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Puhan MA, Clavien PA. Is Statistical Significance Alone Obsolete?: Let's Turn to Meaningful Interpretation of Scientific and Real-world Evidence on Surgical Care. Ann Surg 2024; 279:913-914. [PMID: 38506046 DOI: 10.1097/sla.0000000000006278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Wyss Zurich Translational Center, ETH Zurich and Swiss Medical Network and Faculty of Medicine, University of Zurich, Zurich, Switzerland
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2
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Guidetti C, Müller PC, Magistri P, Jonas JP, Odorizzi R, Kron P, Guerrini G, Oberkofler CE, Di Sandro S, Clavien PA, Petrowsky H, Di Benedetto F. Full robotic versus open ALPPS: a bi-institutional comparison of perioperative outcomes. Surg Endosc 2024:10.1007/s00464-024-10804-z. [PMID: 38698258 DOI: 10.1007/s00464-024-10804-z] [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: 01/16/2024] [Accepted: 03/17/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND In primarily unresectable liver tumors, ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy) may offer curative two-stage hepatectomy trough a fast and extensive hypertrophy. However, concerns have been raised about the invasiveness of the procedure. Full robotic ALPPS has the potential to reduce the postoperative morbidity trough a less invasive access. The aim of this study was to compare the perioperative outcomes of open and full robotic ALPPS. METHODS The bicentric study included open ALPPS cases from the University Hospital Zurich, Switzerland and robotic ALPPS cases from the University of Modena and Reggio Emilia, Italy from 01/2015 to 07/2022. Main outcomes were intraoperative parameters and overall complications. RESULTS Open and full robotic ALPPS were performed in 36 and 7 cases. Robotic ALPPS was associated with less blood loss after both stages (418 ± 237 ml vs. 319 ± 197 ml; P = 0.04 and 631 ± 354 ml vs. 258 ± 53 ml; P = 0.01) as well as a higher rate of interstage discharge (86% vs. 37%; P = 0.02). OT was longer with robotic ALPPS after both stages (371 ± 70 min vs. 449 ± 81 min; P = 0.01 and 282 ± 87 min vs. 373 ± 90 min; P = 0.02). After ALPPS stage 2, there was no difference for overall complications (86% vs. 86%; P = 1.00) and major complications (43% vs. 39%; P = 0.86). The total length of hospital stay was similar (23 ± 17 days vs. 26 ± 13; P = 0.56). CONCLUSION Robotic ALPPS was safely implemented and showed potential for improved perioperative outcomes compared to open ALPPS in an experienced robotic center. The robotic approach might bring the perioperative risk profile of ALPPS closer to interventional techniques of portal vein embolization/liver venous deprivation.
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Affiliation(s)
- Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Philip C Müller
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Hepatopancreatobiliary Diseases, Basel, Switzerland
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Jan Philipp Jonas
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Roberta Odorizzi
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Philipp Kron
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Gianpiero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Christian E Oberkofler
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Vivévis - Clinic Hirslanden Zurich, Zurich, Switzerland
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41124, Modena, Italy.
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3
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Staiger RD, Mehra T, Haile SR, Domenghino A, Kümmerli C, Abbassi F, Kozbur D, Dutkowski P, Puhan MA, Clavien PA. Experts vs. machine - comparison of machine learning to expert-informed prediction of outcome after major liver surgery. HPB (Oxford) 2024; 26:674-681. [PMID: 38423890 DOI: 10.1016/j.hpb.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 02/01/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Machine learning (ML) has been successfully implemented for classification tasks (e.g., cancer diagnosis). ML performance for more challenging predictions is largely unexplored. This study's objective was to compare machine learning vs. expert-informed predictions for surgical outcome in patients undergoing major liver surgery. METHODS Single tertiary center data on preoperative parameters and postoperative complications for elective hepatic surgery patients were included (2008-2021). Expert-informed prediction models were established on 14 parameters identified by two expert liver surgeons to impact on postoperative outcome. ML models used all available preoperative patient variables (n = 62). Model performance was compared for predicting 3-month postoperative overall morbidity. Temporal validation and additional analysis in major liver resection patients were conducted. RESULTS 889 patients included. Expert-informed models showed low average bias (2-5 CCI points) with high over/underprediction. ML models performed similarly: average prediction 5-10 points higher than observed CCI values with high variability (95% CI -30 to 50). No performance improvement for major liver surgery patients. CONCLUSION No clinical relevance in the application of ML for predicting postoperative overall morbidity was found. Despite being a novel hype, ML has the potential for application in clinical practice. However, at this stage it does not replace established approaches of prediction modelling.
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Affiliation(s)
- Roxane D Staiger
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland.
| | - Tarun Mehra
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Sarah R Haile
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Anja Domenghino
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | | | - Fariba Abbassi
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Damian Kozbur
- Department of Economics, University of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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4
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Boggi U, Kauffmann EF, Napoli N, Barreto SG, Besselink MG, Fusai GK, Hackert T, Hilal MA, Marchegiani G, Salvia R, Shrikhande SV, Truty M, Werner J, Wolfgang C, Bannone E, Capretti G, Cattelani A, Coppola A, Cucchetti A, De Sio D, Di Dato A, Di Meo G, Fiorillo C, Gianfaldoni C, Ginesini M, Hidalgo Salinas C, Lai Q, Miccoli M, Montorsi R, Pagnanelli M, Poli A, Ricci C, Sucameli F, Tamburrino D, Viti V, Cameron J, Clavien PA, Asbun HJ. REDISCOVER guidelines for borderline-resectable and locally advanced pancreatic cancer: management algorithm, unanswered questions, and future perspectives. Updates Surg 2024:10.1007/s13304-024-01860-0. [PMID: 38684573 DOI: 10.1007/s13304-024-01860-0] [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: 03/08/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
The REDISCOVER guidelines present 34 recommendations for the selection and perioperative care of borderline-resectable (BR-PDAC) and locally advanced ductal adenocarcinoma of the pancreas (LA-PDAC). These guidelines represent a significant shift from previous approaches, prioritizing tumor biology over anatomical features as the primary indication for resection. Condensed herein, they provide a practical management algorithm for clinical practice. However, the guidelines also highlight the need to redefine LA-PDAC to align with modern treatment strategies and to solve some contradictions within the current definition, such as grouping "difficult" and "impossible" to resect tumors together. Furthermore, the REDISCOVER guidelines highlight several areas requiring urgent research. These include the resection of the superior mesenteric artery, the management strategies for patients with LA-PDAC who are fit for surgery but unable to receive multi-agent neoadjuvant chemotherapy, the approach to patients with LA-PDAC who are fit for surgery but demonstrate high serum Ca 19.9 levels even after neoadjuvant treatment, and the optimal timing and number of chemotherapy cycles prior to surgery. Additionally, the role of primary chemoradiotherapy versus chemotherapy alone in LA-PDAC, the timing of surgical resection post-neoadjuvant/primary chemoradiotherapy, the efficacy of ablation therapies, and the management of oligometastasis in patients with LA-PDAC warrant investigation. Given the limited evidence for many issues, refining existing management strategies is imperative. The establishment of the REDISCOVER registry ( https://rediscover.unipi.it/ ) offers promise of a unified research platform to advance understanding and improve the management of BR-PDAC and LA-PDAC.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy.
| | - Emanuele F Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy
| | - S George Barreto
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Beadfor Park, Australia
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giovanni Marchegiani
- Hepatopancreatobiliary and Liver Transplant Surgery, Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Shailesh V Shrikhande
- Tata Memorial Centre, Gastrointestinal and HPB Service, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mark Truty
- Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, MN, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, LMU, University of Munich, Munich, Germany
| | - Christopher Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisa Bannone
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Alice Cattelani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), University of Bari, Bari, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy
| | | | - Quirino Lai
- Department of General and Specialty Surgery, Sapienza University of Rome, AOU Policlinico Umberto I of Rome, Rome, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Montorsi
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Andrea Poli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Ricci
- Division of Pancreatic Surgery, Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, IRCCS, Azienda Ospedaliero-Universitaria di Bologna (IRCCS AOUBO), Bologna, Italy
| | - Francesco Sucameli
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Via Savi 10, 56126, Pisa, PI, Italy
| | - John Cameron
- Department of Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
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5
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Victor LL, Morise Z, Gomez Gavara C, Gero D, Abu Hilal M, Goh BK, Herman P, Clavien PA, Robles-Campos R, Wakabayashi G. Global Outcomes Benchmarks in Laparoscopic Liver Surgery for Segments 7 and 8: International Multicenter Analysis. J Am Coll Surg 2024:00019464-990000000-00973. [PMID: 38661176 DOI: 10.1097/xcs.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND In recent years, there has been growing interest in laparoscopic liver resection (LLR) and the audit of the results of surgical procedures. The aim of this study was to define reference values for LLR in segments 7 and 8. METHODS Data on LLR in segments 7 and 8 between January 2000 and December 2020 were collected from 19 expert centers. Reference cases were defined as no prior hepatectomy, ASA <3, body mass index <35 kg/m2, no chronic kidney disease, no cirrhosis and portal hypertension, no chronic obstructive pulmonary disease (FEV1<80%), and no cardiac disease. Reference values were obtained from the 75th percentile of the medians of all reference centers. RESULTS Of 585 patients, 461 (78.8%) met the reference criteria. The overall complication rate was 27.5% (6% were Clavien-Dindo≥3a) with a mean CCI of 7.5 ± 16.5. At 90-day follow-up, the references values for overall complications were 31%, Clavien≥3a 7.4%, conversion 4.4%, hospital stay < 6 days, and readmission rate < 8.33%, respectively. Eastern centers patients categorized as low risk had a lower rate of overall complications (20.9% vs 31.2%, p=0.01) with similar Clavien-Dindo≥3a (5.5% and 4.8%, p=0.83) compared to Western centers, respectively. CONCLUSION This study shows the need to establish standards for the postoperative outcomes in LLR based on the complexity of the resection and the location of the lesions.
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Affiliation(s)
- Lopez-Lopez Victor
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Zeniche Morise
- Department of Surgery, Fujita Health University School of Medicine Okazaki Medical Center, Okazaki 444-0827, Aichi, Japan
| | - Concepción Gomez Gavara
- Department of HPB Surgery and Transplants, Vall d'Hebron University Hospital, Barcelona Autonomic University, Barcelona, Spain
| | - Daniel Gero
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Switzerland
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Via Leonida Bissolati 57, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Brian Kp Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Center Singapore, Singapore
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Center Singapore, Singapore. ii) Surgery Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Paulo Herman
- Serviço de Cirurgia do Fígado, Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Ageo, Japan
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6
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Rela M, Rammohan A, Rajalingam R, Clavien PA. Portal Hemodynamics in Liver Resection and Transplantation. Ann Surg 2024:00000658-990000000-00844. [PMID: 38623762 DOI: 10.1097/sla.0000000000006304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The hepatic blood supply and its several homeostatic and pathologic processes has always been a matter of great interest. Many views commonly held today are derived from an earlier era, but major reorientations have occurred recently in almost all aspects of knowledge of the role and regulation of hepatic blood flow. Moreover, with the advent of liver transplantation (LT), especially living donor LT (LDLT) there has been a resurgence of interest in attempting to comprehend this deceptively simple topic. It is nonetheless important to concede that even though our knowledge on the practical modulation of hepatic hemodynamics has expanded enormously, there still remain the need to explore the depths of our remaining ignorance to further improve outcomes in LDLT. This review focuses on the current view, controversies and gaps in knowledge of the hepatic vascular bed, with an emphasis on the importance of portal hemodynamics in liver disease and its impact on liver regeneration and LT.
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Affiliation(s)
- Mohamed Rela
- Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Ashwin Rammohan
- Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
| | - Rajesh Rajalingam
- Dr.Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, India
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7
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Namoto K, Baader C, Orsini V, Landshammer A, Breuer E, Dinh KT, Ungricht R, Pikiolek M, Laurent S, Lu B, Aebi A, Schönberger K, Vangrevelinghe E, Evrova O, Sun T, Annunziato S, Lachal J, Redmond E, Wang L, Wetzel K, Capodieci P, Turner J, Schutzius G, Unterreiner V, Trunzer M, Buschmann N, Behnke D, Machauer R, Scheufler C, Parker CN, Ferro M, Grevot A, Beyerbach A, Lu WY, Forbes SJ, Wagner J, Bouwmeester T, Liu J, Sohal B, Sahambi S, Greenbaum LE, Lohmann F, Hoppe P, Cong F, Sailer AW, Ruffner H, Glatthar R, Humar B, Clavien PA, Dill MT, George E, Maibaum J, Liberali P, Tchorz JS. NIBR-LTSi is a selective LATS kinase inhibitor activating YAP signaling and expanding tissue stem cells in vitro and in vivo. Cell Stem Cell 2024; 31:554-569.e17. [PMID: 38579685 DOI: 10.1016/j.stem.2024.03.003] [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: 07/26/2022] [Revised: 01/24/2024] [Accepted: 03/06/2024] [Indexed: 04/07/2024]
Abstract
The YAP/Hippo pathway is an organ growth and size regulation rheostat safeguarding multiple tissue stem cell compartments. LATS kinases phosphorylate and thereby inactivate YAP, thus representing a potential direct drug target for promoting tissue regeneration. Here, we report the identification and characterization of the selective small-molecule LATS kinase inhibitor NIBR-LTSi. NIBR-LTSi activates YAP signaling, shows good oral bioavailability, and expands organoids derived from several mouse and human tissues. In tissue stem cells, NIBR-LTSi promotes proliferation, maintains stemness, and blocks differentiation in vitro and in vivo. NIBR-LTSi accelerates liver regeneration following extended hepatectomy in mice. However, increased proliferation and cell dedifferentiation in multiple organs prevent prolonged systemic LATS inhibition, thus limiting potential therapeutic benefit. Together, we report a selective LATS kinase inhibitor agonizing YAP signaling and promoting tissue regeneration in vitro and in vivo, enabling future research on the regenerative potential of the YAP/Hippo pathway.
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Affiliation(s)
- Kenji Namoto
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland.
| | - Clara Baader
- Friedrich Miescher Institute for Biomedical Research, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Vanessa Orsini
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | - Eva Breuer
- University Hospital Zurich (USZ), Zurich, Switzerland
| | - Kieu Trinh Dinh
- German Cancer Research Center (DKFZ) Heidelberg, Research Group Experimental Hepatology, Inflammation and Cancer, Heidelberg, Germany; Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | | | | | | | - Bo Lu
- Biomedical Research, Novartis Pharma AG, Cambridge, MA, USA
| | - Alexandra Aebi
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | | | - Olivera Evrova
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Tianliang Sun
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland; Division of Liver Diseases, Institute for Regenerative Medicine, Department of Cell, Developmental and Regenerative Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Julie Lachal
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Emily Redmond
- Biomedical Research, Novartis Pharma AG, Cambridge, MA, USA
| | - Louis Wang
- Biomedical Research, Novartis Pharma AG, Cambridge, MA, USA
| | - Kristie Wetzel
- Biomedical Research, Novartis Pharma AG, Cambridge, MA, USA
| | | | | | - Gabi Schutzius
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | - Markus Trunzer
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | - Dirk Behnke
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | | | | | - Magali Ferro
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Armelle Grevot
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | - Wei-Yu Lu
- University of Edinburgh, Center for Inflammation Research, Edinburgh, UK
| | - Stuart J Forbes
- University of Edinburgh, Center for Regenerative Medicine, Edinburgh, UK
| | - Jürgen Wagner
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | - Jun Liu
- Biomedical Research, Novartis Pharma AG, La Jolla, CA, USA
| | - Bindi Sohal
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | | | | | - Felix Lohmann
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Philipp Hoppe
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Feng Cong
- Biomedical Research, Novartis Pharma AG, Cambridge, MA, USA
| | | | - Heinz Ruffner
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Ralf Glatthar
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Bostjan Humar
- University Hospital Zurich (USZ), Zurich, Switzerland
| | | | - Michael T Dill
- German Cancer Research Center (DKFZ) Heidelberg, Research Group Experimental Hepatology, Inflammation and Cancer, Heidelberg, Germany; Department of Gastroenterology, Infectious Diseases and Intoxication, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Jürgen Maibaum
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland
| | - Prisca Liberali
- Friedrich Miescher Institute for Biomedical Research, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Jan S Tchorz
- Biomedical Research, Novartis Pharma AG, Basel, Switzerland.
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8
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Ding L, Huwyler F, Long F, Yang W, Binz J, Wernlé K, Pfister M, Klug M, Balaz M, Ukropcova B, Ukropec J, Wu C, Wang T, Gao M, Clavien PA, Dutkowski P, Tibbitt MW, Wolfrum C. Glucose controls lipolysis through Golgi PtdIns4P-mediated regulation of ATGL. Nat Cell Biol 2024; 26:552-566. [PMID: 38561547 PMCID: PMC11021197 DOI: 10.1038/s41556-024-01386-y] [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: 06/01/2023] [Accepted: 02/23/2024] [Indexed: 04/04/2024]
Abstract
Metabolic crosstalk of the major nutrients glucose, amino acids and fatty acids (FAs) ensures systemic metabolic homeostasis. The coordination between the supply of glucose and FAs to meet various physiological demands is especially important as improper nutrient levels lead to metabolic disorders, such as diabetes and metabolic dysfunction-associated steatohepatitis (MASH). In response to the oscillations in blood glucose levels, lipolysis is thought to be mainly regulated hormonally to control FA liberation from lipid droplets by insulin, catecholamine and glucagon. However, whether general cell-intrinsic mechanisms exist to directly modulate lipolysis via glucose sensing remains largely unknown. Here we report the identification of such an intrinsic mechanism, which involves Golgi PtdIns4P-mediated regulation of adipose triglyceride lipase (ATGL)-driven lipolysis via intracellular glucose sensing. Mechanistically, depletion of intracellular glucose results in lower Golgi PtdIns4P levels, and thus reduced assembly of the E3 ligase complex CUL7FBXW8 in the Golgi apparatus. Decreased levels of the E3 ligase complex lead to reduced polyubiquitylation of ATGL in the Golgi and enhancement of ATGL-driven lipolysis. This cell-intrinsic mechanism regulates both the pool of intracellular FAs and their extracellular release to meet physiological demands during fasting and glucose deprivation. Moreover, genetic and pharmacological manipulation of the Golgi PtdIns4P-CUL7FBXW8-ATGL axis in mouse models of simple hepatic steatosis and MASH, as well as during ex vivo perfusion of a human steatotic liver graft leads to the amelioration of steatosis, suggesting that this pathway might be a promising target for metabolic dysfunction-associated steatotic liver disease and possibly MASH.
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Affiliation(s)
- Lianggong Ding
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland
| | - Florian Huwyler
- Macromolecular Engineering Laboratory, Institute of Energy and Process Engineering, ETH Zürich, Zurich, Switzerland
| | - Fen Long
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland
| | - Wu Yang
- Interdisciplinary Research Center on Biology and Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai, China
| | - Jonas Binz
- Macromolecular Engineering Laboratory, Institute of Energy and Process Engineering, ETH Zürich, Zurich, Switzerland
| | - Kendra Wernlé
- Department of Surgery and Transplantation, University of Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Matthias Pfister
- Department of Surgery and Transplantation, University of Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Manuel Klug
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland
| | - Miroslav Balaz
- Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Barbara Ukropcova
- Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Jozef Ukropec
- Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Chunyan Wu
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland
| | - Tongtong Wang
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland
| | - Min Gao
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland
- Department of Pharmacy, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University of Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University of Zurich, Zurich, Switzerland
| | - Mark W Tibbitt
- Macromolecular Engineering Laboratory, Institute of Energy and Process Engineering, ETH Zürich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Christian Wolfrum
- Institute of Food, Nutrition and Health, ETH Zürich, Schwerzenbach, Switzerland.
