26
|
Niederwieser T, Braunwarth E, Dasari BVM, Pufal K, Szatmary P, Hackl H, Haselmann C, Connolly CE, Cardini B, Öfner D, Roberts K, Malik H, Stättner S, Primavesi F. Early postoperative arterial lactate concentrations to stratify risk of post-hepatectomy liver failure. Br J Surg 2021; 108:1360-1370. [PMID: 34694377 DOI: 10.1093/bjs/znab338] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 09/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) represents the major determinant for death after liver resection. Early recognition is essential. Perioperative lactate dynamics for risk assessment of PHLF and associated morbidity were evaluated. METHODS This was a multicentre observational study of patients undergoing hepatectomy with validation in international high-volume units. Receiver operating characteristics analysis and cut-off calculation for the predictive value of lactate for clinically relevant International Study Group of Liver Surgery grade B/C PHLF (clinically relevant PHLF (CR-PHLF)) were performed. Lactate and other perioperative factors were assessed in a multivariable CR-PHLF regression model. RESULTS The exploratory cohort comprised 509 patients. CR-PHLF, death, overall morbidity and severe morbidity occurred in 7.7, 3.3, 40.9 and 29.3 per cent of patients respectively. The areas under the curve (AUCs) regarding CR-PHLF were 0.829 (95 per cent c.i. 0.770 to 0.888) for maximum lactate within 24 h (Lactate_Max) and 0.870 (95 per cent c.i. 0.818 to 0.922) for postoperative day 1 levels (Lactate_POD1). The respective AUCs in the validation cohort (482 patients) were 0.812 and 0.751 and optimal Lactate_Max cut-offs were identical in both cohorts. Exploration cohort patients with Lactate_Max 50 mg/dl or greater more often developed CR-PHLF (50.0 per cent) than those with Lactate_Max between 20 and 49.9 mg/dl (7.4 per cent) or less than 20 mg/dl (0.5 per cent; P < 0.001). This also applied to death (18.4, 2.7 and 1.4 per cent), severe morbidity (71.1, 35.7 and 14.1 per cent) and associated complications such as acute kidney injury (26.3, 3.1 and 2.3 per cent) and haemorrhage (15.8, 3.1 and 1.4 per cent). These results were confirmed in the validation group. Combining Lactate_Max with Lactate_POD1 further increased AUC (ΔAUC = 0.053) utilizing lactate dynamics for risk assessment. Lactate_Max, major resections, age, cirrhosis and chronic kidney disease were independent risk factors for CR-PHLF. A freely available calculator facilitates clinical risk stratification (www.liver-calculator.com). CONCLUSION Early postoperative lactate values are powerful, readily available markers for CR-PHLF and associated complications after hepatectomy with potential for guiding postoperative care.Presented in part as an oral video abstract at the 2020 online Congress of the European Society for Surgical Research and the 2021 Congress of the Austrian Surgical Society.
