Optimal Future Liver Remnant in Patients Treated with Extensive Preoperative Chemotherapy for Colorectal Liver Metastases

Background

Patients with colorectal liver metastases (CLM) are increasingly treated with preoperative chemotherapy. Chemotherapy associated liver injury is associated with postoperative hepatic insufficiency (PHI) and mortality. The adequate minimum future liver remnant (FLR) volume in patients treated with extensive chemotherapy remains unknown.

Methods

All patients with standardized FLR > 20 %, who underwent extended right hepatectomy for CLM from 1993-2011, were divided into three cohorts by chemotherapy duration: no chemotherapy (NC, n = 30), short duration (SD, ≤12 weeks, n = 78), long duration (LD, >12 weeks, n = 86). PHI and mortality were compared by using uni-/multivariate analyses. Optimal FLR for LD chemotherapy was determined using a minimum p-value approach.

Results

A total of 194 patients met inclusion criteria. LD chemotherapy was significantly associated with PHI (NC + SD 3.7 vs. LD 16.3%, p = 0.006). Ninety-day mortality rates were 0 % in NC, 1.3 % in SD, and 2.3% in LD patients, respectively (p = 0.95). In patients with FLR > 30 %, PHI occurred in only two patients (both LD, 2/20, 10 %), but all patients with FLR > 30 % survived. The best cutoff of FLR for preventing PHI after chemotherapy >12 weeks was estimated as >30 %. Both LD chemotherapy (odds ratio [OR] 5.4, p = 0.004) and FLR ≤ 30 % (OR 6.3, p = 0.019) were independent predictors of PHI.

Conclusions

Preoperative chemotherapy >12 weeks increases the risk of PHI after extended right hepatectomy. In patients treated with long-duration chemotherapy, FLR > 30 % reduces the rate of PHI and may provide enough functional reserve for clinical rescue if PHI develops.     

Greater Complexity of Liver Surgery is Not Associated with an Increased Incidence of Liver-Related Complications Except for Bile Leak: An Experience with 2,628 Consecutive Resections

Background

Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.

Methods

A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.

Results

Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p?<?0.001), two-stage resection (4.0 vs 1 %; p?<?0.001), extended right hepatectomy (17.6 vs 14.6 %; p?=?0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p?<?0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p?=?0.02) and hemorrhage (0.9 vs 0.3 %; p?=?0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p?=?0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p?=?0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.

Conclusions

The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.     

Incidence of steroid-associated osteonecrosis of the talus: a prospective MRI study

Objective

The purpose of this study was to determine the incidence of steroid-associated osteonecrosis (ON) of the talus in systemic lupus erythematosus (SLE) patients using a prospective magnetic resonance imaging (MRI) study.

Methods

We prospectively evaluated 110 SLE patients (220 tali) who required corticosteroid therapy using MRI. The incidence of ON of the talus was compared with the incidence of ON of the femoral head. We also divided these patients into two groups: those with and without ON of the talus. We compared these groups for gender differences, ages at initial corticosteroid therapy, and highest daily corticosteroid dosages.

Results

The incidence of ON of the talus was significantly lower than the incidence of ON of the femoral head (7.3 versus 49.5 %; p?<?0.001). No significant differences for gender, age at initial corticosteroid therapy, or highest daily corticosteroid dosage were observed between patients with and without ON of the talus. The rate of ON of the bilateral femoral head was significantly higher in those with ON of the talus than in those without ON of the talus.

Conclusion

Our results revealed that the incidence of ON of the talus was significantly lower than the incidence of ON of the femoral head.     

Impact of preoperative factors on catheter position in peritoneal dialysis: a prospective cohort study

Clinical and Experimental Nephrology - Peritoneal dialysis (PD) catheter malposition is one of the complications of renal replacement therapy. This study aimed to determine the preoperative factors...