Background
The dissemination of robotic liver surgery is slow‐paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the ...current position of robotic liver surgery (RLS) worldwide and to identify if improved short‐term outcomes are observed, including secondary meta‐analyses for type of resection, etiology, and cost analysis.
Methods
A PRISMA‐based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle‐Ottawa score. Statistical analysis was performed after heterogeneity test and fixed‐ or random‐effect models were chosen accordingly.
Results
After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta‐analysis from the 38 comparative reports showed that RLS may offer improved short‐term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.
Conclusions
The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.
Highlight
Ciria and colleagues analyzed the impact of robotics in liver surgery. The largest systematic review and short‐term outcomes meta‐analysis performed to date was done on 2728 cases. Few initial advantages were observed for the robotic approach compared with laparoscopy, contrary to significant higher costs. However, a high potential was highlighted.
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•An increasing proportion of patients are being transplanted for non-alcoholic steatohepatitis (NASH) in Europe.•Hepatocellular carcinoma was more common in patients transplanted with ...NASH.•Survival in recipients with NASH is comparable to that of other disease indications.•Age, BMI, and advanced liver disease predicted poorer outcomes in NASH recipients.
Little is known about outcomes of liver transplantation for patients with non-alcoholic steatohepatitis (NASH). We aimed to determine the frequency and outcomes of liver transplantation for patients with NASH in Europe and identify prognostic factors.
We analysed data from patients transplanted for end-stage liver disease between January 2002 and December 2016 using the European Liver Transplant Registry database. We compared data between patients with NASH versus other aetiologies. The principle endpoints were patient and overall allograft survival.
Among 68,950 adults undergoing first liver transplantation, 4.0% were transplanted for NASH – an increase from 1.2% in 2002 to 8.4% in 2016. A greater proportion of patients transplanted for NASH (39.1%) had hepatocellular carcinoma (HCC) than non-NASH patients (28.9%, p <0.001). NASH was not significantly associated with survival of patients (hazard ratio HR 1.02, p = 0.713) or grafts (HR 0.99; p = 0.815) after accounting for available recipient and donor variables. Infection (24.0%) and cardio/cerebrovascular complications (5.3%) were the commonest causes of death in patients with NASH without HCC. Increasing recipient age (61–65 years: HR 2.07, p <0.001; >65: HR 1.72, p = 0.017), elevated model for end-stage liver disease score (>23: HR 1.48, p = 0.048) and low (<18.5 kg/m2: HR 4.29, p = 0.048) or high (>40 kg/m2: HR 1.96, p = 0.012) recipient body mass index independently predicted death in patients transplanted for NASH without HCC. Data must be interpreted in the context of absent recognised confounders, such as pre-morbid metabolic risk factors.
The number and proportion of liver transplants performed for NASH in Europe has increased from 2002 through 2016. HCC was more common in patients transplanted with NASH. Survival of patients and grafts in patients with NASH is comparable to that of other disease indications.
The prevalence of non-alcoholic fatty liver disease has increased dramatically in parallel with the worldwide increase in obesity and diabetes. Its progressive form, non-alcoholic steatohepatitis, is a growing indication for liver transplantation in Europe, with good overall outcomes reported. However, careful risk factor assessment is required to maintain favourable post-transplant outcomes in patients with non-alcoholic steatohepatitis.
Background
Patients with peritoneal metastases of gastric cancer have a poor prognosis and median survival of 7 months. This study compared treatment options and outcomes based on the Peritoneal ...Cancer Index (PCI).
Methods
This retrospective analysis included patients with gastric cancer treated between August 2008 and December 2017 with synchronous peritoneal metastases only diagnosed by laparoscopy. The three treatments were as follows: (1) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in combination with pre- and postoperative systemic chemotherapy (
n
= 58), (2) laparotomy/laparoscopy without CRS, but HIPEC in combination with pre- and postoperative systemic chemotherapy (
n
= 11), and (3) systemic chemotherapy only (
n
= 19).
