Complete mesocolic excision for right hemicolectomy: an updated systematic review and meta-analysis

PURPOSE

Complete mesocolic excision improves lymphadenectomy for right hemicolectomy and respects the embryological planes. However, its effect on cancer-free and overall survival is questioned. Therefore, we aimed to determine the potential benefits of the technique by performing a systematic review of the literature and meta-analysis of the available evidence.

METHODS

Web of Science, PubMed/Medline, and Embase were searched on February 22, 2023. Original studies on short- and long-term oncological outcomes of adult patients undergoing right hemicolectomy with complete mesocolic excision as a treatment for primary colon cancer were considered for inclusion. Outcomes were extracted and pooled using a model with random effects.

RESULTS

A total of 586 publications were identified through database searching, and 18 from citation searching. Exclusion of 552 articles left 24 articles for inclusion. Meta-analysis showed that complete mesocolic excision increased the lymph node harvest (5 studies, 1479 patients, MD 9.62, 95% CI 5.83-13.41, p > 0.0001, I2 84%), 5-year overall survival (5 studies, 2381 patients, OR 1.88, 95% CI 1.14-3.09, p = 0.01, I2 66%), 5-year disease-free survival (4 studies, 1376 patients, OR 2.21, 95% CI 1.51-3.23, p < 0.0001, I2 0%) and decreased the incidence of local recurrence (4 studies, 818 patients, OR 0.27, 95% CI 0.09-0.79, p = 0.02, I2 0%) when compared to standard right hemicolectomy. Perioperative morbidity was similar between the techniques (8 studies, 3899 patients, OR 1.04, 95% CI 0.89-1.22, p = 0.97, I2 0%).

CONCLUSION

Meta-analysis of observational and randomised studies showed that right hemicolectomy with complete mesocolic excision for primary right colon cancer improves oncologic results without increasing morbidity/mortality. These results need to be confirmed by high-quality evidence and randomised trials in selected patients to assess who may benefit from the procedure.

Evaluation of family history in individuals with heterozygous BRCA pathogenic variants diagnosed with breast or ovarian cancer in a single center in Italy

BACKGROUND

BRCA1 and BRCA2 gene mutations are responsible for 5% of breast cancer (BC) and 10-15% of ovarian cancer (EOC). The presence of a germline mutation and therefore the identification of subjects at high risk of developing cancer should ideally precede the onset of the disease, so that appropriate surveillance and risk-reducing treatments can be proposed. In this study, we revisited the family history (FH) of women who tested positive for BRCA mutations after being diagnosed with BC or EOC.

METHODS

The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines®), and the Italian Association of Medical Oncology (AIOM) guidelines were applied to the FH of 157 women who were referred to San Gerardo Hospital for genetic counseling.

RESULTS

Almost 85% of women had an FH of BRCA-related cancer. 63.7% and 52.2% of women could have undergone genetic testing according to NCCN and AIOM testing criteria (p < .05) before tumor diagnosis. An FH of EOC was the most frequent NCCN criterion, followed by BC diagnosed <45 years old. Sixty-five percent of deceased women could have undergone genetic testing before developing cancer.

CONCLUSIONS

FH is a powerful tool to identify high-risk individuals eligible for genetic counseling and testing. Testing of healthy individuals should be considered when an appropriately affected family member is unavailable for testing.

Simultaneous Winslow and Petersen’s Hernias after a Roux-en-Y Gastric Bypass Causing Bowel Obstruction: Laparoscopic Management and Review of the Literature

Internal hernias after Roux-en-Y gastric bypass are one of the most common complications in bariatric surgery leading to hospital readmissions with or without surgery. Due to the insidious and non-specific clinical presentation combined with difficult radiological identification, internal hernias remain a diagnostic and therapeutic challenge. Delay in diagnosis and treatment can lead to severe morbidity and mortality. We report the case of a patient presenting an unusual intestinal obstruction due to two simultaneous and distinct internals hernias affecting the Petersen’s defect and the foramen of Winslow 4 years after a laparoscopic gastric bypass. A 41-year-old female patient with a history of robotic laparoscopic Roux-en-Y gastric bypass presented with proximal small bowel obstruction symptoms and epigastric pain. Computed tomography showed two simultaneous internal hernias, one affecting the Petersen’s defect and the other affecting the foramen of Winslow with an incarcerated transverse colon. We performed an explorative laparoscopy to reduce both hernias and, after an assessment of bowel viability by indocyanine green angiography, we closed both defects with interrupted non-absorbable sutures to prevent recurrence. The follow-up of more than 1 year has been uneventful. In the cases of obstruction and hospital admission after gastric bypass, we suggest that patients undergo a computed tomography directly after the initial examination. Internal hernia diagnosis is often delicate and requires surgical exploration since bowel strangulation can lead to dramatic outcomes. The operation can be safely done laparoscopically, and all internal hernia defects should be repaired with non-absorbable sutures.

Analysis of DCD porcine kidney graft viability during sub-normothermic perfusion using magnetic resonance imaging and spectroscopy

Objective

Better preservation strategies for the storage of donation after circulatory death grafts could increase the number of kidneys available and improve patient survival. Warm (22°C and 37°C) ex-vivo perfusion has emerged as an alternative to hypothermia and a feasible strategy to recover/repair organs, but the underlying mechanism remains elusive. Here, using magnetic resonance imaging spectroscopy (MRIs), we evaluated kidney viability, and adenosine triphosphate (ATP) production during sub-normothermic ex-vivo kidney perfusion (22°C + O2) versus hypothermic machine perfusion (4°C and 4°C + O2) in a porcine kidney autotransplantation model.

Methods

To mimic donation after circulatory death (DCD), kidneys from 8-month-old pigs underwent 60 minutes of warm ischemia, prior to procurement. Kidneys were then perfused ex-vivo at 4°C with (4°C + O2), and without oxygen (4°C) or at 22°C (22°C + O2) before autotransplantation. During the ex-vivo perfusion, and after transplantation we assessed energy metabolites using MRIs. In addition, we performed Gadolinum (Gd) perfusion sequences. Each sample underwent histopathological analyzing and scoring. mRNA expression was analyzed on renal biopsies at various time points.

Results

Using MRI, we found that in pig kidney, total ATP content was 4 times higher during ex-vivo perfusion at sub-normothermic temperature compared to cold perfusion, with or without oxygen. At 22°C, ATP levels gradually increased up to 10 hrs of perfusion, then progressively declined. Similarly, AMP content was increased in SNOP perfused organs, then slowly consumed. over time. In addition, 22°C + O2 improved cortical and medullary perfusion (Gd elimination). Finally, sub-normothermic ex-vivo perfused graft had lower grade of histological damages 1 hour after transplantation compared to cold perfused organs (injury score 22°C + O2 : 8.8–12.2, 4°C : 13.5–18.8, 4°C + O2 : 17.5–18.5).

Conclusion

In kidneys, sub-normothermic perfusion improved graft viability when compared with hypothermic perfusions. These results suggest that sub-normothermic ex-vivo kidney perfusion might dampen the negative effect of warm ischemia and promote kidney metabolism such as ATP production. Future clinical studies will define the benefits of sub-normothermic ex-vivo kidney perfusion in improving kidney graft function, and patient's survival.

Non-alcoholic steatohepatitis alters antigen-specific response against hepatocellular carcinoma in mice

Objective

Non-alcoholic steatohepatitis (NASH) can lead to hepatocellular carcinoma (HCC). At time immunotherapy is used as first line treatment of advanced HCC, the impact of NASH on anti-cancer immunity remains unclear. We aim at assessing the tumor-specific T cell immune response in the presence of NASH in a mouse model of HCC recurrence.

Methods

We engineered an HCC cell line (RIL-175) with a cytoplasmic expression of ovalbumin (OVA) protein. C57BL/6N mice fed a high-fat (HFD) or a control diet (CD) for 35 weeks were injected in the portal vein with 1.5.105 RIL-175-LV-OVA-GFP cells.

