Functional remnant liver volumetry using Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) predicts post-hepatectomy liver failure in resection of more than one segment

BackgroundGd-EOB-DTPA-enhanced magnetic resonance imaging (EOB-MRI) can be used for evaluating liver functional reserve. We assessed whether functional remnant liver volumetry (FRLV) using EOB-MRI predicted post-hepatectomy liver failure (PHLF) in resection of more than one segment.MethodsWe retrospectively analyzed 155 cases of hepatectomy of more than one segment. For assessment of FRLV, signal intensity (SI) of remnant liver was measured in T1-weighted images. Functional remnant liver score was derived by division of SI of liver by SI of muscle (or spleen), resulting in liver-to-muscle ratio (LMR) and liver-to-spleen ratio (LSR). FRLV were calculated by multiplying LMR (or LSR) and remnant liver volume. We investigated preoperative factors predicting PHLF (≥grade B) in study cohort (all cases except for portal vein embolization [PVE], n = 129) and validation cohort (PVE cases, n = 26).ResultsIn study cohort, PHLF occurred in 5 patients (3.9%). In multivariate analysis, FRLV (LMR) was the most reliable predictor of PHLF (P = 0.013). The cutoff value of FRLV (LMR) predicting PHLF was 615 mL/m² (AUC: 0.939). In validation cohort (n = 26), the cutoff value of FRLV (LMR) indicated reliable results, sensitivity (100%), specificity (77.3%), and accuracy (80.8%).ConclusionsFRLV using LMR could precisely predict PHLF of more than one segment, and was useful even in patients who underwent PVE.     

Prediction with functional liver volume assessment to achieve the resection limit after portal vein embolization in patients scheduled major hepatectomy

BackgroundPreoperative portal vein embolization (PVE) stimulates liver hypertrophy and improves the safety of major hepatectomy. It is essential to predict the future remnant liver volume (FRLV) and resection limit following PVE. Previously, we reported that evaluating functional FRLV (fFRLV) using EOB-MRI could predict post-hepatectomy liver failure. In this study, we investigated the usefulness of fFRLV in predicting the achieving of adequate resection limit for safe hepatectomy following PVE.MethodsWe included 55 patients who underwent PVE and were scheduled for major hepatectomy. We calculated the liver-to-muscle ratio in the remnant liver and fFRLV using EOB-MRI. We investigated the pre-PVE variables in determining the nonachievement of the resection limit.ResultsThe median observation period between PVE and the first evaluation was 21 days, and the median growth rate of FRLV was 26.4%. In 54.5% of patients, the resection limit of fFRLV (615 mL/m²) was achieved. In logistic regression and receiver-operating characteristic analyses, pre-PVE fFRLV (p < 0.001, area under the curve: 0.852) was the reliable predictor of achieving the resection limit; the cutoff value of pre-PVE fFRLV was 446 mL/m².ConclusionPre-PVE fFRLV can be useful in predicting the achievement of adequate resection limit following PVE.     

Mechanisms of splenic hypertrophy following hepatic resection

Background

Following hepatic resection, liver regeneration has been associated with concurrent splenic hypertrophy. The mechanisms of this phenomenon are unknown, may be multiple and include: splanchnic sequestration caused by a reduction in the hepatic mass; hepatic growth factors that may indirectly act on the spleen, and the redistribution of the total reticuloendothelial system.

Methods

Seventy-five patients (40 males; median age: 60 years) who underwent minor (16%) or major (84%) hepatectomy between September 2004 and October 2009 were included. Prospective measurements of liver and spleen volumes were obtained preoperatively and postoperatively 1 month after hepatectomy using computed tomography (CT). The future remnant liver volume (RLV) was calculated on preoperative CT and the extent of resection was expressed as the RLV divided by total liver volume (TLV). Liver and spleen hypertrophy were expressed according to the absolute gain or relative increase in the initial volumes (%).The presence of fibrosis >F1, associated extrahepatic resection (except minor resections), and previous hepatectomy (major or minor) within 3 months represented exclusion criteria.

