The Impact of Smoking History on Outcomes and Morbidity After Robotic Hepatectomy

INTRODUCTION

The detrimental effects that smoking has on patient health and postoperative morbidity are well documented. However, literature on the impact that smoking history has on robotic surgery, specifically robotic hepatectomy, is scarce. This study was undertaken to determine whether smoking history impacts the postoperative course of patients undergoing robotic hepatectomy.

METHODS

We prospectively followed 353 patients that underwent robotic hepatectomy. 125 patients had an apposite history of smoking (ie, smokers) and 228 patients were classified as non-smokers. Data were presented as median (mean ± SD). Patients were then propensity-score matched based on patient and tumor characteristics.

RESULTS

Prior to the matching, the MELD score and cirrhosis status in patients who smoke were found to be significantly higher when compared to those who do not (mean MELD score 9 vs 8 and cirrhosis in 25% vs 13% of patients, respectively). Both smokers and non-smokers have similar BMIs, number of previous abdominal operations, ASA physical status classifications, and Child-Pugh scores. Six percent smokers vs one percent non-smokers experienced pulmonary complications (pneumonia, pneumothorax, and COPD exacerbation) (P = .02). No differences were found for postoperative complications of Clavien-Dindo score ≥ III, 30-day mortality, or 30-day readmissions. After the matching, no differences were found between the smokers and the non-smokers.

CONCLUSION

After a propensity-score match analysis, smoking did not appear to negatively affect the intra- and postoperative outcomes after robotic liver resections. We believe that the robotic approach as the most modern minimally invasive technique in liver resection may have the potential to mitigate the known adverse effects of smoking.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

Does metabolic syndrome affect perioperative outcomes in patients undergoing robotic hepatectomy? A propensity score-matched analysis

BACKGROUND

Metabolic syndrome is a known risk factor for postoperative complications after general surgical procedures. Literature analyzing perioperative outcomes of patients with metabolic syndrome undergoing a minimally invasive hepatectomy is limited. We sought to investigate if metabolic syndrome significantly impacts the perioperative course and outcomes of patients undergoing robotic hepatectomy.

METHODS

With IRB, we prospectively followed patients who underwent robotic hepatectomy from 2016 through 2020. A 1:1 propensity score-matched (PSM) analysis was applied to patients with and without metabolic syndrome. Demographic and clinical data were analyzed for those cohorts before and after PSM. Metabolic syndrome was defined as BMI ≥ 28.8 kg/m², diabetes, and hypertension.

RESULTS

A total of 272 patients underwent robotic hepatectomy, 39 (14%) of whom had metabolic syndrome. After performing PSM, we ended up with 74 patients, 37 in each cohort, 28% of them had liver cirrhosis. Patients with metabolic syndrome had higher BMI (34 ± 5.6 vs. 28 ± 5.9 kg/m², p < 0.001) and MELD scores (10 ± 4.5 vs. 8 ± 3.2, p < 0.001) compared to patients without metabolic syndrome. Additionally, patients with metabolic syndrome had an increased incidence of liver cirrhosis (33% vs. 9%, p = 0.0002). Following PSM, BMI (34 ± 5.7 vs. 26 ± 4.4 kg/m², p < 0.001) was the only preoperative variables associated with metabolic syndrome. There were no statistical differences before and after PSM between patients with and without metabolic syndrome in terms of intraoperative metrics including operative time, blood loss, conversion to 'open,' and intraoperative complications. All postoperative outcomes metrics before and after PSM did not correlate with the presence or absence of metabolic syndrome.

CONCLUSIONS

Metabolic syndrome had no impact on intra- or postoperative metrics, complications, or outcomes after robotic hepatectomy. We believe that the robotic approach may mitigate the adverse effects of metabolic syndrome for patients undergoing robotic hepatectomy.

The Effect of Body Mass Index on Patients' Outcomes Following Robotic Distal Pancreatectomy and Splenectomy

Background and Objectives

Obesity has increased over the past decade, yet the correlation among body mass index (BMI), surgical outcomes, and the robotic platform are not well established. This study was undertaken to measure the impact of elevated BMI on outcomes after robotic distal pancreatectomy and splenectomy.

Methods

We prospectively followed patients who underwent robotic distal pancreatectomy and splenectomy. Regression analysis was utilized to identify significant relationships with BMI. For illustrative purposes, the data are presented as median (mean ± SD). Significance was determined at p ≤ 0.05.

