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Cata JP, Soni B, Bhavsar S, Pillai PS, Rypinski TA, Deva A, Siewerdsen JH, Soliz JM. Forecasting intraoperative hypotension during hepatobiliary surgery. J Clin Monit Comput 2024:10.1007/s10877-024-01223-5. [PMID: 39317921 DOI: 10.1007/s10877-024-01223-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 09/13/2024] [Indexed: 09/26/2024]
Abstract
Prediction and avoidance of intraoperative hypotension (IOH) can lead to less postoperative morbidity. Machine learning (ML) is increasingly being applied to predict IOH. We hypothesize that incorporating demographic and physiological features in an ML model will improve the performance of IOH prediction. In addition, we added a "dial" feature to alter prediction performance. An ML prediction model was built based on a multivariate random forest (RF) trained algorithm using 13 physiologic time series and patient demographic data (age, sex, and BMI) for adult patients undergoing hepatobiliary surgery. A novel implementation was developed with an adjustable, multi-model voting (MMV) approach to improve performance in the challenging context of a dynamic, sliding window for which the propensity of data is normal (negative for IOH). The study cohort included 85% of subjects exhibiting at least one IOH event. Males constituted 70% of the cohort, median age was 55.8 years, and median BMI was 27.7. The multivariate model yielded average AUC = 0.97 in the static context of a single prediction made up to 8 min before a possible IOH event, and it outperformed a univariate model based on MAP-only (average AUC = 0.83). The MMV model demonstrated AUC = 0.96, PPV = 0.89, and NPV = 0.98 within the challenging context of a dynamic sliding window across 40 min prior to a possible IOH event. We present a novel ML model to predict IOH with a distinctive "dial" on sensitivity and specificity to predict first IOH episode during liver resection surgeries.
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Affiliation(s)
- Juan P Cata
- Department of Anaesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group (ASORG), Houston, TX, USA
| | - Bhavin Soni
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Surgical Data Science Program, Institute for Data Science in Oncology (IDSO), The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shreyas Bhavsar
- Department of Anaesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Parvathy Sudhir Pillai
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tatiana A Rypinski
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anshuj Deva
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Siewerdsen
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Surgical Data Science Program, Institute for Data Science in Oncology (IDSO), The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose M Soliz
- Department of Anaesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Anesthesiology and Surgical Oncology Research Group (ASORG), Houston, TX, USA.
- Surgical Data Science Program, Institute for Data Science in Oncology (IDSO), The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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2
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D'Amico F, Pruna A, Putowski Z, Dormio S, Ajello S, Scandroglio AM, Lee TC, Zangrillo A, Landoni G. Low Versus High Blood Pressure Targets in Critically Ill and Surgical Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2024; 52:1427-1438. [PMID: 38656245 DOI: 10.1097/ccm.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality. DATA SOURCES We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024. STUDY SELECTION Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings. DATA EXTRACTION The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928. DATA SYNTHESIS Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes. CONCLUSIONS Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Zbigniew Putowski
- Department of Intensive Care and Perioperative Medicine, Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Sara Dormio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Ding L, Duan Y, Yao L, Gao Z. Efficacy and safety of terlipressin infusion during liver surgery: a protocol for systematic review and meta-analysis. BMJ Open 2024; 14:e080562. [PMID: 38553072 PMCID: PMC10982717 DOI: 10.1136/bmjopen-2023-080562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 03/14/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Liver disease causes 2 million deaths annually, accounting for 4% of all deaths worldwide. Liver surgery is one of the effective therapeutic options. Bleeding is a major complication during liver surgery. Perioperative bleeding and allogeneic blood transfusion may deteriorate the prognosis. Terlipressin (TP), a synthetic analogue of the antidiuretic hormone, may reduceblood loss during abdominal surgery. Several clinical centres have attempted to use TP during liver surgery, but the evidence for its effectiveness in reducing blood loss and the need for allogeneic blood transfusion, as well as its safety during the perioperative period, remains unclear. The aim of this systematic review and meta-analysis is to evaluate the efficacy and safety of TP in reducing blood loss and allogeneic blood transfusion needs during liver surgery. METHODS AND ANALYSIS We will search PubMed, EMBASE, the Cochrane Library and Web of Science for studies on perioperative use of TP during liver surgery from inception to July 2023. We will limit the language to English, and two reviewers will independently screen and select articles. The primary study outcomes are estimated blood loss and the need for allogeneic blood transfusion. Secondary outcomes include operating time, intensive care unit stay, length of stay, intraoperative urine output, acute kidney injury rate, postoperative complications, hepatic and renal function during follow-up, and TP-related adverse effects. We will include studies that met the following criteria: (1) randomised controlled trials (RCTs), cohort studies or case-control studies; (2) the publication time was till July 2023; (3) adult patients (≥18 years old) undergoing elective liver surgery; (4) comparison of TP with other treatments and (5) the study includes at least one outcome. We will exclude animal studies, case reports, case series, non-original articles, reviews, paediatric articles, non-controlled trials, unpublished articles, non-English articles and other studies that are duplicates. We will use Review Manager V.5.3 software for meta-analysis and perform stratification analysis for the study quality of RCTs based on the Jadad score. For cohort or case-control studies, the study quality will be analysed based on Newcastle-Ottawa Scale scores. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess confidence in the cumulative evidence. For primary outcomes, we will conduct subgroup analyses based on meta-regression. We will also perform leave-one-out sensitivity analyses to evaluate the effect of each individual study on the combined results by removing the individual studies one by one for outcomes with significant heterogeneity. The protocol follows the Cochrane Handbook for Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION This study is a secondary analysis of existing data; therefore, it does not require ethical approval. We will disseminate the results through peer-reviewed publications. PROSPERO REGISTRATION NUMBER CRD42023450333.
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Affiliation(s)
- Lin Ding
- Department of Anaesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anaesthesiology, Peking University International Hospital, Beijing, China
| | - Yi Duan
- Department of Anaesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lan Yao
- Department of Anaesthesiology, Peking University International Hospital, Beijing, China
| | - Zhifeng Gao
- Department of Anaesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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She WH, Tsang SHY, Dai WC, Chan ACY, Lo CM, Cheung TT. Stage-by-stage analysis of the effect of blood transfusion on survival after curative hepatectomy for hepatocellular carcinoma-a retrospective study. Langenbecks Arch Surg 2024; 409:83. [PMID: 38436871 DOI: 10.1007/s00423-024-03278-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE This study is to examine the impact of perioperative (intraoperative/postoperative) blood transfusion on the outcomes of curative hepatectomy for hepatocellular carcinoma. Hepatectomy is a well-established curative treatment for hepatocellular carcinoma, and blood transfusion cannot always be avoided in treating the disease. METHODS A retrospective study of patients having curative hepatectomy for hepatocellular carcinoma from January 2010 to December 2019 at a single center was conducted. The patients were stratified by their disease stage. Patients with and without perioperative blood transfusion were matched by propensity-score matching and compared for each disease stage. Univariate and multivariate analyses were performed to identify prognostic factors for overall survival for each stage. RESULTS A total of 846 patients were studied. Among them, 125 received perioperative blood transfusion and 720 did not. Patients with blood transfusion had worse disease-free and overall survival. After stratification and matching, the ratios of transfusion to non-transfusion were 33:165 (stage 1), 28:140 (stage 2), and 45:90 (stage 3). Perioperative blood transfusion was associated with a higher incidence of postoperative complications in all three disease stages (p = 0.004/0.006/0.017), and hence longer hospitalization (p < 0.001 in all stages), but had no significant impact on hospital mortality (p = 0.119/0.118/0.723), 90-day mortality (p = 0.259/0.118/0.723), disease-free survival (p = 0.128/0.826/0.511), or overall survival (p = 0.869/0.122/0.122) in any disease stage. Prognostic factors for overall survival included tumor size, tumor number, alpha-fetoprotein level, and postoperative complication of grade ≥ 3A. CONCLUSION Perioperative blood transfusion was associated with a higher incidence of complications but had no significant impact on survival after curative hepatectomy for hepatocellular carcinoma.
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Affiliation(s)
- Wong Hoi She
- Department of Surgery, School of Clinical Medicine, University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Simon Hing Yin Tsang
- Department of Surgery, School of Clinical Medicine, University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, School of Clinical Medicine, University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Albert Chi Yan Chan
- Department of Surgery, School of Clinical Medicine, University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, School of Clinical Medicine, University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Tan To Cheung
- Department of Surgery, School of Clinical Medicine, University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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5
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Sánchez-Del-Valle FJ, Sánchez-Seco MI, Jiménez AG, Acosta F, Fernández-Domínguez P, Pérez-Alegre JJ. Effectiveness of a thrombin-gelatin flowable for treating severe liver bleeding: an experimental study. BMC Gastroenterol 2024; 24:71. [PMID: 38355409 PMCID: PMC10865537 DOI: 10.1186/s12876-023-03114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 12/29/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Current scientific evidence has pointed out the relevance of hemostatic products for improving clinical outcomes in liver trauma, including increased survival rates and reductions in bleeding-related complications. The purpose of this study was to compare the use of the gelatin-thrombin flowable (Flowable) versus the standard technique of Packing in a new experimental liver injury model. METHODS Twenty-four swine were prospectively randomized to receive either Flowable or standard packing technique. We used a novel severe liver injury model, in which the middle and left suprahepatic veins were selectively injured, causing an exsanguinating hemorrhage. The main outcome measure was the percentage of lost blood volume. RESULTS The median total percentage of total blood volume per animal lost, from injury to minute 120, was significantly lower in the Flowable group (15.2%; interquartile range: 10.7-46.7%) than in the Packing group (64.9%; Interquartile range: 53.4-73.0%) (Hodges-Lehmann median difference: 41.1%; 95% CI: 18.9-58.0%, p = 0.0034). The 24-hour survival rate was significantly higher in the Flowable group (87.0%) than in the Packing group (0.0%) (Hazard ratio (HR) 0.08; 95% confidence interval 0.102 to 0.27; p < 0.0001). Mean-arterial pressure was significantly lower at minute 60 and 120 in the Flowable group than in the packing group (p = 0.0258 and p = 0.0272, respectively). At minute 120, hematocrit was higher in the Flowable than in the packing group (Hodges-Lehmann median difference: 5.5%; 95%CI: 1.0 to11.0, p = 0.0267). Finally, the overall-surgical-procedure was significantly shorter with Flowable than with Packing (Hodges-Lehmann median difference: 39.5 s, 95% CI: 25.0 to 54.0 s, p = 0.0004). CONCLUSIONS The use of the Flowable was more effective in achieving hemostasis, reducing blood loss, and improving survival rates than standard packing in a severe porcine-liver bleeding model.
