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1.
Anticancer Res ; 39(11): 6325-6332, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31704863

RESUMO

BACKGROUND/AIM: We aimed to assess surgical outcome and long-term survival after elective hepatic resection for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) in patients aged 80 years or older. PATIENTS AND METHODS: This study included 100 patients aged 70 years or older, who underwent hepatic resection for HCC or CRLM between January 2000 and December 2012. Outcomes and clinicopathological data were compared between the elderly (aged 70-79 years; n=84) and extremely elderly groups (aged 80 years or older; n=16). RESULTS: Incidence of postoperative complications, in-hospital mortality, and postoperative OS in the extremely elderly group were comparable with those of the elderly group. In patients with HCC, the extremely elderly group was associated with shorter DFS (p=0.030) in univariate analysis, while multivariate analysis showed significant and independent factors of cancer recurrence. CONCLUSION: Hepatic resection for HCC and CRLM in patients aged 80 years and older may be safe and acceptable with appropriate selection. For HCC in patients aged 80 years and older, hepatic resection may be effective when negative surgical margins can be achieved.


Assuntos
Carcinoma Hepatocelular/cirurgia , Neoplasias Colorretais/patologia , Hepatectomia , Neoplasias Hepáticas/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Comorbidade , Intervalo Livre de Doença , Feminino , Hepatectomia/mortalidade , Hepatectomia/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/secundário , Masculino , Margens de Excisão , Complicações Pós-Operatórias , Análise de Sobrevida , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(45): e17920, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702672

RESUMO

There is little information concerning the predictive ability of the preoperative platelet to albumin ratio (PAR) in hepatocellular carcinoma (HCC) patients after liver resection. In the current study, we aimed to assess the prognostic power of the PAR in HCC patients without portal hypertension (PH) following liver resection.Approximately 628 patients were included in this study. A receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of the PAR for both recurrence-free survival (RFS) and overall survival (OS). Univariate and multivariate analyses were used to identify the independent risk factors for both RFS and OS.During the follow-up period, 361 patients experienced recurrence, and 217 patients died. ROC curve analysis suggested that the best cut-off value of the PAR for RFS was greater than 4.8. The multivariate analysis revealed that microvascular invasion (MVI), tumor size >5 cm, high aspartate aminotransferase-to-platelet count ratio index (APRI) and high PAR were four independent risk factors for both RFS and OS. Patients with a low PAR had significantly better RFS and OS than those with a high PAR.The PAR may be a useful marker to predict the prognosis of HCC patients after liver resection. HCC patients with a high preoperative PAR had a higher recurrent risk and lower long-term survival rate than those with a low preoperative PAR.


Assuntos
Albuminas/metabolismo , Plaquetas/metabolismo , Carcinoma Hepatocelular/mortalidade , Neoplasias Hepáticas/mortalidade , Recidiva Local de Neoplasia/epidemiologia , Adulto , Biomarcadores/sangue , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/cirurgia , Feminino , Hepatectomia/mortalidade , Hepatectomia/estatística & dados numéricos , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Valor Preditivo dos Testes , Período Pré-Operatório , Intervalo Livre de Progressão , Curva ROC
3.
Medicine (Baltimore) ; 98(30): e16150, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31348228

RESUMO

We evaluated the post-treatment overall survival (OS) of elderly hepatocellular carcinoma (HCC) patients.The archived records of 10,578 HCC patients registered at the Korean Central Cancer Registry from 2008 through 2014 were retrospectively analyzed. In this registry, we selected Barcelona Clinic Liver Cancer (BCLC) 0, A, or B staged HCC patients (n = 4744) treated by surgical resection (SR), local ablation therapy (LAT), or locoregional therapy (LRT). OSs in nonelderly (<70 years) and elderly (≥70 years) patients were compared after propensity score matching (PSM).In BCLC 0-A staged HCC, the cumulative OS rates of elderly patients were poorer than those of nonelderly patients after PSM (P < .001), but not in those with BCLC stage B (P > .05). In BCLC 0-A staged elderly patients, OS after SR was significantly better than after LAT (P = .005) or LRT (P < .001). In BCLC B staged elderly patients, SR achieved better OS than LRT (P = .006). Multivariable analysis showed that LAT (hazard ratio [HR] 1.52, P = .048) or LRT (HR, 2.01, P < .001) as compared with SR, and large (>3 cm) tumor size (HR1.49, P = .018) were poor predictors of OS for elderly patients with BCLC stage 0-A, and that LRT (HR, 2.64, P = .042) was a poor predictor for those with BCLC stage B.SR provided a better OS rate than LAT or LRT in elderly HCC patients with BCLC stage 0-A, than LRT in those with BCLC stage B. SR should be considered the first therapeutic option even in elderly HCC patients with these stages.


