Perioperative nutritional support and fluid therapy in patients with liver diseases

Pathophysiological consequences and treatment strategy of obstructive jaundice

Obstructive jaundice (OJ) is a common problem in daily clinical practice. However, completely understanding the pathophysiological changes in OJ remains a challenge for planning current and future management. The effects of OJ are widespread, affecting the biliary tree, hepatic cells, liver function, and causing systemic complications. The lack of bile in the intestine, destruction of the intestinal mucosal barrier, and increased absorption of endotoxins can lead to endotoxemia, production of proinflammatory cytokines, and induce systemic inflammatory response syndrome, ultimately leading to multiple organ dysfunction syndrome. Proper management of OJ includes adequate water supply and electrolyte replacement, nutritional support, preventive antibiotics, pain relief, and itching relief. The surgical treatment of OJ depends on the cause, location, and severity of the obstruction. Biliary drainage, surgery, and endoscopic intervention are potential treatment options depending on the patient's condition. In addition to modern medical treatments, Traditional Chinese medicine may offer therapeutic benefits for OJ. A comprehensive search was conducted on PubMed for relevant articles published up to August 1970. This review discusses in detail the pathophysiological changes associated with OJ and presents effective strategies for managing the condition.

Orthotopic Transplantation of Functional Bioengineered Livers in Rats

Functional bioengineered livers (FBLs) are promising alternatives to orthotopic liver transplantation. However, orthotopic transplantation of FBLs has not yet been reported. This study aimed to perform the orthotopic transplantation of FBLs in rats subjected to complete hepatectomy. FBLs were developed using rat whole decellularized liver scaffolds (DLSs) with human umbilical vein endothelial cells implanted via the portal vein, and human bone marrow mesenchymal stem cells (hBMSCs) and mouse hepatocyte cell line implanted via the bile duct. FBLs were evaluated in terms of endothelial barrier function, biosynthesis, and metabolism and orthotopically transplanted into rats to determine the survival benefit. The FBLs with well-organized vascular structures exhibited endothelial barrier function, with reduced blood cell leakage. The implanted hBMSCs and hepatocyte cell line were well aligned in the parenchyma of the FBLs. The high levels of urea, albumin, and glycogen in the FBLs indicated biosynthesis and metabolism. Orthotopic transplantation of FBLs achieved a survival time of 81.38 ± 4.263 min in rats (n = 8) subjected to complete hepatectomy, whereas control animals (n = 4) died within 30 min (p < 0.001). After transplantation, CD90-positive hBMSCs and the albumin-positive hepatocyte cell line were scattered throughout the parenchyma, and blood cells were limited within the vascular lumen of the FBLs. In contrast, the parenchyma and vessels were filled with blood cells in the control grafts. Thus, orthotopic transplantation of whole DLS-based FBLs can effectively prolong the survival of rats subjected to complete hepatectomy. In summary, this work was the first to perform the orthotopic transplantation of FBLs, with limited survival benefits, which still has important value for the advancement of bioengineered livers.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Safety and efficacy of peripheral nutrition fluid (MG-TNA®) in patients undergoing surgery for hepatobiliary and pancreatic disease: Results of a phase 4 trial

Backgrounds/Aims

Essential nutritional support and nutrition therapy for patients with hepatobiliary and pancreatic diseases undergoing surgery is critical, as it may improve clinical outcome. How to implement rational fluid therapy and nutritional support after surgery and effectively protect organ function is crucial for postoperative recovery. The aim this study was to examine the safety and efficacy of peripheral nutrition fluid (MG-TNA®) in patients undergoing surgery for hepatobiliary and pancreatic disease.

Methods

All adult patients undergoing surgery for hepatobiliary and pancreatic disease received peripheral nutrition fluid (MG-TNA®) on the second postoperative day for 3 days. During administration of parenteral nutrition, patients were closely monitored for adverse effects (primary endpoint). Secondary endpoints included nutritional parameters such as serum prealbumin, transferrin, and creatine kinase (CK) levels.

Results

Thirty patients completed the study and were included in the full analysis set. There was no evidence of metabolic complications such as hyperglycemia, azotemia, hypertriglyceridemia, metabolic acidosis and hypokalemia. In addition, there were no adverse effects. There was a significant decrease in serum prealbumin and CK on the third postoperative day (p<0.0001). Although not statistically significant, serum transferrin levels tended to decrease (p=0.0519).

Conclusions

Administration of peripheral nutrition fluid (MG-TNA®) during postoperative period in patients undergoing surgery for hepatobiliary and pancreatic disease proved to be safe with improvement of the nutritional state of the patient.

Systematic review of peri-operative nutritional support for patients undergoing hepatobiliary surgery

BACKGROUND

Malnutrition is prevalent among peri-operative patients undergoing hepatobiliary surgery and is an important prognostic factor. Both hepatobiliary disease and surgical trauma significantly affects body's metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatobiliary surgery to receive essential nutritional support during peri-operative period.

METHODS

We summarized our clinical experience and reviewed of related literature to find the way for implementing the appropriate nutritional strategy.

RESULTS

We found after comprehensively evaluating nutrition status, function of liver and gastrointestinal tract, nutritional strategy would be selected correctly. In severe malnutrition, initiation of enteral nutrition (EN) and/or parenteral nutrition (PN) with essential or special formulae is often recommended. Especially nasojejunal feeding is indicated that early application can improve nutritional status and liver function, reduce complications and prolong survival.

CONCLUSIONS

The reasonable peri-operative nutritional support therapy can improve the effect of surgical treatment and promote the patients' recovery.

Hepatectomy for hepatocellular carcinoma larger than 10 cm: preoperative risk stratification to prevent futile surgery

OBJECTIVES

Appropriate patient selection is important to achieving good outcomes and obviating futile surgery in patients with huge (≥10 cm) hepatocellular carcinoma (HCC). The aim of this study was to identify independent predictors of futile outcomes, defined as death within 3 months of surgery or within 1 year from early recurrence following hepatectomy for huge HCC.

METHODS

The outcomes of 149 patients with huge HCCs who underwent resection during 1995-2012 were analysed. Multivariate logistic regression analysis was performed to identify preoperative independent predictors of futility.

RESULTS

Independent predictors of 3-month mortality (18.1%) were: total bilirubin level >34 μmol/l [P = 0.0443; odds ratio (OR) 16.470]; platelet count of <150 000 cells/ml (P = 0.0098; OR 5.039), and the presence of portal vein tumour thrombosis (P = 0.0041; OR 5.138). The last of these was the sole independent predictor of 1-year recurrence-related mortality (17.2%). Rates of recurrence-related mortality at 3 months and 1 year were, respectively, 6.3% and 7.1% in patients with Barcelona Clinic Liver Cancer (BCLC) stage A disease, 12.5% and 14% in patients with BCLC stage B disease, and 37.8% (P = 0.0002) and 75% (P = 0.0002) in patients with BCLC stage C disease.

CONCLUSIONS

According to the present data, among patients submitted to hepatectomy for huge HCC, those with a high bilirubin level, low platelet count and portal vein thrombosis are at higher risk for futile surgery. The presence of portal vein tumour thrombosis should be regarded as a relative contraindication to surgery.