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Affiliation(s)
- Francisco J Sánchez-Del-Valle
- General and Digestive Unit, Central Hospital of Defense Gómez Ulla, Glorieta del Ejército, 1, Madrid, (28047), Spain.
- University of Alcalá de Henares, Madrid, Spain.
| | - María-Isabel Sánchez-Seco
- General and Digestive Unit, Central Hospital of Defense Gómez Ulla, Glorieta del Ejército, 1, Madrid, (28047), Spain
| | | | | | | | - Juan-José Pérez-Alegre
- General and Digestive Unit, Central Hospital of Defense Gómez Ulla, Glorieta del Ejército, 1, Madrid, (28047), Spain
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Gong J, Hu J, Yan X, Xiang L, Chen S, Yang H, Chen Z, Hou Q, Song Y, Xu Y, Liu D, Ji C, Qin Q, Sun H, Peng J, Cao B, Lu Y. Injectable Hydrogels Including Magnetic Nanosheets for Multidisciplinary Treatment of Hepatocellular Carcinoma via Magnetic Hyperthermia. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2300733. [PMID: 37452437 DOI: 10.1002/smll.202300733] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/03/2023] [Indexed: 07/18/2023]
Abstract
Relapse and unresectability have become the main obstacle for further improving hepatocellular carcinoma (HCC) treatment effect. Currently, single therapy for HCC in clinical practice is limited by postoperative recurrence, intraoperative blood loss and poor patient outcomes. Multidisciplinary therapy has been recognized as the key to improving the long-term survival rate for HCC. However, the clinical application of HCC synthetic therapy is restricted by single functional biomaterials. In this study, a magnetic nanocomposite hydrogel (CG-IM) with iron oxide nanoparticle-loaded mica nanosheets (Iron oxide nanoparticles@Mica, IM) is reported. This biocompatible magnetic hydrogel integrated high injectability, magnetocaloric property, mechanical robustness, wet adhesion, and hemostasis, leading to efficient HCC multidisciplinary therapies including postoperative tumor margin treatment and percutaneous locoregional ablation. After minimally invasive hepatectomy of HCC, the CG-IM hydrogel can facilely seal the bleeding hepatic margin, followed by magnetic hyperthermia ablation to effectively prevent recurrence. In addition, CG-IM hydrogel can inhibit unresectable HCC by magnetic hyperthermia through the percutaneous intervention under ultrasound guidance.
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Affiliation(s)
- Jinyu Gong
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Jinlong Hu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Xu Yan
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Luyao Xiang
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Sheng Chen
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Huai Yang
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Zichao Chen
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Qingbing Hou
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Yonghong Song
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
| | - Yunjun Xu
- Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230036, P. R. China
| | - Dongquan Liu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Chaofei Ji
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Qin Qin
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Haiyi Sun
- The First Clinical College, Anhui Medical University, Hefei, 230022, P. R. China
| | - Junbin Peng
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Baoqiang Cao
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, 230041, P. R. China
| | - Yang Lu
- Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, School of Chemistry and Chemical Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, P. R. China
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D'Amico F, Fominskiy EV, Turi S, Pruna A, Fresilli S, Triulzi M, Zangrillo A, Landoni G. Intraoperative hypotension and postoperative outcomes: a meta-analysis of randomised trials. Br J Anaesth 2023; 131:823-831. [PMID: 37739903 DOI: 10.1016/j.bja.2023.08.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Intraoperative hypotension is associated with adverse postoperative outcomes; however these findings are supported only by observational studies. The aim of this meta-analysis of randomised trials was to compare the postoperative effects permissive management with targeted management of intraoperative blood pressure. METHODS We searched PubMed, Cochrane, and Embase up to June 2023 for studies comparing permissive (mean arterial pressure ≤60 mm Hg) with targeted (mean arterial pressure >60 mm Hg) intraoperative blood pressure management. Primary outcome was all-cause mortality at the longest follow-up available. Secondary outcomes were atrial fibrillation, myocardial infarction, acute kidney injury, delirium, stroke, number of patients requiring transfusion, time on mechanical ventilation, and length of hospital stay. RESULTS We included 10 randomised trials including a total of 9359 patients. Mortality was similar between permissive and targeted blood pressure management groups (89/4644 [1.9%] vs 99/4643 [2.1%], odds ratio 0.88, 95% confidence interval [CI], 0.65-1.18, P=0.38, I2=0% with nine studies included). Atrial fibrillation (102/3896 [2.6%] vs 130/3887 [3.3%] odds ratio 0.71, 95% CI 0.53-0.96, P=0.03, I2=0%), and length of hospital stay (mean difference -0.20 days, 95% CI -0.26 to -0.13, P<0.001, I2=0%) were reduced in the permissive management group. No significant differences were found in subgroup analysis for cardiac and noncardiac surgery. CONCLUSION Pooled randomised evidence shows that a target intraoperative mean arterial pressure ≤60 mm Hg is not associated with increased mortality; nevertheless it is surprisingly associated with a reduced rate of atrial fibrillation and of length of hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023393725.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny V Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Triulzi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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8
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Junger H, Mühlbauer M, Brennfleck FW, Schurr LA, Goetz M, Eggenhofer E, Kirchner G, Evert K, Fichtner-Feigl S, Geissler EK, Schlitt HJ, Brunner SM. Early γGT and bilirubin levels as biomarkers for regeneration and outcomes in damaged bile ducts after liver transplantation. Clin Transplant 2023; 37:e14880. [PMID: 36522802 DOI: 10.1111/ctr.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 10/25/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Early patient and allograft survival after liver transplantation (LT) depend primarily on parenchymal function, but long-term allograft success relies often on biliary-tree function. We examined parameters related to cholangiocyte damage that predict poor long-term LT outcomes after donation after brain death (DBD). METHODS Sixty bile ducts (BD) were assessed by a BD damage-score and divided into groups with "major" BD-damage (n = 33) and "no relevant" damage (n = 27) during static cold storage. Patients with "major" BD damage were further investigated by measuring biliary excretion parameters in the first 14 days post-LT (followed-up for 60-months). RESULTS Patients who received LT showing "major" BD damage had significantly worse long-term patient survival, versus grafts with "no relevant" damage (p = .03). When "major" BD damage developed, low bilirubin levels (p = .012) and high gamma-glutamyl transferase (GGT)/bilirubin ratio (p = .0003) were evident in the early post-LT phase (7-14 days) in patients who survived (> 60 months), compared to those who did not. "High risk" patients with bile duct damage and low GGT/bilirubin ratio had significantly shorter overall survival (p < .0001). CONCLUSIONS Once "major" BD damage occurs, a high GGT/bilirubin ratio in the early post-operative phase is likely indicator of liver and cholangiocyte regeneration, and thus a harbinger of good overall outcomes. "Major" BD damage without markers of regeneration identifies LT patients that could benefit from future repair therapies.
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Affiliation(s)
- Henrik Junger
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Marco Mühlbauer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Frank W Brennfleck
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Leonhard A Schurr
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Goetz
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Elke Eggenhofer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Gabriele Kirchner
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Katja Evert
- Department of Pathology, University Regensburg, Regensburg, Germany
| | - Stefan Fichtner-Feigl
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Edward K Geissler
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany.,Fraunhofer Institute for Experimental Medicine and Toxicology, Regensburg, Germany
| | - Hans J Schlitt
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Stefan M Brunner
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
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Martel G, Lenet T, Wherrett C, Carrier FM, Monette L, Workneh A, Brousseau K, Ruel M, Chassé M, Collin Y, Vandenbroucke-Menu F, Hamel-Perreault É, Perreault MA, Park J, Lim S, Maltais V, Leung P, Gilbert RWD, Segedi M, Abou-Khalil J, Bertens KA, Balaa FK, Ramsay T, Fergusson DA. Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:38. [PMID: 36653812 PMCID: PMC9848035 DOI: 10.1186/s13063-022-07008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.
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Affiliation(s)
- Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tori Lenet
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christopher Wherrett
- Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON Canada
| | - François-Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
- Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Leah Monette
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Karine Brousseau
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Monique Ruel
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Michaël Chassé
- Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Yves Collin
- Division of General Surgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Franck Vandenbroucke-Menu
- Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Department of Surgery - Centre Hospitalier de l’Université de Montréal, Montréal, QC Canada
| | - Élodie Hamel-Perreault
- Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Michel-Antoine Perreault
- Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Jeieung Park
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Shirley Lim
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Véronique Maltais
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Philemon Leung
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Richard W. D. Gilbert
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Maja Segedi
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A. Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Fady K. Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Dean A. Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
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Fang Y, Liu Z, Wang H, Luo X, Xu Y, Chan HF, Lv S, Tao Y, Li M. Implantable Sandwich-like Scaffold/Fiber Composite Spatiotemporally Releasing Combretastatin A4 and Doxorubicin for Efficient Inhibition of Postoperative Tumor Recurrence. ACS APPLIED MATERIALS & INTERFACES 2022; 14:27525-27537. [PMID: 35687834 DOI: 10.1021/acsami.2c02103] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Tumor recurrence is a critical conundrum in the postoperative therapy, on account of severe bleeding with disseminated tumor cells, residual tumor cells, and the rich nutrient and oxygen supply transported to tumors by the abundant blood vessels. Biodegradable drug-loaded implants, inserted in the resection cavity right away upon the surgery, possess bleeding prevention and efficient chemotherapeutic capabilities, considered to be a promising strategy to efficiently inhibit the recurrence of the solid tumor. Here, we developed a sandwich-like composite consisting of the combretastatin A4 (CA4)-loaded 3D-printed scaffold and doxorubicin (DOX)-loaded electrospun fiber (Scaffold-CA4@Fiber-DOX), presenting hemostatic, chemotherapeutic, and antibacterial potencies. The lyophilized 3D-printed scaffold with a porous structure rapidly absorbed and clotted the blood cells and disseminated tumor cells to prevent bleeding and tumor metastasis. Subsequently, the preferentially released CA4 from the scaffold disrupted the microtubules of the vascular endothelial cell, resulting in vascular deformation and consequent insufficient nutrient supply to the solid tumor. The sustained release of DOX from the sandwiched electrospun fiber dramatically inhibited the peripheral tumor cell proliferation. This all-in-one multifunctional implant system, combining efficient vascular disruption and chemotherapy, provides a promising strategy for postoperative tumor therapy.
