Preoperative high-dose steroid administration attenuates the surgical stress response following liver resection: results of a prospective randomized study

Impact of intravenous steroids on subjective recovery quality after surgery: A meta-analysis of randomized clinical trials

STUDY OBJECTIVE

Quality of postoperative recovery is a crucial aspect of perioperative care. This meta-analysis aimed to evaluate the efficacy of intravenous steroids in improving the quality of recovery (QoR) after surgery, as measured by validated QoR scales.

DESIGN

Meta-analysis of randomized controlled trials (RCTs).

SETTING

Operating room.

INTERVENTION

The use of a single dose of intravenous steroids as a supplement to general anesthesia.

PATIENTS

Adult patients undergoing surgery.

MEASUREMENTS

A literature search was conducted using electronic databases (e.g., MEDLINE and Embase) from their inception to June 2024. Randomized controlled trials (RCTs) comparing intravenous steroids with placebo or no treatment in adult patients undergoing surgery under general anesthesia were included. The primary outcome was the QoR scores on postoperative days (POD) 1 and 2-3, as assessed by validated QoR scales (QoR-15 and QoR-40). Secondary outcomes included QoR dimensions, analgesic rescue, pain scores, and postoperative nausea and vomiting (PONV).

MAIN RESULTS

Eleven RCTs involving 951 patients were included in this study. The steroid group showed significant improvements in global QoR scores on POD 1 (standardized mean difference [SMD]: 0.52; 95 % confidence interval[CI]: 0.22 to 0.82; P = 0.0007) and POD 2-3 (SMD: 0.50; 95 % CI: 0.19 to 0.81; P = 0.001) compared to the control group. Significant improvements were also observed in all QoR dimensions on POD 1, with the effect sizes ranging from small to moderate. Intravenous steroids also significantly reduced the analgesic rescue requirements (RR: 0.77; 95 % CI: 0.67 to 0.88; P = 0.0003), postoperative pain scores (SMD: -0.41; 95 % CI: -0.68 to -0.14; P = 0.003), and PONV incidence (RR: 0.73; 95 % CI: 0.56 to 0.95; P = 0.02).

CONCLUSIONS

Intravenous administration of steroids significantly improved QoR after surgery. The benefits of steroids extend to all dimensions of QoR and important clinical outcomes such as analgesic requirements, pain scores, and PONV. These findings support the use of steroids as an effective strategy to enhance the postoperative recovery quality.

Effects of perioperative steroid use on surgical stress and prognosis in patients undergoing hepatectomy: a systematic review and meta-analysis of randomized controlled trials

The objective of this study was to evaluate the clinical effects of perioperative steroid hormone usage in hepatectomy patients through a comprehensive systematic review and meta-analysis. Prospective randomized controlled trials (RCTs) investigating the perioperative use of steroid hormones in hepatectomy patients were systematically searched using various databases, including PubMed, Medline, Embase, the Cochrane Library, the Chinese Biomedical Literature Database, Wanfang Data, and the CNKI database. Two researchers independently screened and extracted data from selected studies. Data analysis was performed using RevMan 5.3 software. The results revealed significantly lower levels of total bilirubin (standard mean difference [SMD] = -0.7; 95% CI: -1.23 to -0.18; and p = 0.009), interleukin-6 (SMD = -1.02; 95% CI: -1.27 to -0.77; and p < 0.001), and C-reactive protein (SMD = -0 .65; 95% CI: -1 .18 to -0.11; and p = 0.02) on postoperative day 1 (POD 1), as well as a reduced incidence of postoperative complications in the steroid group compared to the placebo group. No significant differences were observed between the two groups regarding alanine aminotransferase (ALT) levels, aspartic aminotransferase (AST) levels, or specific complications such as intra-abdominal infection (p = 0.72), wound infection (p = 0.1), pleural effusion (p = 0.43), bile leakage (p = 0.66), and liver failure (p = 0.16). The meta-analysis results indicate that perioperative steroid usage can effectively alleviate liver function impairment and inflammation response following hepatectomy while improving patient prognosis.

The Effect of Preoperative Administration of Glucocorticoids on the Postoperative Complication Rate in Liver Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Glucocorticoids may grant a protective effect against postoperative complications. The evidence on their efficacy, however, has been inconclusive thus far. We investigated the effects of preoperatively administered glucocorticoids on the overall postoperative complication rate, and on liver function recovery in patients undergoing major liver surgery. Methods: We performed a systematic literature search on PubMed, Embase, and CENTRAL in October 2021, and repeated the search in April 2023. Pre-study protocol was registered on PROSPERO (ID: CRD42021284559). Studies investigating patients undergoing liver resections or transplantation who were administered glucocorticoids preoperatively and reported postoperative complications were eligible. Meta-analyses were performed using META and DMETAR packages in R with a random effects model. Risk of bias was assessed using RoB2. Results: The selection yielded 11 eligible randomized controlled trials (RCTs) with 964 patients. Data from nine RCTs (n = 837) revealed a tendency toward a lower overall complication rate with glucocorticoid administration (odds ratio: 0.71; 95% confidence interval: 0.38-1.31, p = 0.23), but it was not statistically significant. Data pooled from seven RCTs showed a significant reduction in wound infections with glucocorticoid administration [odds ratio: 0.64; 95% confidence interval: 0.45-0.92 p = 0.02]. Due to limited data availability, meta-analysis of liver function recovery parameters was not possible. Conclusions: The preoperative administration of glucocorticoids did not significantly reduce the overall postoperative complication rate. Future clinical trials should investigate homogenous patient populations with a specific focus on postoperative liver recovery.

Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: protocol for a randomized controlled trial

BACKGROUND

Our previous randomized controlled trial (RCT) have demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval can be applied safely and efficiently in open or laparoscopic hepatectomy in patients with hepatocellular carcinoma (HCC) patients. But prolonging the hepatic inflow blocking time will inevitably aggravate the ischemia-reperfusion injury (IRI) caused by systemic response. This RCT aims to evaluate the effect of administration of dexamethasone versus placebo before clamping the hilar pedicle on postoperative liver function, inflammatory response, and perioperative outcomes among HCC patients undergoing liver resection with 25-min hepatic inflow occlusion.

METHODS AND ANALYSIS

This will be a randomized, dual-arm, parallel-group, double-blinded trial. All eligible and consecutive patients are coming from a regional medical center who are diagnosed with HCC and underwent radical R0/R1 resection. All participates are randomly allocated in dexamethasone group or placebo group. All surgeons, anesthesiologists, and outcome assessors will be blinded to allocation status. Primary endpoints are transaminase-based postoperative hepatic injury on seven consecutive days after surgery and assessed by their peak values as well as area under the curve (AUC) of the postoperative course of aminotransferases. Secondary endpoints are postoperative total bilirubin (TBil), coagulation function, inflammatory cytokines and their respective peaks, intraoperative blood loss, postoperative hospital stay, morbidity, and mortality. The above parameters will be compared using the corresponding statistical approach. Subgroup analysis will be performed according to the liver cirrhosis and major hepatectomy.

DISCUSSION

Based on our previous study, we will explore further the effect of glucocorticoid administration on attenuating the surgical stress response in order to follow securely 25-min hepatic inflow occlusion. Therefore, the trial protocol is reasonable and the results of the trial may be clinically significant.

TRIAL REGISTRATION

This trial was registered on 3 December 2022, in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ), ChiCTR2200066381. The protocol version is V1.0 (20221104).

Influence of ganglioside combined with methylprednisolone sodium succinate on efficacy and neurological function in patients with acute myelitis

BACKGROUND

Acute myelitis (AM) can lead to sudden sensory, motor and autonomic nervous dysfunction, which negatively affects their daily activities and quality of life, so it is necessary to explore optimization from a therapeutic perspective to curb the progression of the disease.

AIM

To investigate the effect of ganglioside (GM) combined with methylprednisolone sodium succinate (MPSS) on the curative effect and neurological function of patients with AM.

