Open and laparoscopic resection of hepatocellular adenoma: trends over 23 years at a specialist hepatobiliary unit

Background

Hepatocellular adenoma (HCA) is a rare benign liver epithelial tumour that can require surgery. This retrospective study reports a 23-year experience of open and laparoscopic resections for HCA.

Methods

Patients with a histological diagnosis of HCA were included in this analysis. Surgical resection was performed in all symptomatic patients and in those with lesions measuring > 5 cm.

Results

Between 1989 and 2012, 62 patients, 59 of whom were female, underwent surgery for HCA (26 by open surgery and 36 by laparoscopic surgery). Overall, 96.6% of female patients had a history of contraceptive use; 54.8% of patients presented with abdominal pain and 11.2% with haemorrhage; the remaining patients were asymptomatic. Patients who underwent laparoscopy had smaller lesions (mean ± standard deviation diameter: 68.3 ± 35.2 mm versus 91.9 ± 42.5 mm; P = 0.022). Operatively, laparoscopic and open liver resection did not differ except in the number of pedicle clamps, which was significantly lower in the laparoscopic group (27.8% versus 57.7% of patients; P = 0.008). Postoperative variables did not differ between the groups. Mortality was nil. Two surgical specimens were classified as HCA/borderline hepatocellular carcinoma. At the 3-year follow-up, all patients were alive with no recurrence of HCA.

Conclusions

Open and laparoscopic liver resections are both safe and feasible approaches for the surgical management of HCA. However, laparoscopic liver resections may be limited by lesion size and location and require advanced surgical skills.     

Differences between bipolar compression and ultrasonic devices for parenchymal transection during laparoscopic liver resection

Objectives

In laparoscopic liver resection, multiple options for parenchymal transection techniques exist; however, none have emerged as superior. The aim of this study was to compare operative characteristics and outcomes between bipolar compression and ultrasonic devices used for parenchymal transection during laparoscopic liver resection.

Methods

A review of a prospective hepatopancreatobiliary database from December 2002 to August 2009 identified 54 patients who underwent laparoscopic liver resection with parenchymal division using either a bipolar compression (n = 35) or an ultrasonic (n = 19) device. Operative data, histology and 90-day complication rates were compared between the groups using analysis of variance (anova) and Pearson''s chi-squared test.

Results

The two groups did not differ significantly in terms of age, body mass index, parenchymal steatosis/inflammation or number of segments resected. A shorter time of parenchymal transection was noted for the bipolar compression device (median: 35 min; range: 20–65 min) vs. the ultrasonic device (median: 55 min; range: 29–75 min) (P < 0.001). Median total operative time was also shorter using the bipolar compression device (130 min) than the ultrasonic device (180 min) (P = 0.050). No significant differences between device groups were noted for estimated blood loss, complications of any type or liver-specific complications.

Conclusions

Bipolar compression devices may offer advantages over ultrasonic devices in terms of decreased transection time and total operative time. No differences in postoperative complications in laparoscopic liver resection emerged between patients operated using the devices.     

Limiting factors for liver regeneration after a major hepatic resection for colorectal cancer metastases

Background

Chemotherapy before resection of colorectal metastases in the liver is extensively used and has been shown to induce histopathological changes in the liver parenchyma, although little is known about the effect of chemotherapy on liver regeneration. The aim of this study was to determine if pre-operative chemotherapy influences the regenerated liver volume after a major liver resection.

Patients and methods

This retrospective cohort study included 74 patients subjected to a major liver resection for colorectal metastases. Patients were divided into two groups depending on whether they had been treated with chemotherapy less than 3 months before surgery or not. Liver volumes were measured before and 1 year after resection.

Results

Pre-operative chemotherapy reduced volumetric liver regeneration (83 ± 2% versus 91 ± 2%; P = 0.007) as compared with patients without chemotherapy. There was a linear correlation between regenerated volume and time interval between the end of chemotherapy to resection (P = 0.031).

Conclusions

Pre-operative chemotherapy in patients with colorectal liver metastases negatively affects volume regeneration after a partial hepatectomy. The time interval between chemotherapy and surgery determines the impact of these affects.     

