Caroli disease patients have excellent survival after liver transplant

BackgroundCaroli disease (CD) is characterized by dilation of the intrahepatic biliary tree, which may result in malignancy. Treatments include management of symptoms and hepatic resection to decrease disease burden. In patients with CD not amenable to these treatments, orthotopic liver transplantation (OLT) has been used. This study examines if OLT is a reasonable treatment for patients with CD.Materials and methodsThe United Network of Organ Sharing/Organ Procurement and Transplantation Network database between September 30, 1987 and March 31, 2011 was queried. Cases without patient or allograft survival time or without a diagnosis were excluded from analysis. Patients with CD were compared to patients with primary biliary cirrhosis (PBC), secondary biliary cirrhosis (BC), primary sclerosing cholangitis (PSC), and all indications for OLT. Survival analysis was performed by log-rank test and Kaplan-Meier.ResultsOne hundred forty patients with CD were compared to 4797 patients with PBC, 489 patients with secondary BC, 6033 patients with PSC, and 92,210 patients post-OLT. Patient and allograft survivals of CD patients at 1, 3, 5, and 10 y are, respectively, 88.5%, 83.4%, 80.9%, and 77.8%; and 81.2%, 74.8%, 70.6%, and 67.9%. CD patients have significantly improved patient and allograft survivals after OLT compared to patients with secondary BC (P = 0.003, P = 0.015) and all other patients undergoing OLT (P = 0.003, P = 0.026). There is a trend towards long-term improved patient and allograft survival in transplanted patients with CD compared to patients with PBC and PSC.ConclusionsThese results suggest that OLT should be considered an effective treatment modality for patients with CD resulting in excellent long-term outcomes.     

The effect of immunosuppressive regimens on the recurrence of primary biliary cirrhosis after liver transplantation

Recurrence of primary biliary cirrhosis (PBC) has been described in liver transplant recipients. Type of immunosuppression has been reported to influence the frequency of recurrence. The aim of this study is to evaluate the occurrence and pattern of recurrent PBC in our liver transplant recipients and determine any association of immunosuppressive agents with its recurrence. Patients who underwent orthotopic liver transplantation (OLT) for PBC were identified from the University of Chicago Liver Transplant Database. Recurrent PBC was diagnosed based on specific pathological criteria. Of 46 patients who underwent OLT for PBC between 1984 and 2000, a total of 7 patients (15%) were diagnosed with recurrent PBC at a median of 78 months (range, 27 to 120 months) after OLT. Forty-three percent of patients were administered cyclosporine, whereas 57% were administered tacrolimus before disease recurrence. Rates of recurrence were not different between patients maintained on cyclosporine therapy (16%) compared with those maintained on tacrolimus therapy (18%; P = 1.0). There also was no difference in frequency of rejection episodes or duration of corticosteroid therapy between those who did and did not have recurrent PBC. In conclusion, recurrent PBC developed in a small number of patients 2 years or longer after OLT. In our population, there was no difference in recurrence rates between those administered cyclosporine or tacrolimus for immunosuppression. (Liver Transpl 2003;9:733-736.)     

Oncological Outcomes of Hepatic Resection vs Transplantation for Localized Hepatocellular Carcinoma

BackgroundScarce data are available comparing outcomes of hepatic resection vs orthotopic liver transplantation (OLT) for localized hepatocellular carcinoma (HCC) patients both meeting and exceeding the Milan criteria. This study compared the clinical and oncological outcomes of patients undergoing hepatic resection vs transplantation localized HCC.MethodBetween January 2005 and February 2017, clinical and oncological outcomes of patients who underwent liver resection (n = 38) vs OLT (n = 28) for localized HCC were compared using a prospectively maintained database.ResultsA total of 66 patients (with a median age of 62) who met the study criteria were analyzed. Comparable postoperative complications (13.2% vs 28.6%, P = .45) and perioperative mortality rates (7.9% vs 10.7%, P = .2) were noted for the resection vs OLT groups. While Child-Pugh Class A patients were more prevalent in the resection group (78.9% vs 7.1%, P = .0001), the rate of patients who met the Milan criteria was higher in the OLT group (89.3% vs 34.25, P = .0001). Recurrence rates were 36.8% in the resection group and 3.6% in the OLT group at the end of the median follow-up period (32 vs 39 months, respectively). The HCC-related mortality rate was significantly higher in the resection group (39.5% vs 10.7%, P = .034).However, a subgroup analysis of patients who met the Milan criteria revealed similar rates of recurrence and HCC-related mortality (15.4% vs 8%, P = .63). Based on logistic regression analysis, number of tumors (P = .034, odds ratio: 2.1) and “resection”-type surgery (P = .008, odds ratio: 20.2) were independently associated with recurrence.ConclusionCompared to liver transplantation, hepatic resection for localized hepatocellular carcinoma is associated with a higher rate of recurrence and disease-related mortality.     

