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Lluís N, Onoe S, Serradilla-Martín M, Achalandabaso M, Mizuno T, Jehaes F, Dasari BVM, Mambrilla-Herrero S, Sparrelid E, Balakrishnan A, Hoogwater FJH, Amaral MJ, Andersson B, Berrevoet F, Doussot A, López-López V, Detry O, Pozo CDD, Machairas N, Pekli D, Alcázar-López CF, Asbun H, Björnsson B, Christophides T, Díez-Caballero A, Francart D, Noel CB, Sousa-Silva D, Toledo-Martínez E, Tzimas GN, Yaqub S, Yamaguchi J, Dokmak S, Prieto-Calvo M, D'Souza MA, Spiers HVM, van den Heuvel MC, Charco R, Lesurtel M, Ebata T, Ramia JM. Intraductal papillary neoplasms of the bile ducts: a comparative study of a rare disease in Europe and Nagoya, Japan. HPB (Oxford) 2024; 26:565-575. [PMID: 38307773 DOI: 10.1016/j.hpb.2024.01.009] [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] [Received: 05/20/2023] [Revised: 08/27/2023] [Accepted: 01/15/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Intraductal papillary neoplasm of the bile ducts (IPNB) is a rare disease in Western countries. The aim of this study was to compare tumor characteristics, management strategies, and outcomes between Western and Eastern patients who underwent surgical resection for IPNB. METHODS A multi-institutional retrospective series of patients with IPNB undergoing surgery between January 2010 and December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), and at Nagoya University Hospital, Japan. RESULTS A total of 85 patients (51% male; median age 66 years) from 28 E-AHPBA centers were compared to 91 patients (64% male; median age 71 years) from Nagoya. Patients in Europe had more multiple lesions (23% vs 2%, P < .001), less invasive carcinoma (42% vs 85%, P < .001), and more intrahepatic tumors (52% vs 24%, P < .001) than in Nagoya. Patients in Europe experienced less 90-day grade >3 Clavien-Dindo complications (33% vs 68%, P < .001), but higher 90-day mortality rate (7.0% vs 0%, P = .03). R0 resections (81% vs 82%) were similar. Overall survival, excluding 90-day postoperative deaths, was similar in both regions. DISCUSSION Despite performing more extensive resections, the low perioperative mortality rate observed in Nagoya was probably influenced by a combination of patient-, tumor-, and surgery-related factors.
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Affiliation(s)
- Núria Lluís
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA.
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mario Serradilla-Martín
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain.
| | - Mar Achalandabaso
- HPB Surgery and Transplantation, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - François Jehaes
- HPB Surgery & Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Bobby V M Dasari
- Liver Transplant and HPB Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Sara Mambrilla-Herrero
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao, Spain
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anita Balakrishnan
- Cambridge HPB Unit, Cambridge University Hospitals NHS Foundation Trust, and Department of Surgery, University of Cambridge, Cambridge, UK
| | - Frederik J H Hoogwater
- HPB Surgery and Liver Transplantation, and Pathology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - María J Amaral
- General Surgery, Centro Hospitalar e Universitário de Coimbra, and Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Bodil Andersson
- Department of Clinical Science Lund, Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - Frederik Berrevoet
- General and HPB Surgery, and Liver Transplantation, University Hospital Gent, Gent, Belgium
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology, Liver Transplantation Unit, CHU Besançon, France
| | - Víctor López-López
- General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | - Olivier Detry
- Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Belgium
| | | | - Nikolaos Machairas
- Second Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Damján Pekli
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Cándido F Alcázar-López
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Horacio Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thalis Christophides
- General Surgery Department, HPB Division, Nicosia General Hospital, Nicosia, Cyprus
| | | | - David Francart
- Department of Abdominal Surgery, CHC Groupe Santé, Liège, Belgium
| | - Colin B Noel
