Postoperative complications following aggressive repeat hepatectomy for colorectal liver metastasis have adverse oncological outcomes

Purposes

Repeat hepatectomy remains the only curative treatment for recurrent colorectal liver metastasis (CLM) after primary hepatectomy. However, the repeat resection rate is still low, and there is insufficient data on the outcomes after repeat hepatectomy. The aim of this study was to investigate the feasibility and prognostic benefit of aggressive repeat hepatectomy for recurrent CLM.

Methods

Data were reviewed from 282 consecutive patients who underwent primary curative hepatectomy for CLM between January 1994 and March 2015. The short- and long-term outcomes were analyzed.

Results

One hundred ninety-three patients (68 %) developed recurrence, and repeat hepatectomy was conducted in 62 patients. Overall, 62 s, 11 third, 4 fourth, and 1 fifth hepatectomies were performed. The postoperative morbidity and mortality rates were low (11.5 and 1.3 %, respectively). The overall survival rates at 3 and 5 years after primary hepatectomy for CLM in the repeat hepatectomy group were 79.5 and 57.4 %, respectively. A multivariate analysis indicated that postoperative complications were independently associated with overall survival after repeat hepatectomy.

Conclusions

Repeat hepatectomy for CLM is feasible, with acceptable rates of perioperative morbidity and mortality, and the potential for long-term survival. However, postoperative complications following aggressive repeat hepatectomy for CLM are associated with adverse oncological outcomes.

     

Prognostic Role of Carcinoembryonic Antigen Level after Preoperative Chemoradiotherapy in Patients with Rectal Cancer

Background

The prognostic role of post-chemoradiotherapy (CRT) carcinoembryonic antigen (CEA) level is not clear. We evaluated the prognostic significance of post-CRT CEA level in patients with rectal cancer after preoperative CRT.

Methods

We reviewed 659 consecutive patients who underwent preoperative CRT and total mesorectal excision for non-metastatic rectal cancer. Patients were categorized into two groups according to post-CRT serum CEA level: low CEA (<?5 ng/mL) and high CEA (≥?5 ng/mL).

Results

Median post-CRT CEA level was 1.7 ng/mL (range, 0.1–207.0). A high post-CRT level was significantly associated with ypStage, ypT category, tumor regression grade, and pre-CRT CEA level. The 5-year overall survival rate of the 659 patients was 87.8% with a median follow-up period of 57.0 months (range, 1.4–176.4). When the post-CRT CEA groups were divided into groups according to pre-CRT CEA level, the 5-year overall survival rates were significantly different (P?<?0.001 and P?=?0.001, respectively). Post-CRT CEA level was an independent prognostic factor for overall survival. Multivariate analysis revealed that operation method, differentiation, perineural invasion, postoperative chemotherapy, tumor regression grade, and post-CRT CEA level were independent prognostic factors for overall survival.

Conclusion

The level of serum CEA after preoperative CRT was an independent prognostic factor for overall survival in patients with rectal cancer.

     

Eradication of Missing Liver Metastases After Fiducial Placement

Background

The risk of colorectal liver metastases (CLM) disappearing on cross-sectional imaging has increased with advances in preoperative chemotherapy, but <50 % of disappearing CLM demonstrate complete pathological response.

Objective

The aim of this study was to evaluate the role of fiducial marker placement before potentially curative treatment of CLM at risk of disappearing with chemotherapy.

Methods

All consecutive patients who underwent fiducial placement for tracking of CLM at a tertiary center were reviewed.

Results

Among 1377 patients undergoing CLM resection between 2005 and 2015, 35 patients underwent fiducial placement. Three patients were excluded due to disease progression. The study population comprised 32 patients who underwent fiducial placement in 41 CLM. Among the 41 marked CLM, 34 (83 %) were located >10 mm deep in the liver parenchyma, 25 (61 %) were in the right liver, and median size was 12 mm (range, 6–20 mm). No complication occurred after fiducial placement. After chemotherapy, 19 (46 %) of the 41 marked metastases disappeared on cross-sectional imaging. All fiducial-tracked CLM were treated with resection (n?=?31) or ablation (n?=?10). After median follow-up of 14 months (range, 0–64 months), no local recurrences were observed.

Conclusion

Fiducial placement represents a safe procedure that facilitates accurate localization for resection or ablation of small CLM at risk of disappearing with chemotherapy.

