搜索结果：Hepatobiliary surgery and nutrition

Gastrointestinal cancer surgery commonly leads to postoperative complications and other adverse outcomes. While prehabilitation shows promise in reducing adverse postoperative outcomes, most hospitals have resource limitations that preclude its use as standard of care. Additionally, the need to expedite surgery from diagnosis often creates a narrow window for prehabilitation initiatives. Online, self-reported screening tools may address these challenges by facilitating early identification of high-risk patients and enabling targeted preoperative interventions, thereby allowing equitable allocation of limited resources. Therefore, the primary aim of this study is to evaluate the predictive utility of a tri-modal (physical, nutritional, psychological) screening tool for patients undergoing gastrointestinal cancer surgery. This prospective international cohort study will recruit 1214 adults undergoing elective gastrointestinal cancer surgery across 35 sites from 19 countries. Participants will complete an online screening tool developed through a comprehensive, multistep, predefined process. The screening tool comprises the Duke Activity Status Index, Patient-Generated Subjective Global Assessment Short Form and the Patient Health Questionnaire-4, in English, Spanish, French or Portuguese. These tools were selected based on a scoping review, followed by an international Delphi consensus process. The primary outcomes include rate of postoperative complications, major complications (Clavien-Dindo Classification grade III-V) and overall complication severity assessed by the Comprehensive Complications Index; all assessed 30 days postoperatively. Secondary outcomes include hospital length of stay, readmission rate within 30 days, discharge destination (home vs other), days at home and alive in 30 days postsurgery, 30-day all-cause mortality and 12-month survival. Primary analyses will establish optimal screening tool cut-points to stratify patients into clinically actionable risk categories for postoperative complications and examine the independent predictive value of these screening scores after adjusting for established clinical risk factors. This study has received ethical approval from the Sydney Local Health District Human Research and Ethics Committee (X25-0333 and 2025/ETH02465) and has been registered on the Open Science Framework (10.17605/OSF.IO/HVCGD). The results of Preoperative Risk Evaluation for Cancer Treatment will be submitted to reputable journals and presented at national and international conferences.

A significant portion of primary liver cancer patients in China are diagnosed at intermediate-to-advanced stages, often making them ineligible for curative surgery. Furthermore, high postoperative recurrence rates, reaching up to 70%, pose a major challenge for long-term survival. The emergence of novel systemic treatments, such as immune checkpoint inhibitor combinations, and advancements in locoregional therapies have created new opportunities for conversion and perioperative strategies. This updated consensus aims to standardize the clinical application of these therapies based on the latest evidence, with the objective of improving patient prognosis. A multidisciplinary committee of 97 experts was convened to revise previous guidelines. The process involved a comprehensive search of medical databases and conference proceedings, with evidence graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Consensus statements were finalized through a formal electronic voting process, requiring at least 80% agreement for approval, resulting in 18 updated statements. The consensus provides refined definitions for conversion and perioperative therapy. It recommends various strategies for oncological conversion, including systemic therapy with anti-angiogenic drugs plus immunotherapy, and locoregional approaches like precision transarterial chemoembolization (TACE) and hepatic artery infusion chemotherapy (HAIC). The document strongly affirms surgical resection as a crucial step for achieving long-term survival after successful conversion and offers guidance on surgical timing and adjuvant therapy. For resectable patients with high-risk features, neoadjuvant and adjuvant treatments are outlined to mitigate recurrence. The consensus also advocates for using dynamic enhanced magnetic resonance imaging (MRI) and the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria for efficacy assessment and underscores the essential role of a multidisciplinary team in management. This updated consensus offers standardized, evidence-based guidance for clinicians on implementing conversion and perioperative strategies to optimize patient-centered care and highlights the need for continued research to further refine these promising approaches.