- HPB Clinical Unit, Gastrointestinal Surgery, Universitas Academic Hospital, University of the Free State, South Africa
| | | | | | - George N Tzimas
- HPB Surgery, Department of Surgery, Hygeia Hospital, Athens, Greece
| | - Sheraz Yaqub
- HPB Surgery, Oslo University Hospital, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Safi Dokmak
- HPB Surgery & Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Mikel Prieto-Calvo
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao, Spain
| | - Melroy A D'Souza
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Harry V M Spiers
- Cambridge HPB Unit, Cambridge University Hospitals NHS Foundation Trust, and Department of Surgery, University of Cambridge, Cambridge, UK
| | - Marius C van den Heuvel
- HPB Surgery and Liver Transplantation, and Pathology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ramón Charco
- HPB Surgery and Transplantation, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Mickaël Lesurtel
- HPB Surgery & Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - José M Ramia
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain; Miguel Hernández University, Alicante, Spain
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2
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Cuadrado A, Fortea JI, Rodríguez-Lope C, Puente Á, Fernández-Vilchez V, Echavarria VJ, Castillo Suescun FJ, Fernández R, Echeverri JA, Achalandabaso M, Toledo E, Pellón R, Rodríguez Sanjuan JC, Crespo J, Fábrega E. Risk of Recurrence of Hepatocarcinoma after Liver Transplantation: Performance of Recurrence Predictive Models in a Cohort of Transplant Patients. J Clin Med 2023; 12:5457. [PMID: 37685524 PMCID: PMC10488177 DOI: 10.3390/jcm12175457] [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: 07/06/2023] [Revised: 08/09/2023] [Accepted: 08/20/2023] [Indexed: 09/10/2023] Open
Abstract
Liver transplantation (LT) is a curative treatment for early-stage hepatocellular carcinoma (HCC) unsuitable for surgical resection. However, tumor recurrence (TR) rates range from 8% to 20% despite strict selection criteria. The validation of new prognostic tools, such as pre-MORAL or RETREAT risks, is necessary to improve recurrence prediction. A retrospective study was conducted at Marqués de Valdecilla University Hospital in Cantabria, Spain, between 2010 and 2019 to determine the rate of TR in LT patients and identify associated factors. Patients with liver-kidney transplantation, re-transplantation, HIV infection, survival less than 90 days, or incidental HCC were excluded. Data on demographic, liver disease-related, LT, and tumor-related variables, as well as follow-up records, including TR and death, were collected. TR was analyzed using the Log-Rank test, and a multivariate Cox regression analysis was performed. The study was approved by the IRB of Cantabria. TR occurred in 13.6% of LT patients (95% CI = 7.3-23.9), primarily as extrahepatic recurrence (67%) within the first 5 years (75%). Increased TR was significantly associated with higher Body Mass Index (BMI) (HR = 1.3 [95% CI = 1.1-1.5]), vascular micro-invasion (HR = 8.8 [1.6-48.0]), and medium (HR = 20.4 [3.0-140.4]) and high pre-MORAL risk (HR = 30.2 [1.6-568.6]). TR also showed a significant correlation with increased mortality. Conclusions: LT for HCC results in a 13.6% rate of tumor recurrence. Factors such as BMI, vascular micro-invasion, and medium/high pre-MORAL risk are strongly associated with TR following LT.
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Affiliation(s)
- Antonio Cuadrado
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - José Ignacio Fortea
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Carlos Rodríguez-Lope
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Ángela Puente
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Vanesa Fernández-Vilchez
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Victor Jose Echavarria
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | | | - Roberto Fernández
- General Surgery Service, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Juan Andrés Echeverri
- General Surgery Service, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Mar Achalandabaso
- General Surgery Service, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Enrique Toledo
- General Surgery Service, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | - Raúl Pellón
- Radiology Service, Marqués de Valdecilla University Hospital, 39008 Santander, Spain