Ischaemic preconditioning of the graft in adult living related right lobe liver transplantation: impact on ischaemia�Creperfusion injury and clinical relevance

Background

Ischaemic preconditioning (IPC) of the right liver graft in the donor has not been studied in adult-to-adult living related liver transplantation (LRLT).

Objective

To assess the IPC effect of the graft on ischaemia reperfusion injury in the recipient and compare recipient and donor outcomes with and without preconditioned grafts.

Patients and methods

Alternate patients were transplanted with right lobe grafts that were (n =22; Group _Precond) or were not (n =22; Group _Control) subjected to IPC in the living donor. Liver ischaemia–reperfusion injury, liver/kidney function, morbidity/mortality rates and outcomes were compared. Univariate and multivariate analyses were performed to identify factors predictive of the aspartate aminotransferase (AST) peak and minimum prothrombin time.

Results

Both groups had similar length of hospital stay, morbidity/mortality, primary non-function and acute rejection rates. Post-operative AST (P =0.8) and alanine aminotransferase (ALT) peaks (P =0.6) were similar in both groups (307 ± 189 and 437 ± 302 vs. 290 ± 146 and 496 ± 343, respectively). In univariate analysis, only pre-operative AST and warm ischemia time (WIT) were significantly associated with post-operative AST peak (in recipients). In multivariate analysis, the graft/recipient weight ratio (P =0.003) and pre-operative bilirubin concentration (P =0.004) were significantly predictive of minimum prothrombin time post-transplantation.

Conclusions

Graft IPC in the living related donor is not associated with any benefit for the recipient or the donor and its clinical value remains uncertain.     

A comparison of laparoscopic radiofrequency ablation versus systemic therapy alone in the treatment of breast cancer metastasis to the liver

Objectives

There is controversy about the roles of locoregional therapies in patients with liver metastases from breast cancer (LMBC). The aim of this study was to analyse survival after laparoscopic radiofrequency ablation (RFA) of LMBC and to compare this with survival in patients receiving systemic therapy (ST) alone.

Methods

During 1996–2011, 24 patients who had failed to respond or had shown an incomplete response to ST underwent laparoscopic RFA for LMBC. Outcomes in these patients were compared with those in 32 patients with LMBC matched by tumour size and number, but treated with ST alone. Clinical parameters and overall survival were compared using t-tests, chi-squared tests and Kaplan–Meier analysis.

Results

The groups were similar in hormone receptor status and chemotherapy exposure. In the laparoscopic RFA and ST groups, respectively, the mean ± standard deviation size of the dominant liver tumour and the number of tumours per patient were 3.7 ± 0.4 cm and 2.4 ± 0.4 cm, and 2.6 ± 0.4 tumours and 3.3 ± 0.4 tumours, respectively. These differences were not significant. At a median follow-up of 20 months in the laparoscopic RFA group, 42% of patients were found to have developed local liver recurrence, 63% had developed new liver disease and 38% had developed extrahepatic disease. Overall survival after the diagnosis of liver metastasis was 47 months in the laparoscopic RFA group and 9 months in the ST-only group (P = 0.0001). Five-year survival after the diagnosis of liver metastasis was 29% in the RFA group and 0% in the ST-only group.

Conclusions

This is the first study to compare outcomes in RFA and ST, respectively, in LMBC. The results show that survival after laparoscopic RFA plus ST is better than that after ST alone.     

Effectiveness of epidural analgesia following open liver resection

Objectives

Epidural analgesia is often considered the reference standard for pain relief following major abdominal surgery; however, the provision of analgesia in the context of liver surgery raises unique challenges. This study investigated the effectiveness of analgesia and the postoperative course of patients who did or did not receive epidural analgesia following liver resection.

Methods

Data were collected retrospectively on 177 patients who underwent open liver resection between June 2007 and June 2009. Patients were divided into two groups consisting, respectively, of those who received epidural analgesia (Epidural group, n= 148) and those who did not (No-Epidural group, n= 29).