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9
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Madadi-Sanjani O, Kuebler JF, Brendel J, Costanzo S, Granström AL, Aydin E, Loukogeorgakis S, Lacher M, Wiesner S, Domenghino A, Clavien PA, Mutanen A, Eaton S, Ure BM. Validation of the Clavien-Madadi Classification for Unexpected Events in Pediatric Surgery: A Collaborative ERNICA Project. J Pediatr Surg 2024:S0022-3468(24)00174-X. [PMID: 38582705 DOI: 10.1016/j.jpedsurg.2024.03.022] [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: 12/31/2023] [Revised: 02/28/2024] [Accepted: 03/10/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The Clavien-Madadi classification is a novel instrument for the assessment and grading of unexpected events in pediatric surgery, based on the Clavien-Dindo classification. The system has been adjusted to better fit the pediatric population in a prospective single-center study. There is a need now to validate the Clavien-Madadi classification within an international expert network. METHODS A pediatric surgical working group created 19 case scenarios with unexpected events in a multi-staged process. Those were circulated within the European Reference Network of Inherited and Congenital Anomalies (ERNICA) and surgeons were instructed to rate the scenarios according to the Clavien-Madadi vs. Clavien-Dindo classification. RESULTS 59 surgeons from 12 European countries completed the questionnaire. Based on ratings of the case scenarios, the Clavien-Madadi classification showed significantly superior agreement rates of the respondents (85.9% vs 76.2%; p < 0.05) and was less frequently considered inaccurate for rating the pediatric population compared to Clavien-Dindo (2.1% vs 11.1%; p = 0.05). Fleiss' kappa analysis showed slightly higher strength of agreement using the Clavien-Madadi classification (0.74 vs 0.69). Additionally, intraclass correlation coefficient was slightly higher for the Clavien-Madadi compared to the Clavien-Dindo classification (ICCjust 0.93 vs 0.89; ICCunjust 0.93 vs 0.89). More pediatric surgeons preferred the Clavien-Madadi classification for the case scenarios (43.0% vs 11.8%; p = 0.002) and advantages of the Clavien-Madadi were confirmed by 81.4% of the surgeons. CONCLUSION The Clavien-Madadi classification is an accurate and reliable instrument for the grading of unexpected events in pediatric surgery. We therefore recommend its application in clinical and academic pediatric surgical practice. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Omid Madadi-Sanjani
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany; Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands.
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany; European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands
| | - Julia Brendel
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany; European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands
| | - Sara Costanzo
- Pediatric Surgery Department, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Anna L Granström
- European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands; Division of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Emrah Aydin
- Department of Pediatric Surgery, Faculty of Medicine, Tekirdağ Namık Kemal University, Tekirdağ, Turkey
| | - Stavros Loukogeorgakis
- Stem Cells and Regenerative Medicine Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Soeren Wiesner
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Anja Domenghino
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Annika Mutanen
- European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands; Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Simon Eaton
- European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands; Stem Cells and Regenerative Medicine Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany; European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA), European Union, Netherlands
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10
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Wehrle CJ, Maspero M, Pinna AD, Dutkowski P, Miller C, Hashimoto K, Clavien PA, Schlegel A. Age Matters: What Affects the Cumulative Lifespan of a Transplanted Liver? Ann Surg 2024:00000658-990000000-00803. [PMID: 38489660 DOI: 10.1097/sla.0000000000006259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Assess factors affecting the cumulative lifespan of a transplanted liver. SUMMARY BACKGROUND DATA Liver ageing is different from other solid organs. It is unknown how old a liver can actually get after liver transplantation (LT). METHODS Deceased donor liver transplants from 1988-2021 were queried from the United States (US) UNOS registry. Cumulative liver age was calculated as donor age + recipient graft survival. RESULTS In total, 184,515 livers were included. Most were DBD-donors (n=175,343). The percentage of livers achieving >70, 80, 90 and 100years cumulative age was 7.8% (n=14,392), 1.9% (n=3,576), 0.3% (n=528), and 0.01% (n=21), respectively. The youngest donor age contributing to a cumulative liver age >90years was 59years, with post-transplant survival of 34years. In pediatric recipients, 736 (4.4%) and 282 livers (1.7%) survived >50 and 60years overall, respectively. Transplanted livers achieved cumulative age >90years in 2.86-per-1000 and >100years in 0.1-per-1000. The US population at-large has a cumulative "liver age" >90years in 5.35-per-1000 persons, and >100y in 0.2-per-1000. Livers aged>60 years at transplant experienced both improved cumulative survival ( P <0.0001) and interestingly improved survival after transplantation ( P <0.0001). Recipient warm-ischemia-time of >30minutes was most predictive of reduced cumulative liver survival overall (n=184,515, HR=1.126, P <0.001) and excluding patients with mortality in the first 6month (n=151,884, HR=0.973, P <0.001). CONCLUSIONS In summary, transplanted livers frequently get as old as those in the average population despite ischemic-reperfusion-injury and immunosuppression. The presented results justify using older donor livers regardless of donation type, even in sicker recipients with limited options.
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Affiliation(s)
- Chase J Wehrle
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
| | - Marianna Maspero
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
- Upper GI Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
| | | | - Andrea Schlegel
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Ohio, US
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11
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Li Z, Rammohan A, Gunasekaran V, Hong S, Chih-Yi Chen I, Kim J, Hervera Marquez KA, Hsu SC, Kirimker EO, Akamatsu N, Shaked O, Finotti M, Yeow M, Genedy L, Dutkowski P, Nadalin S, Boehnert MU, Polak WG, Bonney GK, Mathur A, Samstein B, Emond JC, Testa G, Olthoff KM, Rosen CB, Heimbach JK, Taner T, Wong TC, Lo CM, Hasegawa K, Balci D, Cattral M, Sapisochin G, Selzner N, Jeng LB, Broering D, Joh JW, Chen CL, Suh KS, Rela M, Clavien PA. Biliary complications after adult-to-adult living-donor liver transplantation: An international multicenter study of 3633 cases. Am J Transplant 2024:S1600-6135(24)00165-5. [PMID: 38428639 DOI: 10.1016/j.ajt.2024.02.023] [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: 09/04/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
In living-donor liver transplantation, biliary complications including bile leaks and biliary anastomotic strictures remain significant challenges, with incidences varying across different centers. This multicentric retrospective study (2016-2020) included 3633 adult patients from 18 centers and aimed to identify risk factors for these biliary complications and their impact on patient survival. Incidences of bile leaks and biliary strictures were 11.4% and 20.6%, respectively. Key risk factors for bile leaks included multiple bile duct anastomoses (odds ratio, [OR] 1.8), Roux-en-Y hepaticojejunostomy (OR, 1.4), and a history of major abdominal surgery (OR, 1.4). For biliary anastomotic strictures, risk factors were ABO incompatibility (OR, 1.4), blood loss >1 L (OR, 1.4), and previous abdominal surgery (OR, 1.7). Patients experiencing biliary complications had extended hospital stays, increased incidence of major complications, and higher comprehensive complication index scores. The impact on graft survival became evident after accounting for immortal time bias using time-dependent covariate survival analysis. Bile leaks and biliary anastomotic strictures were associated with adjusted hazard ratios of 1.7 and 1.8 for graft survival, respectively. The study underscores the importance of minimizing these risks through careful donor selection and preoperative planning, as biliary complications significantly affect graft survival, despite the availability of effective treatments.
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Affiliation(s)
- Zhihao Li
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland; Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Vasanthakumar Gunasekaran
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Suyoung Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Itsuko Chih-Yi Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Kris Ann Hervera Marquez
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Shih-Chao Hsu
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
| | | | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan
| | - Oren Shaked
- Division of Transplantation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michele Finotti
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Marcus Yeow
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore
| | - Lara Genedy
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Silvio Nadalin
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Markus U Boehnert
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Glenn K Bonney
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore
| | - Abhishek Mathur
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Benjamin Samstein
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Jean C Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Giuliano Testa
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Kim M Olthoff
- Division of Transplantation, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles B Rosen
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie K Heimbach
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Timucin Taner
- Division of Transplantation Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiffany Cl Wong
- Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Chung-Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan
| | - Deniz Balci
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Mark Cattral
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Long-Bin Jeng
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
| | - Dieter Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Chao-Long Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr. Rela Institute and Medical Centre, Chennai, India
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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12
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Boggi U, Kauffmann E, Napoli N, Barreto SG, Besselink MG, Fusai GK, Hackert T, Abu Hilal M, Marchegiani G, Salvia R, Shrikhande S, Truty M, Werner J, Wolfgang C, Bannone E, Capretti G, Cattelani A, Coppola A, Cucchetti A, De Sio D, Di Dato A, Di Meo G, Fiorillo C, Gianfaldoni C, Ginesini M, Hidalgo Salinas C, Lai Q, Miccoli M, Montorsi R, Pagnanelli M, Poli A, Ricci C, Sucameli F, Tamburrino D, Viti V, Addeo PF, Alfieri S, Bachellier P, Baiocchi G, Balzano G, Barbarello L, Brolese A, Busquets J, Butturini G, Caniglia F, Caputo D, Casadei R, Chunhua X, Colangelo E, Coratti A, Costa F, Crafa F, Dalla Valle R, De Carlis L, de Wilde RF, Del Chiaro M, Di Benedetto F, Di Sebastiano P, Dokmak S, Hogg M, Egorov VI, Ercolani G, Ettorre GM, Falconi M, Ferrari G, Ferrero A, Filauro M, Giardino A, Grazi GL, Gruttaduaria S, Izbicki JR, Jovine E, Katz M, Keck T, Khatkov I, Kiguchi G, Kooby D, Lang H, Lombardo C, Malleo G, Massani M, Mazzaferro V, Memeo R, Miao Y, Mishima K, Molino C, Nagakawa Y, Nakamura M, Nardo B, Panaro F, Pasquali C, Perrone V, Rangelova E, Riu L, Romagnoli R, Romito R, Rosso E, Schulick R, Siriwardena A, Spampinato M, Strobel O, Testini M, Troisi R, Uzunoglo FG, Valente R, Veneroni L, Zerbi A, Vicente E, Vistoli F, Vivarelli M, Wakabayashi G, Zanus G, Zureikat A, Zyromski NJ, Coppola R, D'Andrea V, Davide J, Dervenis C, Frigerio I, Konlon KC, Michelassi F, Montorsi M, Nealon W, Portolani N, Sousa Silva D, Bozzi G, Ferrari V, Trivella MG, Cameron J, Clavien PA, Asbun HJ. REDISCOVER International Guidelines on the Perioperative Care of Surgical Patients With Borderline-resectable and Locally Advanced Pancreatic Cancer. Ann Surg 2024:00000658-990000000-00795. [PMID: 38407228 DOI: 10.1097/sla.0000000000006248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
OBJECTIVE The REDISCOVER consensus conference aimed at developing and validate guidelines on the perioperative care of patients with borderline resectable (BR-) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC). SUMMARY BACKGROUND DATA Coupled with improvements in chemotherapy and radiation, the contemporary approach to pancreatic surgery supports resection of BR-PDAC and, to a lesser extent, LA-PDAC. Guidelines outlining the selection and perioperative care for these patients are lacking. METHODS The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used to develop the REDISCOVER guidelines and create recommendations. The Delphi approach was used to reach consensus (agreement ≥80%) among experts. Recommendations were approved after a debate and vote among international experts in pancreatic surgery and pancreatic cancer management. A Validation Committee used the AGREE II-GRS tool to assess the methodological quality of the guidelines. Moreover, an independent multidisciplinary advisory group revised the statements to ensure adherence to non-surgical guidelines. RESULTS Overall, 34 recommendations were created targeting centralization, training, staging, patient selection for surgery, possibility of surgery in uncommon scenarios, timing of surgery, avoidance of vascular reconstruction, details of vascular resection/reconstruction, arterial divestment, frozen section histology of perivascular tissue, extent of lymphadenectomy, anticoagulation prophylaxis and role of minimally invasive surgery. The level of evidence was however low for 29 of 34 clinical questions. Participants agreed that the most conducive mean to promptly advance our understanding in this field is to establish an international registry addressing this patient population ( https://rediscover.unipi.it/ ). CONCLUSIONS The REDISCOVER guidelines provide clinical recommendations pertaining to pancreatectomy with vascular resection for patients with BR- and LA-PDAC, and serve as the basis of a new international registry for this patient population.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Emanuele Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - S George Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia, Division of Surgery and Perioperative Medicine, Flinders Medical Center, Beadfor Park, Australia
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giovanni Marchegiani
- Hepatopancreatobiliary and Liver Transplant Surgery, Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Shailesh Shrikhande
- Tata Memorial Hospital, Gastrointestinal and HPB Service, Homi Bhabha National Institute, Tata Memorial Centre, Mumbai, India
| | - Mark Truty
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, LMU, University of Munich, Germany
| | - Christopher Wolfgang
- Department of Surgery, The NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Elisa Bannone
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Alice Cattelani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC; Alma Mater Studiorum Università di Bologna; Bologna, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) University of Bari, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | | | - Quirino Lai
- Department of General and Specialty Surgery, Sapienza University of Rome, AOU Policlinico Umberto I of Rome, Rome, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Montorsi
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | | | - Andrea Poli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy, Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna (IRCCS AOUBO)
| | - Francesco Sucameli
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Pietro F Addeo
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Sergio Alfieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | - Philippe Bachellier
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gianluca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia and UOC General Surgery, ASST Cremona, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Linda Barbarello
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Alberto Brolese
- Department of General Surgery & HPB Unit, APSS, Trento, Italy
| | - Juli Busquets
- Division of Pancreatobiliary Surgery and Liver Transplantation, Department of Surgery, Bellvitge University Hospital, IDIBELL, L´Hospitalet de Llobregat, Barcelona, Spain
| | - Giovanni Butturini
- Hepatopancreatobiliary Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Fabio Caniglia
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Damiano Caputo
- Research Unit of General Surgery, Department of Medicine and Surgery, University Campus Bio-Medico di Roma, Via Alvaro del Portillo 200,00128 Rome, Italy
- Operative Research Unit of General Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Italy, Division of Pancreatic Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna (IRCCS AOUBO)
| | - Xi Chunhua
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University
- Pancreas Institute, Nanjing Medical University
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
| | - Ettore Colangelo
- Department of General Surgery, "G. Mazzini" Hospital, Teramo, Italy
| | - Andrea Coratti
- Department of General and Emergency Surgery, AUSL Toscana Sud Est, Misericordia Hospital of Grosseto, Italy
| | - Francesca Costa
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Francesco Crafa
- Division of General, Oncological and Robotic Surgery, San Giuseppe Moscati Hospital, Avellino Italy
| | | | - Luciano De Carlis
- Division of HPB Surgery and Transplantation, Niguarda Hospital , University of Milano-Bicocca, Milan, Italy
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado School of Medicine. Aurora, Colorado, USA
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Pierluigi Di Sebastiano
- Surgical Oncology, Pierangeli Clinic, Department of Innovative Technology in Medicine & Dentistry, G. D'Annunzio University Chieti-Pescara, Italy
| | - Safi Dokmak
- department of HPB surgery and liver transplantation, Beaujon hospital, Clichy, France. University Paris Cité, Paris, France
| | - Melissa Hogg
- Division of HPB Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Vyacheslav I Egorov
- Department for Surgical Oncology and HPB Surgery, Ilyinskaya Hospital, Moscow, Russia
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences - DIMEC; Alma Mater Studiorum Università di Bologna; Bologna, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Transplantation. San Camillo Forlanini Hospital-POIT. Rome, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giovanni Ferrari
- Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, "Umberto I" Mauriziano Hospital, Turin, Italy
| | - Marco Filauro
- Department of Surgery Galliera Hospital, Genova, Italy
| | - Alessandro Giardino
- Hepatopancreatobiliary Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Gian Luca Grazi
- Division of HepatoBiliaryPancreatic Surgery, AOU Careggi, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Salvatore Gruttaduaria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center Italy (UPMC Italy), Palermo, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Jakob R Izbicki
- Department of general visceral and thoracic surgery, University Hospital Eppendorf University of Hamburg, Hamburg, Germany
| | - Elio Jovine
- Department of Surgery, Alma Mater Studiorum University of Bologna, IRCCS Azienda Ospedaliera Universitaria di Bologna
| | - Matthew Katz
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of High Technology Surgery, Moscow Clinical Scientific Center. Moscow, Russia
| | - Gozo Kiguchi
- Department of Surgery, Hirakata Kohsai Hospital, Osaka, Japan
| | - David Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Hauke Lang
- University Medical Centre of the Johannes Gutenberg University Mainz, Germany
| | - Carlo Lombardo
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-oncology, University of Milan HPB Surgery and Liver Transplantation Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Riccardo Memeo
- Department of HPB Surgery, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University
- Pancreas Institute, Nanjing Medical University
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, People's Republic of China
| | - Kohei Mishima
- Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | - Carlo Molino
- Department of General and Speciality Surgery, General and Pancreatic Surgery Team 1, AORN A. Cardarelli, Naples, Italy
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Bruno Nardo
- Division of General Surgery, Department of Surgery and Robotic, Annunziata Hub Hospital, School of Medicine Surgery and TD, University of Calabria, Cosenza, Italy
| | - Fabrizio Panaro
- Department of Surgery, Division of HBP Surgery & Transplantation. Montpellier University Hospital School of Medicine, Montpellier, France
| | - Claudio Pasquali
- Pancreatic & Digestive Endocrine Surgery Research Group - Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Vittorio Perrone
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Elena Rangelova
- Section for Upper Abdominal Surgery at the Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Surgery at the Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Long Riu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People's Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Renato Romagnoli
- Division of General Surgery 2U - Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Raffaele Romito
- Division of General Surgery II and HPB Unit, A.O.U. Maggiore della Carità di Novara, Novara, Italy
| | - Edoardo Rosso
- Service de Chirurgie Générale, Mini-Invasive et Robotique, Centre Hôspitalier de
| | - Richard Schulick
- Department of Surgery, University of Colorado School of Medicine. Aurora, Colorado, USA
| | - Ajith Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, UK
| | - Marcello Spampinato
- Department of General and Minimally Invasive Surgery, "Vito Fazzi" Hospital, Lecce, Italy Luxembourg, Luxembourg, Luxembourg
| | - Oliver Strobel
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J) University of Bari, Italy
| | - Roberto Troisi
- Division of HBP, Minimally Invasive and Robotic Surgery, Transplantation Service Federico II University Hospital - Naples, Italy
| | - Faik G Uzunoglo
- Department of general visceral and thoracic surgery, University Hospital Eppendorf University of Hamburg, Hamburg, Germany
| | | | - Luigi Veneroni
- Chirurgia Generale, Infermi Hospital Rimini, AUSL Romagna, Rimini, Italy
| | | | - Emilio Vicente
- Sanchinarro University Hospital, General Surgery Department, San Pablo University, CEU, Madrid, Spain
| | - Fabio Vistoli
- Division of General Surgery and Transplantation, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Vivarelli
- Division of Hepatobiliary, Pancreatic and Transplantation Surgery, Polytechnic University of Marche, Ospedali Riuniti delle Marche, Ancona, Italy
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Giacomo Zanus
- Second Division of Surgery-Treviso-Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padua, Padua, Italy
| | - Amer Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Roberto Coppola
- Research Unit of General Surgery, Department of Medicine and Surgery, University Campus Bio-Medico di Roma, Via Alvaro del Portillo 200,00128 Rome, Italy
- Operative Research Unit of General Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Vito D'Andrea
- Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - José Davide
- Department of Surgery, HEBIPA - Hepatobiliary and Pancreatic Unit, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | - Isabella Frigerio
- Hepatopancreatobiliary Surgery, Pederzoli Hospital, Peschiera del Garda, Verona, Italy
| | - Kevin C Konlon
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Fabrizio Michelassi
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital at Weill Cornell, New Yourk, NY, USA
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Italy
- Division of General and Digestive Surgery, Department of General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - William Nealon
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Zucker School of Medicine at Hofstra, New Hyde Park, NY, USA
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Italy
| | - Donzília Sousa Silva
- Department of Surgery, HEBIPA - Hepatobiliary and Pancreatic Unit, Hospital de Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | | | | | - John Cameron
- Department of Surgery, John Hopkins University School of Medicine, Baltimore, MD
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
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Abbassi F, Pfister M, Domenghino A, Puhan MA, Clavien PA. Surgical Outcome Reporting. Moving from a Comic to a Tragic Opera? Ann Surg 2024:00000658-990000000-00772. [PMID: 38323468 DOI: 10.1097/sla.0000000000006226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVES To assess the current quality of surgical outcome reporting in the medical literature, and to provide recommendations for improvement. BACKGROUND In 1996, the Lancet labelled surgery as a "comic opera" mostly referring to the poor quality of outcome reporting in the literature impeding improvement in surgical quality and patient care. METHODS We screened three 1st tier and two 2nd tier surgical journals, as well as three leading medical journals for original articles reporting on results of surgical procedures published over a recent 18-month period. The quality of outcome reporting was assessed using a pre-specified 12-item checklist. RESULTS 627 articles reporting surgical outcomes were analyzed, including 125 randomized controlled trials (RCT). Only 1 (0·2%) article met all 12 criteria of the checklist, while 356 articles (57%) fulfilled less than half of criteria. The poorest reporting was on cumulative morbidity burden, which was missing in 94% of articles (n=591) as well as patient reported outcomes missing in 83% of publications (n=518). Comparing journal groups for the individual criterion, we found moderate to very strong statistical evidence for better quality of reporting in high versus lower impact journals for 7 of 12 criteria, and strong statistical evidence for better reporting of patient-reported outcomes in medical versus surgical journals (P<0·001). CONCLUSION The quality of outcome reporting in the medical literature remains poor lacking improvement over the past 20 years on most key endpoints. The implementation of standardized outcome reporting is urgently needed to minimize biased interpretation of data thereby enabling improved patient care and the elaboration of meaningful guidelines.
