Long-term graft survival after liver transplantation in the UW era: late effects of cold ischemia and primary dysfunction

The use of University of Wisconsin (UW) solution in liver transplantation (LTX) has significantly prolonged preservation times and facilitated semielective transplant procedures. Despite this advantage potential risk factors related to the donor, recipient, or cold storage method will persist in the UW era and detrimental effects will be reflected by primary dysfunction (PDF) after LTX. Concern has been voiced about the maximum period of UW preservation in LTX and various cold ischemia times (CIT) are mentioned. To evaluate the effect of UW solution in LTX, a prospective European multicenter study was initiated in 1988 and short-term results have been reported previously. This report focuses on the long-term effects and survival of prolonged preservation with UW solution and primary function after LTX. Three hundred and fifteen LTXs were performed in 288 patients in participating European centers. Complete follow up of at least 6 years was available for 296 grafts in 277 patients. Effects of donor, preservation, and recipient risk factors on PDF including primary non-function (PNF) and initial poor function (IPF) were evaluated. Next, the effect of risk factors on graft survival (GS) was analyzed including the long-term impact of PNF and IPF using multivariate analyses and the Kaplan-Meyer method. PDF occurred in 15.2 % (45/296) with PNF in 7.8 % and IPF in 7.4 %. Patients with IPF had a 34 % lower GS at 3 months those with immediate function (IF; 58 % vs 91 %; P < 0.001). This difference persisted up to 6 years for patients with IPF with a 39 % GS vs 72 % after IF (P < 0.001). Median CIT was significantly longer in grafts with PNF compared to IPF or IF (P = 0.03). Long-term GS, however, was significantly influenced at a lower CIT threshold with a 6-year GS for CIT K 16 h of 67 %, compared to a CIT > 16 h of 51 % (P = 0.02). Other independent risk factors for the 6-year survival rate were re-LTX, ABO incompatibility, and recipient diagnosis of acute hepatic failure. In conclusion, liver patients with PNF, but not with IPF, have a significantly lower CIT. IPF is associated with a significantly lower 3 month GS compared to IF, but this difference of 34 % does not further increase during a 6-year follow up. Although a short term follow up (3 months) shows that with UW solution CIT up to 18 h has no adverse effect on GS, the 6-year data clearyl suggest that CIT should be kept to less than < 16 h to avoid tetrimental effects on lang-term GS after LTX.     

Surgical Complications Following Liver Transplantation in Patients with Portal Vein Thrombosis—A Single-Center Perspective

Introduction

Portal vein thrombosis (PVT) was once considered a contraindication for liver transplantation (LTx) because of technical difficulties. Though no longer a contraindication, it remains a risk factor.

Aim

A study of surgical complications following LTx in patients with and without PVT.

Patients and methods

A retrospective review of 1,171 consecutive patients who underwent LTx between June 1995 and June 2007 was performed, and 78 recipients with PVT (study group) were compared with a stratified random sample of 78 contemporous recipients without PVT (control group) for postoperative complications. Both groups were comparable with respect to age, sex, race, and other confounding variables.

Results

The rate of primary nonfunction (PNF) in the study and control groups was 9.0% and 1.3%, (p?=?0.063), while that of retransplantation was 17.9% and 7.7% (p?=?0.055), respectively. The mean donor risk index (DRI) among the patients with and without PNF in the study group was 2.58?±?0.44 and 2.08?±?0.42, respectively (p?=?0.014). A significantly higher number of packed red blood cells and fresh frozen plasma transfusions were observed in study group compared to controls (p?=?0.012, 0.007, respectively).

Conclusion

A higher rate of PNF was related to the complexity of the surgical procedure and the use of donor livers with a high DRI. Higher rates of PNF eventually led to a higher rate of retransplant. A strategy of offering donor livers with a low DRI might be helpful in decreasing the rate of PNF. Further, a PV interposition graft in difficult cases instead of thrombectomy could lead to a lower rethrombosis rate.     