Results

In the Epidural group, 27 patients (18%) required i.v. opiate analgesia on the day of surgery (DoS) or the first postoperative day (POD1). The Epidural group received significantly more i.v. colloid solution on the DoS (median: 1500 ml vs. 750 ml, range: 0–12 000 ml vs. 0–3500 ml; P= 0.004) and POD1 (median: 0 ml vs. 0 ml, range: 0–5000 ml vs. 0–1000 ml; P= 0.018), and total fluid on the DoS and POD1 combined (median: 6522 ml vs. 5453 ml, range: 2150–21 300 ml vs. 2875–15 886 ml; P= 0.032).

Conclusions

Epidural analgesia provided inadequate postoperative pain relief in approximately 20% of liver resection patients and was associated with the administration of significantly greater volumes of i.v. colloid solution.     

Hyperbaric oxygen therapy reduces the severity of ischaemia, preservation and reperfusion injury in a rat model of liver transplantation

Background

Approaches to increase organ availability for orthotopic liver transplantation (OLT) often result in the procurement of marginal livers that are more susceptible to ischaemia, preservation and reperfusion injury (IPRI).

Methods

The effects of post-OLT hyperbaric oxygen (HBO) therapy on IPRI in a syngeneic rat OLT model were examined at various time-points. The effects of IPRI and HBO on hepatocyte necrosis, apoptosis, proliferation, and sinusoidal morphology and ultrastructure were assessed.

Results

Post-OLT HBO therapy significantly reduced the severity of IPRI; both apoptosis [at 12 h: 6.4 ± 0.4% in controls vs. 1.6 ± 0.7% in the HBO treatment group (p < 0.001); at 48 h: 2.4 ± 0.2% in controls vs. 0.4 ± 0.1% in the HBO treatment group (p < 0.001)] and necrosis [at 12 h: 18.7 ± 1.8% in controls vs. 2.4 ± 0.4% in the HBO treatment group (p < 0.001); at 48 h: 8.5 ± 1.3% in controls vs. 3.4 ± 0.9% in the HBO treatment group (P = 0.019)] were decreased. Serum alanine transaminase was reduced [at 12 h: 1068 ± 920 IU/l in controls vs. 370 ± 63 IU/l in the HBO treatment group (P = 0.030); at 48 h: 573 ± 261 IU/l in controls vs. 160 ± 10 IU/l in the HBO treatment group (P = 0.029)]. Treatment with HBO also promoted liver regeneration [proliferation at 12 h: 4.5 ± 0.1% in controls vs. 1.0 ± 0.3% in the HBO treatment group (p < 0.001); at 48 h: 8.6 ± 0.7% in controls vs. 2.9 ± 0.2% in the HBO treatment group (p < 0.01)] and improved sinusoidal diameter and microvascular density index.

Conclusions

Hyperbaric oxygen therapy has persistent positive effects post-OLT that may potentially transfer into clinical practice.     

Prognostic value of high-sensitivity cardiac troponin T in patients with en-domyocardial-biopsy proven cardiac amyloidosis

Objective To investigate prognostic predictors of long-term survival of patients with cardiac amyloidosis （CA）, and to determine predictive value of high-sensitivity cardiac troponin T （hs-cTnT） in CA patients. Methods We recruited 102 consecutive CA cases and followed these patients for 5 years. We described their clinical characteristics at presentation and used a new, high-sensitivity assay to determine the concentration of cTnT in plasma samples from these patients. Results The patients with poor prognosis showed older age （56 ±12 years vs. 50 ±15 years, P=0.022）, higher incidences of heart failure （36.92%vs. 16.22%, P=0.041）, pericardial effusion （60.00%vs. 35.14%, P=0.023）, greater thickness of interventricular septum （IVS） （15 ±4 mm vs. 13 ±4 mm, P=0.034）, higher level of hs-cTnT （0.186 ±0.249 ng/mL vs. 0.044 ±0.055 ng/mL, P=0.001） and higher NT-proBNP （N-terminal pro-B-type natriuretic pep-tide） levels （11,742 ± 10,464 pg/mL vs. 6,031 ± 7,458 pg/mL, P=0.006）. At multivariate Cox regression analysis, heart failure （HR：1.78, 95%CI：1.09-2.92, P=0.021）, greater wall thickness of IVS （HR：1.44, 95%CI：1.04-3.01, P=0.0375） and higher hs-cTnT level （HR：6.16, 95%CI：2.20-17.24, P=0.001） at enrollment emerged as independent predictors of all-cause mortality. Conclusions We showed that hs-cTnT is associated with a very ominous prognosis, and it is also the strongest predictor of all-cause mortality in multivariate analysis. Examination of hs-cTnT concentrations provides valuable prognostic information concerning long-term outcomes.     