Collapse
|
27
|
Ammar K, Varghese C, K T, Prabakaran V, Robinson S, Pathak S, Dasari BVM, Pandanaboyana S. Impact of routine nasogastric decompression versus no nasogastric decompression after pancreaticoduodenectomy on perioperative outcomes: meta-analysis. BJS Open 2021; 5:6472792. [PMID: 34932101 PMCID: PMC8691053 DOI: 10.1093/bjsopen/zrab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/03/2021] [Indexed: 12/28/2022] Open
Abstract
Background Consensus on the use of nasogastric decompression (NGD) after pancreaticoduodenectomy (PD) is lacking. This meta-analysis reviewed current evidence on the impact of routine NGD versus no NGD after PD on perioperative outcomes. Methods PubMed, Medline, Scopus, Embase and Cochrane databases were searched for studies reporting on the role of NGD after PD on perioperative outcomes. Data up to January 2021were retrieved and analysed. Results Eight studies were included, with a total of 1301 patients enrolled, of whom 668 had routine NGD. Routine NGD was associated with a higher incidence of overall delayed gastric emptying (DGE) (odds ratio (OR) 2.51, 95 per cent c.i. 1.12 to 5.63, I2 = 83 per cent; P = 0.03) and clinically relevant DGE (OR 3.64, 95 per cent c.i. 1.83 to 7.25, I2 = 54 per cent; P < 0.01), a higher rate of Clavien–Dindo grade II or higher complications (OR 3.12, 95 per cent c.i. 1.05 to 9.28, I2 = 88 per cent; P = 0.04) and increased length of hospital stay (mean difference 2.67, 95 per cent c.i. 0.60 to 4.75, I2 = 97 per cent; P = 0.02). There were no significant differences in overall complications (OR 1.07, 95 per cent c.i. 0.79 to 1.46, I2 = 0 per cent; P = 0.66) or postoperative pancreatic fistula (OR 1.21, 95 per cent c.i. 0.86 to 1.72, I2 = 0 per cent; P = 0.28) between patients with or those without routine NGD. Conclusion Routine NGD was associated with increased rates of DGE, major complications and longer length of stay after PD.
Collapse
|
28
|
Pufal K, Lawson A, Hodson J, Bangash M, Patel J, Weston C, Gulik TV, Dasari BVM. 589 Role of Liver Support Systems in The Management of Post Hepatectomy Liver Failure: A Meta-Analysis and Systematic Review of Literature. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
Post hepatectomy liver failure (PHLF) is a rare but serious complication following liver resection. PHLF is associated with high mortality of up to 50% in severe cases. With limited treatment options available, there is a need to evaluate the role of systems that support the function of the liver as treatment modalities following PHLF development.
Method
The aim of this study was to review the literature and summarise the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications were extracted, pooled where possible, and analysed.
Results
Systematic review identified ten studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF development. The sample sizes of included studies were small, ranging from N = 2 to N = 13. Across all studies, the pooled 90-day mortality rate was 40% (95% CI: 15% - 68%). However, there was substantial heterogeneity (I2=64%), likely since the studies used a variety of definitions for PHLF and had different selection criteria for patient eligibility for LSS treatment.
Conclusions
Despite potential benefits, the current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicentre, prospective studies evaluating the conventional and newer modalities of support systems with a view to improve the outcomes in this group of patients.
Collapse
|
29
|
Chong E, Ratnayake B, Dasari BVM, Loveday BPT, Siriwardena AK, Pandanaboyana S. Adjuvant Chemotherapy in the Treatment of Intraductal Papillary Mucinous Neoplasms of the Pancreas: Systematic Review and Meta-Analysis. World J Surg 2021; 46:223-234. [PMID: 34545418 PMCID: PMC8677688 DOI: 10.1007/s00268-021-06309-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 12/28/2022]
Abstract
Background The present systematic review aimed to compare survival outcomes of invasive intraductal papillary mucinous neoplasms (IIPMNs) treated with adjuvant chemotherapy versus surgery alone and to identify pathologic features that may predict survival benefit from adjuvant chemotherapy. Method A systematic search of MEDLINE, PubMed, Scopus, and EMBASE was performed using the PRISMA framework. Studies comparing adjuvant chemotherapy and surgery alone for patients with IIPMNs were included. Primary endpoint was overall survival (OS). A narrative synthesis was performed to identify pathologic features that predicted survival benefits from adjuvant chemotherapy. Results Eleven studies and 3393 patients with IIPMNs were included in the meta-analysis. Adjuvant chemotherapy significantly reduced the risk of death in the overall cohort (HR 0.57, 95% CI 0.38–0.87, p = 0.009) and node-positive patients (HR 0.29, 95% CI 0.13–0.64, p = 0.002). Weighted median survival difference between adjuvant chemotherapy and surgery alone in node-positive patients was 11.6 months (95% CI 3.83–19.38, p = 0.003) favouring chemotherapy. Adjuvant chemotherapy had no impact on OS in node-negative patients (HR 0.53, 95% CI 0.20–1.43, p = 0.209). High heterogeneity (I2 > 75%) was observed in pooled estimates of hazard ratios. Improved OS following adjuvant chemotherapy was reported for patients with stage III/IV disease, tumour size > 2 cm, node-positive status, grade 3 tumour differentiation, positive margin status, tubular carcinoma subtype, and presence of perineural or lymphovascular invasion. Conclusion Adjuvant chemotherapy was associated with improved OS in node-positive IIPMNs. However, the findings were limited by marked heterogeneity. Future large multicentre prospective studies are needed to confirm these findings and explore additional predictors of improved OS to guide patient selection for adjuvant chemotherapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06309-8.