Results

Mean ± standard deviation (SD) liver volume at 1 month was higher than RLV (1187 ± 286 cm³ versus 764 ± 421 cm³; P < 0.001). Mean ± SD splenic volume increased from 252 ± 100 cm³ preoperatively to 300 ± 111 cm³ at 1 month (P < 0.001). Liver and splenic hypertrophy were significant after major hepatectomies (+100% and +26%, respectively; P < 0.001), but not after minor hepatectomies. Liver hypertrophy was inversely correlated to RLV/TLV (r = −0.687, P < 0.001). Splenic hypertrophy was not correlated to RLV/TLV. Liver and splenic hypertrophy were linearly correlated (r = 0.495, P < 0.001). Neoadjuvant chemotherapy (n = 37), preoperative portal vein embolization (n = 10) and postoperative complications (overall: n = 25; major: n = 10; infectious: n = 6) had no impact on hepatic or splenic hypertrophy.

Conclusions

Splenic hypertrophy occurred after major hepatectomy, but was not correlated to the extent of resection, by contrast with liver hypertrophy. Nevertheless, there was a linear correlation between splenic and liver hypertrophy. This correlation suggests the hypothesis of a splenic action of hepatic growth factors or a redistribution of the total reticuloendothelial system rather than an effect of reduction of the portal bed or hepatic outflow.     

Comparative Assessment of Lixisenatide,Exenatide, and Liraglutide Pen Devices: A Pilot User-Based Study

Background:Glucagon-like peptide-1 (GLP-1) receptor agonists are a relatively recent addition to the treatment options for type 2 diabetes mellitus (T2DM) and are administered using prefilled pen devices.Method:In this open-label task and interview-based pilot study, 3 GLP-1 receptor agonist pen devices—exenatide (Byetta^®, Bristol-Myers Squibb/AstraZeneca), liraglutide (Victoza^®, Novo Nordisk), and lixisenatide (Lyxumia^®, Sanofi-Aventis)—were comparatively assessed in a randomized order in 30 participants with T2DM for ease of use, using a series of key performance measures (time taken to complete a series of tasks, number of user errors [successful performance], and user satisfaction rating). Linear and logistic regression analysis was conducted for the lixisenatide and liraglutide pens versus the exenatide pen. Participants’ mean age was 60 years; 27% and 20% of the participants had visual impairments and reduced manual dexterity, respectively.Results:Tasks were completed faster (P < .001) and with higher successful performance (P = .001) with the lixisenatide pen than with the exenatide pen, whereas the liraglutide pen was not statistically significant versus the exenatide pen on these parameters. Overall, user satisfaction was statistically higher for the lixisenatide and liraglutide pens versus the exenatide pen (P < .001 for both).Conclusions:Lixisenatide and liraglutide pens are associated with higher user satisfaction compared with the exenatide pen. In addition, the lixisenatide pen is faster and results in fewer errors than its comparator (exenatide). The lixisenatide pen may therefore be a suitable choice for patients with T2DM, including older and pen device-naïve patients, and those with visual impairments and reduced manual dexterity.     

How I do it: assessment of hepatic functional reserve for indication of hepatic resection

Liver resection of up to 75% of the total liver volume (TLV) has been regarded as safe in normal livers, but this concept was challenged by the results of living donor hepatectomies. In normal livers or livers with resolved jaundice, hepatectomy of 65% of TLV may be safe, except for patients with an indocyanine green retention rate at 15 min (ICG R15) of over 15%, excessive hepatic steatosis, and age of over 70 years. However, the permissible extent of hepatectomy has been much restricted in cirrhotic livers because most post‐hepatectomy liver failure (PHLF) has occurred in cirrhotic livers. Our routine protocols for the assessment of functional hepatic reserve (FHR) include biochemical liver function tests, ICG R15, Doppler ultrasonography, and triphasic liver computed tomogram (CT) with volumetry. Blood cell count and gastroesophageal endoscopic findings are taken into consideration for cirrhotic livers, as well as age, diabetes, cardiopulmonary function, and general performance. Preoperative portal vein embolization has been used for safe hepatectomy even in cirrhotic livers. We think that any cirrhotic liver showing optimal FHR should have a remnant liver of 40% of TLV to prevent PHLF. ICG R15 and triphasic CT with volumetry have been the most useful methods for assessment of FHR and determination of hepatecomy extent in our institution.     