METHODS

First, we selected 108 AM patients visited between September 2019 and September 2022 and grouped them based on treatment modality, with 52 patients receiving gamma globulin (GG) + MPSS and 56 patients receiving GM + MPSS, assigned to the control group (Con) and observation group (Obs), respectively. The therapeutic effect, neurological function (sensory and motor function scores), adverse events (AEs), recovery (time to sphincter function recovery, time to limb muscle strength recovery above grade 2, and time to ambulation), inflammatory factors (IFs) [interleukin (IL)-6, C-reactive protein (CRP), and tumor necrosis factor (TNF)-α] and other data of the two groups were collected for evaluation and comparison.

RESULTS

The Obs had: (1) A significantly higher response rate of treatment than the Con; (2) Higher scores of sensory and motor functions after treatment that were higher than the baseline (before treatment) and higher than the Con levels; (3) Lower incidence rates of skin rash, gastrointestinal discomfort, dyslipidemia, osteoporosis and other AEs; (4) Faster posttreatment recovery of sphincter function, limb muscle strength and ambulation; and (5) Markedly lower posttreatment IL-6, CRP and TNF-α levels than the baseline and the Con levels.

CONCLUSION

From the above, it can be seen that GM + MPSS is highly effective in treating AM, with a favorable safety profile comparable to that of GG + MPSS. It can significantly improve patients’ neurological function, speed up their recovery and inhibit serum IFs.

Short-term outcomes of perioperative glucocorticoid administration in patients undergoing liver surgery: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The purpose of this systematic review and meta-analysis was to investigate whether glucocorticoid might be beneficial after hepatectomy.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library and Web of Science.

ELIGIBILITY CRITERIA

We included studies assessing the efficacy of perioperative glucocorticoid administration in patients undergoing liver surgery.

DATA EXTRACTION AND SYNTHESIS

Four data bases were retrieved for all randomised controlled trials. We considered postoperative complications, hospital stay and postoperative chemistry evaluations as outcomes. Pooled effects of dichotomic variables were expressed as relative risk (RR) with a 95% CI. The mean difference was used for continuous variables and an inverse variance statistical method was adopted.

RESULTS

Fourteen studies with 1205 patients were included. Lower risk of overall complications was associated with glucocorticoid (RR, 0.77; 95% CI 0.64 to 0.92), while no difference was found in hospital stay (RR, 0.02; 95% CI -0.47 to 0.51). There were also improvements in postoperative chemistry evaluations including interleukin 6 on day 1 and 3, C reactive protein on day 1, 2 and 3, international normalised ratio on day 2, total bilirubin on day 1, 2, 3 and 5, albumin on day 1.

CONCLUSION

Current evidence indicated that perioperative glucocorticoid administration for patients undergoing hepatectomy reduced the risk of overall complications with inhibited postoperative inflammatory response and improved postoperative liver function.

PROSPERO REGISTRATION NUMBER

CRD42022307533.

Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature

BACKGROUND

Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature.

METHODS

We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers.

RESULTS

A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course.

CONCLUSION

MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.

The efficacy and safety of glucocorticoid for perioperative patients with hepatectomy: a systematic review and meta-analysis

OBJECTIVE

Glucocorticoids have been used in patients undergoing perioperative hepatectomy, however their safety and efficacy remain controversial. This meta-analysis was conducted to investigate this issue and further provide reference for clinical practice.

METHODS

PubMed/MEDLINE, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) from database inception to December 2022. Literature screening and data extraction were performed independently by two reviewers. The methodological quality of the RCTs was assessed using the Jadad scale. RevMan 5.4 was used for the meta-analysis.

RESULTS

A total of 11 RCTs involving 905 patients were included. Compared with the control group, we found perioperative glucocorticoid administration significantly lowered overall complication rate [RR = 0.67; 95% CI (0.55, 0.83); P = 0.0003], infectious complication rate [RR = 0.41; 95% CI (0.21, 0.82); P = 0.01] and postoperative liver failure [RR = 0.63; 95% CI (0.41, 0.97); P = 0.03]. In addition, glucocorticoids appear to improve liver function (TBil) [MD = -0.36, 95% CI (-0.59, -0.14), P = 0.001] and reduce the release of certain inflammatory cytokines (IL-6) [MD = -48.52, 95% CI (-56.88, -40.16), P < 0.00001].

CONCLUSION

Based on the available evidence, glucocorticoids appear to be safe and effective in patients undergoing hepatectomy, but further research is needed.

Current evidence on posthepatectomy liver failure: comprehensive review

INTRODUCTION

Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF.

METHODS

A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022.

RESULTS

Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited.

DISCUSSION

Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.

Impact of high-dose glucocorticoid on endothelial damage after liver resection - a double-blinded randomized substudy

OBJECTIVES

Postoperative endothelial damage potentially results in increased vascular leakage, tissue edema and subsequent complications. The preventive effect of glucocorticoids on endothelial damage after surgery is sparsely described, including the relation between endothelial damage and the postoperative inflammatory response. Thus, we aimed to assess the preventive effect of high-dose glucocorticoids on postoperative endothelial damage, and the association between endothelial damage and inflammation after surgery.

METHODS

This was a predefined substudy of a randomized double-blinded clinical trial of methylprednisolone 10 mg/kg (high dose) vs. dexamethasone 8 mg (low dose) in patients undergoing liver resection at Rigshospitalet, Copenhagen. In total 25 patients undergoing major liver resection (11 in the high-dose group and 14 in the low-dose group) were included. The primary outcome was changed in five endothelial biomarkers and the secondary outcome was changes in inflammation [C-reactive protein (CRP)] for the first three postoperative days.

RESULTS

No statistically significant difference was found for any endothelial biomarkers postoperatively between the two groups (P &gt; 0.15, for all). High-dose glucocorticoids significantly reduced CRP on day 3 compared to low-dose glucocorticoids [median difference on a postoperative day 3, 59.6 g/L, (84.2; 27.1), P &lt; 0.002]. No significant correlation between endothelial damage and CRP levels was seen.

CONCLUSIONS

No significant effect of high- vs. low-dose glucocorticoids on development in endothelial biomarkers after major liver resection was observed. High-dose glucocorticoids reduce the inflammatory response though without correlation to endothelial damage. Future studies should assess the clinical impact of increased endothelial biomarkers for clinical perioperative outcomes.

Impact of high-dose glucocorticoid on endothelial damage after liver resection - a double-blinded randomized substudy

OBJECTIVES

Postoperative endothelial damage potentially results in increased vascular leakage, tissue edema and subsequent complications. The preventive effect of glucocorticoids on endothelial damage after surgery is sparsely described, including the relation between endothelial damage and the postoperative inflammatory response. Thus, we aimed to assess the preventive effect of high-dose glucocorticoids on postoperative endothelial damage, and the association between endothelial damage and inflammation after surgery.

METHODS

This was a predefined substudy of a randomized double-blinded clinical trial of methylprednisolone 10 mg/kg (high dose) vs. dexamethasone 8 mg (low dose) in patients undergoing liver resection at Rigshospitalet, Copenhagen. In total 25 patients undergoing major liver resection (11 in the high-dose group and 14 in the low-dose group) were included. The primary outcome was changed in five endothelial biomarkers and the secondary outcome was changes in inflammation [C-reactive protein (CRP)] for the first three postoperative days.

RESULTS

No statistically significant difference was found for any endothelial biomarkers postoperatively between the two groups (P > 0.15, for all). High-dose glucocorticoids significantly reduced CRP on day 3 compared to low-dose glucocorticoids [median difference on a postoperative day 3, 59.6 g/L, (84.2; 27.1), P < 0.002]. No significant correlation between endothelial damage and CRP levels was seen.

CONCLUSIONS

No significant effect of high- vs. low-dose glucocorticoids on development in endothelial biomarkers after major liver resection was observed. High-dose glucocorticoids reduce the inflammatory response though without correlation to endothelial damage. Future studies should assess the clinical impact of increased endothelial biomarkers for clinical perioperative outcomes.

