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Palmer DH, Jackson R, Springfeld C, Ghaneh P, Rawcliffe C, Halloran CM, Faluyi O, Cunningham D, Wadsley J, Darby S, Meyer T, Gillmore R, Lind P, Glimelius B, Falk S, Ma YT, Middleton GW, Cummins S, Ross PJ, Wasan H, McDonald A, Crosby T, Hammel P, Borg D, Sothi S, Valle JW, Mehrabi A, Bailey P, Tjaden C, Michalski C, Hackert T, Büchler MW, Neoptolemos JP. Pancreatic Adenocarcinoma: Long-Term Outcomes of Adjuvant Therapy in the ESPAC4 Phase III Trial. J Clin Oncol 2024:JCO2401118. [PMID: 39637340 DOI: 10.1200/jco.24.01118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 09/08/2024] [Accepted: 10/03/2024] [Indexed: 12/07/2024] Open
Abstract
PURPOSE The ESPAC4 trial showed that adjuvant chemotherapy with gemcitabine plus capecitabine (GemCap) produced longer overall survival (OS) than gemcitabine monotherapy. Subsequently, the PRODIGE24-CCTG PA.6 trial showed even longer survival for modified fluorouracil, folinic acid, irinotecan, and oxaliplatin (mFOLFIRINOX) than gemcitabine but had more restrictive eligibility criteria. Our aim was to analyze the ESPAC4 survival on long-term follow-up. METHODS The OS of 732 ESPAC4 patients comparing 367 randomly assigned to gemcitabine and 365 to GemCap was previously reported after a median follow-up time of 43.2 months (95% CI, 39.7 to 45.5) and 458 deaths. Analysis was now carried out after a median follow-up of 104 months (101-108) and 566 deaths. RESULTS The median OS was 29.5 months (27.5-32.1) for all patients, 28.4 months (25.2-32.0) in the gemcitabine group and 31.6 months (26.5-38.0) in the GemCap group (hazard ratio [HR], 0.83 [0.71 to 0.98]; P = .031). R0 patients given gemcitabine had a median survival of 32.2 months (27.9-41.6) compared with 49.9 months (39.0-82.3) for those given GemCap (HR, 0.63 [0.47 to 0.84]; P = .002). Lymph node-negative patients had significantly higher 5 year OS rates on GemCap (59% [49%-71%]) than gemcitabine (53% [42%-66%]; HR, 0.63 [0.41 to 0.98]; P = .04) but not those with positive lymph nodes (P = .225). The OS advantage for GemCap was retained in the PRODIGE24 subgroup of 193 (26.4%) ESPAC4 patients not eligible for PRODIGE24 with a median survival of 20.7 (16.2-27.3) months in patients allocated to gemcitabine compared with 25.9 (22.3-30.2) months for ineligible patients allocated to GemCap (HR, 0.71 [95% CI, 0.52 to 0.98]; χ2log-rank-1df = 4.31; P = .038). CONCLUSION GemCap is a standard option for patients not eligible for mFOLFIRINOX. Exploratory evidence suggests that GemCap may be particularly efficacious in R0 patients and also in lymph node-negative patients.
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Klotz R, Pausch TM, Kaiser J, Joos MC, Hecktor R, Ahmed A, Dörr-Harim C, Mehrabi A, Loos M, Roth S, Michalski CW, Kahlert C. ChatGPT vs. surgeons on pancreatic cancer queries: accuracy & empathy evaluated by patients and experts. HPB (Oxford) 2024:S1365-182X(24)02427-4. [PMID: 39672696 DOI: 10.1016/j.hpb.2024.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 08/19/2024] [Accepted: 11/28/2024] [Indexed: 12/15/2024]
Abstract
BACKGROUND Artificial intelligence (AI) offers potential support in patient-clinician interactions, but its impact on such communication remains unexplored. METHODS In this study, ChatGPT was compared with two pancreatic surgeons in responding to ten pancreatic cancer surgery-related questions, co-designed with the Patient Advisory Board of the Surgical Society's Study Center. A blind evaluation of these responses, considering content congruency and clarity for non-specialists, was conducted by patients and surgeons. RESULTS From June 23 to July 21, 2023, 24 patients and 25 surgeons participated, of which eleven patients and ten surgeons completed the survey in full. Utilizing a quantitative scale from 1 (strong-disagreement) to 5 (full-agreement), consensus was observed among patients and specialists concerning the content delivered by ChatGPT. The metrics for comprehensibility to a non-specialist audience consistently showed positive reception. In the evaluation of empathetic resonance, ChatGPT's responses mirrored those of the surgeons in the patient's view. A significant proportion ranked Surgeon 1's contributions foremost, followed closely by ChatGPT. DISCUSSION This study demonstrates that surgeons and ChatGPT answer common queries from patients regarding pancreatic cancer surgery comparable regarding reliability, lay comprehension and empathy as evaluated by patients and surgical experts. These findings highlight the potential of AI in enhancing patient-provider interactions.
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Fuchs J, Rabaux-Eygasier L, Ruping F, Kessler M, Günther P, Hoffmann K, Czigany Z, Michalski C, Hery G, Mehrabi A, Branchereau S. Reappraisal of liver resection as an alternative to transplantation in locally advanced hepatoblastoma: A systematic review and analysis of pooled individual patient data. Pediatr Blood Cancer 2024; 71:e31339. [PMID: 39334537 DOI: 10.1002/pbc.31339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 08/08/2024] [Accepted: 09/06/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND There is ongoing debate regarding liver transplantation (LT) versus liver resection (LR) for locally advanced hepatoblastoma. However, comparative studies are lacking. Consequently, a significant evidence gap persists, hindering the establishment of consensus guidelines. This study aimed to compare LT and LR for locally advanced hepatoblastoma, using predefined inclusion criteria to ensure comparable intervention groups. METHODS According to current Children's Oncology Group (COG) and SIOPEL (European Childhood Liver Tumour Study Group) recommendations, hepatoblastoma that requires LT evaluation was defined as either PRETEXT (PRE-Treatment EXTent of tumor) IV F+, POST-TEXT (POST-Treatment EXTent of tumor) IV, POST-TEXT P+, and/or POST-TEXT V+. A systematic literature search (Medline/Web-of-Science/Embase) was performed. Only patients who met the aforementioned criteria were included. Patient data were extracted individually and pooled. RESULTS A total of 189 patients with locally advanced hepatoblastoma from 55 studies met the specified criteria, with 111 undergoing LT and 78 LR. There were no significant differences between the two groups in age, alpha-fetoprotein (AFP), and PRETEXT stages. Local recurrence was more common after LR (14% vs. 3% in LT, p = .008), while distant recurrence was more often observed after LT (16% vs. 5% in LR, p = .035). Overall survival (OS) and event-free survival (EFS) did not differ significantly between LT and LR (5-year OS: LT = 75.3% [95% confidence interval: 66.5-85.2], LR = 87.6% [80.4-95.6], p = .140; 5-year EFS: LT = 68.5% [59.3-79.1], LR = 71.1% [60.7-83.3], p = .700). CONCLUSION Real-life data revealed that a considerable number of patients with locally advanced hepatoblastoma underwent LR. This analysis suggests that outcomes are similar and favorable for both approaches. LR can therefore be considered an effective alternative to LT in selected cases even in locally advanced hepatoblastoma.