Results

A total of 122 patients underwent robotic distal pancreatectomy and splenectomy. Median age was 68 (64 ± 13.3), 52% were women, and BMI was 28 (29 ± 6.1) kg/m². One patient was underweight (< 18.5 kg/m²), 31 had normal weight (18.5-24.9 kg/m²), 43 were overweight (25-29.9 kg/m²), and 47 were obese (≥ 30 kg/m²). BMI was inversely correlated with age (p = 0.05) but there was no correlation with sex (p = 0.72). There were no statistically significant relationships between BMI and operative duration (p = 0.36), estimated blood loss (p = 0.42), intraoperative complications (p = 0.64), and conversion to open approach (p = 0.74). Major morbidity (p = 0.47), clinically relevant postoperative pancreatic fistula (p = 0.45), length of stay (p = 0.71), lymph nodes harvested (p = 0.79), tumor size (p = 0.26), and 30-day mortality (p = 0.31) were related to BMI.

Conclusion

BMI has no significant effect on patients undergoing robotic distal pancreatectomy and splenectomy. BMI greater than 30 kg/m² should not defer proceeding with robotic distal pancreatectomy with splenectomy. Limited empirical evidence exists in the literature regarding patients with a BMI greater than 30 kg/m², and thus any proposed operative intervention should invoke sufficient planning and preparation.

Robotic Roux-en-Y Hepaticojejunostomy for Right Hepatic Duct Transection. Application of Minimally Invasive Technique for High Bile Duct Injury

Minimally Invasive bile duct repair is an emerging modern technique in hepatobiliary surgery. Conventional laparoscopic technique had been sporadically reported by high volume surgeons as an alternative to open operation, however, the majority of those repairs were undertaken for biliary injury below the biliary bifurcation. Roux-en-Y Hepaticojejunostomy below the biliary bifurcation is technically much simpler to complete when compared to that above the hilar plate (high bile duct injury). The risk of long-term anastomotic stricture is also higher as bile duct caliber decreases. This is anatomically inherent as we travel further cranial beyond the hilar plate. In this multimedia article, we describe our minimally invasive technique for high bile duct injury repair using robotic technology.

Open Parenchymal Sparing Posterosuperior Liver Tumor Resection for Colorectal Liver Metastasis With Proximity to Hepatic Veins

Liver resection for stage 4 colorectal cancer with liver metastasis is the standard of care, in combination with systemic chemotherapy. R-0 complete resection for colorectal liver metastasis is a curative-intent operation, which is considered the only chance for cure in this disease. The location and proximity of the tumor to major intrahepatic vessels such as hepatic and portal vein determine technical difficulty. Tumors located in the posterosuperior segments of the liver (segments 7 and 8) are technically challenging to resect using a minimally invasive fashion; therefore, conventional open resection is still the technique of choice today. In this video, we demonstrated our approach of an open parenchymal-sparing posterosuperior liver resection for a colorectal liver metastasis.

Robotic Systematic Portal Lymphadenectomy. Description of Surgical Technique

Portal lymphadenectomy is an integral part of gallbladder, intrahepatic cholangiocarcinoma, and perihilar cholangiocarcinoma resection to improve staging and prognostication. This is also believed by many oncologists to potentially serve as therapy to remove cancer containing nodes. While the current guideline requires removal of at least 6 portal lymphnodes, many surgeons face technical difficulty in performing the systematic portal lymphadenectomy especially in minimally invasive fashion. The anatomical complexity of biliovascular structures within the porta hepatis contributes to this technical challenge. In this video, we demonstrate our robotic technique of systematic portal lymphadenectomy for the treatment of gallbladder cancer.

Robotic liver resection for hepatocellular carcinoma: analysis of surgical margins and clinical outcomes from a western tertiary hepatobiliary center

This study was undertaken to determine surgical outcomes of patients undergoing robotic hepatectomy for hepatocellular carcinoma (HCC) and to investigate the correlation between tumor distance to margin and perioperative outcomes, as well as overall survival (OS). To our knowledge, this study represents the largest series of robotic liver resection for HCC in North America. We retrospectively analyzed 58 consecutive patients who underwent robotic liver resection for HCC. Patients were further stratified by tumor distance to margin (≤ 1 mm, 1.1-9.9 mm, ≥ 10 mm) and their clinical outcomes including OS were compared. A majority of patients attained a greater than 1 mm tumor distance to margin (81%). There were no differences in tumor size between patient cohorts who attained ≤ 1 mm, 1.1-9.9 mm, and ≥ 10 mm margins. There were no differences in pre-, intra-, and postoperative outcomes among the three cohorts. Cost variables of interest were also similar. OS was highest in the > 10 mm margin cohort, and this was statistically significant at 3 and 5 years. Robotic HCC resection was associated with adequate tumor distance to margin. Wide margins ≥ 10 mm are associated with the best OS.