Benefit of a flash dose of corticosteroids in digestive surgical oncology: a multicenter, randomized, double blind, placebo-controlled trial (CORTIFRENCH)

Background

The modulation of perioperative inflammation seems crucial to improve postoperative morbidity and cancer-related outcomes in patients undergoing oncological surgery. Data from the literature suggest that perioperative corticosteroids decrease inflammatory markers and might be associated with fewer complications in esophageal, liver, pancreatic and colorectal surgery. Their benefit on cancer-related outcomes has not been assessed.

Methods

The CORTIFRENCH trial is a phase III multicenter randomized double-blind placebo-controlled trial to assess the impact of a flash dose of preoperative corticosteroids versus placebo on postoperative morbidity and cancer-related outcomes after elective curative-intent surgery for digestive cancer. The primary endpoint is the frequency of patients with postoperative major complications occurring within 30 days after surgery (defined as all complications with Clavien-Dindo grade > 2). The secondary endpoints are the overall survival at 3 years, the disease-free survival at 3 years, the frequency of patients with intraabdominal infections and postoperative infections within 30 days after surgery and the hospital length of stay. We hypothesize a reduced risk of major complications and a better disease-survival at 3 years in the experimental group. Allowing for 5% of drop-out, 1 200 patients (600 per arm) should be included.

Discussion

This will be the first trial focusing on the impact of perioperative corticosteroids on cancer related outcomes. If significant, it might be a strong improvement on oncological outcomes for patients undergoing surgery for digestive cancers.

Trial registration

ClinicalTrials.gov, NCT03875690, Registered on March 15, 2019, URL: https://clinicaltrials.gov/ct2/show/NCT03875690.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09998-z.

Modifying the Stress Response - Perioperative Considerations and Controversies

The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.

Preoperative Single-dose Methylprednisolone Prevents Surgical Site Infections After Major Liver Resection: A Randomized Controlled Trial

OBJECTIVE

The primary aim of this study was to evaluate the efficacy of a single preoperative dose of methylprednisolone for preventing postoperative complications after major liver resections.

SUMMARY BACKGROUND DATA

Hepatic resections are associated with a significant acute systemic inflammatory response. This effect subsequently correlates with postoperative morbidity, mortality, and length of recovery. Multiple small trials have proposed that the administration of glucocorticoids may modulate this effect.

METHODS

This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients undergoing elective major hepatic resection (≥3 segments) at a quaternary care institution were included (2013-2019). Patients were randomly assigned to receive a single preoperative 500 mg dose of methylprednisolone versus placebo. The main outcome measure was postoperative complications after liver resection, within 90 days of the index operation. Standard statistical methodology was employed (P < 0.05 = significant).

RESULTS

A total of 151 patients who underwent a major hepatic resection were randomized (mean age = 62.8 years; 57% male; body-mass-index = 27.9). No significant differences were identified between the intervention and control groups (age, sex, body-mass-index, preoperative comorbidities, hepatic function, ASA class, portal vein embolization rate) (P > 0.05). Underlying hepatic diagnoses included colorectal liver metastases (69%), hepatocellular carcinoma (18%), noncolorectal liver metastases (7%), and intrahepatic cholangiocarcinoma (6%). There was a significant reduction in the overall incidence of postoperative complications in the methylprednisolone group (31.2% vs 47.3%; P = 0.042). Patients in the glucocorticoid group also displayed less frequent organ space surgical site infections (6.5% vs 17.6%; P = 0.036), as well as a shorter length of hospital stay (8.9 vs 12.5 days; P = 0.015). Postoperative serum bilirubin and prothrombin timeinternational normalized ratio (PT-INR) levels were also lower in the steroid group (P = 0.03 and 0.04, respectively). Multivariate analysis did not identify any additional significant modifying factor relationships (estimated blood loss, duration of surgery, hepatic vascular occlusion (rate or duration), portal vein embolization, drain use, etc) (P > 0.05).

CONCLUSIONS

A single preoperative dose of methylprednisolone significantly reduces the length of hospital stay, postoperative serum bilirubin, and PT-INR, as well as infectious and overall complications following major hepatectomy.

Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies

Advances in immunosuppression have improved graft survival in pediatric kidney transplant recipients; however, treatment-related toxicities need to be balanced against the possibility of graft rejection. Several immunosuppressive agents are available for use in transplant recipients; however, the optimal combinations of agents remain unclear, resulting in variations in institutional protocols. Lymphocyte-depleting antibodies, specifically ATG, are the most common induction agent used for pediatric kidney transplantation in the US. Basiliximab may be used for induction in immunologically low-risk children; however, pediatric data are scarce. CNIs and antiproliferative agents (mostly Tac and mycophenolate in recent years) constitute the backbone of maintenance immunosuppression. Steroid-avoidance maintenance regimens remain controversial. Belatacept and mTOR inhibitors are used in children under specific circumstances such as non-adherence or CNI toxicity. This article reviews the indications, mechanism of action, efficacy, dosing, and side effect profiles of various immunosuppressive agents available for pediatric kidney transplantation.

Perioperative steroid administration reduces overall complications in patients undergoing liver resection: A meta-analysis

BACKGROUND

Hepatic resection (HR) results in an inflammatory response that can be modified by perioperative steroid administration. However, it remains to be determined if this response's attenuation translates to a reduction in complications.

AIM

To evaluate if perioperative administration of steroids reduces complications following HR.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials to evaluate the effect of perioperative steroid (compared to placebo or no intervention) use in patients undergoing HR. Clinical outcomes were extracted, and meta-analysis was performed.

RESULTS

8 RCTs including 590 patients were included. Perioperative steroid administration was associated with significant reduction in postoperative complications [odds ratios: 0.58; 95% confidence intervals (CI): 0.35-0.97, P = 0.04]. There was also improvement in biochemical and inflammatory markers, including serum bilirubin on postoperative day 1 [MD: -0.27; 95%CI: (-0.47, -0.06), P = 0.01], C-reactive protein on postoperative day 3 [MD: -4.89; 95%CI: (-5.83, -3.95), P < 0.001], and interleukin-6 on postoperative day 1 [MD: -54.84; 95%CI: (-63.91, -45.76), P < 0.001].

CONCLUSION

Perioperative steroids administration in HR may reduce overall complications, postoperative bilirubin, and inflammation. Further studies are needed to determine the optimal dose and duration and patient selection.

Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial

BACKGROUND

Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery.

METHODS

This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity.

RESULTS

A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups.

CONCLUSION

A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).

Impact of Perioperative Steroid Administration in Patients Undergoing Major Hepatectomy with Extrahepatic Bile Duct Resection: A Randomized Controlled Trial

BACKGROUND

To date, five randomized controlled trials have assessed the clinical benefit of perioperative steroid administration in hepatectomy; however, all of these studies involved a substantial number of 'minor' hepatectomies. The benefit of steroid administration for patients undergoing 'complex' hepatectomy, such as major hepatectomy with extrahepatic bile duct resection, is still unclear. This study aimed to evaluate the clinical benefit of perioperative steroid administration for complex major hepatectomy.

METHODS

Patients with suspected hilar malignancy scheduled to undergo major hepatectomy with extrahepatic bile duct resection were randomized into either the control or steroid groups. The steroid group received hydrocortisone 500 mg immediately before hepatic pedicle clamping, followed by hydrocortisone 300 mg on postoperative day (POD) 1, 200 mg on POD 2, and 100 mg on POD 3. The control group received only physiologic saline. The primary endpoint was the incidence of postoperative liver failure.

RESULTS

A total of 94 patients were randomized to either the control (n = 46) or steroid (n = 48) groups. The two groups had similar baseline characteristics; however, there were no significant differences between the groups in the incidence of grade B/C postoperative liver failure (control group, n = 8, 17%; steroid group, n = 4, 8%; p = 0.188) and other complications. Serum bilirubin levels on PODs 2 and 3 were significantly lower in the steroid group than those in the control group; however, these median values were within normal limits in both groups.