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Affiliation(s)
- Fariba Abbassi
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Pfister
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Anja Domenghino
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Professor of Surgery and Transplantation, University of Zurich, Wyss Translational Center, Swiss Medical Network, Zurich, Switzerland
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14
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Lopez-Lopez V, Linecker M, Caballero-Llanes A, Reese T, Oldhafer KJ, Hernandez-Alejandro R, Tun-Abraham M, Li J, Fard-Aghaie M, Petrowsky H, Brusadin R, Lopez-Conesa A, Ratti F, Aldrighetti L, Ramouz A, Mehrabi A, Autran Machado M, Ardiles V, De Santibañes E, Marichez A, Adam R, Truant S, Pruvot FR, Olthof PB, Van Gulick TM, Montalti R, Troisi RI, Kron P, Lodge P, Kambakamba P, Hoti E, Martinez-Caceres C, de la Peña-Moral J, Clavien PA, Robles-Campos R. Liver Histology Predicts Liver Regeneration and Outcome in ALPPS: Novel Findings From A Multicenter Study. Ann Surg 2024; 279:306-313. [PMID: 37487004 DOI: 10.1097/sla.0000000000006024] [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] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND AND AIMS Alterations in liver histology influence the liver's capacity to regenerate, but the relevance of each of the different changes in rapid liver growth induction is unknown. This study aimed to analyze the influence of the degree of histological alterations during the first and second stages on the ability of the liver to regenerate. METHODS This cohort study included data obtained from the International ALPPS Registry between November 2011 and October 2020. Only patients with colorectal liver metastases were included in the study. We developed a histological risk score based on histological changes (stages 1 and 2) and a tumor pathology score based on the histological factors associated with poor tumor prognosis. RESULTS In total, 395 patients were included. The time to reach stage 2 was shorter in patients with a low histological risk stage 1 (13 vs 17 days, P ˂0.01), low histological risk stage 2 (13 vs 15 days, P <0.01), and low pathological tumor risk (13 vs 15 days, P <0.01). Regarding interval stage, there was a higher inverse correlation in high histological risk stage 1 group compared to low histological risk 1 group in relation with future liver remnant body weight ( r =-0.1 and r =-0.08, respectively), and future liver remnant ( r =-0.15 and r =-0.06, respectively). CONCLUSIONS ALPPS is associated with increased histological alterations in the liver parenchyma. It seems that the more histological alterations present and the higher the number of poor prognostic factors in the tumor histology, the longer the time to reach the second stage.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Michael Linecker
- Department of Surgery and Transplantation, University Medical Center Schleswig-Holstein, Campus Kiel, Germany
| | - Albert Caballero-Llanes
- Department of Pathology, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Tim Reese
- Department of Surgery, Division of Liver, Bileduct and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | - Karl J Oldhafer
- Department of Surgery, Division of Liver, Bileduct and Pancreatic Surgery, Asklepios Hospital Barmbek, Hamburg, Germany
| | | | - Mauro Tun-Abraham
- Department of Surgery, Western University, London, Ontario, Canada
- Division of Transplantation/Hepatobiliary Surgery, Department of Surgery, University of Rochester, NY
| | - Jun Li
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mohammad Fard-Aghaie
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Roberto Brusadin
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Asuncion Lopez-Conesa
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Francesca Ratti
- Department of Surgery, Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Luca Aldrighetti
- Department of Surgery, Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, School of Medicine, Milan, Italy
| | - Ali Ramouz
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Victoria Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Eduardo De Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Italian Hospital Buenos Aires, Argentina
| | - Arthur Marichez
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Francois-René Pruvot
- Department of Digestive Surgery and Transplantation, University Hospital, Lille, France
| | - Pim B Olthof
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Thomas M Van Gulick
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Roberto Montalti
- Department of Clinical Medicine and Surgery, Federico II University Hospital Naples, Napoli, Italy
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Federico II University Hospital Naples, Napoli, Italy
| | - Philipp Kron
- HPB and Transplant Unit, St. James's University Hospital, Leeds, UK
| | - Peter Lodge
- HPB and Transplant Unit, St. James's University Hospital, Leeds, UK
| | - Patryk Kambakamba
- Department of Hepatobiliary Surgery and Liver Transplantation, St. Vincent's University Hospital, Dublin, Ireland
| | - Emir Hoti
- Department of Hepatobiliary Surgery and Liver Transplantation, St. Vincent's University Hospital, Dublin, Ireland
| | | | - Jesus de la Peña-Moral
- Department of Pathology, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
| | - Pierre-Alain Clavien
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas transplantation, Virgen de la Arrixaca Clinic and University Hospital, IMIB, Murcia, Spain
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15
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Giudicelli G, Gero D, Romulo L, Chirumamilla V, Iranmanesh P, Owen CK, Bauerle W, Garcia A, Lucas L, Mehdorn AS, Pandey D, Almuttawa A, Cabral F, Tiwari A, Lambert V, Pascotto B, De Meyere C, Yahyaoui M, Haist T, Scheffel O, Robert M, Nuytens F, Azagra S, Kow L, Prasad A, Vaz C, Vix M, Bindal V, Beckmann JH, Soussi D, Vilallonga R, El Chaar M, Wilson EB, Ahmad A, Teixeira A, Hagen ME, Toso C, Clavien PA, Puhan M, Bueter M, Jung MK. Global benchmarks in primary robotic bariatric surgery redefine quality standards for Roux-en-Y gastric bypass and sleeve gastrectomy. Br J Surg 2024; 111:znad374. [PMID: 37981863 PMCID: PMC10771137 DOI: 10.1093/bjs/znad374] [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] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/26/2023] [Accepted: 10/21/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Whether the benefits of the robotic platform in bariatric surgery translate into superior surgical outcomes remains unclear. The aim of this retrospective study was to establish the 'best possible' outcomes for robotic bariatric surgery and compare them with the established laparoscopic benchmarks. METHODS Benchmark cut-offs were established for consecutive primary robotic bariatric surgery patients of 17 centres across four continents (13 expert centres and 4 learning phase centres) using the 75th percentile of the median outcome values until 90 days after surgery. The benchmark patients had no previous laparotomy, diabetes, sleep apnoea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI greater than 50 kg/m2, or age greater than 65 years. RESULTS A total of 9097 patients were included, who were mainly female (75.5%) and who had a mean(s.d.) age of 44.7(11.5) years and a mean(s.d.) baseline BMI of 44.6(7.7) kg/m2. In expert centres, 13.74% of the 3020 patients who underwent primary robotic Roux-en-Y gastric bypass and 5.9% of the 4078 patients who underwent primary robotic sleeve gastrectomy presented with greater than or equal to one complication within 90 postoperative days. No patient died and 1.1% of patients had adverse events related to the robotic platform. When compared with laparoscopic benchmarks, robotic Roux-en-Y gastric bypass had lower benchmark cut-offs for hospital stay, postoperative bleeding, and marginal ulceration, but the duration of the operation was 42 min longer. For most surgical outcomes, robotic sleeve gastrectomy outperformed laparoscopic sleeve gastrectomy with a comparable duration of the operation. In robotic learning phase centres, outcomes were within the established benchmarks only for low-risk robotic Roux-en-Y gastric bypass. CONCLUSION The newly established benchmarks suggest that robotic bariatric surgery may enhance surgical safety compared with laparoscopic bariatric surgery; however, the duration of the operation for robotic Roux-en-Y gastric bypass is longer.
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Affiliation(s)
- Guillaume Giudicelli
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Daniel Gero
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lind Romulo
- Department of Surgery, Orlando Health, University of Central Florida, Orlando, Florida, USA
| | - Vasu Chirumamilla
- Bariatric and Robotic Center of Excellence, Mather Northwell Hospital Health, Port Jefferson, New York, USA
| | - Pouya Iranmanesh
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher K Owen
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Wayne Bauerle
- Department of Surgery, Division of Bariatric Surgery, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
| | - Amador Garcia
- Endocrine-Metabolic and Bariatric Unit, Robotic Surgery, Vall Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lisa Lucas
- Department of Endocrine and Digestive Surgery, University Hospital of Poitiers, Poitiers, France
| | - Anne-Sophie Mehdorn
- Department of General, Abdominal, Thoracic, Transplantation and Paediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
- Kurt Semm Centre for Laparoscopic and Robot Assisted Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Dhananjay Pandey
- Institute of Minimal Access, Bariatric and Robotic Surgery, Max Super Speciality Hospital, Delhi NCR, India
| | - Abdullah Almuttawa
- Department of Endocrine and Digestive Surgery, Strasbourg University Hospital – IRCAD, Strasbourg, France
- Department of Surgery, University of Jeddah, Jeddah, Saudi Arabia
| | | | - Abhishek Tiwari
- Department of Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Virginia Lambert
- Adelaide Bariatric Centre, Department of Surgery, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Beniamino Pascotto
- General and Minimally Invasive (Laparoscopic and Robotic) Surgery Department, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | | | - Marouan Yahyaoui
- Department of Digestive and Bariatric Surgery, Hôpital Edouard Herriot, Lyon, France
| | - Thomas Haist
- Department of General and Visceral Surgery, Asklepios Paulinen Klinik, Wiesbaden, Germany
| | - Oliver Scheffel
- Department of Obesity and Metabolic Surgery, Sana Klinikum Offenbach GmbH, Offenbach am Main, Germany
| | - Maud Robert
- Department of Digestive and Bariatric Surgery, Hôpital Edouard Herriot, Lyon, France
| | | | - Santiago Azagra
- General and Minimally Invasive (Laparoscopic and Robotic) Surgery Department, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Lilian Kow
- Adelaide Bariatric Centre, Department of Surgery, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Arun Prasad
- Department of Surgery, Indraprastha Apollo Hospitals, New Delhi, India
| | - Carlos Vaz
- Robotic Surgery Unit, Cuf Tejo Hospital, Lisbon, Portugal
| | - Michel Vix
- Department of Endocrine and Digestive Surgery, Strasbourg University Hospital – IRCAD, Strasbourg, France
| | - Vivek Bindal
- Institute of Minimal Access, Bariatric and Robotic Surgery, Max Super Speciality Hospital, Delhi NCR, India
| | - Jan H Beckmann
- Department of General, Abdominal, Thoracic, Transplantation and Paediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
- Kurt Semm Centre for Laparoscopic and Robot Assisted Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - David Soussi
- Department of Endocrine and Digestive Surgery, University Hospital of Poitiers, Poitiers, France
| | - Ramon Vilallonga
- Endocrine-Metabolic and Bariatric Unit, Robotic Surgery, Vall Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maher El Chaar
- Department of Surgery, Division of Bariatric Surgery, St. Luke’s University Health Network, Bethlehem, Pennsylvania, USA
| | - Erik B Wilson
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Arif Ahmad
- Bariatric and Robotic Center of Excellence, Mather Northwell Hospital Health, Port Jefferson, New York, USA
| | - Andre Teixeira
- Department of Surgery, Orlando Health, University of Central Florida, Orlando, Florida, USA
| | - Monika E Hagen
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Christian Toso
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Milo Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Marco Bueter
- Department of Surgery and Transplantation, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Minoa K Jung
- Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
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Emhemed M, Salem O, Abdulwahed E, Khalil W, Rhuma H, Alsori M, Mustafa T, Albarouni S, Albishti A, Elhadi M, Elkhuja T, Msherghi A, Hasan NSB, Hasan HB, Hasan NB, Gulbinas A, Barauskas G, Ignatavicius P, Riauka R, Vanagas T, Slepavicius A, Jurgaitis J, Dailidenas S, Eismontas V, Mikutaitis V, Šlepavičius A, Jurgaitis J, Mikutaitis V, Dulskas A, Kuliavas J, Aniukstyte L, Sileikis A, Gulla A, Šileikis A, Tumas J, Strupas K, Petrulionis M, Kvietkauskas M, Strupas K, Vito D, Rosso E, Tan JH, Zakaria AD, Mohamad IS, Meng LV, Huai TZ, Hayati F, Sellappan H, Maiyauen TK, Azman A, Chik I, Zuhdi Z, Yoong B, Soon KP, Kit KJ, Yoong BK, Koong JK, Koh PS, Ibrahim A, Abdullah NAN, Bong J, Ghani S, Zorrilla CF, Cruz MC, Valladares AM, Dominguez-Rosado I, Rosciano AEP, Sebastian GH, Melchor-Ruan J, Garcia-Herrera JS, Sandag E, Erdene S, Orgoi S, Korch M, Boutti AS, boumzebra Y, Boumzebra Y, Hourri F, Gouazar I, Belaid WA, Serji B, Tarik B, Tijani EH, Zentar A, Ghannam A, Bounaim A, Souadka A, Benkabbou A, El Ahmadi B, Amina H, Oumayma L, Amrani L, Majbar MA, Mohsine R, Elhassouni R, Echiguer S, Belkhadir Z, Nashidengo AP, Quayson F, Abebrese J, Nashidengo P, Adhikari KM, Lakhey PJ, Bhandari RS, Besselink MG, Bieze M, Augustinus S, Busch O, Pranger BK, Hoogwater FJH, Klaase JM, Meerdink M, Nijkamp MW, de Meijer VE, Koerkamp BG, van Eijck CHJ, Van Dam JL, Barbier L, Johnston P, Babor R, Chu MJJ, Oliver T, Wen D, Koea J, Koea J, Brown L, Srinivasa S, Bartlett A, Windsor J, Carr-Boyd P, Bindra V, Cross A, Connor S, Hore T, Gunawardene A, Welsh F, Mahadik M, Gordon A, Rossaak J, Adeyeye A, Enoch E, Kayode-Nissi V, Abiyere H, Alatise O, Okomayin A, Odion C, Tagar E, Sheshe AA, Muhammad AB, Garzali IU, Ajayi P, Kadri E, Jabri SA, Azri YA, Pal KMI, Siddiqui T, Waqar U, Waqar U, Chaudhry AA, Abbasy J, Khan MO, Shafqatullah S, Khokhar MI, Akbar A, Afzal A, Asghar M, Ullah S, Butt UI, Butt U, Bari H, Mohammad BN, Hameda M, Jayyab MA, Alzabadiah AHM, Adam I, Abuzaina K, Farid M, Emar MFM, Emar M, Zreqat Q, Titi R, Idkiedek SA, Amro S, Al-Qasrawi S, Almasri TA, Alnammourah WM, Kiswani G, Sinnokrot R, Harb ZA, Nafa'A H, Shtewi L, Salah AO, Joma ABA, Faraj S, Zitawi A, Dawood AJ, Saadeh I, Hmeedan A, Daraghmeh MAM, Janajreh ANA, Manassra F, Yassin LMA, Yassin R, Saleh AO, Faraj SM, Sulaiman AS, Khayyat Z, Joma ABA, Shawahni E, Salah A, khader A, Hammoudeh A, Abdulhaq A, Alawna R, Roman G, Targarona J, Grau RG, Molina R, Alegria CR, Coayla G, Enriquez JCM, Marcos JC, Hasiman AN, Teh C, Cerdeño R, David A, Sarmiento RI, Barroso RR, Alfonso C, Ang DD, Casupang A, Mamuric M, Jardinero JM, Motyka A, Flisińska M, Pierściński S, Mrowiec S, Rymarowicz J, Matyja M, Wikar T, Sierzega M, Pędziwiatr M, Richter P, Durczynski A, Kosztowny K, Ciesielski W, Wardeszkiewicz A, Szwedziak K, Wlazlak M, Grzasiak O, Szewczyk P, Hogendorf P, Wyroślak-Najs J, Rawicz-Pruszyński K, Sędłak K, Solecki M, Polkowski W, Słodkowski M, Wierzchowski M, Korcz W, Nazarewski L, Kornasiewicz O, Lopes M, Martins RM, Martins R, Vigia E, Silva DS, Davide J, Pereira A, Tenreiro N, Castro T, Eisa R, Diaconescu B, Ciubotaru C, Negoi I, Negoiţă V, Radulescu RB, Bacalbaşa N, Dima S, Dumitrascu T, Spanu A, Mardare M, Ginghina O, Catrina E, Brezean I, Misca M, Vilcu M, Aldoescu S, Petrea S, Bartos A, Liviu CC, Iancu I, Barbu ST, Bodea R, Mois E, Florin G, Hajjar NA, Matei S, Zaharie F, Scripcariu V, Musina AM, Roata CE, Dimofte GM, Velenciuc N, Lunca S, Ong WL, Ong WL, Duta C, Brebu D, Braicu V, Belyaev A, Popov A, Batova A, Katysheva A, Mizgirev D, Neledova L, Duberman B, Litvin A, Pobelenko A, Kuznetsov G, Khatkov I, Tyutyunnik P, Izrailov R, Bedzhanyan A, Petrenko K, Bredikhin M, Shatverian DG, Chardarov N, Bagmet N, Lyadov V, Mudryak D, Semenenko I, Tokarev M, Kriger A, Kaldarov A, Ivanov G, Kuchin D, Torgomyan G, Zagainov V, Davydkin V, Baranov AI, Drozdov E, Anatolievna LN, Abdullaev A, Gachabayov M, Ghunaim M, Alharthi M, Aljiffry M, Bogdanovic M, Zivanovic M, Bogdanovic A, Galun D, Dugalic V, Arbutina D, Milic L, Bezmarevic M, Antic A, Radenkovic D, Ignjatovic I, Zdujic P, Kmezic S, Karamarkovic A, Arbutina D, Juloski J, Radulovic R, Radulović R, Cuk V, Jeremic L, Radojkovic M, Stojanovic M, Golijanin D, Ignjatovic MK, Protic M, Chiow A, Seng LL, Thiruchelvam N, Poh BGK, Goh BKP, Quan DCW, Koh YX, TrotovŠek B, Petrič M, Djokić M, Tomazic A, Badovinac D, Loots E, Prodehl L, Khan MU, Marumo T, Devar JWS, Omoshoro-Jones J, Khan ZA, Jugmohan B, Valcarcel AQ, García BM, Mínguez J, Marcello M, Ramia J, Compañ A, Fernandes C, Morales M, Fernández JMV, Del Mar Rico-Morales M, Liñán MÁL, Figueras J, Soliva R, Butori E, Fondevila C, Ausania F, Martín B, Rodríguez M, Sánchez-Cabús S, Sánchez-Velázquez P, Arnau ABM, Domínguez RS, Ielpo B, Pinilla FB, Castro M, Valverde DP, Santos EPG, del Carmen Manzanares Campillo M, Ruiz P, Gutierrez EC, Falgueras L, Quer MTA, Shwely FA, Fragua RL, Gonzalez-Serna DB, Valmorisco MA, Beltran-Miranda P, Busquets J, Secanella L, Pelaez N, Plaza G, Duaigües MLG, álvarez PM, Escartín A, Loinaz C, Dziakova J, de la Serna S, Pérez-Aguirre E, Justo I, Saavedra J, Gomez JC, Boñar NL, Martín-Perez E, Di Martino M, de la Hoz Rogriguez Á, Marcacuzco A, Jiménez-Romero C, de la Rúa JFR, Hinojosa-Arco LC, Suárez-Muñoz MÁ, Martinez DF, Sanchez-Bueno F, Vazquez PG, de León AM, Saiz EC, García LS, Gonzalez-Pinto I, Rodríguez-Pino JC, Segura-Sampedro JJ, Morales R, Morales-Soriano R, Rotellar F, Zozaya G, Martí-Cruchaga P, López-Sánchez J, Muñoz-Bellvis L, Cuadrado A, ortega I, Fernández R, Gómez DD, Vera V, Padillo JP, Luque JB, Millan EI, Jorba R, García-Domingot MI, Redondo C, Cantos DM, Artigues E, Pozo CDD, Llorente CP, Martínez SN, Ibáñez CB, Ibáñez JM, Andujar RL, Dorcaratto D, Forner EM, Garces-Albir M, de Heredia JB, Montes-Manrique M, Rodriguez-Lopez M, Serrablo A, Milian D, Ruiz-Quijano P, Paterna-Lopez S, Dharmapala A, Dassanayake BK, Galketiya KB, Ibrahim AM, Hamid H, Alhaboob N, Abdelmageed A, Taha SSO, Vilhav C, Wennerblom JH, Bratlie SO, Bjornsson B, Lundgren L, Sandström P, Tingstedt B, Andersson R, Andersson B, Williamsson C, Sparrelid E, Holmberg M, Ghorbani P, Gkekas I, Kuemmerli C, Bolli M, Andreou A, Wenning AS, Gloor B, Peloso A, Toso C, Oldani G, Moeckli B, Wassmer CH, Cristaudi A, Pietro MH, Majno-Hurst PE, Roesel R, Abbassi F, Tarantino I, Steffen T, Ferrari C, Schmidt J, Meier O, Weber M, Gutknecht S, Jonas JP, Clavien PA, Al-Haj A, Aljaber A, Kayali AA, Kadoura L, Nashed E, Helaly H, Kayali H, Alhashemi M, Aloulou M, Alshaghel M, Mahli N, Al-Abed O, Azizeh O, Torab SS, Alkhaleel W, Aliwy MA, Alannaz O, Ghazal A, Masri R, Douba Z, Saad AS, Abdulmonem A, Shaban M, Alhouri AN, Alhouri A, Soliman A, Houri HNA, Houri HA, Omran S, Abbas A, Chaaban M, Kudmani MAA, Chaaban MK, Alhmaidi R, Yousef A, Youssef A, Nasri M, Alkhateb H, Almjersah A, Hassan N, Moussa A, Hamdan A, Hammed A, Alloush A, Hassan BH, Issa H, Dahhan HT, Souliman M, Hammed S, Tobba TM, Hamdan A, Ayoub S, Yu MC, Yang PC, Wu CH, Bouaziz H, Rahal K, Slim S, Karim A, Baraket O, Kchaou A, Houssem A, Said MA, Mabrouk MB, Hamida KB, Ghalleb M, Mahmoud AB, Maghrebi H, Kacem MJ, Tez M, Eminesariipek N, çetiindağ Ö, Tüzüner A, Karayalçin K, Emral AC, Dikmen K, Kerem M, Bayhan H, Türkoğlu MA, Iflazoğlu N, özet A, Aday U, öfkeli Ö, Gumusoglu A, Kabuli HA, Karabulut M, Peker K, Saglam S, Rahimi FSİ, Hanefa F, Isik A, Goksoy E, Dulundu E, Atici AE, Ozocak AB, Yegen C, Dural AC, Sahbaz NA, Ulgur HS, Aydin H, Ozkan OF, Duzgun O, çelik M, Pekmezci S, çoker A, Uguz A, Unalp OV, Sert I, Ertekin S, Ozbilgin M, Aydoğan S, Tekin E, Calik B, Yesilyurt D, Atici SD, Arıkan TB, Arıkan T, Gonullu E, Dikicier E, Capoglu R, Bayhan Z, Alfurais S, Colak E, Polat S, Çiftci AB, Milburn J, Jones C, Vass D, Taylor M, Dasari BVM, Kausar A, Sultana A, Subar D, Nunes Q, Skipworth J, Nwogwugwu O, van Laarhoven S, Kourdouli A, Awan AA, Bhatti I, Latif J, Hand F, Robertson F, Holroyd D, Holroyd D, Jamieson N, Lim W, Chang D, Frampton A, Lahiri R, Chakravartty S, Siddique H, Bashir M, Mcnally S, Young A, Smith A, Pine J, Garcea G, Haqq J, Malde D, Dunne D, Burridge I, Szatmary P, Hariharan D, Kocher H, Yip V, Khalil A, Nair AM, Liova I, O'Balogun A, Rothnie A, Chikkala B, Salinas CH, Frola C, Tsakiris C, Raptis D, Chasiotis D, Sharma D, Jessa F, Soggiu F, Fusai G, Kostakis I, Kathirvel M, Elnagar M, Dimitrokallis N, Iype S, Pericleous S, Mohamed A, Val ARD, Tinguely P, Likos-Corbett M, Afzal I, Bhogal R, Patel K, Siriwardena AK, de' Liguori Carino N, Sheen PA, Gareb F, Ammar K, Thakkar R, Pandanaboyana S, Leeds J, Gomez D, Gregory G, Ceresa C, Abbas H, Lazzereschi L, Reddy S, Gordon-Weeks A, Aroori S, Russell T, Roberts K, Chatzizacharias N, Sutcliffe R, Al-Sarireh B, Shingler G, Mortimer M, Skoryi D, Ilin I, Pisetska M, Cheverdiuk D, Kostyantyn K, Kopchak K, Kvasivka O, Valeriia S, Sumarokova V, Kryzhevskyi V, Sikachov S, Khomiak A, Malik A, Khomiak I, Bilyak A, Chooklin S, Chuklin S, Mikheiev I, Shylenko O, Klymenko A, Patel S, Cunningham S, Callery M, Kent T, Raut C, Wang J, Fairweather M, Sulciner M, Hirji S, Clancy T, Nebbia M, Qadan M, Musser A, Hogg M, Rodriquez J, Hamner J, Hennessy L, Dinerman A, Gupta A, Kimbrough C, Thompson R, Zeh HJ, Radi I, Polanco PM, Moris D, Lidsky ME, Lee D, Piper J, Gnerlich J, Tuvin D, Sticca R, Ganai S, Gusani N, Krinock D, Giorgakis E, Hardgrave H, Spencer-Cole RT, Klutts G, Hardgrave H, Nigh J, Nigh J, Andrade JCB, Mavros M, Osborn T, Ferrone C, O'Connor V, Boone B, Harris B, Schmidt C, Schrope B, Chabot J, Kluger M, Lasso ET, Nevler A, Yeo C, Ponzini F, Lavu H, Lamm R, Bowne W, Kyser N, Galanopoulos C, Abbasi A, Park J, Sham J, Dickerson L, Pillarisetty V, Sucandy I, Ross S, Winslow E, Hawksworth J, Radkani P, Fishbein T, Munoz AS, Lindberg J, Martins PN, Al-saban RAM, Al-Saban R, Al-Kubati W, Ghallab AAA, Alsanany GM, Almarashi H, Al-Samawi H, Al-Asadi MAMM, Alsayadi R, Hail S, Shream S, Bajjah HM, Al-Ameri S, Bajjah H, Al-Ameri SAAS, Al-Dowsh NA, AlDowsh NA, Al-Khawlani Q, Murshed YAA, Al-Shehari M, Jahaf AAD, Al-sharabi EAE, Aldumaini H, Alattas Z, Almassaudi A, Bajjah HMAH, Albakry R, Al-Naggar H, Shream SAA, Affary AA, Al-Markiz E, Al-Eryani F, Farhat H, Qadasi QA, Alwafy K, Abdualqader MYM, Ali RAAY, Albar A, Bleem HA, Galeb KSA, Ghushaim M, Sabbar M, Esmail M, Ali RAY, Salem RHM, Salem R, Saif W, Al-Faiq S, Alsharabi E, Hameed ATA, Almekhlafi T, Omairan A, Almarkiz E, Abduljawad H, Mansaleh O, Al-Melhani W, Abdualqader M, Al-Abdi R, Alwan HM, Mbanje C, Chihaka O. Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries. Br J Surg 2024; 111:znad330. [PMID: 38743040 DOI: 10.1093/bjs/znad330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/31/2023] [Accepted: 09/15/2023] [Indexed: 05/16/2024]