Results

After 35 weeks of HFD, mice were obese and developed a massive steatosis with inflammation. In the liver of HFD-fed mice, we observed an increase of the CD8+ T cell subset corresponding to an expansion of the population of CD44+ CXCR6+ PD-1+ CD8+ T cells, known to promote NASH lesions. Fourteen days after injecting RIL-LV-OVA-GFP cells, HFD-fed mice developed a higher percentage of peripheral OVA-specific CD8 T cells than CD-fed mice (8.31 vs. 3.67%; p=0.010), but these cells were not able to prevent HCC growth, resulting in larger tumors in HFD-fed mice (620 vs. 1603mm3, p=0.051). In the liver, OVA-specific CD44+ CXCR6+ CD8+ cells were present in a similar manner in CD and HFD-fed mice, however with a higher expression of PD-1 in HFD-fed mice, suggesting a lower immune activity (MFI 12605 vs. 16083, p=0.0159). Using anti-CD122 antibody acting in decreasing the CXCR6+ PD-1+ cell subset, we were able to restore OVA-specific CD8 activity through a decrease in PD-1 expression (MFI 16406 vs. 10516, p=0.0571), and to decrease HCC growth compared to HFD mice non treated with anti-CD122 (p=0.0286).

Conclusion

The immune system is altered and fails to prevent HCC growth in HFD-fed mice. This effect is primarily linked to a higher representation of CD44+ CXCR6+ PD-1+ CD8+ T cells. Treatment with anti-CD122 act on these cells, and prevent HCC growth.

Hyperspectral evaluation of liver oxygenation in a murine model of metabolic associated liver disease and hepatocellular carcinoma

Objective

Untreated MAFLD is a continuum of disease ranging from hepatic steatosis to cirrhosis and hepatocellular carcinoma (HCC). Throughout the disease progression, a change in hepatic hemodynamics occurs as portal hypertension. Hepatic arterial buffer response is a compensatory mechanism to maintain liver perfusion facing reduction of portal flow. These changes could also impair hepatic oxygenation homeostasis. The aim of this study is to test this hypothesis in mouse models and to shed light on the oxygenation of fatty, portal hypertensive liver and its impact on HCC carcinogenesis.

Methods

C57BL/6 mice were fed a HFD starting from 4 weeks of age, porto-systemic shunts (or sham) were created at 8 weeks, and monitored up to 40 weeks. ND-fed non-shunted mice were used as control group. Hyperspectral imaging (HSI) was utilized to quantify tissue oxygenation (StO2) of ND, HFD and HFD-shunted mice. In a second set of experiment, we explored the role of a common hepatic artery ligation in the studied DEN-induced HFD mouse model.

Results

HFD induced hepatic steatosis and portal pressure compared to ND. Porto-systemic shunt could deviate about 67% of the portal flow through the spleen to the systemic circulation, thus reducing portal pressure close-to-normal levels. Compared to control mice, HFD feeding increased liver oxygenation (p=0.0004), while shunting restored a close to normal level (p&lt;0.001). The oxygenation of small bowel is decreased in a similar manner in both HFD and HFD-shunted mice. In HFD-fed mice, artery ligation led to less carcinogenesis compared to mice without artery ligation (p=0.026). In addition, artery ligation was also associated with smaller HCCs (p=0.027).

Conclusion

Early stages of MAFLD alter hepatic oxygen homeostasis. Fatty liver, when associated to portal hypertension, express higher liver oxygenation levels, compared to control group. This could due to hepatocyte ballooning with a narrowing of portal system, thus bring portal hypertension state with a simultaneous arterial buffer response. Additionally, small bowel of portal hypertensive mice showed lower oxygen levels mirroring an intestinal venous congestion typical of portal hypertension. Oxygen deprivation, through artery ligation, decreases HCC carcinogenesis and reduces HCC nodules volume. Yet further research is needed but oxygen homeostasis seems play a role in MAFLD progression as well in HCC pathophysiology.

Brain metastasis incidence in gastro-esophageal cancer: A meta-analysis

Objective

Upper gastrointestinal cancers (UGC) are a leading cause of cancer related deaths. Brain metastases (BM) from gastric and esophageal cancer are rare and associated with a poor survival time. The precise incidence of BM for UGC is lacking.

Methods

We searched: “Gastric cancer OR Oesophageal Cancer AND Cerebral Metastasis” in Pubmed, EMBASE, Cochrane Library. Inclusion criteria were all studies with an incidence rate of BM from UGC cancer patients cohort. When the inclusion criteria were met, we extracted the following endpoints: year of publication, country of population, tumor localization, histology, number of brain lesion, synchronous or metachronous brain metastases, stage of the primary tumor, other localization of metastases, surgical treatment of the primary tumor, brain metastasis treatment (surgery, steatosic radiosurgery, whole brain radiation, gamma knife surgery), survival and follow-up.

Results

52 studies were included. The total number of patients with oesophageal tumor were described in 30 studies with 41636 patients from which 1234 patients (2.9%) had BM. 526 patients (63%) had an adenocarcinoma, 287 (34%) had a SCC and 17 (3%) other histology. BM was unique in 288 patients (50%) and multiples in 282 patients (50%). A combined radiotherapy and surgery was performed in 129 patients (17.9%). Surgical metastasectomy was performed in 172 patients (24.25%). Stereotaxic radiotherapy was delivered in 60 patients. (8.5%) A whole brain radiotherapy was performed in 265 patients (35.9%). Gamma knife surgery was performed in 43 patients (5.9%). Chemotherapy in 10 patients (1.6%) and no treatment in 43 patients. (5.9%). The median survival was reported from 3 month to 24 months. We identified 12 articles which matched the research criteria for gastric cancer with a total of 73.781 primary gastric tumors where 645 presented brain metastasis (0.87%). 159 patients had single BM (42.3%) compared to 217 patients with multiple BM (57.7%). We identified 434 adenocarcinoma which represent 81.1% of the brain metastasis. Median survival for patients with brain metastasis from gastric cancer was described from 1.3 month to 27 months.

Conclusion

Brain metastases from UGI cancer are rare and associated with a low survival. Multimodal treatment is the most described treatment strategy. More studies are required to assess the role of brain imaging in the initial staging of UGI cancer.

Outcomes of oncologic robotic gastrectomy compared with open gastrectomy for early and locoregional advanced gastric cancer

Objective

Minimally invasive gastrectomy for gastric cancer shows slower adoption in Western countries compared to Asia, probably due to lower incidence, advanced stages and a more frequently proximal localization, which requires a technically more challenging total gastrectomy.

Methods

We retrospectively reviewed a prospectively collected database. A total of 51 patients who underwent oncologic total gastrectomy or subtotal gastrectomy by robotic or open approach of stage pT1-T4a, pN0-3 were identified from June 2016 until June 2020. Nine patients were operated on robotically, and 42 patients by laparotomy. Perioperative outcomes, postoperative 30-day complications as well as pathologic results were compared.

Results

The age of the patients in the robotic group was comparable to that of the open group (64.7 ±9.2 versus 62.8 ±12.9, respectively, p = 0.685). Blood loss was significantly smaller with the robotic approach (185±180 mL versus 425±257 mL, p = 0.038). Pathologic tumor stage included stages pT1–pT4b in the open group, while only stages pT1–pT3 were operated by robotic approach. Fewer tumors were localized in the upper body in the robotic group (0, 0%) than in the open group (12, 28.6%). The length of the proximal margin was comparable in the two groups (104.29 ± 50.29 versus 86.88 ± 64.66, p = 0.516). The mean number of retrieved lymph nodes was comparable in the robotic group and the open group (42.89 ± 12.119 versus 43.22 ± 20.271, p = 0.963). The mean number of metastatic nodes was significantly lower in the robotic group (0.33 ± 0.707 versus 7.02 ± 14.313, p = 0.171). In regards to Lauren classification, diffuse-type cancers were significantly more frequent in the robotic group (3 (33.3%) versus 3 (8.6%), respectively, p = 0.040). Significantly fewer high-grade complications (Clavien/Dindo &gt;3a) appeared in the robotic group (0 (0%) versus 2 (4.8%), p = 0.019). No anastomotic leakage and no death occurred in both groups.

Conclusion

The gold standard of oncologic gastrectomy, especially for advanced stages and bulky lymph nodes, is still the open approach. The minimally invasive approach for gastric cancer may be beneficial in regards to blood loss and postoperative complications but must show comparable pathohistological results in comparison to the open approach in regards to lymph node harvest and proximal tumor margins to be an acceptable alternative to the open approach.

Seroprevalence of and Risk Factors Associated With SARS-CoV-2 Infection in Health Care Workers During the Early COVID-19 Pandemic in Italy

Importance

Identifying health care settings and professionals at increased risk of SARS-CoV-2 infection is crucial to defining appropriate strategies, resource allocation, and protocols to protect health care workers (HCWs) and patients. Moreover, such information is crucial to decrease the risk that HCWs and health care facilities become amplifiers for SARS-CoV-2 transmission in the community.

