Background
This study aimed to externally validate the Iwate scoring model and its prognostic value for predicting the risks of intra- and postoperative complications of laparoscopic liver resection.
...Methods
Consecutive patients who underwent pure laparoscopic liver resection between 2008 and 2019 at a single tertiary center were included. The Iwate scores were calculated according to the original proposition (four difficulty levels based on six indices). Intra- and postoperative complications were compared across difficulty levels. Fitting the obtained data to the cumulative density function of the Weibull distribution and a linear function provided the mean risk curves for intra- and postoperative complications, respectively.
Results
The difficulty levels of 142 laparoscopic liver resections were scored as low, intermediate, advanced, and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%), and 16 (11.3%) patients, respectively. Intraoperative complications were detected in 26 (18.3%) patients and its rates (2.4%, 7.5%, 34.3%, and 62.5%) increased gradually with statistically significant values among difficulty levels (
P
˂ 0.001). Major postoperative complications occurred in 21 (14.8%) patients and its rates (4.8%, 5.6%, 28.1%, 43.7%;
P
˂ 0.001) showed the same trend as for intraoperative complications. Then, the mean risk curves of both complications were obtained. Due to outliers, a new threshold for a
tumor size
index was proposed at 38 mm. The repeated analysis showed improved results.
Conclusions
The Iwate scoring model predicts the probability of complications across difficulty levels. Our proposed
tumor size
threshold (38 mm) improves the quality of the prediction. The model is upgraded by a probability of complications for every difficulty score.
Background and Objectives: The issue of a missing variable precludes the external validation of many prognostic models. For example, the Liverpool score predicts the survival of patients undergoing ...surgical therapy for colorectal liver metastases, but it includes the neutrophil–lymphocyte ratio, which cannot be measured retrospectively. Materials and Methods: We aimed to find the most appropriate replacement for the neutrophil–lymphocyte ratio. Survival analysis was performed on data representing 632 liver resections for colorectal liver metastases from 2000 to 2020. Variables associated with the Liverpool score, C-reactive protein, albumins, and fibrinogen were ranked. The rankings were performed in four ways: The first two were based on the Kaplan-Meier method (log-rank statistics and the definite integral IS between two survival curves). The next method of ranking was based on univariate and multivariate Cox regression analyses. Results: The ranks were as follows: the radicality of liver resection (rank 1), lymph node infiltration of primary colorectal cancer (rank 2), elevated C-reactive protein (rank 3), the American Society of Anesthesiologists Classification grade (rank 4), the right-sidedness of primary colorectal cancer (rank 5), the multiplicity of colorectal liver metastases (rank 6), the size of colorectal liver metastases (rank 7), albumins (rank 8), and fibrinogen (rank 9). Conclusions: The ranking methodologies resulted in almost the same ranking order of the variables. Elevated C-reactive protein was ranked highly and can be considered a relevant replacement for the neutrophil–lymphocyte ratio in the Liverpool score. These methods are suitable for ranking variables in similar models for medical research.
Obesity is a major public health problem and a well-known cause of multiple comorbidities. With the increasing application of minimally invasive surgery for benign and malignant liver lesions, the ...results of laparoscopic liver resection (LLR) in obese patients are of great interest.IntroductionObesity is a major public health problem and a well-known cause of multiple comorbidities. With the increasing application of minimally invasive surgery for benign and malignant liver lesions, the results of laparoscopic liver resection (LLR) in obese patients are of great interest.To evaluate the short-term operative outcomes after LLR in obese patients and compare them to patients with normal weight and overweight.AimTo evaluate the short-term operative outcomes after LLR in obese patients and compare them to patients with normal weight and overweight.All 235 consecutive patients undergoing LLR from 2008 to 2023 were retrospectively analysed. Patients were categorized into 3 groups based on their body mass index (BMI): normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥ 30 kg/m2). The groups were then compared regarding preoperative data and intra- and postoperative outcomes.Material and methodsAll 235 consecutive patients undergoing LLR from 2008 to 2023 were retrospectively analysed. Patients were categorized into 3 groups based on their body mass index (BMI): normal weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), and obese (≥ 30 kg/m2). The groups were then compared regarding preoperative data and intra- and postoperative outcomes.Despite higher ASA score and associated comorbidities in the obese group, there were no significant differences in intraoperative complication (blood loss, damage to surrounding structures, conversion rate) between BMI groups (20.8% vs. 16.8% vs. 22.7%, p = 0.619). There were no significant differences in overall morbidity (34.7% vs. 27.7% vs. 29.5%, p = 0.582), as well as major morbidity (15.9% vs. 11.8% vs. 11.4%, p = 0.784) or mortality rates (1.4% vs. 1.7% vs. 0.0%, p = 1.000). Univariate logistic regression did not show BMI or obesity as a predictive variable for intraoperative complication.ResultsDespite higher ASA score and associated comorbidities in the obese group, there were no significant differences in intraoperative complication (blood loss, damage to surrounding structures, conversion rate) between BMI groups (20.8% vs. 16.8% vs. 22.7%, p = 0.619). There were no significant differences in overall morbidity (34.7% vs. 27.7% vs. 29.5%, p = 0.582), as well as major morbidity (15.9% vs. 11.8% vs. 11.4%, p = 0.784) or mortality rates (1.4% vs. 1.7% vs. 0.0%, p = 1.000). Univariate logistic regression did not show BMI or obesity as a predictive variable for intraoperative complication.Obesity is not a significant, strong risk factor for worse short-term outcomes, and LLR may be considered also in patients with overweight and obesity.ConclusionsObesity is not a significant, strong risk factor for worse short-term outcomes, and LLR may be considered also in patients with overweight and obesity.
