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Malik AK, Davidson BR, Manas DM. Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma. Eur J Surg Oncol 2024:108248. [PMID: 38467524 DOI: 10.1016/j.ejso.2024.108248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.
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Affiliation(s)
- Abdullah K Malik
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK.
| | - Brian R Davidson
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK; NHS Blood and Transplant, Bristol, UK
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Malik AK, Tingle SJ, Chung N, Owen R, Mahendran B, Counter C, Sinha S, Muthasamy A, Sutherland A, Casey J, Drage M, van Dellen D, Callaghan CJ, Elker D, Manas DM, Pettigrew GJ, Wilson CH, White SA. The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation. Am J Transplant 2024:S1600-6135(24)00134-5. [PMID: 38360185 DOI: 10.1016/j.ajt.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024]
Abstract
The time to arrest donors after circulatory death is unpredictable and can vary. This leads to variable periods of warm ischemic damage prior to pancreas transplantation. There is little evidence supporting procurement team stand-down times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following donors after circulatory death (DCD) simultaneous pancreas-kidney transplantation. Data were extracted from the UK transplant registry from 2014 to 2022. Predictors of graft loss were evaluated using a Cox proportional hazards model. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. Three-hundred-and-seventy-five DCD simultaneous kidney-pancreas transplant recipients were included. Increasing TTD was not associated with graft survival (adjusted hazard ratio HR 0.98, 95% confidence interval 0.68-1.41, P = .901). Increasing asystolic time worsened graft survival (adjusted hazard ratio 2.51, 95% confidence interval 1.16-5.43, P = .020). Restricted cubic spline modeling revealed a nonlinear relationship between asystolic time and graft survival and no relationship between TTD and graft survival. We found no evidence that TTD impacts pancreas graft survival after DCD simultaneous pancreas-kidney transplantation; however, increasing asystolic time was a significant predictor of graft loss. Procurement teams should attempt to minimize asystolic time to optimize pancreas graft survival rather than focus on the duration of TTD.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK.
| | - Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Nicholas Chung
- Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Ruth Owen
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Balaji Mahendran
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | | | - Sanjay Sinha
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - John Casey
- Edinburgh Royal Infirmary, Edinburgh, UK
| | - Martin Drage
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Chris J Callaghan
- NHS Blood and Transplant, Bristol, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Doruk Elker
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
| | - Gavin J Pettigrew
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Steven A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
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Owen RV, Carr HJ, Counter C, Tingle SJ, Thompson ER, Manas DM, Shaw JA, Wilson CH, White SA. Multi-Centre UK Analysis of Simultaneous Pancreas and Kidney (SPK) Transplant in Recipients With Type 2 Diabetes Mellitus. Transpl Int 2024; 36:11792. [PMID: 38370534 PMCID: PMC10869449 DOI: 10.3389/ti.2023.11792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/27/2023] [Indexed: 02/20/2024]
Abstract
90% of the UK diabetic population are classified as T2DM. This study aims to compare outcomes after SPK transplant between recipients with T1DM or T2DM. Data on all UK SPK transplants from 2003-2019 were obtained from the NHSBT Registry (n = 2,236). Current SPK transplant selection criteria for T2DM requires insulin treatment and recipient BMI < 30 kg/m2. After exclusions (re-transplants/ambiguous type of diabetes) we had a cohort of n = 2,154. Graft (GS) and patient (PS) survival analyses were conducted using Kaplan-Meier plots and Cox-regression models. Complications were compared using chi-squared analyses. 95.6% of SPK transplants were performed in recipients with T1DM (n = 2,060). Univariate analysis showed comparable outcomes for pancreas GS at 1 year (p = 0.120), 3 years (p = 0.237), and 10 years (p = 0.196) and kidney GS at 1 year (p = 0.438), 3 years (p = 0.548), and 10 years (p = 0.947). PS was comparable at 1 year (p = 0.886) and 3 years (p = 0.237) and at 10 years (p = 0.161). Multi-variate analysis showed comparable outcomes in pancreas GS (p = 0.564, HR 1.221, 95% CI 0.619, 2.406) and PS(p = 0.556, HR 1.280, 95% CI 0.563, 2.911). Comparable rates of common complications were demonstrated. This is the largest series outside of the US evaluating outcomes after SPK transplants and shows similar outcomes between T1DM and T2DM recipients. It is hoped dissemination of this data will lead to increased referral rates and assessment of T2DM patients who could benefit from SPK transplantation.
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Affiliation(s)
- Ruth V. Owen
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Claire Counter
- Statistics and Clinical Research, NHS Blood and Transplant, Bristol, United Kingdom
| | - Samuel J. Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Emily R. Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Derek M. Manas
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - James A. Shaw
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Colin H. Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Steve A. White
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
- Blood and Transplant Unit, Newcastle University, Newcastle Upon Tyne, United Kingdom
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Mahendran B, Tingle SJ, Malik AK, Figueiredo R, Hammond JS, Sen G, Amer A, Talbot D, Manas DM, Sharp L, Exley C, White S, Wilson CH. Racial disparities in outcomes after liver transplantation in the UK: registry analysis. Br J Surg 2024; 111:znae020. [PMID: 38364060 DOI: 10.1093/bjs/znae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Balaji Mahendran
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Abdullah K Malik
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rodrigo Figueiredo
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - John S Hammond
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Gourab Sen
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Aimen Amer
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - David Talbot
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Linda Sharp
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Steven White
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
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Malik AK, Amer AO, Tingle SJ, Thompson ER, White SA, Manas DM, Wilson C. Fibrin-based haemostatic agents for reducing blood loss in adult liver resection. Cochrane Database Syst Rev 2023; 8:CD010872. [PMID: 37551841 PMCID: PMC10411946 DOI: 10.1002/14651858.cd010872.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Liver resection is the optimal treatment for selected benign and malignant liver tumours, but it can be associated with significant blood loss. Numerous anaesthetic and surgical techniques have been developed to reduce blood loss and improve perioperative outcomes. One such technique is the application of topical fibrin-based haemostatic agents (FBHAs) to the resection surface. There is no standard practice for FBHA use, and a variety of commercial agents and devices are available, as well as non-FBHAs (e.g. collagen-based agents). The literature is inconclusive on the effectiveness of these methods and on the clinical benefits of their routine use. OBJECTIVES To evaluate the benefits and harms of fibrin-based haemostatic agents in reducing intraoperative blood loss in adults undergoing liver resection. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index-Science up to 20 January 2023. We also searched online trial registries, checked the reference lists of all primary studies, and contacted the authors of included trials for additional published or unpublished trials. SELECTION CRITERIA We considered for inclusion all randomised clinical trials evaluating FBHAs versus no topical intervention or non-FBHAs, irrespective of publication type, publication status, language of publication, and outcomes reported. Eligible participants could have any liver pathology and be undergoing major or minor liver resections through open or laparoscopic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently screened the results of the literature search and used data extraction forms to collate the results. We expressed dichotomous outcome results as risk ratios (RRs) and continuous outcome results as mean differences (MDs), each with their corresponding 95% confidence interval (CI). We used a random-effects model for the main analyses. Our primary outcomes were perioperative mortality, serious adverse events, haemostatic efficacy, and health-related quality of life. Our secondary outcomes were efficacy as sealant, adverse events considered non-serious, operating time, and length of hospital stay. We assessed the certainty of the evidence with GRADE and presented results in two summary of findings tables. MAIN RESULTS We included 22 trials (2945 participants) evaluating FBHAs versus no intervention or non-FBHAs; 19 trials with 2642 participants provided data for the meta-analyses. Twelve trials reported commercial funding, one trial reported no financial support, and nine trials provided no information on funding. Below we present the most clinically relevant outcome results, also displayed in our summary of findings table. Fibrin-based haemostatic agents versus no intervention Six trials (1001 participants) compared FBHAs with no intervention. One trial was at low risk of bias in all five domains, and all other trials were at high or unclear risk of bias in at least one domain. Two trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with no intervention have an effect on perioperative mortality (RR 2.58, 95% CI 0.89 to 7.44; 4 trials, 782 participants), serious adverse events (RR 0.96, 95% CI 0.88 to 1.05; 4 trials, 782 participants), postoperative transfusion (RR 1.04, 95% CI 0.77 to 1.40; 5 trials, 864 participants), reoperation (RR 2.92, 95% CI 0.58 to 14.61; 2 trials, 612 participants), or postoperative bile leak (RR 1.00, 95% CI 0.67 to 1.48; 4 trials, 782 participants), as the certainty of evidence was very low for all these outcomes. Fibrin-based haemostatic agents versus non-fibrin-based haemostatic agents Sixteen trials (1944 participants) compared FBHAs with non-FBHAs. All trials had at least one domain at high or unclear risk of bias. Twelve trials were at high risk of bias related to blinding. It is unclear if FBHAs compared with non-FBHAs have an effect on perioperative mortality (RR 1.03, 95% CI 0.62 to 1.72; 11 trials, 1436 participants), postoperative transfusion (RR 0.92, 95% CI 0.68 to 1.25; 7 trials, 599 participants), reoperation (RR 0.48, 95% CI 0.25 to 0.90; 3 trials, 358 participants), or postoperative bile leak (RR 1.15, 95% CI 0.60 to 2.21; 9 trials, 1115 participants), as the certainty of evidence was very low for all these outcomes. FBHAs compared with non-FBHAs may have little or no effect on the risk of serious adverse events (RR 0.99, 95% CI 0.95 to 1.03; 9 trials, 1176 participants; low-certainty evidence). AUTHORS' CONCLUSIONS The evidence for the outcomes in both comparisons (FBHAs versus no intervention and FBHAs versus non-FBHAs) was of very low certainty (or low certainty in one instance) and cannot justify the routine use of FBHAs to reduce blood loss in adult liver resection. While the meta-analysis showed a reduced risk of reoperation with FBHAs compared with non-FBHAs, the analysis was confounded by the small number of trials reporting the event and the risk of bias in all these trials. Future trials should focus on the use of FBHAs in people undergoing liver resection who are at particularly high risk of bleeding. Investigators should evaluate clinically meaningful and patient-important outcomes and follow the SPIRIT and CONSORT statements.
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Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Aimen O Amer
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | - Steven A White
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
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Dor FJMF, Porte RJ, Manas DM. The future of organ donation in Europe: Is there a role for organ recovery centers? Am J Transplant 2023:S1600-6135(23)00399-4. [PMID: 37028514 DOI: 10.1016/j.ajt.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Frank J M F Dor
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Robert J Porte
- Erasmus MC Transplant Institute, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Derek M Manas
- NHS Blood and Transplant, Stoke Gifford, Bristol, UK; Liver Transplant Unit, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle University, Newcastle, UK
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Amer A, Scuffell C, Dowen F, Wilson CH, Manas DM. A national survey on enhanced recovery for renal transplant recipients: current practices and trends in the UK. Ann R Coll Surg Engl 2023; 105:166-172. [PMID: 35446720 PMCID: PMC9889185 DOI: 10.1308/rcsann.2021.0365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is well established in many specialties but has not been widely adopted in renal transplantation. The aim of this survey was to understand current national practices and sentiment concerning ERAS for renal transplant recipients in the UK. METHODOLOGY A national web-based survey was sent to consultant surgeons at all 23 UK adult renal transplant units. Completed questionnaires were collected between May and July 2020. Data were analysed according to individual responses and grouped according to the existence of formal ERAS pathways within units. RESULTS All transplant units were represented in this survey. Three units had a formal ERAS pathway for all recipients. Of the remaining units, 65.9% considered implementing an ERAS pathway in the near future. The most commonly perceived barrier to ERAS implementation was 'embedded culture within transplant units' (54.8% of respondents). A fifth of respondents insert surgical drains selectively and 11.7% routinely discontinue patient-controlled analgesia on postoperative day 1. Most respondents routinely remove urinary catheters on day 5 (70%) and ureteric stents 4-6 weeks post-transplantation (81.7%). Median length of stay for deceased donor kidney transplant recipients was lower in units with ERAS programmes (5-7 days versus 8-10 days, respectively). The main cited barriers for discharge were 'suboptimal fluid balance' and 'requirement of treatment for rejection'. CONCLUSIONS Despite slow uptake of ERAS in kidney transplantation, appetite appears to be increasing, particularly in the post-COVID-19 era. The current practice and opinions of transplant specialists highlighted in this survey may help to establish nationally agreed ERAS guidelines in this field.
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Shah T, Manas DM, Ford SJ, Dasari BVM, Gibbs P, Venkataraman H, Moore J, Hughes S, Elshafie M, Karkhanis S, Smith S, Hoti E, O'Toole D, Caplin ME, Isaac J, Mazzafero V, Thorburn D. Where Are We Now with Liver Transplantation in Neuroendocrine Neoplasms? The Place of Liver Transplantation for Grades 1 and 2 Well-Differentiated Unresectable Liver Metastatic Neuroendocrine Tumours. Curr Oncol Rep 2023; 25:135-144. [PMID: 36648705 DOI: 10.1007/s11912-022-01343-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW This review outlines the role of liver transplantation in selected patients with unresectable neuroendocrine tumour liver metastases. It discusses the international consensus on eligibility criteria and outlines the efforts taking place in the UK and Ireland to develop effective national liver transplant programmes for neuroendocrine tumour patients. RECENT FINDINGS In the early history of liver transplantation, indications included cancer metastases to the liver as well as primaries of liver origin. Often, liver transplantation was a salvage procedure. The early results were disappointing, including in patients with neuroendocrine tumours. These data discouraged the widespread adoption of liver transplantation for neuroendocrine tumour liver metastases (NET LM). A few centres persisted in performing liver transplantation for patients with NET LM and in determining parameters predictive of good outcomes. Their work has provided evidence for benefit of liver transplantation in a selected group of patients with NET LM. Liver transplantation for NET LM is now accepted as a valid indication by many professional bodies, including the European Neuroendocrine Tumour Society (ENETS) and the United Network for Organ Sharing (UNOS). It is nevertheless rarely utilised. The UK and the Republic of Ireland are commencing a pilot programme of liver transplantation in selected patients. This programme will help develop the expertise and infrastructure to make liver transplantation for NET LM a routine procedure.