     

Prognostic Impact of the Initial Postoperative CA19-9 Level in Patients with Extrahepatic Bile Duct Cancer

Background

The aim of this study was to investigate the prognostic impact of the initial serum postoperative CA19-9 levels in patients with extrahepatic bile duct cancer.

Methods

Data of a total of 143 patients of extrahepatic bile duct cancer with elevated preoperative serum CA19-9 levels (>37 U/ml) who underwent surgery with curative intent were reviewed retrospectively. The patients were divided into the “Normalization group” and “Non-normalization group” (initial postoperative serum CA19-9 ≤37 and >37 U/ml, respectively), and the clinicopathological factors and survival outcomes in these groups were comparatively analyzed.

Results

The cumulative 5-year overall survival (OS) rate and median survival time (MST) were 39.2 % and 42.9 months, respectively, in the Normalization group and 17.9 % and 24.0 months, respectively, in the Non-normalization group (P?<?0.001). Presence of jaundice, a poorer histological differentiation grade (G3–4), lymph node metastasis, and initial postoperative serum CA19-9 level (>37 U/ml) were significant independent predictors of a poor prognosis on multivariate analysis.

Conclusion

Non-normalization of the serum CA19-9 level in the initial postoperative phase is a strong predictor of a poor prognosis and is a useful marker to identify patients who would need additional treatments and stricter follow-up.

     

Impact of intraoperative blood loss on the short-term outcomes of laparoscopic liver resection

Background

Intraoperative blood loss is one of the predictors of outcome of open hepatectomy. But the impact of blood loss in laparoscopic hepatectomy (LH) on postoperative outcomes is poorly understood. The aim of this study is to analyze the association between blood loss and postoperative outcomes after LH.

Methods

A retrospective analysis of prospectively maintained database of patients undergoing LH from 1995 to 2016 was performed. The data were divided into two groups based on the extent of blood loss: Group 1 (<250 ml) and Group 2 (≥250 ml). The basic characteristics and postoperative outcomes were compared between these groups.

Results

A total of 504 patients underwent 611 LH (Group 1: 414 and Group 2: 197). The mean age was 62.4 years. The most common indication was liver secondaries (71.7%). Major hepatectomy was performed in 37% cases. Mean operative time was 225?±?110.5 min and estimated blood loss was 239?±?399.4 ml (range 0–4500 ml). Group 2 had significantly higher number of patients with malignant lesions undergoing major hepatectomy, anatomical resection with higher requirement for blood transfusion, and longer hospital stay. The incidence of conversion rate, overall complications including liver failure, renal failure, and postoperative mortality, was significantly higher in Group 2. However, the bile leak rate was similar in the two groups.

Conclusion

Intraoperative blood loss is most frequent in patients undergoing major LH. Blood loss ≥250 ml during LH may adversely affect the postoperative outcomes.

     

Can robot-assisted laparoscopic radical prostatectomy (RALP) be performed very soon after biopsy?

Purpose

To identify the perioperative and oncological impact of different intervals between biopsy and robot-assisted laparoscopic radical prostatectomy (RALP) for localized prostate cancer.

Methods

All consecutive patients with localized prostate cancer who underwent RALP with primary curative intent in January 2008–July 2014 in a large tertiary hospital were enrolled in this retrospective cohort study. The patients were divided into groups according to whether the biopsy–RALP interval was ≤2, ≤4, ≤6, or >6 weeks. Estimated blood loss and operating room time were surrogates for surgical difficulty. Surgical margin status and continence at the 1 year were surrogates for surgical efficacy. Biochemical recurrence (BCR) was defined as two consecutive postoperative prostate serum antigen values of ≥0.2 ng/ml.

Results

Of the 1446 enrolled patients, the biopsy–RALP interval was ≤2, ≤4, ≤6, and >6 weeks in 145 (10 %), 728 (50.3 %), 1124 (77.7 %), and 322 (22.3 %) patients, respectively. The >6 week group had a significantly longer mean operation time than the ≤2, ≤4, and ≤6 week groups. The groups did not differ significantly in terms of estimated blood loss or surgical margin status. Kaplan–Meier analysis showed that interval did not significantly affect postoperative BCR-free survival. Multivariable Cox proportional hazards model analysis showed that interval duration was not an independent predictor of BCR (≤2 vs. >2 weeks, HR = 0.859, p = 0.474; ≤4 vs. >4 weeks, HR = 1.029, p = 0.842; ≤6 vs. >6 weeks, HR = 0.84, p = 0.368).