| | | | - Javier Crespo
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, 39011 Santander, Spain
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Lluís N, Serradilla-Martín M, Achalandabaso M, Jehaes F, Dasari BV, Mambrilla-Herrero S, Sparrelid E, Balakrishnan A, Hoogwater FJ, Amaral MJ, Andersson B, Berrevoet F, Doussot A, López-López V, Alsammani M, Detry O, Domingo-del Pozo C, Machairas N, Pekli D, Alcázar-López CF, Asbun H, Björnsson B, Christophides T, Díez-Caballero A, Francart D, Noel CB, Sousa-Silva D, Toledo-Martínez E, Tzimas GN, Yaqub S, Cauchy F, Prieto-Calvo M, D’Souza MA, Spiers HV, van den Heuvel MC, Charco R, Lesurtel M, Ramia JM. Intraductal papillary neoplasms of the bile duct: a European retrospective multicenter observational study (EUR-IPNB study). Int J Surg 2023; 109:760-771. [PMID: 36917142 PMCID: PMC10389541 DOI: 10.1097/js9.0000000000000280] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/19/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND/PURPOSE Intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease in Western countries. The main aim of this study was to characterize current surgical strategies and outcomes in the mainly European participating centers. METHODS A multi-institutional retrospective series of patients with a diagnosis of IPNB undergoing surgery between 1 January 2010 and 31 December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association. The textbook outcome (TO) was defined as a non-prolonged length of hospital stay plus the absence of any Clavien-Dindo grade at least III complications, readmission, or mortality within 90 postoperative days. RESULTS A total of 28 centers contributed 85 patients who underwent surgery for IPNB. The median age was 66 years (55-72), 49.4% were women, and 87.1% were Caucasian. Open surgery was performed in 72 patients (84.7%) and laparoscopic in 13 (15.3%). TO was achieved in 54.1% of patients, reaching 63.8% after liver resection and 32.0% after pancreas resection. Median overall survival was 5.72 years, with 5-year overall survival of 63% (95% CI: 50-82). Overall survival was better in patients with Charlson comorbidity score 4 or less versus more than 4 ( P =0.016), intrahepatic versus extrahepatic tumor ( P =0.027), single versus multiple tumors ( P =0.007), those who underwent hepatic versus pancreatic resection ( P =0.017), or achieved versus failed TO ( P =0.029). Multivariable Cox regression analysis showed that not achieving TO (HR: 4.20; 95% CI: 1.11-15.94; P =0.03) was an independent prognostic factor of poor overall survival. CONCLUSIONS Patients undergoing liver resection for IPNB were more likely to achieve a TO outcome than those requiring a pancreatic resection. Comorbidity, tumor location, and tumor multiplicity influenced overall survival. TO was an independent prognostic factor of overall survival.
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Affiliation(s)
- Núria Lluís
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Mario Serradilla-Martín
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Miguel Servet University Hospital, Zaragoza
| | - Mar Achalandabaso
- HPB Surgery and Transplantation, Hospital Universitario Vall d’Hebron
| | - François Jehaes
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Bobby V.M. Dasari
- Liver Transplant and HPB Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Ernesto Sparrelid
- Department of Clinical Science, Division of Surgery, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm
| | - Anita Balakrishnan
- Cambridge HPB Unit, Cambridge University Hospitals NHS Foundation Trust
- Department of Surgery, University of Cambridge, Cambridge
| | - Frederik J.H. Hoogwater
- Department of HPB Surgery and Liver Transplantation, and Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria J. Amaral
- Department of General Surgery, Centro Hospitalar e Universitário de Coimbra
- Faculty of Medicine, University of Coimbra, Coimbra
| | - Bodil Andersson
- Department of Surgery, Lund University
- Skane University Hospital, Lund
| | - Frederik Berrevoet
- Department of General and HPB Surgery, and Liver Transplantation, University Hospital Gent, Gent
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology, Liver Transplantation Unit, CHU Besançon, Besancon
| | - Víctor López-López
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, Murcia
| | | | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege
| | | | - Nikolaos Machairas
- Second Department of Propaedeutic Surgery, National and Kapodistrian University of Athens
| | - Damján Pekli
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Cándido F. Alcázar-López
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL)
| | - Horacio Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, Florida, USA
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Thalis Christophides
- General Surgery Department, HPB Division, Nicosia General Hospital, Nicosia, Cyprus
| | | | - David Francart
- Department of Abdominal Surgery, CHC Groupe Santé, Liège, Belgium
| | - Colin B. Noel
- HPB Clinical Unit, Gastrointestinal Surgery, Universitas Academic Hospital, University of the Free State, Bloemfontein
| | - Donzília Sousa-Silva
- Department of Surgery, HEBIPA – Hepatobiliary and Pancreatic Unit, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Enrique Toledo-Martínez
- Servicio de Cirugía, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - George N. Tzimas
- Hepatobiliary Surgery Department, Hygeia Hospital, Athens, Greece
| | - Sheraz Yaqub
- Department of HPB Surgery, Oslo University Hospital
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - Mikel Prieto-Calvo
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao
| | - Melroy A. D’Souza
- Department of Clinical Science, Division of Surgery, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Stockholm
| | - Harry V.M. Spiers
- Cambridge HPB Unit, Cambridge University Hospitals NHS Foundation Trust
- Department of Surgery, University of Cambridge, Cambridge
| | - Marius C. van den Heuvel
- Department of HPB Surgery and Liver Transplantation, and Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ramón Charco
- HPB Surgery and Transplantation, Hospital Universitario Vall d’Hebron
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique Hôpitaux de Paris, University of Paris Cité, Clichy, France
| | - José M. Ramia
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL)
- Miguel Hernández University, Alicante
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Llàcer-Millán E, Pavel MC, Memba R, Coronado D, González S, Achalandabaso M, Estalella L, Julià-Verdaguer E, Padilla-Zegarra E, Collins C, Jorba R. Comparison between Comprehensive Complication Index (CCI®) and Clavien-Dindo Classification for laparoscopic single-stage treatment of choledocholithiasis with concomitant cholelithiasis. Langenbecks Arch Surg 2023; 408:100. [PMID: 36813935 DOI: 10.1007/s00423-023-02840-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The Clavien-Dindo Classification (CDC) and the Comprehensive Complication Index (CCI®) are both widely used methods for reporting postoperative complications. Several studies have compared the CCI® with the CDC in evaluating postoperative complications of major abdominal surgery. However, there are no published reports comparing both indexes in single-stage laparoscopic common bile duct exploration with cholecystectomy (LCBDE) for the treatment of common bile duct stones. This study aimed to compare the accuracy of the CCI® and the CDC in evaluating the complications of LCBDE. METHODS In total, 249 patients were included. Spearman's rank test was used to calculate the correlation coefficient between CCI® and CDC with length of postoperative stay (LOS), reoperation, readmission, and mortality rates. Student t-test and Fisher's exact test were used to study, if higher ASA, age, larger surgical time, history of previous abdominal surgery, preoperative ERCP, and intraoperative cholangitis finding were associated with higher CDC grade or higher CCI® score. RESULTS Mean CCI® was 5.17 ± 12.8. CCI® ranges overlap among three CDC grades: II (20.90-36.20), IIIa (26.20-34.60), and IIIb (33.70-52.10). Age > 60 years, ASA ≥ III, and intraoperative cholangitis finding were associated with higher CCI® (p = 0.010, p = 0.044, and p = 0.031) but not with CDC ≥ IIIa (p = 0.158, p = 0.209, and p = 0.062). In patients with complications, LOS presented a significantly higher correlation with CCI® than with CDC (p = 0.044). CONCLUSION In LCBDE, the CCI® assesses better the magnitude of postoperative complications in patients older than 60 years, with a high ASA as well as in those who present intraoperative cholangitis. In addition, the CCI® correlates better with LOS in patients with complications.
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Affiliation(s)