Detection and characterization of respiratory viruses causing acute respiratory illness and asthma exacerbation in children during three different seasons (2011–2014) in Mexico City

Background

Viral infections play a significant role in causing acute respiratory infections (ARIs) and exacerbations of chronic diseases. Acute respiratory infections are now the leading cause of mortality in children worldwide, especially in developing countries. Recently, human rhinovirus (HRV) infection has been emerged as an important cause of pneumonia and asthma exacerbation.

Objectives

To determine the role of several viral agents principally, respiratory syncytial virus, and HRV in children with ARIs and their relationship with asthma exacerbation and pneumonia.

Methods

Between October 2011 and March 2014, 432 nasopharyngeal samples of children <15 years of age with ARI hospitalized at a referral hospital for respiratory diseases were tested for the presence of respiratory viruses using a multiplex RT-qPCR. Clinical, epidemiological, and demographic data were collected and associated with symptomatology and viral infections.

Results

Viral infections were detected in at least 59·7% of the enrolled patients, with HRV (26·6%) being the most frequently detected. HRV infections were associated with clinical features of asthma and difficulty in breathing such as wheezing (P = 0·0003), supraesternal (P = 0·046), and xiphoid retraction (P = 0·030). HRV subtype C (HRV-C) infections were associated with asthma (P = 0·02).

Conclusions

Human rhinovirus was the virus most commonly detected in pediatric patients with ARI. There is also an association of HRV-C infection with asthma exacerbation, emphasizing the relevance of this virus in severe pediatric respiratory disease.     

Catheter ablation of atrial fibrillation in the elderly

Background Atrial fibrillation （AF） catheter ablation has emerged as a promising treatment strategy for AF, but has not been widely adopted in the elderly population. The present study aimed to determine the safety and efficacy of AF catheter ablation in the elderly popula-tion. Methods and Results The study population consisted of 316 patients with paroxysmal AF who underwent left atrial ablation. Ninety-five patients were≥65 years （48 males, mean age 68.9 ± 3.0 years old） and 221 patients were〈65 years old （130 males, mean age 52.5 ± 10.4 years old）. After a mean follow-up period of 34.0 ± 15.1 months, 55 （57.9%） patients in the elderly group were free from ar-rhythmia recurrence compared with 149 （67.4%） patients in the younger group （P=0.169）. Procedural complications were uncommon in both study groups. In logistic regression analysis, left atrial diameter （P=0.003）, hypertension （P=0.001）, dyslipidemia （P=0.039）, and coronary artery disease （P=0.018） were independent predictors of AF recurrence in the elderly population. Conclusions Catheter ablation of AF is safe and effective in older patients. Invasive strategies should be considered as an alternative choice in symptomatic elderly patients with AF.     

Laparoscopic Versus Open Appendectomy: A Comparison of Primary Outcome Measures

Background/Aim:

The aim of the study was to compare laparoscopic and open appendectomy (OA) in terms of primary outcome measures. Study design: A randomized controlled trial. Place and duration of the study: Khyber Teaching Hospital, Peshawar, Pakistan, February 2008 to December 2009.

Patients and Methods:

A total of 160 patients were divided into two groups, A and B. Group A patients were subjected to laparoscopic appendectomy (LA), whereas Group B patients were subjected to OA. Data regarding age, gender, and primary outcome measures, such as hospital stay, operative duration, and postoperative complication, were recorded and analyzed. Percentages were calculated for categorical data, whereas numerical data were represented as mean ± SD. Chi-square test and t test were used to compare categorical and numerical variables, respectively. Probability ≤ 0.05 (P ≤ 0.05) was considered significant.

