Oncologic and surgical outcomes in colorectal cancer patients with liver cirrhosis: A propensity-matched study

Elevated expression patterns of P-element Induced Wimpy Testis (PIWI) transcripts are potential candidate markers for Hepatocellular Carcinoma

BACKGROUND

P-Element-induced wimpy testis (PIWI) proteins, when in combination with PIWI-interacting RNA (piRNA), are engaged in the epigenetic regulation of gene expression in germline cells. Different types of tumour cells have been found to exhibit abnormal expression of piRNA, PIWIL-mRNAs, and proteins. We aimed to determine the mRNA expression profiles of PIWIL1, PIWIL2, PIWIL3, & PIWIL4, in hepatocellular carcinoma patients, and to associate their expression patterns with clinicopathological features.

METHODS

The expression patterns of PIWIL1, PIWIL2, PIWIL3, PIWIL4 mRNA, was assessed via real-time quantitative polymerase chain reaction (RT-QPCR), on tissue and serum samples from HCC patients, their impact for diagnosis was evaluated by ROC curves, prognostic utility was determined, and In Silico analysis was conducted for predicted variant detection, association with HCC microRNAs and Network Analysis.

RESULTS

Expression levels were significantly higher in both HCC tissue and serum samples than in their respective controls (p< 0.001). Additionally, the diagnostic performance was assessed, Risk determination was found to be statistically significant.

CONCLUSION

PIWIL mRNAs are overexpressed in HCC tissue and serum samples, the expression patterns could be valuable molecular markers for HCC, due to their association with age, tumour grade and pattern. To the best of our knowledge, our study is the first to report the expression levels of all PIWIL mRNA and to suggest their remarkable values as diagnostic and prognostic biomarkers, in addition to their correlation to HCC development. Additionally, a therapeutic opportunity might be also suggested through in silico miRNA prediction for HCC and PIWIL genes through DDX4 and miR-124-3p.

Colorectal Cancer in Individuals with Cirrhosis: A Population-Based Study Assessing Practice Patterns, Outcomes, and Predictors of Survival

Those with cirrhosis who develop colorectal cancer (CRC) are an understudied group who may tolerate treatments poorly and are at risk of worse outcomes. This is a retrospective cohort study of 842 individuals from Ontario, Canada, with a pre-existing diagnosis of cirrhosis who underwent surgery for CRC between 2009 and 2017. Practice patterns, overall survival, and short-term morbidity and mortality were assessed. The most common cirrhosis etiology was non-alcoholic fatty liver disease (NAFLD) (52%) and alcohol-associated liver disease (29%). The model for end-stage liver disease score (MELD-Na) was available in 42% (median score of 9, IQR7-11). Preoperative radiation was used in 62% of Stage II/III rectal cancer patients, while postoperative chemotherapy was used in 42% of Stage III colon cancer patients and 38% of Stage II/III rectal cancer patients. Ninety-day mortality following surgery was 12%. Five-year overall survival was 53% (by Stages I-IV, 66%, 55%, 50%, and 11%, respectively). Those with alcohol-associated cirrhosis (HR 1.8, 95% CI 1.5-2.2) had lower survival than those with NAFLD. Those with a MELD-Na of 10+ did worse than those with a lower MELD-Na score (HR 1.9, 95% CI 1.4-2.6). This study reports poor survival in those with cirrhosis who undergo treatment for CRC. Caution should be taken when considering aggressive treatment.

Colorectal Surgery in Patients with Liver Cirrhosis: A Systematic Review

BACKGROUND

Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery.

METHODS

The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale.

RESULTS

Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%.

CONCLUSION

Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes.

Prevalence of benign focal liver lesions and non-hepatocellular carcinoma malignant lesions in liver cirrhosis

Liver cirrhosis is associated with an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may co-exist or may be the only focal liver lesion (FLL) detected. Compared to HCC, comparatively little is known about the frequency and natural history of benign FLL in patients with established liver cirrhosis.