Liver Transplantation Using University of Wisconsin or Celsior Preserving Solutions in the Portal Vein and Euro-Collins in the Aorta

Introduction

Orthotopic liver transplantation (OLT) is today the gold standard treatment of the end-stage liver disease. Different solutions are used for graft preservation. Our objective was to compare the results of cadaveric donor OLT, preserved with the University of Wisconsin (UW) or Celsior solutions in the portal vein and Euro-Collins in the aorta.

Methods

We evaluated retrospectively 72 OLT recipients, including 36 with UW solution (group UW) and 36 with Celsior (group CS). Donors were perfused in situ with 1000 mL UW or Celsior in the portal vein of and 3000 mL of Euro-Collins in the aortia and on the back table managed with 500 mL UW or Celsior in the portal vein, 250 mL in the hepatic artery, and 250 mL in the biliary duct. We evaluated the following variables: donor characteristics, recipient features, intraoperative details, reperfusion injury, and steatosis via a biopsy after reperfusion. We noted grafts with primary nonfunction (PNF), initial poor function (IPF), rejection episodes, biliary duct complications, hepatic artery complications, re-OLT, and recipient death in the first year after OLT.

Results

The average age was 33.6 years in the UW group versus 41 years in the CS group (P = .048). There was a longer duration of surgery in the UW group (P = .001). The other recipient characteristics, ischemia-reperfusion injury, steatosis, PNF, IPF, rejection, re-OLT, and recipient survival were not different. Stenosis of the biliary duct occured in 3 (8.3%) cases in the UW group and 8 (22.2%) in the CS (P = .19) with hepatic artery thrombosis in 4 (11.1%) CS versus none in the UW group (P = .11).

Conclusion

Cadaveric donor OLT showed similar results with organs preserved with UW or Celsior in the portal vein and Euro-Collins in the aorta.     

The surgical management of angiosarcoma of the breast—a single institution experience

Background

Angiosarcoma of the breast is a rare and aggressive tumour of the vascular endothelium. It may arise spontaneously or secondary to radiation. We present our experience of managing breast angiosarcoma, the largest single institution case series from the UK to date along with a summary of the relevant literature.

Methods

Data on all patients with breast angiosarcoma treated in our unit were prospectively recorded (2002–2014). Demographics, surgical details and outcomes were analysed.

Results

Eighteen female patients presented with breast angiosarcoma. Sixteen patients previously underwent adjuvant radiotherapy following surgery for breast carcinoma; the mean duration between radiotherapy and angiosarcoma development was 8.4 years (range 3–21). Resections were as follows: radical mastectomy (n?=?14), simple mastectomy (n?=?1) and wide local excision (n?=?3). Reconstruction was undertaken as follows: pedicled lattisimus dorsi (LD) musculocutaneous flap (n?=?5), pedicled LD muscle flap and split skin graft (n?=?7), free deep inferior epigastric perforator (DIEP) flap (n?=?1), pedicled vertical rectus abdominus muscle (VRAM) flap and split skin graft (n?=?1), pedicled LD muscle and pedicled VRAM muscle flaps and split skin graft (n?=?1), pedicled LD muscle and pedicled (contralateral) pectoralis major muscle flaps and split skin graft (n?=?1) and direct closure (n?=?2). Three patients developed local recurrence; mean duration from resection to recurrence was 12 months (range 9–19). Three patients developed metastasis. Seven patients (38.8 %) died; median survival from presentation was 19 months (range 2–55 months). The remaining eleven patients remain well with no disease recurrence; mean follow-up was 38 months (range 4–125). The estimated 5-year survival (Kaplan-Meier equation) in our cohort was 49 %.

Conclusions

Breast angiosarcomas are rare and challenging to manage. Successful outcomes can be achieved by early, aggressive resection and appropriate reconstruction. Level of Evidence: Level IV, therapeutic study.     

Rubber transcystic drainage reduces the post-removal biliary complications in liver transplantation: a matched case–control study

Purpose

Bile duct (BD) complications continue to be the “Achilles’ heel” of liver transplantation, and the utilization of bile duct drainage is still on debate. We describe the results of a less invasive rubber trancystic biliary drainage (TBD) compared to a standard silicone T-tube (TT).