This study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver ...resection (LLR).
The DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score.
The difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC.
This external validation proved this DSS based on patient's, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.
Key Clinical Message
Hepatocellular carcinoma (HCC) develops in the presence of chronic liver disease, and nonalcoholic fatty liver disease is becoming a frequent cause of HCC in developed regions. ...Spontaneous rupture of HCC (rHCC) is a potentially life‐threatening complication of a tumor. The patient's compliance with surveillance after liver resection is vital for the prevention of rHCC.
Hepatocellular carcinoma (HCC) develops in the presence of chronic liver disease, and nonalcoholic fatty liver disease is becoming a frequent cause of HCC in developed regions. Spontaneous rupture of HCC (rHCC) is a potentially life‐threatening complication of a tumor. The patient's compliance with surveillance after liver resection is vital for the prevention of rHCC.
Abstract Objectives The aim of this study was to assess whether biological markers can provide prognostic information additional to that supplied by the clinical risk score (CRS) in patients with ...colorectal liver metastases. Methods A retrospective review of a prospectively maintained database was conducted. Patients selected for this study were treated between 1996 and 2011 with potentially curative liver surgery. Expressions of p53, Ki-67 and thymidylate synthase were assayed using immunohistochemical techniques on tissue microarrays. Results A total of 98 (24%) of 406 patients met the inclusion criteria. The median follow-up was 103 months. Analysis revealed a correlation between p53 protein overexpression and high CRS ( P = 0.058). Following multivariate analysis, only high CRS remained as an independent negative prognostic predictor of survival ( P = 0.018), as well as an indicator of early recurrence of disease ( P = 0.010). Of the biological markers investigated, only Ki-67 overexpression was identified as a positive predictor of survival on multivariate analysis ( P = 0.038). Conclusions Ki-67 overexpression was a positive predictor of survival. Only high CRS remained an independent negative prognostic predictor.
Background
Various minimally invasive therapies are important adjuncts to management of hepatic injuries. However, there is a certain subset of patients who will benefit from liver resection, but ...there are no reports in the literature on laparoscopic anatomical liver resection for the management of complications after blunt liver trauma.
Case presentation
A 20-year-old male was admitted to the Emergency Unit of a tertiary referral center following a car accident. The patient was hemodynamically stable, and a radiologic workup demonstrated an isolated grade 3 injury of the left hemiliver. Initially, a nonoperative management was indicated, but during days following the injury, a high-volume biliary fistula complicated the clinical course. Despite percutaneous drainage, the development of devastating consequences of biliary peritonitis was imminent. A pure laparoscopic anatomical liver resection was performed. Left lateral sectionectomy eliminated the source of bile leak, and the surgery was completed with abdominal cavity lavage. Postoperative outcome was uneventful, and the patient was discharged on day 9 after injury and day 4 after surgery returning to his normal activity.
Conclusions
In highly selected, hemodynamically stable patients with no other life-threatening concomitant injuries, laparoscopic liver resection in elective setting is feasible and safe for the management of complications after complex blunt trauma of the left liver. Extensive experience with hepatic surgery is needed, and surgeons should understand the increased risk they assume by taking on more complex surgical techniques.