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Affiliation(s)
- Youqiang Fang
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Zheng Liu
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Haixia Wang
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Xing Luo
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Yanteng Xu
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Hon Fai Chan
- Institute for Tissue Engineering and Regenerative Medicine, School of Biomedical Science, The Chinese University of Hong Kong, Hong Kong 999077, China
| | - Shixian Lv
- School of Materials Science and Engineering, Peking University, Beijing 100871, China
| | - Yu Tao
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
| | - Mingqiang Li
- Laboratory of Biomaterials and Translational Medicine, Center for Nanomedicine, Department of Urology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510630, China
- Guangdong Provincial Key Laboratory of Liver Disease, Guangzhou 510630, China
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11
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Yan X, Sun T, Song Y, Peng W, Xu Y, Luo G, Li M, Chen S, Fang WW, Dong L, Xuan S, He T, Cao B, Lu Y. In situ Thermal-Responsive Magnetic Hydrogel for Multidisciplinary Therapy of Hepatocellular Carcinoma. NANO LETTERS 2022; 22:2251-2260. [PMID: 35254836 DOI: 10.1021/acs.nanolett.1c04413] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Current surgical single modality treatments for hepatocellular carcinoma (HCC) were restricted by recurrence, blood loss, significant trauma, and poor prognostic. Although multidisciplinary strategies for HCC treatment have been highly recommended by the clinical guidelines, there was limited choice of materials and treatments. Herein, we reported an in situ formed magnetic hydrogel with promising bioapplicable thermal-responsiveness, strong adhesion in wet conditions, high magnetic hyperthermia, and biocompatibility, leading to efficient HCC multidisciplinary treatment including postoperative treatment and transarterial embolization therapy. In vivo results indicated that this hydrogel could reduce the postoperative recurrence rate. The hemostatic ability of the thermal-responsive hydrogel was further demonstrated in both the liver scratch model and liver tumor resection. Computed tomography imaging suggested that the hydrogel could completely embolize the arterial vessels of rabbit liver tumor by vascular intervention operation, which could serve as multidisciplinary responsive materials to external magnetic field and body temperature for HCC treatment.
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Affiliation(s)
- Xu Yan
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
| | - Tianci Sun
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
| | - Yonghong Song
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
| | - Wei Peng
- Department of General Surgery, Department of Interventional Radiology, Anhui No.2 Provincial People's Hospital, Hefei, 230041, China
| | - Yunjun Xu
- Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Department of Modern Mechanics, University of Science and Technology of China, Hefei, Anhui 230036, China
| | - Guangyi Luo
- Department of General Surgery, Department of Interventional Radiology, Anhui No.2 Provincial People's Hospital, Hefei, 230041, China
| | - Min Li
- Department of General Surgery, Department of Interventional Radiology, Anhui No.2 Provincial People's Hospital, Hefei, 230041, China
| | - Sheng Chen
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
| | - Wei-Wei Fang
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
| | - Liang Dong
- Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Department of Modern Mechanics, University of Science and Technology of China, Hefei, Anhui 230036, China
| | - Shouhu Xuan
- Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Department of Modern Mechanics, University of Science and Technology of China, Hefei, Anhui 230036, China
| | - Tao He
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
| | - Baoqiang Cao
- Department of General Surgery, Department of Interventional Radiology, Anhui No.2 Provincial People's Hospital, Hefei, 230041, China
| | - Yang Lu
- School of Chemistry and Chemical Engineering, Anhui Province Key Laboratory of Advanced Catalytic Materials and Reaction Engineering, Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui 230009, People's Republic of China
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12
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Karanicolas PJ, Lin Y, McCluskey S, Roke R, Tarshis J, Thorpe KE, Ball CG, Chaudhury P, Cleary SP, Dixon E, Eeson G, Moulton CA, Nanji S, Porter G, Ruo L, Skaro AI, Tsang M, Wei AC, Guyatt G. Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial. BMJ Open 2022; 12:e058850. [PMID: 35210348 PMCID: PMC8883280 DOI: 10.1136/bmjopen-2021-058850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched. METHODS AND ANALYSIS This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival. ETHICS AND DISSEMINATION This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT02261415.
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Affiliation(s)
- Paul Jack Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Roke
- Department of Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Chad G Ball
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, Québec, Canada
| | - Sean P Cleary
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elijah Dixon
- Department of Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gareth Eeson
- Department of Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Carol-Anne Moulton
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Geoff Porter
- Department of Surgery, Nova Scotia Health, Halifax, Nova Scotia, Canada
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Leyo Ruo
- Department of Surgery, Juravinski Hospital and Cancer Centre, Hamilton, Ontario, Canada
- Deparment of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anton I Skaro
- Department of Surgery, London Health Sciences Centre, London, Ontario, Canada
- Department of Surgery, University of Western Ontario Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Melanie Tsang
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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13
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Cherkasov GE, Solovyeva IN, Bagmet NN. [Perioperative risk factors of bleeding in extensive liver resections]. Khirurgiia (Mosk) 2021:27-33. [PMID: 34786913 DOI: 10.17116/hirurgia202111127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To study the risk factors of severe blood loss in extensive liver resections, consequences of hemorrhagic problems and their correction. MATERIAL AND METHODS The study included 374 patients. Group 1 comprised 282 patients (118 men and 164 women aged 54.1±0.7 years) who underwent surgery between 2000 and 2012. Group 2 included 92 patients (34 women and 58 men aged 53.6±1.3 years) operated on for the period 2013-2019. RESULTS Technical equipment for mobilization and dissection of hepatic parenchyma has fundamentally changed for the period 2013-2019. This processes reduced blood loss by more 50% and consumption of donor blood components (red blood cells by 2.8 times, FFP by 1.8 times). Compression of hepatoduodenal ligament (Pringle maneuver) and tumor type did not affect intraoperative blood loss. Neoplasms over 10 cm increased blood loss. An increase in the number of resected segments by 2 times contributed to increase of blood loss by 2.7 times. Body mass index >25 kg/m2 was also associated with higher blood loss.
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Affiliation(s)
- G E Cherkasov
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - I N Solovyeva
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky National Research Center of Surgery, Moscow, Russia
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14
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Yan J, Wang Y, Li X, Guo D, Zhou Z, Bai G, Li J, Huang N, Diao J, Li Y, He W, Liu W, Tao K. A Bionic Nano-Band-Aid Constructed by the Three-Stage Self-Assembly of Peptides for Rapid Liver Hemostasis. NANO LETTERS 2021; 21:7166-7174. [PMID: 34448590 DOI: 10.1021/acs.nanolett.1c01800] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Critical challenges remain in trauma emergency and surgical procedures involving liver bleeding, particularly in perforating wounds that cannot be pressed and large wounds that cannot be sewn. Self-assembling peptide hydrogels are particularly attractive due to their intrinsic biocompatibility and programmability. Herein, we develop a nano-band-aid (NBA) through a three-stage self-assembly strategy of two functionalized peptides, which were first coassembled into nanofibers and then woven to a meshlike network driven by Ca2+. Then, catalyzed by blood coagulation factor XIIIa (FXIIIa), NBA underwent a third stage, self-assembly into a densely compacted physical barrier to stop and control the bleeding. As expected, NBA rapidly and efficiently stopped the bleeding in rat liver scratches while effectively reducing the inflammation around the wound and promoting the wound healing. This bionic self-assembly strategy will provide a clinically potential peptide-based treatment for fatal liver bleeding and reinvigorate efforts to develop self-assembling peptide hydrogels as hemostatic agents.
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Affiliation(s)
- Jin Yan
- National & Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, PR China
- Institute for Stem Cell & Regenerative Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Yang Wang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Xiao Li
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Dongnan Guo
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Zhengjun Zhou
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Ge Bai
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Jianhui Li
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Na Huang
- Core Research Laboratory, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Jiajie Diao
- Department of Cancer Biology, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, United States
| | - Yong Li
- Xijing 986 Hospital Department, Fourth Military Medical University, Xi'an 710032, China
| | - Wangxiao He
- Institute for Stem Cell & Regenerative Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
- Department of Talent Highland, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Wenjia Liu
- Institute for Stem Cell & Regenerative Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004, China
| | - Kaishan Tao
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
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15
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Sim JH, Kim SH, Jun IG, Kang SJ, Kim B, Kim S, Song JG. The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study. Cancers (Basel) 2021; 13:cancers13112508. [PMID: 34063772 PMCID: PMC8196581 DOI: 10.3390/cancers13112508] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/05/2021] [Accepted: 05/17/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown. METHODS This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI. RESULTS The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004). CONCLUSIONS Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.
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Affiliation(s)
- Ji Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Sa-Jin Kang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Seonok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
- Correspondence: ; Tel.: +82-2-3010-3869; Fax: +82-2-3010-6790
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Khajeh E, Shafiei S, Al-Saegh SAH, Ramouz A, Hammad A, Ghamarnejad O, Al-Saeedi M, Rahbari N, Reissfelder C, Mehrabi A, Probst P, Oweira H. Meta-analysis of the effect of the pringle maneuver on long-term oncological outcomes following liver resection. Sci Rep 2021; 11:3279. [PMID: 33558606 PMCID: PMC7870962 DOI: 10.1038/s41598-021-82291-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
Hepatic pedicle clamping reduces intraoperative blood loss and the need for transfusion, but its long-term effect on survival and recurrence remains controversial. The aim of this meta-analysis was to evaluate the effect of the Pringle maneuver (PM) on long-term oncological outcomes in patients with primary or metastatic liver malignancies who underwent liver resection. Literature was searched in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (via PubMed), and Web of Science databases. Survival was measured as the survival rate or as a continuous endpoint. Pooled estimates were represented as odds ratios (ORs) using the Mantel-Haenszel test with a random-effects model. The literature search retrieved 435 studies. One RCT and 18 NRS, including 7480 patients who underwent liver resection with the PM (4309 cases) or without the PM (3171 cases) were included. The PM did not decrease the 1-year overall survival rate (OR 0.86; 95% CI 0.67-1.09; P = 0.22) or the 3- and 5-year overall survival rates. The PM did not decrease the 1-year recurrence-free survival rate (OR 1.06; 95% CI 0.75-1.50; P = 0.75) or the 3- and 5-year recurrence-free survival rates. There is no evidence that the Pringle maneuver has a negative effect on recurrence-free or overall survival rates.