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Sabagh M, Sabetkish N, Fakour S, Ramouz A, Weber S, Mieth M, Lurje G, Golriz M, Zeier M, Mehrabi A, Khajeh E. Methods to prevent lymphocele after kidney transplantation: Seeking the optimal technique for avoiding a preventable complication. Transplant Rev (Orlando) 2024; 38:100877. [PMID: 39142043 DOI: 10.1016/j.trre.2024.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND There are multiple methods for preventing lymphocele formation after kidney transplantation (KTx). However, lymphoceles still develop in up to one third of patients and the effectiveness of these different methods in preventing lymphocele is not well described. Here, we summarize the current strategies for preventing lymphocele after KTx. METHODS We conducted searches across several literature databases, including Medline (via PubMed), Web of Science, EMBASE, and Cochrane Central. Lymphocele formation after KTx was the outcome of interest. A random-effects model was applied to evaluate pooled estimates, which were presented as hazard ratios (HRs) and odds ratios (ORs), along with the random pooled estimate (ES), 95% confidence interval (95% CI), and P value. We calculated the pooled rate of lymphocele formation after KTx with the following preventive methods: LigaSure, haemostatic materials, prophylactic drainage, ligation, peritoneal fenestration, and bipolar cautery techniques. RESULTS The literature search retrieved 87 unique studies after excluding duplicates. Twenty papers reporting on 5445 patients were incorporated in the qualitative analysis. The pooled lymphocele rate was 3.0% (95% CI = 0.6-13.7) for the LigaSure method, 8.3% (95% CI = 6.4-10.7) for drainage, 9.2% (95% CI = 5.9-14.1) for haemostatic materials, 12.2% (95% CI = 9.2-16.1) for ligation, 14.4% (95% CI = 12.0-17.3) for peritoneal fenestration, and 20.5% (95% CI = 10.2-36.8) for bipolar sealing. CONCLUSION Despite preventive methods, the incidence of lymphocele following KTx remains high. The use of LigaSure appears to be the most effective method for preventing lymphocele. However, given the broad range of reported lymphocele rates and lack of control groups, further validation of these findings is necessary.
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Khajeh E, Sabetkish N, Ramouz A, Werba A, Klotz R, Michalski CW, Mehrabi A, Pianka F. Risk factors for wound complications after associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) compared to repeated liver resection - a propensity score matching analysis. Langenbecks Arch Surg 2024; 409:347. [PMID: 39535576 PMCID: PMC11561011 DOI: 10.1007/s00423-024-03540-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Accepted: 11/04/2024] [Indexed: 11/16/2024]
Abstract
AIM Sufficient liver function is crucial in extracellular matrix growth, hemostasis, and wound healing. Repeated abdominal surgery is a known risk factor for the development of wound complications. This study aimed to evaluate this high-risk constellation in patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) and repeated liver resections (RLR) in comparison to single liver resection (SLR). METHOD Forty patients who underwent ALPPS between 2011 and 2020 were evenly matched with patients undergoing RLR or SLR (n = 40 per group) using propensity scores. Postoperative outcomes were compared and factors associated with wound complications were analyzed. RESULTS Postoperative wound complications were significantly more frequent in ALPPS group (p = 0.001). The reoperation rate was not significantly different between the three groups (p = 0.143). However, surgical reintervention due to wound complications occurred more frequently in the ALPPS group in relation to RLR and SLR (17.5% vs. 7.5% and 5% respectively). Length of stay was significantly longer in the ALPPS group (p = 0.033). ALPPS was an independent risk factor for postoperative wound complication (OR = 8.55, 95% CI:1.07-68.44, p = 0.043). Risk factor analysis identified age ≥ 60 years (OR = 27.64, 95% CI:3.09-246.75, p = 0.003), BMI ≥ 30 kg/m2 (OR = 30.21, 95% CI:3.35-271.83, p = 0.002), and low postoperative albumin levels (OR = 168.41, 95% CI:7.76-3651.18, p = 0.001) as independent predictors of postoperative wound complications after major liver resection. CONCLUSION Patients undergoing ALPPS and RLR are faced with a high risk of developing wound complications. Older age, obesity, a history of previous abdominal surgery, and a decreased postoperative albumin level were independent risk factors for wound complications.
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Kinny-Köster B, Lambrecht A, Flossmann V, Steinle V, Putri AJ, Heckler M, Kaiser J, Hank T, Roth S, Müller-Stich BP, Strobel O, Diener MK, Schneider M, Berchtold C, Al-Saeedi M, Hackert T, Mehrabi A, Büchler MW, Loos M. Alloplastic Vascular Grafts for Venous Interposition in Pancreatic Surgery: Readily Available and Reliable. Ann Surg 2024:00000658-990000000-01122. [PMID: 39508111 DOI: 10.1097/sla.0000000000006581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2024]
Abstract
OBJECTIVE To investigate patency and clinical outcomes of alloplastic and other venous interposition graft materials in pancreatic surgery. BACKGROUND Vascular pancreatic surgery is increasingly performed for locally advanced pancreatic neoplasms. Different than other centers, we prefer to use alloplastic vascular graft materials for superior mesenteric vein and portal vein interposition in pancreatic surgery. Advantages are off-the-shelf availability at any customizable length, different diameters, and ring-enforcement but proposed concerns are their thrombogenicity and fatal complications. METHODS Patients who underwent elective pancreatic resections with mesoportal venous interposition grafts (ISGPS type 4) between 2003-2022 were identified from the institutional pancreatectomy registry. Alloplastic vascular grafts imply synthetic materials, either based on polytetrafluorethylene (PTFE) or polyethylene terephthalate (PET). Surgical details, clinicopathological, and follow-up data were analyzed. The patients were followed for graft patency by cross-sectional imaging. RESULTS In this study, 201 patients with venous interposition grafts were included (23% simultaneous arterial resections). Total pancreatectomy (41%) and pancreatoduodenectomy (35%) were the most frequent procedures. Vascular graft materials were alloplastic in 180 patients (83% PTFE and 17% PET) with a median diameter of 10 mm and a median length of 33 mm (measurement by CT scan). Patency rates among all graft materials at 7-, 30-, and 90-days were 99%, 93%, and 87%. Alloplastic grafts demonstrated superior patency over other materials (hazard ratio 2.7, P=0.009), and PTFE reached a 1-year patency of 78%. The all-cause 90-day mortality rate was 10%. No graft infection occurred. CONCLUSION Alloplastic venous vascular grafts are safe and readily available tools in pancreatic surgery, especially for long-segmental mesoportal venous reconstructions.