Abstract
BACKGROUND Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide. METHODS This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters. RESULTS A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries. CONCLUSION Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).
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McCarron FN, Yoshino O, Müller PC, Wang H, Wang Y, Ricker A, Mantha R, Driedger M, Beckman M, Clavien PA, Vrochides D, Martinie JB. Expanding the utility of robotics for pancreaticoduodenectomy: a 10-year review and comparison to international benchmarks in pancreatic surgery. Surg Endosc 2023; 37:9591-9600. [PMID: 37749202 DOI: 10.1007/s00464-023-10426-x] [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: 04/04/2023] [Accepted: 08/31/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is an emerging alternative to open pancreaticoduodenectomy (OPD). Although RPD offers various theoretical advantages, it is used in less than 10% of all pancreaticoduodenectomies. The aim of this study was to report our 10-year experience and compare RPD outcomes with international benchmarks for OPD. METHODS A retrospective review of a prospectively maintained institutional database was performed of consecutive patients who underwent RPD between January 2011 and December 2021. Patients were categorized into low-risk and high-risk groups according to the selection criteria set by the benchmark study. Their outcomes were compared to the international benchmark cut off values. Outcomes were then evaluated over time to identify improvements in practice and establish a learning curve. RESULTS Of 201 RPDs, 36 were low-risk and 165 high-risk patients. Compared to the OPD benchmarks, outcomes of low-risk patients were within the cutoff values. High-risk patients were outside the cutoff for blood transfusions (26% vs. ≤ 23%), overall complications (78% vs. ≤ 73%), grade I-II complications (68% vs. ≤ 62%), and readmissions (22% vs ≤ 21%). Oncologic outcomes for high-risk patients were within benchmark cutoffs. Cases at the end of the learning curve included more pancreatic cancer (42% from 17%) and fewer low-risk patients (10% from 24%) than those at the beginning. After 41 RPD there was a decline in conversion rates and operative time. Between 95 and 143 cases operative time, transfusion rates, and LOS declined significantly. Complications did not differ over time. CONCLUSION RPD yields results comparable to the established benchmarks in OPD in both low- and high-risk patients. Along the learning curve, RPD evolved with the inclusion of more high-risk cases while outcomes remained within benchmarks. Addition of a robotic HPB surgery fellowship did not compromise outcomes. These results suggest that RPD may be an option for high-risk patients at specialized centers.
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Affiliation(s)
- Frances N McCarron
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC, 2820, USA.
| | - Osamu Yoshino
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Philip C Müller
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Huaping Wang
- Department of Surgery, Carolinas Center for Surgical Outcomes, Wake Forest Center for Biomedical Informatics, Charlotte, NC, USA
| | - Yifan Wang
- Division of HPB and Transplantation, Department of Surgery, McGill University, Montreal, Canada
| | - Ansley Ricker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Rohit Mantha
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Driedger
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Beckman
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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Abbassi F, Walbert C, Kehlet H, Grocott MPW, Puhan MA, Clavien PA. Perioperative outcome assessment from the perspectives of different stakeholders: need for reconsideration? Br J Anaesth 2023; 131:969-971. [PMID: 37879999 DOI: 10.1016/j.bja.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 10/27/2023] Open
Abstract
Standardised and universal perioperative endpoint reporting are the cornerstone for outcomes assessment, reliable clinical trials, and health services research. The Outcome4medicine initiative recently reported consensus recommendations on how to assess the quality of surgical interventions, proposing a framework for surgical outcome assessment and quality improvement after medical interventions. In the same field, the Standardised Endpoints in Perioperative Medicine - Core Outcome Measures for Perioperative and Anaesthetic Care (StEP-COMPAC) group recently proposed standardised and valid measures of mortality and morbidity, derived from a three-stage Delphi process. Here a core group of the Outcome4medicine conference discusses how these two initiatives are aligned and emphasises the importance of standardised outcome assessment by integrating the perspectives of different stakeholders.
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Affiliation(s)
- Fariba Abbassi
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | | | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton NIHR Biomedical Research Centre, University Hospital Southampton and University of Southampton, Southampton, UK
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Visceral Surgery and Transplantation, University of Zurich, Zurich, Switzerland.
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Sousa Da Silva RX, Breuer E, Shankar S, Kawakatsu S, Hołówko W, Santos Coelho J, Jeddou H, Sugiura T, Ghallab M, Da Silva D, Watanabe G, Botea F, Sakai N, Addeo P, Tzedakis S, Bartsch F, Balcer K, Lim C, Werey F, Lopez-Lopez V, Peralta Montero L, Sanchez Claria R, Leiting J, Vachharajani N, Hopping E, Torres OJM, Hirano S, Andel D, Hagendoorn J, Psica A, Ravaioli M, Ahn KS, Reese T, Montes LA, Gunasekaran G, Alcázar C, Lim JH, Haroon M, Lu Q, Castaldi A, Orimo T, Moeckli B, Abadía T, Ruffolo L, Dib Hasan J, Ratti F, Kauffmann EF, de Wilde RF, Polak WG, Boggi U, Aldrighetti L, McCormack L, Hernandez-Alejandro R, Serrablo A, Toso C, Taketomi A, Gugenheim J, Dong J, Hanif F, Park JS, Ramia JM, Schwartz M, Ramisch D, De Oliveira ML, Oldhafer KJ, Kang KJ, Cescon M, Lodge P, Rinkes IHMB, Noji T, Thomson JE, Goh SK, Chapman WC, Cleary SP, Pekolj J, Regimbeau JM, Scatton O, Truant S, Lang H, Fuks D, Bachellier P, Ohtsuka M, Popescu I, Hasegawa K, Lesurtel M, Adam R, Cherqui D, Uesaka K, Boudjema K, Pinto-Marques H, Grąt M, Petrowsky H, Ebata T, Prachalias A, Robles-Campos R, Clavien PA. Novel Benchmark Values for Open Major Anatomic Liver Resection in Non-cirrhotic Patients: A Multicentric Study of 44 International Expert Centers. Ann Surg 2023; 278:748-755. [PMID: 37465950 DOI: 10.1097/sla.0000000000006012] [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] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE This study aims at establishing benchmark values for best achievable outcomes following open major anatomic hepatectomy for liver tumors of all dignities. BACKGROUND Outcomes after open major hepatectomies vary widely lacking reference values for comparisons among centers, indications, types of resections, and minimally invasive procedures. METHODS A standard benchmark methodology was used covering consecutive patients, who underwent open major anatomic hepatectomy from 44 high-volume liver centers from 5 continents over a 5-year period (2016-2020). Benchmark cases were low-risk non-cirrhotic patients without significant comorbidities treated in high-volume centers (≥30 major liver resections/year). Benchmark values were set at the 75th percentile of median values of all centers. Minimum follow-up period was 1 year in each patient. RESULTS Of 8044 patients, 2908 (36%) qualified as benchmark (low-risk) cases. Benchmark cutoffs for all indications include R0 resection ≥78%; liver failure (grade B/C) ≤10%; bile leak (grade B/C) ≤18%; complications ≥grade 3 and CCI ® ≤46% and ≤9 at 3 months, respectively. Benchmark values differed significantly between malignant and benign conditions so that reference values must be adjusted accordingly. Extended right hepatectomy (H1, 4-8 or H4-8) disclosed a higher cutoff for liver failure, while extended left (H1-5,8 or H2-5,8) were associated with higher cutoffs for bile leaks, but had superior oncologic outcomes, when compared to formal left hepatectomy (H1-4 or H2-4). The minimal follow-up for a conclusive outcome evaluation following open anatomic major resection must be 3 months. CONCLUSION These new benchmark cutoffs for open major hepatectomy provide a powerful tool to convincingly evaluate other approaches including parenchymal-sparing procedures, laparoscopic/robotic approaches, and alternative treatments, such as ablation therapy, irradiation, or novel chemotherapy regimens.
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Affiliation(s)
- Richard X Sousa Da Silva
- Swiss HPB and Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Eva Breuer
- Swiss HPB and Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Sadhana Shankar
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Shoji Kawakatsu
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Wacław Hołówko
- Department of General, Transplant and Liver Surgery, Medical University Warsaw, Warsaw, Poland
| | - João Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Centre, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Heithem Jeddou
- Department of Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Mohammed Ghallab
- Paul Brousse Hospital, AP-HP, University Paris-Saclay, Villejuif, France
| | - Doris Da Silva
- Department of HPB Surgery and Liver Transplantation, AP-HP Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Genki Watanabe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Florin Botea
- Department of Surgery and Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Nozomu Sakai
- Department of General Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Hospital, Strasbourg University, Strasbourg, France
| | - Stylianos Tzedakis
- Department of Hepatobiliary, Digestive and Endocrine Surgery, Cochin Hospital, Paris Cité University, Paris, France
| | - Fabian Bartsch
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Kaja Balcer
- Department of Digestive Surgery and Transplantation, CHU Lille, University Lille, Lille, France
| | - Chetana Lim
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière, Sorbonne Université, Centre de Recherche de Saint-Antoine, Paris, France
| | - Fabien Werey
- Department of Oncology and Digestive Surgery, CHU Amiens-Picardie, Amiens, France
| | - Victor Lopez-Lopez
- Clinic and University Virgen de la Arrixaca Hospital, IMIB, Murcia, Spain
| | - Luciana Peralta Montero
- Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Sanchez Claria
- Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Neeta Vachharajani
- Department of Surgery, Section of Abdominal Organ Transplant, Washington University School of Medicine, St Louis, MO
| | - Eve Hopping
- Hepatobiliary Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide & Hepatobiliary Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Orlando J M Torres
- Department of Gastrointestinal Surgery, Hepatopancreatobiliary Unit, Presidente Dutra Hospital, São Luiz, Brazil
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Daan Andel
- Department of Surgical Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgical Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Alicja Psica
- Department of Transplantation and Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matteo Ravaioli
- Hepato-biliary surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Keun Soon Ahn
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, School of Medicine, Keimyung University, Dongsan Hospital, Daegu, Republic of Korea
| | - Tim Reese
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Leonardo A Montes
- General Surgery Department Liver, Pancreas and Intestinal Transplant Unit, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Ganesh Gunasekaran
- Department of Surgery, Division of HPB Service, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Cándido Alcázar
- Department of Surgery, HPB and Transplant Unit, General Universitary Hospital Alicante and Health and Biomedical Research Institute of Alicante, Alicante, Spain
| | - Jin Hong Lim
- Department of Surgery, Division of HBP Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Muhammad Haroon
- Department of HPB and Liver Transplant, Bahria International Hospital Orchard, Lahore, Pakistan
| | - Qian Lu
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Antonio Castaldi
- Department of Digestive Surgery and Liver Transplant Unit, University Côte d'Azur, CHU de Nice, Nice, France
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Beat Moeckli
- Division of Abdominal and Transplantation Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Teresa Abadía
- HPB Surgical Division, Miguel Servet University Hospital, Zaragoza, Spain
| | - Luis Ruffolo
- Department of HPB and Transplant Surgery, University of Rochester, Rochester, NY
| | - Josefina Dib Hasan
- Transplant Unit, Hospital Aleman de Buenos Aires, Buenos Aires, Argentina
| | - Francesca Ratti
- Division of Hepatobiliary Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | | | - Roeland F de Wilde
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Luca Aldrighetti
- Division of Hepatobiliary Surgery, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
| | - Lucas McCormack
- Transplant Unit, Hospital Aleman de Buenos Aires, Buenos Aires, Argentina
| | | | - Alejandro Serrablo
- HPB Surgical Division, Miguel Servet University Hospital, Zaragoza, Spain
| | - Christian Toso
- Division of Abdominal and Transplantation Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - Jean Gugenheim
- Department of Digestive Surgery and Liver Transplant Unit, University Côte d'Azur, CHU de Nice, Nice, France
| | - Jiahong Dong
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Faisal Hanif
- Department of HPB and Liver Transplant, Bahria International Hospital Orchard, Lahore, Pakistan
| | - Joon Seong Park
- Department of Surgery, Division of HBP Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - José M Ramia
- Department of Surgery, HPB and Transplant Unit, General Universitary Hospital Alicante and Health and Biomedical Research Institute of Alicante, Alicante, Spain
| | - Myron Schwartz
- Department of Surgery, Division of HPB Service, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Diego Ramisch
- General Surgery Department Liver, Pancreas and Intestinal Transplant Unit, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michelle L De Oliveira
- Swiss HPB and Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Semmelweis University of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Koo Jeong Kang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, School of Medicine, Keimyung University, Dongsan Hospital, Daegu, Republic of Korea
| | - Matteo Cescon
- Hepato-biliary surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Peter Lodge
- Department of Transplantation and Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Inne H M Borel Rinkes
- Department of Surgical Oncology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Hokkaido, Japan
| | - John-Edwin Thomson
- Hepatobiliary Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide & Hepatobiliary Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Su Kah Goh
- Hepatobiliary Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide & Hepatobiliary Unit, Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - William C Chapman
- Department of Surgery, Section of Abdominal Organ Transplant, Washington University School of Medicine, St Louis, MO
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Juan Pekolj
- Hepato-Pancreato-Biliary Surgery Section and Liver Transplant Unit, General Surgery Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jean-Marc Regimbeau
- Department of Oncology and Digestive Surgery, CHU Amiens-Picardie, Amiens, France
| | - Olivier Scatton
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière, Sorbonne Université, Centre de Recherche de Saint-Antoine, Paris, France
| | - Stéphanie Truant
- Department of Digestive Surgery and Transplantation, CHU Lille, University Lille, Lille, France
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - David Fuks
- Department of Hepatobiliary, Digestive and Endocrine Surgery, Cochin Hospital, Paris Cité University, Paris, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Hospital, Strasbourg University, Strasbourg, France
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Irinel Popescu
- Department of Surgery and Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, AP-HP Beaujon Hospital, University of Paris Cité, Clichy, France
| | - René Adam
- Paul Brousse Hospital, AP-HP, University Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Paul Brousse Hospital, AP-HP, University Paris-Saclay, Villejuif, France
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Karim Boudjema
- Department of Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Hugo Pinto-Marques
- Hepato-Biliary-Pancreatic and Transplantation Centre, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University Warsaw, Warsaw, Poland
| | - Henrik Petrowsky
- Swiss HPB and Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Tomoki Ebata
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Andreas Prachalias
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | | | - Pierre-Alain Clavien
- Swiss HPB and Transplant Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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20
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Sousa Da Silva RX, Bautista Borrego L, Lenggenhager D, Huwyler F, Binz J, Mancina L, Breuer E, Wernlé K, Hefti M, Mueller M, Cunningham L, De Oliveira ML, Petrowsky H, Weber A, Dutkowski P, Hoffmann W, Gupta A, Tibbitt MW, Humar B, Clavien PA. Defatting of Human Livers During Long-Term e x situ Normothermic Perfusion: Novel Strategy to Rescue Discarded Organs for Transplantation. Ann Surg 2023; 278:669-675. [PMID: 37497663 DOI: 10.1097/sla.0000000000006047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To develop a protocol for the defatting of steatotic liver grafts during long-term ex situ normothermic machine perfusion. BACKGROUND Despite the alarming increase in donor organ shortage, the highly prevalent fatty liver grafts are often discarded due to the risk of primary nonfunction. Effective strategies preventing such outcomes are currently lacking. An exciting new avenue is the introduction of ex situ normothermic machine perfusion (NMP), enabling a liver to remain fully functional for up to 2 weeks and providing a unique window of opportunity for defatting before transplantation. METHODS Over a 5-year period, 23 discarded liver grafts and 28 partial livers from our resection program were tested during ex situ normothermic machine perfusion. The steatosis degree was determined on serial biopsies by expert pathologists, and triglyceride contents were measured simultaneously. RESULTS Of 51 liver grafts, 20 were steatotic, with up to 85% macrovesicular steatosis, and were perfused for up to 12 days. Ten livers displayed marked (5 of which almost complete) loss of fat, while the other 10 did not respond to long-term perfusion. Successful defatting was related to prolonged perfusion, automated glucose control, circadian nutrition, and L-carnitine/fenofibrate supplementation. Pseudopeliotic steatosis and the associated activation of Kupffer/stellate cells were unexpected processes that might contribute to defatting. Synthetic and metabolic functions remained preserved for most grafts until perfusion ended. CONCLUSION Ex situ long-term perfusion effectively reduces steatosis while preserving organ viability and may in the future allow transplantation of primarily unusable high-risk grafts, significantly increasing the number of organs available for transplantation.
