Hpb最新文献

Background: hypertrophy techniques expanded surgical indications, but some patients still experience limited clinical benefit. We aimed to identify futility predictive factors in major hepatectomies after liver venous deprivation (LVD) or ALPPS-variants (tourniquet-ALPPS or hybrid-ALPPS).

Methods: a bi-institutional cohort study conducted between 01/2015 and 07/2024 including major hepatectomies for oncologic disease following one of the three augmentation strategies.

Exclusion criteria: age <18, benign pathology, follow-up < 6-months, and interstage dropout. Futility corresponded to 90-days mortality or very early recurrence (≤6 months). Predictors of futile outcomes were identified by uni- and multi-variate analyses and utilized to build a futility score (0-10).

Results: 84 patients completed the surgical process (dropout rate: 21.1 %): 40.5 % underwent LVD, 33.3 % tourniquet-ALPPS, and 26.2 % hybrid-ALPPS. Futility was observed in 35 patients (41.7 %) and logistic regression identified baseline sFLR (OR 0.89, p = 0.013), associated procedures (OR 3.07, p = 0.046), right trisectionectomy (OR 5.61, p = 0.031), and non-radical resection (OR 4.31, p = 0.01) as independent predictors. A futility score ≥4 (n = 36) predicted a futile outcome with good discrimination (AUC 0.802; p < 0.001).

Conclusion: Technical success after hypertrophy techniques not always equates clinical benefit. Recognizing predictors of futility may improve patient selection and guide more personalized therapeutic strategies.

Background: Optimal perioperative analgesia for upper gastrointestinal (UGI) surgery remains uncertain despite multiple available options. This network meta-analysis (NMA) evaluated the comparative effectiveness of local and regional analgesic techniques on postoperative pain and opiate consumption following open UGI surgery.

Methods: A Bayesian NMA of randomised controlled trials (RCTs) was performed using MEDLINE, Embase, PubMed, and CENTRAL (January 2010-November 2023). The primary outcome was postoperative pain intensity at rest at 24 h.

Results: Fifty-three RCTs (n = 4207 patients) were included. Epidural analgesia provided the greatest reduction in 24-h pain (Mean Difference (MD) -0.976; Credible Interval (CrI) -0.558,-1.401) and opiate consumption (MD -24.717; CrI -16.541,-33.355). The transversus abdominis plane (TAP) block significantly reduced pain at 24 and 48 h, while local wound infiltration and continuous wound catheter infusion demonstrated strong opioid-sparing effects. Only the TAP block resulted in a significant reduction in hospital length of stay. Sensitivity and procedure-specific analyses showed results consistent with the primary analysis.

Conclusion: Epidural analgesia provides the greatest early analgesic and opioid-sparing benefit following open UGI surgery, though these effects do not consistently translate into improved recovery outcomes. TAP block and wound-based analgesic techniques offer effective, less invasive alternatives that may be preferable in selected patients.

Background: Feeding jejunostomy (FJ) is used for providing early enteral nutrition in patients undergoing pancreaticoduodenectomy (PD) but can be associated with complications. This study aims to provide an updated systematic review and meta-analysis of the recent literature to evaluate FJ-tube specific complications and clinical outcomes with FJ use in patients undergoing PD.

Methods: The analysis was performed by identifying eligible studies via search of Medline, PubMed and EMBASE databases. Studies comparing outcomes of patients undergoing PD with FJ and those without were included. Studies looking at tube-specific complications were separately reviewed.

Results: A total of 10 studies were included for review which included a total of 7097 patients undergoing PD which included 1712 patients with FJ, and 5385 patients with no FJ. Patients with FJ inserted were associated with a higher rate of DGE (OR 2.24 [1.62-3.10]), p < 0.00001) than those without FJ. FJ tube-specific complications include dislodgement, blockage, relaparotomy, jejunal emphysema with an incidence rate of 1.4-3.5 %.

Conclusion: Use of FJ, with its benefit and risk profile needs to be carefully considered in each select case of PD.

Background: Split-derived right liver grafts are often considered marginal. This study aimed to compare the long-term outcomes of adult liver transplantation using either whole liver (WL) or right hemi-liver (RHL).

Methods: This single-center retrospective comparative study included liver transplants that were performed between 1991 and 2010.

Results: A total of 775 liver transplants were performed, including 70 RHL cases (9%). Donors were younger in the RHL group (25 ± 11 vs. 39 ± 16 years, p=0.001). Complications were similar between the RHL and WL groups, except for bilioma, more frequent in RHL group (11.4% vs. 2.1%, p= 0.001). The median follow-up was 15,9 (1,2-33,9) years. Graft and recipient survival at 1, 3, 5, 10, and 20 years were similar between the groups (p=0.298). After matching for recipient age, donor sex, and transplant indication, the incidence of bilioma was comparable. Independent factors significantly affecting survival were recipient age (HR = 1.027, p=0.009), donor age (HR = 1.012, p=0.014), and duration of cold ischemia (HR = 1.002, p=0.018).

Conclusion: The very long-term follow-up of this study reinforces the safety and efficacy of RHL transplantation, demonstrating the role in expanding the donor pool without compromising very long-term outcomes.

Background: Focal nodular hyperplasia (FNH) is a benign liver tumor commonly found in women, often linked to oral contraceptive use. Its occurrence in men is rare and frequently mimics malignant liver lesions, complicating diagnosis and management. This systematic review aims to evaluate the clinical presentation, diagnostic challenges, and treatment approaches of FNH in male patients.

Methods: A systematic review was conducted according to PRISMA guidelines and registered in the PROSPERO database (CRD420245397). PubMed, Web of Science, and ScienceDirect were searched up to July 30, 2024, for studies on FNH in male adults. Data extraction and quality assessment were performed independently by multiple reviewers using the Newcastle-Ottawa Scale.