Robotic surgery for gallbladder cancer (GBC) has been on the uptake in the past few years, but few studies have studied oncological outcomes and safety. Robotic radical cholecystectomy (RRC) is a highly complex procedure requiring experienced surgeons and is associated with high morbidity and need for prolonged hospitalisation. Hence, the aim of this systematic review and meta-analysis was to compare between surgical outcomes and long-term survival for robotic radical resection versus laparoscopic radical resection for GBC. PubMed, Ovid Cochrane Library, Medline and Embase were searched with the relevant keywords including laparoscopic and robotic radical cholecystectomy. Relevant studies were analysed both qualitatively and quantitative, and a meta-analysis was performed on selected data. A total of 2,790 papers were screened, with 169 papers selected for full text review. A total of 11 studies met the eligibility criteria with a total of 263 patients undergoing laparoscopic radical resection and 52 patients undergoing robotic radical resection for GBC. Compared to laparoscopic radical cholecystectomy (LRC), RRC has shown to have adequate lymph node yield, no difference in mortality and morbidity rate, no difference in inpatient stays and no difference in overall recurrence rate. No anastomotic leak was reported in the robotic arm, as compared to 13 patients in the laparoscopic arm whose operation was complicated by bile leakage. Robotic surgery can be safely carried out in radical cholecystectomy with adequate resection margins and facilitate early recovery. It can also help to mitigate the risk of postoperative complications such as bile leakage.

Biliary atresia (BA) is a severe pediatric biliary disorder characterized by the progressive obstruction of liver bile ducts. In the absence of treatment, fibrosis advances rapidly in most affected children. In recent years, there has been significant progress in the management of BA, but many challenges remain. This guideline provides expert opinions on the screening, diagnosis, treatment, and follow-up of BA, aiming to assist and guide clinical practice. The guideline steering group, guideline development group, and guideline review group were formed to formulate clinical questions, develop recommendations, and draft guidelines using the GRADE Grid method, nominal group technique (NGT), and Delphi voting method. Three offline meetings were held on November 5, 2022, June 10, 2023, November 10, 2023, and October 27, 2024, respectively, to vote on the recommendations and solicit comments and suggestions from all participating experts. All experts from the United States, Europe, and Asia contributed significantly to this consensus guideline. After summarizing high-quality literature on clinically encountered issues such as early screening, complementary checkup, treatments, follow-up, vaccinations, growth, development, and neurocognition, 23 observations were made and strength of recommendations were given. International guidelines for BA can guide surgeons, patients, medical societies, hospital administrators, and relevant community groups in their current practice. The diagnosis and treatment of BA remains controversial internationally and more research evidence is needed.

Patients with hepatocellular carcinoma (HCC) and microvascular invasion (MVI) are susceptible to early recurrence (ER) after hepatectomy. The use of postoperative adjuvant transcatheter arterial chemoembolization (TACE) for patients with HCC and MVI remains a subject of debate. A total of 1,191 patients with HCC and MVI from 16 participating centers were retrospectively analyzed. A nomogram for predicting ER was developed using risk factors via multivariate logistic regression in the training cohort, with performance validated in the internal and external validation cohorts. Patients were categorized into high- and low-risk groups based on maximum Jordon index, which was used to continue exploring the long-term prognosis and the impact of adjuvant TACE therapy. In total, 217 (43.1%), 115 (45.6%), and 189 (43.4%) patients with ER were found in the training, internal validation and external validation cohort, respectively. The DCDAM score, which incorporates diameter, cirrhosis, differentiation, &#x3b1;-fetoprotein (AFP), and MVI grade, demonstrated superior net benefit and accuracy in predicting ER compared to traditional models across three cohorts. The high-risk group (DCDAM score >169) had higher cumulative recurrence rates and worse overall survival (OS) (median OS: 22.0 vs. 38.3, 17.5 vs. 41.7, and 23.6 vs. 45.2 months, all P<0.001) compared to the low-risk group (DCDAM score &#x2264;169) in all cohorts. TACE-adjuvant therapy improved OS in the high-risk group but not in the low-risk group. DCDAM score achieved an optimal postoperative prediction of ER among patients with HCC and MVI. This model can help screen subjects who can benefit more from postoperative adjuvant TACE.