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Affiliation(s)
- Tahir Shah
- Queen Elizabeth Hospital Birmingham, Birmingham, UK.
| | | | | | | | | | | | | | - Simon Hughes
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Stacey Smith
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Emir Hoti
- St Vincent's University Hospital, Dublin, UK
| | | | | | - John Isaac
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Malik AK, Amer AO, White SA, Manas DM, Wilson CH. O092 Fibrin-based haemostatic agents for reducing blood loss in adult liver resection: a meta-analysis. Br J Surg 2022. [DOI: 10.1093/bjs/znac242.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Introduction
Liver resection can be associated with significant perioperative bleeding. Fibrin based haemostatic agents (FBHAs) are bioabsorbable topical haemostatic agents used to enhance haemostasis and reduce blood loss. We performed a systematic review and meta-analysis, comparing FBHAs with the standard of care and no topical application (SoC), and comparing FBHAs with non-fibrin-based haemostatic agents (NFHAs) to evaluate their efficacy in reducing blood loss and improving perioperative outcomes.
Method
The Cochrane Hepato-Biliary Specialised Register was searched to identify (quasi-) RCTs to include in our meta-analysis. Two authors independently reviewed each study. Primary outcomes were haemostatic efficacy (defined as haemostasis within 4 or 5 minutes post application), adverse events and perioperative mortality (within 30-days of surgery). Statistical analyses were performed using the random effects model and results expressed as odds ratio (OR) with 95% confidence intervals.
Result
Twenty-seven RCTs (3736 participants) were included in our analysis. FBHAs were found to have superior haemostatic efficacy compared to NFHAs (OR 4.03; 1.73–9.36, p=0.001), and were superior to SoC (OR 13.59; 4.06–45.47, p<0.0001). Incidence of adverse events and perioperative mortality was no different when comparing FBHAs with SoC or NFHAs. No differences were detected when testing for post-operative bile leakage, intra-abdominal collections, volume of abdominal drain output, post-operative transfusion requirements, reoperation rates and length of stay (all p>0.05).
Conclusion
FBHAs appear superior to SoC and NFHAs in achieving haemostasis within 4–5 minutes post-application, however this does not translate into improved post-operative outcomes. FBHAs are not justified for routine use based on the available evidence.
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Affiliation(s)
- AK Malik
- Liver Unit, Freeman Hospital , Newcastle upon Tyne
| | - AO Amer
- Liver Unit, Freeman Hospital , Newcastle upon Tyne
| | - SA White
- Liver Unit, Freeman Hospital , Newcastle upon Tyne
| | - DM Manas
- Liver Unit, Freeman Hospital , Newcastle upon Tyne
| | - CH Wilson
- Liver Unit, Freeman Hospital , Newcastle upon Tyne
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Reeves HL, Reicher J, Priona G, Manas DM, Littler P. Selective internal radiation therapy (SIRT) for hepatocellular carcinoma (HCC): informing clinical practice for multidisciplinary teams in England. Frontline Gastroenterol 2022; 14:45-51. [PMID: 36561784 PMCID: PMC9763643 DOI: 10.1136/flgastro-2022-102137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
Objective Hepatocellular carcinoma (HCC) deaths are rising alarmingly. Many patients are unsuitable for available therapies. Poor response rates further hamper outcomes for those that are. Selective internal radiation therapy (SIRT) offers hope, although which patients benefit over standard approaches remains unclear. Design/method As a quality/service improvement, we audited consecutive patients treated with SIRT (2015-2020) by the Newcastle upon Tyne Hospitals National Health Service Foundation Trust HCC multidisciplinary team. Indications, Barcelona clinic liver cancer (BCLC) stage, treatment response, subsequent therapies and survival at 30 September 2021 were assessed. Results Fifty-one patients received SIRT. Thirty-day mortality was zero. Three months partial response, stable disease and progressive disease on imaging were 50%, 22% and 28%, respectively. Overall median survival was 21 months. There were four subgroups: (1) BCLC-B: HCC>7 cm too large for transarterial chemoembolisation (TACE) alone (n=21); (2) BCLC-B: HCC progressed post TACE (n=7); (3) BCLC-C: HCC with any combination of large tumour burden, branch portal vein thrombosis, non-hepatitis C virus aetiology (n=16); (4) BCLC-C: sorafenib inappropriate (n=7). In group 1, 5/21 (23.8%) of patients were downstaged to resection, 33% received subsequent medical therapies and median survival was >40 months. In BCLC-B patients treated second line (group 2), median survival was 14.2 months. In BCLC-C, median survival was 20.2 months for group 3 and 4.2 months for group 4. Conclusion SIRT outcomes for advanced HCC, often bridging patients with adverse predictive factors to subsequent surgery or medical therapies, were encouraging. A role after TACE or for BCLC-C patients requires further assessment.
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Affiliation(s)
- Helen L Reeves
- Newcastle University Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
- Liver Unit, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - John Reicher
- Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Georgia Priona
- Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Peter Littler
- Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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11
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Geh D, Watson R, Sen G, French JJ, Hammond J, Turner P, Hoare T, Anderson K, McNeil M, McPherson S, Masson S, Dyson J, Donnelly M, MacDougal L, Patel P, Hudson M, Anstee QM, White S, Robinson S, Pandanaboyana S, Walker L, McCain M, Bury Y, Raman S, Burt A, Parkinson D, Haugk B, Darne A, Wadd N, Asghar S, Mariappan L, Margetts J, Stenberg B, Scott J, Littler P, Manas DM, Reeves HL. COVID-19 and liver cancer: lost patients and larger tumours. BMJ Open Gastroenterol 2022; 9:e000794. [PMID: 35450934 PMCID: PMC9023844 DOI: 10.1136/bmjgast-2021-000794] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Northern England has been experiencing a persistent rise in the number of primary liver cancers, largely driven by an increasing incidence of hepatocellular carcinoma (HCC) secondary to alcohol-related liver disease and non-alcoholic fatty liver disease. Here we review the effect of the COVID-19 pandemic on primary liver cancer services and patients in our region. OBJECTIVE To assess the impact of the COVID-19 pandemic on patients with newly diagnosed liver cancer in our region. DESIGN We prospectively audited our service for the first year of the pandemic (March 2020-February 2021), comparing mode of presentation, disease stage, treatments and outcomes to a retrospective observational consecutive cohort immediately prepandemic (March 2019-February 2020). RESULTS We observed a marked decrease in HCC referrals compared with previous years, falling from 190 confirmed new cases to 120 (37%). Symptomatic became the the most common mode of presentation, with fewer tumours detected by surveillance or incidentally (% surveillance/incidental/symptomatic; 34/42/24 prepandemic vs 27/33/40 in the pandemic, p=0.013). HCC tumour size was larger in the pandemic year (60±4.6 mm vs 48±2.6 mm, p=0.017), with a higher incidence of spontaneous tumour haemorrhage. The number of new cases of intrahepatic cholangiocarcinoma (ICC) fell only slightly, with symptomatic presentation typical. Patients received treatment appropriate for their cancer stage, with waiting times shorter for patients with HCC and unchanged for patients with ICC. Survival was associated with stage both before and during the pandemic. 9% acquired COVID-19 infection. CONCLUSION The pandemic-associated reduction in referred patients in our region was attributed to the disruption of routine healthcare. For those referred, treatments and survival were appropriate for their stage at presentation. Non-referred or missing patients are expected to present with more advanced disease, with poorer outcomes. While protective measures are necessary during the pandemic, we recommend routine healthcare services continue, with patients encouraged to engage.
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Affiliation(s)
- Daniel Geh
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Robyn Watson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Gourab Sen
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jeremy J French
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Hammond
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul Turner
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tim Hoare
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kirsty Anderson
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael McNeil
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stuart McPherson
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Steven Masson
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jessica Dyson
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mhairi Donnelly
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Louise MacDougal
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Preya Patel
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mark Hudson
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Steven White
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stuart Robinson
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Lucy Walker
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Discovery Medicine, GlaxoSmithKline Plc, Brentford, UK
| | - Misti McCain
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Yvonne Bury
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Shreya Raman
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Alastair Burt
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Daniel Parkinson
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Beate Haugk
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Antony Darne
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nick Wadd
- Department of Oncology, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Syed Asghar
- Department of Oncology, North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - Lavanya Mariappan
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jane Margetts
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Benjamin Stenberg
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John Scott
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Peter Littler
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen L Reeves
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- The Liver Unit, Department of Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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12
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Oppong KW, Nayar MK, Bekkali NLH, Maheshwari P, Haugk B, Darne A, Manas DM, French JJ, White S, Sen G, Pandanaboyana S, Charnley RM, Leeds JS. Impact of prior biliary stenting on diagnostic performance of endoscopic ultrasound for mesenteric vascular staging in patients with head of pancreas and periampullary malignancy. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000864. [PMID: 35301231 PMCID: PMC8932265 DOI: 10.1136/bmjgast-2021-000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/13/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The diagnostic performance of endoscopic ultrasound (EUS) for stratification of head of pancreas and periampullary tumours into resectable, borderline resectable and locally advanced tumours is unclear as is the effect of endobiliary stents. The primary aim of the study was to assess the diagnostic performance of EUS for resectability according to stent status. Design A retrospective study was performed. All patients presenting with a solid head of pancreas mass who underwent EUS and surgery with curative intent during an 8-year period were included. Factors with possible impact on diagnostic performance of EUS were analysed using logistic regression. Results Ninety patients met inclusion criteria and formed the study group. A total of 49 (54%) patients had an indwelling biliary stent at the time of EUS, of which 36 were plastic and 13 were self-expanding metal stents (SEMS). Twenty patients underwent venous resection and reconstruction (VRR). Staging was successfully performed in 100% unstented cases, 97% plastic stent and 54% SEMS, p<0.0001. In successfully staged patients, sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) for classification of resectability were 70%, 70%, 70%, 42% and 88%. For vascular involvement (VI), sensitivity, specificity, accuracy, PPV and NPV were 80%, 68%, 69%, 26% and 96%. Increasing tumour size OR 0.53 (95% CI, 0.30 to 0.95) was associated with a decrease in accuracy of VI classification. Conclusions EUS has modest diagnostic performance for stratification of staging. Staging was less likely to be completed when a SEMS was in situ. Staging EUS should ideally be performed before endoscopic retrograde cholangiopancreatography and biliary drainage.
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Affiliation(s)
- Kofi W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Manu K Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Noor L H Bekkali
- Gastroenterology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | | | - Beate Haugk
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Antony Darne
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Derek M Manas
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Surgery, Newcastle upon Tyne Hopsitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jeremy J French
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Surgery, Newcastle upon Tyne Hopsitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Steven White
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Surgery, Newcastle upon Tyne Hopsitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gourab Sen
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Surgery, Newcastle upon Tyne Hopsitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Sanjay Pandanaboyana
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Surgery, Newcastle upon Tyne Hopsitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastele upon Tyne, UK
| | - Richard M Charnley
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Surgery, Newcastle upon Tyne Hopsitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - John S Leeds
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastele upon Tyne, UK
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13
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Kamarajah SK, Sutandi N, Sen G, Hammond J, Manas DM, French JJ, White SA. Comparative analysis of open, laparoscopic and robotic distal pancreatic resection: The United Kingdom's first single-centre experience. J Minim Access Surg 2022; 18:77-83. [PMID: 35017396 PMCID: PMC8830579 DOI: 10.4103/jmas.jmas_163_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/20/2020] [Accepted: 11/30/2020] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Laparoscopic distal pancreatectomy (LDP) has potential advantages over its open equivalent open distal pancreatectomy (ODP) for pancreatic disease in the neck, body and tail. Within the United Kingdom (UK), there has been no previous experience describing the role of robotic distal pancreatectomy (RDP). This study evaluated differences between ODP, LDP and RDP. METHODS Patients undergoing distal pancreatectomy performed in the Department of Hepatobiliary and Pancreatic Surgery at the Freeman Hospital between September 2007 and December 2018 were included from a prospectively maintained database. The primary outcome measure was length of hospital stay, and the secondary outcome measures were complication rates graded according to the Clavien-Dindo classification. RESULTS Of the 125 patients, the median age was 61 years and 46% were male. Patients undergoing RDP (n = 40) had higher American Society of Anesthesiologists grading III compared to ODP (n = 38) and LDP (n = 47) (57% vs. 37% vs. 38%, P = 0.02). RDP had a slightly lower but not significant conversion rate (10% vs. 13%, P = 0.084), less blood loss (median: 0 vs. 250 ml, P < 0.001) and a higher rate of splenic preservation (30% vs. 2%, P < 0.001) and shorter operative time, once docking time excluded (284 vs. 300 min, P < 0.001) compared to LDP. RDP had a higher R0 resection rate than ODP and LDP (79% vs. 47% vs. 71%, P = 0.078) for neoplasms. RDP was associated with significantly shorter hospital stay than LDP and ODP (8 vs. 9 vs. 10 days, P = 0.001). While there was no significant different in overall complications across the groups, RDP was associated with lower rates of Grade C pancreatic fistula than ODP and LDP (2% vs. 5% vs. 6%, P = 0.194). CONCLUSION Minimally invasive pancreatic resection offers potential advantages over ODP, with a trend showing RDP to be marginally superior when compared to conventional LDP, but it is accepted that that this is likely to be at greater expense compared to the other current techniques.
