Hepatobiliary surgery and nutrition最新文献

Background: Diabetes mellitus is a risk factor of pancreatic cancer (PC). We aimed to develop risk models to predict PC within 1- and 3-year in new onset diabetes mellitus (NODM).

Methods: We utilized territory-wide electronic healthcare database to identify NODM patients [fasting glucose ≥7 mmol/L and/or hemoglobin A1c (HbA1c) ≥6.5%] between 2008 and 2017, and observed for three years until PC development, pancreatectomy or death. Outcome of interest was PC at 1- and 3-year. Clinical variables included age, sex, acute pancreatitis history, body mass index (BMI), blood glucose, lipid profile, estimated glomerular filtration rate (eGFR), alanine transaminase (ALT), alkaline phosphatase (ALP), hemoglobin and baseline medication use {metformin, insulin and other anti-diabetic drugs, aspirin, non-steroidal anti-inflammatory drugs, statins, gastroprotective agents [proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs)]}. The cohort was randomly split (7:3 ratio) into training and testing sets. Logistic regression was conducted to identify predictors of PC at 1 and 3 years.

Results: Among 117,121 NODM patients (mean age: 61.63±12.45 years; male: 51.3%), 189 (0.16%) developed PC within 3-year, with 82 (43.4%) in first year. Predictors in 1- and 3-year risk models included age, sex, acute pancreatitis history, insulin, aspirin, gastroprotective agents, baseline glucose, eGFR, ALT, ALP, and BMI (baseline and change from 1 year prior to baseline). The 1- and 3-year models had area under receiver operating characteristics curve of 0.90 and 0.81, respectively. If specificity was set as 99.9%, number-needed-to-screen (NNS) for one PC case within 1-year was 27.

Conclusions: We developed and validated new risk models with high accuracy to predict 1- and 3-year PC risk among NODM patients for targeted screening.

Background: Primarily unresectable liver tumors may be approached by the Associating Liver Partition and Portal vein Ligation for Staged Hepatectomy (ALPPS) procedure. Post-hepatectomy liver failure (PHLF) poses the most significant risk factor for poor outcomes. The AST-to-platelets ratio index (APRI)/albumin-to-bilirubin index (ALBI) score has been proposed as an easy and routinely available score to monitor liver function. Here, we explored the predictive capability of the APRI/ALBI score to determine PHLF and perioperative morbidity to help determine the optimal timing of the 2nd stage of ALPPS.

Methods: Based on the international multicenter ALPPS registry, patients from 2012 to 2020 with an available APRI/ALBI score were included. Postoperative outcomes (clinically relevant PHLF B + C, 90-day mortality, and severe morbidity (≥ Clavien-Dindo 3b) after ALPPS stage II were assessed. The APRI/ALBI score was monitored perioperatively, and the predictive value was evaluated using logistic regression and receiver operating characteristics. Performance of APRI/ALBI score was compared to the ALPPS futility risk score in this cohort study.

Results: Overall, 464 patients from 16 participating centers were included. Clinically relevant PHLF (B + C) was observed in 7.5% of patients, of which 63% ultimately died. After stage I, the APRI/ALBI score gradually recovered. The pre-stage II APRI/ALBI score significantly predicted clinically relevant PHLF [area under the curve (AUC) =0.78; P<0.001], 90-day mortality (AUC =0.67; P=0.002), and severe morbidity (AUC =0.65; P<0.001). Three clinically relevant APRI/ALBI score risk groups were defined: clinically relevant PHLF occurred in 3.1% in the low-, 8.7% in the intermediate-, and 28.0% in the high-risk groups. 90-day mortality was 6.8% in the low-, 15.9% in the intermediate-, and 19.4% in the high-risk groups. Integrated assessment of the established futility risk score in combination with the APRI/ALBI score documented further increased predictive potential for clinically relevant PHLF (AUC 0.81; P<0.001).

Conclusions: The APRI/ALBI score allows for simple and dynamic liver function recovery monitoring after the first ALPPS stage. Inadequate recovery of the APRI/ALBI score until ALPPS stage II was associated with PHLF B + C, 90-day mortality, and severe morbidity. With the proposed risk model, optimized timing of the second stage of ALPPS may further increase the safety of this procedure.

Background: Robotic surgery (RS) and laparoscopic surgery (LS) are increasingly used for pediatric choledochal cysts (CC); however, it remains unclear which technique is superior. We aimed to compare the clinical outcomes, technical performance and surgical workload between RS and LS.

Methods: From January 2014 to February 2023, 604 CC patients (RS =302, LS =302) were enrolled in this multicenter retrospective cohort study after propensity score matching. Surgical videos were rated for technical performance using the Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments.

Results: During follow-up, overall complication rates were similar between two groups, but RS group had lower anastomotic stricture rate (1.32% vs. 4.30%, P=0.03). Despite longer total operative time, RS group had shorter cyst excision and hepaticojejunostomy time. Moreover, RS group had less estimated intraoperative blood loss, higher left/right hepatic duct exposure rate, higher intrapancreatic bile duct exposure rate, higher OSATS score {31.00 [interquartile range (IQR), 30.00-32.00] vs. 29.00 (IQR, 28.00-30.00), P<0.001}, lower number of errors [46.50 (IQR, 43.33-50.72) vs. 56.00 (IQR, 51.00-61.00) times/patient, P<0.001], lower number of events [4.33 (IQR, 3.51-5.17) vs. 9.33 (IQR, 7.83-11.00) times/patient, P<0.001] and lower National Aeronautics and Space Administration Task Load Index (NASA-TLX) score [61.00 (IQR, 60.00-62.00) vs. 69.00 (IQR, 67.00-72.00), P<0.001]. The total NASA-TLX scores was found to be moderately correlated with total OSATS score (r=-0.420, P<0.001), total number of errors (r=0.502, P<0.001) and events (r=0.614, P<0.001). These improvements in RS were more prominent in patients with aberrant right hepatic artery or small anastomotic diameter. RS had lower fever rate, shorter hospital stays, and lower interleukin-6 and C-reactive protein levels at postoperative days 1 and 3. No cyst malignancy or deaths occurred.

Conclusions: RS for selected pediatric CC offers superior technical performance and less surgeon workload, as well as lower anastomotic stricture rate than LS in high-volume children's centers.