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Affiliation(s)
- Richard X Sousa Da Silva
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Daniela Lenggenhager
- Department of Pathology and Molecular Pathology, University Hospital Zurich and University Zurich, Zurich, Switzerland
| | - Florian Huwyler
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
- Department of Mechanical and Process Engineering, Macromolecular Engineering Laboratory, ETH Zurich
| | - Jonas Binz
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
- Department of Mechanical and Process Engineering, Macromolecular Engineering Laboratory, ETH Zurich
| | - Leandro Mancina
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Eva Breuer
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Kendra Wernlé
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Leslie Cunningham
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
- Department of Mechanical and Process Engineering, Macromolecular Engineering Laboratory, ETH Zurich
| | - Michelle L De Oliveira
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Achim Weber
- Department of Pathology and Molecular Pathology, University Hospital Zurich and University Zurich, Zurich, Switzerland
- Institute of Molecular Cancer Research, University Hospital Zurich and University Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Waldemar Hoffmann
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Anurag Gupta
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Mark W Tibbitt
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
- Department of Mechanical and Process Engineering, Macromolecular Engineering Laboratory, ETH Zurich
| | - Bostjan Humar
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB and Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
- Wyss Zurich Translational Center, ETH Zurich and University of Zurich, Zurich, Switzerland
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21
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Li Z, Rammohan A, Gunasekaran V, Hong S, Chen ICY, Kim J, Hervera Marquez KA, Hsu SC, Kirimker EO, Akamatsu N, Shaked O, Finotti M, Yeow M, Genedy L, Dutkowski P, Nadalin S, Boehnert MU, Polak WG, Bonney GK, Mathur A, Samstein B, Emond JC, Testa G, Olthoff KM, Rosen CB, Heimbach JK, Taner T, Wong TC, Lo CM, Hasegawa K, Balci D, Cattral M, Sapisochin G, Selzner N, Bin Jeng L, Broering D, Joh JW, Chen CL, Suk KS, Rela M, Clavien PA. Novel Benchmark for Adult-to-Adult Living-donor Liver Transplantation: Integrating Eastern and Western Experiences. Ann Surg 2023; 278:798-806. [PMID: 37477016 DOI: 10.1097/sla.0000000000006038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT). BACKGROUND LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. Although references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments. METHODS Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from 3 continents over 5 years (2016-2020), with a minimum follow-up of 1 year. Benchmark criteria included a Model for End-stage Liver Disease ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no intensive care unit admission. Benchmark cutoffs were derived from the 75th percentile of all centers' medians. RESULTS Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs, including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), nonanastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-liver transplantation (LT) (≤3.6%), at 1-year were below the deceased donor LT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and Comprehensive Complication Index (CCI ® ) (≤56) were above the deceased donor LT benchmarks, whereas mortality (≤9.1%) was comparable. The right hemiliver graft, compared with the left, was associated with a lower CCI ® score (34 vs 21, P < 0.001). Preservation of the middle hepatic vein with the right hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI ® score (21 vs 47, P < 0.001), graft loss (3.0% vs 6.5%, P = 0.002), and redo-LT rates (1.0% vs 2.5%, P = 0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes, such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%). CONCLUSIONS Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness, and centralization policy are, however, mandatory to achieve benchmark outcomes worldwide.
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Affiliation(s)
- Zhihao Li
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, TN, India
| | - Vasanthakumar Gunasekaran
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, TN, India
| | - Suyoung Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Itsuko Chih-Yi Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Kris Ann Hervera Marquez
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Shih Chao Hsu
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
| | | | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan
| | - Oren Shaked
- Division of Transplantation, University of Pennsylvania, Philadelphia, PA
| | - Michele Finotti
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Marcus Yeow
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore
| | - Lara Genedy
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Silvio Nadalin
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Markus U Boehnert
- Department of Surgery, Division of HPB and Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Glenn K Bonney
- Division of Hepatobiliary, Pancreatic Surgery and Liver Transplantation, University Surgical Cluster, National University Health System, Singapore
| | - Abhishek Mathur
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Benjamin Samstein
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Jean C Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Giuliano Testa
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Kim M Olthoff
- Division of Transplantation, University of Pennsylvania, Philadelphia, PA
| | - Charles B Rosen
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Julie K Heimbach
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Timucin Taner
- Department of Surgery, Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Tiffany Cl Wong
- Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Chung-Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Division and Hepato-Biliary-Pancreatic Surgery, University of Tokyo, Tokyo, Japan
| | - Deniz Balci
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Mark Cattral
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Long Bin Jeng
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan
| | - Dieter Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Chao-Long Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kyung-Suh Suk
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, TN, India
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
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22
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Kambakamba P, Schneider MA, Linecker M, Kirimker EO, Moeckli B, Graf R, Reiner CS, Nguyen-Kim TDL, Kologlu M, Karayalcin K, Clavien PA, Balci D, Petrowsky H. Early Postoperative Serum Phosphate Drop Predicts Sufficient Hypertrophy After Liver Surgery. Ann Surg 2023; 278:763-771. [PMID: 37465990 DOI: 10.1097/sla.0000000000006013] [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] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE The aim of this study was to assess the impact of postoperative hypophosphatemia on liver regeneration after major liver surgery in the scenario of Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) and living liver donation (LLD). BACKGROUND Hypophosphatemia has been described to reflect the metabolic demands of regenerating hepatocytes. Both ALPPS and LLD are characterized by an exceptionally strong liver regeneration and may be of particular interest in the context of posthepatectomy hypophosphatemia. METHODS Serum phosphate changes within the first 7 postoperative days after ALPPS (n=61) and LLD (n=54) were prospectively assessed and correlated with standardized volumetry after 1 week. In a translational approach, postoperative phosphate changes were investigated in mice and in vitro . RESULTS After ALPPS stage 1 and LLD, serum phosphate levels significantly dropped from a preoperative median of 1.08 mmol/L [interquartile range (IQR) 0.92-1.23] and 1.07 mmol/L (IQR 0.91-1.21) to a postoperative median nadir of 0.68 and 0.52 mmol/L, respectively. A pronounced phosphate drop correlated well with increased liver hypertrophy ( P <0.001). Patients with a low drop of phosphate showed a higher incidence of posthepatectomy liver failure after ALPPS (7% vs 31%, P =0.041). Like in humans, phosphate drop correlated significantly with degree of hypertrophy in murine ALPPS and hepatectomy models ( P <0.001). Blocking phosphate transporter (Slc20a1) inhibited cellular phosphate uptake and hepatocyte proliferation in vitro. CONCLUSION Phosphate drop after hepatectomy is a direct surrogate marker for liver hypertrophy. Perioperative implementation of serum phosphate analysis has the potential to detect patients with insufficient regenerative capacity at an early stage.
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Affiliation(s)
- Patryk Kambakamba
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
- Hepatobiliary Group, St. Vincents's University Hospital, Dublin, Ireland
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Marcel A Schneider
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Michael Linecker
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
- Department of Surgery and Transplantation, University Hospital Schleswig Holstein, Kiel, Germany
| | - Elvan Onur Kirimker
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Beat Moeckli
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Rolf Graf
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Cäcilia S Reiner
- Diagnostic and Interventional Radiology, University Hospital Zürich, Zürich, Switzerland
| | | | - Meltem Kologlu
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Kaan Karayalcin
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
| | - Deniz Balci
- Department of Surgery and Transplantation, Ankara University School of Medicine, Ankara, Turkey
- Department of Surgery and Solid Organ Transplantation, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zürich, Zürich, Switzerland
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23
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Chiche L, Yang HK, Abbassi F, Robles-Campos R, Stain SC, Ko CY, Neumayer LA, Pawlik TM, Barkun JS, Clavien PA. Quality and Outcome Assessment for Surgery. Ann Surg 2023; 278:647-654. [PMID: 37555327 DOI: 10.1097/sla.0000000000006077] [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] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
ABSTRACT This forum summarizes the proceedings of the joint European Surgical Association (ESA)/American Surgical Association (ASA) symposium on Quality and Outcome Assessment for Surgery that took place in Bordeaux, France, as part of the celebrations of the 30th anniversary of the ESA. Three presentations focused on a) the main messages from the Outcome4Medicine Consensus Conference, which took place in Zurich, Switzerland, in June 2022, b) the patient perspective, and c) benchmarking were hold by ESA members and discussed by ASA members in a symposium attended by members of both associations.
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Affiliation(s)
| | - Han-Kwang Yang
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | | | | | | | - Clifford Y Ko
- University of California at Los Angeles and the American College of Surgeons, Los Angeles, CA
| | - Leigh A Neumayer
- University of Florida, College of Medicine-Jacksonville, Jacksonville, FL
| | | | - Jeffrey S Barkun
- Department of Surgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
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24
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Kow AWC, Liu J, Patel MS, De Martin E, Reddy MS, Soejima Y, Syn N, Watt K, Xia Q, Saraf N, Kamel R, Nasralla D, McKenna G, Srinvasan P, Elsabbagh AM, Pamecha V, Palaniappan K, Mas V, Tokat Y, Asthana S, Cherukuru R, Egawa H, Lerut J, Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Emond J, Ascher N, Rammohan A, Bhangui P, Rela M, Kim DS, Ikegami T. Post Living Donor Liver Transplantation Small-for-size Syndrome: Definitions, Timelines, Biochemical, and Clinical Factors for Diagnosis: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2226-2237. [PMID: 37749812 DOI: 10.1097/tp.0000000000004770] [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] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND When a partial liver graft is unable to meet the demands of the recipient, a clinical phenomenon, small-for-size syndrome (SFSS), may ensue. Clear definition, diagnosis, and management are needed to optimize transplant outcomes. METHODS A Consensus Scientific committee (106 members from 21 countries) performed an extensive literature review on specific aspects of SFSS, recommendations underwent blinded review by an independent panel, and discussion/voting on the recommendations occurred at the Consensus Conference. RESULTS The ideal graft-to-recipient weight ratio of ≥0.8% (or graft volume standard liver volume ratio of ≥40%) is recommended. It is also recommended to measure portal pressure or portal blood flow during living donor liver transplantation and maintain a postreperfusion portal pressure of <15 mm Hg and/or portal blood flow of <250 mL/min/100 g graft weight to optimize outcomes. The typical time point to diagnose SFSS is the postoperative day 7 to facilitate treatment and intervention. An objective 3-grade stratification of severity for protocolized management of SFSS is proposed. CONCLUSIONS The proposed grading system based on clinical and biochemical factors will help clinicians in the early identification of patients at risk of developing SFSS and institute timely therapeutic measures. The validity of this newly created grading system should be evaluated in future prospective studies.
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Affiliation(s)
- Alfred Wei Chieh Kow
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore
- Liver Transplantation, National University Center for Organ Transplantation (NUCOT), National University Health System Singapore, Singapore
| | - Jiang Liu
- Department of Surgery, Hepato-pancreato-biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
- Department of Surgery, LKS Faculty of Medicine, HKU-Shenzhen Hospital, University of Hong Kong, Hong Kong/Special Administrative Region (SAR), China
| | - Madhukar S Patel
- Division of Surgical Transplantation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eleonora De Martin
- Department of Hepatology, APHP, Hospital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Yuji Soejima
- Department of Surgery, Shinshu University, Japan
| | - Nicholas Syn
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, National University of Singapore, Singapore
- Liver Transplantation, National University Center for Organ Transplantation (NUCOT), National University Health System Singapore, Singapore
| | - Kymberly Watt
- Division of Gastroenterology/Hepatology, Mayo Clinic, Rochester, MN
| | - Qiang Xia
- Department of Surgery, Division of Liver Transplantation, Renji Hospital, Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine, China
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-the Medicity, New Delhi, India
| | - Refaat Kamel
- Department of Surgery, Ain Shams University, Cairo, Egypt
| | - David Nasralla
- Department of HPB Surgery and Liver Transplantation, Royal Free London, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Greg McKenna
- Department of Surgery, Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Parthi Srinvasan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ahmed M Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Vinayendra Pamecha
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Kumar Palaniappan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Valeria Mas
- Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD
| | - Yaman Tokat
- International Liver Center, Acibadem Healthcare Hospitals, Turkey
| | - Sonal Asthana
- Department of Surgery, Integrated Liver Care Aster CMI Hospital, Bangalore, India
| | - Ramkiran Cherukuru
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Hiroto Egawa
- Hamamatsu Rosai Hospital, Hamamatsu, Shizuoka, Japan
| | - Jan Lerut
- Pôle de chirurgie expérimentale et transplantation, Université Catholique De Louvain, Louvain, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Hepatology and Liver Transplant Unit, Fundación Para La Investigación Del Hospital Universitario La Fe De La CCVV, IIS La Fe, Ciberehd, University of Valencia, Valencia, Spain
| | - Mark Cattral
- Department of Surgery, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Department of Surgery, Chang Gung Memorial Hospital Kaoshiung, Taiwan
| | - Samir Shah
- Institute of Liver Disease, HPB Surgery and Rransplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Department of HPB Surgery and Liver Transplantation, Beijing Friendship Hospital, Beijing, China
| | - Jean Emond
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Nancy Ascher
- Division of Transplant Surgery, University of California San Francisco, San Francisco, CA
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-the Medicity, New Delhi, India
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute, and Medical Centre, Chennai, Tamil Nadu, India
| | - Dong-Sik Kim
- Department of Surgery, Korea University Medical Center, Anam Hospital, Seoul, South Korea
| | - Toru Ikegami
- Department of Surgery, Centennial Hall Kyushu University School of Medicine, Kyushu, Japan
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25
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Kirchner VA, Shankar S, Victor DW, Tanaka T, Goldaracena N, Troisi RI, Olthoff KM, Kim JM, Pomfret EA, Heaton N, Polak WG, Shukla A, Mohanka R, Balci D, Ghobrial M, Gupta S, Maluf D, Fung JJ, Eguchi S, Roberts J, Eghtesad B, Selzner M, Prasad R, Kasahara M, Egawa H, Lerut J, Broering D, Berenguer M, Cattral MS, Clavien PA, Chen CL, Shah SR, Zhu ZJ, Ascher N, Ikegami T, Bhangui P, Rammohan A, Emond JC, Rela M. Management of Established Small-for-size Syndrome in Post Living Donor Liver Transplantation: Medical, Radiological, and Surgical Interventions: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2238-2246. [PMID: 37749813 DOI: 10.1097/tp.0000000000004771] [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] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Small-for-size syndrome (SFSS) following living donor liver transplantation is a complication that can lead to devastating outcomes such as prolonged poor graft function and possibly graft loss. Because of the concern about the syndrome, some transplants of mismatched grafts may not be performed. Portal hyperperfusion of a small graft and hyperdynamic splanchnic circulation are recognized as main pathogenic factors for the syndrome. Management of established SFSS is guided by the severity of the presentation with the initial focus on pharmacological therapy to modulate portal flow and provide supportive care to the patient with the goal of facilitating graft regeneration and recovery. When medical management fails or condition progresses with impending dysfunction or even liver failure, interventional radiology (IR) and/or surgical interventions to reduce portal overperfusion should be considered. Although most patients have good outcomes with medical, IR, and/or surgical management that allow graft regeneration, the risk of graft loss increases dramatically in the setting of bilirubin >10 mg/dL and INR>1.6 on postoperative day 7 or isolated bilirubin >20 mg/dL on postoperative day 14. Retransplantation should be considered based on the overall clinical situation and the above postoperative laboratory parameters. The following recommendations focus on medical and IR/surgical management of SFSS as well as considerations and timing of retransplantation when other therapies fail.
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Affiliation(s)
- Varvara A Kirchner
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sadhana Shankar
- The Liver Unit, King's College Hospital, London, United Kingdom
| | - David W Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - Nicolas Goldaracena
- Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | - Roberto I Troisi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Public Health, Federico II University Hospital, Naples, Italy
| | - Kim M Olthoff
- Department of Surgery, Division of Transplant Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, Department of Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nigel Heaton
- The Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Wojtek G Polak
- The Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Akash Shukla
- Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Ravi Mohanka
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospital, Mumbai, Maharashtra, India
| | - Deniz Balci
- Department of General Surgery and Organ Transplantation Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX
| | - Subash Gupta
- Max Centre for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India
| | - Daniel Maluf
- Program in Transplantation, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, MD
| | - John J Fung
- Department of Surgery, University of Chicago Medicine Transplant Institute, Chicago, IL
| | - Susumu Eguchi
- Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - John Roberts
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Bijan Eghtesad
- Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Markus Selzner
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Raj Prasad
- Division of Transplantation, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mureo Kasahara
- National Center for Child Health and Development, Tokyo, Japan
| | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research-Université catholique de Louvain, Brussels, Belgium
| | - Dieter Broering
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, CIBERehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe-Universidad de Valencia, Valencia, Spain
| | - Mark S Cattral
- HPB and Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Chao-Long Chen
- Liver Transplant Center and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Samir R Shah
- Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University; and Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Toru Ikegami
- Divsion of Hepatobiliary Surgery and Pancreas Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Ashwin Rammohan
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Jean C Emond
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
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26
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Hakeem AR, Mathew JS, Aunés CV, Mazzola A, Alconchel F, Yoon YI, Testa G, Selzner N, Sarin SK, Lee KW, Soin A, Pomposelli J, Menon K, Goyal N, Kota V, Abu-Gazala S, Rodriguez-Davalos M, Rajalingam R, Kapoor D, Durand F, Kamath P, Jothimani D, Sudhindran S, Vij V, Yoshizumi T, Egawa H, Lerut J, Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Preventing Small-for-size Syndrome in Living Donor Liver Transplantation: Guidelines From the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2203-2215. [PMID: 37635285 DOI: 10.1097/tp.0000000000004769] [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] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Small-for-size syndrome (SFSS) is a well-recognized complication following liver transplantation (LT), with up to 20% developing this following living donor LT (LDLT). Preventing SFSS involves consideration of factors before the surgical procedure, including donor and recipient selection, and factors during the surgical procedure, including adequate outflow reconstruction, graft portal inflow modulation, and management of portosystemic shunts. International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplant Society of India Consensus Conference was convened in January 2023 to develop recommendations for the prediction and management of SFSS in LDLT. The format of the conference was based on the Grading of Recommendations, Assessment, Development, and Evaluation system. International experts in this field were allocated to 4 working groups (diagnosis, prevention, anesthesia, and critical care considerations, and management of established SFSS). The working groups prepared evidence-based recommendations to answer-specific questions considering the currently available literature. The working group members, independent panel, and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and evidence-based recommendations provided by working group 2 that can be implemented to prevent SFSS in LDLT patients.