Collapse
|
30
|
Lithgow K, Venkataraman H, Hughes S, Shah H, Kemp-Blake J, Vickrage S, Smith S, Humphries S, Elshafie M, Taniere P, Diaz-Cano S, Dasari BVM, Almond M, Ford S, Ayuk J, Shetty S, Shah T, Geh I. Well-differentiated gastroenteropancreatic G3 NET: findings from a large single centre cohort. Sci Rep 2021; 11:17947. [PMID: 34504148 PMCID: PMC8429701 DOI: 10.1038/s41598-021-97247-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/21/2021] [Indexed: 11/14/2022] Open
Abstract
Neuroendocrine neoplasms are known to have heterogeneous biological behavior. G3 neuroendocrine tumours (NET G3) are characterized by well-differentiated morphology and Ki67 > 20%. The prognosis of this disease is understood to be intermediate between NET G2 and neuroendocrine carcinoma (NEC). Clinical management of NET G3 is challenging due to limited data to inform treatment strategies. We describe clinical characteristics, treatment, and outcomes in a large single centre cohort of patients with gastroenteropancreatic NET G3. Data was reviewed from 26 cases managed at Queen Elizabeth Hospital, Birmingham, UK, from 2012 to 2019. Most commonly the site of the primary tumour was unknown and majority of cases with identifiable primaries originated in the GI tract. Majority of cases demonstrated somatostatin receptor avidity. Median Ki67 was 30%, and most cases had stage IV disease at diagnosis. Treatment options included surgery, somatostatin analogs (SSA), and chemotherapy with either platinum-based or temozolomide-based regimens. Estimated progression free survival was 4 months following initiation of SSA and 3 months following initiation of chemotherapy. Disease control was observed following treatment in 5/11 patients treated with chemotherapy. Estimated median survival was 19 months; estimated 1 year survival was 60% and estimated 2 year survival was 13%. NET G3 is a heterogeneous group of tumours and patients which commonly have advanced disease at presentation. Prognosis is typically poor, though select cases may respond to treatment with SSA and/or chemotherapy. Further study is needed to compare efficacy of different treatment strategies for this disease.