Assuntos
Carcinoma Hepatocelular/epidemiologia , Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/epidemiologia , Neoplasias Hepáticas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas/epidemiologia , Antineoplásicos/uso terapêutico , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Ablação por Cateter/estatística & dados numéricos , Quimioembolização Terapêutica/estatística & dados numéricos , Comorbidade , Feminino , Comportamentos Relacionados com a Saúde , Hepatectomia/estatística & dados numéricos , Hepatite B/epidemiologia , Hepatite C/epidemiologia , Humanos , Testes de Função Hepática , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Estadiamento de Neoplasias , Pontuação de Propensão , Sistema de Registros , República da Coreia/epidemiologia , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Análise de Sobrevida , Carga Tumoral
4.
Medicine (Baltimore) ; 98(23): e15929, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31169712

RESUMO

BACKGROUND: Laparoscopic left hemihepatectomy (LLH) has been widely accepted as a minimally invasive alternative to open liver surgery. We assessed the benefits and drawbacks of LLH compared with open left hemihepatectomy (OLH) using meta-analysis. METHODS: Relevant literature was retrieved using PubMed, Embase, Cochrane, and Ovid Medline databases. Multiple parameters of efficacy and safety were compared between the treatment groups. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models. RESULTS: The meta-analysis included 13 trials involving 1163 patients. Compared with OLH, LLH significantly reduced intraoperative blood loss (MD, -91.01; 95% CI, -139.12 to -42.89; P = .0002), transfusion requirement (OR, 0.24; 95% CI, 0.11-0.54; P = .0004), time to oral intake (MD, -0.80; 95% CI, -1.27 to -0.33; P = .0008), and hospital stay (MD, -3.94; 95% CI, -4.85 to -3.03; P < .0001). However, operative time; complications rate; and postoperative alanine transferase, albumin, and total bilirubin levels did not differ significantly between the 2 surgical groups (P > .05). For hepatolithiasis treatment, there were no significant differences in operative time, residual stones, stone recurrence, and complications rate between the groups (P > .05), but LLH resulted in lower incisional infection rate (OR, 0.44; 95% CI, 0.22-0.89; P = .02) than OLH. The LLH group demonstrated higher bile leakage rate (OR, 1.79; 95% CI, 1.14-2.81; P = .01) and incurred greater hospital costs (MD, 618.56; 95% CI, 154.47-1082.64; P = .009). CONCLUSIONS: LLH has multiple advantages over OLH and should thus be considered as the first choice for left hemihepatectomy.


Assuntos
Hepatectomia/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Hepatopatias/cirurgia , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Hepatectomia/métodos , Humanos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Fígado/cirurgia , Hepatopatias/sangue , Testes de Função Hepática , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Resultado do Tratamento
5.
Saudi Med J ; 40(5): 452-457, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31056621

RESUMO

OBJECTIVES: To compare King Saud University Medical City experience in laparoscopic liver resection with our previously established database for open resections. METHODS: A retrospective study was conducted at King Saud University Medical City, Riyadh, Saudi Arabia. All adult patients who underwent liver resection from 2006 to 2017 were included. Patients who had their procedure converted to open were excluded. RESULTS: Among the 111 liver resections included, 22 (19.8%) were performed laparoscopically and 89 (80.1%) were performed using the open technique. Malignancy was the most common indication in both groups (78.5%). The mean operative time was 275 min (SD 92.2) in the laparoscopic group versus 315 min (SD 104.3) in the open group. Intraoperative blood transfusion was required in the laparoscopic (9%) and open groups (31.4%). The morbidity rate was 13.6% in the laparoscopic group and 31.4% in the open group, and the mortality rate was 0% in the laparoscopic group and 5.6% in the open group. CONCLUSION: Laparoscopic liver resection appears to be a safe technique and can be performed in various benign and malignant cases.


Assuntos
Hepatectomia/métodos , Hepatectomia/estatística & dados numéricos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Adulto , Idoso , Transfusão de Sangue/estatística & dados numéricos , Feminino , Hepatectomia/mortalidade , Humanos , Cuidados Intraoperatórios/estatística & dados numéricos , Laparoscopia/mortalidade , Masculino , Pessoa de Meia-Idade , Morbidade , Duração da Cirurgia , Estudos Retrospectivos , Arábia Saudita/epidemiologia , Fatores de Tempo
6.
Eur Radiol ; 29(11): 5772-5783, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31076864