Measurement of liver function using hepatobiliary scintigraphy improves risk assessment in patients undergoing major liver resection

Background^99mTc-mebrofenin-hepatobiliary-scintigraphy (HBS) enables measurement of future remnant liver (FRL)-function and was implemented in our preoperative routine after calculation of the cut-off value for prediction of postoperative liver failure (LF). This study evaluates our results since the implementation of HBS. Additionally, CT-volumetric methods of FRL-assessment, standardized liver volumetry and FRL/body-weight ratio (FRL-BWR), were evaluated.Methods163 patients who underwent major liver resection were included. Insufficient FRL-volume and/or FRL-function <2.7%/min/m² were indications for portal vein embolization (PVE). Non-PVE patients were compared with a historical cohort (n = 55). Primary endpoints were postoperative LF and LF related mortality. Secondary endpoint was preoperative identification of patients at risk for LF using the CT-volumetric methods.Results29/163 patients underwent PVE; 8/29 patients because of insufficient FRL-function despite sufficient FRL-volume. According to FRL-BWR and standardized liver volumetry, 16/29 and 11/29 patients, respectively, would not have undergone PVE. LF and LF related mortality were significantly reduced compared to the historical cohort. HBS appeared superior in the identification of patients with increased surgical risk compared to the CT-volumetric methods.DiscussionImplementation of HBS in the preoperative work-up led to a function oriented use of PVE and was associated with a significant decrease in postoperative LF and LF related mortality.     

Volumetric analysis and indocyanine green retention rate at 15 min as predictors of post‐hepatectomy liver failure

Objectives

The actual future liver remnant (aFLR) is calculated as the ratio of remnant liver volume (RLV) to total functional liver volume (TFLV). The standardized future liver remnant (sFLR) is calculated as the ratio of RLV to standard liver volume (SLV). The aims of this study were to compare the aFLR with the sFLR and to determine criteria for safe hepatectomy using computed tomography volumetry and indocyanine green retention rate at 15 min (ICG R15).

Methods

Medical records and volumetric measurements were obtained retrospectively for 81 patients who underwent right hemi-hepatectomy for malignant hepatic tumours from January 2010 to November 2013. The sFLR was compared with the aFLR, and a ratio of sFLR to ICG R15 as a predictor of postoperative hepatic function was established.

Results

In patients without cirrhosis, the sFLR showed a stronger correlation with the total serum bilirubin level than the aFLR (R² = 0.499 versus R² = 0.239). Post-hepatectomy liver failure developed only in the group with an sFLR of <25%, regardless of ICG R15. In patients with cirrhosis, the aFLR and sFLR had no correlation with postoperative total serum bilirubin. An sFLR : ICG R15 ratio of >1.9 showed 66.7% sensitivity and 100% specificity.

Conclusions

Regardless of ICG R15, an sFLR of ≥25% in patients without cirrhosis, and an sFLR of ≥25% with an sFLR : ICG R15 ratio of >1.9 in patients with cirrhosis indicate acceptable levels of safety in major hepatectomy.     

Carrier-bound fibrin sealant compared to oxidized cellulose application after liver resection

Objective

The aim of the study was to compare the incidence of post-operative complications between those patients that received TachoSil® to the transection surface of the liver vs. those that received Surgicel®.

Methods

Retrospective study of a prospective database in a tertiary hospital. Primary endpoints were overall complications. Secondary endpoints were liver surgery-specific composite endpoint, major complications and hospital stay. Uni- and multivariate analysis of predictive factors for complications and subgroup analysis were performed.

Results

One hundred thirty-three liver resections were performed between 9 November 2007 and 2 November 2011: 64 with TachoSil® and 69 with Surgicel® application. Both groups were equivalent concerning demographic, clinical and major intra-operative data. No significant differences were observed in overall complication rate (62.5% vs. 62.3%), liver surgery-specific composite endpoint (12.5% vs. 18.8%), major complication rate (18.7% vs. 24.6%) and median hospital stay (13 vs. 10 days) for TachoSil® and Surgicel® application, respectively. Predictive factors for complications in multivariate analysis were: American Society of Anesthesiology Score ≥3 and duration of surgery >240 min. Subgroup analysis found a reduced complication rate with TachoSil® for major hepatectomy.

Conclusion

The results of the present study suggest that the routine use of TachoSil® after a liver resection does not reduce the overall complication rate compared with Surgicel® application. However, TachoSil® may be beneficial in a major hepatectomy.     

