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Linecker M, Botea F, Aristotele Raptis D, Nicolaescu D, Limani P, Alikhanov R, Kim P, Wirsching A, Kron P, Schneider MA, Tschuor C, Kambakamba P, Oberkofler C, De Oliveira ML, Bonvini J, Efanov M, Graf R, Petrowsky H, Khatkov I, Clavien PA, Popescu I. Perioperative omega-3 fatty acids fail to confer protection in liver surgery: Results of a multicentric, double-blind, randomized controlled trial. J Hepatol 2020; 72:498-505. [PMID: 31626819 DOI: 10.1016/j.jhep.2019.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 07/15/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS In a variety of animal models, omega-3 polyunsaturated fatty acids (Ω3-FAs) conferred strong protective effects, alleviating hepatic ischemia/reperfusion injury and steatosis, as well as enhancing regeneration after major tissue loss. Given these benefits along with its safety profile, we hypothesized that perioperative administration of Ω3-FAs in patients undergoing liver surgery may ameliorate the postoperative course. The aim of this study was to investigate the perioperative use of Ω3-FAs to reduce postoperative complications after liver surgery. METHODS Between July 2013 and July 2018, we carried out a multicentric, double-blind, randomized, placebo-controlled trial designed to test whether 2 single intravenous infusions of Omegaven® (Ω3-FAs) vs. placebo may decrease morbidity. The primary endpoints were postoperative complications by severity (Clavien-Dindo classification) integrated within the comprehensive complication index (CCI). RESULTS A total of 261 patients (132 in the Omegaven and 129 in the placebo groups) from 3 centers were included in the trial. Most cases (87%, n = 227) underwent open liver surgery and 56% (n = 105) were major resections (≥3 segments). In an intention-to-treat analysis including the dropout cases, the mortality rate was 4% and 2% in the Omegaven and placebo groups (odds ratio0.40;95% CI 0.04-2.51; p = 0.447), respectively. Any complications and major complications (Clavien-Dindo ≥ 3b) occurred in 46% vs. 43% (p = 0.709) and 12% vs. 10% (p = 0.69) in the Omegaven and placebo groups, respectively. The mean CCI was 17 (±23) vs.14 (±20) (p = 0.417). An analysis excluding the dropouts provided similar results. CONCLUSIONS The routine perioperative use of 2 single doses of intravenous Ω3-FAs (100 ml Omegaven) cannot be recommended in patients undergoing liver surgery (Grade A recommendation). LAY SUMMARY Despite strong evidence of omega-3 fatty acids having liver-directed, anti-inflammatory and pro-regenerative action in various rodent models, 2 single omega-3 fatty acid infusions given to patients before and during liver surgery failed to reduce complications. Because single omega-3 fatty acid infusions failed to confer liver protection in this trial, they cannot currently be recommended. TRIAL REGISTRATION ClinicalTrial.gov: ID: NCT01884948; Institution Ethical Board Approval: KEK-ZH-Nr. 2010-0038; Swissmedic Notification: 2012DR3215.
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Affiliation(s)
- Michael Linecker
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Florin Botea
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Romania
| | - Dimitri Aristotele Raptis
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Department of HPB- and Liver Transplantation Surgery, University College London, Royal Free Hospitals, London, UK
| | - Diana Nicolaescu
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Romania
| | - Përparim Limani
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Pavel Kim
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Andrea Wirsching
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Philipp Kron
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Department of HPB and Transplant Surgery, St. James's University Hospital NHS Trust, Leeds, UK
| | - Marcel A Schneider
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Christoph Tschuor
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Patryk Kambakamba
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Christian Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | | | - John Bonvini
- Department of Anesthesiology, University Hospital Zurich, Switzerland
| | - Michail Efanov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Rolf Graf
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Igor Khatkov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Russia
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
| | - Irinel Popescu
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Romania
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Linecker M, Limani P, Botea F, Popescu I, Alikhanov R, Efanov M, Kim P, Khatkov I, Raptis DA, Tschuor C, Beck-Schimmer B, Bonvini J, Wirsching A, Kron P, Slankamenac K, Humar B, Graf R, Petrowsky H, Clavien PA. "A randomized, double-blind study of the effects of omega-3 fatty acids (Omegaven) on outcome after major liver resection". BMC Gastroenterol 2015; 15:102. [PMID: 26268565 PMCID: PMC4535369 DOI: 10.1186/s12876-015-0331-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023] Open
Abstract
Background The body is dependent on the exogenous supply of omega-3 polyunsaturated fatty acids (n3-PUFA). These essential fatty acids are key players in regulating metabolic signaling but also exert anti-inflammatory and anti-carcinogenic properties. The liver is a major metabolic organ involved in fatty acid metabolism. Under experimental conditions, n3-PUFA exert beneficial effect on hepatic steatosis, regeneration and inflammatory insults such as ischemic injury after surgery. Some of these effects have also been observed in human subjects. However, it is unclear whether perioperative administration of n3-PUFA is sufficient to protect the liver from ischemic injury. Therefore, we designed a randomized controlled trial (RCT) assessing n3-PUFA (pre-) conditioning strategies in patients scheduled for liver surgery. Methods/Design The Omegaven™ trial is a multi-centric, double-blind, randomized, placebo- controlled trial applying two single doses of Omegaven™ or placebo on 258 patients undergoing major liver resection. Primary endpoints are morbidity and mortality one month after hospital discharge, defined by the Clavien- Dindo classification of surgical complications (Ann Surg 240(2):205–13, 2004) as well as the Comprehensive Complication Index (CCI) (Ann Surg 258(1):1–7, 2013). Secondary outcome variables include length of Intensive Care Unit (ICU) and hospital stay, postoperative liver function tests, fatty acid and eicosanoid concentration, inflammatory markers in serum and in liver tissue. An interim analysis is scheduled after the first 30 patients per randomization group. Discussion Long-term administration of n3-PUFA have a beneficial effect on metabolism and hepatic injury. Patients often require surgery without much delay, thus long-term n3-PUFA uptake is not possible. Also, lack of compliance may lead to incomplete n3-PUFA substitution. Hence, perioperative Omegaven™ may provide an easy and controllable way to ensure hepaative application of tic protection. Trial registration ClinicalTrial.gov: ID: NCT01884948, registered June 14, 2013; Institution Ethical Board Approval: KEK-ZH-Nr. 2010–0038; Swissmedic Notification: 2012DR3215.
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Affiliation(s)
- Michael Linecker
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Perparim Limani
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Florin Botea
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Bucharest, Romania.
| | - Irinel Popescu
- Center of General Surgery and Liver Transplantation, Fundeni Institute Bucharest, Bucharest, Romania.
| | - Ruslan Alikhanov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Moscow, Russia.
| | - Michail Efanov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Moscow, Russia.
| | - Pavel Kim
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Moscow, Russia.
| | - Igor Khatkov
- Department of Liver and Pancreatic Surgery, Moscow Clinical Scientific Center, Moscow, Russia.
| | - Dimitri Aristotele Raptis
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Christoph Tschuor
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | | | - John Bonvini
- Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
| | - Andrea Wirsching
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Philipp Kron
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Ksenija Slankamenac
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Bostjan Humar
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Rolf Graf
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Henrik Petrowsky
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Zurich, Switzerland. .,Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
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