Prehabilitation in hepato-pancreato-biliary surgery: A systematic review and meta-analysis. A necessary step forward evidence-based sample size calculation for future trials

INTRODUCTION

Prehabilitation is defined as preoperative conditioning of patients in order to improve post-operative outcomes. Some studies showed an increase in functional recovery following colorectal surgery, but its effect in hepato-pancreato-biliary (HPB) surgery is unclear. The aim of this study was to realize a systematic literature review and meta-analysis on the current available evidence on prehabilitation in HPB surgery.

MATERIALS AND METHODS

A systematic review and a metanalysis were carried out on prehabilitation (physical, nutritional and psychological interventions) in HPB surgery (2009-2019). Assessed outcomes were postoperative complications, length of stay (LOS), 30-day readmission, and mortality.

MAIN RESULTS

Four studies among the 191 screened were included in this systematic review (3 randomized controlled trials, 1 case-control propensity score study), involving 419 patients (prehabilitation group, n=139; control group, n=280). After pooling, no difference was observed on LOS ((-4.37 days [95% CI: -8.86; 0.13]) or postoperative complications (RR 0.83 [95%CI: 0.62; 1.10]), reported by all the included studies. Two trials reported on readmission rate, but given the high heterogeneity, a meta-analysis was not realized. No deaths were reported among the included studies.

CONCLUSION

No effect of prehabilitation programs in HPB surgery was observed on LOS or postoperative complications rate. Future trials with standardized outcomes of measure, and adequately powered samples calculations are thus required.

PROSPERO REGISTRATION

CRD42020165218.

Non-invasive ICG-clearance: a useful tool for the management of hepatic artery thrombosis following liver transplantation

BACKGROUND

The clinical presentation of hepatic artery thrombosis (HAT) post-liver transplantation (LT) varies considerably. Doppler ultrasonography (Doppler US) is the first line investigation, with a diagnostic sensitivity for HAT as high as 92%. Because indocyanine green (ICG) elimination from the blood depends among other factors on the hepatic blood flow, we hypothesized that plasma disappearance rate of indocyanine green (PDR-ICG) can be influenced by the flow in the hepatic artery. Thus, we evaluated the role of PDR-ICG measurement in HAT diagnosis in post-LT patients.

PATIENTS AND METHODS

Fourteen liver transplant patients with no visible flow in the hepatic artery (Doppler US) were identified. Of the 14, seven patients had HAT confirmed by CT-angiography. The PDR-ICG measurement, an investigation routinely used in our center, was performed in all 14 patients.

RESULTS

The PDR-ICG in patients with HAT was significantly lower than in patients without HAT (5.8 ± 4.3 vs. 23.8 ± 7.4%/min, p= 0.0009). In patients with HAT, after the revascularization, the PDR-ICG value increased (5.8 ± 4.3 vs. 15.6 ± 3.5%/min, p = 0.006).

CONCLUSION

The ICG elimination may be an adjunct diagnostic tool in the management of patients with suspected HAT following LT.

A case of recurrent vulvar carcinoma treated with erlotinib, an EGFR inhibitor

BACKGROUND

There is no effective therapy for patients with regional and/or distant recurrence of vulvar carcinoma. Recently two case reports about the use of erlotinib, an EGFR (epithelial growth factor receptor) inhibitor, in the context of recurrent vulvar cancer were published with a good clinical response reported.

CASE

We report a case where erlotinib was used in a 67-year-old patient with recurrent and multi-treated vulvar carcinoma. Utilization of erlotinib was started with rapid clinical improvement. The treatment was well tolerated with palliation of symptoms. A CT scan also showed cutoff "net" improvement, with regression of size and number of hilar and pulmonary metastases. After one month of improvement, despite continuous treatment with erlotinib, dyspnea returned. A new CT scan showed an increased number of hilar nodes, a new hepatic lesion and increase in the size of the known pelvic lesion.