RESUMO

OBJECTIVES: To reappraise the rate of and risk factors for complications of targeted and non-targeted US-guided liver biopsy in a large series. METHODS: We analyzed 2405 liver biopsies performed in 2137 patients (58% males, mean age 54 ± 15 years old) between January 2010 and December 2015. Biopsies were performed for focal liver lesions characterization (targeted) or chronic liver disease assessment (non-targeted). Clinical, laboratory, and technical data were recorded. For targeted biopsies, we also recorded the largest diameter, location, enhancement pattern, and pathology. Advert events were divided into marked symptoms and complications. Those requiring specific treatment (embolization or surgery) were considered as severe. RESULTS: A total of 1283 (53%) targeted and 1122 (47%) non-targeted biopsies were performed. Marked symptoms occurred after 134 biopsies (5.6%) (95 (7.4%) targeted and 39 (3.5%) non-targeted, p < 0.001), the most common being pain (109/134). Complications occurred after 38 biopsies (1.6%) (24 (1.9%) targeted and 14 (1.2%) non-targeted, p = 0.253) and were severe in 13 patients. In univariate analysis, prothrombin time (p = 0.006), serum creatinine level (p < 0.001), largest lesion diameter (p < 0.001), and tumor pathology (p = 0.040) were associated with the occurrence of complications but not platelet count or lesion enhancement pattern. In multivariate analysis, only the largest lesion diameter was retained (OR 1.014 [1.002-1.026], p = 0.018). CONCLUSION: The rate of advert events after US-guided liver biopsy was low, with no difference between targeted and non-targeted biopsies. When focusing on targeted biopsies, the largest lesion diameter but not enhancement pattern appeared as the main risk factor. KEY POINTS: • Targeted and non-targeted liver biopsies are associated with the same observed risk of complication. • Arterial phase hyperenhanced tumors on contrast-enhanced CT or MRI are not associated with a higher risk of complication when compared with non-hyperenhanced ones. • A high serum creatinine level is associated with a higher risk of complication and should motivate strict post-biopsy surveillance.


Assuntos
Hepatopatias/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha/efeitos adversos , Biópsia por Agulha/métodos , Doença Crônica , Embolização Terapêutica/estatística & dados numéricos , Feminino , Hepatectomia/estatística & dados numéricos , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Biópsia Guiada por Imagem/métodos , Hepatopatias/terapia , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Tempo de Protrombina , Fatores de Risco , Ultrassonografia de Intervenção/efeitos adversos , Ultrassonografia de Intervenção/métodos , Adulto Jovem
7.
Updates Surg ; 71(2): 273-283, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31119579

RESUMO

The objective of this study is to define the learning curve in a series of procedures grouped according to their complexity calculated by difficulty index to define a standard for technical improvement. 1032 laparoscopic liver resections performed in a single tertiary referral center were stratified by difficulty scores: low difficulty (LD, n = 362); intermediate difficulty (ID, n = 332), and high difficulty (HD, n = 338). The learning curve effect was analyzed using the cumulative sum (CUSUM) method taking into consideration the expected risk of conversion. The ratio of laparoscopic/total liver resections increased from 5.8% (2005) to 71.1% (2018). The CUSUM analysis per group showed that the average value of the conversion rate was reached at the 60th case in the LD Group and at the 15th in the ID and HD groups. The evolution from LD to ID and HD procedures occurred only when learning curve in LD resections was concluded. Reflecting different degree of complexity, procedures showed significantly different blood loss, morbidity, and conversions among groups. A standard educational model-stepwise and progressive-is mandatory to allow surgeons to define the technical and technological backgrounds to deal with a specific degree of difficulty, providing a help in the definition of indications to laparoscopic approach in each phase of training.


Assuntos
Hepatectomia/educação , Hepatectomia/normas , Laparoscopia/educação , Laparoscopia/normas , Curva de Aprendizado , Melhoria de Qualidade , Cirurgiões/educação , Idoso , Feminino , Hepatectomia/estatística & dados numéricos , Humanos , Laparoscopia/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Modelos Educacionais , Estudos Retrospectivos , Fatores de Tempo
8.
Br J Surg ; 106(8): 1066-1074, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30990885

RESUMO

BACKGROUND: Indications for hepatectomy in patients with hepatocellular carcinoma (HCC) who have portal hypertension (PH) have been controversial. Some studies have concluded that PH is a contraindication to hepatectomy, whereas others have suggested that perioperative prophylactic management (PPM) can help overcome complications after hepatectomy associated with PH. The objective of this retrospective study was to assess the short- and long-term outcomes after hepatectomy for HCC in patients with PH, with or without PPM. METHODS: Records were reviewed of consecutive patients who underwent hepatectomy for HCC, with or without PPM of PH, in a single institution from 1994 to 2015. Patients were divided into three groups: those who received PPM for PH (PPM group), patients who had PH but did not receive PPM (no-PPM group) and those without PH (no-PH group). RESULTS: A total of 1259 patients were enrolled, including 123 in the PPM group, 181 in the no-PPM group and 955 in the no-PH group. Three- and 5-year overall survival rates were 74·3 and 53·1 per cent respectively in the PPM group, 69·2 and 54·9 per cent in the no-PPM group, and 78·1 and 64·2 per cent in the no-PH group (P = 0·520 for PPM versus no PPM, P = 0·027 for PPM versus no PH, and P < 0·001 for no PPM versus no PH). Postoperative morbidity and mortality rates were 26·0 and 0·8 per cent respectively in the PPM group, 29·8 and 1·1 per cent in the no-PPM group, and 20·3 and 0 per cent in the no-PH group. CONCLUSION: The present study has demonstrated acceptable outcomes among patients with HCC who received appropriate management for PH in an Asian population. Enhancement of the safety of hepatic resection through use of PPM may provide a rationale for expansion of indications for hepatectomy in patients with PH.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia/estatística & dados numéricos , Hipertensão Portal/complicações , Neoplasias Hepáticas/cirurgia , Assistência Perioperatória/métodos , Adulto , Idoso , Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/mortalidade , Feminino , Hepatectomia/mortalidade , Humanos , Hipertensão Portal/mortalidade , Hipertensão Portal/terapia , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
9.
World J Surg Oncol ; 17(1): 43, 2019 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-30813932