Methods

The transplanted patients (n?=?248), over a period of 5 years with a TBD (n?=?20), were matched 1:2 with control patients with a TT (n?=?40). Primary end points were the overall incidence of BD complications and graft and patient survival. Secondary end points included the complications after the drainage removal.

Results

Although the bile duct leakage rates were not significantly different between both groups, the TT group had a significantly higher rate of overall 1-year BD stenosis (40 versus 10 %) (p?=?0.036). Three-year patient/graft survival rates were 83.2/80.1 and 84.4/84.4 % for the TT and TBD groups, respectively. The postoperative BD complications, after drainage removal (peritonitis and stenosis), were significantly reduced (p?=?0.011) with the use of a TBD.

Conclusion

The use of rubber TBD in liver transplant recipients does not increase the number of BD complications compared to the T-tube. Furthermore, less BD anastomotic stenosis and post-removal complications were observed in the TBD group compared to the TT group.     

Ghost ileostomy after anterior resection for rectal cancer: a preliminary experience

Purpose

The aim of this study was to describe and evaluate the feasibility and the eventual advantages of ghost ileostomy (GI) versus covering stoma (CS) in terms of complications, hospital stay and quality of life of patients and their caregivers after anterior resection for rectal cancer.

Methods

In this prospective study, we included patients who had rectal cancer treated with laparotomic anterior resection and confectioning a stoma (GI or CS), in the period comprised between January 2008 and January 2009. Short-term and long-term surgery-related mortality and morbidity after primary surgery (including that stoma-related and colorectal anastomosis-related) and consequent to the intervention of intestinal recanalization (CS group) and GI closure were evaluated. We evaluated hospital stay and quality of life of patients and their caregivers.

Results

Stoma-related morbidity rate was higher in the CS group than in GI group (37% vs. 5.5%, respectively, P?=?0.04). Morbidity rate after intestinal recanalization in the CS group was 25.9% and 0% after GI closure (P?=?0.08). Overall stoma morbidity rate was significantly lower in the GI group with respect to CS group (5.5% vs. 40.7%, respectively, P?=?0.03). CS group was characterized by a significantly longer recovery time (P?=?0.0002). Caregivers and stoma-related quality of life were better in the GI group than in CS group (P?<?0.0001 and P?=?0.0005, respectively).

Conclusions

GI is feasible, characterized by shorter recovery, lesser degree of total, as well as anastomosis-related morbidity and higher quality of life of patients and the caregivers in respect to CS. We suggest that GI (should be evaluated as an alternative to conventional ileostomy) could be indicated in selected patients that do not present risk factors, but require caution for anastomotic leakage for the low level of colorectal anastomosis.     

Delayed Gastric Emptying After Stapled Versus Hand-Sewn Anastomosis of Duodenojejunostomy in Pylorus-Preserving Pancreaticoduodenectomy: a Randomized Controlled trial

Background

A retrospective analysis indicated that the incidence of delayed gastric emptying (DGE) was less after using a circular stapler (CS) for duodenojejunostomy than that after hand-sewn (HS) anastomosis in pylorus-preserving pancreaticoduodenectomy (PpPD). This randomized clinical trial compared the incidence of DGE postoperative after CS duodenojejunostomy with that of conventional HS anastomosis in PpPD.

Methods

We randomly assigned 101 patients (age 20–80) undergoing PpPD to receive CS duodenojejunostomy (group CS, n?=?50) or HS duodenojejunostomy (group HS, n?=?51) in two Japanese cancer center hospitals between 2011 and 2013. The patients were stratified by institution and size of the main pancreatic duct (<3 or ≥3 mm). The primary endpoint was the incidence of grade B or C DGE according to the international definition with a non-inferiority margin of 5 %. This trial is registered with University hospital Medical Information Network (UMIN) Center: UMIN000005463.

Results

Per-protocol analysis of data on 95 patients showed that grade B or C DGE was found in 4 (8.9 %) of 45 patients who underwent CS anastomosis and in 8 (16 %) of 50 patients who underwent HS anastomosis (P?=?0.015). There were no differences in the overall incidence of DGE (P?=?0.98), passage of the contrast medium through the anastomosis (P?=?0.55), or hospital stays (P?=?0.22).

