Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial

Nomogram for Predicting Sepsis After Percutaneous Transhepatic Cholangioscopic Lithotripsy

Purpose

Sepsis is a possible complication of percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) for hepatolithiasis, but risk assessment tools are lacking. This study aimed to identify predictors of sepsis after PTCSL and develop a predictive nomogram.

Patients and Methods

In this nested case‒control study, the data from 298 patients who underwent 528 PTCSL sessions between 1 January 2016 and 1 July 2024 were retrospectively reviewed. All sessions demonstrating sepsis complications were included in the sepsis group. For each session in the sepsis group, two treatment date-matched sessions not demonstrating sepsis were randomly selected via a nested case‒control design. All the matched sessions were divided into training and validation sets. Least absolute shrinkage and selection operator (LASSO) analysis was conducted to preliminarily select predictors of sepsis complications. Multivariable logistic regression was performed to identify factors for constructing the nomogram.

Results

Sepsis was diagnosed in 46 patients (53 sessions), for an incidence of 10.69% (53 among 496 sessions). Three characteristic variables were included in the model: operation technique (odds ratio [OR]=0.170, 95% confidence interval [CI]: 0.048-0.599, P=0.006), cirrhosis (OR=3.769, 95% CI: 1.474-9.638, P=0.006), and postoperative prophylactic dexamethasone (OR=0.267, 95% CI: 0.101-0.703, P=0.008). The area under the curve (AUC) for the nomogram was 0.756 (95% CI, 0.658-0.853) in the training set and 0.762 (95% CI, 0.618-0.906) in the validation set, demonstrating relatively high discriminability. The calibration curves demonstrated the consistency between the predicted and actual values. Decision curve analysis indicated that the nomogram offers net clinical benefits.

Conclusion

The operation technique, cirrhosis, and postoperative prophylactic dexamethasone may predict the occurrence of sepsis after PTCSL. We developed a nomogram to predict sepsis complications following PTCSL and demonstrated its relatively strong performance.

The Effects of Perioperative Corticosteroids on Postoperative Complications After Pancreatoduodenectomy: A Debated Topic of Systematic Review and Meta-analysis

BACKGROUND

The intraoperative administration of corticosteroids has been shown to improve postoperative outcomes in patients undergoing surgery; however, the impact of corticosteroids on complications following pancreatoduodenectomy (PD) remains controversial.

OBJECTIVE

This study aimed to evaluate the efficacy of perioperative corticosteroids on postoperative complications after PD.

MATERIALS AND METHODS

A comprehensive search was conducted using the PubMed, Embase, and Web of Science databases for studies published prior to 1 July 2024. Of 7418 articles identified, a total of 5 studies were eligible for inclusion in this meta-analysis. The primary outcome was incidence of postoperative major complications (PMCs), while the additional outcomes were incidences of postoperative pancreatic fistulas (POPFs), infection, delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), bile leakage, reoperation, and 30-day mortality. The study was registered in the PROSPERO database (CRD42024524936).

RESULTS

Finally, 5 studies involving 1449 patients (537 with corticosteroids and 912 without corticosteroids) were analyzed. Intraoperative corticosteroids were not associated with any improvement in PMCs (p = 0.41). The incidence of POPF (p = 0.12), infectious complications (p = 0.15), or DGE (p = 0.81) were not significantly different between the two groups. No obvious differences were found in the incidence of PPH (p = 0.42), bile leakage (p = 0.68), 30-day mortality (p = 0.99), or reoperation (p = 0.26).

CONCLUSION

Perioperative corticosteroids did not significantly demonstrate any protective advantage in terms of postoperative complications after PD. This finding may serve as a reference for the perioperative use of corticosteroids in pancreatic surgery. Well-designed clinical trials are warranted in the near future in order to provide high-level evidence.

Effects of perioperative steroid use on surgical stress and prognosis in patients undergoing hepatectomy: a systematic review and meta-analysis of randomized controlled trials