Summary
BACKGROUND: Preoperative bowel cleaning for elective colorectal surgery is a routine procedure. Synbiotics (probiotics plus prebiotics) are known for their beneficial effects on gut immune ...function and maintenance of the gut barrier. The main purpose of this study was to replace preoperative mechanical bowel cleaning with synbiotics and to assess the systemic inflammatory response and clinical outcome in patients undergoing colorectal surgery. PATIENTS AND METHODS: A prospective double-blind randomized placebo-controlled trial was conducted in 68 patients. The first group of 20 patients received synbiotics, the second group of 28 patients prebiotics and heat-deactivated probiotics, and the third (control) group of 20 patients mechanical bowel cleaning prior to the operation. RESULTS: Significantly higher values of interleukin 6 (IL-6) were detected 72 h after the operation in the synbiotic group (
P
= 0.025), as well as an increase of fibrinogen at 24 h postoperatively (
P
= 0.030). No statistical differences were found in leukocytes count, C-reactive protein or the lymphocyte/granulocyte ratio. There were no differences in postoperative complications between the groups. Mean hospital stay was 9.2 days in the prebiotic group, 9.5 days in the control group, and 10.95 days in the synbiotic group. CONCLUSIONS: Preoperative administration of prebiotics in elective colorectal surgery appears to have the same protective effect in preventing a postoperative inflammatory response as mechanical bowel cleaning. Further prospective studies are needed to verify the effects of synbiotics.
The physiology and pathophysiology of the exocrine pancreas are in close connection to changes in intra-cellular Ca2+ concentration. Most of our knowledge is based on in vitro experiments on acinar ...cells or acini enzymatically isolated from their surroundings, which can alter their structure, physiology, and limit our understanding. Due to these limitations, the acute pancreas tissue slice technique was introduced almost two decades ago as a complementary approach to assess the morphology and physiology of both the endocrine and exocrine pancreas in a more conserved in situ setting. In this study, we extend previous work to functional multicellular calcium imaging on acinar cells in tissue slices. The viability and morphological characteristics of acinar cells within the tissue slice were assessed using the LIVE/DEAD assay, transmission electron microscopy, and immunofluorescence imaging. The main aim of our study was to characterize the responses of acinar cells to stimulation with acetylcholine and compare them with responses to cerulein in pancreatic tissue slices, with special emphasis on inter-cellular and inter-acinar heterogeneity and coupling. To this end, calcium imaging was performed employing confocal microscopy during stimulation with a wide range of acetylcholine concentrations and selected concentrations of cerulein. We show that various calcium oscillation parameters depend monotonically on the stimulus concentration and that the activity is rather well synchronized within acini, but not between acini. The acute pancreas tissue slice represents a viable and reliable experimental approach for the evaluation of both intra- and inter-cellular signaling characteristics of acinar cell calcium dynamics. It can be utilized to assess many cells simultaneously with a high spatiotemporal resolution, thus providing an efficient and high-yield platform for future studies of normal acinar cell biology, pathophysiology, and screening pharmacological substances.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
10.
Vpliv covid-19 na organizacijo kirurške dejavnosti Komadina, Radko; Crnjac, Anton; Sojar, Valentin ...
Zdravniški vestnik (Ljubljana, Slovenia : 1992),
12/2020, Letnik:
89, Številka:
11-12
Journal Article
Recenzirano
Odprti dostop
Pandemija virusa SARS-CoV-2 je popolnoma presenetila celotni svet. V zelo kratkem času je bilo potrebno reorganizirati zdravstveni sistem v celoti. Bolnišnice, ki sprejemajo bolnike s covidom-19, je ...bilo treba čez noč prestrukturirati v del bolnišnice za bolnike s covidom-19 in v del bolnišnice z ostalimi bolniki, ki nimajo covida-19.
Pri delu s kirurškim bolnikom s covidom-19 je potrebna predvsem popolna in dosledna uporaba zaščitnih sredstev, da ne pride do okužbe zdravstvenega osebja.
Prav tako je potrebna posebna klinična pot znotraj bolnišnic, da ne pride do kontaminacije v delu bolnišnice, ki je brez bolnikov s covidom-19.
Začasno so bile odpovedane vse elektivne kirurške obravnave. Zdaj se pod posebnimi pogoji za zaščito zdravstvenih delavcev in bolnikov ponovno sproščajo.
Pred elektivnimi kirurškimi posegi se priporoča jemanje brisov na covid-19, vendar to ni nujno. Brisi so namreč v 30 % negativni oz. nezanesljivi in se nanje ne moremo popolnoma zanesti. Predvsem je pomembno, da bolnik v zadnjih 14 dneh ni imel znakov prehladne bolezni in prav tako ne člani njegove družine. Znotraj ustanove se moramo vesti do vsakega sprejetega bolnika, kot da je lahko okužen z virusom SARS-CoV-2. Enako velja za osebje. Ravnati se je potrebno glede zaščitnih ukrepov tako, kot da je vsak od zaposlenih okužen z virusom SARS-CoV-2.
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