Objective

To assess the association of different health care professional categories and operational units, including in-hospital wards, outpatient facilities, and territorial care departments, with seroprevalence and odds of SARS-CoV-2 infection.

Design, Setting, and Participants

This cross-sectional study was conducted using IgG serological tests collected from April 1 through May 26, 2020, in the Lombardy region in Italy. Voluntary serological screening was offered to all clinical and nonclinical staff providing any health care services or support to health care services in the region. Data were analyzed from June 2020 through April 2021.

Exposures

Employment in the health care sector.

Main Outcomes and Measures

Seroprevalence of positive IgG antibody tests for SARS-CoV-2 was collected, and odds ratios of experiencing infection were calculated.

Results

A total of 140 782 professionals employed in the health sector were invited to participate in IgG serological screening, among whom 82 961 individuals (59.0% response rate) were tested for SARS-CoV-2 antibodies, with median (interquartile range [IQR]; range) age, 50 (40-56; 19-83) years and 59 839 (72.1%) women. Among these individuals, 10 115 HCWs (12.2%; 95% CI, 12.0%-12.4%) had positive results (median [IQR; range] age, 50 [39-55; 20-80] years; 7298 [72.2%] women). Statistically significantly higher odds of infection were found among health assistants (adjusted odds ratio [aOR], 1.48; 95% CI, 1.33-1.65) and nurses (aOR, 1.28; 95% CI, 1.17-1.41) compared with administrative staff and among workers employed in internal medicine (aOR, 2.24; 95% CI, 1.87-2.68), palliative care (aOR, 1.84; 95% CI, 1.38-2.44), rehabilitation (aOR, 1.59; 95% CI, 1.33-1.91), and emergency departments (aOR, 1.56; 95% CI, 1.29-1.89) compared with those working as telephone operators. Statistically significantly lower odds of infection were found among individuals working in forensic medicine (aOR, 0.40; 95% CI, 0.19-0.88), histology and anatomical pathology (aOR, 0.71; 95% CI, 0.52-0.97), and medical device sterilization (aOR, 0.54; 95% CI, 0.35-0.84) compared with those working as telephone operators. The odds of infection for physicians and laboratory personnel were not statistically significantly different from those found among administrative staff. The odds of infection for workers employed in intensive care units and infectious disease wards were not statistically significantly different from those of telephone operators.

Conclusions and Relevance

These findings suggest that professionals partially accustomed to managing infectious diseases had higher odds of SARS-CoV-2 infection. The findings further suggest that adequate organization of clinical wards and personnel, appropriate personal protective equipment supply, and training of all workers directly and repeatedly exposed to patients with clinical or subclinical COVID-19 should be prioritized to decrease the risk of infection in health care settings.

A new clinical severity score for the management of acute small bowel obstruction

Objective

Small bowel obstruction (SBO) is a common hospital admission diagnosis. Identification of patients who will require a surgical resection because of a non-viable small bowel remains a challenge. We aimed to identify risk factors for intestinal resection in patients with SBO and to develop a practical clinical score designed to guide surgical vs. conservative management.

Methods

We performed a prospective cohort study and included all patients admitted for an acute SBO between 2007 and 2016 in our center. Patients were divided in three categories: conservative management, surgical treatment with or without bowel resection. Clinical variables were assessed and compared between groups. Logistic regression models were used to identify the best predictors.

Results

604 patients were included in this study. 438 (73%) had surgery of which 127 (21%) had small bowel resection. 166 (27%) patients were treated conservatively. Among 13 clinical variables, univariate and multivariate logistic regression models identified 8 variables with a strong association with small bowel resection: age ≥70 years, a first episode of SBO, absence of bowel movement for ≥3 days, abdominal guarding, C-reactive protein ≥50, and 3 signs on abdominal CT-scan, namely, small bowel transition point, lack of small bowel contrast enhancement, and the presence of &gt; 500 mL of intra-abdominal fluid. Each variable was given one point. We observed that 71-100% of patients with ≥4 points required a surgical resection. Sensitivity and specificity of this score were 65% and 88%, respectively and the area under the curve (AUC) was 0.84 (95% CI 0.80-0.89). Additionally, we propose two variants of the 8-tem score: a 7-item score excluding the lack of contrast enhancement, specifically designed for patient with contrast allergies or renal insufficiency, and a simplified 4-item score leaving age, guarding, transition zone on CT-scan, and the presence of 500 mL of fluid on CT scan. Both scores showed similar performances compared to the 8-item score with an AUC of 0.83 and 0.80 for the 7- and 4-item scores, respectively.

Conclusion

We developed a practical clinical severity score designed to tailor management of patients presenting with a SBO. A score of ≥ 4 points indicates the need for surgical exploration given the high likelihood of small bowel ischemia in these patients.

Shorter survival after liver pedicle clamping in patients undergoing liver resection for hepatocellular carcinoma revealed by a systematic review and meta-analysis

Objective

Liver pedicle clamping minimizes surgical bleeding during hepatectomy. However, by inducing ischemia-reperfusion injury to the remnant liver, pedicle clamping may be associated with tumor recurrence in the regenerating liver. Hepatocellular carcinoma (HCC) having a high rate of recurrence, evidences demonstrating an eventual association with pedicle clamping is strongly needed.

Methods

We did a systematic review of the literature until April 2020, looking at studies reporting the impact of liver pedicle clamping on long-term outcomes in patients undergoing liver resection for HCC. Primary and secondary outcomes were overall survival (OS) and disease-free survival, respectively.

Results

Results were obtained by random-effect meta-analysis and expressed as standardized mean difference (SMD). Eleven studies were included, accounting for 8087 patients. Results of seven studies were pooled in a meta-analysis. Findings indicated that, as compared to control patients who did not receive liver pedicle clamping, those who did had a significantly shorter OS (SMD = -0.172, 95%CI: -0.298 to -0.047, p = 0.007, I2=76.8%) and higher tumor recurrence rates (odds ratio 1.36 1.01 to 1.83. p = 0.044, I2=50.7%).

Conclusion

This meta-analysis suggests that liver pedicle clamping may have a deleterious impact on long-term outcomes. An individual patient-data meta-analysis of randomized trials evaluating liver pedicle clamping is urgently needed.

Dynamic assessment of the impact of gut microbiota transfer in a mouse model of chronic intestinal dysbiosis

Objective

There is growing evidence supporting that the gut microbiota is a major driver of human health and disease. While gut microbiota transfer (GMT) is commonly used as an approach to restore "eubiosis", there is a surprising lack of data on whether the transferred microbiota efficiently and durably repopulate the gut of the transplanted subject. Moreover, little is known on the effects of GMT on non-alcoholic fatty liver disease (NAFLD).

Methods

Chronic dysbiosis and NAFLD-like liver injury were induced by feeding C57Bl/6j mice for 16 weeks with a high-fat diet. For GMT, dysbiotic mice underwent preliminary gut cleansing, followed by oral gavage with a suspension of fresh fecal matter procured from a pool of lean mice (1 dose, or 10 doses). We next characterized microbiota composition and we measured the relative abundance of specific pathobionts in recipient mice, using high-throughput shotgun analysis in a dynamic manner, over time. All experiments took place in a specific germ-free environment.

Results

After 4 months on a high-fat diet, mice displayed fatty liver infiltration with moderate parenchymal inflammatory changes. Dysbiosis was evidenced by a reduced bacterial diversity, as well as a dramatically increased abundance of Firmicutes, and lower Verrucomicrobia and Actinobacteria. Gut microbiota transfer was associated with a transitory reduction in NAFLD-induced hepatocellular injury. While dysbiotic mice displayed a shift in their microbiota composition towards that of lean donors after GMT, this effect rapidly faded after one week, and mice recovered their initial, dysbiotic microbiota.

Conclusion

The current study indicates that, when used in mice with chronically established dysbiosis, GMT is merely associated with transitory changes in gut microbiota composition, as well as significant but moderate reduction in hepatocellular injury.

Modulating hepatocarcinogenesis by porto-systemic vein shunting in a high-fat diet mouse model

Objective

Non-alcoholic fatty liver disease (NAFLD) is an increasingly common disease, which can lead to hepatocellular carcinoma (HCC). It is associated with an increased portal pressure, which can alter the intestinal barrier, increase the translocation of bacterial products, and further worsen NAFLD. We hypothesized that this vicious circle can be broken by surgical porto-systemic vein shunting (PSVS), and previously demonstrated that PSVS can decrease the histological features of NAFLD in a high-fat diet (HFD) mouse model. We now test whether PSVS can also impact de-novo hepatocarcinogenesis.

