Background
Ingested toothpicks are a relatively rare event, but may cause serious gut injuries with peritonitis, sepsis, or death. Numerous case reports describing the clinical course in this setting ...are available but there is no concise guideline. The aim of the present study was to develop practical guidelines to aid clinicians in the diagnosis and management of acute tooth pick ingestion.
Method
Our Medline search identified 116 publications containing case reports of ingested toothpicks. We then performed a retrospective analysis of patients’ characteristics, medical history, diagnostics, therapy, and clinical outcome.
Results
A total of 136 cases (74 % male, age 52 5–92 years) have been reported in the literature. From the available information, more than 50 % (
n
= 48) of patients were not aware of having swallowed a toothpick. The most common presenting symptoms were abdominal pain (82 %), fever (39 %), and nausea (31 %). The toothpick caused gut perforation in 79 % of all patients. The locations of toothpicks prior removal were esophagus (2 %), stomach (20 %), duodenum (23 %), small intestine (18 %), and large intestine (37 %). The diagnostic procedures included endoscopy (63 %), computed tomography scan (63 %), and ultrasound (47 %); however, in 35 % of cases these investigations failed to detect the toothpick. Therapy was surgery in most cases (58 %). The overall mortality was 9.6 %.
Conclusions
Toothpick ingestion is a medical emergency. Perforations of the intestine are common and the associated mortality is high. Adequate therapy depends on localization of the toothpick in the gastrointestinal tract. Ingested toothpicks should be kept in mind as an important differential diagnosis in patients with acute abdomen.
Surgical procedures in patients with underlying liver disease are still burdened by a high rate of postoperative morbidity, especially posthepatectomy liver failure (PHLF), ranging from 1.2 to 33.8%. ...The aim of this study was to investigate the prognostic value of volume/function analysis for the prediction of hepatectomy-related morbidity in patients with hepatocellular carcinoma.
Clinicopathological data were analysed in 261 patients who underwent liver resection for HCC between 2001 and 2014. Future liver remnant volume (FLRV) and future liver remnant function (FLRF) based on LiMAx test were obtained retrospectively. A subgroup analysis for high-risk patients with impaired liver function was conducted. Univariate and multivariate regression analysis was performed to identify risk factors for major complications, defined by Dindo ≥ IIIb and PHLF grade ≥ B.
In the total cohort, FLRF was independently associated with major complications. FLRV, resected liver volume, and FLRF were independent risk factors for PHLF. In a subgroup analysis of high-risk patients, FLRF was identified as the only independent risk factor for major complications and PHLF development.
These results suggest the superior value of FLRF to FLRV in predicting postoperative complications as well as PHLF in patients with chronic liver disease.
Background
Chemotherapy of colorectal liver metastases (CLMs) prior to liver resection implies the risk of chemotherapy-associated liver injury, leading to increased postoperative morbidity and ...mortality
Objective
The aim of this study was to evaluate the LiMAx (liver maximum capacity) test for diagnosis of chemotherapy-associated liver injury.
Methods
This was a retrospective analysis of patients with CLMs, prior to liver resection. We performed preoperative assessment of liver function using biochemical parameters and the LiMAx test. The individual history of chemotherapy within 12 months, including regimen, number of cycles, and therapy-free interval were collected, and histopathological evaluation of tumor-free liver tissue was performed in resected patients.
Results
A total of 204 patients were included, of whom 127 (62%) had received previous chemotherapy. The LiMAx test was worse after chemotherapy (340 ± 95 vs. 391 ± 82 µg/kg/h;
p
<
0.001). Impaired LiMAx results (<315 µg/kg/h) were determined in 49% of patients after chemotherapy, and no effects of chemotherapy, liver steatosis or fibrosis on biochemical parameters were observed. LiMAx impairment was dependent on the number of oxaliplatin cycles, the therapy-free interval, and obesity in multivariate analysis. In addition, the LiMAx test was worse in patients with relevant steatosis, fibrosis and steatohepatitis. Patients with an impaired LiMAx showed sufficient regeneration during chemotherapy cessation when surgery was postponed (272 ± 57 – 348 ± 72 µg/kg/h;
p
=
0.003).