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Bright R, Mahler CF, Adwaney A, Dosani D, Morganti E, Friedl F, Nusshag C, Speer C, Benning L, Göth D, Schaier M, Sommerer C, Mieth M, Mehrabi A, Zeier M, Morath C, Dor FJMF, Kälble F, Ashby D. Adjusted Donor Age: A Clinical Score to Support Organ Acceptance Decisions in Deceased-Donor Kidney Transplantation. Transpl Int 2024; 37:13477. [PMID: 39575125 PMCID: PMC11578704 DOI: 10.3389/ti.2024.13477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 10/25/2024] [Indexed: 11/24/2024]
Abstract
As transplant programmes have evolved to allow a wider donor pool, organ acceptance decisions have become increasingly complex and lack transparency and equality. Clinical scoring tools exist but there is limited consensus on their use. From a prospective observation of consecutive deceased-donor kidney offers in a large urban transplant centre, a simple score was developed based on donor age and other risk characteristics, excluding ischemia time and graft histology. The score was validated in subsequent cohorts of consecutive offers in the United Kingdom and Germany. In the development cohort of 389 kidney offers, 110 (28%) were transplanted and 175 (45%) declined. Nine risk factors were incorporated into a score based on age, but adjusted for the number of risk factors present, making an "adjusted donor age," with offers separated into equal quintiles by decade. The score was validated in a UK cohort of 380 subsequent offers, and a German cohort of 431 offers. In both cohorts adjusted donor age discriminated between favourable and poor post-transplant outcomes (C-statistic 0.77 in the United Kingdom, 95% CI 0.65-0.88, and 0.71 in Germany, 95% CI 0.64-0.77). Adjusted donor age is a simple score quantifying deceased donor kidney quality, which is consistent with current practice and predicts post-transplant outcome.
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An J, Kurilov R, Peccerella T, Bergmann F, Edderkaoui M, Lim A, Zhou X, Pfütze K, Schulz A, Wolf S, Hu K, Springfeld C, Mughal SS, Zezlina L, Fortunato F, Beyer G, Mayerle J, Roth S, Hulkkonen J, Merz D, Ei S, Mehrabi A, Loos M, Al-Saeedi M, Michalski CW, Büchler MW, Hackert T, Brors B, Pandol SJ, Bailey P, Neoptolemos JP. Metavert synergises with standard cytotoxics in human PDAC organoids and is associated with transcriptomic signatures of therapeutic response. Transl Oncol 2024; 49:102109. [PMID: 39217851 PMCID: PMC11402625 DOI: 10.1016/j.tranon.2024.102109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/18/2024] [Accepted: 08/21/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Despite some recent advances, pancreatic ductal adenocarcinoma (PDAC) remains a growing oncological challenge. New drugs capable of targeting more than one oncogenic pathway may be one way to improve patient outcomes. This study characterizes the effectiveness of Metavert a first-in-class dual inhibitor of GSK3-β and histone deacetylase in treating PDAC as a single agent or in combination with standard cytotoxics. METHODS Thirty-six Patient-Derived Organoids (hPDOs) characterised by RNASeq and whole exome sequencing were treated with Metavert alone or in combination with standard cytotoxics. Transcriptomic signatures (TS) representing sensitivity to Metavert alone or sensitivity to Metavert + irinotecan (IR) were evaluated in 47 patient samples, chemo-naïve in 26 and post-chemotherapy in 21 (gemcitabine=5; FOLFIRINOX=14, both=2) with companion multiplexed immunofluorescence and RNASeq data. RESULTS Metavert combined with gemcitabine, irinotecan, 5FU, oxaliplatin, and paclitaxel was synergistic in the hPDOs. Basal-subtype hPDOs were more sensitive to Metavert alone whereas the Metavert+IR combination exhibited synergy in Classical-subtype hPDOs with increased apoptosis and autophagy. hPDO-derived TS evaluated in PDAC tissues demonstrated that Metavert-TSHi samples were enriched for mRNA splicing and DNA repair processes; they were associated with Basal-like tissues but also with GATA6+ve-chemo-naïve samples and were higher following gemcitabine but not FOLFIRINOX treatment. In contrast, Metavert+IR-TSHI samples were enriched for TP53 pathways; they were associated with Classical-like pretreatment samples and with GATA6+ve/KRT17+ve hybrid cell types following FOLFIRINOX, but not gemcitabine treatment, and were unrelated to transcriptional subtypes. CONCLUSIONS Metavert as a single agent and in combination with irinotecan offers novel strategies for treating pancreatic cancer.
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Sugiyanto RN, Metzger C, Inal A, Truckenmueller F, Gür K, Eiteneuer E, Huth T, Fraas A, Heinze I, Kirkpatrick J, Sticht C, Albrecht T, Goeppert B, Poth T, Pusch S, Mehrabi A, Schirmacher P, Ji J, Ori A, Roessler S. Proteomic profiling reveals CEACAM6 function in driving gallbladder cancer aggressiveness through integrin receptor, PRKCD and AKT/ERK signaling. Cell Death Dis 2024; 15:780. [PMID: 39468006 PMCID: PMC11519453 DOI: 10.1038/s41419-024-07171-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 10/08/2024] [Accepted: 10/18/2024] [Indexed: 10/30/2024]
Abstract
Gallbladder cancer (GBC) presents as an aggressive malignancy with poor patient outcome. Like other epithelial cancers, the mechanisms of GBC cancer progression remain vague and efforts in finding targeted therapies fall below expectations. This study combined proteomic analysis of formalin-fixed paraffin-embedded (FFPE) GBC samples, functional and molecular characterization of potential oncogenes and identification of potential therapeutic strategies for GBC. We identified Carcinoembryonic Antigen-related Cell Adhesion Molecule 6 (CEACAM6) as one of the significantly most upregulated proteins in GBC. CEACAM6 overexpression has been observed in other cancer entities but the molecular function remains unclear. Our functional analyses in vitro and in vivo mouse models revealed that CEACAM6 supported the initial steps of cancer progression and metastasis by decreasing cell adhesion and promoting migration and invasion of GBC cells. Conversely, CEACAM6 knockdown abolished GBC aggressiveness by increasing cell adhesion while reducing cell migration, cell proliferation, and colony formation. BirA-BioID followed by mass-spectrometry revealed Integrin Beta-1 (ITGB1) and Protein Kinase C Delta (PRKCD) as direct molecular and functional partners of CEACAM6 supporting GBC cell migration. ERK and AKT signaling and their downstream target genes were regulated by CEACAM6 and thus the treatment with AKT inhibitor capivasertib or ERK inhibitor ulixertinib mitigated the CEACAM6-induced migration. These findings demonstrate that CEACAM6 is crucially involved in gallbladder cancer progression by promoting migration and inhibiting cell adhesion through ERK and AKT signaling providing specific options for treatment of CEACAM6-positive cancers.