Collapse
|
31
|
Engstrand J, Abreu de Carvalho LF, Aghayan D, Balakrishnan A, Belli A, Björnsson B, Dasari BVM, Detry O, Di Martino M, Edwin B, Erdmann J, Fristedt R, Fusai G, Gimenez-Maurel T, Hemmingsson O, Hidalgo Salinas C, Isaksson B, Ivanecz A, Izzo F, Knoefel WT, Kron P, Lehwald-Tywuschik N, Lesurtel M, Lodge JPA, Machairas N, Marino MV, Martin V, Paterson A, Rystedt J, Sandström P, Serrablo A, Siriwardena AK, Taflin H, van Gulik TM, Yaqub S, Özden I, Ramia JM, Sturesson C. Liver resection and ablation for squamous cell carcinoma liver metastases. BJS Open 2021; 5:6356812. [PMID: 34426830 PMCID: PMC8382975 DOI: 10.1093/bjsopen/zrab060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/17/2021] [Indexed: 12/30/2022] Open
Abstract
Background Limited evidence exists to guide the management of patients with liver metastases from squamous cell carcinoma (SCC). The aim of this retrospective multicentre cohort study was to describe patterns of disease recurrence after liver resection/ablation for SCC liver metastases and factors associated with recurrence-free survival (RFS) and overall survival (OS). Method Members of the European–African Hepato-Pancreato-Biliary Association were invited to include all consecutive patients undergoing liver resection/ablation for SCC liver metastases between 2002 and 2019. Patient, tumour and perioperative characteristics were analysed with regard to RFS and OS. Results Among the 102 patients included from 24 European centres, 56 patients had anal cancer, and 46 patients had SCC from other origin. RFS in patients with anal cancer and non-anal cancer was 16 and 9 months, respectively (P = 0.134). A positive resection margin significantly influenced RFS for both anal cancer and non-anal cancer liver metastases (hazard ratio 6.82, 95 per cent c.i. 2.40 to 19.35, for the entire cohort). Median survival duration and 5-year OS rate among patients with anal cancer and non-anal cancer were 50 months and 45 per cent and 21 months and 25 per cent, respectively. For the entire cohort, only non-radical resection was associated with worse overall survival (hazard ratio 3.21, 95 per cent c.i. 1.24 to 8.30). Conclusion Liver resection/ablation of liver metastases from SCC can result in long-term survival. Survival was superior in treated patients with liver metastases from anal versus non-anal cancer. A negative resection margin is paramount for acceptable outcome.
Collapse
|
32
|
Bari H, Wadhwani S, Dasari BVM. Role of artificial intelligence in hepatobiliary and pancreatic surgery. World J Gastrointest Surg 2021; 13:7-18. [PMID: 33552391 PMCID: PMC7830072 DOI: 10.4240/wjgs.v13.i1.7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/08/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, enhanced preoperative imaging and visualization, improved delineation of the complex anatomical structures of the liver and pancreas, and intra-operative technological advances have helped deliver the liver and pancreatic surgery with increased safety and better postoperative outcomes. Artificial intelligence (AI) has a major role to play in 3D visualization, virtual simulation, augmented reality that helps in the training of surgeons and the future delivery of conventional, laparoscopic, and robotic hepatobiliary and pancreatic (HPB) surgery; artificial neural networks and machine learning has the potential to revolutionize individualized patient care during the preoperative imaging, and postoperative surveillance. In this paper, we reviewed the existing evidence and outlined the potential for applying AI in the perioperative care of patients undergoing HPB surgery.
Collapse
|
33
|
|
34
|
Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
Collapse
|
35
|
Pathanki AM, Attard JA, Bradley E, Powell-Brett S, Dasari BVM, Isaac JR, Roberts KJ, Chatzizacharias NA. Pancreatic exocrine insufficiency after pancreaticoduodenectomy: Current evidence and management. World J Gastrointest Pathophysiol 2020; 11:20-31. [PMID: 32318312 PMCID: PMC7156847 DOI: 10.4291/wjgp.v11.i2.20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is the commonest procedure performed for pancreatic cancer. Pancreatic exocrine insufficiency (PEI) may be caused or exacerbated by surgery and remains underdiagnosed and undertreated. The aim of this review was to ascertain the incidence of PEI, its consequences and management in the setting of PD for indications other than chronic pancreatitis. A literature search of databases (MEDLINE, EMBASE, Cochrane and Scopus) was carried out with the MeSH terms “pancreatic exocrine insufficiency” and “Pancreaticoduodenectomy”. Studies that analysed PEI and its complications in the setting of PD for malignant and benign disease were included. Studies reporting PEI in the setting of PD for chronic pancreatitis, conference abstracts and reviews were excluded. The incidence of PEI approached 100% following PD in some series. The pre-operative incidence varied depending on the characteristics of the patient cohort and it was higher (46%-93%) in series where pancreatic cancer was the predominant indication for surgery. Variability was also recorded with regards to the method used for the diagnosis and evaluation of pancreatic function and malabsorption. Pancreatic enzyme replacement therapy is the mainstay of the management. PEI is common and remains undertreated after PD. Future studies are required for the identification of a well-tolerated, reliable and reproducible diagnostic test in this setting.