This review analyses the prevalence and frequency of benign and malignant FLL others than hepatocellular carcinoma (HCC) in liver cirrhosis including imaging and autopsy studies. Understanding these data should be helpful in avoiding misdiagnoses.

Risk factors and prognoses of invasive Candida infection in surgical critical ill patients with perforated peptic ulcer

BACKGROUND

The risk of invasive Candida infection (ICI) is high in patients with perforated peptic ulcer (PPU) who received laparotomy or laparoscopic surgery, but the risk factors and predictors of morbidity outcomes remain uncertain. This study aims to identify the risk factors of ICI in surgical critically ill PPU patients and to evaluate the impact on patient's outcomes.

METHODS

This is a single-center, retrospective study, with a total of 170 surgical critically ill PPU patients. Thirty-seven patients were ICI present and 133 were ICI absent subjects. The differences in pulmonary complications according to invasive candidiasis were determined by the Mann-Whitney U test. Evaluation of predictors contributing to ICI and 90-day mortality was conducted by using multivariate logistic regression analysis.

RESULTS

Candida albicans was the primary pathogen of ICI (74.29%). The infected patients had higher incidence of bacteremia (p < 0.001), longer intensive care unit (p < 0.001) and hospital (p < 0.001) stay, longer ventilator duration (p < 0.001) and increased hospital mortality (p = 0.02). In the multivariate analysis, serum lactate level measured at hospital admission was independently associated with the occurrence of ICI (p = 0.03). Liver cirrhosis (p = 0.03) and Sequential Organ Failure Assessment (SOFA) score (p = 0.007) were independently associated with the 90-day mortality.

CONCLUSIONS

Blood lactate level measured at hospital admission could be a predictor of ICI and the surgical critically ill PPU patients with liver cirrhosis and higher SOFA score are associated with poor outcomes.

Mortality following elective and emergency colectomy in patients with cirrhosis: a population-based cohort study from England

BACKGROUND

Patients with cirrhosis undergoing colectomy have a higher risk of postoperative mortality, but contemporary estimates are lacking and data on associated risk and longer term outcomes are limited. This study aimed to quantify the risk of mortality following colectomy by urgency of surgery and stage of cirrhosis.

DATA SOURCES

Linked primary and secondary-care electronic healthcare data from England were used to identify all patients undergoing colectomy from January 2001 to December 2017. These patients were classified by the absence or presence of cirrhosis and severity. Case fatality rates at 90 days and 1 year were calculated, and cox regression was used to estimate the hazard ratio of postoperative mortality controlling for age, gender and co-morbidity.

RESULTS

Of the total, 36,380 patients undergoing colectomy, 248 (0.7%) had liver cirrhosis, and 70% of those had compensated cirrhosis. Following elective colectomy, 90-day case fatality was 4% in those without cirrhosis, 7% in compensated cirrhosis and 10% in decompensated cirrhosis. Following emergency colectomy, 90-day case fatality was higher; it was 16% in those without cirrhosis, 35% in compensated cirrhosis and 41% in decompensated cirrhosis. This corresponded to an adjusted 2.57 fold (95% CI 1.75-3.76) and 3.43 fold (95% CI 2.02-5.83) increased mortality risk in those with compensated and decompensated cirrhosis, respectively. This higher case fatality in patients with cirrhosis persisted at 1 year.

CONCLUSION

Patients with cirrhosis undergoing emergency colectomy have a higher mortality risk than those undergoing elective colectomy both at 90 days and 1 year. The greatest mortality risk at 90 days was in those with decompensation undergoing emergency surgery.

Gastrointestinal Cancers and Liver Cirrhosis: Implications on Treatments and Prognosis

Liver cirrhosis tends to increase the risk in the management of gastrointestinal tumors. Patients with gastrointestinal cancers and liver cirrhosis often have serious postoperative complications and poor prognosis after surgery. Multiple studies have shown that the stage of gastrointestinal cancers and the grade of cirrhosis can influence surgical options and postoperative complications. The higher the stage of cancer and the poorer the degree of cirrhosis, the less the surgical options and the higher the risk of postoperative complications. Therefore, in the treatment of patients with gastrointestinal cancer and liver cirrhosis, clinicians should comprehensively consider the cancer stage, cirrhosis grade, and possible postoperative complications. This review summarizes the treatment methods of patients with different gastrointestinal cancer complicated with liver cirrhosis.