Results
A total of 88 patients aged 54.6 ± 10.9 years with mean PCI of 14.3 ± 11.3 were included. The PCI was significantly lower in group 1 (8.3 ± 5.7) than in group 2 (23.9 ± 11.1,
p
< 0.001) and group 3 (27.3 ± 9.3,
p
< 0.001). Mean time from diagnosis to laparoscopy was 5.2 ± 2.9 months. The median overall survival was 9.8 ± 0.7 for group 1, 6.3 ± 3.0 for group 2 and 4.9 ± 1.9 months for group 3 (
p
< 0.001). Predictors for deteriorated overall patient survival included > 4 cycles of preoperative chemotherapy (HR 4.49,
p
< 0.001), lymph-node metastasis (HR 3.53,
p
= 0.005), PCI ≥ 12 (HR 2.11,
p
= 0.036), and incompleteness of cytoreduction (HR 4.30,
p
= 0.001) in patients treated with CRS and HIPEC.
Conclusion
CRS and HIPEC showed convincing results in selected patients with PCI < 12 and complete cytoreduction. Prolonged duration (> 4 cycles) of preoperative intravenous chemotherapy reduced patient survival in patients suitable for CRS and HIPEC.
Introduction
Several studies and meta-analysis showed Single-port or Single-incision laparoscopic surgery (SPL) to be superior over Multiport laparoscopic surgery (MPL) mainly in terms of ...postoperative pain and cosmetic result. But very little is known whether these results are only a short-term effect or are persistent on the long run after SPL. We therefore evaluated and compared long-term outcomes regarding cosmesis and chronic pain after SPL and MPL.
Methods
We conducted a comparative study with propensity score matching of all patients undergoing SPL or MPL between October 2008 and December 2013 in terms of postoperative cosmetic results and chronic pain. Follow-up data were obtained from mailed patient questionnaires and telephone interviews. Postoperative cosmesis was assessed using the patients overall scar opinion on a 10-point scale and the Patients scale of the standardized Patient and Observer Scar assessment scale (POSAS). Chronic pain was assessed by 10-point scales for abdominal and umbilical scar pain.
Results
A total of 280 patients were included in the study with 188 patients (67.1%) after SPL and 92 patients (32.9%) following MPL. 141 patients (50.4%) underwent a cholecystectomy and 139 patients (49.6%) underwent an appendectomy. The mean follow-up time was 61.1 ± 19.1 months. The mean wound satisfaction assed by the overall scar and the PSOAS Patients scale score of the patients showed no significant difference between MPL and SPL. Patients after SPL reported more overall complains than after MPL (8.7% vs. 2.5%, respectively), but without statistical significance (
p
= 0.321). Umbilical pain scores were comparable between the two groups (1.4 ± 1.0 vs. 1.4 ± 1.0,
p
= 0.831).
Conclusion
We found no difference in long-term cosmetic outcomes after SPL and MPL. Chronic pain at the umbilical incision site was comparable on the long run.
Although the incidence of early acute rejection could have been diminished in the past, the long-term renal allograft survival could not benefit from the introduction of more effective ...immunosuppressive regimens mainly aiming at cellular rejection mechanisms. The cause of chronic rejection is still discussed controversially. Here, we demonstrate to what extent human leukocyte antigen (HLA) antibodies (HLAab) posttransplant contribute to late graft outcome.
A total of 1014 deceased kidney transplant recipients transplanted at the Charité hospital were monitored in a cross-sectional manner for the development of HLAab using Luminex Single Antigen beads. Patients with stable kidney function at a median of 5-years posttransplant were tested once for HLAab and monitored for 5.5 years after testing.
Thirty percent of recipients showed HLAab. Donor-specific antibodies (DSA) were found in 31% of antibody positive patients. The presence of DSA was associated with a significantly lower graft survival of 49% vs. 83% in the HLAab negative group (P< or =0.0001). Non-DSAs also had an adverse effect on graft survival (70% vs. 83%; P=0.0001). In a prospective analysis of 195 patients with repeatedly no detectable HLAab, the survival probability was 94% as opposed to 79% survival among patients who developed HLAab de novo after the first testing (P=0.05).
We confirmed that HLAab produced even late after transplantation are detrimental to graft outcome. DSA were proven to have a strong adverse impact on graft survival. The results indicate that a posttransplant HLAab monitoring routine could be appropriate to improve long-term results.