RESUMO

BACKGROUND: The purpose of this study was to explore trends in incidence, incidence-based (IB) mortality, and survival for combined hepatocellular-cholangiocarcinoma (cHCC-CC) utilizing a population-based database to attract people's attention to this disease. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was utilized to investigate the incidence and IB mortality for cHCC-CC from 2000 to 2014. Trends in age-adjusted incidence and IB mortality were characterized by the Joinpoint Regression program. The Kaplan-Meier method and log-rank test were utilized to implement survival analyses. Cox regression was utilized to estimate independent predictors of mortality. RESULTS: The incidence of cHCC-CC was 0.26 per 1,000,000 individuals in 2000 and 0.59 per 1,000,000 individuals in 2014, with an annual percent change (APC) (i.e., the extent of increase in incidence) of 3.84% (95% confidence interval [CI] 1.7-6.1; P < 0.05). The IB mortality also displayed a sustained increase (APC was 4.59%, 95% CI 1.9-7.4; P < 0.05). Compared to patients not undergoing surgery, patients undergoing surgical treatment experienced a significant increase in median survival (3 vs. 28 months; P < 0.001). However, the median survival decreased in patients with tumor size > 5 cm (20 vs. 9 months; P < 0.001). Based on univariate Cox regression analysis, African-American race, distant stage, regionalized stage, tumor size ≥ 5 cm, and no surgery were risk factors for death. CONCLUSIONS: We identified an overall steady increase in the incidence of cHCC-CC, which indicates that primary prevention strategies for cHCC-CC have not improved much in recent years and that cHCC-CC needs to be taken seriously.


Assuntos
Neoplasias dos Ductos Biliares/epidemiologia , Carcinoma Hepatocelular/epidemiologia , Colangiocarcinoma/epidemiologia , Neoplasias Hepáticas/epidemiologia , Mortalidade/tendências , Programa de SEER/estatística & dados numéricos , Idoso , Neoplasias dos Ductos Biliares/patologia , Carcinoma Hepatocelular/patologia , Colangiocarcinoma/patologia , Feminino , Hepatectomia/estatística & dados numéricos , Humanos , Incidência , Fígado/patologia , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Análise de Sobrevida , Estados Unidos/epidemiologia
10.
J Surg Res ; 239: 253-260, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30856518

RESUMO

BACKGROUND: Pringle maneuver (PM) is used for inflow vascular control during hepatectomy, but its use remains controversial. We aimed to report its pattern of use and association with postoperative outcomes. METHODS: We identified hepatectomy patients using the liver-targeted National Surgical Quality Improvement Program database (2014-2016). Associations between PM and posthepatectomy liver failure (PHLF), receipt of blood transfusion, and total hospital length of stay (LOS) were evaluated. RESULTS: We identified 7870 patients (74.9%) with no Pringle maneuver and 2632 (25.1%) with PM. PM patients were older (median age 61 versus 60 y, P = 0.002) and had higher ASA scores (76.1% versus 71.4% were ASA 3-4, P < 0.001). PM had more malignancy (83.0% versus 73.0%, P < 0.001), neoadjuvant therapy (37.7% versus 28.8%, P < 0.001), total lobectomy (30.6% versus 23.2%, P < 0.001), open resection (90.8% versus 74.9%, P < 0.001), and longer operations (246 min versus 212 min, P < 0.001). PM was associated with longer LOS (0.36 d, 95% confidence interval [CI] 0.11-0.60) and increased risk of PHLF (odds ratio [OR] 1.36, 95% CI 1.11-1.66), although not clinically significant grade B/C PHLF (OR 0.82, 95% CI 0.57-1.19), but was not associated with receipt of perioperative blood transfusions (OR 1.00, 95% CI 0.69-1.64). CONCLUSIONS: PM is associated with similar clinically significant PHLF and transfusion requirements but longer LOS compared with no Pringle maneuver.