The objective of this study was to evaluate the clinical effects of perioperative steroid hormone usage in hepatectomy patients through a comprehensive systematic review and meta-analysis. Prospective randomized controlled trials (RCTs) investigating the perioperative use of steroid hormones in hepatectomy patients were systematically searched using various databases, including PubMed, Medline, Embase, the Cochrane Library, the Chinese Biomedical Literature Database, Wanfang Data, and the CNKI database. Two researchers independently screened and extracted data from selected studies. Data analysis was performed using RevMan 5.3 software. The results revealed significantly lower levels of total bilirubin (standard mean difference [SMD] = -0.7; 95% CI: -1.23 to -0.18; and p = 0.009), interleukin-6 (SMD = -1.02; 95% CI: -1.27 to -0.77; and p < 0.001), and C-reactive protein (SMD = -0 .65; 95% CI: -1 .18 to -0.11; and p = 0.02) on postoperative day 1 (POD 1), as well as a reduced incidence of postoperative complications in the steroid group compared to the placebo group. No significant differences were observed between the two groups regarding alanine aminotransferase (ALT) levels, aspartic aminotransferase (AST) levels, or specific complications such as intra-abdominal infection (p = 0.72), wound infection (p = 0.1), pleural effusion (p = 0.43), bile leakage (p = 0.66), and liver failure (p = 0.16). The meta-analysis results indicate that perioperative steroid usage can effectively alleviate liver function impairment and inflammation response following hepatectomy while improving patient prognosis.

The Effect of Preoperative Administration of Glucocorticoids on the Postoperative Complication Rate in Liver Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Glucocorticoids may grant a protective effect against postoperative complications. The evidence on their efficacy, however, has been inconclusive thus far. We investigated the effects of preoperatively administered glucocorticoids on the overall postoperative complication rate, and on liver function recovery in patients undergoing major liver surgery. Methods: We performed a systematic literature search on PubMed, Embase, and CENTRAL in October 2021, and repeated the search in April 2023. Pre-study protocol was registered on PROSPERO (ID: CRD42021284559). Studies investigating patients undergoing liver resections or transplantation who were administered glucocorticoids preoperatively and reported postoperative complications were eligible. Meta-analyses were performed using META and DMETAR packages in R with a random effects model. Risk of bias was assessed using RoB2. Results: The selection yielded 11 eligible randomized controlled trials (RCTs) with 964 patients. Data from nine RCTs (n = 837) revealed a tendency toward a lower overall complication rate with glucocorticoid administration (odds ratio: 0.71; 95% confidence interval: 0.38-1.31, p = 0.23), but it was not statistically significant. Data pooled from seven RCTs showed a significant reduction in wound infections with glucocorticoid administration [odds ratio: 0.64; 95% confidence interval: 0.45-0.92 p = 0.02]. Due to limited data availability, meta-analysis of liver function recovery parameters was not possible. Conclusions: The preoperative administration of glucocorticoids did not significantly reduce the overall postoperative complication rate. Future clinical trials should investigate homogenous patient populations with a specific focus on postoperative liver recovery.

Preoperative dexamethasone administration in hepatectomy of 25-min intermittent Pringle's maneuver for hepatocellular carcinoma: a randomized controlled trial

BACKGROUND

A previous randomized controlled trial demonstrated that intermittent Pringle's maneuver (IPM) with a 25-min ischemic interval could be applied safely and efficiently in hepatectomy for patients with hepatocellular carcinoma (HCC). But prolonging the hepatic inflow clamping time will inevitably aggravate the ischemia-reperfusion injury. Therefore, we aimed to evaluate the effect of prophylactic dexamethasone on alleviating surgical stress for HCC patients with a 25-min ischemic interval.

METHODS

From December 2022 to April 2023, patients who met the inclusion criteria were randomly assigned to the dexamethasone group or control group. Perioperative data and short-term survival outcomes between the two groups were recorded and compared, and subgroup analysis was performed.

RESULTS

Two hundred and seventy patients were allocated to the dexamethasone group ( n =135) and control group ( n =135). Patients in the dexamethasone group had lower area under the curve of serial alanine aminotransferase (AUC ALT ) ( P =0.043) and aspartate aminotransferase (AUC AST ) ( P =0.009), total bilirubin (TB) ( P =0.018), procalcitonin (PCT) ( P =0.012), interleukin-6 (IL-6) ( P =0.006), incidence of major complication ( P =0.031) and shorter postoperative hospital stay ( P =0.046) than those in the control group. Subgroup analysis showed that the dexamethasone group experienced milder hepatocellular injury than the control group for patients with cirrhosis, and for patients without cirrhosis, the dexamethasone group experienced milder inflammatory response. Moreover, the dexamethasone group preserved better liver function and experienced milder inflammatory response for patients undergoing major hepatectomy, although the hepatocellular injury was not significantly improved.

CONCLUSION

Preoperative dexamethasone administration can help improve perioperative outcomes for HCC patients when applying IPM with a 25-min ischemic interval in hepatectomy.

Short-term outcomes of perioperative glucocorticoid administration in patients undergoing liver surgery: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

The purpose of this systematic review and meta-analysis was to investigate whether glucocorticoid might be beneficial after hepatectomy.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library and Web of Science.

ELIGIBILITY CRITERIA

We included studies assessing the efficacy of perioperative glucocorticoid administration in patients undergoing liver surgery.

