BACKGROUND AND AIM:Intestinal fatty acid–binding protein (I-FABP) is a useful marker in the detection of intestinal ischemia. However, more insight into the test characteristics of I-FABP release is ...needed. This study aimed to investigate the relationship between plasma I-FABP levels and the severity of ischemic mucosal injury, and define the clinical usefulness of systemic I-FABP following ischemia.
METHODS:In a human experimental model, 6 cm of the jejunum, to be removed for surgical reasons, was selectively exposed to either 15, 30, or 60 minutes of ischemia (I) followed by 30 and 120 minutes of reperfusion (R). Blood and tissue was sampled at all time points. Arteriovenous (V−A) concentration differences of I-FABP were measured. Tissue sections were stained with hematoxylin/eosin, and villus height was measured to score epithelial damage.
RESULTS:Histologic analysis showed only minor reversible intestinal damage following 15I and 30I; however, severe irreversible epithelial damage was observed in the jejunum exposed to 60I. I-FABP V−A differences paralleled the degree of tissue damage over time 7.79 (±1.8) ng/mL, 128.6 (±44.2) ng/mL, 463.3 (±139.8) ng/mL for 15I, 30I and 60I, respectively. A good correlation was found between histologic epithelial damage and V−A I-FABP (r=−0.82, P<0.001). Interestingly, systemic I-FABP levels were significantly increased after 60I of this short small intestinal segment.
CONCLUSIONS:This study demonstrates the relationship between the duration of ischemia and the extent of tissue damage, which is reflected by I-FABP V−A plasma levels. In addition, systemic I-FABP levels appear valuable in detecting irreversible intestinal ischemia-reperfusion damage.
Summary Background Sustainability of hepatic glutathione (GSH) homeostasis is an important cellular defense against oxidative stress. Therefore, knowledge of liver GSH status is important. However, ...measurement of plasma GSH and tissue is difficult due to its instability. Alternatively, ophthalmate (OPH), an endogenous tripeptide analog of GSH, has been suggested as a potential indicator to assess GSH depletion. Aim To provide an overview of present knowledge with respect to the usefulness of OPH as a biomarker for oxidative stress and hepatic GSH homeostasis. Methods A systematic, computerized search combined with a cross-reference search of the literature described in PubMed (January 1975 to January 2012) was conducted, key words: ‘ophthalmate’ and ‘ophthalmic acid’. Results Twenty-two articles were included. Hepatic OPH levels increase inversely proportional to a drop in hepatic GSH in mice with paracetamol (PCM) induced hepatotoxicity. Little is known about the stability of OPH in human plasma. To measure the very low physiological concentrations of plasma OPH, liquid chromatography-mass spectrometry techniques can be employed. OPH synthesis can be measured in humans, using stable isotope labeling with a deuterated water (2 H2 O) load. Conclusion OPH may be a promising biomarker to indicate hepatic glutathione depletion, but the suggested biological pathways need further unraveling.
Abstract Background The impact of body composition on outcomes after surgery for colorectal liver metastases (CRLM) remains unclear. The aim of the present study was to determine the influence of ...sarcopenia, obesity and sarcopenic obesity on morbidity, diseasefree (DFS) and overall survival (OS). Method Between 2005 and 2012, all patients undergoing a partial liver resection for CRLM in the Maastricht University Medical Centre, and who underwent computed tomography (CT) imaging within 3 months before liver surgery, were included. Body composition was primarily based on preoperative CT measurements. Sarcopenia was based on total muscle area at the level of the third lumbar vertebra and predefined body mass index (BMI) and genderspecific cutoff values for sarcopenia were used. Body fat percentages were calculated and the top 40% for men and women were considered obese. Results Of the 171 included patients undergoing liver surgery for CRLM, 80 (46.8%) patients were sarcopenic, 69 (40.4%) obese and 49 (28.7%) sarcopenic obese. The presence of sarcopenia, obesity or sarcopenic obesity did not affect the complication rates. However, readmission rates were significantly increased in patients with (sarcopenic) obesity ( P < 0.05). Surprisingly, obesity seemed to prolong OS ( P = 0.021) and was identified as an independent predictor hazard ratio (HR):0.58 and P = 0.046 for better OS. Sarcopenia and sarcopenic obesity did not affect DFS or OS. Conclusion Sarcopenia, obesity and sarcopenic obesity did not worsen DFS, OS and complication rates after a partial liver resection for CRLM.