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Affiliation(s)
- Sivesh Kathir Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, UK
| | - Nathania Sutandi
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Gourab Sen
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - John Hammond
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Derek M Manas
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Steven A White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
- Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK
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14
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Kamarajah SK, Gujjuri RR, Hilal MA, Manas DM, White SA. Does minimally invasive liver resection improve long-term survival compared to open resection for hepatocellular carcinoma? A systematic review and meta-analysis. Scand J Surg 2021; 111:14574969211042455. [PMID: 34605328 DOI: 10.1177/14574969211042455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Minimally invasive liver surgery for hepatocellular carcinoma has gained widespread interest as an alternative to conventional open liver surgery. However, long-term survival benefits of this approach seem unclear. This meta-analysis was conducted to investigate long-term survival following minimally invasive liver surgery. METHOD A systematic review was performed to identify studies comparing long-term survival after minimally invasive liver surgery and open liver surgery until January 2020. The I2 test was used to test for statistical heterogeneity and publication bias was assessed using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study factors (region, design), annual center volume, patient factors (American Society of Anesthesiologists (ASA) grade, gender, age, body mass index, cirrhosis, tumor size, and number), and resection extent. Sensitivity analyses were performed on studies by study year, region, annual center volume, and resection type. RESULT The review identified 50 relevant studies including 13,731 patients undergoing liver resection for hepatocellular carcinoma of which 4071 (25.8%) underwent minimally invasive liver surgery. Pooled analysis revealed similar all-cause (odds ratio: 0.83, 95% confidence interval: 0.70-1.11, p = 0.3) and disease-specific (odds ratio: 0.93, 95% confidence interval: 0.80-1.09, p = 0.4) 5-year mortality after minimally invasive liver surgery compared with open liver surgery. Sensitivity analysis of published studies from 2010 to 2019 demonstrated a significantly lower disease-specific 3-year mortality (odds ratio: 0.75, 95% confidence interval: 0.59-0.96, p = 0.022) and all-cause 5-year mortality (odds ratio: 0.63, 95% confidence interval: 0.50-0.81, p = 0.002). Meta-regression identified no confounding factors in all analyses. CONCLUSIONS Improvement in minimally invasive liver surgery techniques over the past decade appears to demonstrate superior disease-specific mortality with minimally invasive liver surgery compared to open liver surgery. Therefore, minimally invasive liver surgery can be recommended as an alternative surgical approach for hepatocellular carcinoma.
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Affiliation(s)
- Sivesh K Kamarajah
- BMedSci, MBChB Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, NE7 7DN, Newcastle upon Tyne, UK Institute of Cellular Medicine, Newcastle University, NE2 4HH, Newcastle upon Tyne, UK
| | - Rohan R Gujjuri
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Moh'd A Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Derek M Manas
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Steven A White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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15
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Tingle SJ, Thompson ER, Ali SS, Ibrahim IK, Irwin E, Sen G, White SA, Manas DM, Wilson CH. O6: EARLY ANASTOMOTIC BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Biliary leaks and anastomotic strictures are common early biliary complications (EBC) following liver transplantation. However, their impact on outcomes remains controversial and poorly described.
Method
The NHS registry on adult liver transplantation between 2006 and 2017 was retrospectively reviewed (n=8304). Multiple imputations were performed to account for missing data. Adjusted regression models were used to assess predictors of EBC, and their impact on outcomes. 35 potential variables were included, and backwards stepwise selection enabled unbiased selection of variables for inclusion in final models.
Result
EBC occurred in 9.6% of patients. Adjusted cox regression revealed that EBCs have a significant and independent impact on graft survival (Leak HR=1.325; P=0.021, Stricture HR=1.514; P=0.002, Leak plus stricture HR=1.533; P=0.034) and patient survival (Leak HR=1.218; P=0.131, Stricture HR=1.578; P<0.001, Leak plus stricture HR=1.507; P=0.044). Patients with EBC had longer median hospital stay (23 versus 15 days; P<0.001) and increased chance for readmission within the first year (56% versus 32%; P<0.001). On adjusted logistic regression the following were identified as independent risk factors for development of EBC: donation following circulatory death (OR=1.280; P=0.009), accessory hepatic artery (OR=1.324; P=0.005), vascular anastomosis time in minutes (OR=1.005; P=0.032) and ethnicity ‘other’ (OR=1.838; P=0.011).
Conclusion
EBCs prolong hospital stay, increase readmission rates and are independent risk factors for diminished graft survival and increased mortality in liver transplantation. We have identified factors that increase the likelihood of EBC occurrence; further research into interventions to prevent EBCs in these at-risk groups is vital to improve liver transplantation outcomes.
Take-home message
Using a large registry database we have shown that early anastomotic biliary complications are independent risk factors for decreased graft survival and increased mortality after liver transplantation. Research into interventions to prevent biliary complications in high risk groups are essential to improve liver transplant outcomes.
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Affiliation(s)
- SJ Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - ER Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - SS Ali
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - IK Ibrahim
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - E Irwin
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - G Sen
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - SA White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - DM Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - CH Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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16
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Tingle SJ, Thompson ER, Ali SS, Figueiredo R, Hudson M, Sen G, White SA, Manas DM, Wilson CH. Risk factors and impact of early anastomotic biliary complications after liver transplantation: UK registry analysis. BJS Open 2021; 5:6226008. [PMID: 33855363 PMCID: PMC8047096 DOI: 10.1093/bjsopen/zrab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background Biliary leaks and anastomotic strictures are common early anastomotic biliary complications (EABCs) following liver transplantation. However, there are no large multicentre studies investigating their clinical impact or risk factors. This study aimed to define the incidence, risk factors and impact of EABC. Methods The NHS registry on adult liver transplantation between 2006 and 2017 was reviewed retrospectively. Adjusted regression models were used to assess predictors of EABC, and their impact on outcomes. Results Analyses included 8304 liver transplant recipients. Patients with EABC (9·6 per cent) had prolonged hospitalization (23 versus 15 days; P < 0·001) and increased chance for readmission within the first year (56 versus 32 per cent; P < 0·001). Patients with EABC had decreased estimated 5-year graft survival of 75·1 versus 84·5 per cent in those without EABC, and decreased 5-year patient survival of 76·9 versus 83·3 per cent; both P < 0.001. Adjusted Cox regression revealed that EABCs have a significant and independent impact on graft survival (leak hazard ratio (HR) 1·344, P = 0·015; stricture HR 1·513, P = 0·002; leak plus stricture HR 1·526, P = 0·036) and patient survival (leak HR 1·215, P = 0·136, stricture HR 1·526, P = 0·001; leak plus stricture HR 1·509; P = 0·043). On adjusted logistic regression, risk factors for EABC included donation after circulatory death grafts, graft aberrant arterial anatomy, biliary anastomosis type, vascular anastomosis time and recipient model of end-stage liver disease. Conclusion EABCs prolong hospital stay, increase readmission rates and are independent risk factors for graft loss and increased mortality. This study has identified factors that increase the likelihood of EABC occurrence; research into interventions to prevent EABCs in these at-risk groups is vital to improve liver transplantation outcomes.
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Affiliation(s)
- S J Tingle
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - E R Thompson
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - S S Ali
- Faculty of Medical Sciences, Imperial College London, South Kensington, London, UK
| | - R Figueiredo
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - M Hudson
- Department of Hepatology, Freeman Hospital, Newcastle upon Tyne, UK
| | - G Sen
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - S A White
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - D M Manas
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
| | - C H Wilson
- National Institute for Health Research Blood and Transplant Research Unit (NIHR BTRU) in Organ Donation and Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne UK
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17
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Gujjuri RR, Kamarajah SK, Hilal MA, Manas DM, White SA. P75 Long-Term Survival After Minimally Invasive Resection versus Open Resection for Hepatocellular Carcinoma: A Systematic Review, Meta-Analysis and Meta-Regression. BJS Open 2021. [DOI: 10.1093/bjsopen/zrab032.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Minimally invasive liver surgery (MILS) for hepatocellular carcinoma (HCC) has gained widespread interest as an alternative to conventional open liver surgery (OLS). However, long-term survival benefits of this approach seem unclear. This meta- analysis was conducted to investigate long-term survival following MILS.
Methods
A systematic review was performed to identify studies comparing long-term survival after MILS and OLS until January 2020. The I2 test was used to test for statistical heterogeneity and publication bias was assessed using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study factors (region, design), annual center volume, patient factors (ASA grade, gender, age, BMI, cirrhosis, tumor size and number), and resection extent. Sensitivity analyses were performed on studies by study year, region, annual centre volume, resection type.
Results
The review identified 50 relevant studies including 13,731 patients undergoing liver resection for HCC of which 4,071 (25.8%) underwent MILS. Pooled analysis revealed similar all-cause (OR: 0.83, 95% CI: 0.70 - 1.11, p = 0.3) and disease-specific (OR: 0.93, 95% CI: 0.80 - 1.09, p = 0.4) 5-year mortality after MILS compared with OLS. Sensitivity analysis of published studies from 2010 to 2019 demonstrated a significantly lower disease-specific 3-year mortality (OR 0.75, 95% CI: 0.59 - 0.96, p = 0.022) and all cause 5-year mortality (OR 0.63, 95% CI: 0.50 - 0.81, p = 0.002). Meta- regression identified no confounding factors in all analyses.
Conclusions
Improvement in MILS techniques over the past decade appears to demonstrate superior disease-specific mortality with MILS compared to OLS. Therefore, MILS can be recommended as a standard surgical approach for HCC.
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Affiliation(s)
- Rohan R Gujjuri
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sivesh K Kamarajah
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Moh’d Abu Hilal
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Derek M Manas
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Steven A White
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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18
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Kamarajah SK, Bundred JR, Littler P, Reeves H, Manas DM, White SA. Treatment strategies for early stage hepatocellular carcinoma: a systematic review and network meta-analysis of randomised clinical trials. HPB (Oxford) 2021; 23:495-505. [PMID: 33309569 DOI: 10.1016/j.hpb.2020.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several treatment strategies for early stage hepatocellular cancers (HCC) have been evaluated in randomised controlled trials (RCTs). This network meta-analysis (NMA) aimed to explore the relative effectiveness of these different approaches on their impact on overall (OS) and recurrence-free survival (RFS). METHODS A systematic review was conducted to identify RCT's reported up to 23rd January 2020. Indirect comparisons of all regimens were simultaneously compared using random-effects NMA. RESULTS Twenty-eight RCT's, involving 3,618 patients, reporting 13 different treatment strategies for early stage HCC were identified. Median follow-up, reported in 22 studies, ranged from 12-93 months. In this NMA, RFA in combination with iodine-125 was ranked first for both RFS (HR: 0.50, 95% CI: 0.19-1.31) and OS (HR: 0.41, 95% CI: 0.19-0.94). In subgroup with solitary HCC, lack of studies reporting RFS precluded reliable analysis. However, RFA in combination with iodine-125 was associated with markedly better OS (HR: 0.21, 95% CI: 0.05-0.93). CONCLUSION This NMA identified RFA in combination with iodine-125 as a treatment delivering better RFS and OS, in patients with early stage HCC, especially for those with solitary HCC. This technique warrants further evaluation in both Asia and Western regions.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, UK; Department of Surgery, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Trust, Birmingham, UK.