Prevalence and characteristics of bone disease in cirrhotic patients under evaluation for liver transplantation

Background

We performed a retrospective study to examine the prevalence of bone disease (BD) among cirrhotic patients being evaluated for liver transplantation (OLT) using bone densitometry dual-energy x-ray absorptiometry in the hip/femoral neck and lumbar spine. The associations of BD with demographic and clinical data, disease etiology and liver function were studied by univariate and multivariate logistic regression analyses. Osteopenia and osteoporosis were defined by World Health Organization criteria.

Results

We included 486 patients (79% men of mean age, 53 ± 8.8 years (range, 21-69) who included 62.6% smoker and 23.7% diabetic subjects. Body mass index (BMI) was 28.8 ± 5.7 kg/m² (range, 16-43). The liver disease was Child-Pugh class A (22%), B (51%), or C (27%); the Model for End-Stage Liver Disease (MELD) score was 14.6 ± 5.4 (range, 7-33). The disease etiology was alcohol (59%), hepatitis C (32%), hepatitis B (10%), primary biliary cirrhosis (PBC) (2.3%), secondary biliary cirrhosis, (2%) or other causes (10%). In all, 350 patients (72%) had BD in the hip/femoral neck and/or lumbar spine: Global hip, 26% (osteopenia, 22%; osteoporosis, 4%); femoral neck, 48% (osteopenia, 43%; osteoporosis, 5%) and lumbar spine, 63% (osteopenia, 40%; osteoporosis, 23%). Univariate analysis showed the BD risk to increase with the following variables: Female gender (odds ratio [OR], 1.88; P = .023) and lower BMI (OR, 0.95; P = .012). Upon multivariate analysis, female gender (OR, 2.43; P = .004), lower BMI (OR, 0.96; P = .016), and tobacco use (OR, 1.59; P = .043) were significant. PBC showed BD in 100% of cases. By adjusting bone mineral density (BMD) values to age (Z-score) in relation to that defined by T-score, we observed a decrease in BD prevalence in both the femoral neck (20% vs 48%) and the lumbar spine (44% vs 63%).

Conclusion

BD, especially in the lumbar spine, is common among cirrhotic patients under evaluation for OLT. Cirrhosis is a major BD risk factor that remains even when BMD values are adjusted for age. Female gender, lower BMI, and tobacco consumption are major risk factors for BD in cirrhotic patients. Bone densitometry must be included in the OLT evaluation of all patients.     

Factors Affecting Survival and Tumor Recurrence in Patients Transplanted for Hepatocellular Carcinoma and Coexistent Hepatitis C Virus

A better understanding of tumor factors influencing patient and graft survival and recurrence of hepatocellular carcinoma (HCC) associated with hepatitis C virus (HCV) cirrhosis may be useful to maximize the benefits of liver transplantation (OLT). Sixty-three adults underwent OLT for end-stage liver disease secondary to HCV with concomitant HCC. The outcome measures were patient and graft survival, as well as recurrence-free survival, computed using a stepwise Cox proportional hazards regression analysis. Kaplan-Meier 1-, 3-, and 5-year patient survival rates were 82%, 80%, and 69%, respectively, they were better for incidentally discovered HCC compared with preoperatively diagnosed HCC (P = .04). The overall recurrence-free survival rates were 81%, 76%, and 61% at 1, 3, and 5 years, respectively. Univariate analysis showed that nonincidental HCC (P = .04), pTNM stage (P = .012) and vascular invasion (P = .003) correlated with recipient mortality. Vascular invasion (odds ratio [OR] = 2.12; P = .001) and pTNM (OR = 1.50; P = .008) were independent predictors of overall survival. A combination of tumor vascular invasion with advanced pTNM was associated with a dismal prognosis (log-rank = 21.89; P = .0001). Tumor grading (OR = 1.2; P = .04), pTNM (OR = 3.7; P = .001) and vascular invasion (OR = 1.6; P = .002) were independent predictors of recurrence. In conclusion, advanced pTNM and the presence of vascular invasion are strong predictors of poor survival and tumor recurrence.     