CONCLUSION

Perioperative steroid administration did not reduce the risk of postoperative complications, including liver failure following major hepatectomy with extrahepatic bile duct resection.

The safety of pulse corticosteroid therapy- Systematic review and meta-analysis

OBJECTIVE

To amass all available evidence from randomized controlled trials regarding the safety of pulse corticosteroids therapy, in order to establish its safety.

PATIENTS AND METHODS

All electronic databases from 1/1966 up to 02/2019 were reviewed to find all randomized controlled trials comparing pulse corticosteroids to oral corticosteroids or to placebo/no treatment. Two reviewers independently extracted and recorded data regarding type of corticosteroid treatment, dosages, length of treatment and follow-up. Risk ratios (RR) with 95% (CI) for differences between pulse corticosteroids and comparator were pooled using a fixed effect meta-analysis. The primary outcome was occurrence of severe adverse events (SAEs). Secondary outcomes included any adverse events (AEs), AEs requiring discontinuation, AEs per system involved and all-cause mortality.

RESULTS

A total of 64 trials were included: 18 trials which compared pulse corticosteroids to oral corticosteroids and 46 trials which compared pulse corticosteroids to placebo/no intervention. Pulse corticosteroids was not associated with increased risk for SAEs for both comparators: RR 0.77 (95% CI 0.52-1.14), and RR 0.99 (95% CI 0.93-1.06), respectively. Sensitivity analysis based on adequate allocation concealment and use of a valid AE grading did not alter the results. Subgroup analysis revealed no increased risk of specific SAEs or AEs with pulse corticosteroids compared to oral corticosteroids.

CONCLUSION

Pulse corticosteroids was not associated with an increase risk of SAEs and should be regarded as safe.

High neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio predict poor survival in rectal cancer patients receiving neoadjuvant concurrent chemoradiotherapy

This study explored the prognostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in rectal cancer patients receiving neoadjuvant concurrent chemoradiotherapy (CCRT).Between January 2006 and December 2016, 184 patients with newly-diagnosed rectal cancer receiving neoadjuvant CCRT were enrolled. Risk of overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method and Cox proportional hazard models. Stratified survival analyses were also performed between post-neoadjuvant pathological (yp) stage.The mean follow-up time was 72.73 ± 36.82 months. High- and low-NLR patients differed significantly in both 5-year DFS (P = .026) and OS (P = .016). High- and low-PLR patients differed significantly in 5-year DFS (P = .011) but not OS (P = .185). Multivariate analyses revealed worse 5-year DFS (adjusted HR [aHR] = 2.8; 95% CI: 1.473-5.41; P = .002) and 5-year OS (aHR = 1.871; 95%CI: 1.029-3.4; P = .04) in the high-NLR group after adjusting for covariates. After adjustments, the high-PLR group had inferior 5-year DFS (aHR = 2.274; 95%CI: 1.473-5.419; P = .038) but not 5-year OS (aHR = 1.156; 95%CI: 0.650-2.056; P = .622). Further stratified analysis indicated that yp stage II and III patients with high NLR had worse 5-year DFS (aHR = 2.334; 95% CI: 1.158-4.725; P = .018) and OS (aHR = 2.226; 95% CI: 1.165-4.251; P = .015). Additionally, yp stage II and III patients with high PLR had inferior 5-year DFS (aHR = 2.012; 95% CI: 1.049-3.861; P = .036).Pre-CCRT NLR and PLR are independent prognostic factors for rectal cancer patients and could be used as a potential biomarker to identify high-risk patients for more intense treatment and care.

Glucocorticoid use and ischemia-reperfusion injury in laparoscopic liver resection: Randomized controlled trial

AIM

Laparoscopic liver resection (LLR) is increasingly carried out worldwide. However, there are concerns regarding ischemia-reperfusion injury caused by pneumoperitoneum and the Pringle maneuver. It is not clear whether perioperative use of glucocorticoids lowers the risk of ischemia-reperfusion hepatic injury in LLR as has been reported for open liver resection. The aim of the present study was to investigate the role of perioperative glucocorticoid use in improving hepatic function and surgical outcomes after LLR.

METHODS

In this double-blind, randomized controlled trial (UMIN000013823), we enrolled 130 patients who presented to our institution for LLR between April 2014 and October 2018. Six patients were excluded, resulting in 124 patients being randomized to either the glucocorticoid or the control group. Preoperatively, patients in the glucocorticoid group received 500 mg methylprednisolone in saline solution, patients in the control group saline solution only. Surgical outcomes and blood parameters were compared between the two groups.

RESULTS

The Pringle maneuver could not be carried out in 24 patients, resulting in 50 patients in each group being included in the analysis. Postoperatively, total, direct and indirect bilirubin, and C-reactive protein and interleukin-6 levels were significantly lower, albumin levels were significantly higher, and prothrombin time was significantly shorter in the glucocorticoid than in the control group. Surgical outcomes were not significantly different between the groups.

CONCLUSION

This first report on preoperative glucocorticoid use in LLR showed that it significantly improved postoperative liver function and thus might enhance the safety of LLR.

Systematic Review and Meta-Analysis of the Benefit and Safety of Preoperative Administration of Steroid in Patients Undergoing Liver Resection

Objective: To evaluate the benefit and safety of preoperative administration of steroid in patients undergoing liver resection.

Methods: Randomized controlled trials (RCTs) which comparing preoperative administration of steroid in patients undergoing liver resection with control group were identified through a systematic literature search in PubMed, Embase, and Cochrane Library Central databases. This meta-analysis was carried out to assess the liver function, inflammatory response, and postoperative complications after liver surgery.

Results: Six RCTs including 411 patients were reviewed. The pooled result showed that there was no significant difference in the incidence of overall complications between the steroid group and the control group (OR, 0.57; 95% CI, 0.27–1.17; P = 0.13). With respect to specific complications, no significant difference was detected between the two groups in infection complications (OR, 0.95; 95% CI, 0.13–6.95; P = 0.96), wound complications (OR, 0.65; 95% CI, 0.32–1.33; P = 0.24), liver failure (OR, 0.41; 95% CI, 0.10–1.64; P = 0.21), bile leakage (OR, 0.57; 95% CI, 0.17–1.89; P = 0.36), and pleural effusion (OR, 1.24; 95% CI, 0.55–2.78; P = 0.60). For liver function, the level of serum total bilirubin (TB) on postoperative day 1 (POD 1) was significantly decreased associated with the intervention of steroid (MD, −0.54; 95% CI, −0.94 to −0.15; P = 0.007). However, no significant difference was found in the level of alanine aminotransferase (ALT) (MD, −69.39; 95% CI, −226.52 to 87.75; P = 0.39) and aspartate aminotransferase (AST) (MD, −93.44; 95% CI, −275.68 to 88.80; P = 0.31) on POD 1 between the two groups. Serum IL-6 level on POD 1 (MD, −57.98; 95% CI, −73.04 to −42.91; P < 0.00001) and CRP level on POD 3 (MD, −4.83; 95% CI, −6.07 to −3.59; P < 0.00001) were significantly reduced in the steroid group comparing to the control group. Compared with the control group, the level of early postoperative IL-10 was significant higher in the steroid group (MD, 17.89; 95% CI, 3.89 to 31.89; P = 0.01).

Conclusion: Preoperative administration of steroid in liver resection can promote the recovery of liver function and inhibit the inflammatory response without increasing postoperative complications. Further studies should focus on determining which patients would benefit most from the steroid.

