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Chang E, Wong FCL, Chasen BA, Erwin WD, Das P, Holliday EB, Koong AC, Ludmir EB, Minsky BD, Noticewala SS, Smith GL, Taniguchi CM, Rodriguez MJ, Beddar S, Martin-Paulpeter RM, Niedzielski JS, Sawakuchi GO, Schueler E, Perles LA, Xiao L, Szklaruk J, Park PC, Dasari AN, Kaseb AO, Kee BK, Lee SS, Overman MJ, Willis JA, Wolff RA, Tzeng CWD, Vauthey JN, Koay EJ. Phase I trial of single-photon emission computed tomography-guided liver-directed radiotherapy for patients with low functional liver volume. JNCI Cancer Spectr 2024; 8:pkae037. [PMID: 38730548 PMCID: PMC11164414 DOI: 10.1093/jncics/pkae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/28/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Traditional constraints specify that 700 cc of liver should be spared a hepatotoxic dose when delivering liver-directed radiotherapy to reduce the risk of inducing liver failure. We investigated the role of single-photon emission computed tomography (SPECT) to identify and preferentially avoid functional liver during liver-directed radiation treatment planning in patients with preserved liver function but limited functional liver volume after receiving prior hepatotoxic chemotherapy or surgical resection. METHODS This phase I trial with a 3 + 3 design evaluated the safety of liver-directed radiotherapy using escalating functional liver radiation dose constraints in patients with liver metastases. Dose-limiting toxicities were assessed 6-8 weeks and 6 months after completing radiotherapy. RESULTS All 12 patients had colorectal liver metastases and received prior hepatotoxic chemotherapy; 8 patients underwent prior liver resection. Median computed tomography anatomical nontumor liver volume was 1584 cc (range = 764-2699 cc). Median SPECT functional liver volume was 1117 cc (range = 570-1928 cc). Median nontarget computed tomography and SPECT liver volumes below the volumetric dose constraint were 997 cc (range = 544-1576 cc) and 684 cc (range = 429-1244 cc), respectively. The prescription dose was 67.5-75 Gy in 15 fractions or 75-100 Gy in 25 fractions. No dose-limiting toxicities were observed during follow-up. One-year in-field control was 57%. One-year overall survival was 73%. CONCLUSION Liver-directed radiotherapy can be safely delivered to high doses when incorporating functional SPECT into the radiation treatment planning process, which may enable sparing of lower volumes of liver than traditionally accepted in patients with preserved liver function. TRIAL REGISTRATION NCT02626312.
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Affiliation(s)
- Enoch Chang
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Franklin C L Wong
- Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Beth A Chasen
- Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William D Erwin
- Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emma B Holliday
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Albert C Koong
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bruce D Minsky
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sonal S Noticewala
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Grace L Smith
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cullen M Taniguchi
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria J Rodriguez
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sam Beddar
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Joshua S Niedzielski
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel O Sawakuchi
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emil Schueler
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis A Perles
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lianchun Xiao
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janio Szklaruk
- Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter C Park
- Radiology Physics, University of California, Davis, Davis, CA, USA
| | - Arvind N Dasari
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ahmed O Kaseb
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bryan K Kee
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunyoung S Lee
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Overman
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason A Willis
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Madorran E, Kocbek Šaherl L, Rakuša M, Munda M. In Vitro Human Liver Model for Toxicity Assessment with Clinical and Preclinical Instrumentation. Pharmaceutics 2024; 16:607. [PMID: 38794269 PMCID: PMC11124512 DOI: 10.3390/pharmaceutics16050607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/19/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
The existing in vitro toxicological models lack translational potential, which makes difficult the application of gathered information to clinical usage. To tackle this issue, we built a model with four different types of primary liver cells: hepatic sinusoidal endothelial cells, hepatic stellate cells, Kupffer cells and hepatocytes. We cultured them in different combinations of composition and volumes of cell medium, hepatocyte proportions of total cells and additions of extracellular matrixes. We added rifampicin (RIF), ibuprofen (IBU) and 5-fluorouracil (5-FU) to this model and observed the microanatomy and physiology changes for a week with preclinical and clinical instruments. Among the different model configurations, we selected the feature combination of the in vitro model that had similar biomarker values to those measured in clinical diagnostics. When we exposed the selected model configuration to RIF, IBU and 5-FU, we observed similar glucose, triglyceride and albumin dynamics as in vivo (from clinical data). Therefore, we have built an in vitro liver model that resembles the liver microenvironment, and we have analysed it with clinical instrumentation to facilitate data translation. Furthermore, during these observations, we found that Kupffer and LSEC cells are suitable candidates for the search for clinical diagnostic markers of liver function.
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Affiliation(s)
- Eneko Madorran
- Faculty of Medicine, Institute of Anatomy, Histology and Embryology, University of Maribor, Taborska Ulica 8, 2000 Maribor, Slovenia; (L.K.Š.); (M.R.); (M.M.)