Collapse
|
36
|
Dasari BVM, Pathanki A, Hodson J, Roberts KJ, Marudanayagam R, Mirza DF, Isaac J, Sutcliffe RP, Muiesan P. Propensity-matched analysis of the influence of perioperative statin therapy on outcomes after liver resection. BJS Open 2019; 3:509-515. [PMID: 31388643 PMCID: PMC6677106 DOI: 10.1002/bjs5.50155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background Perioperative use of statins is reported to improve postoperative outcomes after cardiac and non‐cardiovascular surgery. The aim of this study was to investigate the influence of statins on postoperative outcomes including complications of grade IIIa and above, posthepatectomy liver failure (PHLF), and 90‐day mortality rates after liver resection. Methods Patients who underwent hepatectomy between 2013 and 2017 were reviewed to identify statin users and non‐users (controls). Propensity matching was conducted for age, BMI, type of surgery and preoperative co‐morbidities to compare subgroups. Univariable and multivariable analyses were performed for the following outcomes: 90‐day mortality, significant postoperative complications and PHLF. Results Of 890 patients who had liver resection during the study period, 162 (18·2 per cent) were taking perioperative statins. Propensity analysis selected two matched groups, each comprising 154 patients. Overall, 81 patients (9·1 per cent) developed complications of grade IIIa or above, and the 90‐day mortality rate was 3·4 per cent (30 patients), with no statistically significant difference when the groups were compared before and after matching. The rate of PHLF was significantly lower in patients on perioperative statins than in those not taking statins (10·5 versus 17·3 per cent respectively; P = 0·033); similar results were found after propensity matching (10·4 versus 20·8 per cent respectively; P = 0·026). Conclusion The rate of PHLF was significantly lower in patients taking perioperative statins, but there was no statistically significant difference in severe complications and mortality rates.
Collapse
|
37
|
Dasari BVM. Response to Letter to Editor: Advances in Endoscopic Techniques for Resection of Duodenal Neuroendocrine Tumours Response to: Outcomes of Surgical and Endoscopic Resection of Duodenal Neuroendocrine Tumours (NETs): a Systematic Review of the Literature. J Gastrointest Surg 2019; 23:1288-1289. [PMID: 30887290 DOI: 10.1007/s11605-019-04193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
|
38
|
Mathuram Thiyagarajan U, Brown R, Dasari BVM. Liver Resection and Role of Extended Cytology and Histology : Response to: Viganò L, Costa G, Cimino MM, Procopio F, Donadon M, Del Fabbro D, Belghiti J, Kokudo N, Makuuchi M, Vauthey JN, Torzilli G. R1 Resection for Colorectal Liver Metastases: a Survey Questioning Surgeons about Its Incidence, Clinical Impact, and Management. J Gastrointest Surg. 2018 Oct; 22(10):1752-1763. J Gastrointest Surg 2019; 23:1283-1284. [PMID: 30891660 DOI: 10.1007/s11605-019-04189-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 02/26/2019] [Indexed: 01/31/2023]
|
39
|
Dasari BVM, Hodson J, Roberts KJ, Sutcliffe RP, Marudanayagam R, Mirza DF, Isaac J, Muiesan P. Developing and validating a pre-operative risk score to predict post-hepatectomy liver failure. HPB (Oxford) 2019; 21:539-546. [PMID: 30361111 DOI: 10.1016/j.hpb.2018.09.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/15/2018] [Indexed: 12/12/2022]
Abstract
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.
