Annals of hepato-biliary-pancreatic surgery最新文献

Backgrounds/aims: Patients undergoing liver resection for hepatocellular carcinoma (HCC) often possess good liver reserve, which may limit the prognostic effectiveness of existing liver function scores. This study aimed to develop a novel liver function score and a preoperative prognostic model specifically for HCC resection patients.

Methods: Eight hundred twenty-seven HCC patients undergoing initial liver resection were segregated into training and validation cohorts in a 6:4 ratio. Cox regression analysis was employed to identify significant parameters influencing overall survival. The efficacy of the liver function score and prognostic model was evaluated using metrics such as the area under the receiver operating characteristic curve.

Results: Aspartate aminotransferase (AST) and albumin emerged as significant prognostic indicators. The AST-albumin (ASAL) score, calculated as exp [AST (IU/L) × 0.005 - albumin (g/dL) × 1.043] × 100, outperformed existing scores such as Child-Turcotte-Pugh, albumin-bilirubin, platelet-albumin, and AST-platelet ratio index in both training and validation cohorts. Additionally, a scoring model that combined the ASAL score with alpha-fetoprotein and the up-to-seven criterion exhibited superior discriminatory capabilities compared to the American Joint Committee on Cancer tumor, node, metastasis stage, and Barcelona Clinic Liver Cancer stage.

Conclusions: The proposed prognostic model that integrates the novel ASAL score offers promising prognostic potential for HCC patients undergoing liver resection.

Various treatment modalities are available for small solitary hepatocellular carcinoma (HCC), yet the optimal primary treatment strategy for tumors ≤ 3 cm remains unclear. This network meta-analysis investigates the comparative efficacy of various interventions on the long-term outcomes of patients with solitary HCC ≤ 3 cm. A systematic search of electronic databases from January 2000 to December 2023 was conducted to identify studies that compared at least two of the following treatments: surgical resection (SR), radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). Survival data were extracted, and pooled hazard ratios with 95% confidence intervals were calculated using a frequentist network meta-analysis. A total of 30 studies, comprising 2 randomized controlled trials and 28 retrospective studies, involving 8,053 patients were analyzed. Surgical resection showed the highest overall survival benefit with a p-score of 0.95, followed by RFA at 0.59, MWA at 0.23, and TACE, also at 0.23. Moreover, SR provided the most significant recurrence-free survival advantage, with a p-score of 0.95, followed by RFA at 0.31 and MWA at 0.19. Sensitivity analyses, excluding low-quality or retrospective non-matched studies, corroborated these findings. This network meta-analysis demonstrates that SR is the most effective first-line curative treatment for single HCC ≤ 3 cm, followed by RFA in patients with preserved liver function. The limited data on MWA and TACE underscore the need for further studies.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive tumors, and the most common cause of cancer-related deaths. In the past, vascular infiltration of the tumor rendered the disease unresectable. However, today, venous or arterial involvement of a PDAC is classified as borderline resectable (BR) or locally advanced (LA) disease. Pancreaticoduodenectomy (PD) with vascular resections is a promising intervention intended for complete resection of BR- and LA-PDAC. This study aims to assess the overall survival of patients undergoing PD with vascular resections, compared to those without. A PubMed search was conducted for cohort studies that included patients with BR- or LA-PDAC treated with vascular resections. The retrieved publications were screened following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist. The study protocol was registered at the International Prospective Register for Systematic Reviews (PROSPERO). Sixteen cohort studies were included in our systematic review. Fourteen of them included patients undergoing PD with venous-only resections for PDAC. The 5-year overall survival rates ranged from 8.0% to 22.2% for vascular resection patients, and 4.0% to 24.3% for standard PD patients. Three cohorts included patients with PDAC and arterial and/or venous involvement who were treated with arterial resections. Their median overall survival ranged from 13.7 to 17.0 months, similar to that of patients who did not undergo vascular resections. PD with vascular resections in patients with BR- and LA-PDAC could lead to similar overall survival to that after standard PD.

Backgrounds/aims: The efficacy of neoadjuvant transarterial chemoembolization (N-TACE) in resectable hepatocellular carcinoma (HCC) remains open to debate. While N-TACE may reduce tumor size, its impact on long-term outcomes is inconclusive.

Methods: This meta-analysis reviewed studies on N-TACE before surgical resection vs. liver resection (LR) single large hepatocellular carcinoma (SLHCC) up to March 2023 from four online databases.