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Mahler CF, Friedl F, Nusshag C, Speer C, Benning L, Göth D, Schaier M, Sommerer C, Mieth M, Mehrabi A, Renders L, Heemann U, Krautter M, Schwenger V, Echterdiek F, Zeier M, Morath C, Kälble F. Impact of deceased-donor characteristics on early graft function: outcome of kidney donor pairs accepted for transplantation. Front Immunol 2024; 15:1303746. [PMID: 39439791 PMCID: PMC11493709 DOI: 10.3389/fimmu.2024.1303746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 08/22/2024] [Indexed: 10/25/2024] Open
Abstract
Introduction The impact of deceased donor characteristics on kidney transplant outcomes is controversial. Correspondingly, the predictive performance of deceased donor scores remains moderate, and many transplant centers lack validated criteria for graft acceptance decisions. To better dissect donor-related risk from recipient and periprocedural variables, we analyzed outcomes of kidney donor pairs transplanted in different individuals. Methods This study explored (a)symmetry of early outcomes of 328 cadaveric kidney transplant recipients from 164 donor pairs transplanted at three Eurotransplant centers. The primary discriminatory factor was (a)symmetry of partner graft function, defined as early graft loss or impaired graft function [estimated glomerular filtration rate (eGFR) <30 mL/min] 3 months after transplantation. We reasoned that a relevant impact of donor factors would result in a high concordance rate of limited graft function or failure. Results The observed number of symmetric graft failure after transplantation was less than statistically expected (3 months: 1 versus 2, p = 0.89; and 12 months: 3 versus 5, p = 0.26). However, we found a trend toward an impaired 5-year graft survival of grafts with good function 3 months after transplantation but a failed or impaired partner graft compared to symmetrically well-functioning grafts (p = 0.09). Subsequently, we explored the impact of individual donor and recipient variables on early transplant outcomes. Generalized estimating equations after feature selection with LassoGEE bootstrap selected donor age, donor body mass index, and donor eGFR as the relevant risk factors. Discussion Our findings indicate that donor factors impact early outcomes in kidney transplantation but may have a limited role in long-term graft survival, once a graft has been accepted for transplantation. Utilizing donor-based clinical scores has the potential to aid clinicians in acceptance decisions, giving them an estimate of individual posttransplant outcomes. However, the ultimate decision for acceptance should rest with clinicians, who must consider the complex interplay of donor factors, as well as recipient and periprocedural characteristics.
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Sabagh M, Weber S, Sabetkish N, Ramouz A, Fakour S, Morath C, Mieth M, Zeier M, Khajeh E, Mehrabi A, Golriz M. Modified Peritoneal Fenestration as a Preventive Method for Lymphocele after Kidney Transplantation: A Preliminary Report. J Clin Med 2024; 13:5878. [PMID: 39407938 PMCID: PMC11477912 DOI: 10.3390/jcm13195878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/23/2024] [Accepted: 09/28/2024] [Indexed: 10/20/2024] Open
Abstract
Background: We aimed to assess the safety of a modified peritoneal fenestration technique with clipping of the window edges during kidney transplantation (KTx) and to determine its impact on reducing lymphocele following KTx. We compared the outcomes of this modified method with those of peritoneal fenestration without clipping. Methods: Among 430 consecutive KTxs performed between 2015 and 2019, preventive peritoneal fenestration and clipping of the margins were performed in 25 patients. These patients were compared with 75 matched patients in whom the margins were not clipped. Postoperative lymphocele formation and other patient data were compared between these two groups. Results: The rate of clinically relevant lymphocele decreased by 2.7% after peritoneal fenestration with clipping, although this decrease was not statistically significant (p = 0.829). There was no significant increase in the rate of other complications in the modified fenestration group (p = 0.067). The incidence of clinically significant lymphocele formation was notably higher in patients with a body mass index greater than 25 kg/m2 (p = 0.028). Univariate analysis indicated that older recipients, individuals with a history of previous abdominal surgery, those receiving the kidney from deceased and older donors were at increased risk of developing a clinically relevant lymphocele. Conclusions: Our preliminary results suggest that peritoneal fenestration with clipping may be as effective as the conventional fenestration technique in preventing lymphocele formation. Further clinical trials with larger sample sizes are required to determine the exact role of preventive peritoneal fenestration with clipping in preventing clinically relevant lymphocele after KTx.
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Studier-Fischer A, Özdemir B, Rees M, Ayala L, Seidlitz S, Sellner J, Kowalewski KF, Haney CM, Odenthal J, Knödler S, Dietrich M, Gruneberg D, Brenner T, Schmidt K, Schmitt FCF, Weigand MA, Salg GA, Dupree A, Nienhüser H, Mehrabi A, Hackert T, Müller BP, Maier-Hein L, Nickel F. Crystalloid volume versus catecholamines for management of hemorrhagic shock during esophagectomy: assessment of microcirculatory tissue oxygenation of the gastric conduit in a porcine model using hyperspectral imaging - an experimental study. Int J Surg 2024; 110:6558-6572. [PMID: 38976902 PMCID: PMC11486957 DOI: 10.1097/js9.0000000000001849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/08/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION Oncologic esophagectomy is a two-cavity procedure with considerable morbidity and mortality. Complex anatomy and the proximity to major vessels constitute a risk for massive intraoperative hemorrhage. Currently, there is no conclusive consensus on the ideal anesthesiologic countermeasure in case of such immense blood loss. The objective of this work was to identify the most promising anesthesiologic management in case of intraoperative hemorrhage with regards to tissue perfusion of the gastric conduit during esophagectomy using hyperspectral imaging. MATERIAL AND METHODS An established live porcine model ( n =32) for esophagectomy was used with gastric conduit formation and simulation of a linear stapled side-to-side esophagogastrostomy. After a standardized procedure of controlled blood loss of about 1 l per pig, the four experimental groups ( n =8 each) differed in anesthesiologic intervention, that is, (I) permissive hypotension, (II) catecholamine therapy using noradrenaline, (III) crystalloid volume supplementation, and (IV) combined crystalloid volume supplementation with noradrenaline therapy. Hyperspectral imaging tissue oxygenation (StO 2 ) of the gastric conduit was evaluated and correlated with systemic perfusion parameters. Measurements were conducted before (T0) and after (T1) laparotomy, after hemorrhage (T2), and 60 min (T3) and 120 min (T4) after anesthesiologic intervention. RESULTS StO 2 values of the gastric conduit showed significantly different results between the four experimental groups, with 63.3% (±7.6%) after permissive hypotension (I), 45.9% (±6.4%) after catecholamine therapy (II), 70.5% (±6.1%) after crystalloid volume supplementation (III), and 69.0% (±3.7%) after combined therapy (IV). StO 2 values correlated strongly with systemic lactate values (r=-0.67; CI -0.77 to -0.54), which is an established prognostic factor. CONCLUSION Crystalloid volume supplementation (III) yields the highest StO 2 values and lowest systemic lactate values and therefore appears to be the superior primary treatment strategy after hemorrhage during esophagectomy with regards to microcirculatory tissue oxygenation of the gastric conduit.