Methods

C57BL/6 mice received HFD starting from 4 weeks of age. HCC was induced by intraperitoneal injection of DEN at 25mg/kg on week 2 and PSVS (n = 18) (or sham surgery (n = 18)) are created at 8 weeks. HCC burden was assessed by MRI and, finally, by macroscopic and histomorphology assessments. HCC features of aggressiveness, including solid growth pattern and fat component have been also evaluated.

Results

At 40 weeks of HFD feeding, tumors were identified in all the animals. Shunted HFD mice showed a reduced number of tumor nodules compared to sham (median nodules 8 vs 14, -42.9%; p = 0.0471) while associated to a greater average total tumor volume (709.3 vs 197 mm3, +258,6%; p = 0.0245). This correlated with an increased median tumor volume in shunted mice (16.30 vs 72.45 mm3, +344,5%; p = 0.0011). Notably, HCC histology of shunted mice was hallmarked by accentuated trend concerning HCC fatty change combined to a less pronounced solid growth pattern (p = 0.193).

Conclusion

PSVS leads to the presence of larger HCCs, potentially linked to the proportionally increased arterial supply of the liver. However, it demonstrates a protective effect on HCC carcinogenesis (&lt; number of tumors). Collectively, this data suggests that portal pressure could represent a potential therapeutic target to attenuate liver steatosis and NAFLD-related HCC carcinogenesis.

Mapping of aetiologies and clinical presentation of acute colitis: Results from a prospective cohort study in a tertiary centre

Objective

Our objective was to describe the aetiologies of acute colitis and to identify patients who require diagnostic endoscopy.

Methods

Patients with symptoms of gastrointestinal infection and colonic inflammation on computed tomography were prospectively included. Those immunosuppressed, with history of colorectal cancer or inflammatory bowel disease (IBD) were excluded. Stools were screened with BD-Max and BioFire FilmArray GI panel. Faecal calprotectin was determined. Patients with negative BD-Max underwent colonoscopy. The study was registered into clinicaltrials.gov (NCT02709213).

Results

One hundred and seventy-nine patients were included. BD-Max was positive in 93 patients (52%) and FilmArray in 108 patients (60.3%). Patients with infectious colitis (n = 103, 57.5%) were positive for Campylobacter spp (n = 57, 55.3%), Escherichia coli spp (n = 8, 7.8%), Clostridium difficile (n = 23, 22.3%), Salmonella spp (n = 9, 8.7%), viruses (n = 7, 6.8%), Shigella spp (n = 6, 5.8%), Entamoeba histolytica (n = 2, 1.9%) and others (n = 4, 3.9%). Eighty-six patients underwent colonoscopy, which was compatible with ischemic colitis in 18 patients (10.1%) and IBD in 4 patients (2.2%). Among patients with negative FilmArray, a faecal calprotectin &gt;625μg/g allowed identifying patients with IBD with an area under ROC curve of 85.1%. Introduction of a diagnostic management algorithm including FilmArray and faecal calprotectin could allow decreasing unnecessary colonoscopies from 82 to 29 (corresponding to a decrease of 64.6%).

Conclusion

Computed tomography-proven colitis was mostly of infectious aetiology. Diagnostic management of patients with acute colitis should include broad molecular testing of the stools and, in patients with a calprotectin concentration &gt;625μg/g, colonoscopy to exclude IBD.

How surgical training in Switzerland affects outcomes and new predictors for teaching

Objective

Teaching in the operating room represents the cornerstone of surgical education. Residents need to perform a sufficient number of basic procedures in order to gain independence. However, it is still debated what impact surgical teaching has on outcomes. With this study, we provide recent data of a large national cohort and identify new factors that are associated with increased teaching.

Methods

We studied common procedures that are essential for surgical training: Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), ostomy closure (OC), laparoscopic (LH) and Open Inguinal Hernia Repair (OH). The national database of the Swiss association for quality management in surgery was screened, and 72072 patients were identified from 2009 to 2019. Teaching was defined as a procedure mainly performed by a surgeon in training under supervision.

Results

A minority of basic surgical procedures were used for teaching (LA 28.1%, LC 22.3%, OC 21.5%, OH 31.8%, LH 6.3%), even in teaching hospitals of &gt; 200 beds (LA 33.0%, LC 32.9%, OC 27%, OH 51.5%, LH 6.5%). During the study period, there was also generally a trend towards less teaching, exemplified by the two most frequent procedures: LA 35.6 to 26.7% (-25.0%, p = &lt;0.001), LC 27.6 to 18.9% (-31.5%, p = &lt;0.001). Operating time was significantly longer for procedures that were used for teaching with a more pronounced effect for inguinal hernia repairs: LA 63.4 vs 57.5min (+10.3%, p = &lt;0.001), LC 84.0 vs 74.9min (+12.1%, p = &lt;0.001), OC 88.6 vs 81.6min (+8.6%, p = &lt;0.001), OH 81.5 vs 68.3min (+19.3%, p = &lt;0.001), LH 97.9 vs 73.8min (+32.7%, p = &lt;0.001). The overall complication rate for LA (2.6 vs 1.8%, p = &lt;0.001) and LC (3.6 vs 2.8%, p = &lt;0.001) were slightly higher in the no-teaching group and without a significant difference between the groups for OC, LH and OH. We identified the following parameters associated with increased teaching: A hospital size above 200 beds (OR = 2.48, p = &lt;0.001), an operation during office hours (OR = 1.27, p = &lt;0.001), the summer months (OR = 1.11, p = &lt;0.001) and weekdays (OR = 1.10, p = 0.003).

Conclusion

The teaching of basic surgical procedures appears safe. Even if associated with longer operating times, it should be promoted as teaching is currently only performed in a minority of procedures (10-33%).

COVID-19-related abdominal pain is associated with elevated liver transaminases, which could predict poor clinical outcomes

Objective

Abdominal pain and liver injury have been frequently reported during Coronavirus Disease-2019 (COVID-19). In the setting of a systemic infection these features can induce misleading surgical diagnostics. Our aim was to investigate characteristics of abdominal pain in COVID-19 patients and its association with disease severity and liver injury.

Methods

Data of all COVID-19 hospitalized patients over 16 years old were retrieved from the beginning of the epidemic in Switzerland until end of June 2020. Patients admitted exclusively for other pathologies (including surgical abdominal conditions) and/or recovered from COVID-19, and pregnant women were excluded. Abdominal pain was linked to COVID-19 only after evident alternative diagnostic exclusion. Five times the upper limit of transaminases was considered as liver injury.

Results

Among the 1026 patients who fulfill the inclusion/exclusion criteria, 199 (19.4%) exhibited spontaneous abdominal pain and 165 (16.2%) after abdomen palpation. Systematized abdominal pain was most frequently localized in the epigastric (39.8%) and upper right quadrant (23.7%). Considering baseline ALT levels, 7.14% of patients with epigastric pain had pathological ALT value versus 0.29% of patients without symptoms (p = 0.008). When taking the 30days maximal transaminases value, this reached respectively 16.3% versus 2.7% (p &lt; 0.001) and 20% versus 3.8% (p &lt; 0.001) for respectively AST and ALT.

With logistic regression we demonstrated that baseline pathological AST value was associated with hospital mortality and/or admission to intensive/intermediate care unit with an odds ratio of 13.9 (CI 1.5-124.7, p = 0.019).

Conclusion

These results suggest that COVID-19-induced abdominal pain is associated with liver injury which could predict poor evolution of disease.

Maternal metabolic syndrome induces liver injury and promotes tumor growth in the offspring

Objective

Obesity is a growing disease entity affecting a third of women of reproductive age. Epidemiological studies show that children of obese mothers suffer from obesity, long-term morbidity and an increased rate of childhood cancers. However, the mechanisms of disease transmission remain unknown. The aim of this study is to test this hypothesis in a mouse model and shed light on the involved mechanisms of vertical transmission.

Methods

Female mice were fed a high fat or standard diet (HFD/SD) for 16 weeks before being mated with mice fed a normal diet. Corresponding diet was continued until weaning, all offspring were thereafter fed a SD. Metabolic profile, weight gain, liver enzymes and the gut microbiota profile were assessed in the offspring (n = 24). Additional groups of offspring (n = 48) were injected with a carcinogen (diethylnitrosamine) at week two, tumor characteristics were assessed by computed tomography scan at week 36.