Transarterial chemoembolization (TACE) plays a critical role in the treatment of hepatocellular carcinoma (HCC), yet variability in its performance leads to inconsistent prognostic outcomes, with objective response rates (ORRs) ranging from below 10% to over 60% for intermediate HCC. Published evidence and recommendations emphasize that TACE should be executed with precise targeting and accessibility to superselective catheterization. To enhance quality control and standardize TACE procedures, the concept of "precision TACE" is introduced by an international expert panel of International Society of Multidisciplinary Interventional Oncology (ISMIO), emphasizing the inclusion of standardized angiography, superselective catheterization and embolization, appropriate selection of embolic agents, determination of optimal embolization endpoints, and evaluation for efficacy immediately post-TACE. Precision TACE is divided into superior precision TACE (SP-TACE) and moderate precision TACE (MP-TACE). SP-TACE aims at achieving complete response (CR) or close to CR for all treated intrahepatic lesions in one session, while minimizing damage to normal liver tissue as much as possible. For SP-TACE, ideal candidates are intermediate HCCs with moderate intrahepatic tumor burden (maximum diameters of lesions no more than 5 cm, possibly up to 7 cm, with less than 5 intrahepatic lesions) and early HCCs who are unable or unwilling to receive curative approaches. MP-TACE aims at achieving partial response (PR) or stable disease (SD) for treated intrahepatic lesions with one or repeated sessions of TACE. For MP-TACE, ideal candidates are intermediate HCCs with high intrahepatic tumor burden and locally-advanced HCCs (with vascular invasion). Besides, precision TACE combined with other therapies such as ablation, systemic therapies, and hepatic resection, is discussed. Lastly, a scoring system for quantifying the precision of TACE is proposed to evaluate its effectiveness.

The global prevalence of metabolic diseases, including obesity, type 2 diabetes mellitus (T2DM), and metabolic dysfunction-associated steatotic liver disease (MASLD), continues to rise, representing a major global health threat and economic burden. Dihydroberberine (DHB), a reduced derivative of berberine (BBR), has recently garnered attention due to its superior lipophilicity and intestinal absorption. Pharmacokinetic studies suggested that DHB achieves significantly higher blood concentrations compared to BBR at equivalent doses. This review systematically synthesized the current preclinical evidence regarding the metabolic regulatory mechanisms of DHB. Key pharmacological targets identified in cell and animal models included the activation of AMP-activated protein kinase (AMPK) and glucokinase (GCK), modulation of lipid metabolism, and attenuation of inflammatory and oxidative stress pathways. Furthermore, DHB interacted extensively with the gut microbiota, acting both as a microbial metabolite of BBR and a modulator of microbial composition. Toxicological assessments indicated a favorable safety profile, although potential risks such as hERG channel inhibition required careful evaluation. Importantly, while in vitro and animal studies demonstrated significant metabolic benefits, human clinical trials assessing direct disease outcomes remained highly limited. This review highlighted the pharmacokinetic advantages of DHB and outlined the critical translational gaps that must be addressed in future research.