Is it worth it? Determining the health benefits of sleeve gastrectomy in patients with a body mass index <35 kg/m2

BackgroundCriteria for undergoing sleeve gastrectomy (SG) is restricted among patients with a body mass index (BMI) <35 kg/m².ObjectivesTo determine if low-BMI patients experience similar health benefits after SG compared with patients with a BMI ≥35 kg/m².SettingTeaching and nonteaching hospitals in Michigan.MethodsPatients with a BMI <35 kg/m² at the time of primary SG were identified between 2006 and 2018 (n = 1073, 2.4%). Patient characteristics, 30-day risk-adjusted complication rates, and patient reported outcomes were compared with all patients who underwent SG with a BMI ≥35 kg/m² (n = 44,511, mean BMI 46.7 kg/m²).ResultsLow-BMI patients were more likely to be older (50.7 versus 45.4 yr, P < .0001), have diabetes (36.7 versus 30.9%, P < .0001), hypertension (54.2% versus 51.0%, P = .0372), and hyperlipidemia (57.1% versus 44.8%, P < .0001). Both groups had comparable rates of discontinuation of medications for hypertension (59.7% versus 54.1%, P = .0570), hyperlipidemia (54.3% versus 52.2%, P = .5537), and diabetes (oral, 79.2% versus 78.1%, P = .7294; insulin, 64.2% versus 62.2%, P = .7438). However, low-BMI patients were more likely to achieve a healthy BMI (i.e., BMI ≤25 kg/m²; 36.3% versus 6.01%, P < .0001), and had higher body image scores (50.6 versus 42.4, P < .0001).ConclusionsDespite being older and with higher rates of metabolic disease, low-BMI patients reported high-resolution rates for diabetes, hypertension, and hyperlipidemia (>50%) and were more likely to achieve a healthy weight after SG. Abolishing the BMI threshold for SG among patients with metabolic disease should be considered.     

Abdominal obesity as risk factor for prostate cancer diagnosis and high grade disease: A prospective multicenter Italian cohort study

ObjectiveTo evaluate the association between abdominal obesity and prostate cancer (CaP) diagnosis and grade in patients undergoing prostate biopsy.Materials and methodsBetween 2008 and 2011, we prospectively enrolled patients referred to 3 clinics in Italy who were scheduled for transrectal ultrasound (TRUS) guided prostate biopsy. Before biopsy, digital rectal examination (DRE), prostate specific antigen (PSA), body mass index (BMI), and waist circumference (WC) were measured. Men were categorized in 4 groups of body habitus, according to BMI and waist circumference values. Crude and adjusted logistic regressions were performed to assess the association of BMI (continuous), waist circumference (continuous), body habitus (categorical), and CaP diagnosis and grade.ResultsSix hundred sixty-eight patients were enrolled. CaP was detected in 246 patients (38%), of whom 136 had low-grade (Gleason score ≤ 6) and 110 high-grade cancer (Gleason score ≥ 7). Logistic regression multivariate analysis showed that BMI (OR 1.05 per unit, CI 95% 1.00–1.10 P = 0.033) and waist circumference (OR 1.02 per cm, CI 95% 1.00–1.04 P = 0.026) were significant predictors of CaP diagnosis. BMI (OR 1.11 95% CI 1.04–1.18 P = 0.001) and WC (OR 1.04 95% CI 1.02–1.06 P = 0.001) were also associated with high-grade CaP. Furthermore, obesity with central adiposity (BMI ≥ 30kg/m² and WC ≥ 102 cm) was significantly associated with CaP diagnosis (OR 1.66, CI 95% 1.05–2.63, P = 0.03) and high-grade disease (OR 2.56, CI 95% 1.38–4.76, P = 0.003).ConclusionsObesity defined by BMI and WC seems to be associated with CaP and, more specifically, with high-grade disease at the time of biopsy. The relationship between obesity and CaP is complex and remains to be further addressed.     