Child-Turcotte-Pugh Score as a Predictive Factor for Long-Term Survival After Repeat Hepatectomy for Recurrent Liver Metastases of Colorectal Cancer

Objective

We aimed to evaluate the changes in liver function after repeat hepatectomy and their relationship with survival of patient with colorectal cancer.

Summary of Background Data

Repeat hepatectomy has been accepted as an effective treatment for recurrent liver metastases; however, how repeat hepatectomy changes the liver function during the follow-up period is not well understood.

Methods

Data regarding patients underwent R0 resections at initial hepatectomy for colorectal cancer with liver metastasis from 2012 to 2017 were retrospectively reviewed. Patients were divided into groups according to the total number of hepatectomies. Overall survival and Child-Turcotte-Pugh score after hepatectomy were analyzed.

Results

Fifty-three patients underwent single hepatectomy and 37 patients underwent repeat hepatectomy. There was no significant difference in the overall survival rates between the 2 groups. At 27 months after the initial hepatectomy, mean Child-Turcotte-Pugh scores of patients with repeat hepatectomy started to become statistically higher than those of patients with single hepatectomy. Overall survival of patients who survived after 27 months from the initial hepatectomy showed a statistical difference between the 2 groups. The total number of liver metastases ≥ 4 and Child-Turcotte-Pugh score ≥ 6 at 27 months after the initial hepatectomy were significant risk factors for overall survival of patient who survived after 27 months from the initial hepatectomy.

Conclusions

Liver function after repeat hepatectomy can be deteriorated after a long-term period. Careful approach and continuous assessment of the liver function after hepatectomy are necessary to maintain long-term survival after repeat hepatectomy.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Mortality After Extrahepatic Gastrointestinal and Abdominal Wall Surgery in Patients With Alcoholic Liver Disease: A Systematic Review and Meta-Analysis

AIMS

This meta-analysis aimed to define the perioperative risk of mortality in patients with alcoholic liver disease (ALD) undergoing extrahepatic gastrointestinal surgery.

METHODS

Systematic searches of Embase, Medline and CENTRAL were undertaken to identify studies reporting about patients with ALD undergoing extrahepatic gastrointestinal surgery published since database inception to January 2019. Studies were only considered if they reported on mortality as an outcome. Pooled analysis of mortality was stratified as benign and malignant surgery and specific operative procedures where feasible.

RESULTS

Of the 2899 studies identified, only five studies met inclusion criteria, representing cholecystectomy (one study), umbilical hernia repair surgery (one study) and oesophagectomy (three studies). The total number of patients with ALD in these studies was 172. Therefore, any study on liver disease patients undergoing extrahepatic surgery that crucially included a subset with alcohol aetiology was included as a secondary analysis even though they failed to stratify mortality by underlying aetiology. The total number of studies that met this expanded inclusion criteria was 62, reporting on 37,703 patients with liver disease of which 1735 (4.5%) had a definite diagnosis of ALD. Meta-analysis of proportions of in-hospital mortality in patients with ALD undergoing upper gastrointestinal cancer surgery (oesophagectomy) was 23% [95% confidence interval (CI) 14-35%, I2 = 0%]. In-hospital mortality following oesophagectomy in liver disease patients of all aetiologies was lower, 14% (95% CI 9-21%, I2 = 41.1%).

CONCLUSION

Postoperative in-hospital mortality is high in patients with liver disease and ALD in particular. However, the currently available evidence on ALD is limited and precludes definitive conclusions on postoperative mortality risk.

Does liver cirrhosis affect the surgical outcome of primary colorectal cancer surgery? A meta-analysis

PURPOSE

The purpose of this meta-analysis was to evaluate the effect of liver cirrhosis (LC) on the short-term and long-term surgical outcomes of colorectal cancer (CRC).