Biomarkers for Evaluating the Inflammation Status in Patients with Cancer

Inflammation can be a causative factor for carcinogenesis or can result from a consequence of cancer progression. Moreover, cancer therapeutic interventions can also induce an inflammatory response. Various inflammatory parameters are used to assess the inflammatory status during cancer treatment. It is important to select the most optimal biomarker among these parameters. Additionally, suitable biomarkers must be examined if there are no known parameters. We briefly reviewed the published literature for the use of inflammatory parameters in the treatment of patients with cancer. Most studies on inflammation evaluated the correlation between host characteristics, effect of interventions, and clinical outcomes. Additionally, the levels of C-reactive protein, albumin, lymphocytes, and platelets were the most commonly used laboratory parameters, either independently or in combination with other laboratory parameters and clinical characteristics. Furthermore, the immune parameters are classically examined using flow cytometry, immunohistochemical staining, and enzyme-linked immunosorbent assay techniques. However, gene expression profiling can aid in assessing the overall peri-interventional immune status. The checklists of guidelines, such as STAndards for Reporting of Diagnostic accuracy and REporting recommendations for tumor MARKer prognostic studies should be considered when designing studies to investigate the inflammatory parameters. Finally, the data should be interpreted after adjusting for clinically important variables, such as age and cancer stage.

The preventive effect of Chinese herbal preparation Xuebijing against hyperactive inflammation after hepato-pancreato-biliary surgery

Background

Hepato-pancreato-biliary (HPB) surgery is a primary treatment for benign and malignant diseases of the liver, biliary tract, and pancreas. Hyperactive inflammation has been indicated as a critical risk factor of post-operation death after HPB surgery. Xuebijing is an anti-inflammatory intravenous herbal preparation made from traditional Chinese medicines. Emerging evidence has implicated a protective role of Xuebijing against hyperactive inflammation.

Methods

A retrospective cohort study was conducted. We analyzed a total of 638 cases of HPB surgery, including hepatectomy, Whipple's surgery, and surgeries for cholelithiasis, which were divided into a Xuebijing treatment group and a conventional treatment group according to whether they were treated with Xuebijing injection or not. Clinical data related to liver function and inflammation were compared between the two groups after operation, including liver function index, white blood cell (WBC) count, neutrophil percentage (NE%), C-reactive protein (CRP), serum interleukin-6 (IL-6), body temperature, mortality, incidence of adverse reaction, length of postoperative hospital stay, and hospitalization cost.

Results

Xuebijing injection was found to decrease the levels of inflammatory markers in the blood significantly, including WBC, NE%, CRP, IL-6, and reduce the incidence of postoperative fever without prolonging in-hospital length or increasing cost compared to the conventional treatment group. Moreover, our data demonstrated that Xuebijing injection did not impact liver function after hepatectomy.

Conclusions

These results suggest that Xuebijing injection alleviates hyperactive inflammation caused by HPB surgery, and support the application of Xuebijing injection as a safe therapeutic approach against hyperactive inflammation in patients with HPB surgery.

Can Preoperative Intravenous Corticosteroids Administration Reduce Postoperative Pain Scores Following Spinal Fusion?: A Meta-Analysis

Objective: This meta-analysis aimed to assess whether preoperative intravenous corticosteroids reduced postoperative pain in patients undergoing spinal fusion surgery. Methods: We systematically searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Google databases, from inception to March 29, 2018. Randomized controlled trials (RCTs) that compared preoperative intravenous glucocorticoids against a control treatment for the effect on pain following spinal fusion surgery were included. A meta-analysis was performed to generate a pooled risk ratio (RR) and weighted mean difference (WMD) with corresponding 95% confidence interval (CI) for discontinuous outcomes (the occurrence of postoperative nausea and vomiting [PONV] as well as surgical-site infections) and continuous outcomes (visual analog scale [VAS] scores at 12 h, 24 h, 48 h, and 72 h; total morphine consumption and the length of hospital stay), respectively. Results: Ten RCTs that compared intravenous corticosteroids versus placebo were included in our final meta-analysis. Compared with controls, intravenous corticosteroids were associated with a statistically significant reduction in pain VAS scores at 12 h, 24 h, 48 h, and 72 h. Additionally, intravenous corticosteroids decreased total morphine consumption, PONV, and the length of hospital stay. There was no significant difference between intravenous corticosteroids and controls, regarding the occurrence of infection (p > 0.05). Conclusions: In summary, our results indicated that intravenous corticosteroids not only reduce pain but also have anti-emetic effects. More studies should focus on the adverse effects of administering intravenous corticosteroids.

Dexamethasone for postoperative hyperbilirubinemia in patients after liver resection: An open-label, randomized controlled trial

BACKGROUND

Although prophylactic glucocorticoids have been used before liver resection to minimize liver dysfunction, it is unknown whether treatment with glucocorticoids will accelerates recovery from hyperbilirubinemia after liver resection.

METHODS

In this open-label, randomized, controlled trial, patients with hyperbilirubinemia (>2.5 × and ≤5 × the upper limit of normal) within 7 days after hepatic resection were assigned randomly to the dexamethasone or control groups. For the dexamethasone group, 10 mg, 10 mg, and 5 mg dexamethasone were administered intravenously on days 0, 1, and 2, respectively, after randomization. For the control group, patients received standard treatment only. The primary outcome was time to recovery from hyperbilirubinemia defined as the period from the day of randomization to the day when serum bilirubin decreased to ≤1.5 times that of the upper limit of normal. Secondary outcomes were the prevalence of postoperative complications, postoperative hospital stay, and hospital expense.

RESULTS

Between March 2016 and December 2017, 76 participants were enrolled (38 in each group). Median time to recovery from hyperbilirubinemia was less in the dexamethasone group than in the control group (2 vs 4 days, P < .001). Serum bilirubin levels were less in the dexamethasone group on days 1-3 after randomization (P < .05). The prevalence of infection, posthepatectomy liver failure, postoperative hospital stay, and hospital expense were not different between the groups.

CONCLUSION

Dexamethasone accelerated recovery from hyperbilirubinemia and decreased serum bilirubin levels without causing more side effects in patients after hepatectomy.

Treatment strategy for successful hepatic resection of icteric liver

BACKGROUND

The treatment strategy for jaundiced patients with hilar cholangiocarcinoma (HC) is not well established. In this study, we evaluate the feasibility of our perioperative protocol for jaundiced patients with HC.

METHODS

Twenty patients with HC who underwent hepatic resection at our institute were enrolled, and patients were divided into icteric(n=6) and normal(n=14) group. As a perioperative protocol, Oral administration of Inchinkoto(ICKT), steroid and nafamostat mesilate were introduced. The evaluation of functional future remnant liver(FRL) by asiaroscintigraphy, and postoperative outcomes were retrospectively compared.

RESULTS

Indocyanine green dye retention rate at 15 minutes was higher, and LHL15 values was lower in icteric group. However, in the functional evaluation of FRL, which was the sum of GSA uptake of the future FRL, there was no significant difference of LHL15 values of the remnant liver functional reserve between the two groups. As results, according to the difference of liver function, serum AST level was not different between two groups. The number of patients with postoperative morbidity in the two groups was comparable.

CONCLUSIONS

Even in HC patients with icteric liver, accurate assessment of liver functional reserve and effective perioperative treatment may attribute to successful hepatectomy and favorable post-operative outcomes. J. Med. Invest. 65:37-42, February, 2018.

The impact of sterile inflammation in acute liver injury

BACKGROUND

The liver has a number of functions in innate immunity. These functions predispose the liver to innate immune-mediated liver injury when inflammation goes unchecked. Significant progress has been made in the last 25 years on sterile inflammatory liver injury in a number of models; however, a great deal of controversy and many questions about the nature of sterile inflammation still exist.

AIM

The goal of this article is to review sterile inflammatory liver injury using both a basic approach to what constitutes the inflammatory injury, and through examination of current models of liver injury and inflammation. This information will be tied to human patient conditions when appropriate.

RELEVANCE FOR PATIENTS

Inflammation is one of the most critical factors for managing in-patient liver disease in a number of scenarios. More information is needed for both scientists and clinicians to develop rational treatments.