- Erik Llàcer-Millán
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.
- School of Medicine, Rovira i Virgili University, Reus, Spain.
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain.
| | - Mihai-Calin Pavel
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Robert Memba
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Daniel Coronado
- General Surgery Department, Hepato-Pancreato-Biliary Unit, Sant Joan Despí-Moises Broggi Hospital, Sant Joan Despí, Spain
| | - Sergio González
- General Surgery Department, Hepato-Pancreato-Biliary Unit, Sant Joan Despí-Moises Broggi Hospital, Sant Joan Despí, Spain
| | - Mar Achalandabaso
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Laia Estalella
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Elisabet Julià-Verdaguer
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Erlinda Padilla-Zegarra
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Chris Collins
- Upper Gastrointestinal Surgery Department, Galway University Hospital, Galway, Ireland
| | - Rosa Jorba
- General Surgery Department, Hepato-Pancreato-Biliary Unit, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
- School of Medicine, Rovira i Virgili University, Reus, Spain
- Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
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Balakrishnan A, Jah A, Lesurtel M, Andersson B, Gibbs P, Harper SJF, Huguet EL, Kosmoliaptsis V, Liau SS, Praseedom RK, Ramia JM, Branes A, Lendoire J, Maithel S, Serrablo A, Achalandabaso M, Adham M, Ahmet A, Al-Sarireh B, Albiol Quer M, Alconchel F, Alejandro R, Alsammani M, Alseidi A, Anand A, Anselmo A, Antonakis P, Arabadzhieva E, de Aretxabala X, Aroori S, Ashley S, Ausania F, Banerjee A, Barabino M, Bartlett A, Bartsch F, Belli A, Beristain-Hernandez J, Berrevoet F, Bhatti A, Bhojwani R, Bjornsson B, Blaz T, Byrne M, Calvo M, Castellanos J, Castro M, Cavallucci D, Chang D, Christodoulis G, Ciacio O, Clavien P, Coker A, Conde-Rodriguez M, D'Amico F, D'Hondt M, Daams F, Dasari B, De Beillis M, de Meijer V, Dede K, Deiro G, Delgado F, Desai G, Di Gioia A, Di Martino M, Dixon M, Dorovinis P, Dumitrascu T, Ebata T, Eilard M, Erdmann J, Erkan M, Famularo S, Felli E, Fergadi M, Fernandez G, Fox A, Galodha S, Galun D, Ganandha S, Garcia R, Gemenetzis G, Giannone F, Gil L, Giorgakis E, Giovinazzo F, Giuffrida M, Giuliani T, Giuliante F, Gkekas I, Goel M, Goh B, Gomes A, Gruenberger T, Guevara O, Gulla A, Gupta A, Gupta R, Hakeem A, Hamid H, Heinrich S, Helton S, Heumann A, Higuchi R, Hughes D, Inarejos B, Ivanecz A, Iwao Y, Iype S, Jaen I, Jie M, Jones R, Kacirek K, Kalayarasan R, Kaldarov A, Kaman L, Kanhere H, Kapoor V, Karanicolas P, Karayiannakis A, Kausar A, Khan Z, Kim DS, Klose J, Knowles B, Koh P, Kolodziejczyk P, Komorowski A, Koong J, Kozyrin I, Krishna A, Kron P, Kumar N, van Laarhoven S, Lakhey P, Lanari J, Laurenzi A, Leow V, Limbu Y, Liu YB, Lob S, Lolis E, Lopez-Lopez V, Lozano R, Lundgren L, Machairas M, Magouliotis D, Mahamid A, Malde D, Malek A, Malik H, Malleo G, Marino M, Mayo S, Mazzola M, Memeo R, Menon K, Menzulin R, Mohan R, Morgul H, Moris D, Mulita F, Muttillo E, Nahm C, Nandasena M, Nashidengo P, Nickkholgh A, Nikov A, Noel C, O'Reilly D, O'Rourke T, Ohtsuka M, Omoshoro-Jones J, Pandanaboyana S, Pararas N, Patel R, Patkar S, Peng J, Perfecto A, Perinel J, Perivoliotis K, Perra T, Phan M, Piccolo G, Porcu A, Primavesi F, Primrose J, Pueyo-Periz E, Radenkovic D, Rammohan A, Rowcroft A, Sakata J, Saladino E, Schena C, Scholer A, Schwarz C, Serrano P, Silva M, Soreide K, Sparrelid E, Stattner S, Sturesson C, Sugiura T, Sumo M, Sutcliffe R, Teh C, Teo J, Tepetes K, Thapa P, Thepbunchonchai A, Torres J, Torres O, Torzili G, Tovikkai C, Troncoso A, Tsoulfas G, Tuzuher A, Tzimas G, Umar G, Urbani L, Vanagas T, Varga, Velayutham V, Vigano L, Wakai T, Yang Z, Yip V, Zacharoulis D, Zakharov E, Zimmitti G. Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey. HPB (Oxford) 2022; 24:2006-2012. [PMID: 35922277 DOI: 10.1016/j.hpb.2022.06.014] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies. METHODS A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies. RESULTS Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites. CONCLUSION Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.
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Affiliation(s)
- Anita Balakrishnan
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom.