Results: Out of 1771 records, 20 studies including 38 male patients were analyzed. FNH was incidentally discovered in 22 cases, with most patients asymptomatic or having nonspecific symptoms. Imaging often revealed central stellate scars. Surgical resection was performed in 25 patients, primarily due to diagnostic uncertainty. Observation was chosen in 11 cases.

Conclusion: FNH in men is uncommon and presents diagnostic difficulties due to its overlap with malignancies. The high rate of surgical treatment, even in asymptomatic patients, highlights the need for more accurate, non-invasive diagnostic tools.

Background: The optimal test for diagnosing pancreatic exocrine insufficiency (PEI) remains debated. This study compares the diagnostic accuracy of faecal elastase-1 (FE-1) and the ¹³C Mixed Triglyceride Breath Test (MTGT) in patients undergoing pancreatic surgery.

Methods: Patients undergoing pancreatic resection at Antwerp University Hospital (2016-2023) had FE-1 and MTGT testing before and after surgery. The MTGT was used as the reference standard. Agreement between both tests was evaluated using Cohen's kappa.

Results: Preoperatively, in a patient cohort of 249 patients, PEI was detected in 25.3 % using MTGT and 39.6 % using FE-1 (cutoff <200 μg/g). The sensitivity and specificity of FE-1 were 63.5 % and 68.3 %, respectively. Agreement was fair (κ = 0.27). After pancreatoduodenectomy, the prevalence of PEI increased to 60 % (MTGT) and 92.2 % (FE-1), with only slight agreement between tests (κ = 0.17). Although FE-1 demonstrated high sensitivity (98.1 %), its specificity was poor (16.7 %), resulting in an 83.5 % false-positive rate.

Conclusions: In patients undergoing pancreatic surgery, especially after pancreatoduodenectomy, the agreement between MTGT and FE-1 is substantially lower than expected. FE-1 demostrates low specificity and a high false-positive rate, resulting in overdiagnosis and unnecessary economic and patient burden.

Introduction: The prognostic impact of positive bile duct margins (R1) after resection of perihilar cholangiocarcinoma (PHC) remains unclear, and evidence on the role of adjuvant radiation (RT) is limited.

Methods: We retrospectively reviewed 110 patients who underwent curative-intent resection for PHC from 1997 to 2018. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Univariate and multivariate analyses were performed to identify risk factors of OS and DFS.

Results: R1 margins were present in 50 patients (45.5 %). Median OS and DFS for the cohort were 47.5 and 30.2 months. OS and DFS did not differ by margin status. On multivariable analysis, lymph node metastasis independently predicted worse OS (HR 3.81; p < 0.001) and DFS (HR 3.32; p = 0.001), while larger tumor size predicted recurrence (HR 3.12; p = 0.001). Adjuvant chemotherapy was associated with improved OS (HR 0.45; p = 0.049). Among R1 patients, adjuvant RT was associated with longer DFS (68.6 vs 17.8 months; p = 0.049) but not OS.

Conclusions: R1 resection was not associated with inferior survival in this cohort. Lymph node metastasis was the strongest prognostic factor. Adjuvant RT was associated with improved DFS in the R1 patients, supporting its use for local control and warranting prospective validation.

Background: Oncological characteristics and underlying liver function influence the outcomes of patients with hepatocellular carcinoma. The Albumin-Bilirubin (ALBI) score, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) are predictive instruments. However, for patients undergoing hepatic resection, their value remains unclear, particularly in Western populations.

Methods: ALBI, NLR and PLR were derived from blood tests obtained prior to surgery in 156 consecutive patients who underwent R0 hepatic resections between 2015 and 2020 at a Western academic center. Associations with overall survival (OS) and progression-free survival (PFS) were analyzed using Kaplan-Meier methods and Cox regression models.

Results: Median age was 60 years; 72 % of patients were male, and 45 % had underlying cirrhosis. On univariate analysis, ALBI grade was associated with OS and PFS and NLR with OS, but neither retained significance in multivariate models. PLR was not predictive. Cirrhosis (HR 2.32), ECOG performance status ≥2 (HR 2.67), and AFP >100 ng/mL (HR 2.89) were independently associated with worse OS in multivariate analysis. Tumor number ≥2 and AFP >100 ng/mL were two independent predictors for PFS.

Conclusion: ALBI, NLR and PLR did not emerge as clinically relevant predictive value for OS and PFS in patients undergoing resection for HCC.

Introduction: Hepatocellular carcinoma (HCC) is a common indication for liver transplant. We set out to identify high performing HCC centers to understand their listing and donor acceptance patterns.

Methods: The Organ Procurement and Transplantation Network data was quired identifying patients with HCC. Centers were stratified into high functioning (HFC) and low functioning centers (LFC) based on the percentage of waitlisted patients who were transplanted and patients who died or were delisted (DDL).

Results: Multivariable analysis identified utilization of donor after circulatory death (DCD) (OR 2.25 p < 0.01) as the largest contributing factor in HFC. The current LFC transplant to DDL ratio is 1.3 whereas HFC have experiences a 1.8-fold increase from the implementation of acuity circle (AC) allocation with a transplant to DDL ratio of 9.5. Multivariable analysis suggests that this gain is related to adopting the use of DCD donor after the implantation of AC allocation (OR 4.22, p < 0.01).

Conclusions: High functioning HCC transplant center phenotype exists and appears to be most driven by the utilization of DCD donors. AC allocation has served to exacerbate disparities between HFC and LFC with the key adaptation made being the increased use of DCD donors.