Conclusion

Performing RALP within 2, 4, or 6 weeks of biopsy does not appear to adversely influence surgical difficulty or efficacy or oncological outcomes.

     

Preoperative Fasting C-Peptide Predicts Type 2 Diabetes Mellitus Remission in Low-BMI Chinese Patients After Roux-en-Y Gastric Bypass

Objective

This study investigated the role of preoperative fasting C-peptide (FCP) levels in predicting diabetic outcomes in low-BMI Chinese patients following Roux-en-Y gastric bypass (RYGB) by comparing the metabolic outcomes of patients with FCP >?1 ng/ml versus FCP ≤?1 ng/ml.

Methods

The study sample included 78 type 2 diabetes mellitus patients with an average BMI <?30 kg/m² at baseline. Patients’ parameters were analyzed before and after surgery, with a 2-year follow-up. A univariate logistic regression analysis and multivariate analysis of variance between the remission and improvement group were performed to determine factors that were associated with type 2 diabetes remission after RYGB. Linear correlation analyses between FCP and metabolic parameters were performed. Patients were divided into two groups: FCP >?1 ng/ml and FCP ≤?1 ng/ml, with measured parameters compared between the groups.

Results

Patients’ fasting plasma glucose, 2-h postprandial plasma glucose, FCP, and HbA1c improved significantly after surgery (p?<?0.05). Factors associated with type 2 diabetes remission were BMI, 2hINS, and FCP at the univariate logistic regression analysis (p <?0.05). Multivariate logistic regression analysis was performed then showed the results were more related to FCP (OR = 2.39). FCP showed a significant linear correlation with fasting insulin and BMI (p?<?0.05). There was a significant difference in remission rate between the FCP >?1 ng/ml and FCP ≤?1 ng/ml groups (p?=?0.01). The parameters of patients with FCP >?1 ng/ml, including BMI, plasma glucose, HbA1c, and plasma insulin, decreased markedly after surgery (p?<?0.05).

Conclusion

FCP level is a significant predictor of diabetes outcomes after RYGB in low-BMI Chinese patients. An FCP level of 1 ng/ml may be a useful threshold for predicting surgical prognosis, with FCP >?1 ng/ml predicting better clinical outcomes following RYGB.

     

Outcomes of laparoscopic management of acute small bowel obstruction: a 7-year experience of 110 consecutive cases with various etiologies

Purpose

Laparoscopic surgery is emerging as an alternative to open surgery for treating acute small bowel obstruction (SBO). While postoperative adhesion is the most frequent etiology, the optimum treatment for all types of SBO needs to be evaluated.

Methods

A retrospective review was performed of 110 consecutive patients who underwent laparoscopic surgery at our institution between 2009 and 2015. The short-term outcomes included perioperative factors, while the long-term outcome included the recurrence rate.

Results

Of the 110 patients, 55 were female. The median age at surgery was 69.5 years. Laparoscopic surgery was completed in 91.8 %. The median operative time was 82 min, median amount of bleeding was 0 ml, and median postoperative hospital stay was 8 days. Intraoperative major organ injury was seen in 2.7 %. The complication rate (Clavien–Dindo ≥ class II) was 8.2 %, and the mortality rate was 3.6 %. The recurrence rate was 8.2 %. Only dense and matted adhesion was a predictive factor for conversion (OR 30.244).

Conclusion

Good short-term outcomes and feasible long-term outcomes were achieved with a laparoscopic approach to treating acute SBO. It was a safe and effective method, especially in patients with isolated bands, simple enteral angulation, and foreign body or tumor, while dense and matted adhesions were still challenging.

     

Laparoscopic inguinal hernioplasty after robot-assisted laparoscopic radical prostatectomy

Purpose

To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series.

Results

The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence.

Conclusions

Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.

     

Elevated Serum Carcinoembryonic Antigen Is Associated with a Worse Survival Outcome of Patients After Liver Resection for Hepatocellular Carcinoma: a Propensity Score Matching Analysis

Background

The relationship between serum carcinoembryonic antigen (CEA) and postoperative prognosis in hepatocellular carcinoma (HCC) has not been reported.