| | - James R Bundred
- Leeds Teaching Hospitals NHS Trust Research and Innovation Department, Leeds, UK
| | - Peter Littler
- Department of Interventional Radiology, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Helen Reeves
- Newcastle University Centre for Cancer, Newcastle University Medical School, Newcastle upon Tyne, UK; Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne NHS Foundation Trust, The Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK
| | - Steven A White
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, UK
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19
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Robinson S, Moir JAG, Pedley I, Manas DM, White SA. Chemotherapy for downsizing unresectable liver metastases from colorectal cancer. Hippokratia 2021. [DOI: 10.1002/14651858.cd009335.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Stuart Robinson
- Department of HPB & Transplant Surgery; Newcastle upon Tyne Hospitls NHS Foundation Trust; Newcastle upon Tyne UK
| | | | - Ian Pedley
- Department of Medical Oncology; Northern Centre for Cancer Care, Freeman Hospital; Newcastle upon Tyne UK
| | - Derek M Manas
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
| | - Steven A White
- Institute of Cellular Medicine, Newcastle University; Newcastle upon Tyne UK
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20
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Geh D, Manas DM, Reeves HL. Hepatocellular carcinoma in non-alcoholic fatty liver disease-a review of an emerging challenge facing clinicians. Hepatobiliary Surg Nutr 2021; 10:59-75. [PMID: 33575290 DOI: 10.21037/hbsn.2019.08.08] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/21/2019] [Indexed: 12/14/2022]
Abstract
Importance Non-alcoholic fatty liver disease (NAFLD) is a rapidly growing cause of chronic liver disease and is becoming a leading cause of hepatocellular carcinoma (HCC) in many developed countries. This presents major challenges for the surveillance, diagnosis and treatment of HCC. Objective To discuss the clinical challenges faced by clinicians in managing the rising number of NAFLD-HCC cases. Evidence Review MEDLINE, PubMed and Embase databases were searched using the keywords; NAFLD, HCC, surveillance, hepatectomy, liver transplantation, percutaneous ablation, transarterial chemoembolization (TACE), selective internal radiotherapy treatment (SIRT) and sorafenib. Relevant clinical studies were included. Findings Current HCC surveillance programmes are inadequate because they only screen for HCC in patients with cirrhosis, whereas in NAFLD a significant proportion of HCC develops in the absence of cirrhosis. Consequently NAFLD patients often present with a more advanced stage of HCC, with a poorer prognosis. NAFLD-HCC patients also tend to be older and to have more co-morbidities compared to HCC of other etiologies. This limits the use of curative treatments such as liver resection and orthotopic liver transplantation (OLT). Evidence suggests that although NAFLD-HCC patients who undergo liver resection or OLT have worse perioperative and short-term outcomes, overall long-term survival is comparable to HCC of other etiologies. This highlights the importance of careful patient selection, pre-habilitation and perioperative planning for NAFLD-HCC patients being considered for surgical treatment. Careful consideration is also important for non-surgical treatments, although the evidence supporting treatment selection is frequently lacking, as these patients tend to be poorly represented in clinical trials. Locoregional therapies such as percutaneous ablation and TACE may be less well tolerated and less effective in NAFLD patients with obesity or diabetes. The tyrosine kinase inhibitor sorafenib may also be less effective. Conclusions and Relevance This review highlights how international guidelines, for which NAFLD traditionally has made up a small part of the evidence base, may not be appropriate for all NAFLD-HCC patients. Future guidelines need to reflect the changing landscape of HCC, by making specific recommendations for the management of NAFLD-HCC.
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Affiliation(s)
- Daniel Geh
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen L Reeves
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK.,Hepatopancreatobiliary Multidisciplinary Team, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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21
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Leslie J, Macia MG, Luli S, Worrell JC, Reilly WJ, Paish HL, Knox A, Barksby BS, Gee LM, Zaki MYW, Collins AL, Burgoyne RA, Cameron R, Bragg C, Xu X, Chung GW, Brown CDA, Blanchard AD, Nanthakumar CB, Karsdal M, Robinson SM, Manas DM, Sen G, French J, White SA, Murphy S, Trost M, Zakrzewski JL, Klein U, Schwabe RF, Mederacke I, Nixon C, Bird T, Teuwen LA, Schoonjans L, Carmeliet P, Mann J, Fisher AJ, Sheerin NS, Borthwick LA, Mann DA, Oakley F. Author Correction: c-Rel orchestrates energy-dependent epithelial and macrophage reprogramming in fibrosis. Nat Metab 2021; 3:118-119. [PMID: 33303984 DOI: 10.1038/s42255-020-00326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jack Leslie
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Marina García Macia
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Saimir Luli
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Julie C Worrell
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - William J Reilly
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Hannah L Paish
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Amber Knox
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ben S Barksby
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Lucy M Gee
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Marco Y W Zaki
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Biochemistry Department, Faculty of Pharmacy, Minia University, Minia, Egypt
| | - Amy L Collins
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel A Burgoyne
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rainie Cameron
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Charlotte Bragg
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Xin Xu
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Git W Chung
- Newcells Biotech, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Colin D A Brown
- Newcells Biotech, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Andrew D Blanchard
- Fibrosis Discovery Performance Unit, Respiratory Therapy Area, Medicines Research Centre, GlaxoSmithKline R&D, Stevenage, UK
| | - Carmel B Nanthakumar
- Fibrosis Discovery Performance Unit, Respiratory Therapy Area, Medicines Research Centre, GlaxoSmithKline R&D, Stevenage, UK
| | - Morten Karsdal
- Nordic Bioscience A/S, Biomarkers & Research, Herlev, Denmark
| | - Stuart M Robinson
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gourab Sen
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jeremy French
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Steven A White
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sandra Murphy
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Matthias Trost
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Johannes L Zakrzewski
- Center for Discovery and Innovation and John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ulf Klein
- Division of Haematology & Immunology, Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | | | - Ingmar Mederacke
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Colin Nixon
- Cancer Research UK Beatson Institute, Garscube Estate, Glasgow, UK
| | - Tom Bird
- Cancer Research UK Beatson Institute, Garscube Estate, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Glasgow, UK
- MRC Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Laure-Anne Teuwen
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, Leuven, Belgium
| | - Luc Schoonjans
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, Leuven, Belgium
| | - Peter Carmeliet
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, Leuven, Belgium
| | - Jelena Mann
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Lee A Borthwick
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Derek A Mann
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Oakley
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK.
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22
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Thorburn D, Taylor R, Whitney J, Adair A, Attia M, Gibbs P, Grammatikopoulos T, Isaac JR, Masson S, Marshall A, Mirza DF, Prachalias A, Watson S, Manas DM, Forsythe J. Resuming liver transplantation amid the COVID-19 pandemic. Lancet Gastroenterol Hepatol 2020; 6:12-13. [PMID: 33308431 PMCID: PMC7833625 DOI: 10.1016/s2468-1253(20)30360-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Douglas Thorburn
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK; NHS Blood and Transplant, Stoke Gifford, Bristol, UK
| | | | - Julie Whitney
- NHS Blood and Transplant, Stoke Gifford, Bristol, UK
| | - Anya Adair
- Edinburgh Transplant Centre, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Magdy Attia
- Liver Transplant Unit, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Paul Gibbs
- Department of Surgery, Cambridge Universities Hospital Trust, Cambridge, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, Gastrointestinal, Nutrition Centre and Mowat Labs, King's College Hospital, London, UK
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Steven Masson
- Liver Transplant Unit, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle University, Newcastle NE7 7DN, UK.
| | - Aileen Marshall
- Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK; Liver Unit, Birmingham Children's Hospital, Birmingham, UK
| | | | - Sarah Watson
- Highly Specialised Services, NHS England and NHS Improvement, UK
| | - Derek M Manas
- NHS Blood and Transplant, Stoke Gifford, Bristol, UK; Liver Transplant Unit, Freeman Hospital, Newcastle Hospitals NHS Foundation Trust, Newcastle University, Newcastle NE7 7DN, UK
| | - John Forsythe
- NHS Blood and Transplant, Stoke Gifford, Bristol, UK
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23
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Byrne MHV, Battle J, Sewpaul A, Tingle S, Thompson E, Brookes M, Innes A, Turner P, White SA, Manas DM, Wilson CH. Early protocol computer tomography and endovascular interventions in pancreas transplantation. Clin Transplant 2020; 35:e14158. [PMID: 33222262 DOI: 10.1111/ctr.14158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/19/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early vascular complications following pancreatic transplantation are not uncommon (3%-8%). Typically, cross-sectional imaging is requested in response to clinical change. We instituted a change in protocol to request imaging pre-emptively to identify patients with thrombotic complications. METHODS In 2013, protocol computer tomography angiography (CTA) at days 3-5 and day 10 following pancreas transplantation was introduced. A retrospective analysis of all pancreas transplants performed at our institution from January 2001 to May 2019 was undertaken. RESULTS A total of 115 patients received pancreas transplants during this time period. A total of 78 received pancreas transplant without routine CTA and 37 patients with the new protocol. Following the change in protocol, we detected a high number of subclinical thromboses (41.7%). There was a significant decrease in invasive intervention for thrombosis (78.6% before vs 30.8% after, p = .02), and graft survival was significantly higher (61.5% before vs 86.1% after, p = .04). There was also a significant reduction in the number of graft failures (all-cause) where thrombosis was present (23.4% before vs 5.6% after, p = .02). Patient survival was unaffected (p = .48). CONCLUSIONS Implementation of early protocol CTA identifies a large number of patients with subclinical graft thromboses that are more amenable to conservative management and significantly reduces the requirement for invasive intervention.
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Affiliation(s)
| | - Joseph Battle
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Avinash Sewpaul
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Samuel Tingle
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Emily Thompson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marcus Brookes
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Ailsa Innes
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Paul Turner
- Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Steven A White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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24
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Leslie J, Macia MG, Luli S, Worrell JC, Reilly WJ, Paish HL, Knox A, Barksby BS, Gee LM, Zaki MYW, Collins AL, Burgoyne RA, Cameron R, Bragg C, Xu X, Chung GW, Brown CDA, Blanchard AD, Nanthakumar CB, Karsdal M, Robinson SM, Manas DM, Sen G, French J, White SA, Murphy S, Trost M, Zakrzewski JL, Klein U, Schwabe RF, Mederacke I, Nixon C, Bird T, Teuwen LA, Schoonjans L, Carmeliet P, Mann J, Fisher AJ, Sheerin NS, Borthwick LA, Mann DA, Oakley F. c-Rel orchestrates energy-dependent epithelial and macrophage reprogramming in fibrosis. Nat Metab 2020; 2:1350-1367. [PMID: 33168981 PMCID: PMC7116435 DOI: 10.1038/s42255-020-00306-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
Abstract
Fibrosis is a common pathological feature of chronic disease. Deletion of the NF-κB subunit c-Rel limits fibrosis in multiple organs, although the mechanistic nature of this protection is unresolved. Using cell-specific gene-targeting manipulations in mice undergoing liver damage, we elucidate a critical role for c-Rel in controlling metabolic changes required for inflammatory and fibrogenic activities of hepatocytes and macrophages and identify Pfkfb3 as the key downstream metabolic mediator of this response. Independent deletions of Rel in hepatocytes or macrophages suppressed liver fibrosis induced by carbon tetrachloride, while combined deletion had an additive anti-fibrogenic effect. In transforming growth factor-β1-induced hepatocytes, c-Rel regulates expression of a pro-fibrogenic secretome comprising inflammatory molecules and connective tissue growth factor, the latter promoting collagen secretion from HMs. Macrophages lacking c-Rel fail to polarize to M1 or M2 states, explaining reduced fibrosis in RelΔLysM mice. Pharmacological inhibition of c-Rel attenuated multi-organ fibrosis in both murine and human fibrosis. In conclusion, activation of c-Rel/Pfkfb3 in damaged tissue instigates a paracrine signalling network among epithelial, myeloid and mesenchymal cells to stimulate fibrogenesis. Targeting the c-Rel-Pfkfb3 axis has potential for therapeutic applications in fibrotic disease.
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Affiliation(s)
- Jack Leslie
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Marina García Macia
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Saimir Luli
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Julie C Worrell
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - William J Reilly
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Hannah L Paish
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Amber Knox
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ben S Barksby
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Lucy M Gee
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Marco Y W Zaki
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Biochemistry Department, Faculty of Pharmacy, Minia University, Minia, Egypt
| | - Amy L Collins
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel A Burgoyne
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Rainie Cameron
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Charlotte Bragg
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Xin Xu
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Git W Chung
- Newcells Biotech, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Colin D A Brown
- Newcells Biotech, The Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Andrew D Blanchard
- Fibrosis Discovery Performance Unit, Respiratory Therapy Area, Medicines Research Centre, GlaxoSmithKline R&D, Stevenage, UK
| | - Carmel B Nanthakumar
- Fibrosis Discovery Performance Unit, Respiratory Therapy Area, Medicines Research Centre, GlaxoSmithKline R&D, Stevenage, UK
| | - Morten Karsdal
- Nordic Bioscience A/S, Biomarkers & Research, Herlev, Denmark
| | - Stuart M Robinson
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gourab Sen
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jeremy French
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Steven A White
- Department of Hepatobiliary Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sandra Murphy
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Matthias Trost
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Johannes L Zakrzewski
- Center for Discovery and Innovation and John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ulf Klein
- Division of Haematology & Immunology, Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | | | - Ingmar Mederacke
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Colin Nixon
- Cancer Research UK Beatson Institute, Garscube Estate, Glasgow, UK
| | - Tom Bird
- Cancer Research UK Beatson Institute, Garscube Estate, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Glasgow, UK
- MRC Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Laure-Anne Teuwen
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, Leuven, Belgium
| | - Luc Schoonjans
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, Leuven, Belgium
| | - Peter Carmeliet
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, VIB, Leuven, Belgium
- Laboratory of Angiogenesis and Vascular Metabolism, Center for Cancer Biology, Department of Oncology and Leuven Cancer Institute (LKI), KU Leuven, Leuven, Belgium
| | - Jelena Mann
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil S Sheerin
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Lee A Borthwick
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Derek A Mann
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Oakley
- Newcastle Fibrosis Research Group, Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
- Fibrofind, Medical School, Newcastle University, Newcastle upon Tyne, UK.