Background & Aims Aminotransferases are commonly used to determine the optimal duration of ischemic intervals during intermittent Pringle maneuver (IPM). However, they might not be responsive enough ...to detect small differences in hepatocellular damage. Liver fatty acid-binding protein (L-FABP) has been suggested as a more sensitive marker. This randomized trial aimed to compare hepatocellular injury reflected by L-FABP in patients undergoing liver resection with IPM using 15 or 30 min ischemic intervals. Methods Twenty patients undergoing liver surgery were randomly assigned to IPM with 15 (15IPM) or 30 (30IPM) minutes ischemic intervals. Ten patients not requiring IPM (noIPM) served as controls. Primary endpoint was hepatocellular injury during liver surgery reflected by systemic L-FABP plasma levels. Between group comparisons were performed using area under the curve and repeated measures two-way ANOVA. Results The IPM groups had similar characteristics. Aminotransferases did not differ significantly between 15IPM and 30IPM at any time point. L-FABP levels rose up to 1853 ± 708 ng/ml in the 15IPM and 3662 ± 1355 ng/ml in the 30IPM group after finishing liver transection and decreased rapidly thereafter. There were no significant differences between 15IPM and 30IPM in cumulative L-FABP level ( p = 0.378) or L-FABP level at any time point ( p = 0.149). Blood loss, remnant liver function and morbidity were comparable. Conclusions IPM with 15 or 30 min ischemic intervals induced similar hepatocellular injury measured by the sensitive marker L-FABP. The present study confirms the results of earlier trials, suggesting that IPM with 30 min ischemic intervals may be used.
Abstract Objectives Sarcopenia may negatively affect short‐term outcomes after liver resection. The present study aimed to explore whether total functional liver volume (TFLV) is related to ...sarcopenia in patients undergoing partial liver resection. Methods Analysis of total liver volume and tumour volume and measurements of muscle surface were performed in patients undergoing liver resection using OsiriX® and preoperative computed tomography. The ratio of TFLV to bodyweight was calculated as: TFLV (ml)/bodyweight (g)*100%. The L3 muscle index (cm2 /m2 ) was then calculated by normalizing muscle areas (at the third lumbar vertebral level) for height. Results Of 40 patients, 27 (67.5%) were classified as sarcopenic. There was a significant correlation between the L3 skeletal muscle index and TFLV ( r = 0.64, P < 0.001). Median TFLV was significantly lower in the sarcopenia group than in the non‐sarcopenia group 1396 ml (range: 1129–2625 ml) and 1840 ml (range: 867–2404 ml), respectively; P < 0.05. Median TFLV : bodyweight ratio was significantly lower in the sarcopenia group than in the non‐sarcopenia group 2.0% (range: 1.4–2.5%) and 2.3% (range: 1.5–2.5%), respectively; P < 0.05. Conclusions Sarcopenic patients had a disproportionally small preoperative TFLV compared with non‐sarcopenic patients undergoing liver resection. The preoperative hepatic physiologic reserve may therefore be smaller in sarcopenic patients.
Background
A small remnant liver volume is an important risk factor for posthepatectomy liver failure. ImageJ and OsiriX
®
are both free, open-source image processing software packages. The aim of ...the present study was to compare ImageJ and OsiriX
®
in performing prospective computed tomography (CT) volumetric analysis of the liver on a personal computer (PC) in patients undergoing major liver resection.