Results:

After randomization, 72 patients in group A and 75 patients in group B were analyzed. The mean age of patients in groups A and B was 23.09 ± 8.51 and 23.12 ± 10.42 years, respectively, (P = 0.981). The mean hospital stay was 1.52 ± 0.76 days in group A and 1.70 ± 1.06 days in group B (P = 0.294). The mean operative duration in group A and B were 47.54 ± 12.82 min and 31.36 ± 11.43 min, respectively (P < 0.001). Pain (overall level) was significantly less in group A compared with group B (P = 0.004). The two groups were comparable in terms of other postoperative complications, such as hematoma (P = 0.87), paralytic ileus (P = 0.086), urinary retention (P = 0.504), and wound infection (P = 0.134).

Conclusion:

LA is an equivalent procedure and not superior to OA in terms of primary outcome measures.     

Evaluation of cardiovascular risk in patients with Parkinson disease under levodopa treatment

Background Levodopa is the indispensable choice of medial therapy in patients with Parkinson disease (PD). Since L-dopa treatment was shown to increase serum homocysteine levels, a well-known risk factor for cardiovascular disorders, the patients with PD under L-dopa treatment will be at increased risk for future cardiovascular events. The objective of this study is to evaluate cardiovascular risk in patients with PD under levodopa treatment. Methods The study population consisted of 65 patients with idiopathic PD under L-dopa treatment. The control group included 32 age and gender matched individuals who had no cognitive decline. Echocardiographic measurements, serum homocysteine levels and elastic parameters of the aorta were compared between the patients with PD and controls. Results As an expected feature of L-dopa therapy, the Parkinson group had significantly higher homocystein levels (15.1 ± 3.9 μmol/L vs. 11.5 ± 3.2 μmol/L, P = 0.02). Aortic distensibility was significantly lower in the patients with PD when compared to controls (4.8 ± 1.5 dyn/cm² vs. 6.2 ± 1.9 dyn/cm², P = 0.016). Additionally, the patients with PD had higher aortic strain and aortic stiffness index (13.4% ± 6.4% vs. 7.4% ± 3.6%, P < 0.001 and 7.3 ± 1.5 vs. 4.9 ± 1.9, P < 0.001, respectively). Furthermore, serum homocysteine levels were found to be positively correlated with aortic stiffness index and there was a negative correlation between aortic distensibility and levels of serum homocysteine (r = 0.674, P < 0.001; r = -0.602, P < 0.001, respectively). Conclusions The patients with PD under L-dopa treatment have increased aortic stiffness and impaired diastolic function compared to healthy individuals. Elevated serum homocysteine levels may be a possible pathophysiological mechanism.     

Effects of prophylactic antibiotics in acute pancreatitis

Objectives

The use of prophylactic antibiotics in severe acute pancreatitis (SAP) is controversial. The aim of this study was to compare the effects of antibiotics administered as prophylaxis and as treatment on demand, respectively, in two prospective, non-randomized cohorts of patients.

Methods

The study population consisted of 210 patients treated for SAP. In Group 1 (n = 103), patients received prophylactic antibiotics (ciprofloxacin, metronidazole). In Group 2 (n = 107), patients were treated on demand. Ultrasound-guided drainage and/or surgical debridement of infected necrosis were performed when the presence of infected pancreatic necrosis was demonstrated. The primary endpoints were infectious complication rate, need for and timing of surgical interventions, incidence of nosocomial infections and mortality rate.

Results

Ultrasound-guided fine needle aspiration [in 18 (16.8%) vs. 13 (12.6%) patients; P = 0.714], ultrasound-guided drainage [in 15 (14.0%) vs. six (5.8%) patients; P = 0.065] and open surgical necrosectomy [in 10 (9.3%) vs. five (4.9%) patients; P = 0.206] were performed more frequently and earlier [at 16.6 ± 7.8 days vs. 17.2 ± 6.7 days (P = 0.723); at 19.5 ± 9.4 days vs. 24.5 ± 14.2 days (P = 0.498), and at 22.6 ± 13.5 days vs. 26.7 ± 18.1 days (P = 0.826), respectively] in Group 2 compared with Group 1. There were no significant differences between groups in mortality and duration of stay in the surgical ward or intensive care unit.

Conclusions

The results of this study support the suggestion that the use of prophylactic antibiotics does not affect mortality rate, but may decrease the need for interventional and surgical management, and lower the number of reoperations.     