Conclusions

CS duodenojejunostomy is not inferior to HS anastomosis with respect to the incidence of clinically significant DGE, justifying its use as treatment option.

     

Quality of life after laparoscopy-assisted pylorus-preserving gastrectomy: an evaluation using a questionnaire mailed to the patients

Purpose

This study investigated the postoperative quality of life (QOL) after laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) in comparison to laparoscopy-assisted distal gastrectomy (LADG).

Methods

Twenty-one patients with early-stage gastric cancer underwent minimally invasive LADG (n?=?12) or LAPPG (n?=?9). Demographic and cancer-related data were obtained retrospectively from medical records. QOL was assessed using a 13-item questionnaire and the Japanese edition of the Gastrointestinal Symptom Rating Scale, which were mailed to patients twice postoperatively. Body weight and hemoglobin levels were measured at the same time.

Results

Early upper abdominal pain was rated as significantly worse with LAPPG than with LADG at the first checkup (1.4 vs. 1.0, P?=?0.02) but not at the second checkup (1.3 vs. 1.0, P?=?0.07). There was a trend toward less body weight loss in the LAPPG patients in comparison to the LADG patients. The serum hemoglobin levels of LAPPG patients at the second checkup showed significantly higher than LADG patients (13.3 vs. 11.6?g/dL, P?Conclusions LAPPG and LADG produce similar QOL in patients. Trends toward less body weight loss and improved anemia in LAPPG patients may therefore become more pronounced in future studies that have adequate number of the patients and longer follow-up periods.     

The MELD score predicts the short-term and overall survival after liver transplantation in patients with primary sclerosing cholangitis or autoimmune liver diseases

Purpose

Liver transplantation (LT) is well established in patients with autoimmune liver disease. Despite excellent outcomes, organ scarcity demands careful patients’ selection and timing of transplantation.

Methods

This retrospective study analyzes data of 79 consecutive patients with primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and overlap syndrome, undergoing LT between 2001 and 2012. Overall survival (OS) and graft survival were assessed using Kaplan-Meier estimate. Multivariate survival analysis was performed to identify prognostic factors by using Cox regression model.

Results

After 59.6-month median follow-up, the 5-year OS and graft survival were 75.3 and 68.8 %, respectively. The 5-year survival rates for patients with PSC (n?=?57), AIH (n?=?17), and overlap syndrome (n?=?5) were 76.3, 76.0, and 60.0 %. The 90-day mortality rate of 70.0 % was significantly higher in patients with a labMELD score ≥20 (n?=?10) compared to 26.1 % in 69 patients with a labMELD <20 (p?=?0.009). A lab Model for End-Stage Liver Disease (MELD) score ≥20 was an independent predictor of impaired OS (p?=?0.050, hazard ratio 2.5). The 5-year OS was 55.7 % in patients with a labMELD score ≥20 compared to 84.7 % in patients with a labMELD score <20.

Conclusion

The recipients’ MELD score is a predictor for the short-term outcome after LT in patients with autoimmune liver disease. Meticulous selection for transplant listing remains necessary to safe scarce donor organs.     

Indications, safety, and feasibility of conversion of failed bariatric surgery to Roux-en-Y gastric bypass: a retrospective comparative study with primary laparoscopic Roux-en-Y gastric bypass

Background

Roux-en-Y gastric bypass (RYGB) is considered the “gold standard” revision procedure. The purpose of this study was to compare the surgical outcome of primary laparoscopic RYGB (pLRYGB) to revisional open or laparoscopic Roux-en-Y gastric bypass surgery (rRYGB).

Methods

A retrospective analysis of all patients who underwent pLRYGB or rRYGB from January 2003 to December 2009 has been performed. Demographics, indications for revision, and complications have been reviewed. The rRYGB and pLRYGB patients have been compared.