Results

Mothers fed HFD developed obesity and non-alcoholic fatty liver disease (NAFLD). Female offspring of mothers fed HFD gained significantly more weight (+33.7%, p = 0.001), had increased alanine transaminase levels (62 vs 18 IU/L, p = 0.003) and a significantly altered liver histology exemplified by an increased NAFLD activity score (3.8 vs 0.6, p = 0.016). Expression levels of several candidate genes were studied of which FGF21 showed the largest differential expression between HFD and SD offspring (9 vs 1 2^ΔΔCT, p = &lt;0.001). However, epigenetic analysis of FGF21 in the liver revealed no changes in methylation level between HFD and SD offspring. Furthermore, offspring of HFD mothers had a distinctly altered gut microbiome with lower proportions of Bacteroides caccae, Bacteroidales and Parasutterella excrementihominis. Interestingly, the proportion of female offspring developing tumors was significantly higher in offspring of HFD mothers (83 vs 44%, p = 0.011), the average total tumor volume was larger (234 vs 3.5mm3, p = 0.022) and the offspring developed more tumors (3.5 vs 0.6, p = 0.010).

Conclusion

Maternal obesity promotes liver tumor growth in the offspring, alters metabolic patterns and induces liver suffering in the progeny in a sex-dependent manner. The gut microbiome seems to play a role in this transmission of disease. Yet further research is needed to determine the vectors of transmission and evaluate preventive interventions in obese mothers.

Incidence of hepatocellular carcinoma in patients with non-alcoholic fatty liver disease: A meta-analysis and meta-regression

Objective

Nonalcoholic fatty liver disease (NAFLD) may be a risk factor for hepatocellular carcinoma (HCC), but the extent of this association still needs to be addressed. Pooled-incidence rates of HCC across the disease spectrum of NAFLD have never been estimated by meta-analysis.

Methods

In this systematic review, we searched Web of Science, Embase, Pubmed, and the Cochrane library from January 1st, 1950 through July 30th, 2020. We included studies reporting on HCC incidence in patients with NAFLD. The main outcomes were pooled HCC incidences in patients with NAFLD at distinct severity stages. Summary estimates were calculated with random-effects models. Sensitivity analyses and meta-regression analyses were carried out to address heterogeneity. The protocol for this review was registered in Prospero (CRD42018092861).

Results

Eighteen studies, with a total of 470,404 patients were included. In patients with NAFLD at a stage earlier than liver cirrhosis, HCC incidence was of 0.03 per 100 person-years (PYs) (95% confidence interval 0.01-0.07, I2=98%). This rate rose to 3.78 per 100PYs (2.47-5.78, I2=93%) when considering studies that only included patients with liver cirrhosis. Among the latter patients, those undergoing regular HCC screening displayed an incidence of 4.62 per 100PYs (2.77-7.72, I2= 77%).

Conclusion

Patients with NAFLD-related liver cirrhosis have a risk of developing HCC similar to that reported for patients with cirrhosis from other etiologies. Evidence documenting the risk in patients with NASH or simple steatosis is limited, but HCC incidence in these populations may lie below thresholds used to recommend HCC screening. Well-designed prospective studies in these subsets of patients are needed.

The Impact of Pregnancy on Outcomes After Bariatric Surgery

BACKGROUND

Bariatric surgery is performed mostly on obese women of reproductive age. Many studies have analyzed pregnancy outcomes after bariatric surgery, but only a small number have studied the impact of pregnancy on the postoperative outcomes.

PURPOSE

To study the effect of pregnancy on outcomes after bariatric surgery in women of childbearing age.

METHODS

From January 2010 to October 2017, a retrospective study of a prospectively maintained database was conducted at the University Hospital of Geneva (HUG), where 287 women between the ages of 18 and 45 years had undergone Roux-en-Y gastric bypass (RYGB). A comparison of the results during a 5-year follow-up was performed between women who became pregnant after their bariatric surgery (pregnancy group, n = 40) and postoperative non-pregnant women (non-pregnancy group, n = 247). The two groups were compared for weight loss, complications, and nutritional deficiencies.

RESULTS

The pregnancy group was significantly younger (29.2 ± 5.5 vs. 36.4± 6.3 years, p < 0.001) and heavier (124.0 ± 18.0 kg vs. 114.7 ± 17.1, p < 0.001) compared with the non-pregnancy group at the time of surgery. The percentage of excess BMI loss (%EBMI loss) was similar in both groups during the 5-year follow-up. Complications after RYGB and nutritional deficiencies were nearly identical in the two groups. The interval of time between bariatric surgery and first pregnancy was a median of 20.8 months. Out of 40 first pregnancies, 28 women completed pregnancy successfully with live birth.

CONCLUSION

Pregnancy after bariatric surgery is safe and does not adversely affect outcomes after RYGB.

COVID-19 serological testing for Healthcare Workers in Lombardy, Italy

Issue

COVID-19 pandemic began in Italy on February 20th, 2020. Since the beginning of the emergency Healthcare Workers' (HCWs) involvement was prominent, mainly due to direct assistance to COVID-19 patients. Therefore, we implemented a prevention policy for HCW screening through serological and RT-PCR testing.

Description of the problem

HCW screening for SARS-CoV-2 infection is essential for prevention and control of the pandemic. Lombardy's Healthcare authorities settled a screening process for HCWs divided into three steps: 1) body temperature assessment at the beginning and the end of work shift, if fever > 37.5 °C was present the HCW was sent back home and a nasopharyngeal swab was performed; 2) progressive recruitment for serological testing; 3) on those positive to IgG a nasopharyngeal swab was performed and tested for viral RNA by RT-PCR.

Results

Among 79185 HCW tested, 9589 (12%) were positive on serological IgG testing. Of the 9589 positive a nasopharyngeal swab was performed on 6884. Of these 358 (5%) tested positive and the remaining 6526 (95%) negative to RT-PCR. We calculated a Positive Predictive Value of 5.2%. The rate of positive serological tests for each Healthcare facility varied between 0% and 78%. Five percent of all facilities, belonging to Brescia, Bergamo and Cremona area, reported a positivity rate higher than 40% in HCWs. A second cluster (18% of all facilities), involving the same geographical area, reported a rate between 20% and 40%, whereas the remaining facilities (76%) of the region a rate <20%.

Lessons

Serological IgG testing can be, if followed by immediate nasopharyngeal swab testing, a valid screening intervention on asymptomatic HCWs especially in a high infection prevalence setting.

Key messages

Serological IgG testing can be, if followed by immediate nasopharyngeal swab testing, a valid screening intervention on asymptomatic HCWs.

Infection prevention in HCW may benefit from a screening campaign especially in high prevalence settings.

Liver transplantation for "very early" intrahepatic cholangiocarcinoma: International retrospective study supporting a prospective assessment

The presence of an intrahepatic cholangiocarcinoma (iCCA) in a cirrhotic liver is a contraindication for liver transplantation in most centers worldwide. Recent investigations have shown that "very early" iCCA (single tumors ≤2 cm) may have acceptable results after liver transplantation. This study further evaluates this finding in a larger international multicenter cohort. The study group was composed of those patients who were transplanted for hepatocellular carcinoma or decompensated cirrhosis and found to have an iCCA at explant pathology. Patients were divided into those with "very early" iCCA and those with "advanced" disease (single tumor >2 cm or multifocal disease). Between January 2000 and December 2013, 81 patients were found to have an iCCA at explant; 33 had separate nodules of iCCA and hepatocellular carcinoma, and 48 had only iCCA (study group). Within the study group, 15/48 (31%) constituted the "very early" iCCA group and 33/48 (69%) the "advanced" group. There were no significant differences between groups in preoperative characteristics. At explant, the median size of the largest tumor was larger in the "advanced" group (3.1 [2.5-4.4] versus 1.6 [1.5-1.8]). After a median follow-up of 35 (13.5-76.4) months, the 1-year, 3-year, and 5-year cumulative risks of recurrence were, respectively, 7%, 18%, and 18% in the very early iCCA group versus 30%, 47%, and 61% in the advanced iCCA group, P = 0.01. The 1-year, 3-year, and 5-year actuarial survival rates were, respectively, 93%, 84%, and 65% in the very early iCCA group versus 79%, 50%, and 45% in the advanced iCCA group, P = 0.02.