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Mentor K, Ratnayake B, Akter N, Alessandri G, Sen G, French JJ, Manas DM, Hammond JS, Pandanaboyana S. Meta-Analysis and Meta-Regression of Risk Factors for Surgical Site Infections in Hepatic and Pancreatic Resection. World J Surg 2020; 44:4221-4230. [PMID: 32812136 DOI: 10.1007/s00268-020-05741-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The risk factors for surgical site infection (SSI) after HPB surgery are poorly defined. This meta-analysis aimed to quantify the SSI rates and risk factors for SSI after pancreas and liver resection. METHODS The PUBMED, MEDLINE and EMBASE databases were systematically searched using the PRISMA framework. The primary outcome measure was pooled SSI rates. The secondary outcome measure was risk factor profile determination for SSI. RESULTS The overall rate of SSI after pancreatic and liver resection was 25.1 and 10.4%, respectively (p < 0.001). 32% of pancreaticoduodenectomies developed SSI vs 23% after distal pancreatectomy (p < 0.001). The rate of incisional SSI in the pancreatic group was 9% and organ/space SSI 16.5%. Biliary resection during liver surgery was a risk factor for SSI (25.0 vs 15.7%, p = 0.002). After liver resection, the incisional SSI rate was 7.6% and the organ space SSI rate was 10.2%. Pancreas-specific SSI risk factors were pre-operative biliary drainage (p < 0.001), chemotherapy (p < 0.001) and radiotherapy (p = 0.007). Liver-specific SSI risk factors were smoking (p = 0.046), low albumin (p < 0.001) and significant blood loss (p < 0.001). The rate of organ/space SSI in patients with POPF was 47.7% and in patients without POPF 7.3% (p < 0.001). Organ/space SSI rate was 43% in patients with bile leak and 10% in those without (p < 0.001). CONCLUSIONS The risk factors for SSI following pancreatic and liver resections are distinct from each other, with higher SSI rates after pancreatic resection. Pancreaticoduodenectomy has increased risk of SSI compared to distal pancreatectomy. Similarly, biliary resections during liver surgery increase the rates of SSI.
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Affiliation(s)
- Keno Mentor
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bathiya Ratnayake
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Nasreen Akter
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Giorgio Alessandri
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gourab Sen
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jeremy J French
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John S Hammond
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. .,Population Health Science Institute, Newcastle University, Newcastle upon Tyne, UK.
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26
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Pine JK, Haugk B, Robinson SM, Darne A, Wilson C, Sen G, French JJ, White SA, Manas DM, Charnley RM. Prospective assessment of resection margin status following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma after standardisation of margin definitions. Pancreatology 2020; 20:537-544. [PMID: 31996296 DOI: 10.1016/j.pan.2020.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/21/2019] [Accepted: 01/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical resection remains the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). The prognostic value of resection margin status following pancreatoduodenectomy (PD) remains controversial. Standardised pathological assessment increases positive margins but limited data is available on the significance of involved margins. We investigated the impact of resection margin status in PDAC on patient outcome. METHOD We identified all patients with PD for PDAC at one pancreatic cancer centre between August 2008 and December 2014. Demographic, operative, adjuvant therapeutic and survival data was obtained. Pathology data including resection margin status of specific anatomic margins was collected and analysed. RESULTS 107 patients were included, all pathologically staged as T3 with 102 N1. 87.9% of patients were R1 of which 53.3% showed direct extension to the resection margin. Median survival for R0 patients versus R1<1 mm and R1 = 0 mm was 28.4 versus 15.4 and 25.1 versus 13.4 months. R1 = 0 mm status remained a predictor of poor outcome on multivariate analysis. Evaluation of individual margins (R1<1 mm) showed the SMV and SMA margins were associated with poorer overall survival. Multiple involved margins impacted negatively on outcome. SMA margin patient outcome with R1 = 1-1.9 mm was similar to R1=>2 mm. CONCLUSION Using an R1 definition of <1 mm and standardised pathology we demonstrate that R1 rates in PDAC can approach 90%. R1 = 0 mm remained an independent prognostic factor for overall survival. Using R1<1 mm we have shown that involvement of medial margins and multiple margins has significant negative impact on overall survival. We conclude that not all margin positivity has the same prognostic significance.
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Affiliation(s)
- J K Pine
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK.
| | - B Haugk
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - S M Robinson
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - A Darne
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - C Wilson
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - G Sen
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - J J French
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - S A White
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - D M Manas
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - R M Charnley
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
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27
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Kamarajah SK, Wilson CH, Bundred JR, Lin A, Sen G, Hammond JS, French JJ, Manas DM, White SA. A systematic review and network meta-analysis of parenchymal transection techniques during hepatectomy: an appraisal of current randomised controlled trials. HPB (Oxford) 2020; 22:204-214. [PMID: 31668587 DOI: 10.1016/j.hpb.2019.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/21/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Major liver resection can lead to significant morbidity and mortality. Blood loss is one of the most important factors predicting a good outcome. Although various transection methods have been reported, there is no consensus on the best technique. This systematic review and network meta-analysis aims to characterise and identify the best reported technique for elective parenchymal liver transection based on published randomised controlled trials (RCT's). METHODS A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Central to identify RCT's up to 5th June 2019 that examined parenchymal transection for liver resection. Data including study characteristics and outcomes including intraoperative (blood loss, operating time) and postoperative measures (overall and major complications, bile leaks) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials. RESULTS This study identified 22 RCT's involving 2360 patients reporting ten parenchymal transection techniques. Bipolar cautery has lower blood loss and shorter operating time than stapler (mean difference: 85 mL; 22min) and Tissue Link (mean difference: 66 mL; 29min). Bipolar cautery was ranked first for blood loss and operating time followed by stapler and TissueLink. Harmonic scalpel is associated with lower overall complications than Hydrojet (Odds ratio (OR): 0.48), BiClamp forceps (OR: 0.46) and clamp crushing (OR: 0.41). CONCLUSION Bipolar cautery techniques appear to best at reducing blood loss and associated with shortest operating time. In contrast, Harmonic scalpel appears best for overall and major complications. Given the paucity of data and selective outcome reporting, it is still hard to identify what is the best technique for liver resection. Therefore, further high-quality large-scale RCT's are still needed.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, United Kingdom.
| | - Colin H Wilson
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gourab Sen
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - John S Hammond
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Jeremy J French
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Derek M Manas
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Steven A White
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, United Kingdom
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28
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Thakkar RG, Kanwar A, Singh A, Hawche G, Talbot D, Wilson C, Manas DM, White SA. Preemptive Appendicectomy at the Time of Pancreas Transplantation: Is It Necessary? EXP CLIN TRANSPLANT 2019; 17:792-795. [PMID: 31580234 DOI: 10.6002/ect.2019.0186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Amer A, McColl K, Bouayyad S, Kanwar A, Sen G, French JJ, Wilson CH, Manas DM, Wright MC, White SA. The association of pregnane X receptor activation with outcomes after liver transplantation-A retrospective study. Clin Transplant 2019; 33:e13734. [PMID: 31628872 DOI: 10.1111/ctr.13734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/30/2019] [Accepted: 10/06/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Many complications following liver transplantation are linked to ischemia-reperfusion injury. Activation of the pregnane X receptor (PXR) has been shown to alleviate this process in animal models. The aim of this retrospective study was to investigate the effect of early activation of human PXR (hPXR) on postoperative complications and survival following liver transplantation. METHODS The study included deceased donor liver transplants at a single center over 6 years. Estimated hPXR activation value on day 7 (EPAV7 ) was calculated per patient based on potency/total dose of known hPXR-activating drugs administered in the first week post-transplantation. Patients were divided into low and high hPXR activation groups based on EPAV7 . RESULTS Overall, 240 liver transplants were included. Average EPAV7 was significantly lower in patients who developed anastomotic biliary strictures (17.7 ± 5.5 vs 35.1 ± 5.7 in stricture-free patients; P = .03) and sepsis (16.4 ± 7.1 vs 34.9 ± 5.5; P = .04). Patient survival was significantly improved in the high hPXR group (5-year survival: 88.7% ± 3.8% versus 70.7% ± 5.8% [low hPXR]; P = .023). Regression analysis identified EPAV7 as a significant independent predictor of patient survival. CONCLUSION hPXR activation within the first week of liver transplantation is a prognostic indicator of patient survival, possibly due to the associated lower biliary stricture and infection rates.
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Affiliation(s)
- Aimen Amer
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Kirsty McColl
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Sarah Bouayyad
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Aditya Kanwar
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gourab Sen
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jeremy J French
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Matthew C Wright
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Steve A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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30
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Paish HL, Reed LH, Brown H, Bryan MC, Govaere O, Leslie J, Barksby BS, Garcia Macia M, Watson A, Xu X, Zaki MY, Greaves L, Whitehall J, French J, White SA, Manas DM, Robinson SM, Spoletini G, Griffiths C, Mann DA, Borthwick LA, Drinnan MJ, Mann J, Oakley F. A Bioreactor Technology for Modeling Fibrosis in Human and Rodent Precision-Cut Liver Slices. Hepatology 2019; 70:1377-1391. [PMID: 30963615 PMCID: PMC6852483 DOI: 10.1002/hep.30651] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/03/2019] [Indexed: 12/14/2022]
Abstract
Precision cut liver slices (PCLSs) retain the structure and cellular composition of the native liver and represent an improved system to study liver fibrosis compared to two-dimensional mono- or co-cultures. The aim of this study was to develop a bioreactor system to increase the healthy life span of PCLSs and model fibrogenesis. PCLSs were generated from normal rat or human liver, or fibrotic rat liver, and cultured in our bioreactor. PCLS function was quantified by albumin enzyme-linked immunosorbent assay (ELISA). Fibrosis was induced in PCLSs by transforming growth factor beta 1 (TGFβ1) and platelet-derived growth factor (PDGFββ) stimulation ± therapy. Fibrosis was assessed by gene expression, picrosirius red, and α-smooth muscle actin staining, hydroxyproline assay, and soluble ELISAs. Bioreactor-cultured PCLSs are viable, maintaining tissue structure, metabolic activity, and stable albumin secretion for up to 6 days under normoxic culture conditions. Conversely, standard static transwell-cultured PCLSs rapidly deteriorate, and albumin secretion is significantly impaired by 48 hours. TGFβ1/PDGFββ stimulation of rat or human PCLSs induced fibrogenic gene expression, release of extracellular matrix proteins, activation of hepatic myofibroblasts, and histological fibrosis. Fibrogenesis slowly progresses over 6 days in cultured fibrotic rat PCLSs without exogenous challenge. Activin receptor-like kinase 5 (Alk5) inhibitor (Alk5i), nintedanib, and obeticholic acid therapy limited fibrogenesis in TGFβ1/PDGFββ-stimulated PCLSs, and Alk5i blunted progression of fibrosis in fibrotic PCLS. Conclusion: We describe a bioreactor technology that maintains functional PCLS cultures for 6 days. Bioreactor-cultured PCLSs can be successfully used to model fibrogenesis and demonstrate efficacy of antifibrotic therapies.
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Affiliation(s)
- Hannah L. Paish
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Lee H. Reed
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Helen Brown
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Mark C. Bryan
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Olivier Govaere
- Liver Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Jack Leslie
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Ben S. Barksby
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Marina Garcia Macia
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Abigail Watson
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Xin Xu
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Marco Y.W. Zaki
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Laura Greaves
- Newcastle University LLHW Centre for Ageing and VitalityNewcastle UniversityNewcastle upon TyneUnited Kingdom
- Wellcome Centre for Mitochondrial Research, Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Julia Whitehall
- Newcastle University LLHW Centre for Ageing and VitalityNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Jeremy French
- Department of Hepatobiliary SurgeryNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - Steven A. White
- Department of Hepatobiliary SurgeryNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - Derek M. Manas
- Department of Hepatobiliary SurgeryNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - Stuart M. Robinson
- Department of Hepatobiliary SurgeryNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - Gabriele Spoletini
- Department of Hepatobiliary SurgeryNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUnited Kingdom
| | - Clive Griffiths
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Derek A. Mann
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Lee A. Borthwick
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Michael J. Drinnan
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Jelena Mann
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | - Fiona Oakley
- Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUnited Kingdom
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31
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Reicher J, Mafeld S, Priona G, Reeves HL, Manas DM, Jackson R, Littler P. Early Experience of Trans-arterial Chemo-Embolisation for Hepatocellular Carcinoma with a Novel Radiopaque Bead. Cardiovasc Intervent Radiol 2019; 42:1563-1570. [PMID: 31455987 PMCID: PMC6775038 DOI: 10.1007/s00270-019-02317-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
Aims To evaluate early outcomes of patients with hepatocellular carcinoma (HCC) treated with a novel radiopaque bead, the 75–150 μm DC Bead LUMI™ (Biocompatibles UK Ltd). Materials and Methods This was a retrospective review of the first 40 consecutive patients at a UK tertiary hepato-biliary centre, treated for HCC with TACE using radiopaque beads, between May 2017 and March 2019. Information regarding complications, mortality, lesion response and subsequent ablation procedures was collected from electronic records and case notes. Intra- and post-operative imaging was reviewed for visibility of the embolised territory. Results Fifty-five TACE procedures were performed in 40 patients, with a median age of 70 years (range 28–88) and median lesion size of 3.8 cm (range 1.5–7.8). The median follow-up period was 30 weeks (range 6–101). Mean post-procedure hospital stay was 1.2 days. Complications of CIRSE Grade II or above occurred after 4/55 procedures (7.3%). Mortality at 30 days was zero. Objective response rates (mRECIST) at 1, 3 and 6 months were 32/35 (91.4%), 21/24 (87.5%) and 12/15 (80%), respectively. Complete response rates at 1, 3 and 6 months were 16/35 (45.7%), 12/24 (50%) and 9/15 (60%). The embolised territory was visible on intra-operative and follow-up CT imaging in all patients. The radiopaque beads were used as a fiducial marker to guide ablation in 5/40 patients (12.5%). Conclusion TACE with radiopaque beads shows promising tolerability and efficacy. The radiopaque beads ensure visualisation of the embolised lesion on intra- and post-operative imaging and, in selected cases, can act as a marker for CT-guided ablation.
