Preoperative nutritional score predicts underlying liver status and surgical risk of hepatocellular carcinoma

Background: Given the scarce evidence regarding the impact of preoperative nutritional status on surgical outcomes of patients with hepatocellular carcinoma, predictive powers of nutritional/inflammatory scores for short-term surgical outcomes in patients with hepatocellular carcinoma were investigated. Methods: Outcomes of 1272 patients with hepatocellular carcinoma were reviewed, and predictive powers of nine nutritional/inflammatory scores for short-term surgical outcomes were compared using the receiver-operating characteristic curve analysis. Clinical relevance of the best nutritional score was then studied in detail to clarify its utility as an alternative predictive measure for surgical risk of patients with hepatocellular carcinoma. Results: Receiver-operating characteristic curve analysis showed the controlling nutritional status score has the best performance in prediction of morbidity after hepatectomy for hepatocellular carcinoma (area under the curve, 0.593; 95% confidence interval: 0.552–0.635; p < 0.001), and multivariate analysis confirmed its correlation with the risk of any morbidity (odds ratio per +1 point, 1.17; 95% confidence interval: 1.08–1.27; p < 0.001) and major morbidity (odds ratio per +1 point, 1.14; 95% confidence interval: 0.99–1.27; p = 0.052). The undernutrition grade based on the controlling nutritional status score showed strong correlation with the degree of fibrosis in the liver ( p < 0.001), platelet count ( p < 0.001), and indocyanine green retention rate at 15 min ( p < 0.001). In addition, the controlling nutritional status undernutrition grade well stratified the risk of postoperative morbidity especially in cirrhotic subpopulation (odds ratio, 1.17 per +1 point; 95% confidence interval: 1.05–1.29 for any morbidity and odds ratio, 1.20 per +1 point; 95% confidence interval: 1.03–1.40 for major morbidity). Conclusion: The controlling nutritional status score could be an alternative measure for underlying liver injury and the surgical risk of hepatocellular carcinoma.

Five-year survival after elective open and endovascular aortic aneurysm repair

Background and objective: Current evidence suggests short-term survival benefit from endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in elective abdominal aortic aneurysm (AAA) procedures, but this benefit is lost during long-term follow-up. The aim of this study was to compare short- and mid-term all-cause mortality in patients with non-ruptured aneurysm treated by OSR and EVAR; and to assess the rate of complications and reinterventions, as well as to evaluate their impact on survival. Methods: The medical records of the non-ruptured AAA patients undergoing OSR or EVAR between 1 January 2011 and 31 December 2019 at Tartu University Hospital, Estonia, were retrospectively reviewed. We gathered survival data from the national registry (mean follow-up period was 3.7 ± 2.3 years). Results: A total of 225 non-ruptured AAA patients were treated operatively out of whom 95 (42.2%) were EVAR and 130 (57.8%) were OSR procedures. The difference in estimated all-cause mortality between the OSR and EVAR groups at day 30 was statistically irrelevant (2.3% vs 0%; p = 0.140), but OSR patients showed statistically significantly higher 5 year survival compared with EVAR patients (75.3% vs 50.0%, p = 0.002). Complication and reintervention rates for the EVAR and OSR groups did not differ statistically (26.3% vs 16.9%, p = 0.122; 10.5% vs 11.5%, p = 0.981, respectively). Multivariate analysis revealed that greater aneurysm diameter (p = 0.012), EVAR procedure (p = 0.016), male gender (p = 0.023), and cerebrovascular diseases (p = 0.028) were independently positively associated with 5-year mortality. Conclusions: Thirty-day mortality, and complication and reintervention rates for EVAR and OSR after elective AAA repair were similar. Although the EVAR procedure is an independent risk factor for 5-year mortality, higher age and greater proportion of comorbidities among EVAR patients may influence not only the choice of treatment modality, but also prognosis.

Impact of surgical drain output monitoring on patient outcomes in hepatopancreaticobiliary surgery: A systematic review