Results: Five studies with 1,556 patients were analyzed. No significant differences between N-TACE and LR groups were observed in 1-, 3-, or 5-year overall survival (OS) and disease-free survival (DFS). No significant differences were noted in intraoperative blood loss between groups. Subgroup analysis showed favorable 1-, 3-, and 5-year OS with combination chemotherapy N-TACE (combination group), and better 1-year OS in the LR group with single-agent chemotherapy N-TACE (single-agent group). Five-year DFS favored LR in the single-agent group, and N-TACE in the combination group.

Conclusions: Managing SLHCC requires intricate considerations, and the treatment strategies for this challenging subgroup of HCC need to be improved. The influence of N-TACE on long-term survival depends on the specific chemotherapy regimen employed, and its impact on intraoperative blood loss in SLHCC appears limited.

Backgrounds/aims: Ambulatory laparoscopic cholecystectomy (LC) is increasingly recognized for its advantages over the inpatient approach, which advantages include cost-effectiveness and faster recovery. However, its acceptance is limited by patient concerns regarding safety, and the potential for postoperative complications. The study aims to compare the operative and postoperative outcomes of ambulatory LC versus inpatient LC, specifically addressing patient hesitations related to early discharge.

Methods: In a retrospective analysis, patients who underwent LC were divided into ambulatory or inpatient groups based on American Society of Anesthesiologists (ASA) classification, age, and the availability of postoperative care. Propensity score matching was utilized to ensure comparability between the groups. Data collection focused on demographic information, perioperative data, and postoperative follow-up results to identify the safety of both approaches.

Results: The study included a cohort of 220 patients undergoing LC, of which 48 in each group matched post-propensity score matching. The matched analysis indicated that ambulatory LC patients seem to experience shorter operative times and reduced blood loss, but these differences were not statistically significant (35 minutes vs. 46 minutes, p-value = 0.18; and 8.5 mL vs. 23 mL, p-value = 0.14, respectively). There were no significant differences in complication rates or readmission frequencies, compared to the inpatient cohort.

Conclusions: Ambulatory LC does not compromise safety or efficacy, compared to traditional inpatient procedures. The findings suggest that ambulatory LC could be more widely adopted, with appropriate patient education and selection criteria, to alleviate concerns and increase patient acceptance.

Pancreaticobiliary maljunction (PBM) is associated with the development of neoplasms of bile ducts. Cholecystectomy with diversion of the biliary-pancreatic flow is considered the treatment of choice. To describe the surgical treatment employed for a patient with Komi's type 2 PBM and its long-term results. Laparoscopic common bile duct exploration, intraoperative cholangioscopy, and Roux-en-Y hepatico-jejunostomy were performed. Postoperative evolution was satisfactory. The patient was discharge 72 hours after the surgery. There was no associated morbidity. At 62-month follow-up, clinical examination, laboratory tests, and imaging studies confirmed an adequate patency of bilio-enteric anastomosis. The surgical approach employed was effective and safe, with satisfactory long-term results.

Hepatic compartment syndrome (HCS) is a rare but life-threatening entity that consists of a decreased portal flow due to intraparenchymal hypertension secondary to subcapsular liver hematoma. Lethal liver failure can be observed. We report three cases, and review the literature. A 54-year-old male was admitted for extensive hepatic subcapsular hematoma after blunt abdominal trauma. Initially, he underwent embolization of the hepatic artery's right branch, after which he presented clinical deterioration, major cytolysis (310 times the upper limit of normal [ULN]), and liver failure with a prothrombin time (PT) at 31.0%. A 56-year-old male underwent liver transplantation for acute alcoholic hepatitis. On postoperative day 2, he presented a hemorrhagic shock associated with deterioration of liver function (cytolysis 21 ULN, PT 39.0%) due to extensive hepatic subcapsular hematoma. A 59-year-old male presented a hepatic subcapsular hematoma five days after a cholecystectomy, revealed by abdominal pain with liver dysfunction (cytolysis 10 ULN, PT 63.0%). All patients ultimately underwent urgent surgery for liver capsule excision, hematoma evacuation, and liver packing, if needed. The international literature was screened for this entity. These three patients' outcomes were favorable, and all were alive at postoperative day 90. The literature review found 15 reported cases. HCS can occur after any direct or indirect liver trauma. Surgical decompression is the main treatment, and there is probably no place for arterial embolization, which may increase the risk of liver necrosis. A 13.3% mortality rate is reported. HCS is a rare complication of subcapsular liver hematoma that compresses the liver parenchyma, and leads to liver failure. Urgent surgical decompression is needed.