CONCLUSION

Patients with cirrhosis and very early iCCA may become candidates for liver transplantation; a prospective multicenter clinical trial is needed to further confirm these results. (Hepatology 2016;64:1178-1188).

Effect of ischaemic preconditioning on recurrence of hepatocellular carcinoma in an experimental model of liver steatosis

BACKGROUND

Livers with parenchymal abnormalities tolerate ischaemia-reperfusion (IR) injury poorly. IR injury is a risk factor for hepatocellular carcinoma (HCC) recurrence. This study assessed the link between liver parenchymal abnormalities and HCC recurrence, and evaluated the protective effect of ischaemic preconditioning.

METHODS

C57BL/6 mice were fed a choline-deficient diet for 6 and 12 weeks, or standard chow. Hepatic IR and ischaemic preconditioning were achieved by clamping liver blood inflow. Hepa 1-6 HCC cells were inoculated through the spleen. Thereafter, tumour burden, serum α-fetoprotein and cancer cell aggressiveness were compared among groups.

RESULTS

Hepatocellular damage and expression of inflammatory genes (encoding interleukin 6, tumour necrosis factor α, hypoxia inducible factor 1α and E-selectin) were exacerbated after IR injury in mice with severe steatosis. Compared with control livers or those with minimal steatosis, livers exposed to a prolonged choline-deficient diet developed larger tumour nodules and had higher serum α-fetoprotein levels. Non-ischaemic liver lobes from mice with steatosis were not protected from accelerated tumour growth mediated by IR injury. This remote effect was linked to promotion of the aggressiveness of HCC cells. Ischaemic preconditioning before IR injury reduced the tumour burden to the level of that in non-ischaemic steatotic controls. This protective effect was associated with decreased cancer cell motility.

CONCLUSION

Livers with steatosis tolerated IR poorly, contributing to more severe HCC recurrence patterns in mice with increasingly severe steatosis. IR injury also had a remote effect on cancer cell aggressiveness. Ischaemic preconditioning before IR injury reduced tumour load and serum α-fetoprotein levels.

SURGICAL RELEVANCE

Liver ischaemia-reperfusion (IR) injury is associated with organ dysfunction and surgical morbidity. Livers with steatosis tolerate IR injury poorly in the setting of both liver resection and liver transplantation. Ischaemic preconditioning is a simple method to mitigate IR injury. This study shows that ischaemic preconditioning of mouse livers with steatosis reduces ischaemia-mediated tumour growth acceleration. Liver parenchymal abnormalities such as warm IR injury and liver steatosis should be taken into account to predict accurately the risk of liver cancer recurrence after surgical management. Ischaemic preconditioning strategies may hold therapeutic potential not only to mitigate surgical morbidity but also to reduce postoperative recurrence of liver cancer.

Donor characteristics and risk of hepatocellular carcinoma recurrence after liver transplantation

BACKGROUND

To date, studies assessing the risk of post-transplant hepatocellular carcinoma (HCC) recurrence have focused on tumour characteristics. This study investigated the impact of donor characteristics and graft quality on post-transplant HCC recurrence.

METHODS

Using the Scientific Registry of Transplant Recipients patients with HCC who received a liver transplant between 2004 and 2011 were included, and post-transplant HCC recurrence was assessed. A multivariable competing risk regression model was fitted, adjusting for confounders such as recipient sex, age, tumour volume, α-fetoprotein, time on the waiting list and transplant centre.

RESULTS

A total of 9724 liver transplant recipients were included. Patients receiving a graft procured from a donor older than 60 years (adjusted hazard ratio (HR) 1.38, 95 per cent c.i. 1.10 to 1.73; P = 0.006), a donor with a history of diabetes (adjusted HR 1.43, 1.11 to 1.83; P = 0.006) and a donor with a body mass index of 35 kg/m(2) or more (adjusted HR 1.36, 1.04 to 1.77; P = 0.023) had an increased rate of post-transplant HCC recurrence. In 3007 patients with documented steatosis, severe graft steatosis (more than 60 per cent) was also linked to an increased risk of recurrence (adjusted HR 1.65, 1.03 to 2.64; P = 0.037). Recipients of organs from donation after cardiac death donors with prolonged warm ischaemia had higher recurrence rates (adjusted HR 4.26, 1.20 to 15.1; P = 0.025).

CONCLUSION

Donor-related factors such as donor age, body mass index, diabetes and steatosis are associated with an increased rate of HCC recurrence after liver transplantation.

Surgical management of patients with colorectal cancer and simultaneous liver and lung metastases

Background

The management of patients with colorectal cancer and simultaneously diagnosed liver and lung metastases (SLLM) remains controversial.

Methods

The LiverMetSurvey registry was interrogated for patients treated between 2000 and 2012 to assess outcomes after resection of SLLM, and the factors associated with survival. SLLM was defined as liver and lung metastases diagnosed 3 months or less apart. Survival was compared between patients with resected isolated liver metastases (group 1, control), those with resected liver and lung metastases (group 2), and patients with resected liver metastases and unresected (or unresectable) lung metastases (group 3). An Akaike test was used to select variables for assessment of survival adjusted for confounding variables.

Results

Group 1 (isolated liver metastases, hepatic resection alone) included 9185 patients, group 2 (resection of liver and lung metastases) 149 patients, and group 3 (resection of liver metastases, no resection of lung metastases) 285 patients. Ten variables differed significantly between groups and seven were included in the model for adjusted survival (age, number of liver metastases, synchronicity of liver metastases with primary tumour, carcinoembryonic antigen level, node status of the primary tumour, initial resectability of liver metastases and inclusion in group 3). Adjusted overall 5-year survival was similar for groups 1 and 2 (51·5 and 44·5 per cent respectively), but worse for group 3 (14·3 per cent) (P = 0·001).

Conclusion

Patients who had resection of liver and lung metastases had similar overall survival to those who had undergone removal of isolated liver metastases.

Liver resection in patients with eight or more colorectal liver metastases

BACKGROUND

Patients with large numbers of colorectal liver metastases (CRLMs) are potential candidates for resection, but the benefit from surgery is unclear.

METHODS

Patients undergoing resection for CRLMs between 1998 and 2012 in two high-volume liver surgery centres were categorized according to the number of CRLMs: between one and seven (group 1) and eight or more (group 2). Overall (OS) and recurrence-free (RFS) survival were compared between the groups. Multivariable analysis was performed to identify adverse prognostic factors.

RESULTS

A total of 849 patients were analysed: 743 in group 1 and 106 in group 2. The perioperative mortality rate (90 days) was 0.4 per cent (all group 1). Median follow-up was 37.4 months. Group 1 had higher 5-year OS (44.2 versus 20.1 per cent; P < 0.001) and RFS (28.7 versus 13.6 per cent; P < 0.001) rates. OS and RFS in group 2 were similar for patients with eight to ten, 11-15 or more than 15 metastases (48, 40 and 18 patients respectively). In group 2, multivariable analysis identified three preoperative adverse prognostic factors: extrahepatic disease (P = 0.010), no response to chemotherapy (P = 0.023) and primary rectal cancer (P = 0.039). Patients with two or more risk factors had very poor outcomes (median OS and RFS 16.9 and 2.5 months; 5-year OS zero); patients in group 2 with no risk factors had similar survival to those in group 1 (5-year OS rate 44 versus 44.2 per cent).

CONCLUSION

Liver resection is safe in selected patients with eight or more metastases, and offers reasonable 5-year survival independent of the number of metastases. However, eight or more metastases combined with at least two adverse prognostic factors is associated with very poor survival, and surgery may not be beneficial.

Outcomes of combined liver-kidney transplantation in children: analysis of the scientific registry of transplant recipients

Combined liver-kidney transplantation (CLKT) in children is uncommon and outcomes have not been well defined. Using the Scientific Registry of Transplant Recipients, data were analyzed on 152 primary pediatric CLKTs performed from October 1987 to February 2011, to determine their outcome in the largest series reported to date. Patient survival was 86.8%, 82.1% and 78.9% at 1, 5 and 10 years, liver graft survival was 81.9%, 76.5% and 72.6%, and kidney graft survival was 83.4%, 76.5% and 66.8%. By way of comparison, the Registry was queried for pediatric patient survival following isolated liver transplantation (LT) during the same time frame: 86.7%, 81.2% and 77.4% and following isolated kidney transplant (KT): 98.2%, 95.4% and 90% at 1, 5 and 10 years. In patients having undergone CLKT, primary hyperoxaluria was associated with reduced patient (p = 0.01), liver graft (p = 0.01) and kidney graft survival (p = 0.01). Furthermore, graft outcome following CLKT improved over the past decade (p = 0.04 for liver, p = 0.02 for kidney), but this did not translate into improved patient outcome (p = 0.2). All in all, our results confirmed that survival following LT was less than following KT, and that CLKT offered similar patient survival to isolated LT.