Assuntos
Hepatectomia/efeitos adversos , Falência Hepática/epidemiologia , Neoplasias Hepáticas/terapia , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue/estatística & dados numéricos , Feminino , Hepatectomia/métodos , Hepatectomia/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Falência Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/estatística & dados numéricos , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
11.
World J Surg ; 43(3): 920-928, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30465085

RESUMO

BACKGROUND: We have reported the impact of sarcopenia and body composition on patients undergoing hepatectomy for hepatocellular carcinoma (HCC). However, the impact of bone mineral density (BMD) on outcomes after hepatectomy for HCC and correlation with other parameters including sarcopenia are unclear. METHODS: We retrospectively analyzed 465 patients who underwent primary hepatectomy for HCC between April 2005 and March 2015. We analyzed the plain CT images at the level of the eleventh thoracic vertebra with the region of interest and defined as preoperative BMD. RESULTS: In this cohort, male (n = 367) and female (n = 98) patients showed significant heterogeneity in age, body composition markers, tumor factors, peri-operative parameters and so on. The median preoperative BMD in male and female patients was 155 and 139 HU, respectively (P = 0.005). BMD was negatively correlated with age in female (r = -0.590, P < 0.001) and intramuscular adipose tissue content in both male and female (r = -0.332 and -0.359, respectively, P < 0.001). For males, BMD < 160 HU was associated with worse cancer-specific survival post-hepatectomy (P = 0.015). In contrast, females were not (P = 0.135). For male patients, multivariate analysis identified low BMD as an independent risk factor for death (hazard ratio 1.720, 95% confidence interval 1.038-2.922, P = 0.035) after hepatectomy for HCC. CONCLUSION: Preoperative low BMD was an independent risk factor for cancer-specific mortality after hepatectomy for HCC.


Assuntos
Densidade Óssea/fisiologia , Carcinoma Hepatocelular , Hepatectomia/estatística & dados numéricos , Mortalidade Hospitalar , Neoplasias Hepáticas/cirurgia , Tecido Adiposo/fisiologia , Idoso , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/cirurgia , Feminino , Hepatectomia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Vértebras Torácicas/fisiologia
12.
World J Surg ; 43(3): 910-919, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30465087

RESUMO

BACKGROUND: The effect of various hospital characteristics on failure to rescue (FTR) after liver surgery has not been well examined. We sought to examine the relationship between hospital characteristics and FTR after liver surgery. METHODS: The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was used to identify Medicare beneficiaries who underwent liver surgery. The effect of various hospital characteristics on FTR was compared among the highest mortality hospitals (HMH) and the lowest mortality hospitals (LMH). RESULTS: Among 4902 patients undergoing hepatectomy, patients treated at HMH had a higher risk of FTR (OR 3.08, 95% CI 2.03-4.66). Hospital factors such as total number of beds (OR 0.80, 95% 0.56-1.15), operating rooms (OR 0.81, 95% 0.57-1.14), and overall hospital surgical volume (OR 0.88, 95% 0.61-1.25) were not associated with FTR (all p > 0.05). In contrast, hospitals with a greater nurse-to-patient ratio had a markedly lower risk of FTR following a complication (OR 0.70, 95% CI 0.54-0.91; p = 0.007) (Table 3). As volume of liver operations and nurse-to-patient ratio decreased the risk of FTR increased (p > 0.001). After risk-adjusting for patient characteristics, both the effect of surgical volume (adjusted OR 0.66, 95% CI 0.46-0.94; p = 0.022) and nurse-to-patient ratio (adjusted OR 0.68, 95% CI 0.51-0.90; p = 0.008) remained strongly associated with FTR. CONCLUSION: FTR rates varied considerably among hospital performing hepatectomy. Higher procedure-specific hepatectomy volume, as well as a higher nurse-to-patient ratio, accounted for a reduction in the FTR rates. These data highlight the importance of not only procedure volume, but also adequate nurse staffing in reducing FTR and improving mortality following complex procedures such as hepatectomy.


Assuntos
Hepatectomia/estatística & dados numéricos , Número de Leitos em Hospital/estatística & dados numéricos , Mortalidade Hospitalar , Unidades Hospitalares/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Idoso , Feminino , Humanos , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Risco Ajustado , Fatores de Risco , Estados Unidos
13.
J Gastroenterol Hepatol ; 34(3): 575-579, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30345600

RESUMO

BACKGROUND AND AIM: Geographic differences have existed in the management of hepatocellular carcinoma (HCC), and efforts to reduce regional disparities have been initiated. The aim of this study is to use the Nationwide Inpatient Sample to determine if regional disparities in the treatment of HCC continue to exist. METHOD: A retrospective database analysis using the Nationwide Inpatient Sample was performed that included patients with a primary diagnosis of HCC. Logistic regression models were utilized to determine geographic disparities in liver decompensation, treatment, inpatient mortality, and metastatic disease. RESULTS: This study's locational reach of 62 604 patients included 22 769 patients from the South (36%), 14 554 in the Northeast (23%), 14 041 in the West (22%), and 11 240 in the Midwest (18%). Patients who received treatment in the West were more likely to have inpatient mortality (OR 1.28, 95% CI 1.03, 1.53) than patients who received treatment in the Midwest. No significant differences were observed between rates of resection, ablation, and transarterial chemoembolization when comparing by region. Rates of liver transplantation were lower in the West compared with the Midwest (OR 0.51, 95% CI 0.29, 0.87). There was no significant difference between other regions. CONCLUSION: Geographic disparities in the treatment of HCC are improving.