Evaluation of an easy and affordable flow cytometer for volumetric haematopoietic stem cell counting

Background

Accurate estimation of haematopoietic stem cell (HSC) counts by flow cytometry may be difficult in laboratories in which sophisticated equipment and staff with specific expertise are not available. Affordable flow cytometers that can perform basic functions may help to overcome these difficulties. In this study we compared HSC and leucocyte counts determined by volumetric and bead-based protocols performed with the small, low-cost Accuri^® C6, with those obtained with two gold-standard instruments, the four-colour FACSCalibur^® and the eight-colour FACSCantoII^®, our reference flow cytometers.

Materials and methods

With the three cytometers we tested, in parallel, 111 consecutive samples from cord blood, peripheral blood from patients with myelofibrosis and myeloproliferative syndromes, fresh and thawed HSC collected by apheresis and bone marrow products. The findings were compared with one-way ANOVA, Bland-Altman analysis and linear regression.

Results

The results of HSC and leucocyte enumeration by the three devices were strongly correlated (r²>0.99; p<0.0001). ANOVA performed on different subgroups of samples did not reveal significant differences between HSC count determined by the C6 bead-based and reference flow cytometers in any of the subgroups. Regarding the C6 volumetric protocol, a statistically significant difference was observed only in the cord blood subgroup. Time for instrument set-up, calibration and analysis was slightly longer with Accuri^® C6 (40 min) than with FACSCantoII^® (30 min).

Discussion

Accuri^® C6 is a reliable instrument for HSC enumeration in fresh samples, using both volumetric and bead-based approaches, although the volumetric protocol on cord blood samples needs to be improved. The Accuri^® C6 is easy to use, does not require profound knowledge of flow cytometry and could be employed in an urgent setting. Its performance may be improved by more efficient calibration and shorter analysis time.     

Risk factors for a high Comprehensive Complication Index score after major hepatectomy for biliary cancer: a study of 229 patients at a single institution

BackgroundThe Comprehensive Complication Index (CCI) is a new tool to evaluate the postoperative condition by calculating the sum of all complications weighted by their severity. The aim of this study was to identify independent risk factors for a high CCI score (≥40) in 229 patients after major hepatectomies with biliary reconstruction for biliary cancers.MethodsThe CCI was calculated online via www.assessurgery.com. Independent risk factors were identified by multivariable analysis.Results57 (25%) patients were classified as having CCI ≥ 40. On multivariable analysis, volume of intraoperative blood loss (≥2.5 L) (p = 0.004) and combined pancreatoduodenectomy (PD) (p = 0.006) were independent risk factors for CCI ≥ 40. A high level of maximum serum total bilirubin was identified as independent risk factors for a high volume of intraoperative blood loss. Liver failure (p = 0.046) was more frequent in patients with combined PD than in those without.DiscussionPatients who undergo preoperative external biliary drainage for severe jaundice might have impaired production of coagulation factors. When blood loss during liver transection becomes difficult to control, surgeons should consider various strategies, such as second-stage biliary or pancreatic reconstruction. In patients planned to undergo major hepatectomy with combined PD, preoperative portal vein embolization is mandatory to prevent postoperative liver failure.     

Impact of correcting the lymphocyte count to improve the sensitivity of TB antigen-specific peripheral blood-based quantitative T cell assays (T-SPOT.?TB and QFT-GIT)

Background

The standardized blood-based TB antigen-specific T cell assay, T-SPOT.^®TB, is ~10% more sensitive than QuantiFERON^®-TB-GIT (QFT-GIT) in detecting presumed latent TB infection (LTBI). Whilst T-SPOT.^®TB uses a fixed number of lymphocytes per well, QFT-GIT uses a fixed volume of blood (~1 mL). However, the person-to-person lymphocyte count can vary by 2 to 3 fold. We hypothesized that this variability could explain the reduced sensitivity of QFT-GIT. The findings could have potential implications for improving case detection.

Methods

T-SPOT.^®TB was compared to QFT-GIT readouts before and after normalization of lymphocyte count (by adjusting the blood volume or lymphocyte enrichment within a fixed 1 mL volume) to an arbitrary value of 2.5×10⁶ cells/mL. Within-test variability was evaluated to meaningfully interpret results.

Results

In patient-specific optimization experiments IFN-γ concentrations significantly increased when QFT-GIT positive samples were enriched with increasing concentrations of lymphocytes (1×10⁶ vs. 2.5×10⁶ cells/mL). However, for the group as a whole lymphocyte enrichment whilst maintaining a ~1 mL volume, compared to un-enriched samples, did not significantly increase IFN-γ [median (range): 0.03 (0–4.41) vs. 0.20 (0–2.40) IU/mL; P=0.64]. There was also no increase in IFN-γ readouts when QFT-GIT lymphocyte numbers were corrected (to 2.5×10⁶ lymphocytes/mL) using volume adjustment. Interestingly, adjusted values were significantly lower than unadjusted ones [median (range): 0.02 (0–12.93) vs. 0.09 (0–14.23) IU/mL; P=0.008].