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Schulze A, Haselbeck-Köbler M, Brandenburg JM, Daum MTJ, März K, Hornburg S, Maurer H, Myers F, Reichert G, Bodenstedt S, Nickel F, Kriegsmann M, Wielpütz MO, Speidel S, Maier-Hein L, Müller-Stich BP, Mehrabi A, Wagner M. Aliado - A design concept of AI for decision support in oncological liver surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024:108669. [PMID: 39362815 DOI: 10.1016/j.ejso.2024.108669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 09/03/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND The interest in artificial intelligence (AI) is increasing. Systematic reviews suggest that there are many machine learning algorithms in surgery, however, only a minority of the studies integrate AI applications in clinical workflows. Our objective was to design and evaluate a concept to use different kinds of AI for decision support in oncological liver surgery along the treatment path. METHODS In an exploratory co-creation between design experts, surgeons, and data scientists, pain points along the treatment path were identified. Potential designs for AI-assisted solutions were developed and iteratively refined. Finally, an evaluation of the design concept was performed with n = 20 surgeons to get feedback on the different functionalities and evaluate the usability with the System Usability Scale (SUS). Participating surgeons had a mean of 14.0 ± 5.0 years of experience after graduation. RESULTS The design concept was named "Aliado". Five different scenarios were identified where AI could support surgeons. Mean score of SUS was 68.2 ( ± 13.6 SD). The highest valued functionalities were "individualized prediction of survival, short-term mortality and morbidity", and "individualized recommendation of surgical strategy". CONCLUSION Aliado is a design prototype that shows how AI could be integrated into the clinical workflow. Even without a fleshed out user interface, the SUS already yielded borderline good results. Expert surgeons rated the functionalities favorably, and most of them expressed their willingness to work with a similar application in the future. Thus, Aliado can serve as a surgical vision of how an ideal AI-based assistance could look like.
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Dehne S, Jackson-Gil L, Riede C, Feisst M, Mehrabi A, Michalski CW, Weigand MA, Decker SO, Larmann J. Patient sex and use of tranexamic acid in liver transplantation. Front Med (Lausanne) 2024; 11:1452733. [PMID: 39376656 PMCID: PMC11456493 DOI: 10.3389/fmed.2024.1452733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 09/09/2024] [Indexed: 10/09/2024] Open
Abstract
Background Differences in medical treatment between women and men are common and involve out-of-hospital emergency care, the intensity of pain treatment, and the use of antifibrinolytic treatment in emergency trauma patients. If woman and man receive different antifibrinolytic treatment in highly-standardized major transplant surgery is unknown. Methods We conducted a retrospective cohort study on patients who underwent liver transplantation at Heidelberg University Hospital, Heidelberg, Germany between 2004 and 2017. Logistic regression analyses were performed to determine if sex is associated with the administration of TXA during liver transplantation. Secondary endpoints included venous thrombotic complications, graft failure, mortality, myocardial infarction, hepatic artery thrombosis, and stroke within the first 30 days after liver transplant as well as length of hospital stay and length of intensive care unit stay. Results Out of 779 patients who underwent liver transplantation, 262 patients received TXA. Female sex was not associated with intraoperative administration of TXA [adjusted OR: 0.929 (95% CI 0.654; 1.320), p = 0.681]. The secondary endpoints graft failure (13.2% vs. 8.4%, women vs. men, p = 0.039), pulmonary embolism (3.4% vs. 0.9%, women vs. men, p = 0.012), stroke (1.7% vs. 0.4%, women vs. men, p = 0.049), and deep vein thrombosis (0.8% vs. 0%, women vs. men, p = 0.031) within 30 days after liver transplantation were more frequent in women. Mortality, myocardial infarction, and other secondary endpoints did not differ between groups. However, in women, the use of TXA was associated with a lower rate in thromboembolic complications. Conclusion Our data indicate that different from other scenarios with massive bleeding complications the administration of TXA during liver transplantation is not associated with sex. However, sex is associated with the risk for complications, and in woman TXA might have a preventive effect on the rate of thromboembolic complications. Reasons underlying the observed sex bias rate remain uncertain.
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Abbasi Dezfouli S, Dooghaie Moghadam A, Mayer P, Klauss M, Kauczor HU, Chang DH, Golriz M, Mehrabi A, Hellbach K. Outcome of the novel description of arterial position changes after major liver resections: retrospective study. BJS Open 2024; 8:zrae110. [PMID: 39316638 PMCID: PMC11421472 DOI: 10.1093/bjsopen/zrae110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/18/2024] [Accepted: 08/06/2024] [Indexed: 09/26/2024] Open
Abstract
BACKGROUND After major liver resections, anatomical shifts due to liver parenchymal hypertrophy and organ displacement can happen. The aim of this study was to evaluate the impact of these anatomical changes on the main abdominal arteries (coeliac trunk and superior mesenteric artery) and on patient outcomes. METHODS All patients who underwent major liver resections (between January 2010 and July 2021) and who underwent preoperative and postoperative arterial-phase contrast-enhanced abdominal CT imaging were studied. Observed arterial position changes were classified into three groups: no position changes; class I position changes (vessel displacement with or without kinking with a vessel angle greater than 105°); and class II position changes (kinking less than or equal to 105°). The Mann-Whitney test and the Kruskal-Wallis test were used to compare continuous variables and the chi-squared test and Fisher's exact test were used to compare categorical variables. Univariable and multivariable logistic regression analyses were used to identify the risk factors for morbidity and mortality. RESULTS A total of 265 patients (149 men and median age of 59 years) were enrolled. Arterial position changes were detected in a total of 145 patients (54.7%) (99 patients (37%) with class I position changes and 46 patients (18%) with class II position changes) and were observed more often after extended resection and right-sided resection (P < 0.001). Major complications were seen in 94 patients (35%) and the rate of mortality was 15% (40 patients died). Post-hepatectomy liver failure (P = 0.030), major complications (P < 0.001), and mortality (P = 0.004) occurred more frequently in patients with class II position changes. In multivariable analysis, arterial position change was an independent risk factor for post-hepatectomy liver failure (OR 2.86 (95% c.i. 1.06 to 7.72); P = 0.038), major complications (OR 2.10 (95% c.i. 1.12 to 3.93); P = 0.020), and mortality (OR 2.39 (95% c.i. 1.03 to 5.56); P = 0.042). CONCLUSION Arterial position changes post-hepatectomy are observed in the majority of patients and are significantly related to postoperative morbidities and mortality.