Amoebic crab disease (ACD) in edible crab Cancer pagurus from the English Channel, UK

The genera Paramoeba and Neoparamoeba (Amoebozoa, Dactylopodida, Paramoebidae) include well-known opportunistic pathogens associated with fish (N. peruans; amoebic gill disease), lobsters, molluscs and sea urchins, but only rarely with crabs (grey crab disease of blue crabs). Following reports of elevated post-capture mortality in edible crabs Cancer pagurus captured from a site within the English Channel fishery in the UK, a novel disease (amoebic crab disease, ACD) was detected in significant proportions of the catch. We present histopathological, transmission electron microscopy and molecular phylogenetic data, showing that this disease is defined by colonization of haemolymph, connective tissues and fixed phagocytes by amoeboid cells, leading to tissue destruction and presumably death in severely diseased hosts. The pathology was strongly associated with a novel amoeba with a phylogenetic position on 18S rRNA gene trees robustly sister to Janickina pigmentifera (which groups within the current circumscription of Paramoeba/Neoparamoeba), herein described as Janickina feisti n. sp. We provide evidence that J. feisti is associated with ACD in 50% of C. pagurus sampled from the mortality event. A diversity of other paramoebid sequence types, clustering with known radiations of N. pemaquidensis and N. aestuarina and a novel N. aestuarina sequence type, was detected by PCR in most of the crabs investigated, but their detection was much less strongly associated with clinical signs of disease. The discovery of ACD in edible crabs from the UK is discussed relative to published historical health surveys for this species.

POS1060 CHANGES IN DISEASE ACTIVITY AND PATIENT-REPORTED OUTCOMES IN PSORIATIC ARTHRITIS PATIENTS TREATED WITH IXEKIZUMAB IN A REAL-WORLD US COHORT

Background

Ixekizumab (IXE), an IL-17A inhibitor, has demonstrated efficacy in clinical trials1-3 but real-world effectiveness (RWE) data are limited.4

Objectives

To describe changes in disease activity and patient-reported outcomes (PROs) at 6 and 12 months follow-up among psoriatic arthritis (PsA) patients initiating IXE in a routine clinical setting.

Methods

This retrospective cohort study included patients from the OM1 PsA Registry (OM1, Boston, MA), a linked electronic medical record and administrative claims dataset with over 50,000 patients. Eligible patients had ≥1 prescription for IXE (first = index), were ≥18 years old at index, had ≥1 diagnosis code for PsA in the 12 months before or on index, and had ≥12 months of baseline and ≥6 months of follow-up data as of June 2021. For patients with baseline and follow-up measures available, changes in Clinical Disease Activity Index (CDAI), PROs, and other clinical outcomes from baseline to 6 and 12 months were described. For patients on IXE monotherapy, change in CDAI score from baseline to 6 and 12 months was assessed using mixed effects linear models adjusted for age, sex, and baseline CDAI score.

Results

The study population included 1,812 patients with a mean age of 53.7 years (Table 1). Psoriasis was present in 82% and enthesitis in 28%. Over 60% of patients were obese, and the mean Charlson Comorbidity Index was 1.3. Most patients (84%) had prior treatment with a biologic disease-modifying antirheumatic drug (bDMARD) and 40% with a targeted synthetic DMARD (tsDMARD). The mean number of bDMARDs and tsDMARDs used during all available prior history was 2.3 and 1.1, respectively. The most common prior bDMARDs were secukinumab (n=428, 24%) and adalimumab (n=245, 14%).

Table 1.