Insufficient future liver remnant (FLR) increases the risk of postoperative hepatic insufficiency and death. Liver venous deprivation (LVD) is associated with greater FLR hypertrophy than portal vein embolization (PVE) but may incur additional cost and risk. Our aim was to determine the factors predictive of insufficient FLR hypertrophy after PVE and inform selection for LVD. Consecutive patients who underwent right PVE from January 1998 through December 2020 were identified. Clinicopathologic and treatment-related variables were evaluated for associations with post-PVE standardized FLR (sFLR) &#x2265;30%, kinetic growth rate (KGR) &#x2265;2% per week, or a composite endpoint of sFLR &#x2265;30% or KGR &#x2265;2% per week. In addition, the procedure duration and costs of PVE and LVD were compared in a contemporary cohort [2019-2024]. During 1998-2020, 477 patients underwent PVE. The median (interquartile range) pre-PVE sFLR was 22% (16-29%). Out of 477 patients, 284 (60%) achieved sFLR &#x2265;30%, 271 (57%) achieved KGR &#x2265;2% per week, and 364 (76%) achieved at least one of the two. After PVE, 360 (75%) underwent their planned operation. Multiple logistic regression showed that higher pre-PVE sFLR [odds ratio (OR), 1.4; 95% confidence interval (CI): 1.31-1.49] and extended PVE (OR, 0.47; 95% CI: 0.25-0.87) were predictive of post-PVE sFLR &#x2265;30%. Receiver operating characteristic curve analysis revealed that pre-PVE sFLR >19% was 89% sensitive and 75% specific for post-PVE sFLR &#x2265;30% (area under the curve, 0.914). Conversely, 97% of patients with pre-PVE sFLR >26% achieved sFLR &#x2265;30%. Weight gain after PVE (OR, 0.50; 95% CI: 0.31-0.82), extended PVE (OR, 0.60; 95% CI: 0.40-0.91) and planned staged resection (OR, 0.41; 95% CI: 0.27-0.62) were independently predictive of failure to achieve KGR &#x2265;2% per week. During 2019-2024, 63 patients underwent PVE, and 22 patients underwent LVD. Procedure duration was significantly higher in patients undergoing LVD compared to PVE (median 247 vs. 169 minutes, P<0.001). The average procedural and total costs were 1.22 and 1.44 times greater for LVD, respectively. Patients with baseline sFLR <19% and those with baseline sFLR 19-26% and gross liver abnormalities or planned to undergo staged or extended right hepatectomy are unlikely to achieve adequate liver remnant hypertrophy with PVE. LVD may be the preferred approach for these patients as it is known to induce augmented hypertrophy. Healthy weight maintenance should be encouraged after PVE to optimize liver regeneration.

Postoperative pancreatic fistula (POPF) is a major complication after pancreatic resection. This systematic review and meta-analysis investigated the impact of neoadjuvant therapy (NAT) on POPF rates after pancreatoduodenectomy (Whipple procedure) and distal pancreatectomy. A systematic search of PubMed/MEDLINE, Scopus, Embase, and Cochrane Central Register of Controlled Trials was conducted for studies published since 2016 using the updated International Study Group of Pancreatic Fistula (ISGPF) definition for POPF. Random-effects models were used to pool data. Thirty studies (22,048 patients) were included. Of those, 24 were comparative studies between neoadjuvant and upfront surgery (UPS) groups, while 6 reported POPF rates only in the neoadjuvant group. NAT significantly reduced POPF rates after Whipple procedure [risk ratio (RR) 0.44, 95% confidence intervals (CI): 0.38-0.52, P<0.01]. A harder pancreatic texture was more common after NAT compared to UPS (RR 1.27, 95% CI: 1.23-1.32, P<0.001). There were no significant differences between the neoadjuvant and upfront surgery groups regarding pancreatic duct size or body mass index (BMI). NAT reduces POPF after Whipple procedure, likely by altering pancreatic texture. The exact mechanisms by which the pancreas becomes harder during neoadjuvant treatment remain unclear. This finding could be implemented to improve surgical outcomes in patients with a soft pancreas. However, accurately predicting tumor response to NAT is a prerequisite for such an approach to avoid potential disease progression. Advances in personalized medicine, where tumor response could be predicted, offer hope for tailoring treatment strategies and maximizing outcomes.