Methods
Patients scheduled for a right hemihepatectomy were eligible for inclusion. Two surgeons and one surgical trainee measured volumes of total liver, tumor, and future resection specimen prospectively with ImageJ and OsiriX
®
. A radiologist also measured these volumes with CT scanner-linked Aquarius iNtuition
®
software. Resection volumes were compared with the actual weights of the liver specimens removed during surgery, and differences between the measured liver volumes were analyzed.
Results
A total of 15 patients (8 men, 7 women) with a median age of 63 years (48–79 years) were included. There was a significant correlation between the measured weights of resection specimens and the volumes calculated prospectively with ImageJ and OsiriX
®
(
r
= 0.89;
r
= 0.83, respectively). There was also a significant correlation between the volumes measured with radiological software iNtuition
®
and the volumes measured with ImageJ and OsiriX
®
(
r
= 0.93;
r
= 0.95, respectively).
Conclusions
There were no major differences in total liver volumes, resection volumes, or tumour volumes for these three software packages. Prospective hepatic CT volumetry with ImageJ or OsiriX
®
is reliable and can be accurately used on a PC by nonradiologists. ImageJ and OsiriX
®
yield results comparable to the radiological software iNtuition
®
.
Background
Sarcopenia, obesity and sarcopenic obesity have been linked to impaired outcome after liver surgery. Preoperative liver function of sarcopenic, obese and sarcopenic‐obese patients might be ...reduced, possibly leading to more post‐operative morbidity. The aim of this study was to explore whether liver function and volume were influenced by body composition in patients undergoing liver resection.
Methods
In 2011 and 2012, all consecutive patients undergoing the methacetin breath liver function test were included. Liver volumetry and muscle mass analysis were performed using preoperative CT scans and Osirix® software. Muscle mass and body‐fat% were calculated. Predefined cut‐off values for sarcopenia and the top two body‐fat% quintiles were used to identify sarcopenia and obesity, respectively. Histologic assessment of the resected liver gave insight in background liver disease.
Results
A total number of 80 patients were included. Liver function and volume were comparable in sarcopenic(‐obese) and non‐sarcopenic(‐obese) patients. Obese patients showed significantly reduced liver function 295 (95–508) vs. 358 (96–684) µg/kg/h, P = 0.018 and a trend towards larger liver size 1694 (1116–2685) vs. 1533 (869–2852) mL, P = 0.079 compared with non‐obese patients. Weight (r = −0.40), body surface area (r = −0.32), estimated body‐fat% (r = −0.43) and body mass index (r = −0.47) showed a weak but significant negative (all P < 0.05) correlation with liver function. Moreover, body‐fat% was identified as an independent factor negatively affecting the liver function.
Conclusion
Sarcopenia and sarcopenic obesity did not seem to influence liver size and function negatively. However, obese patients had larger, although less functional, livers, indicating dissociation of liver function and volume in these patients.
The intermittent Pringle maneuver (IPM) is frequently applied to minimize blood loss during liver transection. Clamping the hepatoduodenal ligament blocks the hepatic inflow, which leads to a non ...circulating (hepato)splanchnic outflow. Also, IPM blocks the mesenteric venous drainage (as well as the splenic drainage) with raising pressure in the microvascular network of the intestinal structures. It is unknown whether the IPM is harmful to the gut. The aim was to investigate intestinal epithelial cell damage reflected by circulating intestinal fatty acid binding protein levels (I-FABP) in patients undergoing liver resection with IPM.
Patients who underwent liver surgery received total IPM (total-IPM) or selective IPM (sel-IPM). A selective IPM was performed by selectively clamping the right portal pedicle. Patients without IPM served as controls (no-IPM). Arterial blood samples were taken immediately after incision, ischemia and reperfusion of the liver, transection, 8 hours after start of surgery and on the first post-operative day.
24 patients (13 males) were included. 7 patients received cycles of 15 minutes and 5 patients received cycles of 30 minutes of hepatic inflow occlusion. 6 patients received cycles of 15 minutes selective hepatic occlusion and 6 patients underwent surgery without inflow occlusion. Application of total-IPM resulted in a significant increase in I-FABP 8 hours after start of surgery compared to baseline (p<0.005). In the no-IPM group and sel-IPM group no significant increase in I-FABP at any time point compared to baseline was observed.