IMPORTANCE: Laparoscopic and robotic techniques have both been well adopted as safe options in selected patients undergoing hepatectomy. However, it is unknown whether either approach is superior, ...especially for major hepatectomy such as right hepatectomy or extended right hepatectomy (RH/ERH). OBJECTIVE: To compare the outcomes of robotic vs laparoscopic RH/ERH. DESIGN, SETTING, AND PARTICIPANTS: In this case-control study, propensity score matching analysis was performed to minimize selection bias. Patients undergoing robotic or laparoscopic RH/EHR at 29 international centers from 2008 to 2020 were included. INTERVENTIONS: Robotic vs laparoscopic RH/ERH. MAIN OUTCOMES AND MEASURES: Data on patient demographics, tumor characteristics, and short-term perioperative outcomes were collected and analyzed. RESULTS: Of 989 individuals who met study criteria, 220 underwent robotic and 769 underwent laparoscopic surgery. The median (IQR) age in the robotic RH/ERH group was 61.00 (51.86-69.00) years and in the laparoscopic RH/ERH group was 62.00 (52.03-70.00) years. Propensity score matching resulted in 220 matched pairs for further analysis. Patients’ demographics and tumor characteristics were comparable in the matched cohorts. Robotic RH/ERH was associated with a lower open conversion rate (19 of 220 8.6% vs 39 of 220 17.1%; P = .01) and a shorter postoperative hospital stay (median IQR, 7.0 5.0-10.0 days; mean SD, 9.11 7.52 days vs median IQR, 7.0 5.75-10.0 days; mean SD, 9.94 8.99 days; P = .048). On subset analysis of cases performed between 2015 and 2020 after a center’s learning curve (50 cases), robotic RH/ERH was associated with a shorter postoperative hospital stay (median IQR, 6.0 5.0-9.0 days vs 7.0 6.0-9.75 days; P = .04) with a similar conversion rate (12 of 220 7.6% vs 17 of 220 10.8%; P = .46). CONCLUSION AND RELEVANCE: Robotic RH/ERH was associated with a lower open conversion rate and shorter postoperative hospital stay compared with laparoscopic RH/ERH. The difference in open conversion rate was associated with a significant decrease for laparoscopic but not robotic RH/ERH after a center had mounted the learning curve. Use of robotic platform may help to overcome the initial challenges of minimally invasive RH/ERH.
Background
Single-incision laparoscopic surgery (SILS) is growing in popularity. The increased diameter of the umbilical incision might raise questions about the possibility of a greater risk of ...postoperative incisional hernia in comparison to conventional laparoscopy. This study aims to disclose the frequency of incisional hernia after SILS in long-term follow-up as well as to reveal the factors predisposing patients to this feared complication.
Methods
The patient collective consists of cholecystectomy and appendectomy patients, who were operated on using SILS technique. Follow-up was achieved through letter correspondence, telephone interview, and clinical examination. Effects of demographic variables and operative parameters including age, sex, BMI, ASA score, duration of surgery, pre-existing hernia as well as postoperative incidence of incisional hernia were investigated using univariate and multivariate analyses.
Results
A total of 286 cases with complete follow-up were included in the analyses. Mean follow-up duration was 58.4 months. 192 patients (67.1%) underwent cholecystectomy; 94 (32.9%) had an appendectomy. The study collective consisted of 218 women (76.2%) and 68 men (23.8%). Mean age at the date of the operation was 38.5 (median 36, range 13–74). In 5 cases (1.7%), the surgical approach was converted into conventional laparoscopy. Intraoperative complication rate was 0.3% and postoperative complication rate was 5.9%. 7 patients (2.4%) developed an incisional hernia. Obese patients had an incisional hernia incidence of 10.9%. 3 out of 19 patients (15.8%) with a pre-existing umbilical hernia developed an incisional hernia during follow-up. Obesity and pre-existing umbilical hernia proved to have a significant association with incisional hernia incidence in univariate and multivariate analyses. Sex, age, procedure (appendectomy vs cholecystectomy), presence of acute inflammation, and duration of surgery did not show a statistically significant association with incisional hernia.
Conclusion
Detection of incisional hernia necessitates a long follow-up duration. Obesity and pre-existing umbilical hernia are associated with a higher incidence of this complication. Following a careful patient selection, SILS offers a safe approach for cholecystectomy and appendectomy procedures.
Background
While minimally invasive liver surgery has been increasingly adopted at least for minor resections, experience with robotic liver surgery is still limited to a few highly specialized ...centers. Due to the fear of abdominal adhesions, a history of prior surgeries is still used as an argument for open approaches.