Collapse
|
40
|
Dasari BVM, Hodson J, Sutcliffe RP, Marudanayagam R, Roberts KJ, Abradelo M, Muiesan P, Mirza DF, Isaac J. Developing and validating a preoperative risk score to predict 90-day mortality after liver resection. J Surg Oncol 2019; 119:472-478. [PMID: 30637737 DOI: 10.1002/jso.25350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022]
Abstract
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.
Collapse
|
41
|
Dasari BVM, Ionescu MI, Pawlik TM, Hodson J, Sutcliffe RP, Roberts KJ, Muiesan P, Isaac J, Marudanayagam R, Mirza DF. Outcomes of surgical resection of gallbladder cancer in patients presenting with jaundice: A systematic review and meta-analysis. J Surg Oncol 2018; 118:477-485. [PMID: 30259519 DOI: 10.1002/jso.25186] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/12/2018] [Accepted: 06/30/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Preoperative jaundice is considered a relative contraindication to radical gallbladder cancer (GBC) resection due to poor prognosis and high postoperative morbidity. Recent reports have indicated that aggressive surgery may improve long-term survival for patients with advanced GBC who present with obstructive jaundice. The current systematic review and meta-analysis aimed to compare postoperative outcomes among jaundiced and non-jaundiced patients with resectable GBC. METHODS An electronic search was performed using several Medical Subject Headings terms: cholecyst, gallbladder, tumor, cancer, carcinoma, adenocarcinoma, neoplasia, neoplasm, jaundice, and icterus. Overall survival after surgery was the primary outcome; resectability and postoperative morbidity were the secondary outcomes. RESULTS Overall survival was shorter among patients who presented with jaundice (Hazard ratio [HR]: 2.21, 95% confidence interval [CI], 1.64-2.97; P < 0.001). Patients with jaundice were less likely to have resectable disease (odds ratio: 0.27, 95% CI, 0.17-0.43; P < 0.001). The jaundice group had higher odds of postoperative morbidity, bile-leak, and posthepatectomy failure versus the non-jaundiced control group. CONCLUSIONS Radical surgery for GBC resection for patients presenting with obstructive jaundice was associated with reduced overall survival and increased postoperative morbidity. Jaundiced patients with advanced GBC should be considered for surgical resection but need careful evaluation and counseling before undertaking extensive surgical resection.
Collapse
|
42
|
Roberts KJ, Schrem H, Hodson J, Angelico R, Dasari BVM, Coldham CA, Marudanayagam R, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF. Pancreas exocrine replacement therapy is associated with increased survival following pancreatoduodenectomy for periampullary malignancy. HPB (Oxford) 2017; 19:859-867. [PMID: 28711377 DOI: 10.1016/j.hpb.2017.05.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 05/10/2017] [Accepted: 05/28/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although many patients undergoing pancreatoduodenectomy (PD) for cancer have pancreatic exocrine insufficiency, pancreatic enzyme replacement therapy (PERT) is not routinely used, and effects upon post-operative survival are unclear. METHODS This review of patients undergoing PD for periampullary malignancy sought to test for an association between PERT and overall survival, with post-hoc subgroup analysis performed after stratifying patients by the year of surgery, pancreatic duct width and tumour type. RESULTS Some 202/469 (43.1%) patients received PERT. After accounting for pathological variables and chemotherapy, PERT use was found to be independently associated with improved survival on multivariable analysis [HR 0.72 (95% CI: 0.52-0.99), p = 0.044] and on propensity matched analysis (p = 0.009). The effect of PERT upon improved survival was predominantly observed amongst patients with a dilated pancreatic duct (≥3 mm). DISCUSSION PERT use was independently associated with improved survival following PD for cancer. The validity of this observation is supported by an effect largely confined to those patients with a dilated pancreatic duct. The nutritional status of patients undergoing PD for cancer needs further investigation and the effects of PERT require verification in further clinical studies.
