0.29 (0.09, 0.49), I2 = 0%, p < 0.004), but this corresponded with significantly lower opioid consumption in WC patients (WMD = -6.29 (-7.92, -4.65), I2 = 62%, p < 0.001). There was no significant difference in major hepatectomy, incision length, complications, length of hospital stay or readmissions between groups. CONCLUSION: Despite higher pain scores on the second postoperative day, functional recovery after open hepatectomy is faster in patients with wound catheters compared with epidural analgesia. Wound catheters should be considered the preferred mode of analgesia after open hepatectomy.


Assuntos
Analgesia Epidural/métodos , Analgésicos Opioides/administração & dosagem , Cateterismo/métodos , Hepatectomia/efeitos adversos , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Anestésicos Locais/uso terapêutico , Sistemas de Liberação de Medicamentos , Feminino , Hepatectomia/métodos , Humanos , Infusões Intralesionais , Laparotomia/efeitos adversos , Laparotomia/métodos , Neoplasias Hepáticas/cirurgia , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Resultado do Tratamento , Reino Unido
14.
Langenbecks Arch Surg ; 404(3): 285-292, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30847599

RESUMO

BACKGROUND-OBJECTIVE: The outcomes of split liver transplantation between recipients of deceased donor split liver transplant (SLT) or live donor liver transplants (LDLT) have never been compared in meta-analysis. It is important to understand graft and recipient survival between recipients of these grafts. METHODS: Databases were searched for relevant articles over the previous 20 years (MEDLINE, Embase, Cochrane Library and Google Scholar). Meta-analyses were performed using both fixed- and random-effects models. Patient survival and graft survival were obtained using the inverse variance hazard ratio method. RESULTS: There were differences in the characteristics of the donors and recipients. Donors of the SLT were younger compared to LDLT cohort [mean difference (MD) = - 11.12 years (- 15.41 to - 6.84), p < 0.001] whilst recipients of LDLT were younger [MD = - 2.06 years (- 1.12 to - 3.01), p < 0.001]. Significantly fewer men received grafts after SLT, 45%, compared to those receiving LDLT, 55%, [OR = 0.66 (0.55 to 0.80), p < 0.001]. There were no significant differences detected in postoperative complications, graft and patient 1-, 3- and 5-year survival between the SLT and LDLT cohorts. CONCLUSIONS: There is no apparent difference in overall survival, graft survival or complications between recipients of SLT or LDLT. However, characteristics of the donor and recipients differed suggesting the need for adequate risk-adjusted assessment of outcomes.


Assuntos
Hepatectomia/métodos , Transplante de Fígado/métodos , Doadores Vivos , Doadores de Tecidos/provisão & distribução , Adulto , Sobrevivência de Enxerto , Humanos , Medição de Risco , Taxa de Sobrevida
15.
HPB (Oxford) ; 21(10): 1312-1321, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30862441

RESUMO

BACKGROUND: Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD: Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS: Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION: Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

17.
J Surg Oncol ; 119(4): 472-478, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30637737

RESUMO

BACKGROUND: Hepatobiliary surgeons continue to expand the pool of patients undergoing liver resection using combinations of surgical and interventional procedures with chemotherapy. Improved perioperative care allows for operation on higher risk surgical patients. Postoperative outcomes, including 90-day mortality that improved over the past decade but still varies across cohorts. This study developed a preoperative risk score, on the basis significant clinical and laboratory variables, to predict 90-day mortality after hepatectomy. METHODS: All patients who underwent hepatectomy between 2011 and 2016 were included. Univariable and multivariable analyses were performed to identify the predictors of postoperative mortality and a risk score was derived and validated. RESULTS: The overall 90-day mortality rate in the derivation cohort (n = 1269 patients) was 4.0% (N = 51). Increasing patient age (P < 0.001), extent of resection (P = 0.001), diabetes mellitus (P = 0.006), and low preoperative sodium (P = 0.012) were predictors of the increased 90-day mortality in the multivariable analysis. The risk model developed based on these factors had an AUROC of 0.778 (P < 0.001) and remained significant in a validation cohort of 788 patients (AUROC: 0.703, P < 0.001). CONCLUSION: The proposed preoperative risk score to predict 90-day mortality after liver resection could be useful for appropriate counseling, optimization, and risk-adjusted assessment of surgical outcomes.