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Affiliation(s)
- Abdul Rahman Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Johns Shaji Mathew
- Department of GI, HPB & Multi-Organ Transplant, Rajagiri Hospitals, Kochi, India
| | - Carmen Vinaixa Aunés
- Hepatología y Trasplante Hepático, Servicio de Medicina Digestiva, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Alessandra Mazzola
- Sorbonne Université, Unité Médicale de Transplantation Hépatique, Hépato-gastroentérologie, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Felipe Alconchel
- Department of Surgery and Transplantation, Virgen de la Arrixaca University Hospital, Murcia, Spain
- Biomedical Research Institute of Murcia, IMIB-Pascual Parrilla, Murcia, Spain
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, Seoul, South Korea
| | - Giuliano Testa
- Department of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Nazia Selzner
- Multi-Organ Transplant Program, Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Arvinder Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - James Pomposelli
- University of Colorado School of Medicine, Division of Transplant Surgery, Department of Surgery, Aurora, CO
| | - Krishna Menon
- Institute of Liver Diseases, King's College Hospital, London, United Kingdom
| | - Neerav Goyal
- Liver Transplant and Hepato-Pancreatobiliary Surgery Unit (LTHPS), Indraprastha Apollo Hospital, New Delhi, India
| | - Venugopal Kota
- Department of HPB Surgery and Liver Transplantation, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana, India
| | - Samir Abu-Gazala
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Manuel Rodriguez-Davalos
- Liver Center, Primary Children's Hospital; Transplant Services, Intermountain Transplant Center, Primary Children's Hospital, Salt Lake City, UT
| | - Rajesh Rajalingam
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Dharmesh Kapoor
- Department of Hepatology and Liver Transplantation, Yashoda Hospitals, Secunderabad, Hyderabad, Telangana, India
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy University Paris Cité, Paris, France
| | - Patrick Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Surendran Sudhindran
- Department of Gastrointestinal Surgery and Solid Organ Transplantation, Amrita Institute of Medical Sciences, Kochi, India
| | - Vivek Vij
- Department of HPB Surgery and Liver Transplantation, Fortis Group of Hospitals, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), Université catholique Louvain (UCL), Brussels, Belgium
| | - Dieter Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Unit, Ciberehd, Instituto de Investigación Sanitaria La Fe, Hospital Universitario y Politécnico La Fe, Universidad Valencia, Valencia, Spain
| | - Mark Cattral
- Multi-Organ Transplant Program, Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Zürich, Switzerland
| | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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27
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Chadha R, Sakai T, Rajakumar A, Shingina A, Yoon U, Patel D, Spiro M, Bhangui P, Sun LY, Humar A, Bezinover D, Findlay J, Saigal S, Singh S, Yi NJ, Rodriguez-Davalos M, Kumar L, Kumaran V, Agarwal S, Berlakovich G, Egawa H, Lerut J, Clemens Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2216-2225. [PMID: 37749811 DOI: 10.1097/tp.0000000000004803] [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] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS). METHODS A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India. RESULTS It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion. CONCLUSIONS Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.
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Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Akila Rajakumar
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Alexandra Shingina
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Dhupal Patel
- Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Michael Spiro
- Department of Anaesthesia, Royal Devon and Exeter and Department of Anaesthesia and Intensive Care Medicine, The Royal Free Hospital, London, United Kingdom
| | - Pooja Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Li-Ying Sun
- Department of Critical Liver Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - James Findlay
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Sanjiv Saigal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | - Shweta Singh
- Department of Anesthesiology and Critical Care, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Nam-Joon Yi
- Division of HBP Surgery, Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Manuel Rodriguez-Davalos
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Lakshmi Kumar
- Department of Anesthesiology, Amrita Hospital, Kochi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Department of Surgery, VCU Medical Center, Richmond, VA
| | - Shaleen Agarwal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dieter Clemens Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital and IISLaFe and Ciberehd, Valencia, Spain
| | - Mark Cattral
- Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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Stahel PF, Weckbach S, Ziran N, Smith WR, Moore EE, Pape HC, Clavien PA. Patient Safety in Surgery - announcing the journal's first impact factor (3.7). Patient Saf Surg 2023; 17:22. [PMID: 37644592 PMCID: PMC10466761 DOI: 10.1186/s13037-023-00375-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
- Philip F. Stahel
- Mission Health, 50 Schenck Pkwy, Asheville, NC 28803 USA
- Department of Surgery, Brody School of Medicine, East Carolina University, E. 5th St., Greenville, NC 27858 USA
- Department of Specialty Medicine, College of Osteopathic Medicine, Rocky Vista University, Parker, CO USA
| | | | - Navid Ziran
- Department of Orthopedics, St. Joseph’s Medical Center, Phoenix, AZ USA
| | - Wade R. Smith
- Department of Orthopedics, Swedish Medical Center, Englewood, CO USA
| | - Ernest E. Moore
- Ernest E. Moore Shock Trauma Center, Denver Health, Denver, CO USA
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Heeb LV, Taskoparan B, Katsoulas A, Beffinger M, Clavien PA, Kobold S, Gupta A, Berg JV. HDR-based CRISPR/Cas9-mediated Knockout of PD-L1 in C57BL/6 Mice. Bio Protoc 2023; 13:e4724. [PMID: 37497456 PMCID: PMC10366997 DOI: 10.21769/bioprotoc.4724] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 07/28/2023] Open
Abstract
The immune-inhibitory molecule programmed cell death ligand 1 (PD-L1) has been shown to play a role in pathologies such as autoimmunity, infections, and cancer. The expression of PD-L1 not only on cancer cells but also on non-transformed host cells is known to be associated with cancer progression. Generation of PD-L1 deficiency in the murine system enables us to specifically study the role of PD-L1 in physiological processes and diseases. One of the most versatile and easy to use site-specific gene editing tools is the CRISPR/Cas9 system, which is based on an RNA-guided nuclease system. Similar to its predecessors, the Zinc finger nucleases or transcription activator-like effector nucleases (TALENs), CRISPR/Cas9 catalyzes double-strand DNA breaks, which can result in frameshift mutations due to random nucleotide insertions or deletions via non-homologous end joining (NHEJ). Furthermore, although less frequently, CRISPR/Cas9 can lead to insertion of defined sequences due to homology-directed repair (HDR) in the presence of a suitable template. Here, we describe a protocol for the knockout of PD-L1 in the murine C57BL/6 background using CRISPR/Cas9. Targeting of exon 3 coupled with the insertion of a HindIII restriction site leads to a premature stop codon and a loss-of-function phenotype. We describe the targeting strategy as well as founder screening, genotyping, and phenotyping. In comparison to NHEJ-based strategy, the presented approach results in a defined stop codon with comparable efficiency and timelines as NHEJ, generates convenient founder screening and genotyping options, and can be swiftly adapted to other targets.
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Affiliation(s)
- Laura V. Heeb
- Department of Visceral Surgery and Transplantation University Hospital Zurich, Zurich, Switzerland
| | - Betül Taskoparan
- Institute of Laboratory Animal Science, University of Zurich, Zurich, Switzerland
| | - Antonios Katsoulas
- Institute of Laboratory Animal Science, University of Zurich, Zurich, Switzerland
| | - Michal Beffinger
- Institute of Laboratory Animal Science, University of Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Visceral Surgery and Transplantation University Hospital Zurich, Zurich, Switzerland
| | - Sebastian Kobold
- Division of Clinical Pharmacology, Department of Medicine IV, Klinikum der Universität München, München, Germany
- German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Anurag Gupta
- Department of Visceral Surgery and Transplantation University Hospital Zurich, Zurich, Switzerland
| | - Johannes Vom Berg
- Institute of Laboratory Animal Science, University of Zurich, Zurich, Switzerland
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30
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Horisberger K, Rössler F, Oberkofler CE, Raptis D, Petrowsky H, Clavien PA. The value of intraoperative dynamic liver function test ICG in predicting postoperative complications in patients undergoing staged hepatectomy: a pilot study. Langenbecks Arch Surg 2023; 408:264. [PMID: 37403000 PMCID: PMC10319685 DOI: 10.1007/s00423-023-02983-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE To assess the predictive value of intraoperative indocyanine green (ICG) test in patients undergoing staged hepatectomy. METHODS We analyzed intraoperative ICG measurements of future liver remnant (FLR), preoperative ICG, volumetry, and hepatobiliary scintigraphy in 15 patients undergoing associated liver partition and portal vein ligation for staged hepatectomy (ALPPS). Main endpoints were the correlation of intraoperative ICG values to postoperative complications (Comprehensive Complication Index (CCI®)) at discharge and 90 days after surgery, and to postoperative liver function. RESULTS Median intraoperative R15 (ICG retention rate at 15 min) correlated significantly with CCI® at discharge (p = 0.05) and with CCI® at 90 days (p = 0.0036). Preoperative ICG, volumetry, and scintigraphy did not correlate to postoperative outcome. ROC curve analysis revealed a cutoff value of 11.4 for the intraoperative R15 to predict major complications (Clavien-Dindo ≥ III) with 100% sensitivity and 63% specificity. No patient with R15 ≤ 11 developed major complications. CONCLUSION This pilot study suggests that intraoperative ICG clearance determines the functional capacity of the future liver remnant more accurately than preoperative tests. This may further reduce the number of postoperative liver failures, even if it means intraoperative abortion of hepatectomy in individual cases.
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Affiliation(s)
- Karoline Horisberger
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Fabian Rössler
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- vivèvis AG - Visceral, Tumor and Robotic Surgery Clinic Hirslanden Zürich, Zurich, Switzerland
| | - Dimitri Raptis
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Henrik Petrowsky
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB Center Zurich, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Eshmuminov D, Aminjonov B, Palm RF, Malleo G, Schmocker RK, Abdallah R, Yoo C, Shaib WL, Schneider MA, Rangelova E, Choi YJ, Kim H, Rose JB, Patel S, Wilson GC, Maloney S, Timmermann L, Sahora K, Rössler F, Lopez-Lopez V, Boyer E, Maggino L, Malinka T, Park JY, Katz MHG, Prakash L, Ahmad SA, Helton S, Jang JY, Hoffe SE, Salvia R, Taieb J, He J, Clavien PA, Held U, Lehmann K. FOLFIRINOX or Gemcitabine-based Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Cancer: A Multi-institutional, Patient-Level, Meta-analysis and Systematic Review. Ann Surg Oncol 2023; 30:4417-4428. [PMID: 37020094 PMCID: PMC10250524 DOI: 10.1245/s10434-023-13353-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/01/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Pancreatic cancer often presents as locally advanced (LAPC) or borderline resectable (BRPC). Neoadjuvant systemic therapy is recommended as initial treatment. It is currently unclear what chemotherapy should be preferred for patients with BRPC or LAPC. METHODS We performed a systematic review and multi-institutional meta-analysis of patient-level data regarding the use of initial systemic therapy for BRPC and LAPC. Outcomes were reported separately for tumor entity and by chemotherapy regimen including FOLFIRINOX (FIO) or gemcitabine-based. RESULTS A total of 23 studies comprising 2930 patients were analyzed for overall survival (OS) calculated from the beginning of systemic treatment. OS for patients with BRPC was 22.0 months with FIO, 16.9 months with gemcitabine/nab-paclitaxel (Gem/nab), 21.6 months with gemcitabine/cisplatin or oxaliplatin or docetaxel or capecitabine (GemX), and 10 months with gemcitabine monotherapy (Gem-mono) (p < 0.0001). In patients with LAPC, OS also was higher with FIO (17.1 months) compared with Gem/nab (12.5 months), GemX (12.3 months), and Gem-mono (9.4 months; p < 0.0001). This difference was driven by the patients who did not undergo surgery, where FIO was superior to other regimens. The resection rates for patients with BRPC were 0.55 for gemcitabine-based chemotherapy and 0.53 with FIO. In patients with LAPC, resection rates were 0.19 with Gemcitabine and 0.28 with FIO. In resected patients, OS for patients with BRPC was 32.9 months with FIO and not different compared to Gem/nab, (28.6 months, p = 0.285), GemX (38.8 months, p = 0.1), or Gem-mono (23.1 months, p = 0.083). A similar trend was observed in resected patients converted from LAPC. CONCLUSIONS In patients with BRPC or LAPC, primary treatment with FOLFIRINOX compared with Gemcitabine-based chemotherapy appears to provide a survival benefit for patients that are ultimately unresectable. For patients that undergo surgical resection, outcomes are similar between GEM+ and FOLFIRINOX when delivered in the neoadjuvant setting.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Botirjon Aminjonov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Ryan K Schmocker
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Raëf Abdallah
- Hepatogastroenterology and Gastrointestinal Oncology Department, Hôpital Européen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel André Schneider
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Elena Rangelova
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology (CLINTEC) at Karolinska Institute, Stockholm, Sweden
- Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yoo Jin Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - J Bart Rose
- Division of Surgical Oncology, Pancreatobiliary Disease Center at UAB, The University of Alabama at Birmingham, Birmingham, USA
| | - Sameer Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah Maloney
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lea Timmermann
- Department of Surgery, Charité - Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Klaus Sahora
- Departments of Surgery and Comprehensive Cancer Center, University of Vienna, Medical University of Vienna, Vienna, Austria
| | - Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Laura Maggino
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Thomas Malinka
- Department of Surgery, Charité - Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Laura Prakash
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University, 28 Yongon-dong, Chongno-gu, Seoul, 110-744, Korea
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery. Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Julien Taieb
- Hepatogastroenterology and Gastrointestinal Oncology Department, Hôpital Européen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Jin He
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
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Eshmuminov D, Aminjonov B, Palm RF, Malleo G, Schmocker RK, Abdallah R, Yoo C, Shaib WL, Schneider MA, Rangelova E, Choi YJ, Kim H, Rose JB, Patel S, Wilson GC, Maloney S, Timmermann L, Sahora K, Rössler F, Lopez-Lopez V, Boyer E, Maggino L, Malinka T, Park JY, Katz MHG, Prakash L, Ahmad SA, Helton S, Jang JY, Hoffe SE, Salvia R, Taieb J, He J, Clavien PA, Held U, Lehmann K. ASO Visual Abstract: FOLFIRINOX or Gemcitabine Based Chemotherapy for Borderline Resectable and Locally Advanced Pancreatic Cancer: A Multi-Institutional, Patient-Level Meta-Analysis and Systematic Review. Ann Surg Oncol 2023; 30:4431-4432. [PMID: 37067744 DOI: 10.1245/s10434-023-13489-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Botirjon Aminjonov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Russell F Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Ryan K Schmocker
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Raëf Abdallah
- Hepatogastroenterology and gastrointestinal oncology department, hôpitalEuropéen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Walid L Shaib
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel André Schneider
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Elena Rangelova
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Department of Clinical Science, Intervention, and Technology (CLINTEC) at Karolinska Institute, Stockholm, Sweden
- Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Yoo Jin Choi
- Department of Surgery, Seoul National University, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University, Seoul National University College of Medicine, Seoul, Korea
| | - J Bart Rose
- Division of Surgical Oncology, Pancreatobiliary Disease Center at UAB, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sameer Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah Maloney
- Department of Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Lea Timmermann
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klaus Sahora
- Departments of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Víctor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, Murcia, Spain
| | - Emanuel Boyer
- University of South Florida School of Medicine, Tampa, FL, USA
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Thomas Malinka
- Department of Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Laura Prakash
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jin-Young Jang
- Department of Surgery, Seoul National University, Seoul National University College of Medicine, Seoul, Korea
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Julien Taieb
- Hepatogastroenterology and gastrointestinal oncology department, hôpitalEuropéen Georges-Pompidou, AGEO (Association des Gastro-Enterologues Oncologues), Université de Paris, SIRIC CARPEM, Paris, France
| | - Jin He
- Department of Surgery, The Division of Hepatobiliary and Pancreatic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
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Soin A, Lesurtel M, Bhangui P, Cocchi L, Bouattour M, Clavien PA. Are patients with hepatocellular carcinoma and portal vein tumour thrombosis candidates for liver transplantation? J Hepatol 2023; 78:1124-1129. [PMID: 37208099 DOI: 10.1016/j.jhep.2023.03.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 05/21/2023]
Abstract
In this debate, the authors consider whether patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis are candidates for liver transplantation (LT). The argument for LT in this context is based on the premise that, following successful downstaging treatment, LT confers a much greater clinical benefit in terms of survival outcomes than the available alternative (palliative systemic therapy). A major argument against relates to limitations in the quality of evidence for LT in this setting - in relation to study design, as well as heterogeneity in patient characteristics and downstaging protocols. While acknowledging the superior outcomes offered by LT for patients with portal vein tumour thrombosis, the counterargument is that expected survival in such patients is still below accepted thresholds for LT and, indeed, the levels achieved for other patients who receive transplants beyond the Milan criteria. Based on the available evidence, it seems too early for consensus guidelines to recommend such an approach, however, it is hoped that with higher quality evidence and standardised downstaging protocols, LT may soon be more widely indicated, including for this population with high unmet clinical need.