METHODS

The PubMed, Embase, and Cochrane Library databases were searched from inception to March 23, 2021. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of enrolled studies, and RevMan 5.3 was used for data analysis in this meta-analysis. The registration ID of this current meta-analysis on PROSPERO is CRD42021238042.

RESULTS

In total, five studies with 2485 patients were included in this meta-analysis. For the baseline information, no significant differences in age, sex, tumor location, or tumor T staging were noted. Regarding short-term outcomes, the cirrhotic group had more major complications (OR=5.15, 95% CI=1.62 to 16.37, p=0.005), a higher re-operation rate (OR=2.04, 95% CI=1.07 to 3.88, p=0.03), and a higher short-term mortality rate (OR=2.85, 95% CI=1.93 to 4.20, p<0.00001) than the non-cirrhotic group. However, no significant differences in minor complications (OR=1.54, 95% CI=0.78 to 3.02, p=0.21) or the rate of intensive care unit (ICU) admission (OR=0.76, 95% CI=0.10 to 5.99, p=0.80) were noted between the two groups. Moreover, the non-cirrhotic group exhibited a longer survival time than the cirrhotic group (HR=2.96, 95% CI=2.28 to 3.85, p<0.00001).

CONCLUSION

Preexisting LC was associated with an increased postoperative major complication rate, a higher rate of re-operation, a higher short-term mortality rate, and poor overall survival following CRC surgery.

Clinical Characteristics of Primary Repair for Perforated Peptic Ulcer: 10-Year Experience in a Single Center

Background: Perforated peptic ulcer (PPU) is a disease whose incidence is decreasing. However, PPU still requires emergency surgery. The aim of this study was to review the clinical characteristics of patients who received primary repair for PPU and identify the predisposing factors associated with severe complications. Method: From January 2011 to December 2020, a total of 75 patients underwent primary repair for PPU in our hospital. We reviewed the patients’ data, including general characteristics and perioperative complications. Surgical complications were evaluated using the Clavien-Dindo Classification (CDC) system, with which we classified patients into the mild complication (CDC 0–III, n = 61) and severe complication (CDC IV–V, n = 14) groups. Result: Fifty patients had gastric perforation, and twenty-five patients had duodenal perforation. Among surgical complications, leakage or fistula were the most common (5/75, 6.7%), followed by wound problems (4/75, 5.3%). Of the medical complications, infection (9/75, 12%) and pulmonary disorder (7/75, 9.3%) were common. Eight patients died within thirty days after surgery (8/75, 10.7%). Liver cirrhosis was the most significant predisposing factor for severe complications (HR = 44.392, p = 0.003). Conclusion: PPU is still a surgically important disease that has significant mortality, above 10%. Liver cirrhosis is the most important underlying disease associated with severe complications.

Metastases can occur in cirrhotic livers with patent portal veins

Objectives

Metastases are common in non-cirrhotic livers but are considered unlikely in the setting of cirrhosis. However, the degree of fibrosis in cirrhosis may vary; thus metastases may still access the liver vasculature and present as a mass in cirrhotic livers. This possibility may affect pathologists’ diagnostic algorithms when faced with a liver mass biopsy.

Methods

We hypothesized that metastases can occur in cirrhotic livers if fibrous remodeling is not severe or abnormal veno-arterial shunting exists to override an obstructed portal system. We searched departmental archives for cirrhotic livers with masses, categorizing fibrosis by Laennec staging: 4A = mild cirrhosis, 4B = moderate, 4 C = severe.

Results

Of 1453 cirrhotic livers with masses, 1429 were primary tumors and 24 were metastases (1.7 %). Of livers with metastases, most had 4A or 4B cirrhosis by Laennec staging (n = 17; 71 %). Eleven patients were evaluated by ultrasound Doppler; 2 of 5 with Laennec 4 C had reversal of portal vein flow, but all 4A & 4B patients had patent portal veins without reversed flow. Echocardiograms (13 patients) showed no ventricular or atrial septal defects or arteriovenous shunts.