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Affiliation(s)
- Elias Khajeh
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Saeed Shafiei
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Sadeq Ali-Hasan Al-Saegh
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ali Ramouz
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ahmed Hammad
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Omid Ghamarnejad
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Nuh Rahbari
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Arianeb Mehrabi
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany.
| | - Pascal Probst
- Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Hani Oweira
- Department of Surgery, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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17
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Lim RHG, Liew JXK, Wee A, Masilamani J, Chang SKY, Phan TT. Safety Evaluation of Human Cord-Lining Epithelial Stem Cells Transplantation for Liver Regeneration in a Porcine Model. Cell Transplant 2021; 29:963689719896559. [PMID: 32166974 PMCID: PMC7444229 DOI: 10.1177/0963689719896559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We investigated the safety of using umbilical cord-lining stem cells for liver regeneration and tested a novel method for stem cell delivery. Stem cells are known by their ability to repair damaged tissues and have the potential to be used as regenerative therapies. The umbilical cord's outer lining membrane is known to be a promising source of multipotent stem cells and can be cultivated in an epithelial cell growth medium to produce cell populations which possess the properties of both epithelial cells and embryonic stem cells-termed cord-lining epithelial cells (CLEC). Hepatocytes are epithelial cells of the liver and their proliferation upon injury is the main mechanism in restoring the liver. Earlier studies conducted showed CLEC can be differentiated into functioning hepatocyte-like cells (HLC) and can survive in immunologically competent specimens. In this study, we chose a porcine model to investigate CLEC as a treatment modality for liver failure. We selected 16 immune competent Yorkshire-Dutch Landrace pigs, with a mean weight of 40.5 kg, for this study. We performed a 50% hepatectomy to simulate the liver insufficient disease model. After the surgery, four pigs were transplanted with a saline scaffold while seven pigs were transplanted with a HLC scaffold. Five pigs died on the surgical table and were omitted from the study analysis. This study addressed the safety of transplanting human CLEC in a large animal model. The transplant interfaces were evaluated and no signs of cellular rejection were observed in both groups.
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Affiliation(s)
| | | | - Aileen Wee
- Department of Pathology, Singapore National University Hospital, Singapore
| | | | - Stephen Kin Yong Chang
- Department of Surgery, Singapore National University Hospital, Singapore.,Glad Clinic Pte. Ltd, Singapore
| | - Toan Thang Phan
- Department of Surgery, Singapore National University Hospital, Singapore.,CellResearch Corporation Pte. Ltd, Singapore
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18
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Bos S, van den Boom B, Ow T, Prachalias A, Adelmeijer J, Phoolchund A, Dunsire F, Milan Z, Roest M, Heaton N, Bernal W, Lisman T. Efficacy of pro- and anticoagulant strategies in plasma of patients undergoing hepatobiliary surgery. J Thromb Haemost 2020; 18:2840-2851. [PMID: 33124784 PMCID: PMC7693071 DOI: 10.1111/jth.15060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND In vitro efficacy of pro- and antihemostatic drugs is profoundly different in patients with compensated cirrhosis and in those who have cirrhosis and are critically ill. OBJECTIVES Here we assessed the efficacy of pro- and anticoagulant drugs in plasma of patients undergoing hepato-pancreato-biliary (HPB) surgery, which is associated with unique hemostatic changes. METHODS We performed in vitro analyses on blood samples of 60 patients undergoing HPB surgery and liver transplantation: 20 orthotopic liver transplantations, 20 partial hepatectomies, and 20 pylorus-preserving pancreaticoduodenectomies. We performed thrombin generation experiments before and after in vitro addition of fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), recombinant factor VIIa (rFVIIa), low molecular weight heparin (LMWH), unfractionated heparin, dabigatran, and rivaroxaban. RESULTS We showed that patients undergoing HPB surgery are in a hypercoagulable state by thrombin generation testing. FFP and rFVIIa had minimal effects on thrombin generation, whereas PCC had a more pronounced procoagulant effect in patients compared with controls. Dabigatran showed a more pronounced anticoagulant effect in patients compared with controls, whereas rivaroxaban and LMWH had a decreased anticoagulant effect in patients. CONCLUSION We demonstrate profoundly altered in vitro efficacy of commonly used anticoagulants, in patients undergoing HPB surgery compared with healthy controls, which may have implications for anticoagulant dosing in the early postoperative period. In the correction of perioperative bleeding complications, PCCs appear much more potent than FFP or rFVIIa, and PCCs may require conservative dosing and caution in use in patients undergoing HPB surgery.
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Affiliation(s)
- Sarah Bos
- Department of Internal MedicineUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Bente van den Boom
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver transplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Tsai‐Wing Ow
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
| | - Andreas Prachalias
- Liver Transplant SurgeryInstitute of Liver StudiesKings College HospitalLondonUK
| | - Jelle Adelmeijer
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver transplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Anju Phoolchund
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
| | - Fraser Dunsire
- Anesthetics DepartmentInstitute of Liver studiesKings College Hospital LondonLondonUK
| | - Zoka Milan
- Anesthetics DepartmentInstitute of Liver studiesKings College Hospital LondonLondonUK
| | - Mark Roest
- Synapse Research InstituteCardiovascular Research Institute MaastrichtMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Nigel Heaton
- Liver Transplant SurgeryInstitute of Liver StudiesKings College HospitalLondonUK
| | - William Bernal
- Liver Intensive Care UnitInstitute of Liver StudiesKing College HospitalLondonUK
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver transplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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19
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Arshad F, Lisman T, Porte RJ. Blood Markers of Portal Hypertension Are Associated with Blood Loss and Transfusion Requirements during Orthotopic Liver Transplantation. Semin Thromb Hemost 2020; 46:751-756. [PMID: 32757181 DOI: 10.1055/s-0040-1714202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
There is increasing evidence that portal hypertension plays a major role in bleeding risk during orthotopic liver transplantation (OLT). We investigated the association between preoperative blood levels of von Willebrand factor (VWF) and soluble CD163 (sCD163), which are established markers of portal hypertension, and blood loss and transfusion requirements during OLT. We measured levels of VWF and sCD163 in preoperative serum samples of 168 adult patients undergoing a primary OLT between 1998 and 2012. Preoperative levels of VWF and sCD163 correlated with the model of end-stage liver disease (MELD) score (r = 0.414, p < 0.001 and r = 0.382, p < 0.001, respectively). Patients with high VWF or sCD163 levels (VWF and sCD163 levels above the median) had a substantially increased risk of needing red blood cell transfusion compared with patients with low VWF or sCD163 levels (VWF and sCD163 levels below the median) (odds ratio 3.5 [95% confidence interval, CI 1.7-7.0] and 2.3 [95% CI 1.1-4.5], respectively). Blood loss was highest in patients with both high VWF or sCD163 levels and a high preoperative international normalized ratio. Elevated blood levels of markers of portal hypertension are associated with increased blood loss and transfusion requirements during OLT and support the notion that portal hypertension is an important contributor to perioperative blood loss.
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Affiliation(s)
- Freeha Arshad
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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20
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Cherkasov GE, Bagmet NN, Solovyeva IN, Shatveryan GA. [Blood-saving technologies in extensive liver resections]. Khirurgiia (Mosk) 2020:111-118. [PMID: 32736475 DOI: 10.17116/hirurgia2020071111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The researches devoted to blood-saving technologies in extensive liver resections are analyzed in the manuscript. Resection of three and more liver segments is effective method of surgical treatment of various focal liver lesions. Surgical (anatomical resection with hilar glissonean access, Pringle maneuver, modern technical equipment, etc.), anesthesiological (reduction of central venous pressure, hemostatic agents) and transfusion (autologous blood donation, transfusion, cell saver, etc.) methods contribute to prevention and reduction of blood loss. Intraoperative measures for blood loss prevention should include adequate surgical incision and liver mobilization, precise techniques of parenchymal dissection (for example, cavitation surgical aspirator-destructor), use of clip applicators and local or systemic hemostatic agents.
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Affiliation(s)
- G E Cherkasov
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - I N Solovyeva
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
| | - G A Shatveryan
- Petrovsky Russian Research Center of Surgery, Moscow, Russia
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21
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Neuberger J, Patel J, Caldwell H, Davies S, Hebditch V, Hollywood C, Hubscher S, Karkhanis S, Lester W, Roslund N, West R, Wyatt JI, Heydtmann M. Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology. Gut 2020; 69:1382-1403. [PMID: 32467090 PMCID: PMC7398479 DOI: 10.1136/gutjnl-2020-321299] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.
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Affiliation(s)
- James Neuberger
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jai Patel
- Department of Vascular Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Helen Caldwell
- Liver Unit, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Susan Davies
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Coral Hollywood
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Stefan Hubscher
- Department of Pathology, University of Birmingham, Birmingham, UK
| | - Salil Karkhanis
- Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Judith I Wyatt
- Department of Pathology, St James University Hospital, Leeds, UK
| | - Mathis Heydtmann
- Department of Gastroenterology, Royal Alexandra Hospital, Glasgow, UK
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22
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Amaral B, Vicente M, Pereira CSM, Araújo T, Ribeiro A, Pereira R, Perdigoto R, Marcelino P. Approach to the liver transplant early postoperative period: an institutional standpoint. Rev Bras Ter Intensiva 2020; 31:561-570. [PMID: 31967233 PMCID: PMC7009000 DOI: 10.5935/0103-507x.20190076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 03/04/2019] [Indexed: 12/16/2022] Open
Abstract
The liver transplant program in our center started in 1992, and post-liver transplant patients are still admitted to the intensive care unit. For the intensive care physician, a learning curve started then, skills were acquired, and a specific practice was established. Throughout this time, several concepts changed, improving the care of these patients. The practical approach varies between liver transplant centers, according to local specificities. Hence, we wanted to present our routine practice to stimulate the debate between dedicated teams, which can allow the introduction of new ideas and potentially improve each local standard of care.
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Affiliation(s)
- Beatriz Amaral
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Madalena Vicente
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | | | - Teresa Araújo
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Ana Ribeiro
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Pereira
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Perdigoto
- Unidade de Transplante Hepático, Hospital Curry Cabral - Lisboa, Portugal
| | - Paulo Marcelino
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
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23
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Haemostatic Efficacy of Topical Agents During Liver Resection: A Network Meta-Analysis of Randomised Trials. World J Surg 2020; 44:3461-3469. [PMID: 32488664 DOI: 10.1007/s00268-020-05621-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hepatic resection carries a high risk of parenchymal bleeding both intra- and post-operatively. Topical haemostatic agents are frequently used to control bleeding during hepatectomy, with multiple products currently available. However, it remains unknown which of these is most effective for achieving haemostasis and improving peri-operative outcomes. METHODS A systematic review and random-effects Bayesian network meta-analysis of randomised trials investigating topical haemostatic agents in hepatic resection was performed. Interventions were analysed by grouping into similar products; fibrin patch, fibrin glue, collagen products, and control. Primary outcomes were the rate of haemostasis at 4 and 10 min. RESULTS Twenty randomized controlled trials were included in the network meta-analysis, including a total of 3267 patients and 7 different interventions. Fibrin glue and fibrin patch were the most effective interventions for achieving haemostasis at both 4 and 10 min. There were no significant differences between haemostatic agents with respect to blood loss, transfusion requirements, bile leak, post-operative complications, reoperation, or mortality. CONCLUSIONS Amongst the haemostatic agents currently available, fibrin patch and fibrin glue are the most effective methods for reducing time to haemostasis during liver resection, but have no effect on other peri-operative outcomes. Topical haemostatic agents should not be used routinely, but may be a useful adjunct to achieve haemostasis when needed.