Experience and Development of the Video-Assisted Thoracic Surgery Lobectomy Technique: Comparative Study With Conventional Surgery in Stage I Non-Small Cell Lung Cancer

BackgroundSurgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to compare long- and short-term results of conventional surgery (CS) vs VATS lobectomy in the treatment of stage I NSCLC.Materials and methodsWe performed a retrospective, analytical study of patients undergoing surgery for stage I NSCLC during the period January 1993 to December 2005. The variables analysed were overall survival, recurrence, distant metastasis, morbidity, mortality and hospital stay. During this period, 256 anatomic lung resections were performed: 141 by CS and 115 by VATS.ResultsThere were statistically significant differences in: (i) mean hospital stay in patients with no complications (VATS group: 4.3 days vs CS group: 8.7 days, P=.0001); (ii) mean hospital stay in patients with complications (VATS: 7.2 days vs CS: 13.7 days, P=.0001), and (iii) morbidity (VATS: 15.6% vs CS: 36.52%, P=.0001). No statistically significant differences were found in: (i) mortality (VATS: 2.17% vs CS: 1.7%, P=.88); (ii) 5-year overall survival (VATS: 68.1% vs CS: 63.8%), and (iii) local recurrence and distant metastasis (P=.82).ConclusionsVATS lobectomy is a safe and effective approach, with a shorter hospital stay and lower morbidity than CS; no statistically significant differences were observed in survival in patients undergoing surgery for stage I NSCLC.     

Long-term follow-up after recurrence of primary biliary cirrhosis after liver transplantation in 100 patients

Orthotopic liver transplantation (OLT) is the only effective curative therapy for end-stage primary biliary cirrhosis (PBC). Survival after OLT is excellent, although recent data have shown a recurrence rate of PBC of up to 32% after transplantation. The aim of this study is to investigate the course after disease recurrence, particularly with regard to liver function and survival in a long-term follow-up. Between April 1989 and April 2003, 1,553 liver transplantations were performed in 1,415 patients at the Charité, Virchow Clinic. Protocol liver biopsies were taken after one, three, five, seven, 10 and 13 yr. One hundred (7%) patients suffered from histologically proven PBC. Primary immunosuppression consisted of cyclosporine (n = 54) or tacrolimus (Tac) (n = 46). Immediately after OLT, all patients received ursodeoxycholic acid. Corticosteroids were withdrawn three to six months after OLT. The median age of the 85 women and 15 men was 55 yr (range 25-66 yr). The median follow-up after liver transplantation was 118 months (range 16-187 months) and after recurrence 30 months (range 4-79 months). Actuarial patient survival after five, 10 and 15 yr was 87, 84 and 82% respectively. Ten patients (10%) died after a median survival time of 32 months. Two of these patients developed organ dysfunction owing to recurrence of PBC. Histological recurrence was found in 14 patients (14%) after a median time of 61 months (range 36-122 months). Patients with Tac immunosuppression developed PBC recurrence more often (p < 0.05) and also earlier (p < 0.05). Fifty-seven patients developed an acute rejection and two patients a chronic rejection episode. Liver function did not alter within the first five yr after histologically proven PBC recurrence. Multivariate analysis of the investigated patients showed that the recipient's age and Tac immunosuppression were significant risk factors for PBC recurrence. Long-term follow-up of up to 15 yr after liver transplantation, owing to PBC, in addition to maintenance of liver function, shows excellent organ and patient survival rates. Although protocol liver biopsies revealed histological recurrence in 14 (14%) patients, only two patients developed graft dysfunction. Tac-treated patients showed more frequently and also earlier histologically proven PBC recurrence; however, in our population we could not observe an impact on graft dysfunction and patient's survival.     

Predictive Factors of Lack of Response to Antiviral Therapy Among in Patients With Recurrent Hepatitis C After Liver Transplantation

The current therapy for hepatitis C recurrence after liver transplantation OLT is based on interferon (IFN) and ribavirin (RBV) in monotherapy or combination. The rate of sustained virological response (SVR) varies between 10% and 45%. We have retrospectively analyzed factors that could predict SVR after antiviral therapy. We analyzed 42 patients who completed a cycle of therapy with natural or pegylated IFN plus RBV. There were 15 (35.7%) patients who obtained an SVR. The following factors were significantly associated with a lack of SVR: donor age ≥50 years (P = .046); donor body mass index (BMI) > 27 (P = .016); genotype 1 versus 2 to 3 (P = 0.010), aspartate transferase (AST) before therapy ≥ 140 U/L (P = .046), alanine transferase before therapy ≥ 280 U/L (P = .055), use of natural IFN versus pegylated IFN (P = .016). The only factors remaining after multivariate analysis were: donor BMI, AST before therapy and genotype. Our data confirmed that genotype 1 was associated with poorer outcomes; other additional parameters can influence the response to antiviral therapy.     