Conclusion
The LiMAx test enables non-invasive preoperative diagnosis of chemotherapy-associated liver injury. Preoperative performance of the LiMAx test can augment surgical strategy and timing of surgery after previous chemotherapy, thus avoiding increased postoperative morbidity.
Obesity is increasingly impacting the overall health status and the global costs for health care. The increase in body mass index (BMI) is also observed in kidney allograft recipients and deceased ...organ donors.
In a retrospective single-center study, we analyzed 1132 deceased donor kidney grafts, transplanted at our institution between 2000 and 2009 for recipient and donor BMI and its correlation with delayed graft function (DGF). Recipients/donors were classified according to their BMI (<18.5, 18.5-24.9, 25-29.9, and >30 kg/m(2)). DGF was defined as requirement for one dialysis within the first week after transplantation.
Overall DGF rate was 32.4%, mean recipient BMI was 23.64 ± 3.75 kg/m(2), and mean donor BMI was 24.69 ± 3.44 kg/m(2). DGF rate was 25.2%, 29.8%, 40.9%, and 52.6% in recipients with BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, and more than 30 kg/m, respectively (P<0.0001). Donor BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, more than 30 kg/m(2) resulted in a DGF rate of 22.5%, 31.0%, 37.3%, and 51.2% (P < 0.0001). Multivariate analysis revealed recipient BMI and dialysis duration as independent risk factors for DGF. DGF results in inferior 1- and 5-year graft and patient survival.
Recipient and donor BMI correlate with the incidence of DGF. Awareness thereof should have an impact on peri- and posttransplant measures in renal transplant recipients.
ObjectivesPreoperative hypoalbuminaemia is associated with adverse outcome, including increased postoperative mortality in cardiovascular surgery, neurosurgery, trauma and orthopaedic surgery. ...However, much less is known about the association between preoperative serum albumin and clinical outcomes after liver surgery. In this study, we sought to determine whether hypoalbuminaemia before partial hepatectomy is associated with a worse postoperative outcome.DesignObservational study.SettingUniversity Medical Centre in Germany.ParticipantsWe analysed 154 patients enrolled in the perioperative PHYsostigmine prophylaxis for liver resection patients at risk for DELIrium and postOperative cognitive dysfunction (PHYDELIO) trial with a preoperative serum albumin assessment. Hypoalbuminaemia was defined as serum albumin <35 g/L. Subgroups classified as hypoalbuminaemia and non-hypoalbuminaemia consisted of 32 (20.8%) and 122 (79.2%) patients, respectively.Outcome measuresThe outcome parameters of interest were postoperative complications according to Clavien (moderate: I, II; major: ≥III), length of intensive care unit (ICU) stay, length of hospital stay and survival rates 1 year after surgery.ResultsPreoperative hypoalbuminaemia was associated with the occurrence of major postoperative complications (OR 3.051 (95% CI 1.197 to 7.775); p=0.019) after adjusting for age, sex, randomisation, American Society of Anesthesiologists physical status, preoperative diagnosis and Child-Pugh class. Both ICU and hospital lengths of stay were significantly prolonged in patients with preoperative hypoalbuminaemia (OR 2.573 (95% CI 1.015 to 6.524); p=0.047 and OR 1.296 (95% CI 0.254 to 3.009); p=0.012, respectively). One-year survival was comparable between patients with and without hypoalbuminaemia.ConclusionsWe found that low serum albumin before surgery was associated with a worse short-term outcome after partial hepatectomy, which strengthens the prognostic value of serum albumin in the setting of liver surgery.Trial registration numbersISRCTN18978802 and EudraCT 2008-007237-47.