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Affiliation(s)
- John Reicher
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.
| | - Sebastian Mafeld
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Georgia Priona
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Helen L Reeves
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Derek M Manas
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Ralph Jackson
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Peter Littler
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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32
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Garlipp B, Gibbs P, Van Hazel GA, Jeyarajah R, Martin RCG, Bruns CJ, Lang H, Manas DM, Ettorre GM, Pardo F, Donckier V, Benckert C, van Gulik TM, Goéré D, Schoen M, Pratschke J, Bechstein WO, de la Cuesta AM, Adeyemi S, Ricke J, Seidensticker M. Secondary technical resectability of colorectal cancer liver metastases after chemotherapy with or without selective internal radiotherapy in the randomized SIRFLOX trial. Br J Surg 2019; 106:1837-1846. [PMID: 31424576 PMCID: PMC6899564 DOI: 10.1002/bjs.11283] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Background Secondary resection of initially unresectable colorectal cancer liver metastases (CRLM) can prolong survival. The added value of selective internal radiotherapy (SIRT) to downsize lesions for resection is not known. This study evaluated the change in technical resectability of CRLM with the addition of SIRT to FOLFOX‐based chemotherapy. Methods Baseline and follow‐up hepatic imaging of patients who received modified FOLFOX (mFOLFOX6: fluorouracil, leucovorin, oxaliplatin) chemotherapy with or without bevacizumab (control arm) versus mFOLFOX6 (with or without bevacizumab) plus SIRT using yttrium‐90 resin microspheres (SIRT arm) in the phase III SIRFLOX trial were reviewed by three or five (of 14) expert hepatopancreatobiliary surgeons for resectability. Reviewers were blinded to one another, treatment assignment, extrahepatic disease status, and information on clinical and scanning time points. Technical resectability was defined as at least 60 per cent of reviewers (3 of 5, or 2 of 3) assessing a patient's liver metastases as surgically removable. Results Some 472 patients were evaluable (SIRT, 244; control, 228). There was no significant baseline difference in the proportion of technically resectable liver metastases between SIRT (29, 11·9 per cent) and control (25, 11·0 per cent) arms (P = 0·775). At follow‐up, significantly more patients in both arms were deemed technically resectable compared with baseline: 159 of 472 (33·7 per cent) versus 54 of 472 (11·4 per cent) respectively (P = 0·001). More patients were resectable in the SIRT than in the control arm: 93 of 244 (38·1 per cent) versus 66 of 228 (28·9 per cent) respectively (P < 0·001). Conclusion Adding SIRT to chemotherapy may improve the resectability of unresectable CRLM.
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Affiliation(s)
- B Garlipp
- Otto-von-Guericke-University Hospital, Magdeburg, Germany
| | - P Gibbs
- Department of Medical Oncology, Western Health, Melbourne, Victoria, Australia
| | - G A Van Hazel
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - R Jeyarajah
- Methodist Richardson Medical Center, Dallas, Texas, USA
| | - R C G Martin
- Division of Surgical Oncology, University of Louisville, Louisville, Kentucky, USA
| | - C J Bruns
- University Hospital Cologne, Cologne, Germany
| | - H Lang
- General, Visceral and Transplant Surgery, University Medical Centre of Johannes Gutenberg University, Mainz, Germany
| | - D M Manas
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK
| | | | - F Pardo
- Hepato-Pancreatico-Biliary Surgery and Oncology, Clinica Universidad de Navarra, Pamplona, Spain.,Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - V Donckier
- Jules Bordet Institute, Brussels, Belgium
| | - C Benckert
- Vivantes Klinikum Am Friedrichshain, Berlin, Germany
| | | | - D Goéré
- Institut Gustave Roussy, Villejuif, France
| | - M Schoen
- Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - J Pratschke
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - W O Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | | | - S Adeyemi
- Statsxperts Consulting Limited, Hemel Hempstead, UK
| | - J Ricke
- Deutsche Akademie für Mikrotherapie, Magdeburg, Germany.,Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
| | - M Seidensticker
- Otto-von-Guericke-University Hospital, Magdeburg, Germany.,Deutsche Akademie für Mikrotherapie, Magdeburg, Germany.,Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Munich, Germany
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Thompson ER, Irwin EA, Trotter P, Ibrahim IK, Tingle SJ, White SA, Manas DM, Wilson CH. UK registry analysis of donor substance misuse and outcomes following pancreas transplantation. Clin Transplant 2019; 33:e13481. [DOI: 10.1111/ctr.13481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/17/2018] [Accepted: 01/11/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Emily R. Thompson
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
| | - Ellen A. Irwin
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
| | - Patrick Trotter
- NIHR Blood and Transplant Research Unit, Department of Surgery University of Cambridge, Addenbrookes Hospital Cambridge UK
| | - Ibrahim K. Ibrahim
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
| | - Sam J. Tingle
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
| | - Steve A. White
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
| | - Derek M. Manas
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
| | - Colin H. Wilson
- NIHR Blood and Transplant Research Unit Institute of Transplantation, Freeman Hospital Newcastle upon Tyne UK
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White J, Carolan-Rees G, Dale M, Morgan HE, Patrick HE, See TC, Beeton EL, Swinson DEB, Bell JK, Manas DM, Crellin A, Slevin NJ, Sharma RA. Analysis of a National Programme for Selective Internal Radiation Therapy for Colorectal Cancer Liver Metastases. Clin Oncol (R Coll Radiol) 2018; 31:58-66. [PMID: 30297164 DOI: 10.1016/j.clon.2018.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
AIMS Patients with chemotherapy-refractory colorectal cancer liver metastases have limited therapeutic options. Selective internal radiation therapy (SIRT) delivers yttrium 90 microspheres as a minimally invasive procedure. This prospective, single-arm, observational, service-evaluation study was part of National Health Service England Commissioning through Evaluation. METHODS Patients eligible for treatment had histologically confirmed carcinoma with liver-only/liver-dominant metastases with clinical progression during or following oxaliplatin-based and irinotecan-based chemotherapy. All patients received SIRT plus standard of care. The primary outcome was overall survival; secondary outcomes included safety, progression-free survival (PFS) and liver-specific PFS (LPFS). RESULTS Between December 2013 and March 2017, 399 patients were treated in 10 centres with a median follow-up of 14.3 months (95% confidence interval 9.2-19.4). The median overall survival was 7.6 months (95% confidence interval 6.9-8.3). The median PFS and LPFS were 3.0 months (95% confidence interval 2.8-3.1) and 3.7 months (95% confidence interval 3.2-4.3), respectively. During the follow-up period, 143 patients experienced an adverse event and 8% of the events were grade 3. CONCLUSION Survival estimates from this pragmatic study show clinical outcomes attainable in the National Health Service comparable with previously published data. This study shows the value of a registry-based commissioning model to aid national commissioning decisions for highly specialist cancer treatments.
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Affiliation(s)
- J White
- Cedar, Cardiff & Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - G Carolan-Rees
- Cedar, Cardiff & Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - M Dale
- Cedar, Cardiff & Vale University Health Board, Cardiff Medicentre, Cardiff, UK
| | - H E Morgan
- Cedar, Cardiff University, Cardiff Medicentre, Cardiff, UK
| | - H E Patrick
- Centre for Health Technology Evaluation, National Institute for Health and Care Excellence, London, UK
| | - T C See
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - E L Beeton
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D E B Swinson
- Leeds Teaching Hospitals NHS Trust, St James's Hospital, Leeds, UK
| | - J K Bell
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - D M Manas
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - A Crellin
- NHS England, Institute of Oncology, St James's University Hospital, Leeds, UK
| | - N J Slevin
- The Christie NHS Foundation Trust, Withington, Manchester, UK
| | - R A Sharma
- NIHR University College London Hospitals Biomedical Research Centre, UCL Cancer Institute, University College London, London, UK.
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Margetts J, Ogle LF, Chan SL, Chan AWH, Chan KCA, Jamieson D, Willoughby CE, Mann DA, Wilson CL, Manas DM, Yeo W, Reeves HL. Neutrophils: driving progression and poor prognosis in hepatocellular carcinoma? Br J Cancer 2018; 118:248-257. [PMID: 29123264 PMCID: PMC5785742 DOI: 10.1038/bjc.2017.386] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 09/04/2017] [Accepted: 10/09/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Irrespective of the underlying aetiology, 90% of hepatocellular carcinomas arise and progress on a background of chronic inflammation. We have explored the independent prognostic value of circulating inflammatory cells. METHODS Peripheral blood count data sets from 583 consecutive patients presenting to a single UK centre (2000-2010) were analysed for associations with tumour stage, liver function, performance status (PST) and survival. Validation was in an independent Hong Kong cohort (585 patients; 2007-2013). RESULTS In both UK and Hong Kong cohorts, neutrophils, platelets, lymphocytes, the neutrophil/lymphocyte ratio (NLR) and the Systemic Immune-Inflammation Index (SII) correlated stepwise, either increasing or decreasing (lymphocytes), with tumour node metastasis (TNM) and Childs-Pugh stage, PST and consequently with the combined Barcelona Clinic for Liver Cancer stage. Survival analyses confirmed the NLR and SII as highly significant prognostic biomarkers. Focused on individual cell types, only the neutrophil count was independently associated with both TNM stage and PST, as well as being significantly and independently associated with poorer survival. CONCLUSIONS In this study of 1168 patients, neutrophils alone, rather than lymphocytes or platelets, were independently associated with outcome. These data support further characterisation of a potentially distinctive role for neutrophils as facilitators of tumour progression and deteriorating performance.
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Affiliation(s)
- Jane Margetts
- Northern Centre for Cancer Care, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE2 7DN, UK
- Northern Institute for Cancer Research, The Medical School, Newcastle University, Paul O’Gorman Building, Framlington Place, Newcastle-upon-Tyne NE2 4HH, UK
| | - Laura F Ogle
- Northern Institute for Cancer Research, The Medical School, Newcastle University, Paul O’Gorman Building, Framlington Place, Newcastle-upon-Tyne NE2 4HH, UK
| | - Stephen L Chan
- State Key Laboratory in Oncology of South China, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Anthony W H Chan
- State Key Laboratory in Oncology of South China, Department of Anatomical and Cellular Pathology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - K C Allen Chan
- State Key Laboratory in Oncology of South China, Department of Chemical Pathology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - David Jamieson
- Northern Institute for Cancer Research, The Medical School, Newcastle University, Paul O’Gorman Building, Framlington Place, Newcastle-upon-Tyne NE2 4HH, UK
| | - Catherine E Willoughby
- Northern Institute for Cancer Research, The Medical School, Newcastle University, Paul O’Gorman Building, Framlington Place, Newcastle-upon-Tyne NE2 4HH, UK
| | - Derek A Mann
- Institute of Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne, NE2 4HH, UK
| | - Caroline L Wilson
- Institute of Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne, NE2 4HH, UK
| | - Derek M Manas
- Hepatopancreatobiliary Unit, Surgical Directorate, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE2 7DN, UK
| | - Winnie Yeo
- State Key Laboratory in Oncology of South China, Department of Clinical Oncology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Helen L Reeves
- Northern Centre for Cancer Care, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE2 7DN, UK
- The Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE2 7DN, UK
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Garlipp B, Gibbs P, Van Hazel GA, Jeyarajah R, Martin RCG, Bruns CJ, Lang H, Manas DM, Ettorre GM, Pardo F, Donckier V, Benckert C, van Gulik TM, Goere D, Schoen M, Pratschke J, Bechstein WO, Martínez de la Cuesta A, Adeyemi S, Seidensticker M. REsect: Blinded assessment of amenability to potentially curative treatment of previously unresectable colorectal cancer liver metastases (CRC LM) after chemotherapy ± RadioEmbolization (SIRT) in the randomized SIRFLOX trial. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.3532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3532 Background: Secondary resection and radiofrequency ablation (RFA) of primarily unresectable LM from CRC can prolong survival and cure some patients (pts). Effective downsizing treatments are needed but their impact on secondary amenability to surgery/RFA is difficult to evaluate objectively. The added value of SIRT is not well established. Methods: Baseline (BL) and follow-up (FU) imaging at best response for CRC pts treated with FOLFOX chemotherapy±bevacizumab (bev) (CT) vs. CT+SIRT in the phase III SIRFLOX RCT were reviewed by 3−5 expert HPB surgeons (from a panel of 15) for resectability of LM. Reviewers were blinded to each other and to all clinical information incl. time of imaging (BL/FU). Resectability was defined as ≥60% of reviewers assessing a pt as resectable. For non-resectable cases, surgeons indicated whether a combination of surgery and RFA could completely remove all LM. Lesions deemed suitable for RFA by a surgeon needed to be confirmed by an interventional radiologist. Pts were defined as “clearable” if ≥60% of reviewers assessed them as amenable to complete removal of LM by surgery alone or surgery+RFA. Results: 472 pts were evaluable (CT, n = 228; CT+SIRT, n = 244). There was no significant difference in LM resectability at BL (CT, n = 25, 10.96%; CT+SIRT, n = 29, 11.89%; p = 0.77). At FU, significantly more pts in the SIRT arm had resectable LM (CT, n = 66, 28.95%; CT+SIRT, n = 93, 38.11%; p < 0.0001). Of 203 pts in the CT arm and 215 pts in the CT+SIRT arm deemed unresectable at BL, 46 (22.66%) and 67 (31.16%), respectively, were converted to resectability (p < 0.0001). Assessing “clearability” using surgery and RFA, again no difference was noted at BL (CT, n = 31, 13.60%; CT+SIRT, n = 42, 17.21%; p = 0.309). At FU, a trend in favor of CT+SIRT was seen (CT, n = 79, 34.65%; CT+SIRT, n = 102, 41.80%; p = 0.1296). Conclusions: The addition of SIRT to FOLFOX(±bev) based CT significantly increased the gain in resectability of primarily unresectable CRC LM compared with CT alone. For amenability to the combination of surgery+RFA, this effect was still seen, albeit attenuated. Subgroup analyses are ongoing. Clinical trial information: NCT00724503.