Methods

Data of 5410 consecutive HCC patients who underwent hepatectomy was retrospectively reviewed. Survival curves for overall survival (OS) and tumor recurrence (TR) were depicted using the Kaplan-Meier method and compared using the log-rank test. Independent risk factors of OS and TR were analyzed with Cox hazard regression model. Besides, a one-to-one propensity score-matched (PSM) subset was performed to reduce selection bias. Subgroup analysis was done according to hepatitis B virus (HBV) infection or not.

Results

Serum CEA ≥5.1 μg/L was an independent risk factor of OS and TR in the entire cohort and PSM subset (OS—hazard ratio?=?1.218, 95 % confidence interval?=?1.060–1.400; 1.383, 1.133–1.688, respectively; TR—1.256, 1.114–1.417; 1.258, 1.067–1.484, respectively). Subgroup analysis showed that CEA ≥5.1 μg/L was an independent risk factor of OS and TR in the HBV infection group (OS—1.234, 1.065–1.429; TR—1.231, 1.083–1.399) but not in the non-HBV infection group (OS—1.376, 0.895–2.117; TR—1.437, 0.989–2.088).

Conclusion

Serum CEA ≥5.1 μg/L was an independent risk factor of OS and TR of HCC patients, and patients with CEA ≥5.1 μg/L had poorer prognosis, especially for HCC patients with HBV infection.

     

Simple scoring system for prediction of mortality in Fournier’s gangrene

Purpose

To create new scoring system for prediction of hospital mortality for patients with Fournier’s gangrene(FG).

Material and method

In total, 84 patients with FG were enrolled into this study. The demographic and clinical characteristics of patients were analyzed retrospectively.

Results

The mortality rate was 11.9 %. On multivariate analyses, age >60 years, BUN >40 mg/dl, RDW >14.95 %, albumin level <20 mg/dl and presence of sepsis were significant and independent predictors of mortality. The predictive value of our score for mortality was 95.1 %.

Conclusion

Our scoring system shows adequate discriminatory function for prediction of mortality in patients with FG. Further larger scale studies can improve the performance of our score.

     

Change in kidney function after unilateral adrenalectomy in patients with primary aldosteronism: identification of risk factors for decreased kidney function

Purpose

Glomerular filtration rate (GFR) has been reported to decrease after unilateral adrenalectomy in patients with primary aldosteronism (PA). The aim of this study was to identify clinical predictors for decreased GFR after adrenalectomy in patients with PA.

Methods

The records of 187 patients (98 patients with PA and 89 with non-PA adrenal disease) who were followed up for at least 6 months after unilateral adrenalectomy were retrospectively analyzed. Estimated GFR (eGFR) was investigated at 1, 3, and 6 months postoperatively. Preoperative risk factors for eGFR% decline at 1 month ([preoperative eGFR?eGFR at 1 month]/preoperative eGFR?×?100) and postoperative CKD development were investigated.

Results

The eGFR decreased significantly at 1 month and remained stable in the PA group. However, there were no significant changes in eGFR in the non-PA group over the 6-month period. In the PA group, a high preoperative eGFR and high aldosterone to renin ratio (ARR) were independently associated with eGFR% decline at 1 month. In patients with PA but without preoperative CKD (n?=?68), a low preoperative eGFR and high ARR were independent risk factors for developing postoperative CKD. The best preoperative cut-off values of eGFR and ARR for predicting the development of postoperative CKD were ≤?102 ml/min/1.73 m² and ≥?448 ng/dl:ng/ml/h, respectively.

Conclusions

Renal function deteriorated significantly after unilateral adrenalectomy in patients with PA. Clinicians must pay attention to postoperative renal function in PA patients at elevated risk of developing decreased kidney function.

     

Significant increase in detection of prostate cancer recurrence following radical prostatectomy with an early imaging acquisition protocol with <Superscript>18</Superscript>F-fluorocholine positron emission tomography/computed tomography

Purpose

To highlight a new imaging acquisition protocol during ¹⁸F-fluorocholine PET/CT in patients with biochemical recurrence after RP.

Methods

A total of 146 patients with PSA levels between 0.2 and 1 ng/ml with negative conventional imaging who did not receive salvage treatment were prospectively enrolled. Imaging acquisition protocol included an early dynamic phase (1–8 min), a conventional whole body (10–20 min), and a late phase (30–40 min). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were measured. Univariable and multivariable analyses were performed to identify independent predictors of positive PET/CT.