Conclusions

In QFT-GIT negative subjects lymphocyte enrichment did not increase QFT-GIT positivity rates. The reduced clinical sensitivity of the QFT-GIT assay, compared to T-SPOT.^®TB, is likely to be due to factors other than lymphocyte count alone. Further studies are required to clarify these findings.     

A pilot study of short‐term hemodynamic effects of negative pressure ventilation in chronic obstructive pulmonary disease assessed using electrical cardiometry

BackgroundPulmonary rehabilitation combined with negative pressure ventilation (NPV) demonstrated benefits in patients with chronic obstructive pulmonary disease (COPD). The effect of NPV remains unknown. This study aims to clarify the short‐term response of the hemodynamic outcome of NPV in patients with COPD undergoing pulmonary rehabilitation program by electrical cardiometry.MethodsThis is an observational retrospective study of COPD patients who had been treated in a pulmonary rehabilitation unit with NPV between January 2018 and December 2019 that were enrolled to analyze the hemodynamic outcomes.ResultsThirty patients with COPD that were undergoing a pulmonary rehabilitation program and were regularly receiving NPV were enrolled. Cardiac output (p < .001) and heart rate (p < .001) showed a significant decrease after NPV. Stroke volume did not demonstrate significant change (p = .15). There was a significant decrease in thoracic fluid content (p = .016) and a significant increase in stroke volume variation (p = .038) systemic vascular resistance (p < .001) and left ventricular ejection time (p < .001). Other hemodynamic parameters were all comparable before and after NPV.ConclusionsNegative pressure ventilation demonstrated an impact on hemodynamics in patients with chronic obstructive pulmonary disease undergoing pulmonary rehabilitation. Electrical cardiometry is a feasible method of determining the hemodynamic effects of negative pressure ventilation. Thoracic fluid content significantly decreased immediately after the NPV.     

Systematic review and meta-analysis of outcomes after liver resection in patients with hepatocellular carcinoma (HCC) with and without bile duct thrombus

IntroductionThis meta-analysis aimed to compare perioperative and survival outcomes in patients who underwent hepatectomy with and without Bile Duct Tumour Thrombus (BDTT).MethodsA comprehensive search of Cochrane Library, PubMed, MEDLINE and EMBASE was performed to identify relevant articles. The perioperative, postoperative and long term outcomes were compared.ResultsEleven studies including 6051 patients met the inclusion criteria. The perioperative outcomes were comparable between the 2 groups. The BDTT group had higher proportion poorly differentiated tumours (OR = 1.87, X² = 10.00, df = 6, p = 0.002, I² = 40%), Lymphovascular invasion (LVI) (OR = 4.85, X² = 28.21, df = 9, p = <0.001, I² = 68%) and Macrovascular invasion (MVI) (OR = 5.41, X² = 8.73, df = 9, p = <0.001, I² = 0%). There was no difference in 1 and 3 year survival, however 5-yr survival was poorer in the BDTT group (OR = 0.37, X² = 37.04, df = 7, p = <0.001, I² = 81%). The mean difference (MD) in overall survival in the BDTT group was −20 months [−32.31, −7.06], p = 0.002, I² = 95%.ConclusionPatients with HCC with BDTT had more advanced stage HCC with adverse histological features including higher rates of MVI, LVI and poor differentiation. Hepatectomy in this group of patients offers similar survival at 3 years but inferior long-term survival and should be considered when feasible.Abbreviations: BDTT, bile duct tumour thrombus; HCC, hepatocellular carcinoma; BCLC, Barcelona clinical liver cancer; RR, risk ratio; CI, confidence interval; NOS, Newcastle–Ottawa score     

Atherosclerotic coronary lesions with inadequate compensatory enlargement have smaller plaque and vessel volumes: observations with three dimensional intravascular ultrasound in vivo