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Lee FT, Williams J, Nordgren R, Schwarz JL, Setia N, Roggin K, Polite B, Rangrass G, Liao CY, Millis JM, Keutgen XM. Single center outcomes from parenchymal-sparing resections and microwave ablations for neuroendocrine tumor liver metastases. Am J Surg 2024; 229:17-23. [PMID: 37802701 DOI: 10.1016/j.amjsurg.2023.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/02/2023] [Accepted: 09/13/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Reported outcomes after surgical debulking in patients with advanced neuroendocrine tumor liver metastases (NETLM) are sparse. METHODS NETLM patients that underwent surgical debulking from 2019 to 2021 were reviewed. Trends in perioperative liver function, complications, symptom response, and progression-free survival were examined. RESULTS 1069 liver lesions were debulked from 53 patients using a combination of parenchymal-sparing resections (PSR) and ultrasound-guided microwave ablations (MWA). Post-operative transaminitis and thrombocytopenia were common, and severity correlated with increasing number of lesions. Laboratory markers for synthetic liver function did not differ according to the number of lesions debulked. 13% of patients sustained a Clavien-Dindo grade 3 or 4 complication which was not associated with the number of lesions targeted. All patients with preoperative symptoms had improvement after surgery. Median time to progression was 10.9 months. CONCLUSIONS PSR with MWA for large numbers of NETLM is safe and effective for symptom control and does not affect synthetic liver function.
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Affiliation(s)
- Frances T Lee
- Southern Illinois University, Department of Surgery. 701 N. 1st St, Springfield IL 62794, USA
| | - Jelani Williams
- University of Chicago, Department of Surgery. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Rachel Nordgren
- University of Chicago, Department of Public Health Sciences. 5481 S Maryland Ave, Chicago, IL 60637, USA
| | - Jason L Schwarz
- University of Chicago, Department of Surgery. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Namrata Setia
- University of Chicago, Department of Pathology. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Kevin Roggin
- University of Chicago, Department of Surgery. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Blase Polite
- University of Chicago, Department of Medicine, Section of Hematology/Oncology. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Govind Rangrass
- University of Chicago, Department of Anesthesia and Critical Care. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Chih-Yi Liao
- University of Chicago, Department of Medicine, Section of Hematology/Oncology. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - J Michael Millis
- University of Chicago, Department of Surgery. 5841 S Maryland Ave, Chicago IL 60637, USA
| | - Xavier M Keutgen
- University of Chicago, Department of Surgery. 5841 S Maryland Ave, Chicago IL 60637, USA.
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Saad Ali Lashin OA, Mohamed Elzahaby HM, Talaat Taha SM, Abd- Elfattah Ghoneim MM, Mohamed Awad Rashed MM. Propofol/dexmedetomidine Versus Desflaurane Effects on Post Hepatectomy Hepatocellular Injury. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2190865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
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5
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Verhoeff K, Connell M, Shapiro AJ, Strickland M, Bigam DL, Anantha RV. Rate of prophylactic anti-Xa achievement and impact on venous thromboembolism following oncologic hepato-pancreatico-biliary surgery: A prospective cohort study. Am J Surg 2023; 225:1022-1028. [PMID: 36526454 DOI: 10.1016/j.amjsurg.2022.12.001] [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: 11/06/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepato-pancreatico-biliary (HPB) patients experience competing risk of venous thromboembolism (VTE) and bleeding. We sought to evaluate the effect of anti-Xa levels on VTE and bleeding, and to characterize factors associated with subprophylaxis. METHODS This prospective cohort study evaluated adult HPB surgical patients; cohorts were described by anti-Xa levels as subprophylactic (<0.2 IU/mL), prophylactic (0.2-0.5 IU/mL), and supraprophylactic (>0.5 IU/mL). Primary outcome evaluated bleeding and VTE complications. Secondary outcomes evaluated factors associated with subprophylaxis. RESULTS We included 157 patients: 68 (43.6%) attained prophylactic anti-Xa and 89 (56.7%) were subprophylactic. Subprophylactic patients experienced more VTE compared to prophylactic patients (6.9% vs 0%; p = 0.028) without differences in bleeding complications (14.6% vs 5.9%; p = 0.081). Factors associated with subprophylactic anti-Xa included female sex (OR 2.90, p = 0.008), and Caprini score (OR 1.30, p = 0.035). Enoxaparin was protective against subprophylaxis compared to tinzaparin (OR 0.43, p = 0.029). CONCLUSIONS Many HPB patients have subprophylactic anti-Xa levels, placing them at risk of VTE. Enoxaparin may be preferential, however, studies evaluating optimized prophylaxis are needed.