CONCLUSION

EGFR inhibitors appear to be promising agents for this devastating and fatal disease. As with other studies with these agents, our patient showed a rapid response with important palliation of symptoms, however of short duration.

Expression of stromelysin-3 in atherosclerotic lesions: regulation via CD40-CD40 ligand signaling in vitro and in vivo

Stromelysin-3 is an unusual matrix metalloproteinase, being released in the active rather than zymogen form and having a distinct substrate specificity, targeting serine proteinase inhibitors (serpins), which regulate cellular functions involved in atherosclerosis. We report here that human atherosclerotic plaques (n = 7) express stromelysin-3 in situ, whereas fatty streaks (n = 5) and normal arterial specimens (n = 5) contain little or no stromelysin-3. Stromelysin-3 mRNA and protein colocalized with endothelial cells, smooth muscle cells, and macrophages within the lesion. In vitro, usual inducers of matrix metalloproteinases such as interleukin-1, interferon-gamma, or tumor necrosis factor alpha did not augment stromelysin-3 in vascular wall cells. However, T cell-derived as well as recombinant CD40 ligand (CD40L, CD154), an inflammatory mediator recently localized in atheroma, induced de novo synthesis of stromelysin-3. In addition, stromelysin-3 mRNA and protein colocalized with CD40L and CD40 within atheroma. In accordance with the in situ and in vitro data obtained with human material, interruption of the CD40-CD40L signaling pathway in low density lipoprotein receptor-deficient hyperlipidemic mice substantially decreased expression of the enzyme within atherosclerotic plaques. These observations establish the expression of the unusual matrix metalloproteinase stromelysin-3 in human atherosclerotic lesions and implicate CD40-CD40L signaling in its regulation, thus providing a possible new pathway that triggers complications within atherosclerotic lesions.

Factors influencing indoor concentrations of nitric oxide in a Parisian intensive care unit

In low concentrations, inhaled nitric oxide (NO) increases arterial oxygenation in patients with severe acute respiratory distress syndrome. When present in the ambient atmosphere, NO and its oxidative derivate, nitrogen dioxide (NO2), are considered pollutants. The aim of this study was to assess whether the administration of inhaled NO to mechanically ventilated patients was associated with an increased risk of exposure to NO and NO2 for medical and paramedical staff. During a 1-yr period, indoor and outdoor NO and NO2 concentrations were measured using chemiluminescence in a 14-bed intensive care unit (ICU) to assess the possible influence of therapeutic NO administration on indoor pollution. Ambient concentrations of NO within the ICU were 237 +/- 147 parts per billion (ppb) during periods of NO administration and 289 +/- 147 ppb during periods without NO administration (mean +/- SD, NS). Indoor concentrations of NO and NO2 were entirely dependent on outdoor concentrations and were mainly influenced by climatic conditions such as atmospheric pressure, mass of clouds, and speed of the wind. Therapeutic administration of concentrations of inhaled NO < or = 5 ppm to critically ill patients did not affect the ambient concentration of NO and NO2 within the ICU, which was mainly dependent on the outdoor air pollution. As a consequence, scavenging of exhaust NO from the breathing circuit in the ventilator does not appear mandatory in ICUs located in areas with significant urban pollution when NO concentrations < or = 5 ppm are administered.

Extraction of light filth from spirulina powders and tablets: collaborative study

Results are reported for a collaborative study of a method for the extraction of light filth from spirulina (a blue-green alga) powder and tablets. A 50 g portion of either powder or tablets is dispersed in water, and then boiled with dilute HCI solution. Hairs and insect fragments are isolated by wet sieving on a No. 230 sieve, flotation with mineral oil, and washings of the mineral oil in a percolator. Average recoveries by 12 collaborators for tablets and powders were 70.6 and 70.2%, respectively, for 10 rat hair spikes and 68.3 and 84.4%, respectively, for 20 insect fragment spikes. The method has been approved interim official first action.