Assuntos
Carcinoma Hepatocelular/terapia , Geografia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Neoplasias Hepáticas/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/mortalidade , Quimioembolização Terapêutica/estatística & dados numéricos , Bases de Dados como Assunto , Feminino , Hepatectomia/estatística & dados numéricos , Humanos , Neoplasias Hepáticas/mortalidade , Transplante de Fígado/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Ablação por Radiofrequência/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
14.
J Robot Surg ; 13(4): 557-565, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30484059

RESUMO

The safety of hepatectomy continues to improve and it holds a key role in the management of benign and malignant hepatic lesions. Laparoscopic and robotic approaches to hepatectomy are increasingly utilized. The purpose of this study was to compare outcomes and costs of laparoscopic and robotic vs. open approaches to hepatectomy and to determine the national nonelective postoperative readmission rate, including readmission to other hospitals. The Nationwide Readmission Database from 2013 to 2014 was queried for all patients undergoing hepatectomy. Patients undergoing laparoscopic and robotic hepatectomies were compared to patients undergoing open hepatectomy. Multivariate logistic regression was implemented to determine the odds ratios (OR) for non-elective readmission within 45 days. There were 10,870 patients who underwent hepatectomy from 2013 to 2014 and 724 (6.7%) were approached with laparoscopic or robotic technique. The robotic cohort had lower mean cost of the index admission ($24,983 ± $18,329 vs. open $32,391 ± $31,983, p < 0.001, 95% CI - 18,292 to 534), shorter LOS (4.5 ± 3.8 vs. lap 6.8 ± 6.0 vs. open 7.6 ± 7.7 days, p < 0.01), and were less likely to be readmitted within 45 days (7.9% vs. 13.0% lap vs. 13.8% open, p = 0.05). The robotic cohort was slightly younger (mean age 57.5 ± 13.5 vs. lap 60.1 ± 13.8 vs. open 58.9 ± 13.7, p < 0.05), and no significant differences were seen by Charlson Comorbidity Index. Anastomosis of hepatic duct to GI tract carried higher odds of mortality (OR 2.87, p < 0.01) and higher odds of readmission (OR 1.40, p < 0.01). LOS above 7 days increased odds of readmission (OR 2.24, p < 0.01). Nearly one-fifth of patients readmitted after hepatectomy present to a different hospital. Robotic hepatectomy was associated with favorable cost and readmission outcomes compared to laparoscopic and open hepatectomy patients, despite similar patient comorbid burdens and patient's age. Length of stay over 7 days and anastomosis of hepatic duct to GI tract are strong risk factors for readmission and mortality.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Hepatectomia/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Hepatectomia/efeitos adversos , Hepatectomia/economia , Hepatectomia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/economia , Resultado do Tratamento , Estados Unidos , Adulto Jovem
15.
Langenbecks Arch Surg ; 404(1): 11-19, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30519886

RESUMO

BACKGROUND: Improved outcome after liver resections have been reported in several series, but outcomes from national cohorts are scarce. Our aim was to evaluate nationwide practice and short-term outcomes after liver surgery in a universal healthcare system. METHODS: A complete 5-year cohort of all liver resections from the Norwegian Patient Registry (NPR). Short-term outcomes were aggregated length of stay (a-LoS), reoperation and 90-day mortality. RESULTS: Of 2118 liver resections, 605 (28.6%) were major, median age was 65 years and 1184 (55%) were male. Most common indication was metastatic disease (n = 1554; 73.4%) and primary malignancy (n = 328; 15.3%). Laparoscopy was performed in 513 (33.9%) of minor and 37 (6.1%) of major liver resections and increased over time to 39.1% of minor resections in 2016. Median a-LoS was 12 days for major resections, 8 days for open minor and 3 days for laparoscopic minor resections. Reoperation was reported for 159 (7.4%) and 90-day mortality for 44 (2.1%). Primary malignancy, male gender, elderly patients and major resections were associated with poorer outcome. CONCLUSIONS: In a national cohort, laparoscopy is used for a substantial proportion of minor resections and was associated with reduced a-LoS. Risk factors for reoperation and mortality were male gender, increased age and major resection for primary malignancy.


Assuntos
Hepatectomia/efeitos adversos , Neoplasias Hepáticas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Idoso , Estudos de Coortes , Feminino , Hepatectomia/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Reoperação , Taxa de Sobrevida , Resultado do Tratamento
16.
Khirurgiia (Mosk) ; (11): 24-30, 2018.
Artigo em Russo | MEDLINE | ID: mdl-30531749

RESUMO

AIM: To assess an experience of robot-assisted liver resection using CUSUM-test. MATERIAL AND METHODS: The results of 46 robot-assisted liver resections were retrospectively analyzed by using of CUSUM-test. RESULTS: There were 3 periods in development of the technology. The 1st period - procedures with the lowest index of difficulty (n=16), the 2nd period - expansion of the indications for difficult resections (n=18) and the 3rd period - stabilization of the results (n=12). The dynamics of difficulty index, intraoperative blood loss, duration of procedure and morbidity (Clavien-Dindo Grade II-V) were evaluated. Five liver resections were needed to decrease blood loss and duration of the procedure. Expansion of indications was feasible after 16 procedures. Stable results were obtained after 34 liver resections.


