Radiomic analysis of liver grafts from brain-dead donors can predict early allograft dysfunction following transplantation: a proof-of-concept study

BackgroundSelection of liver grafts suitable for transplantation (LT) mainly depends on a surgeon's subjective assessment. This study aimed to investigate the role of radiomic analysis of donor-liver CTs after brain death (DBD) to predict the occurrence of early posttransplant allograft dysfunction (EAD).MethodsWe retrospectively extracted and analyzed the left lobe radiomic features from CT scans of DBD livers in training and validation cohorts. Multivariate analysis was performed to identify predictors of EAD.ResultsFrom 126 LTs included in the study in the training cohort, 27 (21.4%) had an EAD. For each patient, 279 radiomic features were extracted of which 5 were associated with EAD (AUC = 0.81) (95% CI 0.72–0.89). Among donor and recipient clinical characteristics, cardiac arrest, steatosis on donor's CT, cold ischemic time and age of recipient were also identified as independent risk factors for EAD. Combined radiomic signature and clinical risk factors showed a strong predictive performance for EAD with a C-index of 0.90 (95% CI 0.84–0.96). A validation cohort of 23 patients confirmed these results.ConclusionRadiomic signatures extracted from donor CT scan, independently or combined with clinical risk factors is an objective and accurate biomarker for prediction of EAD after LT.     

Impact of an enhanced recovery after surgery protocol on short-term outcomes in elderly patients undergoing pancreaticoduodenectomy

BackgroundTo determine whether the short-term benefits associated with an enhanced recovery after surgery programme (ERAS) following pancreaticoduodenectomy (PD) vary with age.Methods830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (<75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS).ResultsOf the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p < 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7–27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95% CI: 9.2–21.6%, p < 0.001), with the effect size being similar in each group.ConclusionERAS protocols can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. Implementation of an ERAS protocol was associated with a significant reduction in postoperative LOS in both elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.     

Comparison of the effectiveness of i-scan and conventional endoscopy in the detection of the endoscopic signs of atrophic gastritis: A clinical trial

Background and study aimsThis study aimed to determine whether the use of i-scan endoscopy provides additional benefits to conventional endoscopy in the diagnosis of gastric precancerous lesions.Patients and methodsA total of 120 patients with histologically-verified intestinal metaplasia (IM) or atrophic gastritis (AG) were prospectively evaluated by esophagogastroduodenoscopy. Endoscopic examinations were performed using i-scan and high-definition white-light endoscopy (HD-WLE). The diagnostic yields of both techniques and the number of targeted biopsies per patient were compared.ResultsA total of 318 suspicious lesions were detected in 108 patients with i-scan (n = 186) and 81 patients with HD-WLE (n = 132). The diagnostic yields of i-scan and HD-WLE were 81.6% (98/120) versus 77.5% (93/120), respectively (p > 0.05). When only targeted biopsies were taken into account, the diagnostic yields of i-scan and HD-WLE were 89.8% versus 65.4%, respectively (p < 0.05). The mean number of biopsies per patient for i-scan and HD-WLE were 3.27 (393/120) and 7.3 (882/120), respectively (p < 0.05). The mean endoscopic procedure times were 16 and 17 min for i-scan and HD-WLE, respectively (p > 0.05).ConclusionsAlthough targeted biopsies with i-scan were not found to be significantly superior to either targeted or random biopsies with HD-WLE, the number of biopsies required to confirm these lesions was much lower.     

Theoretical Investigation of Chitosan-Assisted Controlled Release of Digestive System Antitumor Drug Fluorouracil

5-Fluorouracil (5-FU) has been applied to treat pancreatic cancer, which is one of the most common types of digestive system tumors. However, due to poor tumor selectivity, 5-FU's therapeutic effect has certain limitations. 5-FU's activity and selectivity against tumor cells can be improved by chitosan assisted drug delivery systems. Understanding the atomic interaction mechanism between chitosan and 5-FU is important. In this work, the interactions between 5-FU and different types of chitosan were systematically investigated by using molecular dynamics (MD) simulation. Based on the radial distribution function and the free energy calculation, our results demonstrate that the functional groups of chitosan could greatly regulate the interaction behavior between chitosan and 5-FU. Moreover, 5-FU could gradually release from chitosan at a more acidic pH (tumor tissues) environment. These results revealed the underlying atomic interaction mechanism between 5-FU and chitosan at various pH levels, and may be helpful in the design of chitosan-based drug delivery systems.     