Results

The median trigger PSA was 0.6 ng/ml (IQR 0.43–0.76). Median PSA doubling time (PSA DT) was 7.91 months (IQR 4.42–11.3); median PSA velocity (PSAV) was 0.02 ng/ml per month (IQR 0.02–0.04). Overall, ¹⁸F-fluorocholine PET/CT was positive in 111 of 146 patients (76 %). Out of 111 positive examinations, 80 (72.1 %) were positive only in the early dynamic phase. Sensitivity, specificity, PPV, NPV, and accuracy were 78.9, 76.9, 97.2, 26.3, and 78.7 %, respectively. At multivariable logistic regression, trigger PSA ≥ 0.6 ng/ml [odds ratio (OR) 3.13; p = 0.001] and PSAV ≥ 0.04 ng/ml per month (OR 4.95; p = 0.004) were independent predictors of positive PET/CT. The low NPV remains the main limitation of PET/CT in this setting of patients.

Conclusions

The increased sensitivity, thanks to the early imaging acquisition protocol, makes ¹⁸F-fluorocholine PET/CT an attractive tool to detect prostate cancer recurrences in patients with a PSA level <1 ng/ml.

     

Subcutaneous dissection area contributes less to endoscopic thyroidectomy-related invasiveness

Objective

To clarify the contribution of the subcutaneous area during breast approach endoscopic thyroidectomy (BAET), with regard to invasiveness-related outcomes.

Methods

Seventy-two patients were randomly assigned to two groups: standard dissection and limited dissection. Postoperative pain and inflammatory response were compared between groups.

Results

The groups were well matched except for subcutaneous dissection area (137.11 ± 21.10 vs. 83.69 ± 12.10 cm², p < 0.0001). No significant difference was found with regard to VAS score and postoperative inflammatory response.

Conclusion

Our RCT indicated that the subcutaneous area plays a less important role with regard to BAET-related postoperative pain.

     

Recurrence Following Hepatectomy for Metastatic Colorectal Cancer: Development of a Model that Predicts Patterns of Recurrence and Survival

Background

While several prognostic models have been developed to predict survival of patients who undergo hepatectomy for metastatic colorectal cancer (mCRC), few data exist to predict survival after recurrence. We sought to develop a model that predicts survival for patients who have developed recurrence following hepatectomy for mCRC.

Methods

A retrospective analysis was performed on data from consecutive patients that underwent hepatectomy for mCRC. Clinicopathologic data, recurrence patterns, and outcomes were analyzed. Kaplan–Meier survival analysis and univariate and multivariate analyses were performed. An integer-based model was created to predict the patterns of recurrence and survival after recurrence.

Results

This analysis included 280 patients with a median follow-up of 50.1 months. Of these, 53% underwent major hepatectomy and 87% had negative margins. Recurrent disease developed in 63% of patients. After hepatectomy, factors associated with short disease-free interval (DFI) and overall survival (OS) included CEA > 200 ng/ml (P < 0.0005), >1 metastasis (P < 0.0005), and a high Fong score (P < 0.0005). After recurrence, the pattern of recurrence was a strong predictor of OS (P < 0.0005). Independent predictors of the pattern of recurrence on multivariate analysis include CEA > 200 ng/ml, tumor size >5 cm, and >1 liver metastasis. A simple predictive scoring system was developed from the beta coefficients of this analysis that correlated with recurrence pattern (P < 0.0005).

Conclusions

After hepatectomy, survival of patients with recurrent mCRC is strongly predicted by the patterns of recurrence, and the recurrence pattern can be predicted with a simple model. This can also be extended to create a scoring system that estimates expected survival.

     

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Objective

To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.

Design

Cohort study.

Setting

District hospital.

Patients

Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of?>?20 mm.

Intervention

Fracture fixation with either an intramedullary nail or a plate.

Outcome measurements

Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.

Results

Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.

Conclusion

Severe displacement of the lesser trochanter (>?20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.

Level of evidence

II.

     

Osteosynthese dislozierter Tuberculum-majus-Frakturen mit der Bamberger Platte

Objective

Internal fixation of displaced fractures of the greater tuberosity allowing functional aftercare.