Conclusions

Metastases are uncommon in cirrhotic livers, accounting for 1.7 % of masses. Most involved livers had mild or moderate cirrhosis (Laennec 4A/4B) and patent portal veins; however, as some Laennec 4 C cases also contained metastases, obstructed portal access may not be enough to deter metastatic access.

Platinum ineligibility in squamous cell carcinoma of the head and neck: consensus from Central America and the Caribbean

The high incidence of head and neck cancer in Central America and the Caribbean, together with limitations in the healthcare system for patients with locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) in this region necessitate a consensus of opinion based on a review of the literature on therapy with cisplatin plus radiation. Such an approach will ensure appropriate selection of patients who can benefit from therapy and reduce the incidence of related adverse events. Therefore, we recorded the opinion of experts in the region in order to identify needs and challenges in the treatment of LA SCCHN.

Quantitative magnetic resonance imaging predicts individual future liver performance after liver resection for cancer

The risk of poor post-operative outcome and the benefits of surgical resection as a curative therapy require careful assessment by the clinical care team for patients with primary and secondary liver cancer. Advances in surgical techniques have improved patient outcomes but identifying which individual patients are at greatest risk of poor post-operative liver performance remains a challenge. Here we report results from a multicentre observational clinical trial (ClinicalTrials.gov NCT03213314) which aimed to inform personalised pre-operative risk assessment in liver cancer surgery by evaluating liver health using quantitative multiparametric magnetic resonance imaging (MRI). We combined estimation of future liver remnant (FLR) volume with corrected T1 (cT1) of the liver parenchyma as a representation of liver health in 143 patients prior to treatment. Patients with an elevated preoperative liver cT1, indicative of fibroinflammation, had a longer post-operative hospital stay compared to those with a cT1 within the normal range (6.5 vs 5 days; p = 0.0053). A composite score combining FLR and cT1 predicted poor liver performance in the 5 days immediately following surgery (AUROC = 0.78). Furthermore, this composite score correlated with the regenerative performance of the liver in the 3 months following resection. This study highlights the utility of quantitative MRI for identifying patients at increased risk of poor post-operative liver performance and a longer stay in hospital. This approach has the potential to inform the assessment of individualised patient risk as part of the clinical decision-making process for liver cancer surgery.

Risk Factors for Postoperative Morbidity and Mortality after Small Bowel Surgery in Patients with Cirrhotic Liver Disease-A Retrospective Analysis of 76 Cases in a Tertiary Center

Simple Summary

It is well known that the incidence of liver cirrhosis is increasing and it negatively affects outcome after surgery. While there are several studies investigating the influence of liver cirrhosis on colorectal, hepatobiliary, or hernia surgery, data about its impact on small bowel surgery are completely lacking. Therefore, a retrospective analysis over a period of 17 years was performed including 76 patients with liver cirrhosis and small bowel surgery. Postsurgical complications were analyzed, and 38 parameters as possible predictive factors for a worse outcome were investigated. We observed postsurgical complications in over 90% of the patients; in over 50%, the complications were classified as severe. When subdividing postoperative complications, bleeding, respiratory problems, wound healing disorders and anastomotic leakage, hydropic decompensation, and renal failure were most common. The most important predictive factors for those complications after uni- and multivariate analysis were portal hypertension, poor liver function, emergency or additional surgery, ascites, and high ASA score. We, therefore, recommend treatment of portal hypertension before small bowel surgery to avoid extension of the operation to other organs than the small bowel and in case of ascites to evaluate the creation of an anastomosis stoma instead of an unprotected anastomosis to prevent leakages.