Impact of a physician-supervised exercise-nutrition program with testosterone substitution in partial androgen-deficient middle-aged obese men

Background Partial androgen deficiency syndrome in the aging male is associated with signs of aging such as a development of abdominal obesity, sexual dysfunction, increase body fat, weight gain and the development of cardiac disease. Objective We assessed the outcome of a commercially available physician supervised nutrition and exercise program with concomitant testosterone replacement therapy in middle age obese men with partial androgen deficiency in order to reduce cardiac risks factors. Methods Fifty-six self referred men without diabetes mellitus, hypertension, or cardiovascular disease (ages 52.3 ± 7.8 years) were randomly selected from a large cohort. Baseline weight, body fat composition, fasting glucose, hemoglobin A1c and fasting lipid levels, as well as free and total testosterone levels were assessed. All patients were assessed and followed 6–18 months after initiation of the program. The program consisted of a low glycemic load balanced nutrition diet, a recommended structured daily exercise program of 30–60 minutes, as well as once to twice weekly intramuscular testosterone injections (113.0 ± 27.8 mg). Results At follow up, weight was reduced from 233.9 ± 30.0 pounds (lbs) to 221.3 ± 25.1 lbs (P < 0.001), BMI was reduced from 33.2 ± 3.3 kg/m² to 31.3 ± 2.8 kg/m² (P < 0.0001). Total body fat was 27.1% ± 5.2% vs. 34.3% ± 5.7% at baseline (P < 0.0001). Fasting glucose was reduced from 95.3 ± 14.4 mg/dL to 87.5 ± 12.6 mg/dL (P < 0.0001). Total cholesterol was reduced from 195.4 ± 33.0 mg/dL to 172.7 ± 35.0 mg/dL (P < 0.005). No clinically significant adverse events were recorded. Conclusions Testosterone replacement therapy in middle aged obese men with partial androgen deficiency appeared safe and might have promoted the effects of a weight reduction diet and daily exercise program as long as an adequate physician supervision and follow up was granted. The combination therapy significantly reduced coronary risk factors such as glucose intolerance and hyperlipidemia.     

An initial study on left ventricular diastolic function in patients with hypertrophy cardiomyopathy using single-beat, real-time, three-dimensional echocardiography

Objectives To assess the regional diastolic function in patients with hypertrophic cardiomyopathy (HCM) by using single-beat, real-time, three-dimensional echocardiography (RT-3DE). Methods Sixty-five patients with HCM in sinus rhythm together with fifty age- and gender-matched normal controls were studied by two–dimensional echocardiography (2DE) and RT-3DE. The parameters analyzed by RT-3DE included: left ventricular (LV) volumes, left ventricular ejection fraction (LVEF), end diastolic sphericity index (EDSI), diastolic dyssynchrony index (DDI), dispersion end diastole (DISPED), and normalized 17 segmental volume-time curves. Results LVEF was slightly lower evaluated by RT-3DE compared with 2DE (63.2 ± 6.8% vs. 59.1 ± 6.4%, P < 0.0001). Normal subjects had relatively uniform volumetric curves for all LV segments. In HCM patients, the segmental volumetric curves were dyssynchronous. Increased DDI and DISPED in end diastole were observed in patients with HCM (9.95 ± 3.75, 41.76 ± 17.19, P < 0.0001), not all abnormal volumetric segments occurred in the hypertrophic regions. Conclusions Patients with HCM have presented regional diastolic dyssynchrony in the diastole phase, and this preclinical lesion can be recognized by single-beat RT-3DE.     

Intermediate-term mortality and incidence of ICD therapy in octogenarians after cardiac resynchronization therapy