BMI and male gender are associated with increased operative time during total shoulder arthroplasty: an analysis of 16,568 patients

IntroductionOperative time has been shown to be a significant risk factor for short-term complications following total shoulder arthroplasty (TSA). Identifying TSA cases that require increased operative time may potentially lead to improved outcomes, yet there is a lack of previous research on specific risk factors associated with prolonged TSA operative time. The purpose of this study was to determine independent predictors for prolonged operative time following TSA.MethodsAdult patients undergoing primary TSA from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients with sepsis, disseminated cancer, infection, or who underwent emergency surgery were excluded from our dataset. Prolonged operative time was defined as ≥ 150 minutes, or one standard deviation above the mean operative time of 109 minutes. Clinical characteristics assessed included age, sex, race, BMI, American Society of Anesthesiologists class, surgical setting (inpatient vs. outpatient), anesthesia type, preoperative albumin, and hematocrit. Comorbidities assessed included diabetes, smoking, dyspnea, functional status, chronic obstructive pulmonary disease, ascites, congestive heart failure, hypertension, renal failure, dialysis, steroid use, weight loss, bleeding disorder, and preoperative transfusion. Risk factors were assessed using bivariate and multivariate analysis.ResultsOf 16,568 total patients undergoing TSA, 14.8% (2,453) had prolonged operative time. On bivariate analysis, younger age, male sex, nonwhite race, increased BMI, outpatient procedure, smoking status, dyspnea, steroid use, and bleeding disorder were significantly associated with prolonged operative time (all, P < .05). After controlling for confounding variables on multivariate analysis, increased BMI (OR 1.023; P = .045) and male gender (OR 1.647; P < .001) were found to be independent predictors of prolonged TSA operative time. Notably, age was not found to be an independent predictor of prolonged operative time (P > .05).ConclusionIncreased BMI and male gender were found to be predictive of prolonged TSA operative time. Since increased operative time has been shown to be associated with increased short-term postoperative complications, surgeons and perioperative teams should be aware of the potential for prolonged operative time in patients with these risk factors who undergo TSA.Level of EvidenceLevel III; Retrospective Case-control Comparative Study     

Urothelial carcinoma at the uretero-enteric junction: Multi-center evaluation of oncologic outcomes after radical nephroureterectomy

ObjectiveThe natural history of urothelial carcinoma arising at the uretero-enteric junction (UEJ) is poorly defined, and the data guiding clinical management of these patients is limited. Therefore, we evaluated oncologic outcomes of patients treated for urothelial carcinoma at the UEJ.MethodsUtilizing a multi-institutional database of patients treated with radical nephroureterectomy (RNU), we assessed the clinicopathologic parameters and oncologic outcomes of UEJ tumors compared with other upper tract urothelial carcinomas (UTUC). Survival analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU.ResultsThe study included 1,363 patients, 921 men and 442 women with 36 months median follow-up after RNU. Compared with UTUC in the kidney or ureter, UEJ tumors (n = 22) were more likely to demonstrate features of advanced disease, which were proved to be independent predictors of disease recurrence and cancer-specific mortality after RNU. The 5 year disease-free survival (DFS) and cancer-specific survival (CSS) rates were 25% and 39% in those with UEJ tumors vs. 69% and 73% in those with UTUC in the kidney or ureter (P = 0.001 and P = 0.008, respectively).ConclusionsUEJ tumors harbor features of locally advanced disease associated with high risk of systemic recurrence and death from cancer after RNU. Our findings suggest the need for integration of systemic therapy into the management paradigm of these patients.     