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Affiliation(s)
- Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Matthew Connell
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Am James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Matt Strickland
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - David L Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Ram V Anantha
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
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Liu ZY, Xing ZH, Wang W, Liu YX, Wang RT, Li JY. Lean body mass predicts postoperative liver failure in patients with hepatocellular carcinoma. Cancer Biomark 2022; 35:419-427. [PMID: 36404538 DOI: 10.3233/cbm-220172] [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: 11/16/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is a severe complication of liver surgery in hepatocellular carcinoma (HCC) patients. Reduced lean body mass (LBM) decreases the immune activity and increases adverse clinical outcomes among cancer patients. OBJECTIVE We aimed to assess the association between LBM and PHLF in HCC patients. METHODS PHLF was defined and graded based on the International Study Group of Liver Surgery (ISGLS) criteria. Patients with Grade B or Grade C were included in PHLF ⩾ Grade B group, while others in PHLF < Grade B group. LBM was measured via preoperative computed tomography images. Binary logistic regression was applied for investigating the association between LBM and PHLF. The receiver operating characteristic curve was used to identify potential cut-off values and assess the predictive ability of the measured variables. RESULTS The PHLF ⩾ Grade B group had significantly lower LBM levels (means ± standard deviation: 57.0 ± 14.1) than PHLF < Grade B group (67.2 ± 15.7) (p< 0.001). After controlling other variables, LBM was an independent protective factor for PHLF ⩾ Grade B (Odds Ratio: 0.406, 95% confidence interval: 0.172-0.957, p= 0.039). The prevalence of PHLF ⩾ Grade B in each quartile of LBM was 29.4% (15/51), 25.5% (13/51), 19.2% (10/52) and 4.0% (2/50), respectively (ptrend< 0.001). CONCLUSIONS LBM might be a protective factor for PHLF in HCC patients. Our findings might help to develop a novel strategy to reduce the occurrence of hepatic dysfunction following major liver resection. Multicentric prospective studies and further molecular biologic investigation are needed.
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Affiliation(s)
- Zeng-Yao Liu
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China.,Department of Interventional Medicine, The First Affiliated Hospital, Harbin Medical University, Harbin, Heilongjiang, China.,Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China
| | - Zhao-Hui Xing
- Department of Urology Surgery, Heilongjiang Provincial Hospital, Harbin, Heilongjiang, China.,Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China
| | - Wen Wang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China.,Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China
| | - Yu-Xi Liu
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China
| | - Rui-Tao Wang
- Department of Internal Medicine, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, Heilongjiang, China
| | - Jia-Yu Li
- Institute of Intensive Care Unit, Heilongjiang Academy of Medical Science, Harbin, Heilongjiang, China
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7
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Qiu C, Xie S, Sun Y, Yu Y, Zhang K, Wang X, Zhu J, Grimm R, Shen W. Multi-parametric magnetic resonance imaging of liver regeneration in a standardized partial hepatectomy rat model. BMC Gastroenterol 2022; 22:430. [PMID: 36210451 PMCID: PMC9549623 DOI: 10.1186/s12876-022-02517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
We aimed to evaluate the correlation between the pathological changes and multi-parameter MRI characteristics of liver regeneration (LR) in a standard partial hepatectomy (PH) rat model.
Methods
Seventy Sprague–Dawley rats were randomly divided into two groups: MR scan group (n = 14) and pathologic analysis (PA) group (n = 56). All 14 rats in the MR group underwent liver T1 mapping, T2 mapping, and diffusion kurtosis imaging before and the 1st, 2nd, 3rd, 5th, 7th, 14th, and 21st day after 70% hepatectomy. Seven rats in the PA group were euthanized at each time point to determine Ki-67 indices, hepatocyte size (HTS), steatosis grade, and inflammation score.
Results
Liver T1 and T2 values increased to maximum on day 2 (P < 0.001 vs. baseline), D and K values decreased to minimum on day 3 and 2, respectively (P < 0.001 vs. baseline), then all parameters returned to baseline gradually. Hepatocyte Ki-67, hepatocyte size, steatosis grade, and inflammation score initially increased after surgery (P < 0.05 vs. baseline), followed by a gradual decline over time. Both T2 and K values correlated well with Ki-67 indices (r = 0.765 and − 0.807, respectively; both P < 0.001), inflammation (r = 0.809 and − 0.724, respectively; both P < 0.001), steatosis grade (r = 0.814 and − 0.725, respectively; both P < 0.001), and HTS (r = 0.830 and − 0.615, respectively; both P < 0.001).
Conclusions
PH induced liver changes that can be observed on MRI. The MRI parameters correlate with the LR activity and allow monitoring of LR process.
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Burjorjee J, Phelan R, Hopman WM, Ho AMH, Nanji S, Jalink D, Mizubuti GB. Plasma bupivacaine levels (total and free/unbound) during epidural infusion in liver resection patients: a prospective, observational study. Reg Anesth Pain Med 2022; 47:rapm-2022-103683. [PMID: 36002226 DOI: 10.1136/rapm-2022-103683] [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: 04/01/2022] [Accepted: 08/09/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Liver resection patients may be at an increased risk of local anesthetic (LA) toxicity because the liver is essential for metabolizing LA and producing proteins (mainly α1-acid glycoprotein (AAG)) that bind to it and reduce the free (and pharmacologically active/toxic) levels in circulation. The liver resection itself, manipulation during surgery, and pre-existing liver disease may all interfere with normal hepatic protein synthesis and result in an attenuation of the increased AAG (a positive acute-phase protein) that normally occurs postoperatively. The purpose of this study was to determine whether the AAG response is attenuated postoperatively following liver resection and whether patients approach toxicity thresholds with continuous postoperative epidural infusion of bupivacaine. METHODS Prospective, observational study with blood drawn preoperatively, in the postanesthetic care unit, on postoperative day (POD) 2, and prior to discontinuation of epidural analgesia on POD3/POD4. Plasma was analyzed for total and unbound bupivacaine via liquid chromatography-mass spectrometry and AAG via ELISA. Signs/symptoms of local anesthetic systemic toxicity (LAST), pain, and sedation scores were also recorded. RESULTS For the 19 patients completed, total plasma bupivacaine was correlated with total administered, but unbound levels were not associated with the total administered. Unlike non-hepatectomy surgery where unbound LA plasma levels remain stable (or decrease) with continuous postoperative epidural administration, we observed an overall increase. Several patients approached toxicity thresholds and 47% reported at least one symptom of LAST, but no epidurals were discontinued because of LAST. In contrast to the AAG response reported following major non-liver surgery where AAG levels increase twofold, we observed a reduction until POD2 and the magnitude was proportional to resection weight. DISCUSSION Our results are supported by the literature in suggesting that major liver resection patients may be at an increased vulnerability for LAST. Factors such as the extent of liver disease, resection and intraoperative blood loss should be considered when using continuous postoperative epidural infusion of bupivacaine and vigilance should be used in monitoring, for signs/symptoms of LAST, even for those subtle and non-specific. Future research will be required to verify these findings. TRIAL REGISTRATION NUMBER NCT03145805.
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Affiliation(s)
- Jessica Burjorjee
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Rachel Phelan
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Wilma M Hopman
- Kingston General Hospital Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Anthony M-H Ho
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Sulaiman Nanji
- Department of Surgery, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Diederick Jalink
- Department of Surgery, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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Routine Postoperative Antibiotic Prophylaxis Offers No Benefit after Hepatectomy—A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11050649. [PMID: 35625294 PMCID: PMC9138010 DOI: 10.3390/antibiotics11050649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Prophylactic antibiotics are frequently administered after major abdominal surgery including hepatectomies aiming to prevent infective complications. Yet, excessive use of antibiotics increases resistance in bacteria. The aim of this systematic review and meta-analysis is to assess the efficacy of prophylactic antibiotics after hepatectomy (postoperative antibiotic prophylaxis, POA). Method: This systematic review and meta-analysis were completed according to the current PRISMA guidelines. The protocol has been registered prior to data extraction (PROSPERO registration Nr: CRD42021288510). MEDLINE, Web of Science and CENTRAL were searched for clinical reports on POA in hepatectomy restrictions. A random-effects model was used for synthesis. Methodological quality was assessed with RoB2 and ROBINS-I. GRADE was used for the quality of evidence assessment. Results: Nine comparative studies comprising 2987 patients were identified: six randomized controlled trials (RCTs) and three retrospectives. POA did not lead to a reduction in postoperative infective complications or have an effect on liver-specific complications—post-hepatectomy liver failure and biliary leaks. POA over four or more days was associated with increased rates of deep surgical site infections compared to short-term administration for up to two days (OR 1.54; 95% CI [1.17;2.03]; p = 0.03). Routine POA led to significantly higher MRSA incidence as a pathogen (p = 0.0073). Overall, the risk of bias in the studies was low and the quality of evidence moderate. Conclusion: Routine POA cannot be recommended after hepatectomy since it does not reduce postoperative infection or liver-specific complications but contributes to resistance in bacteria. Studies into individualized risk-adapted antibiotic prophylaxis strategies are needed to further optimize perioperative treatment in liver surgery.
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Tzimas P, Lefkou E, Karakosta A, Argyrou S, Papapetrou E, Pantazi D, Tselepis A, Van Dreden P, Stratigopoulou P, Gerotziafas GT, Glantzounis G. Perioperative coagulation profile in major liver resection for cancer: a prospective observational study. Thromb Haemost 2022; 122:1662-1672. [PMID: 35483884 DOI: 10.1055/a-1839-0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hepatectomy induced coagulation disturbances have been well studied over the past decade. Cumulative evidence supports the superiority of global coagulation analysis compared to conventional coagulation tests (i.e. PT or aPTT) for clinical decision making. Cancer, however, represents an acquired prothrombotic state and liver resection for cancer deserves a more thorough investigation. This prospective observational study was conducted to assess the perioperative coagulation status of patients undergoing major hepatectomies for primary or metastatic hepatic malignancy. Patients were followed up to the 10th postoperative day by serial measurements of conventional coagulation tests, plasma levels of coagulation factors and thrombin generation assay parameters. An abnormal coagulation profile was detected at presentation and included elevated FVIII levels, decreased levels of antithrombin and lag time prolongation in thrombin generation. Serial hematological data demonstrated increased vWF, FVIII, D-dimer, fibrinogen and decreased levels of natural anticoagulant proteins in the early postoperative period predisposing to a hypercoagulable state. The ratio of the anticoagulant protein C to the procoagulant FVIII was low at baseline and further declined postoperatively, indicating a prothrombotic state. Though no bleeding complications were reported, one patient experienced pulmonary embolism while under thromboprophylaxis. Overall, patients with hepatic carcinoma presenting for elective major hepatectomy may have baseline malignancy associated coagulation disturbances, aggravating the hypercoagulable state documented in the early postoperative period.
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11
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Yang S, Yang R, Wang H, Huang Y, Jia Y. CDK5RAP3 Deficiency Restrains Liver Regeneration after Partial Hepatectomy Triggering Endoplasmic Reticulum Stress. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:2403-2416. [PMID: 32926856 DOI: 10.1016/j.ajpath.2020.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 12/19/2022]
Abstract
CDK5 regulatory subunit-associated protein 3 (CDK5RAP3) plays a crucial role in mammalian liver development and hepatic function by controlling hepatocyte proliferation and differentiation, glucose and lipid metabolism, UFMylation, and endoplasmic reticulum homeostasis. However, the role of CDK5RAP3 in liver regeneration remains unknown. A liver-specific Cdk5rap3 knockout (CKO) mouse model was used to study the function of CDK5RAP3 during liver regeneration induced by standard two-thirds partial hepatectomy (PHx). Twenty-four hours after PHx, the liver-to-body weight ratio was markedly higher in CKO mice than in wild-type mice. However, this ratio did not increase significantly and gradually over time after PHx in CKO mice. Hepatocyte proliferation was significantly delayed in CKO mice compared with wild-type mice. Meanwhile, CDK5RAP3 deficiency increased lipid accumulation, impaired glycogen synthesis, and lowered blood glucose levels after PHx. Critically, the absence of CDK5RAP3 seemed to promote an inflammatory response and induce apoptosis at a late stage of liver regeneration. In addition, CDK5RAP3 deficiency disrupted UFMylation homeostasis and aggravated endoplasmic reticulum stress in hepatocytes after PHx. Taken together, these data suggest that CDK5RAP3 enhances liver regeneration, at least partially via controlling cell cycle and glucose and lipid metabolism.
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Affiliation(s)
- Shuchun Yang
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Medical Genetics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Yang
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Medical Genetics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huanmin Wang
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Medical Genetics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Huang
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Medical Genetics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yuyan Jia
- State Key Laboratory of Medical Molecular Biology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Medical Genetics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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12
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Oo J, Allen M, Loveday BPT, Lee N, Knowles B, Riedel B, Burbury K, Thomson B. Coagulation in liver surgery: an observational haemostatic profile and thromboelastography study. ANZ J Surg 2020; 90:1112-1118. [PMID: 32455509 DOI: 10.1111/ans.15912] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/13/2020] [Accepted: 04/02/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND International normalized ratio (INR) is used as a marker of the haemostatic status following liver resection. However, the impact of liver resection on haemostasis is complex and beyond what can be measured by INR. This study aimed to prospectively assess haemostatic profile following liver resection and determine if INR measurement can safely guide post-operative thromboprophylaxis. METHODS In this prospective cohort study, patients undergoing liver resection had coagulation parameters (International normalised ratio (INR), prothrombin time (PT), activated partial thromboplastin time, fibrinogen, d-dimer, von Willebrand factor antigen, procoagulant activity of phospholipids and clotting factors II, VII, VIIIc, IX and X) and thromboelastogram parameters assessed perioperatively. Clinical follow-up assessed for thromboembolism and haemorrhage. RESULTS In the 41 patients included, INR was significantly (P < 0.0001) elevated post-operatively, and INR >1.5 was observed in seven of 41 (17.1%) on post-operative day 1 and one of 41 (2.4%) patients on post-operative day 3, respectively. Factor VII levels showed transient reduction but other factors, especially factors II and X, remained within normal range following liver resection. Thromboelastogram parameters remained normal or supranormal for all patients at all time points. One incident of post-hepatectomy haemorrhage occurred, despite a normal coagulation profile. Two patients suffered late pulmonary embolic episodes. CONCLUSION Post liver resection haemostasis is complex and poorly reflected by INR, which should not guide initiation of chemical thromboprophylaxis in the immediate post-operative period.
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Affiliation(s)
- June Oo
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Megan Allen
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin P T Loveday
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of General Surgical Specialties, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nora Lee
- Department of Hematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Brett Knowles
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of General Surgical Specialties, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kate Burbury
- Department of Hematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Benjamin Thomson
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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13
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Hoffmann K, Nagel AJ, Tanabe K, Fuchs J, Dehlke K, Ghamarnejad O, Lemekhova A, Mehrabi A. Markers of liver regeneration-the role of growth factors and cytokines: a systematic review. BMC Surg 2020; 20:31. [PMID: 32050952 PMCID: PMC7017496 DOI: 10.1186/s12893-019-0664-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
Background Post-hepatectomy liver failure contributes significantly to postoperative mortality after liver resection. The prediction of the individual risk for liver failure is challenging. This review aimed to provide an overview of cytokine and growth factor triggered signaling pathways involved in liver regeneration after resection. Methods MEDLINE and Cochrane databases were searched without language restrictions for articles from the time of inception of the databases till March 2019. All studies with comparative data on the effect of cytokines and growth factors on liver regeneration in animals and humans were included. Results Overall 3.353 articles comprising 40 studies involving 1.498 patients and 101 animal studies were identified and met the inclusion criteria. All included trials on humans were retrospective cohort/observational studies. There was substantial heterogeneity across all included studies with respect to the analyzed cytokines and growth factors and the described endpoints. Conclusion High-level evidence on serial measurements of growth factors and cytokines in blood samples used to predict liver regeneration after resection is still lacking. To address the heterogeneity of patients and potential markers, high throughput serial analyses may offer a method to predict an individual’s regenerative potential in the future.
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Affiliation(s)
- Katrin Hoffmann
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany.
| | - Alexander Johannes Nagel
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany
| | - Kazukata Tanabe
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany
| | | | - Karolin Dehlke
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany
| | - Anastasia Lemekhova
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, Ruprecht Karls University, Im Neuenheimer Feld, 110 69120, Heidelberg, Germany
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14
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Xie G, Yin S, Zhang Z, Qi D, Wang X, Kim D, Yagai T, Brocker CN, Wang Y, Gonzalez FJ, Wang H, Qu A. Hepatocyte Peroxisome Proliferator-Activated Receptor α Enhances Liver Regeneration after Partial Hepatectomy in Mice. THE AMERICAN JOURNAL OF PATHOLOGY 2018; 189:272-282. [PMID: 30448405 DOI: 10.1016/j.ajpath.2018.10.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/18/2018] [Accepted: 10/10/2018] [Indexed: 12/25/2022]
Abstract
Peroxisome proliferator-activated receptor α (PPARα) is a key nuclear receptor involved in the control of lipid homeostasis. In rodents, PPARα is also a potent hepatic mitogen. Hepatocyte-specific disruption of PPARα inhibits agonist-induced hepatocyte proliferation; however, little is known about the exact role of PPARα in partial hepatectomy (PHx)-induced liver regeneration. Herein, using hepatocyte-specific PPARα-deficient (PparaΔHep) mice, the function of hepatocyte PPARα in PHx-induced liver regeneration was investigated. PPARα protein level and transcriptional activity were increased in the liver after PHx. Compared with the Pparafl/fl mice, PparaΔHep mice exhibited significantly reduced hepatocyte proliferation at 32 hours after PHx. Consistently, reduced Ccnd1 and Pcna mRNA and CYCD1 and proliferating cell nuclear antigen protein were observed at 32 hours after PHx in PparaΔHep mice. Furthermore, PparaΔHep mice showed increased hepatic lipid accumulation and enhanced hepatic triglyceride contents because of impaired hepatic fatty acid β-oxidation when compared with that observed in Pparafl/fl mice. These results indicate that PPARα promotes liver regeneration after PHx, at least partially via regulating the cell cycle and lipid metabolism.
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Affiliation(s)
- Guomin Xie
- School of Pharmacy, Anhui Provincial Hospital, Anhui Medical University, Hefei, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Capital Medical University, Beijing, China
| | - Shi Yin
- Department of Geriatrics, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Zhenzhen Zhang
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
| | - Dan Qi
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Capital Medical University, Beijing, China
| | - Xia Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Capital Medical University, Beijing, China
| | - Donghwan Kim
- Laboratory of Metabolism, National Cancer Institute, NIH, Bethesda, Maryland
| | - Tomoki Yagai
- Laboratory of Metabolism, National Cancer Institute, NIH, Bethesda, Maryland
| | - Chad N Brocker
- Laboratory of Metabolism, National Cancer Institute, NIH, Bethesda, Maryland
| | - Yan Wang
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
| | - Frank J Gonzalez
- Laboratory of Metabolism, National Cancer Institute, NIH, Bethesda, Maryland
| | - Hua Wang
- School of Pharmacy, Anhui Provincial Hospital, Anhui Medical University, Hefei, China; Department of Oncology, First Affiliated Hospital, Anhui Medical University, Hefei, China; Institute for Liver Diseases, Anhui Medical University, Hefei, China.
| | - Aijuan Qu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Capital Medical University, Beijing, China.
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15
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Sultana A, Brooke-Smith M, Ullah S, Figueras J, Rees M, Vauthey JN, Conrad C, Hugh TJ, Garden OJ, Fan ST, Crawford M, Makuuchi M, Yokoyama Y, Büchler M, Padbury R. Prospective evaluation of the International Study Group for Liver Surgery definition of post hepatectomy liver failure after liver resection: an international multicentre study. HPB (Oxford) 2018; 20:462-469. [PMID: 29287736 DOI: 10.1016/j.hpb.2017.11.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/18/2017] [Accepted: 11/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The International Study Group for Liver Surgery (ISGLS) definition of post hepatectomy liver failure (PHLF) was developed to be consistent, widely applicable, and to include severity stratification. This international multicentre collaborative study aimed to prospectively validate the ISGLS definition of PHLF. METHODS 11 HPB centres from 7 countries developed a standardised reporting form. Prospectively acquired anonymised data on liver resections performed between 01 July 2010 and 30 June 2011 was collected. A multivariate analysis was undertaken of clinically important variables. RESULTS Of the 949 patients included, 86 (9%) met PHLF requirements. On multivariate analyses, age ≥70 years, pre-operative chemotherapy, steatosis, resection of >3 segments, vascular reconstruction and intraoperative blood loss >300 ml significantly increased the risk of PHLF. Receiver operator curve (ROC) analysis of INR and serum bilirubin relationship with PHLF demonstrated post-operative day 3 and 5 INR performed equally in predicting PHLF, and day 5 bilirubin was the strongest predictor of PHLF. Combining ISGLS grades B and C groups resulted in a high sensitivity for predicting mortality compared to the 50-50 rule and Peak bilirubin >7 mg/dl. CONCLUSIONS The ISGLS definition performed well in this prospective validation study, and may be the optimal definition for PHLF in future research to allow for comparability of data.
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Affiliation(s)
- Asma Sultana
- Flinders Medical Centre and Flinders University of South Australia, Australia
| | - Mark Brooke-Smith
- Flinders Medical Centre and Flinders University of South Australia, Australia.
| | - Shahid Ullah
- Flinders Medical Centre and Flinders University of South Australia, Australia; South Australian Health and Medical Research Institute, Australia
| | | | | | | | | | - Thomas J Hugh
- Royal North Shore Hospital and University of Sydney, Australia
| | | | | | | | | | | | | | - Robert Padbury
- Flinders Medical Centre and Flinders University of South Australia, Australia
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16
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Gilg S, Sparrelid E, Saraste L, Nowak G, Wahlin S, Strömberg C, Lundell L, Isaksson B. The molecular adsorbent recirculating system in posthepatectomy liver failure: Results from a prospective phase I study. Hepatol Commun 2018; 2:445-454. [PMID: 29619422 PMCID: PMC5880195 DOI: 10.1002/hep4.1167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/06/2018] [Accepted: 02/10/2018] [Indexed: 12/11/2022] Open
Abstract
Posthepatectomy liver failure (PHLF) represents the single most important cause of postoperative mortality after major liver resection, yet no effective treatment option is available. Extracorporeal liver support devices might be helpful, but systematic studies are lacking. Accordingly, we aimed to assess the safety and feasibility of the Molecular Adsorbent Recirculating System (MARS) in patients with PHLF. Between December 2012 and May 2015, a total of 206 patients underwent major or extended hepatectomy, and 10 consecutive patients with PHLF (according to the Balzan 50:50 criteria) were enrolled into the study. MARS treatment was initiated on postoperative day 5-7, and five to seven consecutive treatment sessions were completed for each patient. In total, 59 MARS cycles were implemented, and MARS was initiated and completed without major complications in any patient. However, 1 patient developed an immense asymptomatic hyperbilirubinemia (without encephalopathy), 1 had repeated clotting problems in the MARS filter, and 2 patients experienced access problems with the central venous line. Otherwise, no adverse events were observed. In 9 patients, the bilirubin level and international normalized ratio decreased significantly (P < 0.05) during MARS treatment. The 60- and 90-day mortality was 0% and 10%, respectively. Among the 9 survivors, 4 still had liver dysfunction at 90 days postoperatively. Five patients were alive 1 year postoperatively without any signs of liver dysfunction or disease recurrence. Conclusion: The use of MARS in PHLF is feasible and safe and improves liver function in patients with PHLF. In the present study, 60- and 90-day mortality rates were unexpectedly low compared to a historical control group. The impact of MARS treatment on mortality in PHLF should be further evaluated in a randomized controlled clinical trial. (Hepatology Communications 2018;2:445-454).
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Affiliation(s)
- Stefan Gilg
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Ernesto Sparrelid
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Lars Saraste
- Department of Anesthesiology and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Greg Nowak
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Transplantation Surgery Karolinska University Hospital Stockholm Sweden
| | - Staffan Wahlin
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Hepatology Karolinska University Hospital Stockholm Sweden
| | - Cecilia Strömberg
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Lars Lundell
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Bengt Isaksson
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgical Sciences Uppsala University Hospital Uppsala Sweden
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17
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Christ B, Dahmen U, Herrmann KH, König M, Reichenbach JR, Ricken T, Schleicher J, Ole Schwen L, Vlaic S, Waschinsky N. Computational Modeling in Liver Surgery. Front Physiol 2017; 8:906. [PMID: 29249974 PMCID: PMC5715340 DOI: 10.3389/fphys.2017.00906] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/25/2017] [Indexed: 12/13/2022] Open
Abstract
The need for extended liver resection is increasing due to the growing incidence of liver tumors in aging societies. Individualized surgical planning is the key for identifying the optimal resection strategy and to minimize the risk of postoperative liver failure and tumor recurrence. Current computational tools provide virtual planning of liver resection by taking into account the spatial relationship between the tumor and the hepatic vascular trees, as well as the size of the future liver remnant. However, size and function of the liver are not necessarily equivalent. Hence, determining the future liver volume might misestimate the future liver function, especially in cases of hepatic comorbidities such as hepatic steatosis. A systems medicine approach could be applied, including biological, medical, and surgical aspects, by integrating all available anatomical and functional information of the individual patient. Such an approach holds promise for better prediction of postoperative liver function and hence improved risk assessment. This review provides an overview of mathematical models related to the liver and its function and explores their potential relevance for computational liver surgery. We first summarize key facts of hepatic anatomy, physiology, and pathology relevant for hepatic surgery, followed by a description of the computational tools currently used in liver surgical planning. Then we present selected state-of-the-art computational liver models potentially useful to support liver surgery. Finally, we discuss the main challenges that will need to be addressed when developing advanced computational planning tools in the context of liver surgery.
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Affiliation(s)
- Bruno Christ
- Molecular Hepatology Lab, Clinics of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig, University of Leipzig, Leipzig, Germany
| | - Uta Dahmen
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Karl-Heinz Herrmann
- Medical Physics Group, Institute for Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University Jena, Jena, Germany
| | - Matthias König
- Department of Biology, Institute for Theoretical Biology, Humboldt University of Berlin, Berlin, Germany
| | - Jürgen R Reichenbach
- Medical Physics Group, Institute for Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University Jena, Jena, Germany
| | - Tim Ricken
- Mechanics, Structural Analysis, and Dynamics, TU Dortmund University, Dortmund, Germany
| | - Jana Schleicher
- Experimental Transplantation Surgery, Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany.,Department of Bioinformatics, Friedrich Schiller University Jena, Jena, Germany
| | | | - Sebastian Vlaic
- Leibniz Institute for Natural Product Research and Infection Biology, Hans Knöll Institute, Jena, Germany
| | - Navina Waschinsky
- Mechanics, Structural Analysis, and Dynamics, TU Dortmund University, Dortmund, Germany
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18
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Impact of Perioperative Phosphorus and Glucose Levels on Liver Regeneration and Long-term Outcomes after Major Liver Resection. J Gastrointest Surg 2016; 20:1305-16. [PMID: 27121234 DOI: 10.1007/s11605-016-3147-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/31/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The impact of phosphorus as well as glycemic alterations on liver regeneration has not been directly examined. We sought to determine the impact of phosphorus and glucose on liver regeneration after major hepatectomy. METHODS Early and late liver regeneration index was defined as the relative increase of liver volume (RLV) within 2[(RLV2m-RLVp)/RLVp] and 7 months[(RLV7m-RLVp)/RLVp] following surgery. The association of perioperative metabolic factors, liver regeneration, and outcomes was assessed. RESULTS On postoperative day 2, 50 (52.6 %) patients had a low phosphorus level (≤2.4 mg/dl), while 45 (47.4 %) had a normal/high phosphorus level (>2.4 mg/dl). Despite comparable clinicopathologic characteristics (all P > 0.05) and RLV/TLV at surgery (P = 0.84), regeneration index within 2 months was lower in the normal/high phosphorus group (P = 0.01) with these patients having increased risk for postoperative liver failure (P = 0.01). The inhibition of liver regeneration persisted at 7 months (P = 0.007) and was associated with a worse survival (P = 0.02). Preoperative hypoglycemia was associated only with a lower early regeneration index (P = 0.02). CONCLUSIONS Normal/high phosphorus was associated with inhibition of early and late liver regeneration, as well as with an increased risk of liver failure and worse long-term outcomes. Immediate preoperative hypoglycemia was associated with a lower early volumetric gain. Metabolic factors may represent early indicators of liver failure that could identify patients at increased risk for worse outcomes.
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19
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Douaiher J, Dhir M, Smith L, Are C. Differences in Perioperative Outcomes Between Right and Left Hepatic Lobectomy. Indian J Surg Oncol 2016; 7:44-51. [PMID: 27065681 DOI: 10.1007/s13193-015-0464-2] [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: 06/24/2015] [Accepted: 09/01/2015] [Indexed: 11/30/2022] Open
Abstract
The safety of hepatic resection is well documented, but outcome studies comparing right and left hepatic lobectomy are sparse, especially in the context of malignancy. This study analyzes the differences in outcomes between right and left hepatic lobectomy in patients with malignant diagnoses. All patients undergoing right and left hepatic lobectomies for malignancy were extracted from the National Surgical Quality Improvement Program (NSQIP) database (2005-2010). The data was analyzed to determine differences in perioperative mortality and morbidity between the two groups. A total of 1680 patients who underwent right or left hepatic lobectomy for malignant diagnoses were identified. Patients undergoing right hepatic lobectomy had a four-fold increase in perioperative mortality, compared to left lobectomy (p < 0.0001). Mortality in right lobectomy patients increased incrementally with age, with a 12-fold increase in patients > 81 years of age. Patients undergoing right lobectomy also experienced a statistically significant increase in morbidity involving several systems (infectious, pulmonary, cardiac and renal). The results of our study demonstrate that patients undergoing right hepatic lobectomy for malignancy experience a significantly higher incidence of mortality and multi-system morbidity when compared to left lobectomy. This information will be crucial for pre-operative risk-stratification of patients undergoing hepatic resection for malignancy.
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Affiliation(s)
- Jeffrey Douaiher
- Department of Surgery, University of Nebraska Medical Center, 984030 Nebraska Medical Center, Omaha, NE 68198-3280 USA
| | - Mashaal Dhir
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA USA
| | - Lynette Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE USA
| | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, 984030 Nebraska Medical Center, Omaha, NE 68198-3280 USA
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