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24
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Lekerika Royo N, Martinez Ruiz A, Arco Vázquez J, Gutierrez Rico RM, Prieto Molano L, Arana Arri E, Valdivieso Lopez A. Transfusional optimization in liver transplant using viscoelastic test guided therapy. ACTA ACUST UNITED AC 2020; 67:292-300. [PMID: 32439229 DOI: 10.1016/j.redar.2020.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/30/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Assess the reduction of packed red blood cells (PRBCs) transfusion in liver transplantation (LT) after the introduction of the thromboelastometry as intraoperative coagulation monitor. METHODS We conducted a retrospective cohort study (n=92), randomized into two groups: groupA (control), in whom transfusion therapy was based on conventional laboratory tests (CLT), and groupB (ROTEM), whose blood transfusion was performed as protocolized algorithms, guided by thromboelastometry (ROTEM). We analyzed packed red blood cells (PRBCs) units, transfused units of fresh frozen plasma (FFP), platelets units, fibrinogen and tranexamic acid. We used the chi square test for the comparison of proportions and Student's t test to compare means when the distribution was normal. Otherwise, Mann-Whitney U test was performed. RESULTS In groupA 84.8% of patients required transfusion of PRBCs, with a median (IQR) of 4 (1.5-6), compared with 67.4% in groupB with a median (IQR) of 2 (0-4) (P<.05). We also found differences in the following variables: FFP transfusion rate was 84.8% with a median (IQR) of 5 (2-12) IU in groupA and 56.5% (median (IQR) of 1 (0-4.5) in B (P<.001) and in the fibrinogen administration, that was 6.5% in groupA and 34.8% in groupB (P<.01). Backward stepwise logistic regression model showed associations between the clamping time, the preoperative hemoglobin, the portal hypertension (PHT) and being or not in the treatment group and the need for perioperative transfusion. We didn't find significant differences in the incidence of complication during the early postoperative period between the two groups. CONCLUSIONS The introduction of thromboelastometry (ROTEM) measurements in hemostatic therapy algorithms reduces the transfusion rate of FFP and PRBCs during liver transplantation. The using of ROTEM derived thresholds leads to detecting higher requirements of fibrinogen compared to conventional laboratory tests.
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Affiliation(s)
- N Lekerika Royo
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España.
| | - A Martinez Ruiz
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - J Arco Vázquez
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - R M Gutierrez Rico
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - L Prieto Molano
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - E Arana Arri
- Unidad de Epidemiología Clínica, BioCruces Health Research Institute, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - A Valdivieso Lopez
- Unidad de Cirugía Hepatobiliar y Trasplante Hepático, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
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25
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Park L, Gilbert R, Baker L, Shorr R, Workneh A, Turcotte S, Bertens KA, Abou-Khalil J, Balaa FK, Martel G. The safety and efficacy of hypovolemic phlebotomy on blood loss and transfusion in liver surgery: a systematic review and meta-analysis. HPB (Oxford) 2020; 22:340-350. [PMID: 31734240 DOI: 10.1016/j.hpb.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7-10 mL/kg) without volume replacement. The subsequent central venous pressure (CVP) reduction is hypothesized to decrease blood loss and the need for blood transfusion. The objective was to conduct a systematic assessment of the safety and efficacy of HP on blood loss and transfusion in the liver surgery literature. METHODS MEDLINE, EMBASE, and Cochrane Library databases were searched. Outcomes of interest included blood loss, allogenic red blood cell transfusion, postoperative adverse events, and CVP change. A qualitative synthesis and meta-analysis were performed as appropriate. RESULTS Four cohort studies, one case series, and three randomized controlled trials involving 2255 patients were included. Meta-analysis of studies involving liver resections for any indication (n = 6) found no difference in transfusion (OR 0.38, p = 0.12) or incidence of adverse events with HP compared to non-use. Pooling of studies involving liver resections for an underlying pathology (n = 4) revealed HP was associated with significant reduction in transfusion (OR 0.25, p = 0.03) but no differences in blood loss (-173 mL, p = 0.17). CONCLUSION This review suggests HP is safe and associated with decreased transfusion in patients undergoing liver surgery. It supports further investigation.
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Affiliation(s)
- Lily Park
- Faculty of Medicine, University of Ottawa, Canada
| | - Richard Gilbert
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Laura Baker
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada
| | - Simon Turcotte
- Hepatopancreatobiliary and Liver Transplantation Division, Centre hospitalier de l'Université de Montréal, Canada
| | - Kimberley A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Canada.
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26
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Martel G, Baker L, Wherrett C, Fergusson DA, Saidenberg E, Workneh A, Saeed S, Gadbois K, Jee R, McVicar J, Rao P, Thompson C, Wong P, Abou Khalil J, Bertens KA, Balaa FK. Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility. Br J Surg 2020; 107:812-823. [PMID: 31965573 DOI: 10.1002/bjs.11463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/28/2019] [Accepted: 11/15/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial. METHODS Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL). RESULTS A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326). CONCLUSION Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - L Baker
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - C Wherrett
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - D A Fergusson
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - E Saidenberg
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - A Workneh
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Saeed
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K Gadbois
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - R Jee
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J McVicar
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Rao
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - C Thompson
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Wong
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Abou Khalil
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - K A Bertens
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - F K Balaa
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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Mangieri CW, Strode MA, Bandera BC. Improved hemostasis with major hepatic resection in the current surgical era. Hepatobiliary Pancreat Dis Int 2019; 18:439-445. [PMID: 31307940 DOI: 10.1016/j.hbpd.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 07/02/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Major hepatic resection, predominantly performed for oncologic intent, is a complex procedure with the potential for severe intraoperative hemorrhage. The current surgical era has the ability to improve hemostasis throughout the performance of major hepatic resections which decreases blood transfusions and the detrimental effects associated with transfusion. We evaluated hemostasis and outcomes in the current surgical era of performing hepatic resections. METHODS Utilizing the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database all major hepatic resections performed between 2012 and 2016 were analyzed in regards to hemostasis. Hemostasis was evaluated by the need for and magnitude of blood transfusions. Additional perioperative variables (including operative time, length of hospital stay, and mortality rates) were analyzed to assess for outcomes with hemostasis. The NSQIP results were compared to previous publications involving major hepatic resections to detect improvement in hemostasis and outcomes in the current surgical era. RESULTS A total of 22777 major hepatic resections met the inclusion criteria for analysis in the NSQIP database. An additional 21198 cases were compiled within the selected publications for comparative analysis. The transfusion rate in the current surgical era was 13.3% versus 38.7% in the previous era (P = 0.0001). When a transfusion was required in the current surgical era there was a two-fold reduction in the number of units transfused (1.5 U vs. 3.8 U, P = 0.0001). Statistically significant improvements in operative time and length of hospital stay were presented within the current surgical era (P = 0.0001). When a transfusion was required there was an increased relative risk score of 7 for mortality (4.9% vs. 0.7%, P = 0.0001), however, improvement in mortality rates did not reach statistical significance across surgical eras (1.3% vs. 4.0%, P = 0.0001). CONCLUSIONS The conduction of major hepatic resection in the current surgical era is more hemostatic. Correlated with improved hemostasis are better outcomes for both clinical and financial endpoints. These findings should encourage continued and increased performance of major hepatic resections.
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Affiliation(s)
- Christopher W Mangieri
- Department of Surgery, Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA 30809, USA.
| | - Matthew A Strode
- Department of Surgery, Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA 30809, USA; Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY 14203, USA
| | - Bradley C Bandera
- Department of Surgery, Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA 30809, USA
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28
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Kempski KM, Wiacek A, Graham M, González E, Goodson B, Allman D, Palmer J, Hou H, Beck S, He J, Bell MAL. In vivo photoacoustic imaging of major blood vessels in the pancreas and liver during surgery. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-12. [PMID: 31411010 PMCID: PMC7006046 DOI: 10.1117/1.jbo.24.12.121905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/22/2019] [Indexed: 05/07/2023]
Abstract
Abdominal surgeries carry considerable risk of gastrointestinal and intra-abdominal hemorrhage, which could possibly cause patient death. Photoacoustic imaging is one solution to overcome this challenge by providing visualization of major blood vessels during surgery. We investigate the feasibility of in vivo blood vessel visualization for photoacoustic-guided liver and pancreas surgeries. In vivo photoacoustic imaging of major blood vessels in these two abdominal organs was successfully achieved after a laparotomy was performed on two swine. Three-dimensional photoacoustic imaging with a robot-controlled ultrasound (US) probe and color Doppler imaging were used to confirm vessel locations. Blood vessels in the in vivo liver were visualized with energies of 20 to 40 mJ, resulting in 10 to 15 dB vessel contrast. Similarly, an energy of 36 mJ was sufficient to visualize vessels in the pancreas with up to 17.3 dB contrast. We observed that photoacoustic signals were more focused when the light source encountered a major vessel in the liver. This observation can be used to distinguish major blood vessels in the image plane from the more diffuse signals associated with smaller blood vessels in the surrounding tissue. A postsurgery histopathological analysis was performed on resected pancreatic and liver tissues to explore possible laser-related damage. Results are generally promising for photoacoustic-guided abdominal surgery when the US probe is fixed and the light source is used to interrogate the surgical workspace. These findings are additionally applicable to other procedures that may benefit from photoacoustic-guided interventional imaging of the liver and pancreas (e.g., biopsy and guidance of radiofrequency ablation lesions in the liver).