Total-IPM in patients undergoing liver resection is associated with a substantial increase in arterial I-FABP, pointing to intestinal epithelial injury during liver surgery.
ClinicalTrials.gov NCT01099475.
Healthcare literature suggests that leadership behavior has a profound impact on nurse work-related well-being. Yet, more research is needed to better conceptualize, measure, and analyse the concepts ...of leadership and well-being, and to understand the psychological mechanisms underlying this association. Combining Self-Determination and Job Demands-Resources theory, this study aims to investigate the association between engaging leadership and burnout and work engagement among nurses by focusing on two explanatory mechanisms: perceived job characteristics (job demands and resources) and intrinsic motivation.
A cross-sectional survey of 1117 direct care nurses (response rate = 25%) from 13 general acute care hospitals in Belgium. Validated instruments were used to measure nurses' perceptions of engaging leadership, burnout, work engagement, intrinsic motivation and job demands and job resources. Structural equation modeling was performed to test the hypothesised model which assumed a serial mediation of job characteristics and intrinsic motivation in the relationship of engaging leadership with nurse work-related well-being.
Confirmatory factor analysis indicated a good fit of the measurement model. The findings offer support for the hypothesized model, indicating that engaging leadership is linked to enhanced well-being, as reflected in increased work engagement, and reduced burnout. The results further showed that this association is mediated by nurses' perceptions of job resources and intrinsic motivation. Notably, while job demands mediated the relationship between EL and nurses' well-being, the relationship became unsignificant when including intrinsic motivation as second mediator.
Engaging leaders foster a favourable work environment for nursing staff which is not only beneficial for their work motivation but also for their work-related well-being. Engaging leadership and job resources are modifiable aspects of healthcare organisations. Interventions aimed at developing engaging leadership behaviours among nursing leaders and building job resources will help healthcare organisations to create favourable working conditions for their nurses.
The study described herein is funded under the European Union's Horizon 2020 Research and Innovation programme from 2020 to 2023 (Grant Agreement 848031). The protocol of Magnet4Europe is registered in the ISRCTN registry (ISRCTN10196901).
Background
A small remnant liver volume is an important risk factor for posthepatectomy liver failure and can be predicted accurately by computed tomography (CT) volumetry using radiologic image ...analysis software. Unfortunately, this software is expensive and usually requires support by a radiologist. ImageJ is a freely downloadable image analysis software package developed by the National Institute of Health (NIH) and brings liver volumetry to the surgeon’s desktop. We aimed to assess the accuracy of ImageJ for hepatic CT volumetry.
Methods
ImageJ was downloaded from http://www.rsb.info.nih.gov/ij/. Preoperative CT scans of 15 patients who underwent liver resection for colorectal cancer liver metastases were retrospectively analyzed. Scans were opened in ImageJ; and the liver, all metastases, and the intended parenchymal transection line were manually outlined on each slice. The area of each selected region, metastasis, resection specimen, and remnant liver was multiplied by the slice thickness to calculate volume. Volumes of virtual liver resection specimens measured with ImageJ were compared with specimen weights and calculated volumes obtained during pathology examination after resection.
Results
There was an excellent correlation between the volumes calculated with ImageJ and the actual measured weights of the resection specimens (r² = 0.98, p < 0.0001). The weight/volume ratio amounted to 0.88 ± 0.04 (standard error) and was in agreement with our earlier findings using CT‐linked radiologic software.
Conclusion
ImageJ can be used for accurate hepatic CT volumetry on a personal computer. This application brings CT volumetry to the surgeon’s desktop at no expense and is particularly useful in cases of tertiary referred patients, who already have a proper CT scan on CD‐ROM from the referring institution. Most likely the discrepancy between volume and weight results from exsanguination of the liver after resection.
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