Objective—To compare vessel, lumen, and plaque volumes in atherosclerotic coronary lesions with inadequate compensatory enlargement versus lesions with adequate compensatory enlargement.
Design—35 angiographically significant coronary lesions were examined by intravascular ultrasound (IVUS) during motorised transducer pullback. Segments 20 mm in length were analysed using a validated automated three dimensional analysis system. IVUS was used to classify lesions as having inadequate (group I) or adequate (group II) compensatory enlargement.
Results—There was no significant difference in quantitative angiographic measurements and the IVUS minimum lumen cross sectional area between groups I (n = 15) and II (n = 20). In group I, the vessel cross sectional area was 13.3 (3.0) mm² at the lesion site and 14.4 (3.6) mm² at the distal reference (p < 0.01), whereas in group II it was 17.5 (5.6) mm² at the lesion site and 14.0 (6.0) mm² at the distal reference (p < 0.001). Vessel and plaque cross sectional areas were significantly smaller in group I than in group II (13.3 (3.0) v 17.5 (5.6) mm², p < 0.01; and 10.9 (2.8) v 15.2 (4.9) mm², p < 0.005). Similarly, vessel and plaque volume were smaller in group I (291.0 (61.0) v 353.7 (110.0) mm³, and 177.5 (48.4) v 228.0 (92.8) mm³, p < 0.05 for both). Lumen areas and volumes were similar.
Conclusions—In lesions with inadequate compensatory enlargement, both vessel and plaque volume appear to be smaller than in lesions with adequate compensatory enlargement.

     

Liver angulometry: a simple method to estimate liver volume and ratios

Objectives

Volumetry is standard method for evaluating the volumes of the right liver (RL), left liver (LL), left lateral segments (LLS), total liver (TL) and future liver remnant (FLR). The aim of this study was to report a simple technique based on measurements of liver angles (angulometry) that can be used to predict liver ratios.

Methods

Fifty computed tomography (CT) scans obtained in subjects with normal liver were studied. Four CT scan levels were preselected: level 1 passed by the upper part of the hepatic veins; level 2 passed by the left portal vein branch division; level 3 passed by the right portal vein branch division, and level 4 passed by the gallbladder bed. Left and right tangent lines passing the liver edges were drawn and joined to the centre of the vertebra defining the TL angle. Two lines through, respectively, the plane of the middle hepatic vein and the left portal branches determined the angles of the RL, LL and LLS. Volumetric and angulometric data obtained on levels 2 and 3 in 50 different subjects were compared.

Results

Level 2 CT scans represented the most accurate way of obtaining angulometric measurements. The mean ± standard deviation (SD) angles of the TL and LL were 134 ± 12 ° and 55 ± 12 °, respectively. The mean ± SD percentages of the TL represented by the LL in angulometry and volumetry were 38 ± 7% and 36 ± 6%, respectively (non-significant difference). The mean ± SD percentages of the TL represented by the LLS in angulometry and volumetry were 25 ± 4% and 20 ± 3%, respectively (P < 0.05). The mean ± SD overestimation of the percentage of the TL represented by the LLS in angulometry was 2.7 ± 7.0%.

Conclusions

Angulometry is a simple and accurate technique that can be used to estimate the ratio of the FLR to TL volume on one or two CT (or magnetic resonance imaging) slices. It can be helpful for clinicians, especially before right or extended right hepatectomy and after right portal vein occlusion techniques.     

External biliary drainage following major liver resection for perihilar cholangiocarcinoma: impact on development of liver failure and biliary leakage

BackgroundPreoperative biliary drainage is considered essential in perihilar cholangiocarcinoma (PHC) requiring major hepatectomy with biliary-enteric reconstruction. However, evidence for postoperative biliary drainage as to protect the anastomosis is currently lacking. This study investigated the impact of postoperative external biliary drainage on the development of post-hepatectomy biliary leakage and liver failure (PHLF).MethodsAll patients who underwent major liver resection for suspected PHC between 2000 and 2015 were retrospectively analyzed. Biliary leakage and PHLF was defined as grade B or higher according to the International Study Group of Liver Surgery (ISGLS) criteria.ResultsEighty-nine out of 125 (71%) patients had postoperative external biliary drainage. PHLF was more prevalent in the drain group (29% versus 6%; P = 0.004). There was no difference in the incidence of biliary leakage (32% versus 36%). On multivariable analysis, postoperative external biliary drainage was identified as an independent risk factor for PHLF (Odds-ratio 10.3, 95% confidence interval 2.1–50.4; P = 0.004).ConclusionsExternal biliary drainage following major hepatectomy for PHC was associated with an increased incidence of PHLF. It is therefore not recommended to routinely use postoperative external biliary drainage, especially as there is no evidence that this decreases the risk of biliary anastomotic leakage.     