| | - Asif Jah
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Mickael Lesurtel
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University of Paris Cité, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Bodil Andersson
- Department of Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Paul Gibbs
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Simon J F Harper
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Emmanuel L Huguet
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Vasilis Kosmoliaptsis
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Siong S Liau
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Raaj K Praseedom
- Department of HPB Surgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, United Kingdom
| | - Jose M Ramia
- Department of Surgery, Hospital General Universitario de Alicante, Avenida Pintor Baeza, 12 03010 Alicante, Spain
| | - Alejandro Branes
- Department of HPB Surgery, Hospital Sotero del Rio, Av. Concha y Toro 3459, Puente Alto, Región Metropolitana, Chile
| | - Javier Lendoire
- Department of Surgery, University of Buenos Aires, Hospital Dr Cosme Argerich, Buenos Aires, Argentina
| | - Shishir Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, 30322 USA
| | - Alejandro Serrablo
- Department of HPB Surgery, Miguel Servet University Hospital, Zaragoza, Spain
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Caiña Ruiz R, Toledo Martínez E, Anderson EJ, Valbuena Jabares V, Fernández Santiago R, Castillo F, Echeverri J, Achalandabaso M, González Sánchez FJ, Fábrega E, Cuadrado A, Fortea JI, Crespo J, Rodríguez Sanjuán JC. Effect of Bridging Therapy on Survival in Hepatocellular Carcinoma Patients Who Receive Liver Transplants. Transplant Proc 2022. [DOI: 10.1016/j.transproceed.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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Memba R, Morató O, Estalella L, Pavel MC, Llàcer-Millán E, Achalandabaso M, Julià E, Padilla E, Olona C, O'Connor D, Jorba R. Prevention of Incisional Hernia after Open Hepato-Pancreato-Biliary Surgery: A Systematic Review. Dig Surg 2021; 39:6-16. [PMID: 34875657 DOI: 10.1159/000521169] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/21/2021] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Most hepato-pancreato-biliary (HPB) procedures are still performed through open approach. Incisional hernia (IH) is one of the most common complications after open surgery. To date, published data on IH after HPB surgery are scarce; therefore, the aim of this study was to assess the current evidence regarding incidence, risk factors, and prevention. METHODS Medline/PubMed (1946-2020), EMBASE (1947-2020), and the Cochrane library (1995-2020) were searched for studies on IH in open HPB surgery. Animal studies, editorials, letters, reviews, comments, short case series and liver transplant, laparoscopic, or robotic procedures were excluded. The protocol was registered with PROSPERO (CRD42020163296). RESULTS A total of 5,079 articles were retrieved. Eight studies were finally included for the analysis. The incidence of IH after HPB surgery ranges from 7.7% to 38.8%. The identified risk factors were body mass index, surgical site infection, ascites, Mercedes or reversed T incisions, and previous IH. Prophylactic mesh might be safe and effective. CONCLUSIONS IH after open HPB surgery is still an important matter. Some of the risk factors are specific for the HPB operations and the incision type should be carefully considered. Randomized controlled trials are required to confirm the role of prophylactic mesh after HPB operations.
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Affiliation(s)
- Robert Memba
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.,School of Medicine, Rovira i Virgili University, Reus, Spain
| | - Olga Morató
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Laia Estalella
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.,School of Medicine, Rovira i Virgili University, Reus, Spain
| | - Mihai C Pavel
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.,School of Medicine, Rovira i Virgili University, Reus, Spain
| | - Erik Llàcer-Millán
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.,School of Medicine, Rovira i Virgili University, Reus, Spain
| | - Mar Achalandabaso
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.,School of Medicine, Rovira i Virgili University, Reus, Spain
| | - Elisabet Julià
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Erlinda Padilla
- Abdominal Wall Surgery Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Carles Olona
- School of Medicine, Rovira i Virgili University, Reus, Spain.,Abdominal Wall Surgery Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain
| | - Donal O'Connor
- Department of Surgery, School of Medicine, Trinity College Dublin, College Green, Dublin, Ireland
| | - Rosa Jorba
- Hepato-Pancreato-Biliary Unit, General Surgery Department, University Hospital of Tarragona Joan XXIII, Tarragona, Spain.,School of Medicine, Rovira i Virgili University, Reus, Spain
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Jorba R, Pavel MC, Llàcer-Millán E, Estalella L, Achalandabaso M, Julià-Verdaguer E, Nve E, Padilla-Zegarra ED, Badia JM, O'Connor DB, Memba R. Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons. Surg Endosc 2021; 35:5024-5033. [PMID: 32968916 DOI: 10.1007/s00464-020-07984-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 06/05/2020] [Accepted: 09/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concomitant gallstones and common bile duct stones (CBDS) is a relatively frequent presentation. The optimal treatment remains controversial and the debate persists between two strategies. The one-stage approach: laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE) has been shown to be equally safe and more cost-effective than the more traditional two-stage approach: endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy (ERCP + LC). However, many surgeons worldwide still prefer the two-stage procedure. This survey evaluated contemporary management of CBDS in Spain and assessed the impact of surgeon and hospital factors on provision of LCBDE. METHODS A 25-item, web-based anonymous survey was sent to general surgeons members of the Spanish Surgeons Association. Descriptive statistics were applied to summarize results. RESULTS Responses from 305 surgeons across 173 Spanish hospitals were analyzed. ERCP is the initial approach for preoperatively suspected CBDS for 86% of surgeons. LCBDE is the preferred method for only 11% of surgeons and only 11% treat more than 10 cases per year. For CBDS discovered intraoperatively, 59% of respondents attempt extraction while 32% defer to a postoperative ERCP. The main reasons cited for not performing LCBDE were lack of equipment, training and timely availability of an ERCP proceduralist. Despite these barriers, most surgeons (84%) responded that LCBDE should be implemented in their departments. CONCLUSIONS ERCP was the preferred approach for CBDS for the majority of respondents. There remains limited use of LCBDE despite many surgeons indicating it should be implemented. Focused planning and resourcing of both training and operational demands are required to facilitate adoption of LCBDE as option for patients.