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Affiliation(s)
- Arvinder Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, India
| | - Mickaël Lesurtel
- Department of HPB Surgery & Liver Transplantation, APHP Beaujon Hospital, University of Paris Cité, 100, bd General Leclerc, 92110 Clichy, France
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Gurgaon, India
| | - Lorenzo Cocchi
- Department of HPB Surgery & Liver Transplantation, APHP Beaujon Hospital, University of Paris Cité, 100, bd General Leclerc, 92110 Clichy, France
| | - Mohamed Bouattour
- Department of Hepatology, APHP Beaujon Hospital, University of Paris Cité, 100, Bd General Leclerc, 92110 Clichy, France
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Eshmuminov D, Studer DJ, Lopez Lopez V, Schneider MA, Lerut J, Lo M, Sher L, Musholt TJ, Lozan O, Bouzakri N, Sposito C, Miceli R, Barat S, Morris D, Oehler H, Schreckenbach T, Husen P, Rosen CB, Gores GJ, Masui T, Cheung TT, Kim-Fuchs C, Perren A, Dutkowski P, Petrowsky H, Thiis-Evensen E, Line PD, Grat M, Partelli S, Falconi M, Tanno L, Robles-Campos R, Mazzaferro V, Clavien PA, Lehmann K. Controversy Over Liver Transplantation or Resection for Neuroendocrine Liver Metastasis: Tumor Biology Cuts the Deal. Ann Surg 2023; 277:e1063-e1071. [PMID: 35975918 DOI: 10.1097/sla.0000000000005663] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In patients with neuroendocrine liver metastasis (NELM), liver transplantation (LT) is an alternative to liver resection (LR), although the choice of therapy remains controversial. In this multicenter study, we aim to provide novel insight in this dispute. METHODS Following a systematic literature search, 15 large international centers were contacted to provide comprehensive data on their patients after LR or LT for NELM. Survival analyses were performed with the Kaplan-Meier method, while multivariable Cox regression served to identify factors influencing survival after either transplantation or resection. Inverse probability weighting and propensity score matching was used for analyses with balanced and equalized baseline characteristics. RESULTS Overall, 455 patients were analyzed, including 230 after LR and 225 after LT, with a median follow-up of 97 months [95% confidence interval (CI): 85-110 months]. Multivariable analysis revealed G3 grading as a negative prognostic factor for LR [hazard ratio (HR)=2.22, 95% CI: 1.04-4.77, P =0.040], while G2 grading (HR=2.52, 95% CI: 1.15-5.52, P =0.021) and LT outside Milan criteria (HR=2.40, 95% CI: 1.16-4.92, P =0.018) were negative prognostic factors in transplanted patients. Inverse probability-weighted multivariate analyses revealed a distinct survival benefit after LT. Matched patients presented a median overall survival (OS) of 197 months (95% CI: 143-not reached) and a 73% 5-year OS after LT, and 119 months (95% CI: 74-133 months) and a 52.8% 5-year OS after LR (HR=0.59, 95% CI: 0.3-0.9, P =0.022). However, the survival benefit after LT was lost if patients were transplanted outside Milan criteria. CONCLUSIONS This multicentric study in patients with NELM demonstrates a survival benefit of LT over LR. This benefit depends on adherence to selection criteria, in particular low-grade tumor biology and Milan criteria, and must be balanced against potential risks of LT.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Debora J Studer
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Victor Lopez Lopez
- Clinic and University Virgen de la Arrixaca Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Marcel A Schneider
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan Lerut
- Institute for Experimental and Clinical Research (IREC), UCLouvain, Brussels, Belgium, Université Catholique Louvain (UCL), Brussels, Belgium
| | - Mary Lo
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Linda Sher
- Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Thomas J Musholt
- Clinic of General, Visceral- and Transplantation Surgery, University Medical Center Mainz, Mainz, Germany
| | - Oana Lozan
- Clinic of General, Visceral- and Transplantation Surgery, University Medical Center Mainz, Mainz, Germany
| | - Nabila Bouzakri
- Clinic of General, Visceral- and Transplantation Surgery, University Medical Center Mainz, Mainz, Germany
| | - Carlo Sposito
- Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Rosalba Miceli
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS, Instituto Nazionale dei Tumori, Milan, Italy
| | - Shoma Barat
- South East Sydney Local Health District, Sydney, NSW, Australia
| | - David Morris
- South East Sydney Local Health District, Sydney, NSW, Australia
| | - Helga Oehler
- Department of General, Visceral, Transplantation and Thoracic Surgery, Goethe University Frankfurt, Frankfurt University Hospital, Frankfurt/Main, Germany
| | - Teresa Schreckenbach
- Department of General, Visceral, Transplantation and Thoracic Surgery, Goethe University Frankfurt, Frankfurt University Hospital, Frankfurt/Main, Germany
| | - Peri Husen
- Division of Transplant Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Charles B Rosen
- Division of Transplant Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | | | - Toshihiko Masui
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tan-To Cheung
- University of Hong Kong Queen Mary Hospital, Hong Kong, China
| | - Corina Kim-Fuchs
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Aurel Perren
- Inselspital Bern, Institute of Pathology, Bern, Switzerland
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | | | - Pål-Dag Line
- Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Michal Grat
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Stefano Partelli
- Pancreas Translational & Clinical Research Center, San Raffaele Hospital IRCCS, Vita-Salute University, Milan, Italy
| | - Massimo Falconi
- Pancreas Translational & Clinical Research Center, San Raffaele Hospital IRCCS, Vita-Salute University, Milan, Italy
| | - Lulu Tanno
- University Hospital Southampton, ENETS Center of Excellence, Southampton, UK
| | | | - Vincenzo Mazzaferro
- Università degli Studi di Milano, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Pierre-Alain Clavien
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Kuno Lehmann
- Department of Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
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35
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Görgec B, Benedetti Cacciaguerra A, Pawlik TM, Aldrighetti LA, Alseidi AA, Cillo U, Kokudo N, Geller DA, Wakabayashi G, Asbun HJ, Besselink MG, Cherqui D, Cheung TT, Clavien PA, Conrad C, D’Hondt M, Dagher I, Dervenis C, Devar J, Dixon E, Edwin B, Efanov M, Ettore GM, Ferrero A, Fondevilla C, Fuks D, Giuliante F, Han HS, Honda G, Imventarza O, Kooby DA, Lodge P, Lopez-Ben S, Machado MA, Marques HP, O’Rourke N, Pekolj J, Pinna AD, Portolani N, Primrose J, Rotellar F, Ruzzenente A, Schadde E, Siriwardena AK, Smadi S, Soubrane O, Tanabe KK, Teh CS, Torzilli G, Van Gulik TM, Vivarelli M, Wigmore SJ, Abu Hilal M. An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS). Ann Surg 2023; 277:821-828. [PMID: 35946822 PMCID: PMC10082050 DOI: 10.1097/sla.0000000000005668] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [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] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To reach global expert consensus on the definition of TOLS in minimally invasive and open liver resection among renowned international expert liver surgeons using a modified Delphi method. BACKGROUND Textbook outcome is a novel composite measure combining the most desirable postoperative outcomes into one single measure and representing the ideal postoperative course. Despite a recently developed international definition of Textbook Outcome in Liver Surgery (TOLS), a standardized and expert consensus-based definition is lacking. METHODS This international, consensus-based, qualitative study used a Delphi process to achieve consensus on the definition of TOLS. The survey comprised 6 surgical domains with a total of 26 questions on individual surgical outcome variables. The process included 4 rounds of online questionnaires. Consensus was achieved when a threshold of at least 80% agreement was reached. The results from the Delphi rounds were used to establish an international definition of TOLS. RESULTS In total, 44 expert liver surgeons from 22 countries and all 3 major international hepato-pancreato-biliary associations completed round 1. Forty-two (96%), 41 (98%), and 41 (98%) of the experts participated in round 2, 3, and 4, respectively. The TOLS definition derived from the consensus process included the absence of intraoperative grade ≥2 incidents, postoperative bile leakage grade B/C, postoperative liver failure grade B/C, 90-day major postoperative complications, 90-day readmission due to surgery-related major complications, 90-day/in-hospital mortality, and the presence of R0 resection margin. CONCLUSIONS This is the first study providing an international expert consensus-based definition of TOLS for minimally invasive and open liver resections by the use of a formal Delphi consensus approach. TOLS may be useful in assessing patient-level hospital performance and carrying out international comparisons between centers with different clinical practices to further improve patient outcomes.
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Affiliation(s)
- Burak Görgec
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrea Benedetti Cacciaguerra
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Adnan A. Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Norihiro Kokudo
- Department of Surgery, Hepatobiliary Pancreatic Surgery Division, National Center for Global Health and Medicine, Tokyo, Japan
| | - David A. Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Horacio J. Asbun
- Hepato-Biliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL
| | - Marc G. Besselink
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Paul Brousse University Hospital, Villejuif, France
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Pierre-Alain Clavien
- Department of surgery and transplantation, University Hospital Zurich, Switzerland
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart, France
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - John Devar
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Hepato-Pancreatico-Biliary Unit, Department of General Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery and The Intervention Center, Oslo University Hospital Oslo, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettore
- General Surgery and Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | | | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Felice Giuliante
- Chirurgia Epatobiliare, Università Cattolica del Sacro Cuore-IRCCS, Rome, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Oscar Imventarza
- Department of surgery, Hospital Argerich, Buenos Aires, Argentina
- Department of surgery, Hospital Garrahan, Buenos Aires, Argentina
| | - David A. Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA
| | - Peter Lodge
- HPB and Transplant Unit, St James’s University Hospital, Leeds, UK
| | - Santiago Lopez-Ben
- Department of General and Digestive Surgery, HPB Unit, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | | | - Hugo P. Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Nick O’Rourke
- Department of HPB Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Juan Pekolj
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Antonio D. Pinna
- Abdominal Transplant and HPB Center, Cleveland Clinic Florida, Weston, Florida
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Italy
| | - John Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Fernando Rotellar
- Department of General and Digestive Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | | | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
- Division of Transplant Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Ajith K. Siriwardena
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, UK
| | - Sameer Smadi
- Department of Surgery, King Hussein Medical Center, Amman, Jordan
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Kenneth K. Tanabe
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Catherine S.C. Teh
- Section of Hepatobiliary Pancreatic Surgery, Surgical Oncology, and Minimally Invasive Surgery, St Luke’s Medical Center, Quezon City, Philippines
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, Italy
| | - Thomas M. Van Gulik
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stephen J. Wigmore
- Department of Hepato-Pancreato-Biliary (HPB)/Transplant Surgery, The University of Edinburgh Clinical Surgery, Edinburgh, UK
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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36
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Guo Z, Zhao Q, Jia Z, Huang C, Wang D, Ju W, Zhang J, Yang L, Huang S, Chen M, Zhu X, Hu A, Ma Y, Wu L, Chen Y, Han M, Tang Y, Wang G, Wang L, Li L, Xiong W, Zhang Z, Shen Y, Tang Z, Zhu C, Chen X, Hu X, Guo Y, Chen H, Ma Y, Zhang T, Huang S, Zeng P, Lai S, Wang T, Chen Z, Gong J, Yu J, Sun C, Li C, Tan H, Liu Y, Dong Y, Sun C, Liao B, Ren J, Zhou Z, Andrea S, Björn N, Cai C, Gong F, Rong J, Huang W, Guan X, Clavien PA, Stefan TG, Huang J, He X. A randomized-controlled trial of ischemia-free liver transplantation for end-stage liver disease. J Hepatol 2023:S0168-8278(23)00233-7. [PMID: 37086919 DOI: 10.1016/j.jhep.2023.04.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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: 01/22/2023] [Revised: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND & AIMS Ischemia-reperfusion injury (IRI) has thus far been considered as an inevitable component of organ transplantation, compromising outcomes, and limiting organ availability. Ischemia-free organ transplantation is a novel approach designed to avoid IRI, with the potential to improve outcomes. METHODS In this randomized, controlled clinical trial, recipients of livers from donors after brain death were randomly assigned to receive either an ischemia-free or a 'conventional' transplant. Primary end point was the incidence of early allograft dysfunction. Secondary end points included complications related to graft IRI. RESULTS 65 out of 68 randomized patients underwent transplants and were included in the analysis. 32 patients received ischemia-free liver transplantation (IFLT), and 33 received conventional liver transplantation (CLT). Early allograft dysfunction occurred in 2 (6%) randomized to IFLT and in 8 (24%) randomized to CLT (difference, -18%; 95% CI, -35% to -1%; P=.044). Post-reperfusion syndrome occurred in 3 (9%) randomized to IFLT and in 21 (64%) randomized to CLT (difference, -54%; 95% CI, -74% to -35%; P < .001). Non-anastomotic biliary strictures diagnosed with protocol magnetic resonance cholangiopancreatography at 12 months were observed in 2 recipients (8%) randomized to IFLT and in 9 recipients (36%) randomized to CLT (difference, -28%; 95% CI, -50% to -7%; P = .014). The comprehensive complication index at one year after transplantation was 30.48 (95% CI, 23.25-37.71) in the IFLT group vs 42.14 (95% CI, 35.01-49.26) in the CLT group (difference, -11.66; 95% CI, -21.81 to -1.51; P = .025). CONCLUSIONS Among patients with end-stage liver disease, IFLT, compared with conventional approach, significantly reduced complications related to ischemia reperfusion injury. CLINICAL TRIAL REGISTRATION Chictr.org. ChiCTR1900021158 IMPACT AND IMPLICATIONS: Ischemia reperfusion injury has thus far been considered as an inevitable event in organ transplantation, compromising outcomes and limiting organ availability. Ischemia-free liver transplantation is a novel approach of transplanting donor livers without interruption of blood supply. We showed that in patients with end-stage liver disease, ischemia-free liver transplantation, compared with conventional approach led to reduced complications related to ischemia reperfusion injury in this randomized trial. This new approach is expected to change the current practice in organ transplantation improving transplant outcomes, increasing organ utilization, while providing a clinical model to delineate the impact of organ injury on alloimmunity.
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Affiliation(s)
- Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China; NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University).
| | - Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Zehua Jia
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Changjun Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Jian Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510080, China
| | - Lu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Shanzhou Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Anbin Hu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Yi Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Yinghua Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Yunhua Tang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Guodong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Linhe Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Lifen Li
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhiheng Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Yuekun Shen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhaoxia Tang
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Caihui Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Xiaoxiang Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoguang Hu
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yiwen Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Honghui Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Yihao Ma
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Tao Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Shunwei Huang
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Ping Zeng
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Simei Lai
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Tielong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Zhitao Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Jinlong Gong
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Jia Yu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Canhui Sun
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Chang Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Haiyi Tan
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yao Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Yuqi Dong
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Chengjun Sun
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
| | - Bing Liao
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jun Ren
- Department of Blood Transfusion, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhenhai Zhou
- Department of Blood Transfusion, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Schlegel Andrea
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan 20100, Italy
| | - Nashan Björn
- Organ Transplantation Center, The First Affiliated Hospital of the University of Science and Technology of China, Hefei 230001, China
| | - Changjie Cai
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Fengqiu Gong
- Operating Room and Anesthesia Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jian Rong
- Department of Cardiopulmonary Bypass, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiangdong Guan
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Zurich 8044, Switzerland
| | - Tullius G Stefan
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, MA, USA
| | - Jiefu Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China.
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Sun K, Bochicchio D, Clavien PA, Dutkowski P, Humar B. Surgical Approach, Challenges, and Resolutions for Uterus Transplantation in Rats. J Vis Exp 2023. [PMID: 37125791 DOI: 10.3791/64757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Uterine transplantation (UTx) is a new approach for treating women with absolute uterine factor infertility (AUFI). An estimated 3%-5% of women suffer from AUFI. These women were deprived of the option to have children until the advent of UTx. The clinical application of UTx was driven by experimental studies in animals, and the first successful UTx was achieved in rats. Given their physiological, immunological, genetic, and reproductive characteristics, rats are a suitable model system for such transplants. In particular, their short gestation period is a clear advantage, as the usual endpoint of experimental UTx is successful pregnancy with live birth. The biggest challenge for rat models remains the small anatomy, which requires advanced microsurgical skills and experience. Although UTx has led to pregnancy in the clinic, the procedure is not established and requires continuous experimental optimization. Here, a detailed protocol is presented, including essential troubleshooting for rat UTx, which is expected to make the entire procedure easier to grasp for those without experience in this type of microsurgery.
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Affiliation(s)
- Keyue Sun
- Swiss HPB Laboratory, Department of Visceral & Transplant Surgery, University Hospital Zürich
| | - Daniela Bochicchio
- Swiss HPB Laboratory, Department of Visceral & Transplant Surgery, University Hospital Zürich
| | - Pierre-Alain Clavien
- Swiss HPB Laboratory, Department of Visceral & Transplant Surgery, University Hospital Zürich
| | - Philipp Dutkowski
- Swiss HPB Laboratory, Department of Visceral & Transplant Surgery, University Hospital Zürich
| | - Bostjan Humar
- Swiss HPB Laboratory, Department of Visceral & Transplant Surgery, University Hospital Zürich;
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38
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Laurinavicius P, Müller PC, Ghafoor S, Jonas JP, Oberkofler CE, Clavien PA, Petrowsky H. Right-sided ALPPS after preoperative emergency embolization of the right hepatic artery: case report with a favorable anatomy. J Surg Case Rep 2023; 2023:rjad180. [PMID: 37064062 PMCID: PMC10101734 DOI: 10.1093/jscr/rjad180] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/14/2023] [Indexed: 04/18/2023] Open
Abstract
In patients with extensive colorectal liver metastases (CRLM) and insufficient future liver remnant (FLR) a faster and more effective FLR augmentation than portal vein embolization is the associating liver partition and portal vein ligation in staged hepatectomy (ALPPS). Before ALPPS, the presence of arterial blood supply to the subsequently resected hemiliver must be ensured. We present a case with neoadjuvant-treated CRLM and insufficient FLR who developed a large intrahepatic hematoma after liver biopsy. For continuous bleeding, the right hepatic artery was embolized. Fortunately, an accessory right hepatic artery arising from the superior mesenteric artery was present, which enabled the ALPPS procedure to be performed. After ALPPS, the patient did not experience liver failure. The case exemplifies that preoperative evaluation of the vascular supply of the liver is of paramount importance in advanced hepatic surgery such as ALPPS.
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Affiliation(s)
- Petras Laurinavicius
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Philip C Müller
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Soleen Ghafoor
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Jan Philipp Jonas
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Petrowsky
- Correspondence address. Department of Surgery and Transplantation, Swiss HPB and Transplantation Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. Tel: +41 (0)44-255-23-00; Fax: +41 (0)44-255-44-49; E-mail:
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39
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Schlegel A, Mueller M, Muller X, Eden J, Panconesi R, von Felten S, Steigmiller K, Sousa Da Silva RX, de Rougemont O, Mabrut JY, Lesurtel M, Cerisuelo MC, Heaton ND, Allard MA, Adam R, Monbaliu D, Jochmans I, Haring MPD, Porte RJ, Parente A, Muiesan P, Kron P, Attia M, Kollmann D, Berlakovich G, Rogiers X, Petterson K, Kranich AL, Amberg S, Müllhaupt B, Clavien PA, Dutkowski P. A multicenter randomized-controlled trial of hypothermic oxygenated perfusion (HOPE) for human liver grafts before transplantation. J Hepatol 2023; 78:783-793. [PMID: 36681160 DOI: 10.1016/j.jhep.2022.12.030] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND & AIMS Machine perfusion is a novel method intended to optimize livers before transplantation. However, its effect on morbidity within a 1-year period after transplantation has remained unclear. METHODS In this multicenter controlled trial, we randomly assigned livers donated after brain death (DBD) for liver transplantation (LT). Livers were either conventionally cold stored (control group), or cold stored and subsequently treated by 1-2 h hypothermic oxygenated perfusion (HOPE) before implantation (HOPE group). The primary endpoint was the occurrence of at least one post-transplant complication per patient, graded by the Clavien score of ≥III, within 1-year after LT. The comprehensive complication index (CCI), laboratory parameters, as well as duration of hospital and intensive care unit stay, graft survival, patient survival, and biliary complications served as secondary endpoints. RESULTS Between April 2015 and August 2019, we randomized 177 livers, resulting in 170 liver transplantations (85 in the HOPE group and 85 in the control group). The number of patients with at least one Clavien ≥III complication was 46/85 (54.1%) in the control group and 44/85 (51.8%) in the HOPE group (odds ratio 0.91; 95% CI 0.50-1.66; p = 0.76). Secondary endpoints were also not significantly different between groups. A post hoc analysis revealed that liver-related Clavien ≥IIIb complications occurred less frequently in the HOPE group compared to the control group (risk ratio 0.26; 95% CI 0.07-0.77; p = 0.027). Likewise, graft failure due to liver-related complications did not occur in the HOPE group, but occurred in 7% (6 of 85) of the control group (log-rank test, p = 0.004, Gray test, p = 0.015). CONCLUSIONS HOPE after cold storage of DBD livers resulted in similar proportions of patients with at least one Clavien ≥III complication compared to controls. Exploratory findings suggest that HOPE decreases the risk of severe liver graft-related events. IMPACT AND IMPLICATIONS This randomized controlled phase III trial is the first to investigate the impact of hypothermic oxygenated perfusion (HOPE) on cumulative complications within a 12-month period after liver transplantation. Compared to conventional cold storage, HOPE did not have a significant effect on the number of patients with at least one Clavien ≥III complication. However, we believe that HOPE may have a beneficial effect on the quantity of complications per patient, based on its application leading to fewer severe liver graft-related complications, and to a lower risk of liver-related graft loss. The HOPE approach can be applied easily after organ transport during recipient hepatectomy. This appears fundamental for wide acceptance since concurring perfusion technologies need either perfusion at donor sites or continuous perfusion during organ transport, which are much costlier and more laborious. We conclude therefore that the post hoc findings of this trial should be further validated in future studies.
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Affiliation(s)
- Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland; The Liver Unit, Queen Elizabeth University Hospital Birmingham, UK
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland; Department of Surgery and Liver Transplantation, Croix Rousse University Hospital, Hepatology Institute of Lyon, INSERM 1052, Lyon, France
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Rebecca Panconesi
- General Surgery 2U-Liver Transplant Unit, Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Italy
| | - Stefanie von Felten
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Klaus Steigmiller
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Richard X Sousa Da Silva
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Jean-Yves Mabrut
- Department of Surgery and Liver Transplantation, Croix Rousse University Hospital, Hepatology Institute of Lyon, INSERM 1052, Lyon, France
| | - Mickaël Lesurtel
- Department of Surgery and Liver Transplantation, Croix Rousse University Hospital, Hepatology Institute of Lyon, INSERM 1052, Lyon, France
| | | | - Nigel D Heaton
- Liver Transplant Surgery, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Marc Antoine Allard
- AP-HP Hôpital Paul Brousse, Research Unit "Chronotherapy, Cancers and Transplantation", Univ Paris-Saclay, Villejuif, France
| | - Rene Adam
- AP-HP Hôpital Paul Brousse, Research Unit "Chronotherapy, Cancers and Transplantation", Univ Paris-Saclay, Villejuif, France
| | - Diethard Monbaliu
- Department of Microbiology, Immunology and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Belgium; Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Microbiology, Immunology and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Belgium; Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Martijn P D Haring
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, UK; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, 20122, Italy
| | - Philipp Kron
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland; Department of Transplantation and Hepatobiliary Surgery, Leeds Teaching Hospitals Trust, UK
| | - Magdy Attia
- Department of Transplantation and Hepatobiliary Surgery, Leeds Teaching Hospitals Trust, UK
| | - Dagmar Kollmann
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Gabriela Berlakovich
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Xavier Rogiers
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Karin Petterson
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Anne L Kranich
- ODC BV, Keizersgracht 62-64, 1015, Amsterdam EBC, the Netherlands
| | - Stefanie Amberg
- ODC BV, Keizersgracht 62-64, 1015, Amsterdam EBC, the Netherlands
| | - Beat Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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Clavien PA, Ure BM, Madadi-Sanjani O. Discussing Complications after Surgery Consists of Multiple Dimensions. Eur J Pediatr Surg 2023; 33:103-104. [PMID: 36931292 DOI: 10.1055/s-0043-1764454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Affiliation(s)
- Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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41
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Domenghino A, Walbert C, Birrer DL, Puhan MA, Clavien PA. Consensus recommendations on how to assess the quality of surgical interventions. Nat Med 2023; 29:811-822. [PMID: 37069361 DOI: 10.1038/s41591-023-02237-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/26/2023] [Indexed: 04/19/2023]
Abstract
Postoperative complications represent a major public health burden worldwide. Without standardized, clinically relevant and universally applied endpoints, the evaluation of surgical interventions remains ill-defined and inconsistent, opening the door for biased interpretations and hampering patient-centered health care delivery. We conducted a Jury-based consensus conference incorporating the perspectives of different stakeholders, who based their recommendations on the work of nine panels of experts. The recommendations cover the selection of postoperative outcomes from the perspective of patients and other stakeholders, comparison and interpretation of outcomes, consideration of cultural and demographic factors, and strategies to deal with unwarranted outcomes. With the recommendations developed exclusively by the Jury, we provide a framework for surgical outcome assessment and quality improvement after medical interventions, that integrates the main stakeholders' perspectives.