Assuntos
Hepatectomia/métodos , Hepatopatias/cirurgia , Fígado/cirurgia , Procedimentos Cirúrgicos Robóticos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Hepatectomia/estatística & dados numéricos , Humanos , Morbidade , Duração da Cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Resultado do Tratamento
17.
J Surg Oncol ; 118(8): 1227-1236, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30399204

RESUMO

BACKGROUND AND OBJECTIVES: Spontaneous rupture of Hepatocellular Carcinoma (srHCC) is a life-threatening emergency. We sought to identify the pre-operative predictors of early tumor recurrence/mortality including the role of inflammatory indices after partial hepatectomy for srHCC. METHODS: Between 2000-2015, 79 patients with srHCC were identified to have undergone upfront partial hepatectomy following srHCC. Clinicopathologic data were retrospectively analyzed to identify pre-operative predictors of early (<1 year) recurrence and mortality. RESULTS: Seventy-nine patients were identified to have undergone partial hepatectomy for srHCC. The 1-year mortality and 1-year recurrence rate in our series was 30.3% and 41.8% respectively. On multivariate analyses, free tumor rupture and a tumor size > 10 cm were identified to be independent predictors of early recurrence while an alpha fetoprotein (AFP) > 200 ng/mL was an independent predictor of early mortality. Neutrophil-to-lymphocyte ratio > 3 and prognostic nutritional index < 40 were predictors of early recurrence while PLR > 180 was a predictor of early mortality on univariate analyses but not multivariate analyses. CONCLUSIONS: Tumor size > 10 cm, free tumor rupture, and an AFP > 200 ng/mL were useful predictors in avoiding "futile surgery" in patients with srHCC undergoing a partial hepatectomy. Preoperative inflammatory markers appear to be less useful as predictors of early recurrence/mortality in this cohort of patients.


Assuntos
Carcinoma Hepatocelular/metabolismo , Carcinoma Hepatocelular/mortalidade , Mediadores da Inflamação/metabolismo , Neoplasias Hepáticas/metabolismo , Neoplasias Hepáticas/mortalidade , Recidiva Local de Neoplasia/metabolismo , Recidiva Local de Neoplasia/mortalidade , Idoso , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/cirurgia , Feminino , Hepatectomia/métodos , Hepatectomia/estatística & dados numéricos , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Valor Preditivo dos Testes , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Ruptura Espontânea/patologia
18.
BMJ Open ; 8(10): e021269, 2018 10 18.
Artigo em Inglês | MEDLINE | ID: mdl-30341113

RESUMO

OBJECTIVE: Hepatocellular carcinoma (HCC) is the third leading cause of cancer death worldwide. We conducted network meta-regression within a Bayesian framework to compare and rank different treatment strategies for HCC through direct and indirect evidence from international studies. METHODS AND ANALYSES: We pooled the OR for 1-year, 3-year and 5-year overall survival, based on lesions of size ˂ 3 cm, 3-5 cm and ≤5 cm, using five therapeutic options including resection (RES), radiofrequency ablation (RFA), microwave ablation (MWA), transcatheter arterial chemoembolisation (TACE) plus RFA (TR) and percutaneous ethanol injection (PEI). RESULTS: We identified 74 studies, including 26 944 patients. After adjustment for study design, and in the full sample of studies, the treatments were ranked in order of greatest to least benefit as follows for 5 year survival: (1) RES, (2) TR, (3) RFA, (4) MWA and (5) PEI. The ranks were similar for 1- and 3-year survival, with RES and TR being the highest ranking treatments. In both smaller (<3 cm) and larger tumours (3-5 cm), RES and TR were also the two highest ranking treatments. There was little evidence of inconsistency between direct and indirect evidence. CONCLUSION: The comparison of different treatment strategies for HCC indicated that RES is associated with longer survival. However, many of the between-treatment comparisons were not statistically significant and, for now, selection of strategies for treatment will depend on patient and disease characteristics. Additionally, much of the evidence was provided by non-randomised studies and knowledge gaps still exist. More head-to-head comparisons between both RES and TR, or other approaches, will be necessary to confirm these findings.


Assuntos
Carcinoma Hepatocelular/terapia , Ablação por Cateter/estatística & dados numéricos , Quimioembolização Terapêutica/estatística & dados numéricos , Etanol/uso terapêutico , Hepatectomia/estatística & dados numéricos , Neoplasias Hepáticas/terapia , Terapia Combinada , Intervalo Livre de Doença , Humanos , Estadiamento de Neoplasias , Resultado do Tratamento
19.
Surgery ; 164(6): 1251-1258, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30201232