A Pilot First-in-Human Study of Embrace,a Polyethylene Glycol-Based Liquid Embolic Agent,in the Embolization of Malignant and Benign Hypervascular Tumors

PurposeTo investigate the safety and efficacy of an aqueous polyethylene glycol-based liquid embolic agent, Embrace Hydrogel Embolic System (HES), in the treatment of benign and malignant hypervascular tumors.Materials and MethodsA prospective, single-arm, multicenter study included 8 patients, 5 males and 3 females, with a median age of 58.5 years (30–85 years), who underwent embolization in 8 tumors between October 2019 and May 2020. Technical success was defined as successful delivery of HES to the index vessel, with disappearance of >90% of the targeted vascular enhancement or, for portal vein embolization, occlusion of the portal branches to the liver segments for future resection. The volume of HES administered, ease of use (5 point Likert scale), administration time, and adverse events (AEs) were recorded. Evaluation was performed at 7, 30, and 90 days via clinical assessment and blood testing, and follow-up imaging was performed at 30 days.ResultsEight patients were enrolled, and 10 embolizations were performed in 8 lesions. Tumors included hepatocellular carcinoma (n = 4), renal angiomyolipoma (n = 3), and intrahepatic cholangiocarcinoma (n = 1). Technical success was 100%, and the average ease of use was 3.3 ± 1.0 SD. The HES delivery time was 1–28 minutes (median, 16.5 minutes), and the HES volume injected was 0.4–4.0 mL (median, 1.3 mL). All patients reached 30-day follow-up with imaging, and 6 patients reached 90-day follow-up. There were 3 serious AEs in 2 patients that were unrelated to the embolic agent.ConclusionHES resulted in a 100% embolization technical success rate. The product ease of use was acceptable, and no target vessel recanalization was noted on follow-up imaging at 30 days.     

What is the impact of zinc deficiency for pancreatectomies in patients with pancreatic ductal adenocarcinoma?

Backgroundand purpose: Zinc is an essential element for human health and plays an important role in metabolic, immunological and other biological processes. The present study was conducted to investigate the association between zinc deficiency (ZD) and the perioperative clinical course in patients with pancreatic ductal adenocarcinoma (PDAC).MethodsOf 216 patients with PDAC who underwent elective pancreatectomy between 2013 and 2017 at our institution, 206 patients with sufficient clinical data were retrospectively reviewed. The perioperative variables were compared and the risk factors associated with infectious complications were identified.ResultsZD was preoperatively present in 36 (17.5%) of 206 patients with PDAC. In the patients of the ZD group, a higher proportion of males, higher preoperative modified Glasgow prognostic scores, a higher neutrophil-to-lymphocyte ratio, and a higher occurrence of postoperative infectious complications after pancreatectomy were observed, compared to the non-ZD group. By a univariate analysis, three risk factors were significantly associated with infectious complications after pancreatectomy: ZD (vs non-ZD: p = 0.002), serum albumin <3.5 g/dl (vs ≥ 3.5 g/dl: p = 0.005), and the procedure of pancreaticoduodenectomy (vs others: p = 0.013). By multivariate logistic regression analysis, the occurrence of infectious complications was significantly associated with ZD (OR 3.430, 95%CI 1.570 to 7.490, p = 0.002) and the procedure of pancreaticoduodenectomy (OR 2.030, 95%CI 1.090 to 3.770, p = 0.025).ConclusionsThe current study newly demonstrated that ZD could serve as a preoperative predictor of infectious complications after pancreatectomies in the patients with PDAC.     

Predicting loss of independence after high-risk gastrointestinal abdominal surgery: Frailty vs. NSQIP risk calculator

BackgroundLoss of independence (LOI) is a significant concern for patients undergoing high-risk abdominal surgery. Although the risk for morbidity and mortality has been well studied, there is a dearth of data on risk for LOI.MethodsThis study utilized NSQIP data from 2015 to 2018 in a retrospective cohort study of patients undergoing high-risk gastrointestinal surgery (e.g. gastric, colorectal, liver, and pancreatic).ResultsThe study included 229,573 patients who were preoperatively functionally independent. Of those, 5.3% experienced LOI. The median age for LOI patients was 74 (CI: 67–81), and 56% were female. The most common race was white (n = 9585), followed by African-American (n = 1223) and other (n = 369). The most common GI procedure was colorectal (65%), followed by the pancreas (23%), liver (8.2%), and gastric (3%). On univariate analysis, age, sex, BMI, race, frailty, and pancreatectomy were associated with LOI. On multivariate analysis age (≥85, OR 18.3 CI:16.9–19.9 p < 0.001), female sex (OR 1.24CI: 1.19–1.29 p < 0.001), BMI <18.5 (OR 1.66 CI:1.48–1.86 p < 0.001), BMI >40 (OR 1.43 CI:1.31–1.56 p < 0.001), African American race (OR 1.20 CI:1.12–1.28 p < 0.001), smoking (OR 1.21 CI:1.14–1.28 p < 0.001), frailty (MFI-5 > 2, OR 4.47 CI:2.63–7.31 p < 0.001), and pancreatectomy (OR 1.86 CI:1.74–1.98 p < 0.001) continued to be associated with LOI. To better define a predictive model, the NSQIP risk calculator was compared to the modified frailty index-5. AUC was 0.80 (CI: 0.797–0.805) and 0.76 (0.760–0.769), respectively.ConclusionLOI occurs in over five percent of patients undergoing high-risk abdominal surgery. LOI occurs more commonly after pancreatectomy or for those who are frail, underweight, or morbidly obese. Both frailty and the NSQIP risk calculator models similarly predicted LOI.