Recurrence of hepatocellular carcinoma after liver transplantation

Outcome after liver transplantation (OLT) clearly depends on recurrence of hepatocellular carcinoma (HCC). After recurrence, patient outcome will depend on the time and site of appearance. The aim of this study was to analyze the therapeutic implications of tumor recurrence behavior. From October 1988 to December 2005, 685 patients received OLT, including 202 due to HCC (32%). We analyzed 28 recurrences (15.2%) among 184 patients who survived at least 3 months (minimum follow-up 1 year). According to the time of recurrence, we divided the patients into early recurrence (ER < 12 months; n = 9; 32.1%) and late recurrence (LR > 12 months n = 19; 67.9%). Actuarial survivals at 1, 5, and 10 years were 82%, 65%, and 50% and disease-free survival, 80%, 58%, and 46%, respectively. Risk factors for recurrence were: vascular invasion (P < .01), bad differentiation (P < .01), and previous hepatectomy (P < .05). After OLT, ER presented at: 5.7 ± 2.3 months (range 3-10) vs 33.5 ± 24.3 months (range 12-103) for LR P < .001). Survival postrecurrence (SPR) was shorter: 3.1 ± 2.4 (range 1-8) months vs 16.4 ± 14.2 (range 1-5) months (P < .001). Treatment was offered to one ER (11%) and to eight LR (47.1%; P < .05), achieving in these cases longer SPR: 20.1 ± 14 vs 6.9 ± 9 months (P < .05).The most common sites of recurrence were liver (n = 7), lung (n = 7), bone (n = 5), adrenal gland (n = 2), peritoneum (n = 2), lymph node (n = 2), skin (n = 2) or cerebral (n = 1). Early recurrences showed short survivals; no treatment could be offered to these patients. Liver recurrence appeared early. In contrast, most lung recurrences appeared later with the possibility of treatment and longer SPR. Bone recurrence appeared later, usually associated with other locations. Treatment was paliative and prognosis was worse. Skin and lymph node recurrences can be treated curatively with prolonged survival. In conclusion, HCC recurrence was difficult to treat curatively and was only prevented by employing restricted criteria.     

Predictive Factors of Recurrence of Hepatocellular Carcinoma After Liver Transplantation: A Multivariate Analysis

We analyzed predictive risk factors for recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT). We retrospectively analyzed the clinical data from 109 consecutive HCC patients who underwent OLT at our center from 1988 to 2007. We excluded all patients who died due to factors other than tumor recurrence within the first year (n = 24). The remaining 85 patients were enrolled in either a recurrence group (A; n = 19) or a nonrecurrence group (B; n = 66). Upon univariate analysis, the 2 groups were significantly different for 11 parameters. Group A included more females (P = .05), noncirrhotic liver recipients (P = .003), “up-to 7 status” patients (HCC with 7 as the sum of the size of the largest tumor [cm] and the number of tumors, P < .0001), patients exceeding Milan criteria (MC; P < .0001) or University of California San Francisco (UCSF) criteria (P < .0001), and OLT performed before 1999 (P = .003). Group A also showed a higher number of lesions (P = .035), a greater sum of diameters of the lesions (P < .0001), a major number of macrovascular (P < .0001) and microvascular invasions (P < .0001), and an increased number of G3-G4 grading (P = .006). Only microvascular invasion (P = .007) and exceeding UCSF criteria (P = .003) were independent risk factors for recurrence upon multivariate analysis. Patients with both these parameters are not candidates for OLT. Microvascular invasion is a good predictive parameter, but is impossible to detect preoperatively. New pre-OLT predictive risk factors are needed to achieve optimal results.     

Conversion of gastric sleeve to Roux-en-Y gastric bypass: overall outcomes and predictors of below-average weight loss

BackgroundConversion of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) has been utilized to promote further weight loss, but results are variable in available literature.ObjectivesTo evaluate outcomes of SG to RYGB conversion for weight loss and to identify predictors of below-average weight loss.SettingUniversity-affiliated hospital, United States.MethodsChart review was performed of our patients who underwent SG to RYGB conversion from November 1, 2013, to November 1, 2020. Primary outcomes were below-average percent excess weight loss (%EWL) at 1 and 2 years. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for preconversion demographics to evaluate their relationship to the primary outcome.ResultsSixty-two patients underwent conversion from SG to RYGB with weight loss as a goal. One-year data was available for 47 patients. The average %EWL at 1 year was 41.5%. Twenty-six patients had below-average %EWL at 1 year. Interval to conversion <2 years (OR = 4.41, 95% CI [1.28,15.17], P = .019) and preconversion body mass index (BMI) >40 (OR = 4.00, 95% CI [1.17,13.73], P = .028) were statistically significant predictors of below-average 1-year %EWL. Two-year data was available for 36 patients. The average %EWL at 2 years was 30.8%. Seventeen patients had below-average %EWL at 2 years. Evaluated demographics were not statistically significant predictors of below-average 2-year %EWL.ConclusionsFollowing SG to RYGB conversion, %EWL outcomes are lower at 1 year (41.5%) and 2 years (30.8%) than reported values for primary RYGB. Interval to conversion <2 years and preconversion BMI >40 are predictors of below-average 1-year weight loss after conversion.     