Safety of Perioperative Glucocorticoids in Elective Noncardiac Surgery

Background

Glucocorticoids are increasingly used perioperatively, principally to prevent nausea and vomiting. Safety concerns focus on the potential for hyperglycemia and increased infection. The authors hypothesized that glucocorticoids predispose to such adverse outcomes in a dose-dependent fashion after elective noncardiac surgery.

Methods

The authors conducted a systematic literature search of the major medical databases from their inception to April 2016. Randomized glucocorticoid trials in adults specifically reporting on a safety outcome were included and meta-analyzed with Peto odds ratio method or the quality effects model. Subanalyses were performed according to a dexamethasone dose equivalent of low (less than 8 mg), medium (8 to 16 mg), and high (more than 16 mg). The primary endpoints of any wound infection and peak perioperative glucose concentrations were subject to meta-regression.

Results

Fifty-six trials from 18 countries were identified, predominantly assessing dexamethasone. Glucocorticoids did not impact on any wound infection (odds ratio, 0.8; 95% CI, 0.6 to 1.2) but did result in a clinically unimportant increase in peak perioperative glucose concentration (weighted mean difference, 20.0 mg/dl; CI, 11.4 to 28.6; P &lt; 0.001 or 1.1 mM; CI, 0.6 to 1.6). Glucocorticoids reduced peak postoperative C-reactive protein concentrations (weighted mean difference, −22.1 mg/l; CI, −31.7 to −12.5; P &lt; 0.001), but other adverse outcomes and length of stay were unchanged. No dose–effect relationships were apparent.

Conclusions

The evidence at present does not highlight any safety concerns with respect to the use of perioperative glucocorticoids and subsequent infection, hyperglycemia, or other adverse outcomes. Nevertheless, collated trials lacked sufficient surveillance and power to detect clinically important differences in complications such as wound infection.

Metabolic consequences of modern immunosuppressive agents in solid organ transplantation

Among other factors, sophistication of immunosuppressive (IS) regimen accounts for the remarkable success attained in the short- and medium-term solid organ transplant (SOT) survival. The use of steroids, mycophenolate mofetil and calcineurin inhibitors (CNI) have led to annual renal graft survival rates exceeding 90% in the last six decades. On the other hand, attrition rates of the allograft beyond the first year have remained unchanged. In addition, there is a persistent high cardiovascular (CV) mortality rate among transplant recipients with functioning grafts. These shortcomings are in part due to the metabolic effects of steroids, CNI and sirolimus (SRL), all of which are implicated in hypertension, new onset diabetes after transplant (NODAT), and dyslipidemia. In a bid to reduce the required amount of harmful maintenance agents, T-cell-depleting antibodies are increasingly used for induction therapy. The downsides to their use are greater incidence of opportunistic viral infections and malignancy. On the other hand, inadequate immunosuppression causes recurrent rejection episodes and therefore early-onset chronic allograft dysfunction. In addition to the adverse metabolic effects of the steroid rescue needed in these settings, the generated proinflammatory milieu may promote accelerated atherosclerotic disorders, thus setting up a vicious cycle. The recent availability of newer agent, belatacept holds a promise in reducing the incidence of metabolic disorders and hopefully its long-term CV consequences. Although therapeutic drug monitoring as applied to CNI may be helpful, pharmacodynamic tools are needed to promote a customized selection of IS agents that offer the most benefit to an individual without jeopardizing the allograft survival.

[Role of octreotide and prednisolone in prophylactic of poshepatectomy liver failure. Experimental study]

AIM

Comparative morphologic assessment of the liver tissue response to the preoperative infusion of octreotide and prednisolon after the major hepatic resection was studied in rats.

MATERIAL AND METHODS

25 male Wistar rats weighing 230--280 g were used. All rats underwent 70--80% hepatectomy. The rats were divided into three groups according to the infusions before hepatectomy: group 1 (n=7) -- received octreotide, group 2 (n=8) -- prednisolone, group 3 (n=10) -- 0.9% saline solution as the control. Histologic features of the remnant liver were evaluated in the sacrificied rats after 72 hours post-hepatectomy.

RESULTS

In the group 1 we observed more rapid decrease of edema and tendency to the accelerated regeneration process of hepatocytes.

CONCLUSION

Octreotide infusion before the major hepatic resection may have protective effect on hepatocytes and accelerate the regeneration in the remnant liver.

The impact of preoperative corticosteroids on the systemic inflammatory response and postoperative complications following surgery for gastrointestinal cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis examined the impact of preoperative corticosteroids on interleukin 6 (IL-6), C-reactive protein (CRP), and complications following surgery for gastrointestinal cancer.

METHODS

A systematic review was performed using appropriate keywords. Random-effects meta-analysis was performed.

RESULTS

11 RCTs with 474 patients, were included. Corticosteroids were significantly associated with lower IL-6 on postoperative day 1 (mean difference -148pg/mL, 95% CI -205 to -92, p<0.001), 2 (-33pg/mL, 95% CI -58 to -8, p=0.01), and 3 (-31pg/mL, 95% CI -52 to -11, p=0.002), lower CRP on day 3 (-45mg/L, 95% CI -68 to -21, p<0.001), and 7 (-14mg/L, 95% CI -27 to -1, p=0.04), and fewer postoperative infective complications (OR 0.47, 95% CI 0.26-0.83, p=0.01).

CONCLUSION

Corticosteroids were associated with reduction in the postoperative systemic inflammatory response and complications following surgery for gastrointestinal cancer.

Premedication with Intravenous Ibuprofen Improves Recovery Characteristics and Stress Response in Adults Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Trial

OBJECTIVES

Examine the effect of preoperative dose of IV ibuprofen on stress response and postoperative recovery in laparoscopic cholecystectomy patients.

DESIGN

Prospective, randomized, controlled, double-blind, multicenter trial.

SETTING

Three university-based, tertiary care hospitals.

SUBJECTS

Fifty-five adults, ASA 1, 2, or 3 scheduled for laparoscopic cholecystectomy were given a single preoperative dose of placebo or IV ibuprofen 800 mg.

METHODS

Neurobehavioral assessments were evaluated preoperatively, in PACU, POD 1, and POD 3, using the 40-item Quality of Recovery questionnaire (QoR40), 9-item Modified Fatigue Severity Scale (MFSS), and 15-item Geriatric Depression scale (GDS). Blood samples were taken for cytokines (TNF-alpha, IL-1β, IL-2, IL-6, IL-10, IFNγ), cortisol, CRP, epinephrine, and norepinephrine prior to the administration of study drug/placebo, intraoperatively, and after surgery.

RESULTS

Global QoR40 scores remained at baseline for ibuprofen patients but significantly decreased in the placebo group. Severity of fatigue increased in patients receiving placebo but had no change with ibuprofen. The placebo group had lower GDS scores on POD 3. Epinephrine and norepinephrine were significantly lower intraoperatively for the ibuprofen group. Cortisol decreased postoperatively in the ibuprofen group. There was an impact of drug treatment on the immune response, as seen by an increase in TNFα and an increase in IL-10 when compared with placebo.

CONCLUSIONS

Our results suggest the addition of NSAIDs may improve the overall quality of recovery, postsurgical fatigue, and early postoperative outcomes. Preoperative administration of IV ibuprofen modulates the stress and inflammatory response, as demonstrated by a decrease in the level of catecholamines, cortisol, and cytokines.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: 01938040.

Inflammatory mediators in intra-abdominal sepsis or injury - a scoping review

INTRODUCTION

Inflammatory and protein mediators (cytokine, chemokine, acute phase proteins) play an important, but still not completely understood, role in the morbidity and mortality of intra-abdominal sepsis/injury. We therefore systematically reviewed preclinical and clinical studies of mediators in intra-abdominal sepsis/injury in order to evaluate their ability to: (1) function as diagnostic/prognostic biomarkers; (2) serve as therapeutic targets; and (3) illuminate the pathogenesis mechanisms of sepsis or injury-related organ dysfunction.