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Affiliation(s)
| | - Peter Gibbs
- Department of Medical Oncology, Royal Melbourne Hospital Western Health, Melbourne, Australia
| | | | | | | | | | - Hauke Lang
- University Medical Center of the Johannes Gutenberg University, General, Visceral and Transplant Surgery, Mainz, Germany
| | - Derek M. Manas
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | | | - Fernando Pardo
- HPB Surgery and HPB Oncology Area, Clinica Universidad de Navarra, and IDISNA, Pamplona, Spain
| | | | | | | | | | | | | | - Wolf O. Bechstein
- Department of General and Visceral Surgery, University Hospital Frankfurt, Frankfurt, Germany
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Robinson SM, Mann DA, Manas DM, Oakley F, Mann J, White SA. Response to 'Comment on 'The potential contribution of tumour-related factors to the development of FOLFOX-induced sinusoidal obstruction syndrome'’. Br J Cancer 2016; 115:e8. [PMID: 27632370 PMCID: PMC5061903 DOI: 10.1038/bjc.2016.268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Manas DM, Figueras J, Azoulay D, Garcia Valdecasas JC, French J, Dixon E, O'Rourke N, Grovale N, Mazzaferro V. Expert opinion on advanced techniques for hemostasis in liver surgery. Eur J Surg Oncol 2016; 42:1597-607. [PMID: 27329369 DOI: 10.1016/j.ejso.2016.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 04/26/2016] [Accepted: 05/05/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Reduction of perioperative blood loss and intraoperative transfusion are two major factors associated with improving outcomes in liver surgery. There is currently no consensus as to the best technique to achieve this. METHODS An international Panel of Experts (EP), made up of hepatobiliary surgeons from well-known high-volume centres was assembled to share their experience with regard to the management of blood loss during liver resection surgery. The process included: a review of the current literature by the panel, a face-to-face meeting and an on-line survey completed by the EP prior to and following the face-to-face meeting, based on predetermined case scenarios. During the meeting the most frequently researched surgical techniques were appraised by the EP in terms of intraoperative blood loss. RESULTS All EP members agreed that high quality research on the subject was lacking. Following an agreed risk stratification algorithm, the EP concurred with the existing research that a haemostatic device should always be used along with any user preferred surgical instrumentation in both open and laparoscopic liver resection procedures, independently from stratification of bleeding risk. The combined use of Ultrasonic Dissector (UD) and saline-coupled bipolar sealing device (Aquamantys(®)) was the EP preferred technique for both open and laparoscopic surgery. CONCLUSIONS This EP propose the use of a bipolar sealer and UD for the best resection technique and essential equipment to minimise blood loss during liver surgery, stratified according to transfusion risk, in both open and laparoscopic liver resection.
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Affiliation(s)
- D M Manas
- Newcastle Upon Tyne and Newcastle NHS Trust, Tyne and Wear, NE1 7RU, UK.
| | - J Figueras
- Josep Trueta Hospital in Girona, Avinguda de França, S/N, 17007 Girona, Spain.
| | - D Azoulay
- Henri Mondor Hospital, 51 Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - J C Garcia Valdecasas
- University of Barcelona, Gran Via de Les Corts Catalanes, 585, 08007 Barcelona, Spain.
| | - J French
- Newcastle Upon Tyne and Newcastle NHS Trust, Tyne and Wear, NE1 7RU, UK.
| | - E Dixon
- University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4, Canada.
| | - N O'Rourke
- Wesley Medical Centre, 30 Chasely St, Auchenflower, QLD 4066, Australia.
| | - N Grovale
- Medtronic Regional Clinical Center, Via Aurelia 475-477, 00165 Rome, Italy.
| | - V Mazzaferro
- National Cancer Institute, Via Venezian 1, 20133 Milano, Italy.
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Hogg HDJ, Manas DM, Lee D, Dildey P, Scott J, Lunec J, French JJ. Surgical outcome and patterns of recurrence for retroperitoneal sarcoma at a single centre. Ann R Coll Surg Engl 2016; 98:192-7. [PMID: 26876538 DOI: 10.1308/rcsann.2016.0057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Retroperitoneal sarcoma is a surgically managed condition that can recur locally following macroscopically complete resection. Owing to the low incidence of the condition, advances in treatment are reported infrequently but complete compartmental resection and adjuvant or neoadjuvant radiotherapy are areas under investigation. Given the practical difficulty of randomised trials, observational data can highlight advantages from progressive treatment approaches. METHODS A retrospective database of consecutive retroperitoneal sarcoma resections performed at a single referral centre between March 1997 and March 2013 was interrogated. Histological, radiological and clinical data were collected. Univariate and multivariate analyses for disease free and overall survival were performed to establish independent predictors of disease recurrence and patient survival. RESULTS A total of 79 patients underwent 90 resections (63 primary). The mean five-year overall and disease free survival rates were 55.3% and 24.8% respectively. Higher patient age, high tumour grade, presence of extraretroperitoneal disease and invasive tumour phenotype were found to significantly predict survival following multivariate analysis. Half (50%) of the tumours displayed invasive behaviour on histopathology and 42% of locoregional recurrence was intraperitoneal. CONCLUSIONS Retroperitoneal sarcoma is commonly an infiltrative tumour and often recurs outside of the retroperitoneum. These features limit the therapeutic impact of interventions that focus on gaining local control such as complete compartmental resection and radiotherapy. It seems likely that future advances in the management of this cancer will involve new systemic agents to treat this frequently systemic disease.
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Affiliation(s)
- H D J Hogg
- Newcastle upon Tyne Hospitals NHS Foundation Trust , UK
| | - D M Manas
- Newcastle upon Tyne Hospitals NHS Foundation Trust , UK
| | - D Lee
- Newcastle upon Tyne Hospitals NHS Foundation Trust , UK
| | - P Dildey
- Newcastle upon Tyne Hospitals NHS Foundation Trust , UK
| | - J Scott
- Newcastle upon Tyne Hospitals NHS Foundation Trust , UK
| | | | - J J French
- Newcastle upon Tyne Hospitals NHS Foundation Trust , UK
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Brooks AMS, Carter V, Liew A, Marshall H, Aldibbiat A, Sheerin NS, Manas DM, White SA, Shaw JAM. De Novo Donor-Specific HLA Antibodies Are Associated With Rapid Loss of Graft Function Following Islet Transplantation in Type 1 Diabetes. Am J Transplant 2015; 15:3239-46. [PMID: 26227015 DOI: 10.1111/ajt.13407] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 04/03/2015] [Accepted: 04/23/2015] [Indexed: 02/07/2023]
Abstract
Outcomes after islet transplantation continue to improve but etiology of graft failure remains unclear. De novo donor-specific human leukocyte antigen (HLA) antibodies (DSA) posttransplant are increasingly recognized as a negative prognostic marker. Specific temporal associations between DSA and graft function remain undefined particularly in programs undertaking multiple sequential transplants. Impact of de novo DSA on graft function over 12 months following first islet transplant was determined prospectively in consecutive recipients taking tacrolimus/mycophenolate immunosuppression at a single center. Mixed-meal tolerance test was undertaken in parallel with HLA antibody assessment pretransplant and 1-3 months posttransplant. Sixteen participants received a total of 26 islet transplants. Five (19%) grafts were associated with de novo DSA. Five (31%) recipients were affected: three post-first transplant; two post-second transplant. DSA developed within 4 weeks of all sensitizing grafts and were associated with decreased stimulated C-peptide (median [interquartile range]) at 3 months posttransplant (DSA negative: 613(300-1090); DSA positive 106(34-235) pmol/L [p = 0.004]). De novo DSA directed against most recent islet transplant were absolutely associated with loss of graft function despite maintained immunosuppression at 12 months in the absence of a rescue nonsensitizing transplant. Alemtuzumab induction immunosuppression was associated with reduced incidence of de novo DSA formation (p = 0.03).
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Affiliation(s)
- A M S Brooks
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - V Carter
- Histocompatibility and Immunogenetics Laboratory, National Health Service Blood and Transplant, Newcastle upon Tyne, UK
| | - A Liew
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - H Marshall
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - A Aldibbiat
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - N S Sheerin
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - D M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - S A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - J A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Moir JAG, Burns J, Barnes J, Colgan F, White SA, Littler P, Manas DM, French JJ. Selective internal radiation therapy for liver malignancies. Br J Surg 2015; 102:1533-40. [PMID: 26364826 DOI: 10.1002/bjs.9924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 07/06/2015] [Accepted: 07/24/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Selective internal radiation therapy (SIRT) is a non-ablative technique for the treatment of liver primaries and metastases, with the intention of reducing tumour bulk. This study aimed to determine optimal patient selection, and elucidate its role as a downsizing modality. METHODS Data were collected retrospectively on patients who underwent SIRT between 2011 and 2014. The procedure was performed percutaneously by an expert radiologist. Response was analysed in two categories, based on radiological (CT/MRI according to Response Evaluation Criteria In Solid Tumours (RECIST)) and biological (α-fetoprotein, carcinoembryonic antigen, carbohydrate antigen 19-9, chromogranin A) parameters. RESULTS Forty-four patients were included. Liver metastases from colorectal cancer (22 patients) and hepatocellular carcinoma (HCC) (9) were the most common pathologies. Radiological response data were collected from 31 patients. A reduction in sum of diameters (SOD) was observed in patients with HCC (median -24.1 (95 per cent c.i. -43.4 to -3.8) per cent) and neuroendocrine tumours (-30.0 (-45.6 to -7.7) per cent), whereas a slight increase in SOD was seen in patients with colorectal cancer (4.9 (-10.6 to 55.3) per cent). Biological response was assessed in 17 patients, with a reduction in 12, a mixed response in two and no improvement in three. Six- and 12-month overall survival rates were 71 and 41 per cent respectively. There was no difference in overall survival between the RECIST response groups (median survival 375, 290 and 214 days for patients with a partial response, stable disease and progressive disease respectively; P = 0.130), or according to primary pathology (P = 0.063). Seven patients underwent liver resection with variable responses after SIRT. CONCLUSION SIRT may be used to downsize tumours and may be used as a bridge to surgery in patients with tumours deemed borderline for resection.
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Affiliation(s)
- J A G Moir
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J Burns
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J Barnes
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - F Colgan
- Departments of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S A White
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - P Littler
- Departments of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, UK
| | - D M Manas
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - J J French
- Departments of Hepatopancreatobiliary and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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Vallance AE, Wilson CH, Dennison A, Manas DM, White SA. Total pancreatectomy and islet autotransplantation for chronic pancreatitis. Hippokratia 2015. [DOI: 10.1002/14651858.cd011799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Abigail E Vallance
- The Freeman Hospital; Institute of Transplantation; Freeman Road High Heaton Newcastle upon Tyne UK NE7 7DN
| | - Colin H Wilson
- The Freeman Hospital; Institute of Transplantation; Freeman Road High Heaton Newcastle upon Tyne UK NE7 7DN
| | - Ashley Dennison
- Leicester General Hospital; Department of Hepatobiliary Surgery; Gwendolen Road Leicester UK LE5 4PW
| | - Derek M Manas
- The Freeman Hospital; Institute of Transplantation; Freeman Road High Heaton Newcastle upon Tyne UK NE7 7DN
| | - Steven A White
- Institute of Cellular Medicine, Newcastle University; Newcastle upon Tyne UK NE2 4HH
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Tsirlis T, Ausania F, White SA, French JJ, Jaques BC, Charnley RM, Manas DM. Implications of the index cholecystectomy and timing of referral for radical resection of advanced incidental gallbladder cancer. Ann R Coll Surg Engl 2015; 97:131-6. [PMID: 25723690 PMCID: PMC4473390 DOI: 10.1308/003588414x14055925060073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2014] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Advanced (pT2/T3) incidental gallbladder cancer is often deemed unresectable after restaging. This study assesses the impact of the primary operation, tumour characteristics and timing of management on re-resection. METHODS The records of 60 consecutive referrals for incidental gallbladder cancer in a single tertiary centre from 2003 to 2011 were reviewed retrospectively. Decision on re-resection of incidental gallbladder cancer was based on delayed interval restaging at three months following cholecystectomy. Demographics, index cholecystectomy data, primary pathology, CA19-9 tumour marker levels at referral and time from cholecystectomy to referral as well as from referral to restaging were analysed. RESULTS Thirty-seven patients with pT2 and twelve patients with pT3 incidental gallbladder cancer were candidates for radical re-resection. Following interval restaging, 24 patients (49%) underwent radical resection and 25 (51%) were deemed inoperable. The inoperable group had significantly more patients with positive resection margins at cholecystectomy (p=0.002), significantly higher median CA19-9 levels at referral (p=0.018) and were referred significantly earlier (p=0.004) than the patients who had resectable tumours. On multivariate analysis, urgent referral (p=0.036) and incomplete cholecystectomy (p=0.048) were associated significantly with inoperable disease following restaging. CONCLUSIONS In patients with incidental, potentially resectable, pT2/T3 gallbladder cancer, inappropriate index cholecystectomy may have a significant impact on tumour dissemination. Early referral of breached tumours is not associated with resectability.