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Dehne S, Riede C, Feisst M, Klotz R, Etheredge M, Hölle T, Merle U, Mehrabi A, Michalski CW, Büchler MW, Weigand MA, Larmann J. Tranexamic Acid Administration During Liver Transplantation Is Not Associated With Lower Blood Loss or With Reduced Utilization of Red Blood Cell Transfusion. Anesth Analg 2024; 139:598-608. [PMID: 38236761 DOI: 10.1213/ane.0000000000006804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
BACKGROUND Current clinical guidelines recommend antifibrinolytic treatment for liver transplantation to reduce blood loss and transfusion utilization. However, the clinical relevance of fibrinolysis during liver transplantation is questionable, a benefit of tranexamic acid (TXA) in this context is not supported by sufficient evidence, and adverse effects are also conceivable. Therefore, we tested the hypothesis that use of TXA is associated with reduced blood loss. METHODS We performed a retrospective cohort study on patients who underwent liver transplantation between 2004 and 2017 at Heidelberg University Hospital, Heidelberg, Germany. Univariable and multivariable linear regression analyses were used to determine the association between TXA administration and the primary end point intraoperative blood loss and the secondary end point intra- and postoperative red blood cell (RBC) transfusions. For further secondary outcome analyses, the time to the first occurrence of a composite end point of hepatic artery thrombosis, portal vein thrombosis, and thrombosis of the inferior vena cava were analyzed using a univariable and multivariable Cox proportional hazards model. RESULTS Data from 779 transplantations were included in the final analysis. The median intraoperative blood loss was 3000 mL (1600-5500 mL). Intraoperative TXA administration occurred in 262 patients (33.6%) with an average dose of 1.4 ± 0.7 g and was not associated with intraoperative blood loss (regression coefficient B, -0.020 [-0.051 to 0.012], P = .226) or any of the secondary end points (intraoperative RBC transfusion; regression coefficient B, 0.023 [-0.006 to 0.053], P = .116), postoperative RBC transfusion (regression coefficient B, 0.007 [-0.032 to 0.046], P = .717), and occurrence of thrombosis (hazard ratio [HR], 1.110 [0.903-1.365], P = .321). CONCLUSIONS Our data do not support the use of TXA during liver transplantation. Physicians should exercise caution and consider individual factors when deciding whether or not to administer TXA.
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Fuchs J, Loos M, Kinny-Köster B, Hackert T, Schneider M, Mehrabi A, Berchtold C, Al-Saeedi M, Müller BP, Strobel O, Feißt M, Kessler M, Günther P, Büchler MW. Pancreatic Surgery in Children: Complex, Safe, and Effective. Ann Surg 2024; 280:332-339. [PMID: 38386903 PMCID: PMC11224565 DOI: 10.1097/sla.0000000000006125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
OBJECTIVE The aim of this study was to assess indications for and report outcomes of pancreatic surgery in pediatric patients. BACKGROUND Indications for pancreatic surgery in children are rare and data on surgical outcomes after pediatric pancreatic surgery are scarce. METHODS All children who underwent pancreatic surgery at a tertiary hospital specializing in pancreatic surgery between 2003 and 2022 were identified from a prospectively maintained database. Indications, surgical procedures, and perioperative as well as long-term outcomes were analyzed. RESULTS In total, 73 children with a mean age of 12.8 years (range: 4 mo to 18 y) underwent pancreatic surgery during the observation period. Indications included chronic pancreatitis (n=35), pancreatic tumors (n=27), and pancreatic trauma (n=11). Distal pancreatectomy was the most frequently performed procedure (n=23), followed by pancreatoduodenectomy (n=19), duodenum-preserving pancreatic head resection (n=10), segmental pancreatic resection (n=7), total pancreatectomy (n=3), and others (n=11). Postoperative morbidity occurred in 25 patients (34.2%), including 7 cases (9.6%) with major complications (Clavien-Dindo≥III). There was no postoperative (90-d) mortality. The 5-year overall survival was 90.5%. The 5-year event-free survival of patients with chronic pancreatitis was 85.7%, and 69.0% for patients with pancreatic tumors. CONCLUSION This is the largest single-center study on pediatric pancreatic surgery in a Western population. Pediatric pancreatic surgery can be performed safely. Centralization in pancreatic centers with high expertise in surgery of adult and pediatric patients is important as it both affords the benefits of pancreatic surgery experience and ensures that surgical management is adapted to the specific needs of children.
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Majlesara A, Aminizadeh E, Ramouz A, Khajeh E, Shahrbaf M, Borges F, Goncalves G, Carvalho C, Golriz M, Mehrabi A. Evaluation of quality and quantity of randomized controlled trials in hepatobiliary surgery: A scoping/mapping review. Eur J Clin Invest 2024; 54:e14210. [PMID: 38624140 DOI: 10.1111/eci.14210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/17/2024]
Abstract
AIM To evaluate the quantity and quality of randomized controlled trials (RCTs) in hepatobiliary surgery and for identifying gaps in current evidences. METHODS A systematic search was conducted in MEDLINE (via PubMed), Web of Science, and Cochrane Controlled Register of Trials (CENTRAL) for RCTs of hepatobiliary surgery published from inception until the end of 2023. The quality of each study was assessed using the Cochrane risk-of-bias (RoB) tool. The associations between risk of bias and the region and publication date were also assessed. Evidence mapping was performed to identify research gaps in the field. RESULTS The study included 1187 records. The number and proportion of published randomized controlled trials (RCTs) in hepatobiliary surgery increased over time, from 13 RCTs (.0005% of publications) in 1970-1979 to 201 RCTs (.003% of publications) in 2020-2023. There was a significant increase in the number of studies with a low risk of bias in RoB domains (p < .01). The proportion of RCTs with low risk of bias improved significantly after the introduction of CONSORT guidelines (p < .001). The evidence mapping revealed a significant research focus on major and minor hepatectomy and cholecystectomy. However, gaps were identified in liver cyst surgery and hepatobiliary vascular surgery. Additionally, there are gaps in the field of perioperative management and nutrition intervention. CONCLUSION The quantity and quality of RCTs in hepatobiliary surgery have increased over time, but there is still room for improvement. We have identified gaps in current research that can be addressed in future studies.
