Hepatobiliary surgery and nutrition最新文献

Background: Although offering the best chance of potential cure for patients with localized perihilar cholangiocarcinoma (pCCA), resection has been associated with high morbidity and sometimes poor long-term outcomes due to recurrence. We sought to develop a predictive model to identify individuals at high risk for very early recurrence (VER) after curative-intent surgery for pCCA.

Methods: Patients who underwent curative-intent surgery for pCCA between 2000-2023 were identified from a multi-institutional database. An eXtreme Gradient Boosting (XGBoost) model was developed to estimate the risk of VER, defined as recurrence within 6 months after resection. The relative importance of clinicopathologic factors was determined using SHapley Additive exPlanations (SHAP) values.

Results: Among 434 patients undergoing curative-intent resection for pCCA, 65 (15.0%) patients developed VER. Median overall survival (OS) among patients with and without VER was 8.4 [interquartile range (IQR) 6.6-11.3] versus 38.5 (IQR 31.9-45.7) months (P<0.001). An XGBoost model was able to stratify patients relative to the risk of VER [low-risk: 6-month recurrence-free survival (RFS) 94.6% vs. intermediate-risk: 6-month RFS 88.3% vs. high-risk: 6-month RFS 40.0%; P<0.001]. Similarly, 3-year OS incrementally worsened based on VER risk (low-risk: 75.3% vs. intermediate-risk: 19.5% vs. high-risk: 4.6%; P<0.001). The SHAP algorithm identified age, preoperative carbohydrate antigen 19-9 (CA19-9) levels, tumor size and differentiation/grade, as well as lymph node metastasis as the five most important predictors of VER. The predictive accuracy of the model was good in the training [c-index: 0.74, 95% confidence interval (CI): 0.67-0.81] and internal validation (c-index: 0.77, 95% CI: 0.71-0.83) cohorts. An easy-to-use risk calculator for VER was developed and made available online at: https://junkawashima.shinyapps.io/VER_hilar/.

Conclusions: A novel, machine learning based model was able to predict accurately the chance of VER after curative-intent resection of pCCA. In turn, the tool may help surgeons in the selection of patients likely to benefit the most from resection, as well as counsel individuals about the anticipated risk of recurrence in the early post-operative period.

Background and objective: Selective internal radiation therapy (SIRT) represents an endovascular treatment option for patients with hepatocellular carcinoma (HCC). Its use is widely recognized in the intermediate and advanced HCC, but it has become more prevalent in recent years in different Barcelona Clinic Liver Cancer (BCLC) stages. The aim of this review is to summarize the role of SIRT and its clinical implications through different stages of HCC.

Methods: A literature review of papers on this topic was performed using PubMed MEDLINE, focusing exclusively on the role of yttrium-90 SIRT across all BCLC stages and comparing it with other treatments. Only English-language papers currently available until September 2023 were considered.

Key content and findings: Many studies have shown that SIRT is a promising tool with multiple uses, such as tumour control in the context of bridge-to-liver transplantation or resection, tumour downstaging, and curative therapy in selected patients. Therefore, according to the recent update of BCLC staging system criteria, SIRT now emerges as a potential curative treatment for early-stage HCC patients, serving as an alternative when ablation or resection is not feasible. It is also a promising treatment compared to transarterial chemoembolization (TACE) as well as in combination with immunotherapies.

Conclusions: SIRT is a safe and effective treatment for selected patients at all BCLC stages of HCC. Therefore, due to its numerous advantages, SIRT may prove useful in many complex HCC treatment situations in the near future.

Keywords: Hepatocellular carcinoma (HCC); radioembolization; yttrium-90 (⁹⁰Y); selective internal radiation therapy (SIRT); transarterial radioembolization (TARE).

Background: Minimally invasive surgeries are increasingly central to modern medicine, particularly in liver transplantation. These techniques, which offer reduced trauma, precise operations, minimal bleeding, and swift recovery, are, however, unevenly adopted across China. Only a limited number of centers routinely perform minimally invasive donor hepatectomies, indicating a significant imbalance in the development and application of these advanced procedures. Additionally, there lacks a set of standardized guidelines that are tailored to meet China's unique healthcare challenges and conditions.

Methods: In August 2023, the Branch of Organ Transplant of Chinese Medical Association and the Branch of Organ Transplant Physicians of Chinese Medical Doctor Association convened a group of national liver transplantation experts to establish a guideline development committee. This committee conducted a thorough review of relevant literature, evaluated existing guidelines and consensus, and assessed factors such as the evidence base, patient preferences, and the cost-effectiveness of interventions within China. After multiple rounds of discussions, both online and offline, the committee finalized the guidelines.

Results: This collaborative effort led to the creation of the "Chinese guidelines for minimally invasive donor hepatectomy in living donor liver transplantation (2024 edition)". These guidelines address crucial aspects such as the safety and advantages of minimally invasive surgery for living donor liver transplantation, donor selection criteria, anesthesia strategies, surgical technical details, and learning curves associated with these procedures, resulting in a comprehensive set of 26 recommendations.

Conclusions: The formulation of these guidelines represents a significant advancement towards standardizing minimally invasive liver transplantation surgeries in China. They are designed to enhance outcomes for both donors and recipients by synthesizing expert consensus with contemporary research and clinical practices. Moreover, they serve as a crucial reference for surgeons and medical institutions, promoting the refinement and adoption of minimally invasive surgical techniques in liver transplantation.

Background: Pancreaticoduodenectomy (PD) is associated with severe postoperative pain. Optimized pain management can potentially elevate patients' postoperative quality of life. This study focused on comparing the analgesic efficacy and subsequent functional recovery of three techniques, continuous local wound infiltration (LWI), four-quadrant transversus abdominis plane (4QTAP) block, and needle electrical twitch obtaining intramuscular stimulation (NETOIMS), in patients subjected to open PD.

Methods: This is a prospective, single-blinded, randomized controlled study. Among a total of 80 eligible patients, 72 were randomized into the LWI, 4QTAP block, or NETOIMS groups for postoperative pain management. The primary outcome measured was the pain score, which was recorded on postoperative days (PODs) 0, 1, 2, 3, 5, 7, 14, and 28. Additionally, consumption of morphine milligram equivalents (MMEs) and ibuprofen until POD 3 was analyzed. Functional recovery indicators, such as gait speed and peak cough flow (PCF), were assessed on the day before surgery (baseline), and on PODs 2, 7, 14, and 28. A one-way analysis of variance, with subsequent post-hoc Bonferroni analysis, was used to compare these main outcomes.

Results: Out of the 72 patients, 68 (LWI, 22; 4QTAP, 23; NETOIMS 23) were included in the final analysis. Compared to the LWI group, both the 4QTAP block and NETOIMS group demonstrated significantly lower pain scores from PODs 0 through 7 (P<0.001 for POD 0-5; P=0.001 for POD 7, for both groups). The pain scores in the 4QTAP block and NETOIMS groups were comparable across all recorded time points. Up to POD 3, there was a significant reduction in both MMEs (P<0.001) and ibuprofen consumption (P=0.003) in these groups. Additionally, on POD 2, the 4QTAP block and NETOIMS groups exhibited superior PCF (P<0.001) and faster gait speed (P=0.008) compared to the LWI group.

Conclusions: Compared to LWI, both 4QTAP block and NETOIMS were more effective in reducing postoperative pain, necessitated fewer analgesics, and facilitated improved functional recovery after PD.

Trial registration: Clinical Research Information Service of Korea Disease Control and Prevention Agency; cris.nih.go.kr; registration ID: KCT0005814.