Background Clinical outcomes of cardiac resynchronization therapy （CRT） in patients over the age of 80 have not been well de-scribed.MethodsWe retrospectively identified 96 consecutive patients≥ 80 years old who underwent an initial implant or an upgrade to CRT, with or without defibrillator （CRT-Dvs. CRT-P）, at our institution between January 2003 and July 2008. The control cohort consisted of 177 randomly selected patients 〈 80 years old undergoing CRT implant during the same time period. The primary efficacy endpoint was all-cause mortality at 36 months, assessed by Kaplan-Meier time to first event curves.Results In the octogenarian cohort, mean age at CRT implant was 83.1 ± 2.9 yearsvs. 60.1 ± 8.8 years among controls （P 〈 0.001）. Across both groups, 70% were male, mean left ventricular ejection fraction （LVEF） was 24.8% ± 14.1% and QRS duration was 154 ± 24.8 ms, without significant differences between groups. Octo-genarians were more likely to have ischemic cardiomyopathy （74%vs. 37%,P 〈 0.001） and more likely to undergo upgrade to CRT instead of an initial implant （42%vs. 19%,P 〈 0.001）. The rate of appropriate defibrillator shocks was lower among octogenarians （14%vs. 27%,P = 0.02） whereas the rate of inappropriate shocks was similar （3%vs. 6%,P = 0.55）. At 36 months, there was no significant difference in the rate of all-cause mortality between octogenarians （11%） and controls （8%,P = 0.381）.ConclusionAppropriately selected octogenarians who are candidates for CRT have similar intermediate-term mortality compared to younger patients receiving CRT.     

Short-term results of thoracoscopic lobectomy and segmentectomy for lung cancer in koo foundation sun yat-sen cancer center

Background

Thoracoscopic lobectomy and segmentectomy have been demonstrated to be safe and technically feasible for curative resection of lung cancer. This minimally invasive surgery is increasingly popular and adopted by the world all over. We report our short-term results of thoracoscopic lobectomy/segmentectomy operations comparing with previous surgical approach for lung cancer resection by muscle-sparing vertical minithoracotomy in Koo Foundation Sun Yat-Sen Cancer Center.

Methods

We performed a retrospective review of 317 consecutive patients who underwent lobectomy or segmentectomy either by thoracoscopic surgery (n=121) or muscle-sparing vertical mini-thoracotomy (n=195) for lung cancer in Koo Foundation Sun Yat-Sen Cancer center between Jan 2000 and Jun 2009. The operative details, postoperative complication, and length of stay were statistically analyzed.

Results

Thoracoscopic lobectomy and segmentectomy were performed successfully in 121 patients. One patient was converted to open thoracotomy during operation due to uncontrolled bleeding. There is no significant difference in age factors (p=0.763), forced expiratory volume in one second (p=0.480) or comorbidities (p=0.549) between these two groups. Thoracoscopic group had a significantly predominant percentage in women, diabetes mellitus, less smoking index and chronic obstructive pulmonary disease incidence. Patients undergoing a thoracoscopic surgery had a shorter length of stay (6.8±3.4 vs. 10.2±9.1 days, p<0.001), longer operative time (3.6±1.0 vs. 3.2±1.2 hours, p=0.004), and less blood loss (102.7±95.7 vs. 140.1±171.2 ml, p<0.029). There was no significant difference in postoperative complication rate between the two groups (18.2% vs. 23.6%, p=0.255). No surgical mortality was found in the thoracoscopic group.

Conclusions

Our findings suggested thoracoscopic surgery for lung cancer would be as safe as muscle-sparing vertical mini-thoracotomy in lobectomy and segmentectomy.     

Deferasirox, deferiprone and desferrioxamine treatment in thalassemia major patients: cardiac iron and function comparison determined by quantitative magnetic resonance imaging

Background

Oral deferiprone was suggested to be more effective than subcutaneous desferrioxamine for removing heart iron. Oral once-daily chelator deferasirox has recently been made commercially available but its long-term efficacy on cardiac iron and function has not yet been established. Our study aimed to compare the effectiveness of deferasirox, deferiprone and desferrioxamine on myocardial and liver iron concentrations and bi-ventricular function in thalassemia major patients by means of quantitative magnetic resonance imaging.

Design and Methods

From the first 550 thalassemia subjects enrolled in the Myocardial Iron Overload in Thalassemia network, we retrospectively selected thalassemia major patients who had been receiving one chelator alone for longer than one year. We identified three groups of patients: 24 treated with deferasirox, 42 treated with deferiprone and 89 treated with desferrioxamine. Myocardial iron concentrations were measured by T2* multislice multiecho technique. Biventricular function parameters were quantitatively evaluated by cine images. Liver iron concentrations were measured by T2* multiecho technique.