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Affiliation(s)
- Kelley M. Kempski
- University of Delaware, Department of Biomedical Engineering, Newark, Delaware, United States
| | - Alycen Wiacek
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Michelle Graham
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Eduardo González
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Bria Goodson
- Delta State University, Department of Biology, Cleveland, Mississippi, United States
| | - Derek Allman
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Jasmin Palmer
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Cambridge, Massachusetts, United States
| | - Huayu Hou
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Sarah Beck
- Johns Hopkins Medicine, Department of Molecular and Comparative Pathobiology, Baltimore, Maryland, United States
| | - Jin He
- Johns Hopkins Medicine, Department of Surgery, Baltimore, Maryland, United States
- Johns Hopkins Medicine, Department of Oncology, Baltimore, Maryland, United States
| | - Muyinatu A. Lediju Bell
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States
- Address all correspondence to Muyinatu A. Lediju Bell, E-mail:
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29
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ELAyashy M, Hosny H, Hussein A, AbdelAal Ahmed Mahmoud A, Mukhtar A, El-Khateeb A, Wagih M, AboulFetouh F, Abdelaal A, Said H, Abdo M. The validity of central venous to arterial carbon dioxide difference to predict adequate fluid management during living donor liver transplantation. A prospective observational study. BMC Anesthesiol 2019; 19:111. [PMID: 31228943 PMCID: PMC6589166 DOI: 10.1186/s12871-019-0776-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the validity of central and pulmonary veno-arterial CO2 gradients to predict fluid responsiveness and to guide fluid management during liver transplantation. METHODS In adult recipients (ASA III to IV) scheduled for liver transplantation, intraoperative fluid management was guided by pulse pressure variations (PPV). PPV of ≥15% (Fluid Responding Status-FRS) indicated fluid resuscitation with 250 ml albumin 5% boluses repeated as required to restore PPV to < 15% (Fluid non-Responding Status-FnRS). Simultaneous blood samples from central venous and pulmonary artery catheters (PAC) were sent to calculate central venous to arterial CO2 gap [C(v-a) CO2 gap] and pulmonary venous to arterial CO2 gap [Pulm(p-a) CO2 gap]. CO and lactate were also measured. RESULTS Sixty seven data points were recorded (20 FRS and 47 FnRS). The discriminative ability of central and pulmonary CO2 gaps between the two states (FRS and FnRS) was poor with AUC of ROC of 0.698 and 0.570 respectively. Central CO2 gap was significantly higher in FRS than FnRS (P = 0.016), with no difference in the pulmonary CO2 gap between both states. The central and Pulmonary CO2 gaps are weakly correlated to PPV [r = 0.291, (P = 0.017) and r = 0.367, (P = 0.002) respectively]. There was no correlation between both CO2 gaps and both CO and lactate. CONCLUSION Central and the Pulmonary CO2 gaps cannot be used as valid tools to predict fluid responsiveness or to guide fluid management during liver transplantation. CO2 gaps also do not correlate well with the changes in PPV or CO. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03123172 . Registered on 31-march-2017.
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Affiliation(s)
- Mohamed ELAyashy
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt
| | - Hisham Hosny
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt. .,Department of Anaesthesia and Intensive care, Royal Brompton Hospital, RBHT, Sydney Street, London, SW3 6NP, UK.
| | - Amr Hussein
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt
| | | | - Ahmed Mukhtar
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt
| | - Amira El-Khateeb
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt.,Department of Anaesthesia and Intensive care, Royal Brompton Hospital, RBHT, Sydney Street, London, SW3 6NP, UK
| | - Mohamed Wagih
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt
| | - Fawzia AboulFetouh
- Department of Anesthesia and Intensive Care, Kasr Al-Ainy Faculty of Medicine, Cairo University, Kasr Al-Ainy Street, Cairo, Egypt
| | - Amr Abdelaal
- Department of Surgery, Ain Shams University, Cairo, Egypt
| | - Hany Said
- Department of Surgery, Ain Shams University, Cairo, Egypt
| | - Mostafa Abdo
- Department of Surgery, Ain Shams University, Cairo, Egypt
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30
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Baker L, Bennett S, Rekman J, Workneh A, Wherrett C, Abou-Khalil J, Bertens KA, Balaa FK, Martel G. Hypovolemic phlebotomy in liver surgery is associated with decreased red blood cell transfusion. HPB (Oxford) 2019; 21:757-764. [PMID: 30501988 DOI: 10.1016/j.hpb.2018.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/25/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis. METHODS Consecutive patients who underwent liver resection at one institution (2010-2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression. RESULTS A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H2O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068-0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64-5.18, p = 0.0003), preoperative hemoglobin < 125 g/L (OR 6.02, 95% CI 3.44-10.56, p < 0.0001), and underlying liver disease (OR 2.24, 95% CI 1.27-3.95, p = 0.0051) were significantly associated with perioperative RBC transfusion. CONCLUSION Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.
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Affiliation(s)
- Laura Baker
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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31
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Parasar K, Varshney VK, Mishra PK, Saluja SS. Gall Bladder Carcinoma in Patients with Portal Hypertension. Am Surg 2018. [DOI: 10.1177/000313481808401204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kunal Parasar
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
| | - Vaibhav Kumar Varshney
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
| | - Pramod Kumar Mishra
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
| | - Sundeep Singh Saluja
- Department of Gastrointestinal Surgery Govind Ballabh Pant Institute of Post Graduate Medical Education and Research New Delhi, India
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32
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Zhang Z, Kuang G, Zong S, Liu S, Xiao H, Chen X, Zhou D, Huang Y. Sandwich-Like Fibers/Sponge Composite Combining Chemotherapy and Hemostasis for Efficient Postoperative Prevention of Tumor Recurrence and Metastasis. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2018; 30:e1803217. [PMID: 30306650 DOI: 10.1002/adma.201803217] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/10/2018] [Indexed: 05/07/2023]
Abstract
Intraoperative bleeding is an essential factor leading to the earliest recurrence and tumor metastasis frequently seen after resection of solid tumors. Local drug delivery implants show the unique advantages on postoperative cancer therapy. Herein, a sandwich-like cisplatin-loaded fibers/sponge composite (CFSC) combining chemotherapy and hemostasis is constructed. The obtained implantable CFSC is able to simultaneously stop bleeding and absorb disseminated tumor cells after tumor resection. More importantly, sustained released cisplatin can kill local residual tumor cells as well as those concentrated in the CFSC, which significantly inhibits local tumor recurrence and distant tumor metastasis on the subcutaneous postoperative recurrence model and metastasis models. This dual functional implant strategy with low toxicity to healthy organs may inspire new aspects for efficient postoperative cancer therapy.
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Affiliation(s)
- Zhiyun Zhang
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Gaizhen Kuang
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- Department of Gastroenterology, the Second Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an, 710004, P. R. China
| | - Shan Zong
- The First Hospital of Jinlin University, Changchun, 130021, P. R. China
| | - Shi Liu
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Haihua Xiao
- State Key Laboratory of Polymer Physics and Chemistry, Beijing National Laboratory for Molecular Sciences, Institute of Chemistry, Chinese Academy of Sciences, Beijing, 100190, P. R. China
| | - Xuesi Chen
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Dongfang Zhou
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Yubin Huang
- State Key Laboratory of Polymer Physics and Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
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33
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A Systematic Review and Meta-Analysis Comparing Liver Resection with the Rf-Based Device Habib™-4X with the Clamp-Crush Technique. Cancers (Basel) 2018; 10:cancers10110428. [PMID: 30413094 PMCID: PMC6266432 DOI: 10.3390/cancers10110428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/25/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023] Open
Abstract
Liver cancer is the sixth most common cancer and third most common cause of cancer-related mortality. Presently, indications for liver resections for liver cancers are widening, but the response is varied owing to the multitude of factors including excess intraoperative bleeding, increased blood transfusion requirement, post-hepatectomy liver failure and morbidity. The advent of the radiofrequency energy-based bipolar device Habib™-4X has made bloodless hepatic resection possible. The radiofrequency-generated coagulative necrosis on normal liver parenchyma provides a firm underpinning for the bloodless liver resection. This meta-analysis was undertaken to analyse the available data on the clinical effectiveness or outcomes of liver resection with Habib™-4X in comparison to the clamp-crush technique. The RF-assisted device Habib™-4X is considered a safe and feasible modality for liver resection compared to the clamp-crush technique owing to the multitude of benefits and mounting clinical evidence supporting its role as a superior liver resection device. The most intriguing advantage of the RF-device is its ability to induce systemic and local immunomodulatory changes that further expand the boundaries of survival outcomes following liver resection.
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34
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Bjelović M, Ayguasanosa J, Kim RD, Stojanović M, Vereczkei A, Nikolić S, Winslow E, Emre S, Xiao G, Navarro-Puerto J, Courtney K, Barrera G. A Prospective, Randomized, Phase III Study to Evaluate the Efficacy and Safety of Fibrin Sealant Grifols as an Adjunct to Hemostasis as Compared to Cellulose Sheets in Hepatic Surgery Resections. J Gastrointest Surg 2018; 22:1939-1949. [PMID: 29967969 DOI: 10.1007/s11605-018-3852-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Local hemostatic agents have a role in limiting bleeding complications associated with liver resection. METHODS In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T4) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T2, T3, T5, T7, and T10. RESULTS The rate of hemostasis by T4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T2, T5, and T7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%). CONCLUSIONS FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.
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Affiliation(s)
- Miloš Bjelović
- Department for Minimally Invasive Upper Digestive Surgery, Clinical Center of Serbia, Hospital for Digestive Surgery - First Surgical Hospital, Dr Koste Todorovica Street No 66, Belgrade, 11000, Serbia.
| | | | - Robin D Kim
- Division of Transplantation and Advanced Hepatobiliary Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - András Vereczkei
- Department of Surgery, Medical School, University of Pécs, Pécs, Hungary
| | - Srdjan Nikolić
- Clinic of Surgical Oncology, Institute of Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Emily Winslow
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Sukru Emre
- Department of Surgery: Transplant & Immunology, Yale-New Haven Hospital, New Haven, CT, USA
| | - Gary Xiao
- Division of Multi-Organ Transplantation and Hepato-Pancreato-Biliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
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Abstract
Chronic liver disease has been associated with pulmonary dysfunction both before and after liver transplantation. Post-liver transplantation pulmonary complications can affect both morbidity and mortality often necessitating intensive care during the immediate postoperative period. The major pulmonary complications include pneumonia, pleural effusions, pulmonary edema, and atelectasis. Poor clinical outcomes have been known to be associated with age, severity of liver dysfunction, and preexisting lung disease as well as perioperative events related to fluid balance, particularly transfusion and fluid volumes. Delineating each and every one of these pulmonary complications and their associated risk factors becomes paramount in guiding specific therapeutic strategies.