Bariatric surgery in the super-super morbidly obese: outcome analysis of patients with BMI >70 using the ACS-NSQIP database

BackgroundBariatric surgery offers patients short- and long-term benefits to their health and quality of life. Currently, we see more patients with superior body mass index (BMI) looking for these benefits. Evidence-based medicine is integral in the evaluation of risks versus benefit; however, data are lacking in this high-risk population.ObjectivesTo assess the morbidity and mortality of patients with BMI ≥70 undergoing bariatric surgery.SettingUniversity Hospital, Bronx, New York, United States using national database.MethodsUsing the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for years 2005 to 2016, we identified patients who underwent primary laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Patients with BMI ≥70 were assigned to the BMI >70 (BMI70+) cohort and less obese patients were assigned to the BMI <70 (U70) cohort. Length of stay and 30-day morbidity and mortality were compared.ResultsA total of 163,413 patients underwent non-revisional bariatric surgery. Of those, 2322 had a BMI ≥70. BMI70+ was associated with increased mortality (.4% versus .1%, P = .0001), deep vein thrombosis (.6% versus .3%, P = .007), pulmonary (1.9% versus .5%, P = .0001), renal (.9% versus .2%, P = .0001), and infectious complications (1.1% versus .4%, P = .0001). BMI70+ patients had longer mean length of stay (2.6 versus 2.1 d, P = .0001) and operative time (126.1 versus 114.5 min, P = .0001). There was no statistically significant difference in the number of myocardial infarctions (.1% versus .1%, P = .319), pulmonary embolisms (.3% versus .2%, P = .596), and transfusion requirements (.1% versus .1%, P = .105) between groups.ConclusionsEvaluation of risk and benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for BMI70+ patients undergoing bariatric surgery was increased over U70 patients but was still relatively low. Our study will allow surgeons to incorporate objective data into their assessment of risk for super-obese patients pursuing bariatric surgery.     

High Viremia,Prolonged Lamivudine Therapy and Recurrent Hepatocellular Carcinoma Predict Posttransplant Hepatitis B Recurrence†

Hepatitis B virus (HBV) recurrence following orthotopic liver transplantation (OLT) is generally preventable by prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine (LAM). However, HBV recurrence sometimes develops despite prophylaxis. This study assessed posttransplant outcomes and identified predictors of HBV recurrence. We analyzed the outcomes of 209 consecutive patients positive for hepatitis B surface antigen who underwent OLT, who received either combination prophylaxis with HBIG and LAM (89.0%) or HBIG monoprophylaxis (11.0%). The median follow‐up was 36.8 months (range, 1.0–84.4). Posttransplant HBV recurrence occurred in 22 patients (10.5%), including 13 patients with drug‐resistant mutations. HBV recurrence was observed in six patients after hepatocellular carcinoma (HCC) recurrence. Independent predictors of HBV recurrence were recurrent HCC (p < 0.001), LAM therapy >1.5 years (p = 0.001) and high HBV DNA titers (≥10⁵ copies/mL) at OLT (p = 0.036). In conclusion, high viremia at OLT and prolonged exposure to LAM should be further stressed as main predictors of HBV recurrence.     