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Affiliation(s)
- Anja Domenghino
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | | | - Dominique Lisa Birrer
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland.
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Domenghino A, Staiger RD, Abbassi F, Serra-Burriel M, Leutwyler K, Aeby G, Turina M, Gutschow CA, Clavien PA, Puhan MA. Delivering Safe Surgical Care While Simultaneously Caring for Patients With COVID-19; Assessment of Patient Selection, Volume and Outcomes in a Tertiary Care Hospital. Int J Public Health 2023; 68:1605640. [PMID: 37051309 PMCID: PMC10083247 DOI: 10.3389/ijph.2023.1605640] [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] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives: Compare patient selection and postoperative outcomes after surgical treatment for gastrointestinal disorders before and during the SARS-CoV-2 pandemic.Methods: We assessed gastrointestinal surgeries conducted at a tertiary center from 2017–2021 for differences in patient populations and procedures before (up to February 2020) and during the pandemic (March 2020 to December 2021). We analyzed mortality, Intensive Care Unit (ICU) length of stay, admission to ICU and postoperative complications for complex procedures using descriptive statistics and regression models.Results: 7309 procedures were analyzed, showing a caseload reduction in March and October 2020, but no statistical evidence for fewer overall procedures overall. Population characteristics differed with lower Body Mass Indices in 2020 and 2021, more patients smoking and with diabetes treated in 2020. There was no increased mortality, ICU length of stay and in 1,144 complex procedures assessed low overall morbidity at 90 days postoperative.Conclusion: Delivering surgical care while treating patients for COVID-19 in the same hospital was safe. Healthcare officials should consider continuing surgical care during future health crises as consequences of limiting surgical treatment for gastrointestinal disorders may be fatal for patients.
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Affiliation(s)
- Anja Domenghino
- Department of Surgery and Transplantation, University Hospital Zürich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zürich, Switzerland
| | - Roxane Diane Staiger
- Department of Surgery and Transplantation, University Hospital Zürich, Zurich, Switzerland
| | - Fariba Abbassi
- Department of Surgery and Transplantation, University Hospital Zürich, Zurich, Switzerland
| | - Miquel Serra-Burriel
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zürich, Switzerland
| | | | - Guillaume Aeby
- Department of Surgery and Transplantation, University Hospital Zürich, Zurich, Switzerland
| | - Matthias Turina
- Department of Surgery and Transplantation, University Hospital Zürich, Zurich, Switzerland
| | | | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zürich, Zurich, Switzerland
| | - Milo Alan Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zürich, Switzerland
- *Correspondence: Milo Alan Puhan,
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Balci D, Nadalin S, Mehrabi A, Alikhanov R, Fernandes ESM, Di Benedetto F, Hernandez-Alejandro R, Björnsson B, Efanov M, Capobianco I, Clavien PA, Kirimker EO, Petrowsky H. Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes. Surgery 2023; 173:1398-1404. [PMID: 36959071 DOI: 10.1016/j.surg.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes. METHODS This proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes. RESULTS In total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155-460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6-60 days). Post-stage 1 and post-stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node-negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%. CONCLUSION This study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.
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Affiliation(s)
- Deniz Balci
- Department of Surgery, Bahcesehir University School of Medicine, Istanbul, Turkey.
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., Russia
| | - Eduardo S M Fernandes
- Department of General Surgery and Transplantation, Hospital Adventista Silvestre, and Department of Surgery, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Brazil
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | | | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., Russia
| | - Ivan Capobianco
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Germany
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Switzerland
| | | | - Henrik Petrowsky
- Department of Surgery and Transplantation, Swiss Hepatopancreaticobiliary and Transplant Center Zürich, University Hospital Zürich, Switzerland
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44
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Madadi-Sanjani O, Kuebler JF, Brendel J, Wiesner S, Mutanen A, Eaton S, Domenghino A, Clavien PA, Ure BM. Implementation and validation of a novel instrument for the grading of unexpected events in paediatric surgery: Clavien-Madadi classification. Br J Surg 2023; 110:576-583. [PMID: 36848201 PMCID: PMC10364500 DOI: 10.1093/bjs/znad034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/03/2023] [Accepted: 01/22/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Inconsistent definitions of complications and unexpected events have limited accurate analysis of surgical outcomes. Perioperative outcome classifications currently used for adult patients have limitations when used for children. METHODS A multidisciplinary group of experts modified the Clavien-Dindo classification to increase its utility and accuracy in paediatric surgery cohorts. Organizational and management errors were considered in the novel Clavien-Madadi classification, which focuses on procedural invasiveness rather than anaesthetic management. Unexpected events were prospectively documented in a paediatric surgery cohort. Results of the Clavien-Dindo and Clavien-Madadi classifications were compared and correlated with procedure complexity. RESULTS Unexpected events were prospectively documented in a cohort of 17 502 children undergoing surgery between 2017 and 2021. The results of both classifications were highly correlated (ρ = 0.95), although the novel Clavien-Madadi classification identified 449 additional events (organizational and management errors) over the Clavien-Dindo classification, increasing the total number of events by 38 per cent (1605 versus 1158 events). The results of the novel system correlated significantly with the complexity of procedures in children (ρ = 0.756). Furthermore, grading of events > grade III according to the Clavien-Madadi classification showed a higher correlation with procedure complexity (ρ = 0.658) than the Clavien-Dindo classification (ρ = 0.198). CONCLUSION The Clavien-Madadi classification is a tool for the detection of surgical and non-medical errors in paediatric surgery populations. Further validation in paediatric surgery populations is required before widespread use.
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Affiliation(s)
- Omid Madadi-Sanjani
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.,European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA)
| | - Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.,European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA)
| | - Julia Brendel
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.,European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA)
| | - Soeren Wiesner
- Institute of Biostatistics, Hannover Medical School, Hannover, Germany
| | - Annika Mutanen
- European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA).,Department of Pediatric Surgery, New Children´s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Simon Eaton
- European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA).,Stem Cells and Regenerative Medicine Section, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Anja Domenghino
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Benno M Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.,European Reference Network for Rare Inherited and Congenital Anomalies (ERNICA)
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Abou Khouzam R, Lehn JM, Mayr H, Clavien PA, Wallace MB, Ducreux M, Limani P, Chouaib S. Hypoxia, a Targetable Culprit to Counter Pancreatic Cancer Resistance to Therapy. Cancers (Basel) 2023; 15:cancers15041235. [PMID: 36831579 PMCID: PMC9953896 DOI: 10.3390/cancers15041235] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/17/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer, and it is a disease of dismal prognosis. While immunotherapy has revolutionized the treatment of various solid tumors, it has achieved little success in PDAC. Hypoxia within the stroma-rich tumor microenvironment is associated with resistance to therapies and promotes angiogenesis, giving rise to a chaotic and leaky vasculature that is inefficient at shuttling oxygen and nutrients. Hypoxia and its downstream effectors have been implicated in immune resistance and could be contributing to the lack of response to immunotherapy experienced by patients with PDAC. Paradoxically, increasing evidence has shown hypoxia to augment genomic instability and mutagenesis in cancer, suggesting that hypoxic tumor cells could have increased production of neoantigens that can potentially enable their clearance by cytotoxic immune cells. Strategies aimed at relieving this condition have been on the rise, and one such approach opts for normalizing the tumor vasculature to reverse hypoxia and its downstream support of tumor pathogenesis. An important consideration for the successful implementation of such strategies in the clinic is that not all PDACs are equally hypoxic, therefore hypoxia-detection approaches should be integrated to enable optimal patient selection for achieving improved patient outcomes.
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Affiliation(s)
- Raefa Abou Khouzam
- Thumbay Research Institute for Precision Medicine, Gulf Medical University, Ajman P.O. Box 4184, United Arab Emirates
| | - Jean-Marie Lehn
- Institut de Science et d’Ingénierie Supramoléculaires (ISIS), Université de Strasbourg, 8 Allée Gaspard Monge, F-67000 Strasbourg, France
| | - Hemma Mayr
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
- Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
- Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Michael Bradley Wallace
- Gastroenterology, Mayo Clinic, Jacksonville, FL 32224, USA
- Division of Gastroenterology and Hepatology, Sheikh Shakhbout Medical City, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Michel Ducreux
- Department of Cancer Medicine, Gustave Roussy Cancer Institute, F-94805 Villejuif, France
| | - Perparim Limani
- Swiss Hepato-Pancreato-Biliary (HPB) and Transplantation Center, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
- Department of Surgery & Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
- Correspondence: (P.L.); (S.C.); Tel.: +41-78-859-68-07 (P.L.); +33-(0)1-42-11-45-47 (S.C.)
| | - Salem Chouaib
- Thumbay Research Institute for Precision Medicine, Gulf Medical University, Ajman P.O. Box 4184, United Arab Emirates
- INSERM UMR 1186, Integrative Tumor Immunology and Immunotherapy, Gustave Roussy, Faculty of Medicine, University Paris-Saclay, F-94805 Villejuif, France
- Correspondence: (P.L.); (S.C.); Tel.: +41-78-859-68-07 (P.L.); +33-(0)1-42-11-45-47 (S.C.)
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Birrer DL, Kachaylo E, Breuer E, Linecker M, Kron P, Ungethüm U, Hagedorn C, Steiner R, Kälin C, Borrego LB, Dufour JF, Foti M, Hornemann T, Clavien PA, Humar B. Normalization of lipid oxidation defects arising from hypoxia early posthepatectomy prevents liver failure in mouse. Am J Transplant 2023; 23:190-201. [PMID: 36804129 DOI: 10.1016/j.ajt.2022.10.003] [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: 04/25/2022] [Revised: 10/10/2022] [Accepted: 10/23/2022] [Indexed: 01/13/2023]
Abstract
Surgical liver failure (SLF) develops when a marginal amount of hepatic mass is left after surgery, such as following excessive resection. SLF is the commonest cause of death due to liver surgery; however, its etiology remains obscure. Using mouse models of standard hepatectomy (sHx) (68%, resulting in full regeneration) or extended hepatectomy (eHx) (86%/91%, causing SLF), we explored the causes of early SLF related to portal hyperafflux. Assessing the levels of HIF2A with or without oxygenating agent inositol trispyrophosphate (ITPP) indicated hypoxia early after eHx. Subsequently, lipid oxidation (PPARA/PGC1α) was downregulated and associated with persisting steatosis. Mild oxidation with low-dose ITPP reduced the levels of HIF2A, restored downstream PPARA/PGC1α expression along with lipid oxidation activities (LOAs), and normalized steatosis and other metabolic or regenerative SLF deficiencies. Promotion of LOA with L-carnitine likewise normalized the SLF phenotype, and both ITPP and L-carnitine markedly raised survival in lethal SLF. In patients who underwent hepatectomy, pronounced increases in serum carnitine levels (reflecting LOA) were associated with better recovery. Lipid oxidation thus provides a link between the hyperafflux of O2-poor portal blood, the metabolic/regenerative deficits, and the increased mortality typifying SLF. Stimulation of lipid oxidation-the prime regenerative energy source-particularly through L-carnitine may offer a safe and feasible way to reduce SLF risks in the clinic.
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Affiliation(s)
- Dominique Lisa Birrer
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Ekaterina Kachaylo
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Eva Breuer
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Michael Linecker
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Philipp Kron
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Udo Ungethüm
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Catherine Hagedorn
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Regula Steiner
- Institute for Clinical Chemistry, University Hospital Zürich, Zürich, Switzerland
| | - Carola Kälin
- Institute for Clinical Chemistry, University Hospital Zürich, Zürich, Switzerland
| | - Lucia Bautista Borrego
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Jean-Francois Dufour
- University Clinic for Visceral Surgery and Medicine and Hepatology, Department of BioMedical Research, University of Berne, Berne, Switzerland
| | - Michelangelo Foti
- Department of Cell Physiology and Metabolism, University of Geneva, Geneva, Switzerland
| | - Thorsten Hornemann
- Institute for Clinical Chemistry, University Hospital Zürich, Zürich, Switzerland
| | - Pierre-Alain Clavien
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Bostjan Humar
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Zürich, Switzerland.
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Schuler MJ, Becker D, Mueller M, Bautista Borrego L, Mancina L, Huwyler F, Binz J, Hagedorn C, Schär B, Gygax E, Weisskopf M, Sousa Da Silva RX, Antunes Crisóstomo JM, Dutkowski P, Rudolf von Rohr P, Clavien PA, Tibbitt MW, Eshmuminov D, Hefti M. Observations and findings during the development of a subnormothermic/normothermic long-term ex vivo liver perfusion machine. Artif Organs 2023; 47:317-329. [PMID: 36106378 DOI: 10.1111/aor.14403] [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: 04/03/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Ex situliver machine perfusion at subnormothermic/normothermic temperature isincreasingly applied in the field of transplantation to store and evaluateorgans on the machine prior transplantation. Currently, various perfusionconcepts are in clinical and preclinical applications. Over the last 6 years ina multidisciplinary team, a novel blood based perfusion technology wasdeveloped to keep a liver alive and metabolically active outside of the bodyfor at least one week. METHODS Within thismanuscript, we present and compare three scenarios (Group 1, 2 and 3) we werefacing during our research and development (R&D) process, mainly linked tothe measurement of free hemoglobin and lactate in the blood based perfusate. Apartfrom their proven value in liver viability assessment (ex situ), these twoparameters are also helpful in R&D of a long-term liver perfusion machine and moreover supportive in the biomedical engineering process. RESULTS Group 1 ("good" liver on the perfusion machine) represents the best liver clearance capacity for lactate and free hemoglobin wehave observed. In contrast to Group 2 ("poor" liver on the perfusion machine), that has shown the worst clearance capacity for free hemoglobin. Astonishingly,also for Group 2, lactate is cleared till the first day of perfusion andafterwards, rising lactate values are detected due to the poor quality of theliver. These two perfusate parametersclearly highlight the impact of the organ quality/viability on the perfusion process. Whereas Group 3 is a perfusion utilizing a blood loop only (without a liver). CONCLUSION Knowing the feasible ranges (upper- and lower bound) and the courseover time of free hemoglobin and lactate is helpful to evaluate the quality ofthe organ perfusion itself and the maturity of the developed perfusion device. Freehemoglobin in the perfusate is linked to the rate of hemolysis that indicates how optimizing (gentle blood handling, minimizing hemolysis) the perfusion machine actually is. Generally, a reduced lactate clearancecapacity can be an indication for technical problems linked to the blood supplyof the liver and therefore helps to monitor the perfusion experiments.Moreover, the possibility is given to compare, evaluate and optimize developed liverperfusion systems based on the given ranges for these two parameters. Otherresearch groups can compare/quantify their perfusate (blood) parameters withthe ones in this manuscript. The presented data, findings and recommendations willfinally support other researchers in developing their own perfusion machine ormodifying commercially availableperfusion devices according to their needs.
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Affiliation(s)
- Martin J Schuler
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Dustin Becker
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Matteo Mueller
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Leandro Mancina
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Florian Huwyler
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Jonas Binz
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Catherine Hagedorn
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Beatrice Schär
- Entwicklung biomedizinische Anwendungen, Securecell AG, Urdorf, Switzerland
| | - Erich Gygax
- Forschung und Entwicklung, Fumedica AG, Muri, Switzerland
| | - Miriam Weisskopf
- Center of Surgical Research, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Richard Xavier Sousa Da Silva
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | | | - Philipp Dutkowski
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Rudolf von Rohr
- Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Mark W Tibbitt
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
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48
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Di Benedetto F, Magistri P, Di Sandro S, Sposito C, Oberkofler C, Brandon E, Samstein B, Guidetti C, Papageorgiou A, Frassoni S, Bagnardi V, Clavien PA, Citterio D, Kato T, Petrowsky H, Halazun KJ, Mazzaferro V. Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma. JAMA Surg 2023; 158:46-54. [PMID: 36416833 PMCID: PMC9685546 DOI: 10.1001/jamasurg.2022.5697] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/31/2022] [Indexed: 11/24/2022]
Abstract
Importance Long-term oncologic outcomes of robotic surgery remain a hotly debated topic in surgical oncology, but sparse data have been published thus far. Objective To analyze short- and long-term outcomes of robotic liver resection (RLR) for hepatocellular carcinoma (HCC) from Western high-volume centers to assess the safety, reproducibility, and oncologic efficacy of this technique. Design, Setting, and Participants This cohort study evaluated the outcomes of patients receiving RLR vs open liver resection (OLR) for HCC between 2010 and 2020 in 5 high-volume centers. After 1:1 propensity score matching, a group of patients who underwent RLR was compared with a validation cohort of OLR patients from a high-volume center that did not perform RLR. Main Outcomes and Measures A retrospective analysis was performed of prospectively maintained databases at 2 European and 2 US institutions of patients who underwent RLR for HCC between January 1, 2010, and September 30, 2020. The main outcomes were safety and feasibility of RLR for HCC and its oncologic outcomes compared with a European OLR validation cohort. A 2-sided P < .05 was considered significant. Results The study included 398 patients (RLR group: 125 men, 33 women, median [IQR] age, 66 [58-71] years; OLR group: 315 men, 83 women; median [IQR] age, 70 [64-74] years), and 106 RLR patients were compared with 106 OLR patients after propensity score matching. The RLR patients had a significantly longer operative time (median [IQR], 295 [190-370] minutes vs 200 [165-255] minutes, including docking; P < .001) but a significantly shorter hospital length of stay (median [IQR], 4 [3-6] days vs 10 [7-13] days; P < .001) and a lower number of admissions to the intensive care unit (7 [6.6%] vs 21 [19.8%]; P = .002). Incidence of posthepatectomy liver failure was significantly lower in the RLR group (8 [7.5%] vs 30 [28.3%]; P = .001), with no cases of grade C failure. The 90-day overall survival rate was comparable between the 2 groups (RLR, 99.1% [95% CI, 93.5%-99.9%]; OLR, 97.1% [95% CI, 91.3%-99.1%]), as was the cumulative incidence of death related to tumor recurrence (RLR, 8.8% [95% CI, 3.1%-18.3%]; OLR, 10.2% [95% CI, 4.9%-17.7%]). Conclusions and Relevance This study represents the largest Western experience to date of full RLR for HCC. Compared with OLR, RLR performed in tertiary centers represents a safe treatment strategy for patients with HCC and those with compromised liver function while achieving oncologic efficacy.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Carlo Sposito
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Christian Oberkofler
- Swiss Hepato-Pancreato-Biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ellie Brandon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, New York
| | - Benjamin Samstein
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Weill Cornell Medical College, New York, New York
| | - Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Alexandros Papageorgiou
- Swiss Hepato-Pancreato-Biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Davide Citterio
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Tomoaki Kato
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, New York
| | - Henrik Petrowsky
- Swiss Hepato-Pancreato-Biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Karim J. Halazun
- Division of Hepatobiliary and Pancreatic Surgery, New York University Langone Health, New York, New York
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Nazionale Tumori di Milano, Milan, Italy
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Eshmuminov D, Clavien PA. Long-term dynamic ex vivo organ preservation. Nat Rev Gastroenterol Hepatol 2022; 20:267-268. [PMID: 36564518 DOI: 10.1038/s41575-022-00727-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Dilmurodjon Eshmuminov
- Wyss Zurich, ETH Zurich, University of Zurich, Zurich, Switzerland.,Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Wyss Zurich, ETH Zurich, University of Zurich, Zurich, Switzerland. .,Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.
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50
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Lopez-Lopez V, Linecker M, Petrowsky H, Clavien PA, Robles-Campos R. Authors' response to 'Liver growth prediction in ALPPS-A multicenter analysis from the international ALPPS registry'. Liver Int 2022; 42:2908. [PMID: 35924397 DOI: 10.1111/liv.15373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Victor Lopez-Lopez
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University. IMIB-ARRIXACA, El Palmar, Spain
| | - Michael Linecker
- Department of Surgery and Transplantation, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Henrik Petrowsky
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Ricardo Robles-Campos
- Department of Surgery and Liver and Pancreas Transplantation, Virgen de la Arrixaca Clinic and University. IMIB-ARRIXACA, El Palmar, Spain
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