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Affiliation(s)
- T Tsirlis
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - F Ausania
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - SA White
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - JJ French
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - BC Jaques
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - RM Charnley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - DM Manas
- Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Robinson SM, Arlott L, Sen G, French JJ, Charnley RM, Manas DM, White SA. The impact of open colectomy on resection of colorectal liver metastases. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.3_suppl.783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
783 Background: Laparoscopic liver resection (LLR) is increasingly utilized in the management of patients with metastatic colorectal cancer. The aim of this study was to determine the impact of open vs. colonic resection of the primary tumour on outcomes following LLR. Methods: A prospectively maintained database was searched to identify all patients undergoing laparoscopic resection for colorectal liver metastases (CRLM) between 1/1/2007 and 31/12/2013. Demographic, histological, surgical outcome and survival data were collated retrospectively. Statistical analysis was performed using SPSS. Results: A total of 71 patients (median age 66 yr; 64% male) underwent resection in this study of whom 35 had a laparoscopic colectomy (LC). The presence of a previous open colectomy (OC) surgical morbidity (17% vs. 11%; p=0.53); conversion to open surgery (22% both groups; p=0.95); duration of surgery (240 min vs. 285 min; p=0.28); or length of hospital stay (5 vs. 6 days; p=0.98). Overall survival in this series was 47 months with no difference between groups (p=0.58). Patients who underwent OC appeared to have a poorer recurrence free survival (8 vs. 21 months; p=0.03) although on multivariate analysis the only factor predictive of early recurrence was a node positive primary (OR 3.8; p=0.05). Conclusions: In patients being considered for LLR for metastasic colorectal cancer the surgical approach to colectomy has no bearing on either short term surgical outcomes or longer term disease specific survival.
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Affiliation(s)
| | - Lucas Arlott
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Gourab Sen
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Jeremy J. French
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Richard M. Charnley
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Derek M. Manas
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Steve A. White
- Department of HPB Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
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Cornell L, Munck JM, Alsinet C, Villanueva A, Ogle L, Willoughby CE, Televantou D, Thomas HD, Jackson J, Burt AD, Newell D, Rose J, Manas DM, Shapiro GI, Curtin NJ, Reeves HL. DNA-PK-A candidate driver of hepatocarcinogenesis and tissue biomarker that predicts response to treatment and survival. Clin Cancer Res 2014; 21:925-33. [PMID: 25480831 DOI: 10.1158/1078-0432.ccr-14-0842] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE Therapy resistance and associated liver disease make hepatocellular carcinomas (HCC) difficult to treat with traditional cytotoxic therapies, whereas newer targeted approaches offer only modest survival benefit. We focused on DNA-dependent protein kinase, DNA-PKcs, encoded by PRKDC and central to DNA damage repair by nonhomologous end joining. Our aim was to explore its roles in hepatocarcinogenesis and as a novel therapeutic candidate. EXPERIMENTAL DESIGN PRKDC was characterized in liver tissues from of 132 patients [normal liver (n = 10), cirrhotic liver (n = 13), dysplastic nodules (n = 18), HCC (n = 91)] using Affymetrix U133 Plus 2.0 and 500 K Human Mapping SNP arrays (cohort 1). In addition, we studied a case series of 45 patients with HCC undergoing diagnostic biopsy (cohort 2). Histological grading, response to treatment, and survival were correlated with DNA-PKcs quantified immunohistochemically. Parallel in vitro studies determined the impact of DNA-PK on DNA repair and response to cytotoxic therapy. RESULTS Increased PRKDC expression in HCC was associated with amplification of its genetic locus in cohort 1. In cohort 2, elevated DNA-PKcs identified patients with treatment-resistant HCC, progressing at a median of 4.5 months compared with 16.9 months, whereas elevation of activated pDNA-PK independently predicted poorer survival. DNA-PKcs was high in HCC cell lines, where its inhibition with NU7441 potentiated irradiation and doxorubicin-induced cytotoxicity, whereas the combination suppressed HCC growth in vitro and in vivo. CONCLUSIONS These data identify PRKDC/DNA-PKcs as a candidate driver of hepatocarcinogenesis, whose biopsy characterization at diagnosis may impact stratification of current therapies, and whose specific future targeting may overcome resistance.
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Affiliation(s)
- Liam Cornell
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom. Early Drug Development Center and Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joanne M Munck
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Clara Alsinet
- Barcelona Clinic Liver Cancer Group (BCLC, Translational Research laboratory and Liver Unit), Hospital Clinic, IDIBAPS, Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), University of Barcelona, Catalonia, Spain
| | - Augusto Villanueva
- Barcelona Clinic Liver Cancer Group (BCLC, Translational Research laboratory and Liver Unit), Hospital Clinic, IDIBAPS, Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), University of Barcelona, Catalonia, Spain. Institute of Liver Studies, Division of Transplantation and Mucosal Biology, King's College, Denmark Hill, London, United Kingdom
| | - Laura Ogle
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine E Willoughby
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Despina Televantou
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Huw D Thomas
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jennifer Jackson
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alastair D Burt
- Institute of Cell and Molecular Biosciences, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom. School of Medicine, The University of Adelaide, Adelaide, Australia
| | - David Newell
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John Rose
- Radiology Department, The Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Derek M Manas
- Hepatopancreatobiliary Team, The Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Geoffrey I Shapiro
- Early Drug Development Center and Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nicola J Curtin
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Helen L Reeves
- Northern Institute for Cancer Research, Framlington Place, The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom. Hepatopancreatobiliary Team, The Freeman Hospital, Newcastle upon Tyne, United Kingdom
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Rehman S, John SKP, Lochan R, Jaques BC, Manas DM, Charnley RM, French JJ, White SA. Oncological feasibility of laparoscopic distal pancreatectomy for adenocarcinoma: a single-institution comparative study. World J Surg 2014; 38:476-83. [PMID: 24081543 DOI: 10.1007/s00268-013-2268-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is performed increasingly for pancreatic pathology in the body and tail of the pancreas. However, only few reports have compared its oncological efficacy with open distal pancreatectomy (ODP). We compared these two techniques in patients with pancreatic ductal adenocarcinoma. METHODS From a prospectively maintained database, all patients who underwent either LDP or ODP for adenocarcinoma in the body and tail of the pancreas between January 2008 and December 2011 were compared. Data were analysed using SPSS(®) v19 utilising standard tests. A p value <0.05 was considered significant. RESULTS Of 101 patients who underwent distal pancreatectomy, 22 had histologically confirmed adenocarcinoma (LDP n = 8, ODP n = 14). Both groups were well matched for age and the size of tumour (22 vs. 32 mm, p = 0.22). Intraoperative blood loss was 306 ml compared with 650 ml for ODP (p = 0.152). A longer operative time was noted for LDP (376 vs. 274 min, p < 0.05). Total length of stay was shorter for LDP compared with ODP (8 vs. 12 days, p = 0.05). The number of postoperative pancreatic fistulas were similar (LDP n = 2 vs. ODP n = 3, p = 0.5). Complete resection (R0) was achieved in 88 % of LDP (n = 7) compared with 86 % of ODP (n = 12). The median number of lymph nodes harvested was 16 for LDP versus 14 for ODP. Overall 3-year survival also was similar: LDP = 82 %, ODP = 74 % (p = 0.89). CONCLUSIONS From an oncological perspective, LDP is a viable procedure and its results are comparable to ODP for ductal adenocarcinomas arising in the body and tail of the pancreas.
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Affiliation(s)
- S Rehman
- Department of Hepatobiliary and Transplantation Surgery, Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK,
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Moir J, White SA, French JJ, Littler P, Manas DM. Systematic review of irreversible electroporation in the treatment of advanced pancreatic cancer. Eur J Surg Oncol 2014; 40:1598-604. [PMID: 25307210 DOI: 10.1016/j.ejso.2014.08.480] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 07/29/2014] [Accepted: 08/26/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Irreversible electroporation (IRE) is a novel procedure to combat pancreatic cancer, whereby high voltage pulses are delivered, resulting in cell death. This represents an ideal alternative to other thermal treatment modalities, as there is no overriding heat effect, therefore reducing the risk of injury to vessels and ducts. METHODS Multiple databases were searched to January 2014. Primary outcome measures were survival and associated morbidity. 41 articles were initially identified; of these 4 studies met the inclusion criteria, yielding 74 patients in total. RESULTS 94.5% of patients had locally advanced tumours, the remainder had metastatic disease. Treated tumour size ranged from 1 to 7 cm. IRE approach included open (70.3%), laparoscopic (2.7%) and percutaneous (27%; ultrasound-guided 30%, CT-guided 70%) Morbidity ranged from 0 to 33%; due to the high number of simultaneous procedures performed (resection/bypass) it was difficult to ascertain IRE-related complications. However no significant bleeding occurred when IRE-alone was performed. Survival statistics suggest a prognostic benefit. Reported survival included: 6 month survival of 40% (n = 5) and 70% (n = 14); PFS and OS 14 and 20 months respectively (n = 54). Results of most interest showed a significant survival benefit in matched IRE vs non-IRE groups (PFS 14 vs 6 mths; p = 0.01, OS 20 vs 11 mths; p = 0.03). CONCLUSION Initial evidence suggests IRE incurs a prognostic benefit with minimal morbidity. More high quality research is required to determine the role IRE may play in the multi-modal management of pancreatic cancers.
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Affiliation(s)
- J Moir
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, UK.
| | - S A White
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, UK
| | - J J French
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, UK
| | - P Littler
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, UK
| | - D M Manas
- HPB Unit, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, UK
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Mountford CG, Manas DM, Thompson NP. A practical approach to the management of high-output stoma. Frontline Gastroenterol 2014; 5:203-207. [PMID: 28839771 PMCID: PMC5369744 DOI: 10.1136/flgastro-2013-100375] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 10/04/2013] [Accepted: 10/05/2013] [Indexed: 02/04/2023] Open
Abstract
The development of a high-output stoma (HOS) is associated with water, electrolyte and nutritional complications. Prompt, careful assessment and management is required to avoid rapid clinical deterioration in this patient population. A multidisciplinary approach to management ensures the best possible outcome and quality of life for patients who experience HOS. This article outlines the important considerations in the identification and pathophysiology of HOS. A systematic approach to the management of the condition is outlined, considering fluid and electrolyte requirements, nutrient deficiencies and manipulation of gastrointestinal absorption, motility and secretions using medical and surgical therapies.
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Affiliation(s)
- Christopher G Mountford
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nicholas P Thompson
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Chatterjee S, Oppong KW, Scott JS, Jones DE, Charnley RM, Manas DM, Jaques BC, White SA, French JJ, Sen GS, Haugk B, Nayar MK. Autoimmune Pancreatitis – Diagnosis, Management and Longterm Follow-up. JGLD 2014; 23:179-85. [DOI: 10.15403/jgld.2014.1121.232.sc1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background & Aims: Autoimmune pancreatitis (AIP) is a fibroinflammatory condition affecting the pancreas and could present as a multisystem disorder. Diagnosis and management can pose a diagnostic challenge in certain groups of patients. We report our experience of managing this condition in a tertiary pancreaticobiliary centre in the North East of England.Methods: Patients were identified from a prospectively maintained database of patients diagnosed with AIP between 2005 and 2013. Diagnosis of definite/probable AIP was based on the revised HISORt criteria. When indicated, patients were treated with steroids and relapses were treated with azathioprine. All patients have been followed up to date.Results: Twenty-two patients were diagnosed with AIP during this period. All patients had pancreatic protocol CT performed while some patients had either MR or EUS as part of the work up. Fourteen out of 22 (64%) had an elevated IgG4 level (mean: 10.9 g/L; range 3.4 - 31 g/L). Four (18%) patients underwent surgery. Extrapancreatic involvement was seen in 15 (68%) patients, with biliary involvement being the commonest. Nineteen (86%) were treated with steroids and five (23%) required further immunosuppression for treatment of relapses. The mean follow up period was 36.94 months (range 7 - 94).Conclusion: Autoimmune pancreatitis is being increasingly recognized in the British population. Extrapancreatic involvement, particularly extrahepatic biliary involvement seems to be a frequent feature.Diagnosis should be based on accepted criteria as this significantly reduces the chances of overlooking malignancy. Awareness of this relatively rare condition and a multi-disciplinary team approach will help us to diagnose and treat this condition more efiectively thereby reducing unnecessary interventions.
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