Results

Seventy-two patients underwent rRYGB, and 652 patients underwent pLRYGB. Mean follow-up was 35 and 45?months, respectively. Fifty-six rRYGB procedures were performed laparoscopically. The primary operations had consisted of laparoscopic gastric banding (n?=?28), laparoscopic vertical banded gastroplasty (n?=?19), laparoscopic sleeve gastrectomy (n?=?6), laparoscopic RYGB (n?=?3), and biliopancreatic diversion with duodenal switch (n?=?16). Indications included weight regain (n?=?29), malabsorption (n?=?16), gastrogastric fistula (n?=?5), band-associated problems (n?=?3), and refractory stomal ulceration (n?=?1). There was no significant difference in early or late postoperative complications when comparing rRYGB to pLRYGBP patients (11.1% vs. 5.52%, P?=?0.069 and 19.4% vs. 24.2%, P?=?0.465 respectively). Five rRYGB patients (7.04%) required reintervention (3 internal hernias, 1 ventral hernia, 1 laparoscopic exploration) compared with 101 pLRYGB patients (15.71%; P?=?0.051). None of the patients died. Mean hospital stay was not significantly longer in the rRYGB group (5.38 vs. 4.95?days, P?=?0.058).

Conclusions

In our series, hospital stay, morbidity, and mortality of rRYGB were not significantly higher compared with pLRYGB. Furthermore, we believe that this type of revisional bariatric surgery should be performed in high-volume bariatric centers.     

Clinical Application of Mucosal Valve Technique for Anastomosis During Esophagogastrostomy

Background

The study aims to compare the efficacy in prevention of anastomotic complications using layer-to-layer mucosal valve technique versus circular stapled technique for esophagogastric intrathoracic anastomosis after resection for esophageal and gastric cardiac carcinoma.

Methods

From January 2005 to December 2010, 136 patients received layer-to-layer mucosal valve technique (LM group), 219 received circular stapled anastomosis (CS group) after curative intent resection for esophageal and gastric cardiac carcinoma. The technique details were reported and the clinical results were analyzed.

Results

The two groups were comparable on clinical baseline characteristics. The average duration of operation was longer with LM technique by 16 min, but without statistical significance (P?=?0.073). There was no anastomotic leakage in the LM group, while in the CS group, leakage occurred in seven patients (3.2 %, P?=?0.047). Both the incidence and grade of postoperative dysphagia were significantly lower in the LM group (P?<?0.05). Significantly fewer patients experienced stricture after LM technique (3.8 %) compared with CS anastomosis (18.2 %, P?<?0.001). CS anastomosis was associated with a significantly higher incidence of persistent stricture requiring more dilatation (P?<?0.001). Symptoms of reflux were better controlled by LM technique; 82.7 % of patients were asymptomatic with respect to reflux compared to 58.9 % in the CS group, P?<?0.001. And there was a significant reduction in the incidence of esophagitis in remnant esophagus in the LM group (P?=?0.001).

Conclusions

The layered mucosal valve anastomosis could significantly diminish the incidence of anastomotic complications and could be used as an alternative for esophagogastric anastomosis after resection of esophageal and gastric cardiac carcinoma.     

Effects of sevelamer hydrochloride on mortality, lipid abnormality and arterial stiffness in hemodialyzed patients: a propensity-matched observational study

Background

Cause-and-effect associations between sevelamer hydrochloride (HCl) and mortality have yet to be clarified. The effects of sevelamer HCl on mortality, lipid abnormality and arterial stiffness were examined in patients with chronic kidney disease stage 5D.

Methods

The effects of sevelamer HCl were studied by a single-center cohort study that was conducted from January 1, 2005 to December 31, 2008 (n?=?483). By the end of the study, 172 patients (Sevelamer group) had succeeded in continuing sevelamer HCl for >6?months (median 37?months), and 300 patients (Control group) had received calcium carbonate (n?=?264) or no phosphate binder (n?=?36). The mortality and other outcomes were compared between these two groups after matching by a propensity score calculated using age, gender, diabetes prevalence, and dialysis vintage.

Results

All-cause [hazard ratio (HR) 0.4, P?=?0.02] and cardiovascular (CV)-cause [HR 0.29, P?=?0.03] cumulative mortality were significantly lower in the matched Sevelamer group than in the matched Control group. The matched Sevelamer group showed increased high-density lipoprotein cholesterol (P?=?0.003) and no change in pulse wave velocity (PWV) and ankle-brachial index (ABI), whereas the matched Control group showed increased serum low-density lipoprotein (LDL) cholesterol (P?=?0.003), increased PWV (P?=?0.03), and decreased ABI (P?=?0.0009). Change in serum LDL cholesterol level correlated inversely with sevelamer HCl dosage (P?=?0.02).