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36
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Bennett S, Ayoub A, Tran A, English S, Tinmouth A, McIsaac DI, Fergusson D, Martel G. Current practices in perioperative blood management for patients undergoing liver resection: a survey of surgeons and anesthesiologists. Transfusion 2018; 58:781-787. [PMID: 29322515 DOI: 10.1111/trf.14465] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/06/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Development of intraoperative techniques and blood management strategies in liver resection, and the multidisciplinary nature of perioperative transfusion decision making, creates an opportunity for practice variation. The aim of this study was to describe the current practices in perioperative blood management and explore differences between surgeons and anesthesiologists. STUDY DESIGN AND METHODS A Web-based survey was developed, piloted, and circulated to Canadian liver surgeons and anesthesiologists. The survey focused on management of preoperative anemia, blood conservation strategies, estimation of blood loss, and transfusion decision making in a multidisciplinary setting. RESULTS A total of 198 physicians received the survey, with 117 responding (59%). Most responding surgeons (67%) perform more than 20 liver resections per year, while most responding anesthesiologists (90%) take part in fewer than 20. Anesthesiologists most commonly stated that preoperative anemia is managed by someone else (38%), while surgeons most commonly reported "no specific treatment" (45%). The most common intraoperative blood conservation technique used is administration of antifibrinolytics (63% used them at least occasionally). The most important factor for anesthesiologists when deciding on an intraoperative transfusion was hemoglobin value (47%); for surgeons, it was patient hemodynamics (33%). Compared to when they started their career, 60% of respondents felt that they were less likely to transfuse a patient now. CONCLUSION The results of our survey provide insights into current transfusion practice and decision making in liver resection, including a comparison between anesthesiologist and surgeon transfusion behavior. Management of preoperative anemia, increased use of intraoperative blood conservation techniques, and improved communication between providers were identified as targets for quality improvement.
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Affiliation(s)
- Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, University of Ottawa, Ontario.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Abdul Ayoub
- Faculty of Medicine, University of Ottawa, Ontario
| | - Alexandre Tran
- Liver and Pancreas Unit, Department of Surgery, University of Ottawa, Ontario.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ontario
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ontario
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa, Ontario
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, University of Ottawa, Ontario.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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37
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Nacoti M, Cazzaniga S, Colombo G, Corbella D, Fazzi F, Fochi O, Gattoni C, Zambelli M, Colledan M, Bonanomi E. Postoperative complications in cirrhotic pediatric deceased donor liver transplantation: Focus on transfusion therapy. Pediatr Transplant 2017; 21. [PMID: 28681471 DOI: 10.1111/petr.13020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 12/28/2022]
Abstract
Intraoperative transfusions seem associated with patient death and graft failure after PLTx. A retrospective analysis of recipients' and donors' characteristics and transplantation data in a cohort of patients undergoing PLTx from 2002 to 2009 at the Bergamo General Hospital was performed. A two-stage hierarchical Cox proportional hazard regression with forward stepwise selection was used to identify the main risk factors for major complications. In addition, propensity score analysis was used to adjust risk estimates for possible selection biases in the use of blood products. Over the 12-year period, 232 pediatric cirrhotic patients underwent PLTx. One-year patient and graft survival rates were 92.3% and 83.7%, respectively. The Kaplan-Meier shows that the main decrease in both graft and patient survival occurs during the first months post-transplantation. At the same time, it appears that most of the complications occur during the first month post-transplantation. One-month and 1-year patient complication-free survival rates were 24.8% and 12.1%, respectively. Our study shows that intraoperative red blood cells and platelet transfusions are independent risk factors for developing one or more major complications in the first year after PLTx. Decreasing major complications will improve the health status and overall long-term patient survival after pediatric PLTx.
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Affiliation(s)
- M Nacoti
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | | | - G Colombo
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - D Corbella
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | - F Fazzi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | - O Fochi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - C Gattoni
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - M Zambelli
- Liver Transplant Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M Colledan
- Liver Transplant Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - E Bonanomi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
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Song JL, Yang J, Yan LN, Yang JY, Wen TF, Li B, Zeng Y, Wu H, Wang WT, Xu MQ, Chen ZY, Wei YG, Jiang L. A new index predicts early allograft dysfunction following living donor liver transplantation: A propensity score analysis. Dig Liver Dis 2017; 49:1225-1232. [PMID: 28750872 DOI: 10.1016/j.dld.2017.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE/AIM The aim of this study was to identify a new index to predict early allograft dysfunction following living donor liver transplantation. METHODS The study enrolled 260 adult living donor liver transplantation recipients. Postoperative laboratory variables were assessed for their association with the prevalence of early allograft dysfunction using the inverse probability of treatment weighting and propensity-score matching (n=93 pairs) analysis. RESULTS Forty-seven recipients (18.1%) developed early allograft dysfunction. In multivariable analysis, the alanine aminotransferase and gamma-glutamyl transpeptidase levels on postoperative day 1 were independent predictors of early allograft dysfunction. The alanine aminotransferase to gamma-glutamyl transpeptidase ratio (AGR) was developed. All cases were divided into two groups (Group 1 [AGR≥8.47, n=103] and Group 2 [AGR<8.47, n=157]). AGR≥8.47 (OR 10.345, 95%CI 4.502-23.772, p<0.001), hepatorenal syndrome (OR 3.016, 95%CI 1.119-8.125, p=0.029), and graft to recipient weight ratio <0.8% (OR 2.155, 95%CI 1.004-4.624, p=0.049) were independent risk factors for early allograft dysfunction. The prevalence of early allograft dysfunction was higher in group 1 (after adjusting for inverse probability of treatment weighting [n=39; 37.9% vs n=8; 5.1%] and propensity-score matching [n=33; 35.5% vs n=2; 2.2%]) than that in group 2 (p<0.001). CONCLUSIONS The postoperative AGR is a practical index for predicting early allograft dysfunction after living donor liver transplantation.
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Affiliation(s)
- Jiu-Lin Song
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jian Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lu-Nan Yan
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jia-Yin Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Tian-Fu Wen
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Li
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yong Zeng
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Hong Wu
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wen-Tao Wang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Ming-Qing Xu
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhe-Yu Chen
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yong-Gang Wei
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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Lisman T, Porte RJ. Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases. Res Pract Thromb Haemost 2017; 1:150-161. [PMID: 30046685 PMCID: PMC6058283 DOI: 10.1002/rth2.12028] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Lisman T, Bernal W. Management of Hemostatic Disorders in Patients With Advanced Liver Disease Admitted to an Intensive Care Unit. Transfus Med Rev 2017; 31:245-251. [DOI: 10.1016/j.tmrv.2017.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/19/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
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Kawasaki S, Origasa H, Tetens V, Kobayashi M. Comparison of TachoSil and TachoComb in patients undergoing liver resection-a randomized, double-blind, non-inferiority trial. Langenbecks Arch Surg 2017; 402:591-598. [PMID: 28365804 PMCID: PMC5437221 DOI: 10.1007/s00423-017-1571-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 02/22/2017] [Indexed: 01/19/2023]
Abstract
Background This study aimed to demonstrate the noninferior efficacy of TachoSil vs. TachoComb in Japanese patients undergoing liver resection and to assess the safety of TachoSil vs. TachoComb in these patients. Methods This randomized, double-blind, noninferiority study (JapicCTI-090684) involved participants scheduled for liver resection/living donors (age ≥ 20 years). TachoSil or TachoComb (1:1 allocation ratio) was applied to control persistent exudative bleeding after primary hemostasis during liver resection/removal for donation. The primary outcome was hemostasis 5 min after study treatment application. The 95% confidence interval (CI) for the difference in the proportion of participants with hemostasis 5 min after application of TachoSil/TachoComb was determined; noninferiority of TachoSil was indicated if the lower limit of the CI was ≥−14%. Adverse events (AEs) were recorded. Results All participants in the efficacy analysis (TachoSil: 54/54, 100%; TachoComb: 54/54, 100%) achieved hemostasis 5 min after study treatment application. Therefore, TachoSil was noninferior to TachoComb. All participants experienced ≥1 AE; however, none discontinued because of an AE. Most (≥97.8%) AEs were mild or moderate in severity. Conclusions These findings confirm the safety profile and noninferior hemostatic efficacy of TachoSil compared with TachoComb.
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Affiliation(s)
- S Kawasaki
- Department of Hepatobiliary Pancreatic Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - H Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama City, Japan
| | - V Tetens
- Clinical Science, Takeda Development Centre Europe Ltd, London, UK
| | - M Kobayashi
- R&D Japan, CSL Behring K.K, 1-7-12 Shinonome, Koto-ku, Tokyo, 135-0062, Japan.
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42
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Ryckx A, Christiaens C, Clarysse M, Vansteenkiste F, Steelant PJ, Sergeant G, Parmentier I, Pottel H, D'Hondt M. Central Venous Pressure Drop After Hypovolemic Phlebotomy is a Strong Independent Predictor of Intraoperative Blood Loss During Liver Resection. Ann Surg Oncol 2017; 24:1367-1375. [PMID: 28054191 DOI: 10.1245/s10434-016-5737-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative hypovolemic phlebotomy (HP) has been suggested to reduce central venous pressure (CVP) before hepatectomy. This study aimed to analyze the impact of CVP drop after HP on intraoperative blood loss and postoperative renal function. METHODS A retrospective review of a prospective database including 100 consecutive patients (43 males and 57 females; mean age, 65 years; range 23-89 years) undergoing liver resection with HP was performed. The primary outcome variable was estimated blood loss (EBL), and the secondary outcome was postoperative serum creatinin (Scr). A multivariate linear regression analysis was performed to identify predictors of intraoperative blood loss. RESULTS The median CVP before blood salvage was 8 mmHg (range 4-30 mmHg). The median volume of hypovolemic phlebotomy was 400 ml (range 200-1000 ml). After HP, CVP decreased to a median of 3 mmHg (range -2 to 16 mmHg), resulting in a median CVP drop of 5.5 mmHg (range 2-14 mmHg). The median EBL during liver resection was 165 ml (range 0-800 ml). The median preoperative serum creatinin (Scr) was 0.82 g/dl (range 0.5-1.74 g/dl), and the postoperative Scr on day 1 was 0.74 g/dl (range 0.44-1.68 g/dl). The CVP drop was associated with EBL (P < 0.001). There was no significant impact of CVP drop on postoperative Scr. CONCLUSION A CVP drop after HP is a strong independent predictor of EBL during liver resection. The authors advocate the routine use of HP to reduce perioperative blood loss and transfusion rates in liver surgery. As a predictive tool, CVP drop might help surgeons decide whether a laparoscopic approach is safe.