RESUMO

BACKGROUND: Opioid overprescription can contribute to suboptimal patient outcomes. Surgeon-performed transversus abdominis plane blocks appear to be associated with pain reduction. We compared the analgesic efficacy of surgeon-performed transversus abdominis plane blocks for major hepatectomy with or without concurrent neuraxial analgesia. METHODS: We performed a single-institution review, assessing surgeon-performed transversus abdominis plane blocks for major hepatectomy during 2013-2016. The primary outcome was patient-reported pain (11-point numeric pain-rating scale) and the secondary outcome was opioid consumption. Independent factors predictive of pain control were identified using logistic regression and reported as odds ratios with 95% confidence intervals. RESULTS: A total of 232 patients with a mean (± SD) age of 56.5 (±13.9) years; 51.7% were female. Operative duration, incision type, and American Society of Anesthesiologists score were similar between groups. The 24-hour pain score was decreased substantially in patients who received a transversus abdominis plane block compared with those who did not (3 [2-4] versus 5 [4-6], P = .001) and this decrease in pain sscore persisted at 48 hours (2 [1-2] versus 4 [4-5], P = .001). In patients who received a transversus abdominis plane block, there were decreasess in consumption of oral morphine equivalents at 24 hours (322 [± 18] versus 183 [± 15], P = .0001) and 48 hours (100 [± 11] versus 33 [± 9.4], P = .03) compared with those without transversus abdominis plane block respectively. CONCLUSION: In patients receiving a transversus abdominis plane block, early patient opioid consumption was decreased and utilization was predictive for improved pain control. Routine transversus abdominis plane block administration should be considered during major hepatectomy as a step toward curbing systematic reliance on opioids for pain management. A prospective study on the utility of transversus abdominis plane block in hepatectomy is warranted.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestesia por Condução/estatística & dados numéricos , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Músculos Abdominais , Adulto , Idoso , Feminino , Hepatectomia/efeitos adversos , Hepatectomia/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/etiologia , Estudos Retrospectivos
20.
JAMA Surg ; 153(10): e182721, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-30073257

RESUMO

Importance: A reduced incidence of microvascular invasion (MVI) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) may be associated with a decreased risk of early tumor recurrence and better survival after partial hepatectomy. Objective: To examine the association of preoperative antiviral treatment (AVT) with the incidences of MVI and posthepatectomy early tumor recurrence in HBV-related HCC. Design, Setting, and Participants: Data on a cohort of 2362 patients who underwent R0 resection for HBV-related HCC between January 2008 and April 2010 at the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China, were reviewed. The median (interquartile range) postoperative follow-up was 44.8 (22.8-59.3) months. Data were analyzed from June 2016 to October 2017. Interventions: Preoperative AVT and partial hepatectomy. Main Outcomes and Measures: Overall survival and time to recurrence after surgery were calculated and compared using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Independent risk factors of MVI presence were assessed by logistic regression analysis. Results: Among 2362 included patients, 1999 (84.6%) were men, and the median (interquartile range) age was 50.6 (43.1-57.3) years. A total of 2036 patients (86.2%) did not receive any preoperative AVT, while 326 (13.8%) received ongoing AVT more than 90 days before surgery. In the non-AVT group, compared with a preoperative HBV DNA level of less than 2000 IU/mL, a preoperative HBV DNA level of 2000 IU/mL or greater was associated with an increased risk of MVI (odds ratio [OR], 1.399; 95% CI, 1.151-1.701). Compared with the non-AVT group, patients receiving AVT had a lower incidence of MVI (38.7% [126 of 326] vs 48.6% [989 of 2036]; P = .001) and reduced risk of MVI (OR, 0.758; 95% CI, 0.575-0.998). A complete response to AVT was an independent protective factor of MVI (OR, 0.690; 95% CI, 0.500-0.952). Accordingly, preoperative AVT was associated with decreased 6-month, 1-year, and 2-year recurrences vs non-AVT (14.2%, 24.6%, and 38.5%, respectively, vs 23.4%, 37.1%, and 52.3%; P < .001); AVT was protective of early tumor recurrence (hazard ratio, 0.732; 95% CI, 0.605-0.886). In addition, patients in the non-AVT group were more likely to have multiple intrahepatic recurrences (49.1% [549 of 1119] vs 36.2% [54 of 149]; P = .003) and recurrences involving multiple hepatic segments compared with patients receiving AVT. Conclusions and Relevance: A high preoperative HBV DNA level was an independent risk factor of MVI. Antiviral treatment administered more than 90 days before surgery was associated with reduced incidences of MVI and early tumor recurrence after partial hepatectomy for HBV-related HCC.


Assuntos
Antivirais/uso terapêutico , Carcinoma Hepatocelular/cirurgia , Hepatite B Crônica/tratamento farmacológico , Neoplasias Hepáticas/cirurgia , Neoplasias Vasculares/patologia , Adulto , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/virologia , DNA Viral/metabolismo , Feminino , Hepatectomia/estatística & dados numéricos , Vírus da Hepatite B/genética , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/virologia , Masculino , Microvasos , Pessoa de Meia-Idade , Invasividade Neoplásica , Recidiva Local de Neoplasia/virologia , Cuidados Pré-Operatórios/métodos , Fatores de Risco
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