Abstract

(1) Purpose: As it is known, patients with liver cirrhosis (LC) undergoing colon surgery or hernia surgery have high perioperative morbidity and mortality. However, data about patients with LC undergoing small bowel surgery is lacking. This study aimed to analyze the morbidity and mortality of patients with LC after small bowel surgery in order to determine predictive risk factors for a poor outcome. (2) Methods: A retrospective analysis was performed of all patients undergoing small bowel surgery between January 2002 and July 2018 and identified 76 patients with LC. Postoperative complications were analyzed using the classification of Dindo/Clavien (D/C) and further subdivided (hemorrhage, pulmonary complication, wound healing disturbances, renal failure). A total of 38 possible predictive factors underwent univariate and multivariate analyses for different postoperative complications and in-hospital mortality. (3) Results: Postoperative complications [D/C grade ≥ II] occurred in 90.8% of patients and severe complications (D/C grade ≥ IIIB) in 53.9% of patients. Nine patients (11.8%) died during the postoperative course. Predictive factors for overall complications were “additional surgery” (OR 5.3) and “bowel anastomosis” (OR 5.6). For postoperative mortality, we identified the model of end-stage liver disease (MELD) score (OR 1.3) and portal hypertension (OR 5.8) as predictors. The most common complication was hemorrhage, followed by pulmonary complications, hydropic decompensation, renal failure, and wound healing disturbances. The most common risk factors for those complications were portal hypertension (PH), poor liver function, emergency or additional surgery, ascites, and high ASA score. (4) Conclusions: LC has a devastating influence on patients’ outcomes after small bowel resection. PH, poor liver function, high ASA score, and additional or emergency surgery as well as ascites were significant risk factors for worse outcomes. Therefore, PH should be treated before surgery whenever possible. Expansion of the operation should be avoided whenever possible and in case of at least moderate preoperative ascites, the creation of an anastomotic ostomy should be evaluated to prevent leakages.

Hypertriglyceridaemia as a risk factor for critical care admission in acute pancreatitis: A prospective study

BACKGROUND AND AIMS

Hypertriglyceridaemia is both a primary cause of acute pancreatitis and an epiphenomenon. This study aimed to define the associations between hypertriglyceridaemia and clinical outcomes in patients admitted with acute pancreatitis.

METHODS

This single-centre prospective observational study included patients with a confirmed clinical, biochemical or radiological diagnosis of acute pancreatitis from August 2017 to September 2018. Baseline demographics, aetiology of pancreatitis, and fasting triglyceride concentrations were recorded and assessed against the surrogate markers of severity: admission to critical care, length of stay (LOS), readmission to hospital, and mortality.

RESULTS

In total, 304 patients with a mean ± SD age of 56.1 ± 19.7 years met the inclusion criteria. There were 217 (71.4%) patients with normotriglyceridaemia (<150 mg/dL or <1.7 mmol/L), 47 (15.5%) with mild hypertriglyceridaemia (150-199 mg/dL or 1.7-2.25 mmol/L) and 40 (13.2%) with moderate-to-severe hypertriglyceridaemia (≥200 mg/dL or >2.25 mmol/L). The underlying aetiologies of acute pancreatitis were gallstones (55%), alcohol (18%), idiopathic (15%), hypertriglyceridaemia (9%), iatrogenic (2%) and bile duct abnormalities (1%). Patients with hypertriglyceridaemia were younger than those with normotriglyceridaemia (p < 0.05). On multivariate regression, moderate-to-severe hypertriglyceridaemia (OR 5.66, 95% CI: 1.87 to 17.19, p = 0.002) and an elevated C-reactive protein concentration ≥120 mg/L (OR 1.00, 95% CI: 1.00-1.01, p = 0.040) were associated with admission to critical care. Moderate-to-severe hypertriglyceridaemia was also associated with an increased LOS (p = 0.002) but not readmission (p = 0.752) or mortality (p = 0.069).

CONCLUSION

Moderate-to-severe hypertriglyceridaemia in all aetiological causes of acute pancreatitis was predictive of admission to critical care and prolonged LOS but not readmission or mortality.