Indications

Displaced fractures of the greater tuberosity >5 mm. Displaced fractures of the greater tuberosity >3 mm in athletes or overhead workers. Multiply fragmented fractures of the greater tuberosity.

Contraindications

Displaced 3? or 4?part fractures of the proximal humerus. Nondisplaced fractures of the greater tuberosity.

Surgical technique

Exposure of the fracture of the greater tuberosity by an anterolateral approach. Open reduction and temporary retention with a Kirschner wire or a “Kugelspieß” or reinforcement of the supraspinatus tendon and distal retention. Bending and positioning of the Bamberg plate and fixation by conventional or locking screws. Optional fixation of the rotator cuff to the plate. Exact monitoring of the implant position using the image intensifier to avoid inadequate distalization of the greater tuberosity.

Postoperative management

Arm sling (e.?g. Gilchrist) for 2 weeks. Start passive assisted exercise on postoperative day 1. Movement allowed up to the pain threshold. Physiotherapeutic treatment to prevent adhesions and capsular shrinking.

Results

In all, 10 patients with displaced fractures of the greater tuberosity underwent osteosynthesis using the Bamberg plate. After a follow-up of at least 6 months, a Constant–Murley score of 94.2  points (range 91–98 points) was achieved. The patients’ average age was 45.6 years (range 29–68 years).

     

Predictors of Futile Liver Resection for Patients with Barcelona Clinic Liver Cancer Stage B/C Hepatocellular Carcinoma

Background

There is little information concerning futile liver resection for patients with Barcelona Clinic Liver Cancer (BCLC) stage B/C hepatocellular carcinoma (HCC). This study aimed to establish a predictive model of futile liver resection for patients with BCLC stage B/C HCC.

Methods

The outcomes of 484 patients with BCLC stage B/C HCC who underwent liver resection at our centre between 2010 and 2016 were reviewed. Patients were randomised and divided 2:1 into training and validation sets. A novel risk-scoring model and prognostic nomogram were developed based on the results of multivariate analysis.

Results

Fifty-seven futile operations were observed. Multivariate analyses revealed tumour numbers > 3, Vp4 portal vein tumour thrombosis (PVTT) and alpha-fetoprotein (AFP) > 400 ng/ml independently associated with futile liver resection. A risk-scoring model based on the above-mentioned factors was developed (predictive risk score = 1 × (if AFP > 400 ng/ml) + 2 × (if tumour number > 3) + 3 × (if with Vp4 PVTT)). The area under the receiver-operating characteristic curve of this model was 0.845, with a sensitivity of 60.0% and a specificity of 94.8%. A prognostic nomogram was also developed and achieved a C-index of 0.831. The validation studies optically supported these results.

Conclusion

A risk-scoring model and predictive nomogram for futile liver resection were developed in the present study. T`he BCLC stage B/C HCC patients with a high risk obtained no benefit from liver resection.

     

Continuous local analgesia is effective in postoperative pain treatment after medium and large incisional hernia repair

Introduction

Incisional hernias are a frequent complication of laparotomy. Open surgery is still an option for the treatment of incisional hernias with medium and large wall defects. Major opioids are routinely used in the treatment of postoperative pain, with several side effects. Continuous local analgesia can be effective in postoperative pain management after various surgical interventions. However, very few reports exist on its application in incisional hernias.

Purpose

We assessed the effectiveness of ropivacaine in reducing the need for systemic analgesics in postoperative pain management related to these interventions.

Methods

We conducted an open-label, prospective, randomized design study. One hundred patients with medium and large incisional hernias were treated by open surgery. Thirty patients with abdominal defects > 8 cm received continuous postoperative local analgesia with ropivacaine 5 mg/ml. Thirty four and 36 patients (abdominal defects of more, and respectively less than 8 cm) received conventional analgesia.

Results

Continuous local anesthesia during the first 72 h after surgery reduced the number of patients needing analgesia with pethidine (17 vs 47% and 53%, p = 0.006), as well as the cumulative doses of pethidine (p < 0.05), tramadol (p < 0.001), and metamizole (p < 0.001) needed to control postoperative pain. Catheter installation for local anesthesia did not increase surgery time (p = 0.16) or the rate of local complications.

Conclusion

Continuous local analgesia reduces the need for systemic opioids and can be successfully used in the postoperative pain management after medium and large incisional hernias treated by open surgery.