Early studies of pediatric acute liver failure (PALF) estimate that 60%-70% of patients survive with their native liver (SNL), 20%-25% require an emergent liver transplant (LT), and 10%-15% are mortalities. These studies were largely limited to academic centers and focused on short-term outcomes. Herein, we analyzed California Department of Healthcare Access and Information data, which is demographically representative of the US population. Between June 1990 and December 2018, 2270 children were admitted to California hospitals with PALF. The overall incidence of PALF was 16.75 per 100,000 live births, with no evidence of seasonality. LT was performed in 188 (8.3%) patients and 425 (18.7%) patients died. Mortality was associated with contraindications to transplant, such as concomitant hematologic malignancy or cardiac disease. With a median follow-up of 4.5 years, nearly all deaths occurred within 4 months of presentation, with no long-term liver-related comorbidities in patients with SNL. Implementation of pediatric end-stage liver disease/MELD-based organ allocation in 2002 resulted in a more than 2-fold increase in the likelihood of LT in children <10 years (subdistribution hazard ratio: 3.35). Patients receiving care at transplant centers after this change were younger (10 vs. 12&#xa0;y), more often from urban areas (98.2% vs. 94%), and more likely to receive LT for metabolic, genetic, or "other" causes of PALF (up to subdistribution hazard ratio 6.4 [1.84-22.26], p<0.01). While mortality was higher at transplant centers (26.5% vs. 14.6%), the time to mortality was also increased (31 vs. 7&#xa0;d), likely reflecting disease complexity requiring management in a specialized children's hospital. In conclusion, this study supports an estimate of incidence and long-term outcomes of PALF across a large population and highlights the role of specialized pediatric transplant centers for the optimized care of PALF.

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Although the frequency of incidental diagnosis of gallbladder cancer (GBC) after cholecystectomy is increasing and further resection is necessary for stage T2 GBC or higher, the optimal timing of reoperation remains debated. The objective of the current study was to compare short- and long-term outcomes according to the interval between initial cholecystectomy and reoperation. Among 802 patients who underwent extended cholecystectomy for T2 GBC between November 2004 and October 2022 at five tertiary referral centers in Korea, 148 underwent reoperation after initial cholecystectomy and were included in this study. Patient outcomes were compared according to the interval between initial cholecystectomy and reoperation. Patients were divided into three groups according to the interval between initial cholecystectomy and reoperation: <4 weeks (group A), 4-8 weeks (group B), and >8 weeks (group C). Operation time (A vs. B vs. C: 225.3&#xb1;124.7 vs. 179.4&#xb1;85.6 vs. 169.3&#xb1;56.4 min, P<0.001) and estimated blood loss {median (interquartile range), 100 [100-300] vs. 100 [100-100] vs. 100 [87.5-100] cc, P=0.03} were greater in group A. The median follow-up duration was 52 months. Five-year recurrence-free survival was worst in group C (64.0% vs. 83.6% vs. 58.9%, P=0.02). In multivariable analysis, long interval [hazard ratio (HR) 5.74, P=0.002] and residual disease (HR 5.42, P<0.001) were independent risk factors for recurrence. The optimal interval between initial cholecystectomy and reoperation for postoperatively diagnosed T2 GBC is 4-8 weeks. Early reoperation is associated with worse intraoperative outcomes, and delayed reoperation is associated with higher risk of recurrence.

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Development of new-onset steatotic liver disease (SLD) has been increasingly observed after pancreatectomy. However, the pathophysiology of post-operative SLD remains poorly understood. This study aimed to clarify the risk factors for new-onset SLD after pancreatectomy and verify the utility of monitoring plasma apolipoprotein A2-isoforms (apoA2-i) as a potentially promising biomarker for evaluating pancreatic exocrine function. In this retrospective study of 79 patients who underwent pancreatectomy [47 pancreaticoduodenectomies (PDs) and 32 distal pancreatectomies (DPs)] between March 2021 and March 2024, the plasma apoA2-i (AT/AT and ATQ/ATQ) levels were measured using enzyme-linked immunosorbent assay (ELISA) methods, and non-contrast-enhanced computed tomography (CT) images were manually reviewed for the diagnosis of SLD. Comparing the minimum value of apoA2-AT/AT after surgery between the SLD (n=32) and non-SLD group (n=47), the apoA2-AT/AT value in the SLD group was significantly lower than that in the non-SLD group (P<0.001). The plasma apoA2-AT/AT levels <9.58 &#xb5;g/mL (median of this cohort) was significantly associated with SLD (P<0.001) and an independent risk factor of SLD with both univariable [odds ratio (OR), 20.1; 95% confidence interval (CI): 6.59-74.5; P<0.001] and multivariable (OR, 13.6; 95% CI: 2.68-134.2; P=0.001) logistic regression analysis. Moreover, even when stratified by pre-onset pancrelipase administration, the cumulative incidence of SLD was significantly higher in patients with plasma apoA2-AT/AT levels <9.58 &#xb5;g/mL (P<0.001). The point estimate of the area under the curve for detecting SLD of apoA2-AT/AT was 0.843. SLD associated with malnutrition following pancreatectomy can be predicted using plasma apoA2-i monitoring.