Backgrounds/aims: Pancreaticoduodenectomy (PD) is being performed more frequently. A pancreaticojejunostomy (PJ) leak is the major determinant of patient outcomes. An omental flap around PJ might improve postoperative outcomes.

Methods: A prospective randomized controlled trial was planned at PGIMER, Chandigarh. Fifty-eight patients meeting the criteria were included in the study. Group A underwent PD with omental roll-up and group B underwent standard PD.

Results: The mean age of patients in group A was 57.1 ± 14.3 years and 51.2 ± 10.7 in group B. Jaundice (p = 0.667), abdominal pain (p = 0.69), and co-morbidities were equal among the groups. The body mass index of patients in group B was higher at 24.3 ± 5.4 kg/m² (p = 0.03). The common bile duct diameter (12.6 ± 5.3 mm vs. 17.2 ± 10.3 mm, p = 0.13) and the pancreatic duct diameter (4.06 ± 2.01 mm vs. 4.60 ± 2.43 mm, p = 0.91) were comparable. The intraoperative blood loss (mL) was significantly higher in group B (233.33 ± 9.57 vs. 343.33 ± 177.14, p = 0.04). Drain fluid amylase levels on postoperative day (POD) 1 (p = 0.97) and POD3 (p = 0.92) were comparable. The rate of postoperative pancreatic fistula (POPF) grade A (p ≥ 0.99) and grade B (p = 0.54) were comparable. The mean postoperative length of stay among was similar (p = 0.89).

Conclusions: An omental wrap can be performed without increase in complexity of the procedure. However, its utility in preventing POPFs and morbidity remains unclear.

The role of surgical resection in patients with recurrent pancreatic cancer is unclear. We aimed to evaluate the survival outcomes of pancreatic re-resection for locally recurrent pancreatic cancer following index pancreatectomy. A literature search was carried out in CENTRAL, EMBASE, MEDLINE, CINAHL, and Web of Science. Proportion meta-analysis model was constructed to quantify 1 to 5-year survival after pancreatic re-resection for locally recurrent pancreatic cancer. Random-effects modelling was applied to calculate pooled outcome data. Fifteen retrospective studies were included, reporting a total of 250 patients who underwent pancreatic re-resection for locally recurrent pancreatic cancer following their index pancreatectomy. Pancreatic re-resection was associated with 1-year survival 70.6% (95% confidence interval [CI], 65.0-76.2), 2-year survival 38.8% (95% CI, 28.6-49.0), 3-year survival 20.2% (95% CI, 13.8-26.7), and 5-year survival 9.2% (95% CI, 5.5-12.8). The between-study heterogeneity was insignificant in all outcome syntheses. Repeat pancreatectomy for local recurrence of pancreatic cancer in the remnant pancreas following the index pancreatectomy is associated with acceptable overall patient survival. We recommend selective re-resection of such recurrences in younger patients with favorable tumor size and location. Our findings may encourage more robust studies to be conducted in this context to provide stronger evidence.

This systematic review and meta-analysis aimed to evaluate the impact of prospective payment systems (PPSs) on cholecystectomy. A comprehensive literature review was conducted, examining studies published until December 2023. The review process focused on identifying research across major databases that reported critical outcomes such as length of stay (LOS), mortality, complications, admissions, readmissions, and costs following PPS for cholecystectomy. The studies were specifically selected for their relevance to the impact of PPS or the transition from fee-for-service (FFS) to PPS. The study analyzed six papers, with three eligible for meta-analysis, to assess the impact of the shift from FFS to PPS in laparoscopic and open cholecystectomy procedures. Our findings indicated no significant changes in LOS and mortality rates following the transition from FFS to PPS. Complication rates varied and were influenced by the diagnosis-related group categorization and surgeon cost profiles under episode-based payment. There was a slight increase in admissions and readmissions, and mixed effects on hospital costs and financial margins, suggesting varied responses to PPS for cholecystectomy procedures. The impact of PPS on cholecystectomy is nuanced and varies across different aspects of healthcare delivery. Our findings indicate a need for adaptable, patient-centered PPS models that balance economic efficiency with high-quality patient care. The study emphasizes the importance of considering specific surgical procedures and patient demographics in healthcare payment reforms.