Collapse
|
43
|
Dasari BVM, Pasquali S, Vohra RS, Smith AM, Taylor MA, Sutcliffe RP, Muiesan P, Roberts KJ, Isaac J, Mirza DF. Extended Versus Standard Lymphadenectomy for Pancreatic Head Cancer: Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg 2015; 19:1725-32. [PMID: 26055135 DOI: 10.1007/s11605-015-2859-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/11/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The evidence for improved prognostic assessment and long-term survival for extended pancreatoduodenectomy (EPD) compared to standard pancreatoduodenectomy (SPD) in patients with carcinoma of the head of the pancreas has not been considered from only randomized controlled trials (RCTs). METHODS The aim of this study was to conduct a systematic review and meta-analysis of the outcomes comparing SPD and EPD in RCTs. Searches were performed on MEDLINE, Embase and Cochrane databases using MeSH keyword combinations: 'pancreatic cancer', 'pancreaticoduodenectomy', 'extended', 'randomized' and 'lymphadenectomy'. RCTs published up to 2014 were included. Overall post-operative survival, morbidity, 30-day mortality and length of hospital stay were the outcomes assessed. RESULTS Five eligible RCTs with 546 participants were included (EPD = 276 and SPD = 270). EPD was associated with a significantly higher number of excised lymph nodes (LNs) compared to SPD (mean difference = 15.73, 95% confidence interval (CI) = 9.41-22.04; P < 0.00001; I(2) = 88%). LN metastasis was detected in 58-68 and 55-70% of patients who had EPD and SPD, respectively. EPD did not improve overall survival (hazard ratio (HR) = 0.88, 95% CI = 0.75-1.03; P = 0.11) but did worsen post-operative morbidity compared to SPD (risk ratio (RR) = 1.23; 95% CI = 1.01-1.50; P = 0.004; I(2) = 9%). There were no differences in the 30-day mortality (RR = 0.81; 95% CI = 0.32-2.06; P = 0.66; I(2) = 0%) or length of hospital stay (mean difference = 1.39, 95% CI = -2.31 to 5.09; P = 0.46; I(2) = 67%). CONCLUSION SPD is associated with reduced morbidity, but equivalent long-term benefits compared to patients undergoing EPD.
Collapse
|
44
|
Dasari BVM, Rahman R, Khan S, Bennett D, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts KJ, Sutcliffe RP. Safety and feasibility of an enhanced recovery pathway after a liver resection: prospective cohort study. HPB (Oxford) 2015; 17:700-6. [PMID: 26099347 PMCID: PMC4527855 DOI: 10.1111/hpb.12447] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND In contrast to colorectal surgery, enhanced recovery pathways (ERPs) have not yet become standard practice after major upper abdominal surgery. The aim of this study was to assess the feasibility and outcomes after implementation of an ERP after liver a resection. METHODS Patients who underwent a liver resection in two consecutive 6-month periods before (July-December 2013) and after (January-June 2014) implementation of an ERP were included in a prospective study. Patients who underwent live donation, ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) or concomitant procedures were excluded. Peri-operative outcomes were compared between groups, and multivariate analysis of factors influencing the length of hospital stay (LOS) was performed. RESULTS Two hundred and eleven patients (93 pre-ERP and 91 post-ERP patients) underwent a liver resection during the study period. There was no significant difference in the median LOS (P = 0.907) and 30-day readmission rates (P = 0.645) between the groups. Severe (Clavien grade III-V) complications were reduced in ERP patients (13.9% versus 4.3%; P = 0.039). On multivariate analysis, an increased age (< 0.001), open resection (< 0.001) and complications (< 0.001) were associated with an increased LOS. CONCLUSION Enhanced recovery after a liver resection appears to be safe, feasible and may reduce severe complications. However, the LOS was significantly influenced by patient age, open surgery and post-operative complications, but not by an ERP.