The prognoses and postoperative outcomes of patients with both colorectal cancer and liver cirrhosis based on a nationwide cohort in Korea

Purpose

The management of patients with colorectal cancer (CRC) who have liver cirrhosis (LC) requires a thorough understanding of both diseases; however, the prognoses and postoperative outcomes of such patients remain understudied. We investigated the effect of LC on surgical and oncologic outcomes in patients with CRC, and identified prognostic factors.

Methods

We analyzed 453 patients with CRC and LC (CRC-LC group), 906 with CRC only (CRC group), 906 with LC only (LC group), and 1,812 healthy subjects using health insurance claim data (2008–2013).

Results

The CRC-LC group had a higher frequency of intensive care unit admission than the CRC group; there were no differences between the 2 groups in terms of early and late postoperative small bowel obstruction and incisional hernia. However, the 30-day, 60-day, and 90-day mortality rates were all significantly higher in the CRC-LC group. The higher Charlson comorbidity index (hazard ratio [HR], 1.127) and the lower socioeconomic status (HR, 0.985) were significant worse predictors of 5-year survival. Patients with underlying LC had a significantly higher HR in both the advanced CRC (HR, 1.858) and nonadvanced CRC (HR, 1.799) subgroups. However, the nonadvanced CRC subgroup showed a lower HR than the LC group (HR, 0.730).

Conclusion

Patients with CRC who had underlying LC had a lower survival rate than did those without LC, although the incidence rates of postoperative complications were not significantly different. The presence of LC was associated with a significantly lower survival rate regardless of CRC presence.

NOD-like receptor C4 Inflammasome Regulates the Growth of Colon Cancer Liver Metastasis in NAFLD

Nonalcoholic fatty liver disease (NAFLD) enhances the growth and recurrence of colorectal cancer (CRC) liver metastasis. With the rising prevalence of NAFLD, a better understanding of the molecular mechanism underlying NAFLD-associated liver metastasis is crucial. Tumor-associated macrophages (TAMs) constitute a large portion of the tumor microenvironment that promotes tumor growth. NOD-like receptor C4 (NLRC4), a component of an inflammasome complex, plays a role in macrophage activation and interleukin (IL)-1β processing. We aimed to investigate whether NLRC4-mediated TAM polarization contributes to metastatic liver tumor growth in NAFLD. Wild-type and NLRC4^-/- mice were fed low-fat or high-fat diet for 6 weeks followed by splenic injection of mouse CRC MC38 cells. The tumors were analyzed 2 weeks after CRC cell injection. High-fat diet-induced NAFLD significantly increased the number and size of CRC liver metastasis. TAMs and CD206-expressing M2 macrophages accumulated markedly in tumors in the presence of NAFLD. NAFLD up-regulated the expression of IL-1β, NLRC4, and M2 markers in tumors. In NAFLD, but not normal livers, deletion of NLRC4 decreased liver tumor growth accompanied by decreased M2 TAMs and IL-1β expression in tumors. Wild-type mice showed increased vascularity and vascular endothelial growth factor (VEGF) expression in tumors with NAFLD, but these were reduced in NLRC4^-/- mice. When IL-1 signaling was blocked by recombinant IL-1 receptor antagonist, liver tumor formation and M2-type macrophages were reduced, suggesting that IL-1 signaling contributes to M2 polarization and tumor growth in NAFLD. Finally, we found that TAMs, but not liver macrophages, produced more IL-1β and VEGF following palmitate challenge. Conclusion: In NAFLD, NLRC4 contributes to M2 polarization, IL-1β, and VEGF production in TAMs, which promote metastatic liver tumor growth.

Familial and non-familial risk factors associated with colorectal cancer survival in young and middle-aged patients

BACKGROUND

Survival following colorectal cancer (CRC) survival may be influenced by a number of factors including family history, individual medical history, and comorbidities. The impact of these factors may vary based on the patient's age.

METHODS

The study cohort consisted of individuals born in Western Australia between 1945 and 1996, who had been diagnosed with CRC prior to 2015 (n = 3220). Hospital, cancer, and mortality data were extracted for each patient from state health records and were used to identify potential risk factors associated with CRC survival. Family linkage data, in combination with cancer registry data, were used to identify first-degree family members with a history of CRC. The association between survival following CRC diagnosis and identified risk factors was examined using Cox proportional hazard models.