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Affiliation(s)
- Rosa Jorba
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain.
| | - Mihai C Pavel
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Erik Llàcer-Millán
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Laia Estalella
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Mar Achalandabaso
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Elisabet Julià-Verdaguer
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Esther Nve
- Department of General Surgery, Hospital de Granollers, Granollers, Spain
| | - Erlinda D Padilla-Zegarra
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
| | - Josep M Badia
- Department of General Surgery, Hospital de Granollers, Granollers, Spain
| | - Donal B O'Connor
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - Robert Memba
- Department of Abdominal and General Surgery, Hospital Universitari de Tarragona, Joan XXIII, Dr Mallafre Guasch, 4, 43005, Tarragona, Spain
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9
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Pavel MC, Casanova R, Estalella L, Memba R, Llàcer-Millán E, Achalandabaso M, Julià E, Geoghegan J, Jorba R. The effect of preoperative chemotherapy on liver regeneration after portal vein embolization/ligation or liver resection in patients with colorectal liver metastasis: a systematic review protocol. Syst Rev 2020; 9:279. [PMID: 33276812 PMCID: PMC7718667 DOI: 10.1186/s13643-020-01545-w] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver resection (LR) in patients with liver metastasis from colorectal cancer remains the only curative treatment. Perioperative chemotherapy improves prognosis of these patients. However, there are concerns regarding the effect of preoperative chemotherapy on liver regeneration, which is a key event in avoiding liver failure after LR. The primary objective of this systematic review is to assess the effect of neoadjuvant chemotherapy on liver regeneration after (LR) or portal vein embolization (PVE) in patients with liver metastasis from colorectal cancer. The secondary objectives are to evaluate the impact of the type of chemotherapy, number of cycles, and time between end of treatment and procedure (LR or PVE) and to investigate whether there is an association between degree of hypertrophy and postoperative liver failure. METHODS This meta-analysis will include studies reporting liver regeneration rates in patients submitted to LR or PVE. Pubmed, Scopus, Web of Science, Embase, and Cochrane databases will be searched. Only studies comparing neoadjuvant vs no chemotherapy, or comparing chemotherapy characteristics (bevacizumab administration, number of cycles, and time from finishing chemotherapy until intervention), will be included. We will select studies from 1990 to present. Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Primary outcome will be future liver remnant regeneration rate. Bias of the studies will be evaluated with the ROBINS-I tool, and quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a qualitative systematic review will be performed. DISCUSSION The results of this systematic review may help to better identify the patients affected by liver metastasis that could present low regeneration rates after neoadjuvant chemotherapy. These patients are at risk to develop liver failure after extended hepatectomies and therefore are not good candidates for such aggressive procedures. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42020178481 (July 5, 2020).
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Affiliation(s)
- Mihai-Calin Pavel
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain. .,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain.
| | - Raquel Casanova
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Laia Estalella
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Robert Memba
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Erik Llàcer-Millán
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Mar Achalandabaso
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Elisabet Julià
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Justin Geoghegan
- HPB and Liver Transplant Surgery Department, St. Vincent's University Hospital, Dublin, Ireland
| | - Rosa Jorba
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
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