Abstract Background13 C-liver function breath tests can facilitate the assessment of hepatic function in-vivo and may help surgeons to identify candidates for safe liver surgery. However, their ...acceptance into clinical practice is dependent on evaluation of technical efficacy and repeatability. The aims of this study were to evaluate the within-subject repeatability of the LiMAx (maximum liver function capacity) test in healthy individuals and in surgical patients to determine liver function in the perioperative workup. Material and methods The LiMAx test, which is based on intravenous injection of13 C-methacetin at a dosage of 2 mg/kg body weight was performed in eighty-six healthy subjects to determine a reference range. Twenty-four subjects underwent repeat LiMAx testing the following day to assess within-subject repeatability. Twenty-one patients undergoing elective extra-abdominal surgery under general anesthesia (GA group) received pre- and post-operative examinations. Results The normal range of LiMAx was found to be 430 ± 86 μg/kg/h and revealed a one-sided cut-off value of 315 μg/kg/h. The intraclass correlation coefficient of the repeat LiMAx tests was 0.85 (95% confidence interval 0.69–0.93) in the control group and 0.81 (95% confidence interval 0.60–0.92) in the group of patients with GA. Conclusions The LiMAx test shows excellent reproducibility in subjects with normal liver function. GA has no effect on test results.
MELD score and MELD score derivates are used to objectify and grade the risk of liver-related death in patients with liver cirrhosis. We recently proposed a new predictive model that combines serum ...creatinine levels and maximum liver function capacity (LiMAx®), namely the CreLiMAx risk score. In this validation study we have aimed to reproduce its diagnostic accuracy in patients with end-stage liver disease.
Liver function of 113 patients with liver cirrhosis was prospectively investigated. Primary end-point of the study was liver-related death within 12 months of follow-up.
Alcoholic liver disease was the main cause of liver disease (n = 51; 45%). Within 12 months of follow-up 11 patients (9.7%) underwent liver transplantation and 17 (15.1%) died (13 deaths were related to liver disease, two not). Measures of diagnostic accuracy were comparable for MELD, MELD-Na and the CreLiMAx risk score as to power in predicting short and medium-term mortality risk in the overall cohort: AUROCS for liver related risk of death were for MELD 6 months 0.89 (95% CI 0.80-0.98) p < 0.001; 12 months 0.89 (95% CI 0.81-0.96) p < 0.001; MELD-Na 6 months 0.93 (95% CI 0.85-1.00) p < 0.001 and 12 months 0.89 (95% CI 0.80-0.98) p < 0.001; CPS 6 months 0.91 (95% CI 0.85-0.97) p < 0.01 and 12 months 0.88 (95% CI 0.80-0.96) p < 0.001 and CreLiMAx score 6 months 0.80 (95% CI 0.67-0.96) p < 0.01 and 12 months 0.79 (95% CI 0.64-0.94) p = 0.001. In a subgroup analysis of patients with Child-Pugh Class B cirrhosis, the CreLiMAx risk score remained the only parameter significantly differing in non-survivors and survivors. Furthermore, in these patients the proposed score had a good predictive performance.
The CreLiMAx risk score appears to be a competitive and valid tool for estimating not only short- but also medium-term survival of patients with end-stage liver disease. Particularly in patients with Child-Pugh Class B cirrhosis the new score showed a good ability to identify patients not at risk of death.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Resection and reconstruction of infiltrated vessels achieve resectability of extended pancreatic tumors. The aim of the present study was to assess the feasibility of bovine pericardium as graft ...material for the individualised portal vein reconstruction and demonstrate a surgical technique for abdominal vein repair.
We performed a MEDLINE search to review the methods for complex abdominal vein reconstruction in the course of extended pancreatectomy. Moreover, clinical data of patients receiving portal vein reconstruction using a bovine pericardial patch at our institution were retrospectively analyzed.