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Affiliation(s)
- Andries Ryckx
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Mathias Clarysse
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Franky Vansteenkiste
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Gregory Sergeant
- Department of Abdominal and Hepatobiliary Surgery, Jessa Hospital, Hasselt, Belgium
| | - Isabelle Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, Kortrijk, Belgium
| | - Hans Pottel
- Interdisciplinary Research Center, Leuven University Campus, Kortrijk, Belgium
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
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44
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Karanicolas PJ, Lin Y, Tarshis J, Law CHL, Coburn NG, Hallet J, Nascimento B, Pawliszyn J, McCluskey SA. Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid. HPB (Oxford) 2016; 18:991-999. [PMID: 27765582 PMCID: PMC5144548 DOI: 10.1016/j.hpb.2016.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/19/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection. METHODS In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration. RESULTS No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA. CONCLUSIONS There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182.
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Affiliation(s)
- Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Calvin H L Law
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barto Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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Rekman J, Wherrett C, Bennett S, Gostimir M, Saeed S, Lemon K, Mimeault R, Balaa FK, Martel G. Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections. Surgery 2016; 161:650-657. [PMID: 27712877 DOI: 10.1016/j.surg.2016.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/22/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations. METHODS Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H2O). The target phlebotomy volume was 7-10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison. RESULTS A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3 cm H2O (0-15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications. CONCLUSION Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.
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Affiliation(s)
- Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Miso Gostimir
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sara Saeed
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Kristina Lemon
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Richard Mimeault
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
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Koea JB, Batiller J, Aguirre N, Shen J, Kocharian R, Bochicchio G, Garden OJ. A multicentre, prospective, randomized, controlled trial comparing EVARREST™ fibrin sealant patch to standard of care in controlling bleeding following elective hepatectomy: anatomic versus non-anatomic resection. HPB (Oxford) 2016; 18:221-8. [PMID: 27017161 PMCID: PMC4814597 DOI: 10.1016/j.hpb.2015.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 12/23/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND This multicentre, randomized clinical trial assessed the safety and effectiveness of the EVARREST™ Fibrin Sealant Patch (FP) in treating parenchymal bleeding following anatomic and non-anatomic liver resections. METHODS One hundred and two patients were stratified according to the type of hepatic resection (anatomic/non-anatomic), and randomized (1:1) after identification of an appropriate bleeding site, to FP vs Standard of Care (SoC, manual compression ± topical haemostat). The primary endpoint was haemostasis at 4 min from bleeding site identification with no re-bleeding requiring re-treatment. RESULTS The FP was superior in achieving haemostasis at 4 min (96%, 48/50) to SoC (46%, 24/52; p < 0.001). Stratification for resection type showed treatment differences for primary endpoint for anatomic (24/25 FP vs 13/23 SoC; p = 0.001) and non-anatomic liver resections (24/25FP vs 11/29 SoC; p < 0.001). Adverse events related to the study procedure were reported in 40/50 patients (80%) in the FP group and 43/52 patients (83%) in the SoC group. One (2%) adverse event (infected intra-abdominal fluid collection) was possibly related to study treatment. CONCLUSION This clinical trial confirms that the FP is safe and highly effective in controlling parenchymal bleeding following hepatectomy regardless of the type of resection. ClinicalTrials.gov NCT01993888.
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Affiliation(s)
- Jonathan B Koea
- The Department of Surgery, Auckland City Hospital, Auckland, New Zealand.
| | | | | | | | | | - Grant Bochicchio
- Washington University School of Medicine, St. Louis, MO, United States
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Margonis GA, Kim Y, Samaha M, Buettner S, Sasaki K, Gani F, Amini N, Pawlik TM. Blood loss and outcomes after resection of colorectal liver metastases. J Surg Res 2016; 202:473-80. [PMID: 27038662 DOI: 10.1016/j.jss.2016.01.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/06/2016] [Accepted: 01/13/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The influence of intraoperative blood loss (IBL) on long-term outcomes of patients undergoing liver resection for colorectal cancer liver metastases (CRLM) remains not well defined. MATERIALS AND METHODS A total of 433 patients who underwent curative-intent hepatic resection for CRLM between 2000 and 2013 at Johns Hopkins were identified. Demographics, IBL data, and long-term outcomes were collected and analyzed. Clinicopathologic predictors of IBL and the association of IBL and outcomes were assessed. RESULTS The median patient age was 54 y (interquartile range, 44-64), most patients were male (58.9%; n = 255). At surgery, the median IBL was 400 mL (range, 10-5100 mL). Two-hundred eighty-seven patients (66.3%) had an IBL of >250 mL. Factors associated with increased IBL (>250 mL) on multivariate analysis were male sex (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.68-4.09; P < 0.001), tumor size >3 cm (OR, 1.88; 95% CI, 1.18-2.99; P = 0.008), and major hepatic resection (OR, 3.08; 95% CI, 1.92-4.92; P < 0.001). At a median follow-up time of 30.6 mo, the median survival times were 70.5, 56.4, and 36.9 mo for IBL <250, 250-1000, and >1000 mL, respectively (P = 0.004). IBL >250 mL remained an independent prognostic factor of overall survival in multivariate analysis (hazard ratio, 1.41; 95% CI, 1.01-1.97; P = 0.04) after adjusting for other factors including the receipt of blood transfusion. CONCLUSIONS The magnitude of IBL during CRLM resection was related to biologic characteristics of the tumor and the extent of surgery. Increased IBL during CRLM resection was an independent prognostic factor for worse patient survival. Furthermore, a dose-response relationship between increasing IBL and worsening survival was evident.
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Affiliation(s)
| | - Yuhree Kim
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Mario Samaha
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Stefan Buettner
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kazunari Sasaki
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Faiz Gani
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Neda Amini
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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Groeneveld DJ, Adelmeijer J, Hugenholtz GCG, Ariëns RAS, Porte RJ, Lisman T. Ex vivo addition of fibrinogen concentrate improves the fibrin network structure in plasma samples taken during liver transplantation. J Thromb Haemost 2015; 13:2192-201. [PMID: 26453059 DOI: 10.1111/jth.13167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/26/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Optimal hemostatic management during orthotopic liver transplantation (OLT) remains a challenge. The cause of bleeding during OLT is multifactorial, and may include hemostatic imbalance. Fibrinogen concentrates are increasingly being used to control perioperative bleeding during OLT. However, administration is based on arbitrary thresholds of fibrinogen levels. Importantly, studies on fibrin clot structure during OLT are lacking. OBJECTIVE We determined the hemostatic efficacy of fibrinogen concentrate in correcting the fibrin structure. METHODS Plasma samples taken at various times during OLT from 15 patients and 15 healthy controls were spiked with 1 g L(-1) fibrinogen concentrate or saline. Turbidity, fibrin fiber density and permeability of the fibrin clots were assessed. RESULTS Clotting rate and turbidity were significantly decreased at the start of surgery, and decreased even further during surgery. Addition of fibrinogen significantly increased the clotting rate and turbidity at all time points, but did not normalize it. Fibrin density was significantly reduced after reperfusion as compared with the density at the start of surgery and in healthy controls. Fibrin density improved significantly after addition of fibrinogen in samples taken at the start of surgery and after reperfusion. The severely impaired polymerization and decreased density after reperfusion were accompanied by significantly increased permeability of the clot as compared with the start of surgery and in controls, which was completely restored after addition of fibrinogen. CONCLUSIONS Ex vivo addition of fibrinogen concentrate during OLT substantially improves the structural properties of the fibrin clot, which, particularly after reperfusion, shows hypocoagulable features. These data support the use of fibrinogen concentrate to control bleeding complications during OLT.
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Affiliation(s)
- D J Groeneveld
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - G C G Hugenholtz
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - R A S Ariëns
- Thrombosis Research Group, Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre and Leeds Institute for Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - R J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - T Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Preoperative anemia is associated with increased use of hospital resources in patients undergoing elective hepatectomy. Surgery 2015; 158:1027-36; discussion 1036-8. [DOI: 10.1016/j.surg.2015.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/18/2015] [Accepted: 06/03/2015] [Indexed: 12/12/2022]
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Xin Y, Liu L, Chen B, Zhang L, Tong Y. Affinity purification of aprotinin from bovine lung. J Sep Sci 2015; 38:1441-8. [PMID: 25677462 DOI: 10.1002/jssc.201401188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 01/27/2015] [Accepted: 01/28/2015] [Indexed: 11/06/2022]
Abstract
An affinity protocol for the purification of aprotinin from bovine lung was developed. To simulate the structure of sucrose octasulfate, a natural specific probe for aprotinin, the affinity ligand was composed of an acidic head and a hydrophobic stick, and was then linked with Sepharose. The sorbent was then subjected to adsorption analysis with pure aprotinin. The purification process consisted of one step of affinity chromatography and another step of ultrafiltration. Then purified aprotinin was subjected to sodium dodecyl sulfate polyacrylamide gel electrophoresis, trypsin inhibitor activity, gel-filtration, and thin-layer chromatography analysis. As calculated, the theoretical maximum adsorption (Qmax ) of the affinity sorbent was 25,476.0 ± 184.8 kallikrein inactivator unit/g wet gel; the dissociation constant of the complex "immobilized ligand-aprotinin" (Kd ) was 4.6 ± 0.1 kallikrein inactivator unit/mL. After the affinity separation of bovine lung aprotinin, reducing sodium dodecyl sulfate polyacrylamide gel electrophoresis analysis and gel-filtration chromatography revealed that the protein was a single polypeptide, and the purities were ∼ 97 and 100%, respectively; the purified peptide was also confirmed with aprotinin standard by gel-filtration chromatography and thin-layer chromatography. After the whole purification process, protein, and bioactivity recoveries were 2.2 and 92.6%, respectively; and the specific activity was up to 15,907.1 ± 10.2 kallikrein inactivator unit/mg.
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Affiliation(s)
- Yu Xin
- School of Biotechnology, Jiangnan University, Key Laboratory of Industry Biotechnology, Ministry of Education, Jiangsu, P. R. China
| | - Lanhua Liu
- Nanchang Wanhua Biochem Products Co., Ltd, Nanchang, Jiangxi, P. R. China
| | - Beizhan Chen
- Nanchang Wanhua Biochem Products Co., Ltd, Nanchang, Jiangxi, P. R. China
| | - Ling Zhang
- School of Biotechnology, Jiangnan University, Key Laboratory of Industry Biotechnology, Ministry of Education, Jiangsu, P. R. China
| | - Yanjun Tong
- School of Biotechnology, Jiangnan University, Key Laboratory of Industry Biotechnology, Ministry of Education, Jiangsu, P. R. China
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