Liver grafts with >30% macrovesicular steatosis (Mas30) have shown acceptable long-term graft survival (GS) in steatotic liver disease (SLD) recipients. However, grouping SLD etiologies under a single umbrella ignores their distinct metabolic profiles and may lead to suboptimal allocation decisions. Considering the 2023 Delphi consensus nomenclature, we aimed to compare early and long-term GS following Mas30 liver transplantation (LT) across SLD subtypes. We analyzed adult LT recipients in the U.S. national transplant registry from 2014 to 2024. Donor macrovesicular steatosis was categorized as none (<5%), mild (5-30%), and Mas30 (>30%). SLD recipients were classified as metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-related liver disease (MetALD), or alcohol-associated liver disease (ALD). Primary endpoints were early (90-day) and long-term (3-year) GS. Time-to-event analyses were conducted using Kaplan-Meier and multivariable Cox regression. Among 27,164 LT recipients (14,270 SLD and 12,894 non-SLD), Mas30 utilization declined over time (P<0.001). MASLD recipients of Mas30 grafts had reduced early GS (87.8% vs. 93.6% mild vs. 95.3% none; P<0.001) and long-term GS (83.0% vs. 86.6% vs. 87.5%; P=0.01). After adjustment, Mas30 grafts conferred nearly threefold higher early failure risk [adjusted hazard ratio (aHR) 2.93, P<0.001] and persistent long-term risk (aHR 1.66, P=0.002). No association was observed in MetALD or ALD recipients (all P>0.17). Sensitivity analyses including competing risk models confirmed these findings (MASLD: early sHR 3.18, P=0.001; long-term sHR 2.18, P=0.01). MASLD recipients receiving Mas30 grafts experience substantially reduced GS extending to 3 years post-LT, while MetALD and ALD recipients remain unaffected. Our findings support etiology-specific allocation strategies for steatotic liver grafts.

Metabolic dysfunction-associated steatotic liver disease (MASLD) has been recognized as an accurate reflection of the pathogenesis of fatty liver disease by a consensus document. However, the relationship between MASLD and the prognosis of hepatocellular carcinoma (HCC) patients receiving hepatectomy remains unclear. The aim of this study is to investigate whether MASLD affects the long-term prognosis of HCC patients undergoing hepatectomy. A multivariate Cox proportional hazards model and a propensity score matching (PSM) analysis were implemented to ensure equal baseline characteristics. The Kaplan-Meier survival curves were employed for prognosis comparison between the two groups. This study involved 909 HCC patients who underwent hepatectomy between January 2011 and December 2017 at the West China Hospital of Sichuan University, including 97 patients with MASLD (MASLD group) and 812 patients without MASLD (non-MASLD group). According to the multivariate analysis, patients in the MASLD group showed worse recurrence-free survival (RFS) [hazard ratio (HR) =1.23; 95% confidence interval (CI), 1.13-1.72; P=0.03] and overall survival (OS) (HR =2.04; 95% CI, 1.06-2.73; P=0.03) than those in the non-MASLD group. After conducting a PSM analysis, Kaplan-Meier survival curve analysis disclosed significant differences in both the RFS and OS between the two groups (P=0.02 and P=0.01, respectively). All results showed that MASLD had a poor long-term prognosis for HCC patients undergoing hepatectomy. In summary, our study suggests that MASLD might be a risk factor for the OS and RFS in HCC patients who underwent hepatectomy through multivariate analysis and PSM analysis. These findings indicate that preoperative diagnosis of MASLD in HCC patients holds crucial significance in guiding the long-term prognosis of patients after hepatectomy.