Background and objective: Surgical drains are widely utilized in hepatopancreaticobiliary surgery to prevent intra-abdominal collections and identify postoperative complications. Surgical drain monitoring ranges from simple-output measurements to specific analysis for constituents such as amylase. This systematic review aimed to determine whether surgical drain monitoring can detect postoperative complications and impact on patient outcomes. Methods: A systematic review was performed, and the following databases searched between 02/03/20 and 26/04/20: MEDLINE, EMBASE, The Cochrane Library, and Clinicaltrials.gov. All studies describing surgical drain monitoring of output and content in adult patients undergoing hepatopancreaticobiliary surgery were considered. Other invasive methods of intra-abdominal sampling were excluded. Results: The search returned 403 articles. Following abstract review, 390 were excluded and 13 articles were included for full review. The studies were classified according to speciality and featured 11 pancreatic surgery and 2 hepatobiliary surgery studies with a total sample of 3262 patients. Postoperative monitoring of drain amylase detected pancreatic fistula formation and drain bilirubin testing facilitated bile leak detection. Both methods enabled early drain removal. Improved patient outcomes were observed through decreased incidence of postoperative complications (pancreatic fistulas, intra-abdominal infections, and surgical-site infections), length of stay, and mortality rate. Isolated monitoring of drain output did not confer any clinical benefits. Conclusions: Surgical drain monitoring has advantages in the postoperative care for selected patients undergoing hepatopancreaticobiliary surgery. Enhanced surgical drain monitoring involving the testing of drain amylase and bilirubin improves the detection of complications in the immediate postoperative period.

Long-term pain relief after groin hernia repair for sports groin: A nationwide cohort study

Background: The groin is a complex anatomical area with multiple structures that can be injured and cause pain. One condition with groin pain is the so-called “sports groin,” which can be treated with a groin hernia repair even though no hernia is present. The aim of this study was to assess the prevalence of chronic groin pain several years after a groin hernia repair performed in patients with a sports groin. Methods: This nationwide cohort study included adults who had a groin hernia repair for a sports groin through the years 1998–2011. The patients were identified through the Danish Hernia Database and in surgical records. Patients were asked to fill out four questionnaires several years after the repair: a visual analogue scale, the Activity Assessment Scale, the Inguinal Pain Questionnaire, and a questionnaire about treatment satisfaction. Results: Of 118 contacted patients, 71 gave informed consent and were included in the study (60%), and of these the response rate was 100%. The questionnaires were filled out median 14 years after surgery. Most of the patients were pain-free in the operated groin (87%), and only a few had physical impairment caused by groin pain (20%). Prior to surgery, 79% had groin pain that they could not ignore. Overall, 90% of the patients were satisfied with the treatment. Conclusions: Most patients were pain-free and without physical impairment several years after groin hernia repair for a sports groin and with high satisfaction rate.

Does minimally invasive liver resection improve long-term survival compared to open resection for hepatocellular carcinoma? A systematic review and meta-analysis

Introduction: Minimally invasive liver surgery for hepatocellular carcinoma has gained widespread interest as an alternative to conventional open liver surgery. However, long-term survival benefits of this approach seem unclear. This meta-analysis was conducted to investigate long-term survival following minimally invasive liver surgery. Method: A systematic review was performed to identify studies comparing long-term survival after minimally invasive liver surgery and open liver surgery until January 2020. The I2 test was used to test for statistical heterogeneity and publication bias was assessed using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study factors (region, design), annual center volume, patient factors (American Society of Anesthesiologists (ASA) grade, gender, age, body mass index, cirrhosis, tumor size, and number), and resection extent. Sensitivity analyses were performed on studies by study year, region, annual center volume, and resection type. Result: The review identified 50 relevant studies including 13,731 patients undergoing liver resection for hepatocellular carcinoma of which 4071 (25.8%) underwent minimally invasive liver surgery. Pooled analysis revealed similar all-cause (odds ratio: 0.83, 95% confidence interval: 0.70–1.11, p = 0.3) and disease-specific (odds ratio: 0.93, 95% confidence interval: 0.80–1.09, p = 0.4) 5-year mortality after minimally invasive liver surgery compared with open liver surgery. Sensitivity analysis of published studies from 2010 to 2019 demonstrated a significantly lower disease-specific 3-year mortality (odds ratio: 0.75, 95% confidence interval: 0.59–0.96, p = 0.022) and all-cause 5-year mortality (odds ratio: 0.63, 95% confidence interval: 0.50–0.81, p = 0.002). Meta-regression identified no confounding factors in all analyses. Conclusions: Improvement in minimally invasive liver surgery techniques over the past decade appears to demonstrate superior disease-specific mortality with minimally invasive liver surgery compared to open liver surgery. Therefore, minimally invasive liver surgery can be recommended as an alternative surgical approach for hepatocellular carcinoma.