Conclusions

Reduced mortality in patients with sevelamer HCl may, at least in part, be explained by an improvement in dyslipidemia and arterial stiffness by sevelamer HCl.     

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Background

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia.

Methods

37 patients underwent placement of a SEMS during a 3?year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures.

Results

SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n?=?6), severe heartburn (n?=?1), and upper gastrointestinal bleeding requiring SEMS revision (n?=?1). Dysphagia scores improved significantly from 3.2?±?0.4 before stent placement to 1.4?±?1.0 at 1?month (P?P?P?=?0.0018) at 6?months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n?=?3), stent malfunction (n?=?5), and stent migration (n?=?3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3?±?143.6 (range, 13–680) days.

Conclusions

Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.     

The Improvement of Surgical Treatment for Patients with Gallbladder Cancer: Analysis of 208 Consecutive Cases Over the Past Decade

Objectives

The aim of this study was to determine if there has been improvement in survival for patients with gallbladder cancer treated with surgical procedures.

Methods

A retrospective review of all patients with gallbladder cancer admitted during the past 11?years was conducted. The patients were categorized into two periods: period 1, from 1 January 2000 to 31 December 2005 (group 1, n?=?77); and period 2, from 1 January 2006 to 31 December 2010 (group 2, n?=?131).

Results

The two groups have similar age, sex distribution, and symptoms. There were more patients with advanced stage in group 2 (P?=?0.001). And patients in group 2 were treated with more aggressive surgical procedures compared with group 1. Patients of group 2 had a better surgical outcomes and longer 5-year overall survival (9?% vs. 19?%, P?=?0.040) and disease-free survival (P?=?0.017). Median survival in group 1 was 14.7?months, while in group 2 it was 22.3?months. Patients underwent R0 resection in group 2 had better survival than that in group 1 (P?=?0.009), while they had similar survival for those who underwent non-R0 resection in both periods (P?=?0.108).

Conclusions

A significant improvement of disease-free survival and long-term survival results was observed in the past decade.     

Evaluation of the MD Anderson Prognostic Index for Local-Regional Recurrence After Breast Conserving Therapy in Patients Receiving Neoadjuvant Chemotherapy

Background

We previously developed a prognostic index for assessing local-regional recurrence (LRR) risk in patients undergoing breast conservation therapy (BCT) after neoadjuvant chemotherapy. The prognostic index assigns a point for each of the following variables: clinical N2/N3 disease, lymphovascular invasion, residual pathologic tumor size >2?cm, and multifocal residual disease on pathology. The current study was undertaken to evaluate this prognostic index in an independent cohort.

Methods

We identified 551 patients treated from 2001 to 2005 with neoadjuvant chemotherapy, mastectomy or BCT, and radiation. These patients were not used in the original development of the prognostic index. Outcomes were stratified by prognostic index. The 5-year LRR-free survival was calculated using the Kaplan?CMeier method, and differences were compared using the log-rank test.

Results

For patients undergoing BCT, the 5-year LRR-free survival rates were 92, 92, 84, and 69% when the prognostic index was 0 (n?=?91), 1 (n?=?82), 2 (n?=?38), or 3?C4 (n?=?13) (P?=?0.01). The 5-year LRR-free survival rates were similar between patients undergoing mastectomy or BCT when the prognostic index score was 0, 1, or 2. When the prognostic index score was 3?C4, the 5-year LRR-free survival was significantly lower for patients treated with BCT compared with mastectomy (69 vs. 93%, P?=?0.007).

Conclusion

The previously developed prognostic index was successful in stratifying patients with respect to LRR in an independent cohort undergoing BCT after neoadjuvant chemotherapy. The prognostic index can be used to identify patients at high risk for LRR who may be considered for more extensive surgery or enrollment into clinical trials evaluating novel strategies for local-regional control.     