Collapse
|
45
|
Dasari BVM, Baker J, Markar S, Gardiner K. Laparoscopic appendicectomy in obese is associated with improvements in clinical outcome: systematic review. Int J Surg 2014; 13:250-256. [PMID: 25498498 DOI: 10.1016/j.ijsu.2014.11.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 11/07/2014] [Accepted: 11/29/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Obese patients with general surgical emergencies provide unique challenges to the emergency surgical teams. Acute appendicitis is the most common adult acute surgical emergency encountered in practice. This systematic review evaluates the role of laparoscopic appendicectomy in obese by comparing the outcomes of laparoscopic appendicectomy in obese versus non-obese and the laparoscopic versus open appendicectomy in obese patients. METHODS Relevant comparative studies were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990-2013). Primary outcomes evaluated were mortality, overall morbidity and duration of surgery. Secondary outcomes evaluated were superficial (superficial wound infection) and deep surgical site infection (intra-abdominal abscesses), conversion to open surgery, and cost of the procedure. RESULTS Seven retrospective cohort studies and one prospective randomized controlled trial met the inclusion criteria. There was no statistically significant difference in the primary and secondary outcomes between the obese and non-obese patients undergoing laparoscopic appendicectomy. Laparoscopic appendicectomy in obese patients is associated with reduced mortality (risk ratio [RR]: 0.19 (95% CI 0.12-0.30), reduced overall morbidity (RR: 0.49 (95% CI: 0.47-0.51)), reduced superficial wound infections (RR: 0.27 (95% CI 0.21-0.35)), shorter operating times and post-operative length of hospital stay, compared to open appendicectomy. Methodological quality of the included studies is low. CONCLUSION Laparoscopic appendicectomy appears to be a safer alternative approach to open surgery in obese adult patents. There is no significant difference in the outcomes between the obese and non-obese patients undergoing laparoscopic appendicectomy.
Collapse
|
46
|
Dasari BVM, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA. Surgical versus endoscopic treatment of bile duct stones. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [PMID: 23999986 DOI: 10.1002/14651858.cd003327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known. OBJECTIVES We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). SELECTION CRITERIA We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5. MAIN RESULTS Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. AUTHORS' CONCLUSIONS Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.
Collapse
|
47
|
Dasari BVM, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2013:CD003327. [PMID: 23999986 DOI: 10.1002/14651858.cd003327.pub3] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known. OBJECTIVES We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). SELECTION CRITERIA We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5. MAIN RESULTS Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. AUTHORS' CONCLUSIONS Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.
Collapse
|
48
|
Dasari BVM, McElvanna K, Loughrey M, Diamond T. IgG4-related systemic sclerosing disease: a diagnosis to be considered!! BMJ Case Rep 2013; 2013:bcr-2012-007101. [PMID: 23542646 DOI: 10.1136/bcr-2012-007101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IgG4-related systemic sclerosing disease is a chronic autoimmune disorder with diverse clinical presentation. We report a 56-year-old patient who has presented with obstructive jaundice, bulky pancreas and mesenteric lymph node mass. He was later diagnosed to have IgG4-sclerosing disease involving pancreas, small bowel mesentery, common bile duct, liver, gallbladder and submandibular salivary glands and has required multiple surgical interventions. IgG4-related systemic sclerosing disease appears to be more commonly encountered than it was once thought and needs considered in patients presenting with pancreatitis of no obvious underlying cause. Although the disease is primarily managed by medical therapy, there is a role for surgical intervention in order to obtain tissue for diagnosis, exclude other possible neoplastic aetiology and to manage disease-related complications.
Collapse
|
49
|
Dasari BVM, Tan CJ, Gardiner K. Authors' reply: Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction ( Br J Surg 2012; 99: 469–476). Br J Surg 2012. [DOI: 10.1002/bjs.8930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
50
|
Dasari BVM, Tan CJ, Gardiner K. Authors' reply: Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction ( Br J Surg 2012; 99: 469–476). Br J Surg 2012. [DOI: 10.1002/bjs.8926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|