Assuntos
Hepatectomia/mortalidade , Fatores Etários , Idoso , Complicações do Diabetes/mortalidade , Feminino , Humanos , Hiponatremia/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Risco
18.
HPB (Oxford) ; 21(1): 26-33, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30049642

RESUMO

BACKGROUND: Unplanned hospital readmission after pancreaticoduodenectomy (PD) is usually due to surgical complications and has significant clinical and economic impact. This study developed a risk score to predict 30-day readmission after PD. METHODS: Patients undergoing PD between 2009 and 2016 were reviewed from a prospective database. Predictors of readmission were identified using a multivariable logistic regression model, from which a points-based risk scoring system was derived. RESULTS: 81 of 518 patients (15.6%) were readmitted within 30 days. History of cardiac disease ([odds ratio] OR = 2.12; 95% CI: 1.12-4.56), CRP>140 mg/L on post-operative day 3 (OR = 2.34; 95% CI: 1.37-4.35) and comprehensive complication index >14 (OR = 1.74; 95% CI: 1.03-2.85) were independent predictors of readmission. The regression coefficients were used to generate a risk score with excellent calibration (p = 0.917) and good discrimination (c-index = 0.65; 95% CI: 0.58-0.71; p < 0.001). Patients were categorised as low, moderate and high risk, with readmission rates of 6.4%, 13.4% and 23.0% respectively (p < 0.001). CONCLUSION: The risk score identifies patients at high risk of readmission after pancreaticoduodenectomy. Such patients may benefit from pre-discharge imaging and/or enhanced follow-up, which may potentially reduce the impact of readmissions.


Assuntos
Técnicas de Apoio para a Decisão , Pancreaticoduodenectomia/efeitos adversos , Readmissão do Paciente , Idoso , Bases de Dados Factuais , Inglaterra , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
HPB (Oxford) ; 21(5): 539-546, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30361111

RESUMO

BACKGROUND: Post hepatectomy liver failure (PHLF) is a serious complication in patients undergoing liver resection. This study hypothesized that a new pre-operative risk score developed through statistical modeling to predict PHLF could be used to stratify patients at higher risk of PHLF. METHODS: Patients who underwent hepatectomy between 2008 and 2016 were included in the derivation and validation cohorts. A multivariable binary logistic regression model was performed to identify predictors of PHLF, and a prognostic score was derived. RESULTS: A total of 1269 patients were included in the derivation cohort. PHLF was encountered in 13.1% and was associated with significantly increased 90-day mortality and prolonged post-operative hospital stay (both p < 0.001). Multivariable analysis identified the extent of surgery (p < 0.001) and pre-operative bilirubin (p = 0.015), INR (p < 0.001), and creatinine (p = 0.048) to be independent predictors of PHLF. A risk score derived from these factors returned an area under the ROC curve (AUROC) of 0.816 (p < 0.001) for an internal validation cohort (N = 453), significantly outperforming the MELD score (AUROC: 0.643). CONCLUSION: The PHLF risk score could be used to stratify the risk of PHLF among patients planned for hepatectomy.


Assuntos
Hepatectomia , Falência Hepática/etiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco/métodos , Idoso , Biomarcadores/análise , Feminino , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Período Pré-Operatório , Estudos Retrospectivos
20.
Gastrointest Tumors ; 5(1-2): 21-31, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30574478

RESUMO

Objective: Six principal adjuvant chemotherapy treatments (ACTs) are currently available for patients with resected colorectal liver metastases. This meta-analysis was designed to determine the optimal ACT, as evaluated by 2-year disease-free survival (DFS) and 5-year overall survival (OS) rates as well as by hepatic recurrences and adverse events (AEs). Methods: A systematic literature search of the PubMed, EMBASE, Medline, Cochrane Library, and Google Scholar databases was performed. The probability of the optimal therapeutic scheme and the mean ranking were estimated for each treatment using network meta-analysis. Results: Systemic chemotherapy (SCT) had the best 2-year DFS rate (hazard ratio [HR] = 0.78, 95% confidence interval [CI] = 0.48-1.27, 95% prediction interval [PI] = 0.17-3.56, surface under the cumulative ranking area [SUCRA] = 73) and the lowest AE rate (estimated SUCRA = 65 and predicted SUCRA = 62). Hepatic arterial infusion (HAI) plus SCT had the best 5-year OS rate (HR = 0.81, 95% CI = 0.64-1.01, 95% PI = 0.50-1.29) and the lowest hepatic recurrence rate (odds ratio = 2.87, 95% CI = 1.56-5.30, 95% PI = 0.61-13.62). Conclusion: Both SCT and HAI plus SCT showed superior efficacy and safety. Clinical trials in homogeneous populations with strict selection criteria are needed to compare these two ACTs.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA