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Reese T, Gilg S, Böcker J, Wagner KC, Vali M, Engstrand J, Kern A, Sturesson C, Oldhafer KJ, Sparrelid E. Impact of the future liver remnant volume before major hepatectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108660. [PMID: 39243696 DOI: 10.1016/j.ejso.2024.108660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/27/2024] [Accepted: 09/02/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Following major liver resection, posthepatectomy liver failure (PHLF) is associated with a high mortality rate. As there is no therapy for PHLF available, avoidance remains the main goal. A sufficient future liver remnant (FLR) is one of the most important factors to reduce the risk for PHLF; however, it is not known which patients benefit of volumetric assessment prior to major surgery. METHODS A retrospective, bi-institutional cohort study was conducted including all patients who underwent major hepatectomy (extended right hepatectomy, right hepatectomy, extended left hepatectomy and left hepatectomy) between 2010 and 2023. RESULTS A total of 1511 major hepatectomies were included, with 29.4 % of patients undergoing FLR volume assessment preoperatively. Overall, PHLF B/C occurred in 9.8 % of cases. Multivariate analysis identified diabetes mellitus, extended right hepatectomy, perihilar cholangiocarcinoma (pCCA), gallbladder cancer (GBC) and cirrhosis as significant risk factors for PHLF B/C. High-risk patients (with one or more risk factors) had a 15 % overall incidence of PHLF, increasing to 32 % with a FLR <30 %, and 13 % with an FLR of 30-40 %. Low-risk patients with a FLR <30 % had a PHLF rate of 21 %, which decreased to 8 % and 5 % for FLRs of 30-40 % and >40 %, respectively. For right hepatectomy, the PHLF rate was 23 % in low-risk and 38 % in high-risk patients with FLR <30 %. CONCLUSION Patients scheduled for right hepatectomy and extended right hepatectomy should undergo volumetric assessment of the FLR. Volumetry should always be considered before major hepatectomy in patients with risk factors such as diabetes, cirrhosis, GBC and pCCA. In high-risk patients, a FLR cut-off of 30 % may be insufficient to prevent PHLF, and additional liver function assessment should be considered.
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Affiliation(s)
- Tim Reese
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany.
| | - Stefan Gilg
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jörg Böcker
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Kim C Wagner
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Marjan Vali
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Jennie Engstrand
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Kern
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Sturesson
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany; Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Ernesto Sparrelid
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Pravisani R, Isola M, Lorenzin D, Cherchi V, Boscolo E, Mocchegiani F, Terrosu G, Baccarani U. Re-thinking of T-tube use in whole liver transplantation: an analysis on the risk of delayed graft function. Updates Surg 2022; 74:571-577. [PMID: 35325442 PMCID: PMC8995289 DOI: 10.1007/s13304-022-01267-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/28/2022] [Indexed: 02/07/2023]
Abstract
The liver–gut axis has been identified as crucial mediator of liver regeneration. Thus, the use of a T-tube in liver transplantation (LT), which interrupts the enterohepatic bile circulation, may potentially have a detrimental effect on the early allograft functional recovery. We retrospectively analyzed a cohort of 261 patients transplanted with a whole liver graft, with a duct-to-duct biliary anastomosis, who did not develop any surgical complication within postoperative day 14. Early allograft dysfunction (EAD) was defined according to the criteria of Olthoff et al. (EAD-O), and graded according to the Model for Early Allograft Function (MEAF) score. EAD-O developed in 24.7% of recipients and the median MEAF score was 4.0 [interquartile range 2.9–5.5]. Both MEAF and EAD predicted 90-day post-LT mortality. A T-tube was used in 49.4% of cases (n = 129). After a propensity score matching for donor age, cold and warm ischemia time, donor risk index, balance of risk score, Child–Pugh class C, and MELD score, the T-tube group showed a significantly higher prevalence of EAD-O and value of MEAF than the no-T-tube group (EAD-O: 29 [34.1%] vs 16 [19.0%], p = 0.027; MEAF 4.5 [3.5–5.7] vs 3.7 [2.9–5.0], p = 0.014). In conclusion, T-tube use in LT may be a risk factor for EAD and higher MEAF, irrespective of graft quality and severity of pre-LT liver disease.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Miriam Isola
- Division of Medical Statistic, Department of Medicine, University of Udine, Udine, Italy
| | - Dario Lorenzin
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Vittorio Cherchi
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Erica Boscolo
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Mocchegiani
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Giovanni Terrosu
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
- Dipartimento Di Area Medica, University of Udine, P.Le Kolbe, Via Colugna 50, 33100 Udine, Italy
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Yagi S, Hirata M, Miyachi Y, Uemoto S. Liver Regeneration after Hepatectomy and Partial Liver Transplantation. Int J Mol Sci 2020; 21:ijms21218414. [PMID: 33182515 PMCID: PMC7665117 DOI: 10.3390/ijms21218414] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023] Open
Abstract
The liver is a unique organ with an abundant regenerative capacity. Therefore, partial hepatectomy (PHx) or partial liver transplantation (PLTx) can be safely performed. Liver regeneration involves a complex network of numerous hepatotropic factors, cytokines, pathways, and transcriptional factors. Compared with liver regeneration after a viral- or drug-induced liver injury, that of post-PHx or -PLTx has several distinct features, such as hemodynamic changes in portal venous flow or pressure, tissue ischemia/hypoxia, and hemostasis/platelet activation. Although some of these changes also occur during liver regeneration after a viral- or drug-induced liver injury, they are more abrupt and drastic following PHx or PLTx, and can thus be the main trigger and driving force of liver regeneration. In this review, we first provide an overview of the molecular biology of liver regeneration post-PHx and -PLTx. Subsequently, we summarize some clinical conditions that negatively, or sometimes positively, interfere with liver regeneration after PHx or PLTx, such as marginal livers including aged or fatty liver and the influence of immunosuppression.
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Pravisani R, Baccarani U, Eguchi S. In search of a pathogenesis for impaired liver regeneration after major hepatectomy with extrahepatic bile duct resection: The plot thickens! Hepatol Res 2019; 49:1091-1093. [PMID: 31347747 DOI: 10.1111/hepr.13414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/11/2019] [Accepted: 07/21/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Riccardo Pravisani
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.,Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplant Unit - Department of Medicine, University of Udine, Udine, Italy
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Rahnemai-Azar AA, Cloyd JM, Weber SM, Dillhoff M, Schmidt C, Winslow ER, Pawlik TM. Update on Liver Failure Following Hepatic Resection: Strategies for Prediction and Avoidance of Post-operative Liver Insufficiency. J Clin Transl Hepatol 2018; 6:97-104. [PMID: 29577036 PMCID: PMC5863005 DOI: 10.14218/jcth.2017.00060] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/22/2017] [Accepted: 10/23/2017] [Indexed: 01/27/2023] Open
Abstract
Liver resection is increasingly used for a variety of benign and malignant conditions. Despite advances in preoperative selection, surgical technique and perioperative management, posthepatectomy liver failure (PHLF) is still a leading cause of morbidity and mortality following liver resection. Given the devastating physiological consequences of PHLF and the lack of effective treatment options, identifying risk factors and preventative strategies for PHLF is paramount. In the past, a major limitation to conducting high quality research on risk factors and prevention strategies for PHLF has been the absence of a standardized definition. In this article, we describe relevant definitions for PHLF, discuss risk factors and prediction models, and review advances in liver assessment tools and PHLF prevention strategies.
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Affiliation(s)
- Amir A. Rahnemai-Azar
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA
| | - Jordan M. Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sharon M. Weber
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carl Schmidt
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Emily R. Winslow
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin Hospital, Madison, WI, USA
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- *Correspondence to: Timothy M. Pawlik, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Department of Surgery, Wexner Medical Center, Ohio State University, 395 W. 12 Ave., Suite 670, Columbus, OH 43210, USA. Tel: +1-614 293 8701, Fax: +1-614 293 4063, E-mail:
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Ribero D, Zimmitti G, Aloia TA, Shindoh J, Fabio F, Amisano M, Passot G, Ferrero A, Vauthey JN. Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma. J Am Coll Surg 2016; 223:87-97. [PMID: 27049784 PMCID: PMC4925184 DOI: 10.1016/j.jamcollsurg.2016.01.060] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA. STUDY DESIGN This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at 2 centers, from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of hepatic insufficiency and liver failure-related death. RESULTS The study included 133 patients with right or left major (n = 67) or extended (n = 66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III to IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them from liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p < 0.05) were preoperative cholangitis (odds ratio [OR] 3.2), future liver remnant (FLR) volume < 30% (OR 3.5), preoperative total bilirubin level >3 mg/dL (OR 4), and albumin level < 3.5 mg/dL (OR 3.3). Only preoperative cholangitis (OR 7.5, p = 0.016) and FLR volume < 30% (OR 7.2, p = 0.019) predicted postoperative liver failure-related death. CONCLUSIONS Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure-related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.
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Affiliation(s)
- Dario Ribero
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Giuseppe Zimmitti
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Thomas A Aloia
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Junichi Shindoh
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Forchino Fabio
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Marco Amisano
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Guillaume Passot
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Alessandro Ferrero
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
| | - Jean-Nicolas Vauthey
- Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey)
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Olthof PB, Coelen RJ, Wiggers JK, Besselink MG, Busch OR, van Gulik TM. External biliary drainage following major liver resection for perihilar cholangiocarcinoma: impact on development of liver failure and biliary leakage. HPB (Oxford) 2016; 18:348-53. [PMID: 27037204 PMCID: PMC4814608 DOI: 10.1016/j.hpb.2015.11.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative biliary drainage is considered essential in perihilar cholangiocarcinoma (PHC) requiring major hepatectomy with biliary-enteric reconstruction. However, evidence for postoperative biliary drainage as to protect the anastomosis is currently lacking. This study investigated the impact of postoperative external biliary drainage on the development of post-hepatectomy biliary leakage and liver failure (PHLF). METHODS All patients who underwent major liver resection for suspected PHC between 2000 and 2015 were retrospectively analyzed. Biliary leakage and PHLF was defined as grade B or higher according to the International Study Group of Liver Surgery (ISGLS) criteria. RESULTS Eighty-nine out of 125 (71%) patients had postoperative external biliary drainage. PHLF was more prevalent in the drain group (29% versus 6%; P = 0.004). There was no difference in the incidence of biliary leakage (32% versus 36%). On multivariable analysis, postoperative external biliary drainage was identified as an independent risk factor for PHLF (Odds-ratio 10.3, 95% confidence interval 2.1-50.4; P = 0.004). CONCLUSIONS External biliary drainage following major hepatectomy for PHC was associated with an increased incidence of PHLF. It is therefore not recommended to routinely use postoperative external biliary drainage, especially as there is no evidence that this decreases the risk of biliary anastomotic leakage.
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Affiliation(s)
- Pim B. Olthof
- Correspondence Pim B. Olthof, Department of Experimental Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Tel: +31 20 56 68837. Fax: +31 20 697 6621.
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Takagi T, Yokoyama Y, Kokuryo T, Yamaguchi J, Nagino M. Liver regeneration following experimental major hepatectomy with choledochojejunostomy. Br J Surg 2015; 102:1410-7. [PMID: 26312457 DOI: 10.1002/bjs.9908] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 06/30/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Surgical treatment for perihilar cholangiocarcinoma frequently involves hepatectomy and extrahepatic bile duct resection with a choledochojejunostomy (CJ). Cholangitis owing to bilioenteric anastomosis is a common complication. The impact of CJ or regurgitating cholangitis on the liver regeneration process after major hepatectomy is unknown. METHODS Rats underwent 70 per cent hepatectomy (Hx group) or hepatectomy with CJ (Hx + CJ group). The intrahepatic inflammatory response, hepatic regeneration rate, and expression of regeneration-associated genes in the liver and blood were compared between these two groups. RESULTS Levels of hepatobiliary markers in the blood were significantly higher 4 and 7 days after operation in the Hx + CJ group than the Hx group. Intrahepatic expression of inflammation-associated genes, such as interleukin 6 and tumour necrosis factor α, was also significantly higher in the Hx + CJ group on days 4 and 7. A progressive periportal inflammatory response was identified in the Hx + CJ group by histological examination. The hepatic regeneration rate was significantly lower in the Hx + CJ group than in the Hx group on day 2 (mean(s.d.) 14·2(6·3) versus 21·4(2·6) per cent; P = 0·013) and day 4 (32·4(5·3) versus 41·3(4·4) per cent; P = 0·004). Gene expression levels of hepatic regeneration-promoting factors such as hepatocyte growth factor were significantly lower in the Hx + CJ group than the Hx group on day 1. CONCLUSION CJ perturbs early liver regeneration after hepatectomy. An excessive inflammatory response in the liver and suppression of liver regeneration-associated factors may play a role. Surgical relevance Patients with perihilar cholangiocarcinoma may need major hepatectomy with extrahepatic bile duct resection and choledochojejunostomy. This carries a substantial risk of postoperative complications including liver failure. A rat model of partial hepatectomy with choledochojejunostomy was established. The molecular mechanisms underlying liver regeneration, and perturbation of this process by duodenobiliary reflux via the choledochojejunostomy, are described. The results give insight into the pathophysiological events following major hepatectomy with extrahepatic bile duct resection and choledochojejunostomy. This may help to develop a treatment strategy to reduce postoperative liver failure.
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Affiliation(s)
- T Takagi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan 466-8550
| | - Y Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan 466-8550
| | - T Kokuryo
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan 466-8550
| | - J Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan 466-8550
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan 466-8550
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Miyazaki M, Yoshitomi H, Miyakawa S, Uesaka K, Unno M, Endo I, Ota T, Ohtsuka M, Kinoshita H, Shimada K, Shimizu H, Tabata M, Chijiiwa K, Nagino M, Hirano S, Wakai T, Wada K, Isayama H, Iasayama H, Okusaka T, Tsuyuguchi T, Fujita N, Furuse J, Yamao K, Murakami K, Yamazaki H, Kijima H, Nakanuma Y, Yoshida M, Takayashiki T, Takada T. Clinical practice guidelines for the management of biliary tract cancers 2015: the 2nd English edition. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:249-73. [PMID: 25787274 DOI: 10.1002/jhbp.233] [Citation(s) in RCA: 157] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract and ampullary carcinomas in 2008. Novel treatment modalities and handling of clinical issues have been proposed after the publication. New approaches for editing clinical guidelines, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, also have been introduced for better and clearer grading of recommendations. METHODS Clinical questions (CQs) were proposed in seven topics. Recommendation, grade of recommendation and statement for each CQ were discussed and finalized by evidence-based approach. Recommendation was graded to grade 1 (strong) and 2 (weak) according to the concept of GRADE system. RESULTS The 29 CQs covered seven topics: (1) prophylactic treatment, (2) diagnosis, (3) biliary drainage, (4) surgical treatment, (5) chemotherapy, (6) radiation therapy, and (7) pathology. In 27 CQs, 19 recommendations were rated strong and 11 recommendations weak. Each CQ included the statement of how the recommendation was graded. CONCLUSIONS This guideline provides recommendation for important clinical aspects based on evidence. Future collaboration with cancer registry will be a key for assessment of the guidelines and establishment of new evidence. Free full-text articles and a mobile application of this guideline are available via http://www.jshbps.jp/en/guideline/biliary-tract2.html.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Yokoyama Y, Ebata T, Igami T, Sugawara G, Mizuno T, Nagino M. The adverse effects of preoperative cholangitis on the outcome of portal vein embolization and subsequent major hepatectomies. Surgery 2014; 156:1190-6. [DOI: 10.1016/j.surg.2014.04.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/16/2014] [Indexed: 01/12/2023]
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Miyake T, Yokoyama Y, Kokuryo T, Mizutani T, Imamura A, Nagino M. Endothelial nitric oxide synthase plays a main role in producing nitric oxide in the superacute phase of hepatic ischemia prior to the upregulation of inducible nitric oxide synthase. J Surg Res 2013; 183:742-51. [DOI: 10.1016/j.jss.2013.01.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 12/23/2012] [Accepted: 01/24/2013] [Indexed: 02/07/2023]
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