Surgical Outcome of Autologous External Iliac Vein Grafting in Cases of Hepato-Pancreato-Biliary Malignancy: How I Do It

Introduction

Operative indications and surgical outcomes of an autologous graft usage for hepato-pancreato-biliary malignancy have not been adequately investigated. Sixty consecutive patients who underwent sleeve resection of the portal vein (PVR, n?=?45) or hepatic vein (HVR, n?=?15) and right external iliac vein (REIV) graft reconstruction were reviewed.

Results

Median graft length and reconstruction time were 3?cm (range, 2?C7?cm) and 25?min (range, 16?C40?min), respectively. Overall morbidity and surgical mortality were acceptable at 48?% and 1.6?%. Postoperative graft obstructions were seen in one patient with PVR and two patients with HVR; however, these patients did not suffer from the life-threatening complications.

Conclusion

REIV graft reconstruction shows acceptable morbidity and mortality. Our strategy may extend the operative indications for advanced disease and impaired liver function.     

Surgical management of vertebral and basilar artery aneurysms: a single center experience in 41 patients

Objective

To study an effective method for surgical management of vertebral and basilar artery aneurysms.

Methods

Forty-one patients with 43 aneurysms of the vertebral and basilar arteries were managed by microsurgical clipping. Cerebral angiography revealed basilar apex aneurysms in 17 patients, basilar trunk in six patients, vertebrobasilar (VB) junction aneurysms in three patients and vertebral aneurysms in 15 patients. One patient had two basilar aneurysms, and another had bilateral vertebral artery aneurysm.

Surgical technique

We used a pterional approach in basilar apex aneurysms (n?=?17 patients), orbitozygomatic and its variants in upper basilar trunk aneurysms (n?=?2 patients), combined petrosal and far-lateral approach in mid basilar trunk aneurysms (n?=?4 patients), far-lateral and transcondylar approach for the aneurysms at VB junction (n?=?3 patients) and transcondylar approach for the vertebral aneurysms (n?=?15 patients). Bypass graft was performed in 14 patients with fusiform and wide neck aneurysms, to prevent potential cerebral ischemia due to prolonged temporary occlusion or possibility of intraoperative parent artery sacrifice.

Results

Neurological outcomes were measured on the basis of Glasgow Outcome Score (GOS). The rate of back-to-normal life after surgery in basilar tip aneurysm, basilar trunk aneurysms, VB junction aneurysms and vertebral artery aneurysms was 15/17 (82.5 %), 5/6 (83 %), 3/3 (100 %) and 14/15 (93.3 %), respectively. Thirty-six (87.8 %) patients had uneventful postoperative courses. Two patient with basilar apex aneurysm suffered severe neurological deficits related to midbrain ischemia, two patient with occipital artery (OA) graft bypass had postoperative partial lower cranial nerve palsy, and one death with basilar trunk aneurysm occurred after the 20th day of surgery. Thirty-nine patients accepted postoperative digital subtraction angiography (DSA) and eight patients accepted computed tomography (CT) angiogram, whereas two patient denied either one. All the images demonstrated afferent and efferent vessels without aneurysm in situ. Out of 14 patients with graft bypass, 11 patients on cerebral angiographies disclosed the aneurysm clip and the graft bypass patency, one patient on angiography had unidentified graft bypass patency but no symptom related to the graft bypass patency, and two patients denied the postoperative cerebral angiographies. In 40 patients with a mean follow-up of 3.4 years, 37 patients had good outcome, two patients needed assistance for daily living, and one death occurred due to brainstem infarction related to surgery.

Conclusion

Selection of proper cranial base approach with adequate exposure is effective in clipping VB aneurysms, minimizing the postoperative complications. Graft bypass may avoid parent artery sacrifice and its branches occlusion in patients with fusiform and wide neck aneurysms.     

Routine Gastrostomy Tube Placement in Gastric Bypass Patients: Impact on Length of Stay and 30-Day Readmission Rate

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. Current average length of hospital stay (LOS) after RYGB is 2–3 days and 30-day readmission rate is 8–13 %. The aim of our study is to evaluate the effect of routine gastrostomy tube placement in perioperative outcomes of RYGB patients.