Toward a better liver graft allocation that accounts for candidates with and without hepatocellular carcinoma

In some countries where the Model for End-Stage Liver Disease (MELD) score is used for graft allocation, selected patients with hepatocellular carcinoma (HCC) receive a fixed number of exception points at listing, and increasing priority on the list by accruing additional exception points at regular time intervals. This system originally aimed at balancing the risks of HCC patients of developing contraindications and of non-HCC patients of dying before transplantation, is not ideal because it appears to offer an advantage to HCC patients, regardless of tumor characteristics and response to loco-regional treatment. Scores modulated by HCC characteristics have been proposed. They are based on a more refined estimate of the risk of pretransplant drop-out or of the posttransplant transplant benefit expressed as the life-years gained for each graft. This review describes the newly proposed systems, and discusses their advantages and drawbacks. We believe that the current exception points allocation should be revised and that drop-out-equivalent or transplant benefit-equivalent models should be studied further. As with all policy changes, these should be done under close monitoring that allows subsequent revisions.

Systematic review and meta-analysis of percutaneous subclavian vein puncture versus surgical venous cutdown for the insertion of a totally implantable venous access device

Background

Totally implantable venous access devices (TIVADs) are commonly used in patients with cancer. Although several methods of implantation have been described, there is not enough evidence to support the use of a specific technique on a daily basis. The objective of this study was systematically to assess the literature comparing percutaneous subclavian vein puncture with surgical venous cutdown.

Methods

MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched by two independent authors. No time limits were applied. A systematic review and meta-analysis was carried out according to the recommendations of the Cochrane Collaboration, including randomized clinical trials comparing primary percutaneous subclavian vein puncture with surgical venous cutdown.

Results

Six trials were included, with 772 patients overall. The primary implantation failure rate was significantly lower for the percutaneous approach compared with surgical cutdown (odds ratio (OR) 0·26, 95 per cent confidence interval (c.i.) 0·07 to 0·94; P = 0·039). There was no evidence supporting a significant difference in terms of risk of pneumothorax, haematoma, venous thrombosis, infectious events or catheter migration. After taking between-study heterogeneity into account by using a random-effects model, procedure duration was not significantly longer for surgical cutdown: weighted mean difference +4 (95 per cent c.i. –12 to 20) min (P = 0·625).

Conclusion

Percutaneous subclavian vein puncture is associated with a higher TIVAD implantation success rate and a procedure duration similar to that of surgical cutdown. Pneumothorax develops exclusively after percutaneous puncture and requires special attention from clinicians dealing with TIVAD insertion.

Transplanted human pancreatic islets after long-term insulin independence

Long-term insulin independence after islets of Langerhans transplantation is rarely achieved. The aims of this study were to identify the histological and immunological features of islets transplanted in a type 1 diabetic patient who died of a cerebral hemorrhage after >13 years insulin independence. Islets were pooled from two donors with respectively one and five HLA mismatches. Insulin-positive islets were found throughout the right and left liver, and absent in the pancreas. Two- and three-dimensional analysis showed that islets lost their initial rounded and compact morphology, had a mean diameter of 136 μm and were constituted of an unfolded epithelial band of 39.1 μm. Leukocyte phenotyping showed no evidence of a tolerogenic environment in the islet-containing portal spaces. Finally, HLA typing of microdissected islets showed HLA from the best matched donor in all 23 microdissection samples, compared to 1/23 for the least matched donor. This case report demonstrates that allogeneic islets can survive over 13 years while maintaining insulin independence. Allogeneic islets had unique morphologic features and implanted in the liver regardless of their size. Finally, our results suggest that, in this case, rejection had been prevalent over autoimmunity, although this hypothesis warrants further investigation.

Systematic review and meta-analysis of the effect of perioperative steroids on ischaemia-reperfusion injury and surgical stress response in patients undergoing liver resection

BACKGROUND

Several therapeutic strategies, such as ischaemic preconditioning, intermittent or selective pedicle clamping and pharmacological interventions, have been explored to reduce morbidity caused by hepatic ischaemia-reperfusion injury and the surgical stress response. The role of steroids in this setting remains controversial.

METHODS

A comprehensive literature search in MEDLINE, Embase and the Cochrane Register of Clinical Trials (CENTRAL) was conducted (1966 onwards), identifying studies comparing perioperative administration of intravenous steroids with standard care or placebo, in the setting of liver surgery. Randomized Controlled trials (RCTs) and non-RCTs were included. Critical appraisal and meta-analysis were carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement.

RESULTS

Six articles were included; five were RCTs. Pooling the results revealed that patients receiving intravenous glucocorticoids were 24 per cent less likely to suffer postoperative morbidity compared with controls (risk ratio 0.76, 95 per cent confidence interval 0.57 to 0.99; P = 0.047). The treated group experienced a significantly greater rise in early postoperative interleukin (IL) 10 levels compared with controls. In addition, steroids significantly reduced postoperative blood levels of bilirubin, and of inflammatory markers such as IL-6 and C-reactive protein. There was no evidence supporting a risk difference in infectious complications and wound healing between study groups.

CONCLUSION

Perioperative steroids have a favourable impact on postoperative outcomes after liver resection.

Recurrence of type 1 diabetes after simultaneous pancreas-kidney transplantation in the absence of GAD and IA-2 autoantibodies

We report herein the patterns of type 1 diabetes recurrence in a simultaneous pancreas-kidney transplant (SPK) recipient, in the absence of rejection. A 38-year-old female underwent SPK for end-stage nephropathy secondary to type 1 diabetes. Fasting blood glucose, HbA1c, fructosamine, C-peptide and autoantibodies (GAD-65, IA-2) were monitored throughout follow-up. At 3.5 years post-SPK, HbA1c and fructosamine increased sharply, indicating loss of perfect metabolic control, despite C-peptide levels in the normal-high range. Exogenous insulin was restarted 4 months later. C-peptide levels abruptly fell and became undetectable at 5.5 years. Autoantibody levels, which were undetectable at the time of SPK, never converted to positivity. Pancreas retranspantation was performed at 6 years. The failed pancreas graft had a normal macroscopic appearance. On histology, there were no signs of cellular or humoral rejection in the kidney or pancreas. A selective peri-islet lymphocytic infiltrate was observed, together with near-total destruction of β cells. At 2.5 years post retransplantation, pancreatic graft function is perfect. This observation indicates unequivocally that pancreas graft can be lost to recurrence of type 1 diabetes in the absence of rejection. GAD-65 and IA-2 autoantibodies are not reliable markers of autoimmunity recurrence.

Eculizumab in acute recurrence of thrombotic microangiopathy after renal transplantation

Renal thrombotic microangiopathy (TMA) is a severe complication of systemic lupus erythematosus (SLE), which is associated with the presence of antiphospholipid (aPL) antibodies. In its most fulminant form, TMA leads to a rapid and irreversible end-stage renal failure. Eculizumab, an anti-C5 monoclonal antibody, is a novel therapy of choice for patients with paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome. Here, we report the case of a 27-year-old woman, known for SLE and end-stage renal disease due to fulminant TMA. Both aPL antibodies and antinucleosome antibodies were positive. The patient underwent a living-related kidney transplantation with immediate production of urine. Although serum creatinine was remaining high, a graft biopsy, performed on day 6, demonstrated a TMA recurrence. Despite a treatment with plasma exchange, the situation got worse and dialysis was started. Eculizumab treatment was subsequently administered and renal function improved rapidly. Three months after transplantation, serum creatinine was at 100 μmol/L, without proteinuria. This case illustrates the benefit of eculizumab therapy in a fulminant recurrence of TMA after kidney transplantation, resistant to classical therapy.