METHODS

We searched MEDLINE, PubMed, EMBASE and the Cochrane Library. Two investigators independently reviewed all identified abstracts and selected articles for full-text review. We included original studies assessing mediators in intra-abdominal sepsis/injury.

RESULTS

Among 2437 citations, we selected 182 studies in the scoping review, including 79 preclinical and 103 clinical studies. Serum procalcitonin and C-reactive protein appear to be useful to rule out infection or monitor therapy; however, the diagnostic and prognostic value of mediators for complications/outcomes of sepsis or injury remains to be established. Peritoneal mediator levels are substantially higher than systemic levels after intra-abdominal infection/trauma. Common limitations of current studies included small sample sizes and lack of uniformity in study design and outcome measures. To date, targeted therapies against mediators remain experimental.

CONCLUSIONS

Whereas preclinical data suggests mediators play a critical role in intra-abdominal sepsis or injury, there is no consensus on the clinical use of mediators in diagnosing or managing intra-abdominal sepsis or injury. Measurement of peritoneal mediators should be further investigated as a more sensitive determinant of intra-abdominal inflammatory response. High-quality clinical trials are needed to better understand the role of inflammatory mediators.

Preoperative single-dose methylprednisolone versus placebo after major liver resection in adults: protocol for a randomised controlled trial

INTRODUCTION

Although randomised controlled trials have demonstrated that preoperative glucocorticoids may improve postoperative surrogate outcomes among patients undergoing major liver resection, evidence supporting improved patient-important outcomes is lacking. This superiority trial aims to evaluate the effect of administration of a bolus of the glucocorticoid methylprednisolone versus placebo during induction of anaesthesia on postoperative morbidity among adults undergoing elective major liver resection.

METHODS AND ANALYSIS

This will be a randomised, dual-arm, parallel-group, superiority trial. All consecutive adults presenting to a large Canadian tertiary care hospital who consent to undergo major liver resection will be included. Patients aged <18 years and those currently receiving systemic corticosteroid therapy will be excluded. We will randomly allocate participants to a preoperative 500 mg intravenous bolus of methylprednisolone versus placebo. Surgical team members and outcome assessors will be blinded to treatment allocation status. The primary outcome measure will be postoperative complications. Secondary outcome measures will include mortality, the incidence of several specific postoperative complications, and blood levels of select proinflammatory cytokines, acute-phase proteins, and laboratory liver enzymes or function tests on postoperative days 0, 1, 2 and 5. The incidence of postoperative complications and mortality will be compared using Fisher's exact test, while the above laboratory measures will be compared using mixed-effects models with a subject-specific random intercept.

ETHICS AND DISSEMINATION

This trial will evaluate the protective effect of a single preoperative dose of methylprednisolone on the hazard of postoperative complications. A report releasing study results will be submitted for publication in an appropriate journal, approximately 3 months after finishing the data collection.

TRIAL REGISTRATION NUMBER

NCT01997658; Pre-results.

Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor

We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.

Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review

BACKGROUND

Operative injury to the body from all procedures causes a stereotypical cascade of neuroendocrine, cytokine, myeloid, and acute phase responses. This response has been examined commonly by the use of cortisol, interleukin-6 (IL-6), white cell count, and C-reactive protein (CRP). We aimed to determine which markers of the systemic inflammatory response were useful in determining the magnitude of injury after elective operations.

METHODS

A systematic review of the literature was performed using surgery, endocrine response, systemic inflammatory response, cortisol, IL-6, white cell count, and CRP. For each analyte the studies were grouped according to whether the operative injury was considered to be minor, moderate, or major and then by the operative procedure.

RESULTS

A total of 164 studies were included involving 14,362 patients. The IL-6 and CRP responses clearly were associated with the magnitude of operative injury and the invasiveness of the operative procedure. For example, the peak CRP response increased from 52 mg/L with cholecystectomy to 123 mg/L with colorectal cancer resection, 145 mg/L with hip replacement, 163 mg/L after abdominal aortic aneurysm repair, and 189 mg/L after open cardiac surgery. There also appeared to be a difference between minimally invasive/laparoscopic and open procedures such as cholecystectomy (27 vs 80 mg/L), colorectal cancer resection (97 vs 133 mg/L), and aortic aneurysm repair (132 vs 180 mg/L).

CONCLUSION

Peak IL-6 and CRP concentrations consistently were associated with the magnitude of operative injury and operative procedure. These markers may be useful in the objective assessment of which components of Enhanced Recovery after Surgery are likely to improve patient outcome and to assess the possible impact of operative injury on immune function.

Meta-analysis of associations between neutrophil-to-lymphocyte ratio and prognosis of gastric cancer

Background

The prognostic role of inflammation indices, such as the neutrophil-to-lymphocyte ratio (NLR) in gastric cancer (GC) remains controversial. We conducted a meta-analysis to determine the predictable value of NLR in the clinical outcome of GC patients.

Methods

We searched Embase, PubMed and the Cochrane Library database for relevant randomised controlled trials. Statistical analyses were conducted to calculate the hazard ratio (HR) and 95% confidence intervals of overall survival (OS) and progression-free survival (PFS) using either random-effect or fixed-effect models according to the heterogeneity of the included studies. An analysis was carried out based on data from nine studies to evaluate the association between NLR and OS in patients with GC.

Results

Our analysis indicated that elevated pre-treatment NLR predicted poorer OS (HR: 2.16, 95% CI: 1.86 to 2.51, P < 0.001) and PFS (HR 2.78, 95% CI: 1.95 to 3.96; P < 0.00001) in patients with GC. Over a 3-year follow-up period, high NLR was a significant predictor of poor outcomes at year 1 (HR 1.99; 95% CI: 1.39 to 2.85; P = 0.0002), year 2 (HR 2.24; 95% CI: 1.69 to 2.97; P < 0.00001) and year 3 (HR 2.80; 95% CI: 1.98 to 3.96; P < 0.00001).

Conclusions

Elevated preoperative NLR is associated with poorer rates of survival in GC patients and may play a role in GC surveillance programmes as a means of delivering more personalised cancer care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-015-0530-9) contains supplementary material, which is available to authorized users.

Short-term administration of steroids does not affect postoperative complications following liver resection: Evidence from a meta-analysis of randomized controlled trials

AIM

Although perioperative short-term administration of steroids can attenuate surgical stress response following liver resection, there is no consensus concerning the effect on postoperative complications. This study aims to use meta-analysis to quantitatively investigate the effect of perioperative short-term administration of steroids on postoperative complications following liver resection.

METHODS

A systematic published work search was performed to detect randomized controlled trials (RCT) assessing the effect of perioperative short-term administration of steroids on outcomes following liver resection. Parameters of surgical stress, hospital stay and postoperative complications were analyzed. Two authors independently assessed study quality and extracted data. All data were analyzed using RevMan version 5 and meta-analyses were performed using a random-effects model.

RESULTS

Five RCT published between 2001 and 2011 containing a total of 379 patients were eligible for final analysis. Serum total bilirubin, interleukin-6 and C-reactive protein were significantly lower in the steroid than in the control group on postoperative day 1 (P = 0.02, 0.004 and 0.02, respectively). There was no difference in duration of hospital stay between the steroid and control group (P = 0.37). The analysis of end-points including infective complications (odds ratio [OR], 0.95), wound complications (OR, 0.67), bile leakage (OR, 0.58) and overall complications (OR, 0.50) revealed no difference between steroid administration and no treatment. There was no postoperative death or adverse effect attributable to steroid treatment in all patients.

CONCLUSION

On currently available evidence, short-term administration of steroids does not increase incidence of complications in patients undergoing liver resection.

Preoperative low-dose steroid can prevent respiratory insufficiency after thymectomy in generalized myasthenia gravis

BACKGROUND

Postoperative respiratory insufficiency (PRI) in myasthenia gravis (MG) often occurs within several days after thymectomy and remains problematic. In limited studies reporting that preoperative steroids prevented PRI in patients with MG, high doses of steroids were used and detailed information on the use of steroids is limited. Because high-dose steroids significantly increase the risk of adverse effects, we studied 37 patients with generalized MG to investigate whether low-dose steroids might prevent PRI.