Based on the results of a review of the literature, autologous venous grafts using the internal jugular vein represent the most popular option for segmental portal vein reconstruction in case of impossible direct suture. At our center, segmental portal vein reconstruction with bovine pericardial patch in course of pancreatic surgery was performed in 4 patients. No case of vascular complications such as occlusion, segmental stenosis or thrombosis occurred.
Our experience suggests a surgical procedure for an individual size-matched portal vein reconstruction using bovine pericardium. Although first results appear promising, prospective studies are required to objectively assess the patency of bovine pericardium compared with autologous and synthetic interposition grafts for portal vein reconstruction.
BACKGROUND AND AIMHepatic encephalopathy (HE) is a frequent complication of cirrhosis, characterized by cognitive deficits that negatively impact patients’ quality of life. The mild, minimal hepatic ...encephalopathy (mHE) can only be detected by psychometric tests and early mHE detection can prevent more severe complications or even survival times. Here, we aimed to investigate the feasibility and validity of the novel-developed electronic number connection test (eNCT), which is designed as a fast and easy-to-perform mHE patient self-test.
METHODSThe eNCT design was inspired by the paper-pencil number connection test version A, showing 25 numbers on the screen (1–25), in a random order. The time required to tap on all digits in the correct order was measured. A total of 238 individuals (112 patients with liver cirrhosis) were enrolled in this study and eNCT times were compared with well-established paper-pencil tests. The Psychometric Hepatic Encephalopathy Score test battery was used to detect mHE and cut-off values for mHE detection by the eNCT were defined.
RESULTSOverall, cirrhotic patients showed significantly slower test completion times compared with control participants. The eNCT performance was inversely correlated with Psychometric Hepatic Encephalopathy Score test performance in cirrhotic patients, independent of the HE status. Thirty cirrhotic patients fulfilled the mHE criteria and receiver operating characteristic curve analysis showed high sensitivity (>82%) and specificity (>85%) for mHE detection. Finally, the eNCT showed excellent test–retest reliability (intraclass correlation coefficient=0.94).
CONCLUSIONThe novel eNCT is a reliable HE self-test to monitor cognitive function and detect cognitive impairment in cirrhotic patients.
Background
Despite improved survival a substantial number of Fontan patients eventually develop late failure. Fontan-associated liver disease (FALD) is the most frequent end-organ dysfunction. ...Although impaired hemodynamics and Fontan failure correlate with FALD severity, no association between hepatic functional metabolic impairment and Fontan hemodynamics has been established.
Hypothesis
Metabolic liver function measured by liver maximum function capacity test (LiMAx®) correlates with Fontan hemodynamics and Fontan failure.
Methods
From 2020 to 2022, 58 adult Fontan patients median age: 29.3 years, IQR (12.7), median follow-up time after Fontan operation: 23.2 years, IQR (8.7) were analyzed in a cross-sectional study. Hemodynamic assessment included echocardiography, cardiopulmonary exercise testing and invasive hemodynamic evaluation. Fontan failure was defined based on commonly applied clinical criteria and our recently composed multimodal Fontan failure score.
Results
LiMAx® test revealed normal maximum liver function capacity in 40 patients (>315 μg/h
*
kg). In 18 patients a mild to moderate impairment was detected (140–314 μg/h
*
kg), no patient suffered from severe hepatic deterioration (≤ 139 μg/kg
*
h). Fontan failure was present in 15 patients. Metabolic liver function was significantly reduced in patients with increased pulmonary artery pressure (
p
= 0.041. r = −0.269) and ventricular end-diastolic pressure (
p
= 0.033, r = −0.325), respectively. In addition, maximum liver function capacity was significantly impaired in patients with late Fontan failure (289.0 ± 99.6 μg/kg
*
h vs. 384.5 ± 128.6 μg/kg
*
h,
p
= 0.007).
Conclusion
Maximum liver function capacity as determined by LiMAx® was significantly reduced in patients with late Fontan failure. In addition, elevated pulmonary artery pressure and end-diastolic ventricular pressure were associated with hepatic functional metabolic impairment.
PDF