Risk factors for biochemical recurrence following radical perineal prostatectomy in a large contemporary series: A detailed assessment of margin extent and location

ObjectivesThe implications of positive surgical margin (PSM) extent and location during radical perineal prostatectomy (RPP) have not been assessed in a contemporary series. We aimed to examine the incidence, location, and extent of PSM as well as their impact on biochemical recurrence (BCR) following RPP.Materials and methodsA total of 794 patients underwent RPP by a single surgeon between June 1993 and August 2010. Covariates included age, pathologic T stage, pathologic Gleason sum, preoperative PSA, prostate volume, PSM extent, and location. Life table, Kaplan-Meier, and Cox regression analyses assessed predictors of BCR following RPP.ResultsPSM were recorded in 162 patients (20.4%); of these, 83 (51.2%) were focal (≤1 mm) whereas 79 (48.8%) were broad (>1 mm). Location of PSM was anterior 10.5%, posterior or lateral 14.8%, bladder neck 23.5%, apical 32.1%, and multifocal 19.1%. At a median follow-up of 54 months, the 5-year BCR-free probability was 90.8% in patients with negative margins, 77.5% in patients with focal PSM, and 47.5% in patients with broad PSM. On multivariable analyses adjusted for age, pathologic T stage, pathologic Gleason sum, preoperative PSA, and prostate volume, broad PSM, (HR = 3.49, P < 0.001) as well as anterior (HR = 3.77, P = 0.003), bladder neck (HR = 2.25, P = 0.01) and multifocal (HR = 3.55, P < 0.001) PSM were independent predictors of BCR.ConclusionsIn this study, we present oncologic outcomes following RPP in a large contemporary cohort of patients undergoing RPP. In adjusted analyses, broad and anterior PSM carried the highest risk of recurrence after RPP.     

Effectiveness of adjuvant radiotherapy for high recurrence risk patients with upper tract urothelial carcinoma

PurposeA recent study has shown that upper tract urothelial carcinoma (UTUC) patients with high-risk factors have a high local recurrence rate. The purpose of this work was to investigate the benefit of adjuvant radiotherapy (ART) for patients with high recurrence factors.MethodsFour hundred twenty-four UTUC patients who received radical nephroureterectomy (RNU) in our hospital between 2010 and 2018 were reviewed. The significance of factors on cancer-specific survival (CSS) and recurrence-free survival (RFS) were assessed using Cox multivariate analysis. In patients with high recurrence factors, propensity score matching was used to adjust the confounding factors for ART.ResultsThe median follow-up time was 40 (range 3–77) months. Multivariate analysis showed that multifocal tumor, G3, pT3/4 stage and positive lymph node (N+) were independent predictors for worse RFS. Multifocal tumor and pT3/4 stage were independent predictors of worse CSS in UTUC after surgery. A total of 286 patients with these high recurrence factors were identified: 192 (67.1%) patients received RNU only, and 94 (32.9%) patients received ART. Overall, ART did not improve CSS (ART 86.1% vs. RNU 78.5%.; P = 0.11). After propensity score matching, ART significantly improved the CSS of patients with high recurrence factors. The 3-year CSS was 73.1% in patients treated with RNU alone vs. 86.1% in patients treated with ART (P = 0.016).ConclusionsResults of our study demonstrated benefit of adjuvant radiotherapy in cancer specific survival in UTUC patients with high recurrence factors(multifocal tumor ,pT3/4,G3 and positive lymph node).     

Incisional Hernia Repair After Liver Transplantation: Role of the Mesh

Background

Patients undergoing orthotopic liver transplantation (OLT) show a high risk of developing an incisional hernia. The aim of this retrospective study was to establish the incidence and the factors influencing the outcomes of this complication.

Methods

We reviewed 450 consecutive OLT performed in 422 adult recipient between January 2000 and December 2005. Herniae were analysed with aspect to localization, classification, repair technique, and recurrence. All treated herniae were followed for a median of 50.5 months.

Results

Incisional herniae occurred in 36 patients (8.5%, Group 1). Their mean age OLT was 51.4 years with 94.4% male subjects. No significant difference was observed between affects and unaffected individuals for age, OLT indication, Child-Pugh score, albumin, comorbidities, operative time, transfusions, immunosuppressant regimen, and graft rejection episodes as well as for the incisional approach and hospital stay. Gender, body mass index (BMI), preoperative ascites, and pulmonary complications after OLT were significantly different (P < .01). Herniae were small (<5 cm; n = 12), medium (5-10 cm; n = 28), or large (> 10 cm; n = 2). Herniorrhaphy techniques included primary suture repair in 5 (13.9%) and mesh repair in 31 (86.1%) cases. In 3 patients with a primary repair and 1 patient with a mesh repair there were recurrences.

Conclusions

Preoperative ascites, gender, BMI, and pulmonary complications after OLT seemed to have significant influences on the formation of incisional herniae. Polypropylene mesh may be a first choice for the surgical treatment of there transplant recipients.