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Majlesara A, Golriz M, Ramouz A, Khajeh E, Sabetkish N, Wielpütz MO, Rio Tinto H, Abbasi Dezfouli S, Loos M, Mehrabi A, Chang DH. Postoperative Management of Portal Vein Arterialization: An Interdisciplinary Institutional Approach. Cancers (Basel) 2024; 16:2459. [PMID: 39001521 PMCID: PMC11240632 DOI: 10.3390/cancers16132459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/16/2024] Open
Abstract
Portal vein arterialization (PVA) is a surgical procedure that plays a crucial role in hepatic vascular salvage when hepatic artery flow restoration remains elusive. Dedicated diagnostic vascular imaging and the timely management of PVA shunts are paramount to preventing complications, such as portal hypertension and thrombosis. Regrettably, a lack of standardized postoperative management protocols for PVA has increased morbidity and mortality rates post-procedure. In response to this challenge, we developed a PVA standard operating procedure (SOP) tailored to the needs of interventional radiologists. This SOP is designed to harmonize postoperative care, fostering scientific comparability across cases. This concise brief report aims to offer radiologists valuable insights into the PVA technique and considerations for post-PVA care and foster effective interdisciplinary collaboration.
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Kinny-Köster B, Halm D, Tran D, Kaiser J, Heckler M, Hank T, Hinz U, Berchtold C, Al-Saeedi M, Roth S, Mehrabi A, Marchegiani G, Büchler MW, Loos M. Who Do We Fail to Rescue after Pancreatoduodenectomy? Outcomes Among >4000 Procedures Expose Windows of Opportunity. Ann Surg 2024:00000658-990000000-00971. [PMID: 38967356 DOI: 10.1097/sla.0000000000006429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
OBJECTIVE Our investigation on in-hospital mortality after 4474 pancreatoduodenectomies aimed to identify time-dependent risks as well as windows of opportunity to rescue patients from complications. BACKGROUND Pancreatoduodenectomy is generally considered a safe procedure with a 1-10% perioperative mortality based on complexity and surgical volume. Yet, patients are susceptible for life-threatening complications particularly with extended resections. Recognition of distinct vulnerabilities over time while patients recover is required to permit focused monitoring, sophisticated resource allocation, and greatest surgical safety. METHODS Patients who deceased in-hospital after pancreatoduodenectomy between 2003-2021 were retrieved from the institutional pancreatectomy registry and analyzed in detail with respect to their postoperative course. RESULTS Among 4474 pancreatoduodenectomies, 156 patients deceased in-hospital (3.5%). When assessing root causes of mortality, we observed 3 different clusters of complications which were postpancreatectomy-specific (47.4%), visceral vasculature-associated (25.6%), or cardiopulmonary in origin (23.7%). The median times of root cause onset in the 3 categories were postoperative day (POD) 9, POD 4.5 ( P =0.008) and POD 3 ( P <0.001), and medians of in-hospital mortality were POD 31, POD 18 ( P =0.009) and POD 8 ( P <0.001), respectively. Intervals between root cause onset and mortality varied with medians of 23 days, 11 days ( P =0.017), and 1 days ( P <0.001). The 3 categories were similarly distributed between different types of surgical complexity. CONCLUSION Postpancreatectomy-specific complications prompt almost half of in-hospital mortalities after pancreatoduodenectomy, with rather long intervals for interventions to prevent failure to rescue. In contrast, visceral vasculature-related events and cardiopulmonary complications dominate early in-hospital mortalities with short intervals until mortality, demanding rigorous management of such events or preoperative conditioning. These data externally validate a previous high-volume initiative and highlight distinct windows of opportunity to optimize perioperative safety.
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Reichelt S, Merle U, Klauss M, Kahlert C, Lurje G, Mehrabi A, Czigany Z. Shining a spotlight on sarcopenia and myosteatosis in liver disease and liver transplantation: Potentially modifiable risk factors with major clinical impact. Liver Int 2024; 44:1483-1512. [PMID: 38554051 DOI: 10.1111/liv.15917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/07/2024] [Accepted: 03/17/2024] [Indexed: 04/01/2024]
Abstract
Muscle-wasting and disease-related malnutrition are highly prevalent in patients with chronic liver diseases (CLD) as well as in liver transplant (LT) candidates. Alterations of body composition (BC) such as sarcopenia, myosteatosis and sarcopenic obesity and associated clinical frailty were tied to inferior clinical outcomes including hospital admissions, length of stay, complications, mortality and healthcare costs in various patient cohorts and clinical scenarios. In contrast to other inherent detrimental individual characteristics often observed in these complex patients, such as comorbidities or genetic risk, alterations of the skeletal muscle and malnutrition are considered as potentially modifiable risk factors with a major clinical impact. Even so, there is only limited high-level evidence to show how these pathologies should be addressed in the clinical setting. This review discusses the current state-of-the-art on the role of BC assessment in clinical outcomes in the setting of CLD and LT focusing mainly on sarcopenia and myosteatosis. We focus on the disease-related pathophysiology of BC alterations. Based on these, we address potential therapeutic interventions including nutritional regimens, physical activity, hormone and targeted therapies. In addition to summarizing existing knowledge, this review highlights novel trends, and future perspectives and identifies persisting challenges in addressing BC pathologies in a holistic way, aiming to improve outcomes and quality of life of patients with CLD awaiting or undergoing LT.
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Klotz R, Hank T, Berente MP, Joos M, Hinz U, Pianka F, Kinny-Köster B, Al-Saeedi M, Strobel O, Hackert T, Schneider M, Müller-Stich B, Berchtold C, Mehrabi A, Loos M, Büchler MW. Preoperative Surgical or Endoscopic Bile Duct Drainage in Pancreatic Cancer. Ann Surg 2024:00000658-990000000-00946. [PMID: 38904102 DOI: 10.1097/sla.0000000000006407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
BACKGROUND Patients with pancreatic cancer and obstructive jaundice routinely undergo endoscopic stent placement (ES). It is well known that ES causes bacterial contamination and infectious complications after pancreatic resection. OBJECTIVE To compare short-term outcomes and survival in patients undergoing pancreatic head resection after preoperative ES vs preoperative surgical drainage (SD) via T-tube insertion. METHODS Patients with obstructive jaundice who underwent SD or ES from 2016 to 2022 were identified from a prospective database. Outcome analyses included microbiological bile contamination, overall morbidity and assessment of the overall complication burden using the Comprehensive Complication Index (CCI). Overall survival was investigated by Kaplan‒Meier analysis. RESULTS A total of 55 patients with SD were identified and matched with 110 ES patients. After the primary intervention, ES patients experienced more complications (ES: 17.3% vs. SD: 3.6%; P=0.013). The overall complication burden after pancreatic resection was higher in ES patients than in SD patients (CCI: 27.2 vs. 19.9; P=0.022). Additionally, bacterial contamination of the bile was more frequent in ES patients compared to SD individuals (94.3% vs. 7.1%; P<0.001) with similar bacteria in 83.3% of postoperative abdominal infections in ES patients. While overall survival did not differ between the two groups, patients with postinterventional complications after ES had an impaired survival compared to those without complications (11.3 mo vs. 20.4 mo; P=0.03). CONCLUSION SD for obstructive jaundice in resectable pancreatic cancer is associated with a lower overall complication burden. Additionally, patients with complications after ES experience worse overall survival. These findings indicate to rethink our standards of treatment of obstructive jaundice in patients with pancreatic cancer.