RESULTS

Age and sex were not significantly associated with survival in young patients. However, in middle-aged patients increasing age (HR 1.03, 95% CI 1.01-1.05, p = 0.003) and being male (HR 0.72, 95% CI 0.60-0.87, p < 0.001) were associated with reduced survival. Being diagnosed with polyps and having a colonoscopy prior to CRC diagnosis were associated with improved survival in both young and middle-aged patients, while a history of non-CRC and liver disease was associated with reduced survival. In middle-aged patients, having diabetes-related hospital admissions (HR 1.53, 95% CI 1.15-2.03, p = 0.004) was associated with reduced survival.

CONCLUSIONS

In both young and middle-aged patients with CRC, factors associated with early screening and detection were associated with increased CRC survival while a history of liver disease and non-CRC was associated with decreased CRC survival.

Routine monitoring of liver function tests in lung cancer resections - a necessary burden?

BACKGROUND

Increased availability of routine investigations results in significant over-investigation, burdening patients with unnecessary tests as well as increasing cost. We aimed to identify the extent of monitoring of liver function tests in lung resections, and to ascertain whether any impact on clinical decision-making occurred.

METHODS

Cases were identified using theatre records coded as "lobectomy/bilobectomy" in the three-month period 20 June 2017 to 20 September 2017. Electronic records were used to collect patient data.

RESULTS

A total of 91 cases were included; 77 (85%) patients had 1 set of pre-operative LFTs, 12 (13%) patients had 2 sets, and 2 (2%) patients had 0 sets; 69 (76%) had normal LFTs pre-operatively; 298 sets of LFTs were measured post-operatively, with a median of 3 sets per patient; 61 (67%) patients had either normal or static LFTs post-operatively, 13 (14%) had isolated rise in GGT, 16 (17%) had derangement of ALT and AST, and 1 patient (1%) had deranged ALP. Altered clinical decision-making due to LFTs derangement was recorded in two cases (2%).

CONCLUSION

Clinicians have an obligation to justify expense, and practise in a cost-effective manner. Our data suggest that the routine perioperative monitoring of LFTs in thoracic surgery does not give any clear benefit to patient care.

Meta-analysis of short- and long-term outcomes after pure laparoscopic versus open liver surgery in hepatocellular carcinoma patients

Background

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

Methods

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

Results

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

Conclusions

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

Temporary closure of colostomy with suture before colostomy takedown improves the postoperative outcomes

PURPOSE

Temporary loop colostomy is a common surgical procedure used to avoid complications in high-risk distal anastomosis as well as pelvic inflammation. Issues regarding postoperative outcomes of colostomy takedown have been widely discussed in the literature, wound infection especially. Temporary closure of colostomy with suture before takedown was adopted in our study, which provided excellent traction to aid mobilization of stomy and avoided stool spillage to downgrade the wound classification to "clean contamination." We aimed to determine the effects of the procedure on postoperative outcomes.

METHODS

This was a prospective case-control study at a single tertiary medical center. Patients presenting for elective colostomy takedown were included. Allis clamp (n = 50) or silk suture (n = 60) was applied to mobilize the colostomy, and results were compared. Operative time and wound infection rate were measured as primary postoperative outcomes. Univariate and multivariate analyses were used to demonstrate the association between the two groups and outcomes.

RESULTS

In univariate analyses, significantly shorter operative time (median = 57 min, p = 0.003) and lower postoperative wound infection rate (3%, p = 0.03) were noted in the group receiving silk suture. Multivariate analyses results showed that silk suture was significantly associated with both operative time (B = - 8.5, p = 0.01) and wound infection (odds ratio = 0.18, p = 0.04).

CONCLUSION

With the advantage of enhancing traction and decreasing contamination, the temporary closure of colostomy with suture improved takedown outcomes, including a shorter operative time and lower wound infection rate.