Methods
Clinical data of all consecutive robotic resections at our center, using the da Vinci Xi surgical system, between April, 2018 and December, 2020, were collected and analyzed as part of a prospective, post-marketing observational study (DRKS00017229). Prior abdominal surgeries were specified according to the surgical approach and localization. Baseline and perioperative outcome criteria were compared between patients with prior surgeries (PS) and patients with no prior surgeries (NPS) in univariate and multivariate analyses.
Results
Out of the 126 patients undergoing robotic liver resections, 59% had a history of abdominal surgeries, which were most often colorectal resections (28%) followed by liver resections (20%). Patients with NPS were more likely to undergo robotic liver resection for hepatocellular carcinoma or benign tumors, and to have underlying liver cirrhosis when compared to patients with PS. Other baseline characteristics as well as the extent of resections were similar. Duration of surgery (258 min), conversion rates (6%), and postoperative complications rates (21% Clavien–Dindo ≥ 3) showed no differences between NPS and PS. A subgroup of patients with a history of prior liver surgery showed a longer duration of surgery in univariate analysis. However, this was not confirmed in multivariate analysis which instead revealed tumor entity and liver cirrhosis as independently correlated with duration of surgery.
Conclusions
We propose robotic liver resection to be safe and feasible, including in patients with prior abdominal surgeries. Each patient should be evaluated for a minimally invasive procedure regardless of a history of previous operations.
Background
Cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) represents a multimodal treatment concept for patients with peritoneal surface ...malignancies. The use of intraperitoneal cisplatin (CDDP) is associated with a risk of acute kidney injury (AKI). The aim of this study is to evaluate the protective effect of perioperative sodium thiosulfate (STS) administration on kidney function in patients undergoing CRS and CDDP-based HIPEC.
Patients and Methods
We retrospectively analyzed clinical data of all patients who underwent CRS and CDDP-based HIPEC at our hospital between March 2017 and August 2020. Patients were stratified according to the use of sodium thiosulfate (STS vs. no STS). We compared kidney function and clinical outcome parameters between both groups and determined risk factors for postoperative AKI on univariate and multivariate analysis. AKI was classified according to acute kidney injury network (AKIN) criteria.
Results
Of 238 patients who underwent CRS and CDDP-based HIPEC, 46 patients received STS and 192 patients did not. There were no significant differences in baseline characteristics. In patients who received STS, a lower incidence (6.5% vs. 30.7%;
p
= 0.001) and severity of AKI (
p
= 0.009) were observed. On multivariate analysis, the use of STS (OR 0.089,
p
= 0.001) remained an independent kidney-protective factor, while arterial hypertension (OR 5.283,
p
< 0.001) and elevated preoperative urea serum level (OR 5.278,
p
= 0.032) were predictors for postoperative AKI.
Conclusions
The present data suggest that STS protects patients from AKI caused by CRS and CDDP-based HIPEC. Further prospective studies are needed to validate the benefit of STS among kidney-protective strategies.
Considering the expected increase in the elderly population and the growing emphasis on aging-related biomedical research, the demand for aged laboratory animals has surged, challenging established ...husbandry practices. Our objective was to establish a cost-effective method for environmental enrichment, utilizing the liver as a representative organ to assess potential metabolic changes in response to differing enrichment levels.
We conducted a six-month study involving 24 male Sprague Dawley rats, randomly assigned to four environmental enrichment groups. Two groups were housed in standard cages, while the others were placed in modified rabbit cages. Half of the groups received weekly playtime in an activity focused rat housing unit. We evaluated hormone levels, playtime behavior, and subjective handling experience. Additionally, liver tissue proteomic analysis was performed.
Initial corticosterone levels and those after 3 and 6 months showed no significant differences. Yet, testosterone levels were lower in the control group by the end of the study (p = 0.007). We observed 1871 distinct proteins in liver tissue, with 77% being common across groups. In gene ontology analysis, no specific pathways were overexpressed. In semiquantitative analysis, we observed differences in proteins associated in lipid metabolism such as Apolipoprotein A-I and Acyl-CoA 6-desaturase, which were lower in the control group (p = 0.024 and p = 0.009). Rats in the intervention groups with weekly playtime displayed the least amount of reported distress during inspection or upon room entry and were less prone to accepting treats. Removing animals from their enclosure was most effortless for those in the large cage group. Over time, there was a decrease in conflicts among rats that interacted only twice weekly during playpen time.
In summary, refining husbandry practices for aging rats is both simple and budget-friendly, with no apparent adverse effects on stress levels, animal development, or relevant metabolic changes in the liver.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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