Methods

Between January 2008 and December 2010, a total of 840 patients underwent RYGB at our institution. All RYGB patients had gastrostomy tube placed, which was kept for 6 weeks. A retrospective review of a prospectively collected database was performed for all RYGB patients, noting the outcomes and complications of the procedure.

Results

Average LOS in our patient population was 1.1 days (range, 1–14 days), and 824 (98.3 %) patients were discharged on postoperative day 1. Readmissions within 30 days after the index RYGB was observed in 31 (3.7 %) patients. Reasons included abdominal pain (n?=?14), nausea/vomiting (n?=?6), gastrostomy tube-related complications (n?=?5), chest pain (n?=?3), allergic reaction (n?=?1), urinary tract infection (n?=?1), and dehydration (n?=?1). Of these readmitted patients, nine (1.1 %) patients required reoperations due to small bowel obstruction (n?=?5), perforated anastomotic ulcer (n?=?1), anastomotic leak (n?=?1), subphrenic abscess (n?=?1), and appendicitis (n?=?1).

Conclusions

Routine gastrostomy tube placement in the gastric remnant at the time of RYGB seems to have contributed to our short LOS and low 30-day readmission rate.     

Comparison of polypropylene mesh and porcine-derived,cross-linked urinary bladder matrix materials implanted in the rabbit vagina and abdomen

Introduction and hypotheses

Our aim was to compare histological and biomechanical effects of polypropylene (PP) mesh and porcine-derived, cross-linked urinary bladder matrix (cUBM) graft materials using a rabbit vaginal and abdominal model.

Methods

Forty rabbits were implanted with PP mesh (n?=?20) or cUBM (n?=?20) in the vagina and abdomen. Two grafts (PP or cUBM) of the same type were placed into each site, so each rabbit had four grafts. Grafts were harvested 12 weeks later and processed for histologic analysis and biomechanical testing.

Results

There were high rates of two types of grafts missing in the vagina. Vaginal PP was associated with erosion reaction (67 %), whereas abdominal PP and cUBM showed no sign of erosion. All patches adhered to rectus abdominis or vaginal mucosa and shrank to varying degrees, especially for PP grafts. Compared with vaginal PP, vaginal cUBM induced milder chronic inflammation response, had lower scores (P?=?0.000) for inflammation response, and showed higher scores for neovascularization (P?=?0.000) and fibroblastic proliferation (P?=?0.002). In the abdomen, both histopathological parameters were insignificantly different (P?>?0.05) between cUBM and PP. The mechanical properties of UBM did not deteriorate following implantation, whereas the ultimate tensile strength and elastic modulus of vaginal PP increased. PP had higher scores for tensile and break strength than did cUBM (P?<?0.05).

Conclusions

The cUBM has good biocompatibility, high ability to integrate with the vagina, and maintains mechanical properties in vivo. It may be a promising material for pelvic floor reconstruction.     

Anatomic Versus Nonanatomic Hepatectomy for a Solitary Hepatocellular Carcinoma

Background

It remains controversial whether anatomical resection (AR) improves the prognosis for hepatocellular carcinoma (HCC) or not. To our knowledge, there have been a few well-matched studies about this issue. The aim of the present study was to compare the recurrence-free survival of AR versus nonanatomical resection (NAR) for a solitary HCC using propensity score matching.

Methods

The present study included 236 patients who had a solitary HCC without macroscopic vessel thrombosis. Those patients were divided into AR (n?=?139) and NAR (n?=?97) groups. A propensity score matching was performed to minimize the effect of potential confounders.

Results

Sixty-four patients from each group were matched. Preoperative confounding factors were balanced between the two groups. The median recurrence-free survival times in the AR and NAR groups were 33.8 and 30.8 months, respectively (P?=?0.520). There were no significant differences in the intrahepatic recurrence pattern (P?=?0.097). Operative procedure was not a significant risk factor for recurrence in both uni- and multivariate analyses.

Conclusions

This case-matching study using a propensity score shows that there is no superiority of AR to NAR relevant to the recurrence-free survival in patients with a single HCC.