METHODS

The low-dose steroids were started orally, and the dose was gradually increased to the maximum level (30 mg/day). Immediately before thymectomy, patients received the maximum dose of oral steroids daily. PRI was defined as the development of restrictive dysfunction requiring mechanical ventilation within 3 days after thymectomy and total postoperative mechanical ventilation support time of >24 h.

RESULTS

The rate of PRI in the low-dose steroid use group was significantly lower than that in the no-steroid use group. The postoperative stay in the intensive care unit was shorter in the steroid use group.

CONCLUSIONS

Extended thymectomy is a well-accepted surgical treatment for selected patients with MG. However, PRI remains problematic. Our results suggest that not only preoperative high-dose steroid treatment, but also low-dose steroid treatment can prevent PRI.

The emerging role of neutrophil to lymphocyte ratio in determining colorectal cancer treatment outcomes: a systematic review and meta-analysis

BACKGROUND

There is growing evidence suggesting that the neutrophil to lymphocyte ratio (NLR) can act as an independent predictor of long-term outcomes in patients undergoing treatment for colorectal cancer (CRC). This study aims to systematically review the role of NLR in predicting survival for patients with CRC undergoing treatments, and to evaluate its utility within a CRC surveillance program.

METHODS

This meta-analysis was performed according to PRISMA guidelines. Outcomes of interest included disease-free survival (DFS) for patients undergoing treatment with curative intent and progression-free survival (PFS) in patients undergoing treatments with palliative intent.

RESULTS

Thirteen observational cohort studies published from 2007 to 2013 evaluated the role of NLR as a predictor of outcome following treatment for CRC. These included (i) patients undergoing surgery to resect the primary cancer (seven studies); (ii) those undergoing palliative chemotherapy (three studies); and (iii) patients undergoing potentially curative treatments for CRC liver metastases (three studies). When all studies were considered, a high pretreatment NLR independently predicted survival (HR 2.08; 95 % CI 1.64-2.64). A high NLR also predicted significantly poorer survival in each of the three groups. Finally, over a 3-year follow-up period, high NLR became a significant predictor of poor outcome at year 2 (HR 2.76; 95 % CI 2.06-3.69; p < 0.00001) and 3 (HR 2.03; 95 % CI 1.48-2.78; p < 0.0001), but not in the first year of follow-up (HR 1.47; 95 % CI 0.89-2.41; p = 0.13).

CONCLUSIONS

Elevated preoperative NLR is associated with poorer survival in CRC patients undergoing treatment and may have a role in CRC surveillance programs as a means of delivering more personalized cancer care.

Systematic review of pathophysiological changes following hepatic resection

OBJECTIVES

Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection.

METHODS

The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were 'hepatectomy/', 'liver function/', 'liver failure/' and 'physiology/'.

RESULTS

Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure.

CONCLUSIONS

The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.

The association of perioperative dexamethasone, smoking and alcohol abuse with wound complications after laparotomy

BACKGROUND

A number of perioperative risk factors may suppress the immune system and contribute to the development of post-operative complications. The association between surgical site infection (SSI) and other wound-related complications resulting from immunosuppression through either perioperative administration of dexamethasone, pre-operative smoking or alcohol abuse is, however, uncertain.

METHODS

This study was a post hoc analysis of data from the PROXI randomized trial in 1386 patients who underwent emergency or elective laparotomy. We assessed the associations of use of dexamethasone, smoking status and alcohol abuse with the primary outcome, being a composite of SSI, anastomotic leak, wound dehiscence, burst abdomen and 30-day mortality.

RESULTS

The primary outcome occurred in 21% of patients receiving dexamethasone versus 28% of patients not receiving dexamethasone, and this was not statistically significant when adjusting for stratification variables originally used in the PROXI trial [OR 0.90, 95% CI (0.65-1.24)]. In smokers, the primary outcome occurred in 32%, compared with 23% of non-smokers (P = 0.0001). Smokers also had a higher frequency of SSI (25% vs 17%, P < 0.0001) and burst abdomen (3.8% vs 2.4%, P = 0.04). In alcohol abusers, the primary outcome occurred in 48%, compared with 25% in patients who did not abuse alcohol (P = 0.0006). Burst abdomen occurred more commonly in alcohol abusers (15% vs 2.3%, P < 0.0001).

CONCLUSION

Perioperative administration of dexamethasone was not significantly associated with SSI or other wound-related complications. Conversely, smoking and alcohol abuse were both significant predictors of the primary outcome consisting of wound-related complications and mortality.

Highest intraoperative lactate level could predict postoperative infectious complications after hepatectomy, reflecting the Pringle maneuver especially in chronic liver disease

BACKGROUND

The Pringle maneuver is used to minimize blood loss during liver transection; however, it may cause reperfusion injury, which can cause increased intraoperative lactate levels and an immune compromised state. This may further lead to infectious complications.

METHODS

Here, we divided 77 patients who underwent hepatectomy between December 2007 and August 2010 into two groups: the chronic hepatitis and liver cirrhosis (CH + LC) group and normal liver (NL) group. We investigated the effect of the highest intraoperative lactate level on occurrence of infectious complications after hepatectomy by assessing the correlations of the highest intraoperative lactate level with total Pringle time, operative factors, and various parameters in serum after surgery. Parameters showing significant correlations with postoperative complications of Clavien-Dindo grade III or higher, with a wound or intra-abdominal infection, were analyzed by using interactive dot diagrams to determine cut-off values with the highest sensitivity and specificity.

RESULTS

We noted that, to prevent postoperative infectious complications, the highest lactate level during liver resection should be maintained at <44.0 mg/dL in the NL group and <29.0 mg/dL in the CH + LC group.

CONCLUSIONS

Minimizing the highest intraoperative lactate level may be important to prevent increase in postoperative infectious complications after hepatectomy, reflecting the Pringle maneuver especially in chronic liver disease.

Use of pre-operative steroids in liver resection: a systematic review and meta-analysis

BACKGROUND

By attenuating the systemic inflammatory response to major surgery, the pre-operative administration of steroids may reduce the incidence of complications.

METHODS

A systematic review was conducted to identify randomized controlled trials (RCT) comparing pre-operative steroid administration with placebo during a liver resection. Meta-analyses were performed.

RESULTS

Five RCTs were identified including a total of 379 patients. Pre-operative steroids were associated with statistically significant reductions in the levels of serum bilirubin and interleukin 6 (IL-6) on post-operative day one. There was a trend towards a lower incidence of post-operative complications and prothrombin time (PT), but this did not reach statistical significance.

CONCLUSION

Pre-operative steroids may be associated with a clinically significant benefit in liver resection.

Surrogate endpoints in liver surgery related trials: a systematic review of the literature

BACKGROUND

Although the safety of liver surgery has improved enormously, hepatic surgery continues to face challenging complications. Therefore, improvements supported by evidence-based guidelines are still required. The conduct of randomized controlled trials in liver surgery using dichotomous outcomes requires a large sample size. The use of surrogate endpoints (SEPs) reduces sample size but SEPs should be validated before use.

AIM

The aim of this review was to summarize the SEPs used in hepatic surgery related trials, their definitions and recapitulating the evidence validating their use.

METHOD

A systematic computerized literature search in the biomedical database PubMed using the MeSH terms 'hepatectomy' or 'liver resection' or 'liver transection' was conducted. Search was limited to papers written in the English language and published between 1 January 2000 and 1 January 2010.

RESULTS

A total of 593 articles met the search terms and 49 articles were included in the final selection. Standard biochemical liver functions tests were the most frequently used SEP (32 of 49 the studies). The used definitions of SEPs varied greatly among the studies. Most studies referred to earlier published material to justify their choice of SEP. However, no validating studies were found.

CONCLUSION

Many SEPs are used in liver surgery trials however there is little evidence validating them.