Liver resection and metabolic disorders: An undescribed mechanism leading to postoperative mortality

Combining 99mTc-GSA single-photon emission-computed tomography and Gd-EOB-DTPA-enhanced magnetic resonance imaging for staging liver fibrosis

Preoperative assessment of the degree of liver fibrosis is important to determine treatment strategies. In this study, galactosyl human serum albumin single-photon emission-computed tomography and ethoxybenzyl (EOB) contrast-enhanced magnetic resonance imaging (MRI) were used to assess the changes in hepatocyte function after liver fibrosis, and the standardized uptake value (SUV) was combined with gadolinium EOB-diethylenetriaminepentaacetic acid to evaluate its added value for liver fibrosis staging. A total of 484 patients diagnosed with hepatocellular carcinoma who underwent liver resection between January 2010 and August 2018 were included. Resected liver specimens were classified based on pathological findings into nonfibrotic and fibrotic groups (stratified according to the Ludwig scale). Galactosyl human serum albumin-single-photon emission-computed tomography and EOB contrast-enhanced MRI examinations were performed, and the mean SUVs (SUVmean) and contrast enhancement indices (CEIs) were obtained. The diagnostic value of the acquired SUV and CEIs for fibrosis was assessed by calculating the area under the receiver operating characteristic curve (AUC). In the receiver operating characteristic analysis, SUV + CEI showed the highest AUC in both fibrosis groups. In particular, in the comparison between fibrosis groups, SUV + CEI showed significantly higher AUCs than SUV and CEI alone in discriminating between fibrosis (F3 and 4) and no or mild fibrosis (F0 and 2) (AUC: 0.879, vs SUV [P = 0.008], vs. CEI [P = 0.023]), suggesting that the combination of SUV + CEI has greater diagnostic performance than the individual indices. Combining the SUV and CEI provides high accuracy for grading liver fibrosis, especially in differentiating between grades F0 and 2 and F3-4. SUV and gadolinium EOB-diethylenetriaminepentaacetic acid-enhanced MRI can be noninvasive diagnostic methods to guide the selection of clinical treatment options for patients with liver diseases.

[Evaluation of the Validity of ROI Setting in CEI Used for the Assessment of Liver]

PURPOSE

The enhancement effect ratio using ethoxybenzyl (EOB) contrast is useful in the assessment of liver fibrosis. Since the enhancement effect ratio is calculated by setting a region of interest (ROI) in the liver, the ROI setting method may affect the enhancement effect ratio. One of the methods of setting the ROI in liver fibrosis evaluation is by placing the ROI in each Quinault segment, but this method requires considerable time. Therefore, it is necessary to consider a reproducible ROI setting method in contrast to the method of placing ROIs in each Quinault segment.

METHOD

In contrast to the method of placing one ROI in each Quinault segment, we examined the method of setting four ROIs (two in the right lobe and two in the left lobe) and two ROIs (one in the right lobe and one in the left lobe). The size of the ROI was set to 1 cm², 4 cm², and the maximum area that fits within each placement area.

CONCLUSION

In the ROI setting method for CEI calculation, reproducibility can be maintained by setting the number of ROIs in four locations and by setting ROIs of 4 cm² or more.

The effect of metabolic syndrome on postoperative outcomes following laparoscopic colectomy

BACKGROUND

Among the criteria used to diagnose metabolic syndrome (MS), obesity and diabetes mellitus (DM) are associated with poor postoperative outcomes following colectomy. MS is also associated with colorectal cancer (CRC) and diverticulosis, both of which may be treated with colectomy. However, the effect of MS on postoperative outcomes following laparoscopic colectomy has yet to be clarified.

METHODS

In an academic tertiary hospital, data from all consecutive patients undergoing laparoscopic colectomy from 2005 to 2014 were prospectively recorded and analysed. Patients presenting with MS [defined by the presence of three or more of the following criteria: elevated blood pressure, body mass index > 28 kg/m², dyslipidemia (decreased serum HDL cholesterol, increased serum triglycerides) and increased fasting glucose/DM] were compared with patients without MS regarding peri-operative outcome [mainly anastomotic leaks, severe postoperative complications (Clavien-Dindo III and IV)] and mortality.

RESULTS

Overall, 1236 patients were included: 508 (41.1%) right colectomies and 728 (58.9%) left colectomies. Seven hundred seventy-two (62.4%) of these procedures were performed for CRC. MS was diagnosed in 85 (6.9%) patients, who were significantly older than the others (70 vs. 64.2 years, p < 0.001), and presented with more cardiac comorbidities (p < 0.001). MS was associated with increased blood loss (122.5 vs. 79.9 mL p = 0.001) and blood transfusion requirement (5.9 vs. 1.7%, p = 0.021). The anastomotic leak rate was 6.6% (with 2.2% of anastomotic leaks requiring surgical treatment), and the overall reoperation rate was 6.9%. The incidence of severe postoperative complications was 11.5%, and the overall mortality rate 0.6%. No differences were found between the groups in overall postoperative morbidity and mortality. Median length of stay was similar in both groups (7 days).

CONCLUSIONS

MS does not jeopardize postoperative outcomes following laparoscopic colectomy.

Consequences of metabolic syndrome on postoperative outcomes after pancreaticoduodenectomy

AIM

To analyze immediate postoperative outcomes after pancreaticoduodenectomy regarding metabolic syndrome.

METHODS

In two academic centers, postoperative outcomes of patients undergoing pancreaticoduodenectomy from 2002 to 2014 were prospectively recorded. Patients presenting with metabolic syndrome [defined as at least three criteria among overweight (BMI ≥ 28 kg/m²), diabetes mellitus, arterial hypertension and dyslipidemia] were compared to patients without metabolic syndrome.

RESULTS

Among 270 consecutive patients, 29 (11%) presented with metabolic syndrome. In univariable analysis, patients with metabolic syndrome were significantly older (69.4 years vs 62.5 years, P = 0.003) and presented more frequently with soft pancreas (72% vs 22%, P = 0.0001). In-hospital morbidity (83% vs 71%) and mortality (7% vs 6%) did not differ in the two groups so as pancreatic fistula rate (45% vs 30%, P = 0.079) and severity of pancreatic fistula (P = 0.257). In multivariable analysis, soft pancreas texture (P = 0.001), pancreatic duct diameter < 3 mm (P = 0.025) and BMI > 30 kg/m² (P = 0.041) were identified as independent risk factors of pancreatic fistula after pancreaticoduodenectomy, but not metabolic syndrome.

CONCLUSION

In spite of logical reasoning and appropriate methodology, present series suggests that metabolic syndrome does not jeopardize postoperative outcomes after pancreaticoduodenectomy. Therefore, definition of metabolic syndrome seems to be inappropriate and fatty pancreas needs to be assessed with an international consensual histopathological classification.