Intra-abdominal hypertension and abdominal compartment syndrome in critically ill patients: A narrative review of past, present, and future steps

Background and objective: Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. In this narrative review, we aim to provide a comprehensive overview of current insights into intra-abdominal pressure monitoring, intra-abdominal hypertension, and abdominal compartment syndrome. The focus of this review is on the pathophysiology, risk factors and outcome of intra-abdominal hypertension and abdominal compartment syndrome, and on therapeutic strategies, such as non-operative management, surgical decompression, and management of the open abdomen. Finally, future steps are discussed, including propositions of what a future guideline should focus on. Conclusions: Pathological intra-abdominal pressure is a continuum ranging from mild intra-abdominal pressure elevation without clinically significant adverse effects to substantial increase in intra-abdominal pressure with serious consequences to all organ systems. Intra-abdominal pressure monitoring should be performed in all patients at risk of intra-abdominal hypertension. Although continuous intra-abdominal pressure monitoring is feasible, this is currently not standard practice. There are a number of effective non-operative medical interventions that may be performed early in the patient’s course to reduce intra-abdominal pressure and decrease the need for surgical decompression. Abdominal decompression can be life-saving when abdominal compartment syndrome is refractory to non-operative treatment and should be performed expeditiously. The objectives of open abdomen management are to prevent fistula and to achieve delayed fascial closure at the earliest possible time. There is still a lot to learn and change. The 2013 World Society of Abdominal Compartment Syndrome guidelines should be updated and multicentre studies should evaluate the effect of intra-abdominal hypertension treatment on patient outcome.

The liver-first approach for synchronous colorectal liver metastases: A systematic review and meta-analysis of completion rates and effects on survival

Background: Patients presenting with synchronous colorectal liver metastases are increasingly being considered for a curative treatment, and the liver-first approach is gaining popularity in this context. However, little is known about the completion rates of the liver-first approach and its effects on survival. Methods: A systematic review and meta-analysis of liver-first strategy for colorectal liver metastasis. The primary outcome was an assessment of the completion rates of the liver-first approach. Secondary outcomes included overall survival, causes of non-completion, and clinicopathologic data. Results: Seventeen articles were amenable for inclusion and the total study population was 1041. The median completion rate for the total population was 80% (range 20–100). The median overall survival for the completion and non-completion groups was 45 (range 12–69) months and 13 (range 10.5–25) months, respectively. Metadata showed a significant survival benefit for the completion group, with a univariate hazard ratio of 12.0 (95% confidence interval, range 5.7–24.4). The major cause of non-completion (76%) was liver disease progression before resection of the primary tumor. Pearson tests showed significant negative correlation between median number of lesions and median size of the largest metastasis and completion rate. Conclusions: The liver-first approach offers a complete resection to most patients enrolled, with an overall survival benefit when completion can be assured. One-fifth fails to return to intended oncologic therapy and the major cause is interim metastatic progression, most often in the liver. Risk of non-completion is related to a higher number of lesions and large metastases. The majority of studies stem from primary rectal cancers, which may influence on the return to intended oncologic therapy as well. PROSPERO id no: 170459

The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study

Introduction: Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks. Methods: A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index. Results: A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 ( p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 ( p < 0.001). Conclusions: A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.

The impact of cirrhosis on the postoperative outcomes of patients undergoing splenectomy: Propensity score matched analysis of the 2011–2017 US hospital database

Background & objective: While splenectomy is performed for various trauma and non-trauma indications, there is little information about the impact of cirrhosis on the post-splenectomy outcomes, despite the intricate physiological and vascular connection between the liver and the spleen. Methods: 2011–2017 National Inpatient Sample was used to select patient cases who underwent the splenectomy procedure, who were further stratified using cirrhosis. The cirrhosis-absent controls were matched to the study cohort using propensity score matching with nearest neighbor matching method. Endpoints included mortality, length of stay, hospitalization costs, and postoperative complications. Results: There were 675 patients with cirrhosis and 675 matched controls identified from the database. Cirrhosis cohort had higher mortality (20.0 vs 7.26%, p < 0.001, OR = 3.19, 95% CI = 2.26–4.52) and hospitalization costs ($210,716 vs $186,673, p = 0.003), but shorter length of stay (11.8 vs 12.5d, p = 0.04). In terms of complications, cirrhosis cohorts had higher postoperative bleeding (7.26 vs 4.3%, p = 0.027, OR = 1.74, 95% CI = 1.09–2.80) and shock (3.7 vs 1.04%, p = 0.002, OR = 3.67, 95% CI = 1.58–8.54), and were more likely to be discharged to short-term hospitals and home with home health care. On multivariate analysis, presence of cirrhosis resulted in higher mortality (p < 0.001, aOR = 3.30, 95% CI = 2.33–4.69). Conclusions: Cirrhosis is an independent risk factor of postoperative mortality in patients undergoing splenectomy; given this finding, further precautious and multidisciplinary care should be rendered in these at-risk patients with cirrhosis in the setting of splenectomy.