Liver transplantation for hepatocellular carcinoma: five steps to prevent recurrence

Liver transplantation is the best treatment of patients with unresectable early hepatocellular carcinoma, allowing disease-free survival rates of 60-80% at 5 years. Despite these good results, some 10% of recipients experience a posttransplant HCC recurrence, which leads to death in almost all patients. Recurrence is either due to the growth of occult metastases or to the engraftment of circulating tumor cells. It can be hypothesized that strategies to decrease the engraftment of circulating tumor cells could decrease the risk of recurrence and, in addition, extend access to transplantation to patients with more advanced HCC. These potential strategies can be schematized into five steps, including (1) selecting recipients with low baseline levels of circulating HCC cells, by adding biological markers (such as alpha fetoprotein or molecular signatures) to the accepted combination of morphological criteria; (2) decreasing the perioperative release of HCC cells, with careful perioperative handling of the tumors; (3) preventing the engraftment of circulating HCC cells by decreasing liver graft ischemia-reperfusion injury, which has been shown to promote cancer cell engraftment and growth; (4) using anticancer drugs, including mammalian target of rapamycin inhibitors and (5) tuning immunity toward HCC clearance.

Liver transplantation for hepatocellular carcinoma: five steps to prevent recurrence

Liver transplantation is the best treatment of patients with unresectable early hepatocellular carcinoma, allowing disease-free survival rates of 60-80% at 5 years. Despite these good results, some 10% of recipients experience a posttransplant HCC recurrence, which leads to death in almost all patients. Recurrence is either due to the growth of occult metastases or to the engraftment of circulating tumor cells. It can be hypothesized that strategies to decrease the engraftment of circulating tumor cells could decrease the risk of recurrence and, in addition, extend access to transplantation to patients with more advanced HCC. These potential strategies can be schematized into five steps, including (1) selecting recipients with low baseline levels of circulating HCC cells, by adding biological markers (such as alpha fetoprotein or molecular signatures) to the accepted combination of morphological criteria; (2) decreasing the perioperative release of HCC cells, with careful perioperative handling of the tumors; (3) preventing the engraftment of circulating HCC cells by decreasing liver graft ischemia-reperfusion injury, which has been shown to promote cancer cell engraftment and growth; (4) using anticancer drugs, including mammalian target of rapamycin inhibitors and (5) tuning immunity toward HCC clearance.

The management of splenic artery aneurysm in patients awaiting liver transplantation

Splenic artery aneurysms (SAAs) are the third most common forms of intra-abdominal aneurysm, and the most commonly encountered visceral aneurysms in the general population. SAAs occur more commonly in patients with portal hypertension and liver failure and, as such, are often encountered in patients undergoing high-resolution abdominal imaging as part of a work-up for liver transplantation. While rupture rates of between 2% and 10% have been reported in the literature, little is known about the natural history and behavior of these lesions in patients with liver disease. Interventional management options pose a challenge given the high anesthetic and surgical risk of such patients. This study was conducted to study the management of all SAAs diagnosed among patients presenting for a liver transplant assessment at a single center over a three-yr period. We discuss the presentation and management options, with elective and emergent presentation of SAA in patients with end-stage liver disease.

IV immunoglobulin is associated with a reduced risk of Alzheimer disease and related disorders

OBJECTIVE

To compare the incidence of Alzheimer disease and related disorders (ADRD) in patients treated with IV immunoglobulin (IVIg) for non-Alzheimer disease (AD) indications vs untreated controls.

METHODS

This retrospective case-control analysis used medical claims for patients > or =65 years old from a national database of 20 million age-qualified patients. Cases received > or =1 IVIg administration during April 1, 2001-August 31, 2004, had claims 1 year prior to first (index) IVIg administration to confirm absence of pre-index ADRD, and had > or =3 years of continuous claims post-index. Untreated controls had their first medical claim during April 1, 2000-August 31, 2004, and otherwise met the same requirements as cases. Controls were matched 100:1 to cases on age, gender, and risk factors for ADRD. The relative incidence of ADRD post-index for the IVIg-treated cases vs untreated controls was estimated using Kaplan-Meier survival curves and a Cox proportional hazards model.

RESULTS

Treated patients in the Kaplan-Meier analysis had lower ADRD incidence (p = 0.02) with an estimated 2.6% of the 847 IVIg-treated vs 4.6% of 84,700 controls diagnosed with ADRD at 60 months after index date. Treated patients in the Cox proportional hazard model had a 42% lower risk of being diagnosed with ADRD (hazard ratio, 0.577; 95% confidence interval, 0.359 to 0.930; p = 0.024) with an estimated 2.8% of treated vs 4.8% of controls diagnosed with ADRD at 60 months after index date.

CONCLUSIONS

Previous treatment with IV immunoglobulin was associated with a reduced risk of developing Alzheimer disease and related disorders (ADRD) in this study. Evidence from additional studies is needed to evaluate the relationship between IVIg exposure and ADRD diagnosis.

AEB-071 has minimal impact on onset of autoimmune diabetes in NOD mice

Protein kinase C (PKC) is an important signaling enzyme in the activation and regulation of T lymphocytes. T-cell-mediated destruction of beta-cells is a characteristic feature of autoimmune (Type 1) diabetes. Here we explore the ability of PKC inhibition, using the PKC inhibitor AEB-071 (AEB), to reduce disease in two animal models of spontaneous autoimmune diabetes (non-obese diabetic (NOD) mouse and biobreeding rat (BB)). NOD mice were treated with AEB for 4 weeks, starting at either 4 weeks of age (prior to the development of insulitis) or at 8 weeks of age, once insulitis is present. Animals treated with AEB during the effector phase of the disease (treatment onset at 8 weeks of age), showed a 2-week delay in diabetes onset (p < 0.05). In these animals, the extent of insulitis was lower than in vehicle-treated controls; however, neither serum autoimmune anti-GAD65 antibody levels nor pancreatic insulin content were different between experimental groups. Overall, inhibition of PKC can mildly reduce lymphocytic infiltrate of pancreatic islets and modestly delay onset of autoimmune diabetes in NOD mice. AEB, a T-cell-targeted immunosuppressive strategy, is only sufficient as a monothereapy to modestly delay onset of autoimmune disease in the NOD mouse.

Quality of life after islet transplantation: data from the GRAGIL 1 and 2 trials

BACKGROUND

Rigorous assessment of health-related quality of life (HRQL) is mandatory to establish the benefits of islet transplantation.

METHODS

The 36-Item Short Form Health Survey (SF-36) and the Diabetes Quality of Life (DQOL) scales were completed by patients included in an Islet Transplantation Alone (ITA) trial (n = 10) and an Islet After Kidney (IAK) trial (n = 10).

RESULTS

The two populations differed by HRQL scores at baseline, with poorer scores in ITA patients. SF-36 scores for physical limitations, bodily pain, general health perception, social functioning, and health transition improved significantly in ITA patients 6 and 12 months post transplantation. The DQOL global score was significantly improved at 6 months and remained so at 12 months, because of a significant improvement in the dimensions of satisfaction and impact of diabetes. No improvement was observed in the IAK patients.

CONCLUSION

HRQL assessment may help in the selection of candidates with brittle diabetes for islet transplantation.

Optimal implantation site for pancreatic islet transplantation

BACKGROUND

Since the first report of successful pancreatic islet transplantation to reverse hyperglycaemia in diabetic rodents, there has been great interest in determining the optimal site for implantation. Although the portal vein remains the most frequently used site clinically, it is not ideal. About half of the islets introduced into the liver die during or shortly after transplantation. Although many patients achieve insulin independence after portal vein infusion of islets, in the long term most resume insulin injections.

METHODS

This review considers possible sites and techniques of islet transplantation in small and large animal models, and in humans. Metabolic, immunological and technical aspects are discussed.

RESULTS AND CONCLUSION

Many groups have sought an alternative site that might offer improved engraftment and long-term survival, together with reduced procedure-related complications. The spleen, pancreas, kidney capsule, peritoneum and omental pouch have been explored. The advantages and disadvantages of various sites are discussed in order to define the most suitable for clinical use and to direct future research.

The role of macrophage migration inhibitory factor on glucose metabolism and diabetes

Macrophage migration inhibitory factor (MIF) is a proinflammatory cytokine involved in many inflammatory reactions and disorders, and it has become evident that it also affects glucose homeostasis. The protein is produced by pancreatic beta cells and can promote the release of insulin. It also modulates glucose uptake, glycolysis and insulin resistance in insulin target cells such as the adipocyte, myocyte and cardiomyocyte. Possessing both immunological and endocrinological properties, MIF has been associated with the development of type 1 and type 2 diabetes, and it may be important in the setting of islet transplantation. The present review summarises our current knowledge, based on clinical and research data, on the impact of MIF on both physiological and pathological aspects of glucose metabolism.