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Halder A, Liesenfeld O, Whitfield N, Uhle F, Schenz J, Mehrabi A, Schmitt FCF, Weigand MA, Decker SO. A 29-mRNA host-response classifier identifies bacterial infections following liver transplantation - a pilot study. Langenbecks Arch Surg 2024; 409:185. [PMID: 38865015 PMCID: PMC11169022 DOI: 10.1007/s00423-024-03373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/01/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Infections are common complications in patients following liver transplantation (LTX). The early diagnosis and prognosis of these infections is an unmet medical need even when using routine biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT). Therefore, new approaches are necessary. METHODS In a prospective, observational pilot study, we monitored 30 consecutive patients daily between days 0 and 13 following LTX using the 29-mRNA host classifier IMX-BVN-3b that determine the likelihood of bacterial infections and viral infections. True infection status was determined using clinical adjudication. Results were compared to the accuracy of CRP and PCT for patients with and without bacterial infection due to clinical adjudication. RESULTS Clinical adjudication confirmed bacterial infections in 10 and fungal infections in 2 patients. 20 patients stayed non-infected until day 13 post-LTX. IMX-BVN-3b bacterial scores were increased directly following LTX and decreased until day four in all patients. Bacterial IMX-BVN-3b scores detected bacterial infections in 9 out of 10 patients. PCT concentrations did not differ between patients with or without bacterial, whereas CRP was elevated in all patients with significantly higher levels in patients with bacterial infections. CONCLUSION The 29-mRNA host classifier IMX-BVN-3b identified bacterial infections in post-LTX patients and did so earlier than routine biomarkers. While our pilot study holds promise future studies will determine whether these classifiers may help to identify post-LTX infections earlier and improve patient management. CLINICAL TRIAL NOTATION German Clinical Trials Register: DRKS00023236, Registered 07 October 2020, https://drks.de/search/en/trial/DRKS00023236.
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Hoegen-Saßmannshausen P, Naumann P, Hoffmeister-Wittmann P, Ben Harrabi S, Seidensaal K, Weykamp F, Mielke T, Ellerbrock M, Habermehl D, Springfeld C, Dill MT, Longerich T, Schirmacher P, Mehrabi A, Chang DH, Hörner-Rieber J, Jäkel O, Haberer T, Combs SE, Debus J, Herfarth K, Liermann J. Carbon ion radiotherapy of hepatocellular carcinoma provides excellent local control: The prospective phase I PROMETHEUS trial. JHEP Rep 2024; 6:101063. [PMID: 38737600 PMCID: PMC11087711 DOI: 10.1016/j.jhepr.2024.101063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 05/14/2024] Open
Abstract
Background & Aims Inoperable hepatocellular carcinoma (HCC) can be treated by stereotactic body radiotherapy. However, carbon ion radiotherapy (CIRT) is more effective for sparing non-tumorous liver. High linear energy transfer could promote therapy efficacy. Japanese and Chinese studies on hypofractionated CIRT have yielded excellent results. Because of different radiobiological models and the different etiological spectrum of HCC, applicability of these results to European cohorts and centers remains questionable. The aim of this prospective study was to assess safety and efficacy and to determine the optimal dose of CIRT with active raster scanning based on the local effect model (LEM) I. Methods CIRT was performed every other day in four fractions with relative biological effectiveness (RBE)-weighted fraction doses of 8.1-10.5 Gy (total doses 32.4-42.0 Gy [RBE]). Dose escalation was performed in five dose levels with at least three patients each. The primary endpoint was acute toxicity after 4 weeks. Results Twenty patients received CIRT (median age 74.7 years, n = 16 with liver cirrhosis, Child-Pugh scores [CP] A5 [n = 10], A6 [n = 4], B8 [n = 1], and B9 [n = 1]). Median follow up was 23 months. No dose-limiting toxicities and no toxicities exceeding grade II occurred, except one grade III gamma-glutamyltransferase elevation 12 months after CIRT, synchronous to out-of-field hepatic progression. During 12 months after CIRT, no CP elevation occurred. The highest dose level could be applied safely. No local recurrence developed during follow up. The objective response rate was 80%. Median overall survival was 30.8 months (1/2/3 years: 75%/64%/22%). Median progression-free survival was 20.9 months (1/2/3 years: 59%/43%/43%). Intrahepatic progression outside of the CIRT target volume was the most frequent pattern of progression. Conclusions CIRT of HCC yields excellent local control without dose-limiting toxicity. Impact and implications To date, safety and efficacy of carbon ion radiotherapy for hepatocellular carcinoma have only been evaluated prospectively in Japanese and Chinese studies. The optimal dose and fractionation when using the local effect model for radiotherapy planning are unknown. The results are of particular interest for European and American particle therapy centers, but also of relevance for all specialists involved in the treatment and care of patients with hepatocellular carcinoma, as we present the first prospective data on carbon ion radiotherapy in hepatocellular carcinoma outside of Asia. The excellent local control should encourage further use of carbon ion radiotherapy for hepatocellular carcinoma and design of randomized controlled trials. Clinical Trials Registration The study is registered at ClinicalTrials.gov (NCT01167374).
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Rauber C, Pfeiffenberger J, Mehrabi A, Mieth M, Zizer E, Merle U. Exacerbation of Myopathy in Glycogen Debrancher Deficiency After Liver Transplantation: Case Report and Review of the Literature. Transplant Proc 2024; 56:1153-1156. [PMID: 38834415 DOI: 10.1016/j.transproceed.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/26/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Glycogen storage disorder (GSD) type IIIa is a rare inherited genetic disorder affecting liver and muscle tissue. Liver transplantation (LT) improves metabolic control, but muscle involvement persists. CASE We report the case of a 31-year-old man who underwent orthotopic LT for end-stage liver disease caused by GSD type IIIa. After LT, he developed worsening clinical signs of myopathy, along with exponentially increasing levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and creatine kinase. Liver-related elevations of AST and ALT were excluded through liver biopsy and endoscopic cholangiography; consequently, AST and ALT elevations were attributed to the underlying muscle involvement. Exacerbation of muscle disease after LT could be attributed to restoration of liver glycogen metabolism after LT, leading to increased glucose accumulation in muscle cells, where the gene defect persists. A dietary intervention with a high-protein, ketogenic diet was initiated but did not lead to significant improvement of myalgia. CONCLUSION LT exacerbated muscle disease in a patient with GSD type IIIa. Patients should be counseled about this possible side effect of LT in GSD type IIIa.
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