Effect of portal vein embolization on treatment plan prior to major hepatectomy for hepatocellular carcinoma

BackgroundPortal vein embolization (PVE) is used before major hepatectomy for hepatocellular carcinoma (HCC) to increase future liver remnant (FLR) volume. However, this may increase tumour growth rate, leading to more extensive resections. This study aimed to determine the effect of tumour growth, following PVE, on treatment plan.MethodRetrospective cohort study conducted on patients treated from 2008 to 2015 with PVE before major hepatectomy for HCC. Liver and tumour volumetry was performed on pre- and post-PVE CT scans. Image-based and actioned plans were compared before and after PVE.ResultsThirty-one patients received PVE. Non-tumour total liver volume decreased (median 1440 to 1394 cm³; p = 0.031), while tumour (median 161–240 cm³; p < 0.001) and FLR volumes (median 430–574 cm³; p < 0.001) increased. The treatment plan changed in 15/31 patients: more extensive resection (n = 6), less extensive resection (n = 1), no resection as scheduled (n = 8). Tumour progression accounted for a clinically relevant change in treatment plan in 8/31 patients.ConclusionFollowing PVE in the setting of HCC, tumour progression accounts for a change in treatment plan in approximately a quarter of patients. Further research is warranted to determine whether additional liver directed therapy should routinely be used to slow the growth of HCC post-PVE.     

Accuracy and Injection Force of the Gla-300 Injection Device Compared With Other Commercialized Disposable Insulin Pens

Background:

To deliver insulin glargine 300 U/mL (Gla-300), the widely used SoloSTAR^® pen has been modified to allow for accurate and precise delivery of required insulin units in one-third of the volume compared with insulin glargine 100 U/mL, while improving usability. Here we compare the accuracy and injection force of 3 disposable insulin pens: Gla-300 SoloSTAR^®, FlexPen^®, and KwikPen™.

Methods:

For the accuracy assessment, 60 of each of the 3 tested devices were used for the delivery of 3 different doses (1 U, half-maximal dose, and maximal dose), which were measured gravimetrically. For the injection force assessment, 20 pens of each of the 3 types were tested twice at half-maximal and once at maximal dose, at an injection speed of 6 U/s.

Results:

All tested pens met the International Organization for Standardization (ISO) requirements for dosing accuracy, with Gla-300 SoloSTAR showing the lowest between-dose variation (greatest reproducibility) at all dose levels. Mean injection force was significantly lower for Gla-300 SoloSTAR than for the other 2 pens at both half maximal and maximal doses (P < .0271).

Conclusion:

All tested pens were accurate according to ISO criteria, and the Gla-300 SoloSTAR pen displayed the greatest reproducibility and lowest injection force of any of the 3 tested devices.     

Ratio of remnant to total liver volume or remnant to body weight: which one is more predictive on donor outcomes?

Backround

Right lobe donations are known to expose the donors to more surgical risks than left lobe donations. In the present study, the effects of remnant volume on donor outcomes after right lobe living donor hepatectomies were investigated.

Methods

The data on 262 consecutive living liver donors who had undergone a right hepatectomy from January 2004 to June 2011 were retrospectively analysed. The influence of the remnant on the outcomes was investigated according to the two different definitions. These were: (i) the ratio of the remnant liver volume to total liver volume (RLV/TLV) and (ii) the remnant liver volume to donor body weight ratio (RLV/BWR). For RLV/TLV, the effects of having a percentage of 30% or below and for RLV/BWR, the effects of values lower than 0.6 on the results were investigated.

Results

Complication and major complication rates were 44.7% and 13.2% for donors with RLV/TLV of ≤30%, and 35.9% and 9.4% for donors with RLV/BWR of < 0.6, respectively. In donors with RLV/TLV of ≤30%, RLV/BWR being below or above 0.6 did not influence the results in terms of liver function tests, complications and hospital stay. The main impact on the outcome was posed by RLV/TLV of ≤30%.

Conclusion

Remnant volume in a right lobe living donor hepatectomy has adverse effects on donor outcomes when RLV/TLV is ≤30% independent from the rate of RLV/BWR with a cut-off point of 0.6.