Results

The global heart T2* value was significantly higher in the deferiprone (34±11ms) than in the deferasirox (21±12 ms) and the desferrioxamine groups (27±11 ms) (P=0.0001). We found higher left ventricular ejection fractions in the deferiprone and the desferrioxamine versus the deferasirox group (P=0.010). Liver iron concentration, measured as T2* signal, was significantly lower in the desferrioxamine versus the deferiprone and the deferasirox group (P=0.004).

Conclusions

The cohort of patients treated with oral deferiprone showed less myocardial iron burden and better global systolic ventricular function compared to the patients treated with oral deferasirox or subcutaneous desferrioxamine.     

Patients ≥75 years with acute coronary syndrome but without critical epicardial coronary disease: prevalence, characteristics, and outcome

Objective Absence of significant epicardial coronary artery disease (CAD) in patients with acute onset of chest pain and elevation of myocardial necrosis markers is occasionally observed. The aim of this study was to analyse the clinical characteristics and outcome of such patients with advanced age. Methods We retrospectively analysed 4,311 patients with acute onset of chest pain plus necrosis marker elevation. Two hundred and seventy two patients without CAD on angiogram (6.3%) were identified. Out of them, 50 (1.2%) patients ≥ 75 years (Group I) were compared with (1) 222 acute coronary syndrome (ACS) patients without CAD on angiogram < 75 years (Group II), and (2) 610 consecutive patients ≥ 75 years with Non-ST-elevation Myocardial Infarction (NSTEMI) undergoing percutaneous coronary intervention (Group III). Results Group I compared to Group III patients made up for more females (64.0% vs. 49.2%; P < 0.0001), and had more severe anginal symptoms on presentation [Canadian Cardiovascular Society (CCS) class I/II, 26.0% vs. 49.8%; P = 0.02]. Group I patients also had lower troponin levels (0.62 ± 0.8 ng/mL vs. 27 ± 74 ng/mL; P < 0.02), lower leukocyte count (9.4 ± 3.13 × 10⁹ vs. 12 ± 5.1 × 10⁹; P = 0.001) and better preserved left ventricular function (56.7% ± 14.3% vs. 45% ± 11%; P < 0.0001). Event-free survival (cardiac death, myocardial infarction, recurrent angina, and re-hospitalisation) was more frequent in Group I and II patients compared to Group III patients (64.9%, 66.7%, and 41.6%, respectively; P < 0.0001). Conclusions ACS in patients ≥ 75 years without CAD is very infrequent, associated with a (1) similar outcome compared to ACS patients < 75 years without CAD, and (2) significant better outcome compared to NSTEMI patients ≥ 75 years.     

The LiMAx test: a new liver function test for predicting postoperative outcome in liver surgery

Background:

Liver failure has remained a major cause of mortality after hepatectomy, but it is difficult to predict preoperatively. This study describes the introduction into clinical practice of the new LiMAx test and provides an algorithm for its use in the clinical management of hepatic tumours.

Methods:

Patients with hepatic tumours and indications for hepatectomy were investigated perioperatively with the LiMAx test. In one patient, analysis of liver volume was carried out with preoperative three-dimensional virtual resection.

Results:

A total of 329 patients with hepatic tumours were evaluated for hepatectomy. Blinded preoperative LiMAx values were significantly higher before resection (n= 139; mean 351 µg/kg/h, range 285–451 µg/kg/h) than before refusal (n= 29; mean 299 µg/kg/h, range 223–376 µg/kg/h; P= 0.009). In-hospital mortality rates were 38.1% (8/21 patients), 10.5% (2/19 patients) and 1.0% (1/99 patients) for postoperative LiMAx of <80 µg/kg/h, 80–100 µg/kg/h and >100 µg/kg/h, respectively (P < 0.0001). A decision tree was developed to avoid critical values and its prospective preoperative application revealed a reduction in mortality from 9.4% to 3.4% (P= 0.019).

Discussion:

The LiMAx test can validly determine liver function capacity and is feasible in every clinical situation. Combination with virtual resection could enable the calculation of residual liver function. The LiMAx decision tree algorithm for hepatectomy might significantly improve preoperative evaluation and postoperative outcome in liver surgery.