Demographic and Clinical Characteristics by Therapy Status

All Patients(N=1,812)Monotherapy(N=1,485)Combination Therapy(N=327)Age (years)Mean (s.d.)53.7 (12.2)53.9 (12.3)52.9 (11.7)Median (Q1-Q3)55 (46-62)55 (46-62)54 (45-61)SexFemale1,108 (61.1%)909 (61.2%)199 (60.9%)Male704 (38.9%)576 (38.8%)128 (39.1%)Charlson Comorbidity IndexMean (s.d.)1.3 (1.6)1.3 (1.6)1.5 (1.7)Median (Q1-Q3)1 (0-2)1 (0-2)1 (0-2)BMIUnderweight: <18.510 (0.6%)10 (0.7%)0 (0.0%)Normal weight: 18.5-24.9210 (12.2%)172 (12.2%)38 (12.1%)Overweight: 25-29.9455 (26.5%)379 (27.0%)76 (24.2%)Obese: >= 301,045 (60.8%)845 (60.1%)200 (63.7%)Missing927913Domains of PsA: PsoriasisYes1,490 (82.2%)1,222 (82.3%)268 (82.0%)No322 (17.8%)263 (17.7%)59 (18.0%)Domains of PsA: EnthesitisYes510 (28.1%)409 (27.5%)101 (30.9%)No1,302 (71.9%)1,076 (72.5%)226 (69.1%)

Of patients with a baseline CDAI score, 61% had moderate or severe disease activity. For all patients, CDAI scores improved (decreased) by an average of 3.4 and 3.7 points at 6 and 12 months, respectively, from a baseline mean of 15.4. All disease activity measures and PROs improved from baseline to 6 and 12 months (Figure 1). In patients persistent with IXE, 35.3% and 33.7% were in CDAI remission or low disease activity at 6 and 12 months after initiation, respectively. For IXE monotherapy users (82% of patients), at baseline, patients had a mean CDAI of 14.3 (n=131) and 15.1 (n=105) for the 6 and 12 month analyses, respectively. Adjusted mean changes in CDAI from baseline to 6 months (-3.6 points, p < 0.0001) and 12 months (-4.9 points, p < 0.0001) were statistically significant.

Conclusion

In this cohort of PsA patients with multiple prior b/tsDMARD failures, improvements in disease activity and PROs were observed at 6 and 12 months after initiating treatment with IXE. Improvements were observed in patients overall and in the monotherapy subgroup. More real-world research on IXE and other bDMARDs are important to understand the effect of treatment choices on clinical and PROs in both bDMARD-naive and experienced PsA patients.

References

[1]Mease PJ. Ann. Rheum. Dis. 2017;76(1):79-87

[2]Nash P. Lancet. 2017;389(10086):2317-2327

[3]Mease PJ. Ann. Rheum. Dis. 2020;79(1):123-131

[4]Berman J. Biologics. 2021 Nov 18;15:463-470

Disclosure of Interests

Julie Birt Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis,, Pfizer, UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, UCB, Cristi Cavanaugh: None declared, Yoojin Jung: None declared, Aisha Vadhariya Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Sarah Ross Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Jess Paulus: None declared, Aubrey Trevelin Sprabery Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Ennio Lubrano: None declared

Analysis of Oncological Outcomes After Robotic Liver Resection for Intrahepatic Cholangiocarcinoma

BACKGROUND

Concerns regarding minimally invasive liver resection of intrahepatic cholangiocarcinoma (IHCC) include inadequate resection margins and inferior long-term overall survival (OS) when compared to an "open" approach. Limited data exists to address these issues. We aimed to compare perioperative variables, tumor distance to margin, and long-term outcomes after IHCC resection based on surgical approach (robotic vs open) in our hepatobiliary center to address these concerns.

METHODS

With IRB approval, 34 patients who underwent robotic or open hepatectomy for IHCC were prospectively followed. Patients were stratified by tumor distance to resection margin (≤1 mm, 1.1-9.9 mm, ≥10 mm) for illustrative purposes and by approach (robotic vs open). Where appropriate, regression analysis and cox model of proportional hazards were utilized. Survival was stratified by margin distance and approach utilizing Kaplan-Meier curves. Data are presented as median (mean ± SD).

RESULTS

Patients undergoing robotic vs open hepatectomy had similar demographics. Patients undergoing the robotic approach had significantly lower estimated blood loss (EBL). Tumor distance to margin between the two approaches were similar (P = .428). Median OS between the two approaches was similar in patients of any margin distance.In the subgroup analysis by margin distance, the robotic approach yielded less EBL for patients in the 1.1-9.9 mm and ≥10 mm margin groups, and a shorter ICU length of stay for patients with ≥10 mm margin.

DISCUSSION

Similar margins were attained via either approach, translating into oncological non-inferiority of robotic IHCC resection. Robotic approach for the treatment of IHCC should be considered an alternative to an open approach.