DATA EXTRACTION AND SYNTHESIS

Four data bases were retrieved for all randomised controlled trials. We considered postoperative complications, hospital stay and postoperative chemistry evaluations as outcomes. Pooled effects of dichotomic variables were expressed as relative risk (RR) with a 95% CI. The mean difference was used for continuous variables and an inverse variance statistical method was adopted.

RESULTS

Fourteen studies with 1205 patients were included. Lower risk of overall complications was associated with glucocorticoid (RR, 0.77; 95% CI 0.64 to 0.92), while no difference was found in hospital stay (RR, 0.02; 95% CI -0.47 to 0.51). There were also improvements in postoperative chemistry evaluations including interleukin 6 on day 1 and 3, C reactive protein on day 1, 2 and 3, international normalised ratio on day 2, total bilirubin on day 1, 2, 3 and 5, albumin on day 1.

CONCLUSION

Current evidence indicated that perioperative glucocorticoid administration for patients undergoing hepatectomy reduced the risk of overall complications with inhibited postoperative inflammatory response and improved postoperative liver function.

PROSPERO REGISTRATION NUMBER

CRD42022307533.

Laser Speckle Contrast Imaging-based diagnosis of severe mesenteric traction syndrome: Hemodynamics and prostacyclin - A prospective cohort study

BRIEF ABSTRACT

Today, the diagnosis and grading of mesenteric traction syndrome relies on a subjective assessment of facial flushing. However, this method has several limitations. In this study, Laser Speckle Contrast Imaging and a predefined cut-off value are assessed and validated for the objective identification of severe mesenteric traction syndrome.

BACKGROUND

Severe mesenteric traction syndrome (MTS) is associated with increased postoperative morbidity. The diagnosis is based on an assessment of the developed facial flushing. Today this is performed subjectively, as no objective method exists. One possible objective method is Laser Speckle Contrast Imaging (LSCI), which has been used to show significantly higher facial skin blood flow in patients developing severe MTS. Using these data, a cut-off value has been identified. This study aimed to validate our predefined LSCI cut-off value for identifying severe MTS.

METHODS

A prospective cohort study was performed on patients planned for open esophagectomy or pancreatic surgery from March 2021 to April 2022. All patients underwent continuous measurement of forehead skin blood flow using LSCI during the first hour of surgery. Using the predefined cut-off value, the severity of MTS was graded. In addition, blood samples for prostacyclin (PGI₂) analysis and hemodynamics were collected at predefined time points to validate the cut-off value.

MAIN RESULTS

Sixty patients were included in the study. Using our predefined LSCI cut-off value, 21 (35 %) patients were identified as developing severe MTS. These patients were found to have higher concentrations of 6-Keto-PGF_aα (p = 0.002), lower SVR (p < 0.001), lower MAP (p = 0.004), and higher CO (p < 0.001) 15 min into surgery, as compared with patients not developing severe MTS.

CONCLUSION

This study validated our LSCI cut-off value for the objective identification of severe MTS patients as this group developed increased concentrations of PGI₂ and more pronounced hemodynamic alterations compared with patients not developing severe MTS.

Impact of perioperative steroid administration in patients undergoing elective liver resection: meta-analysis

BACKGROUND

Perioperative steroid administration may improve postoperative outcomes in major abdominal surgery by reducing the systemic inflammatory response. The aim of this systematic review was to evaluate the impact of perioperative steroid administration on outcomes after elective liver resection.

METHODS

PubMed, Cochrane Library, and Web of Science were systematically searched for randomized clinical trials (RCTs) comparing perioperative steroid administration with placebo, standard of care, or no steroids with respect to postoperative outcomes, particularly postoperative complications. Two independent reviewers critically appraised the studies and extracted data. Meta-analyses were performed using a random-effects model with ORs calculated for dichotomous outcomes and mean differences (MDs) for continuous outcomes.

RESULTS

Ten RCTs comprising 930 patients were included. Perioperative steroid administration significantly reduced the overall postoperative complication rate (OR 0.61, 95 per cent c.i. 0.43 to 0.87; P = 0.006; I2 = 26 per cent). No significant differences were shown for individual complications. Several postoperative laboratory parameters were positively affected, like total serum bilirubin (MD -0.46; 95 per cent c.i. -0.74 to -0.18; P = 0.001; I2 = 80 per cent), interleukin 6 (MD -48.99; 95 per cent c.i. -60.72 to -37.27; P < 0.001; I2 = 0 per cent) and C-reactive protein (MD -5.20; 95 per cent c.i. -7.62 to -2.77; P < 0.001; I2 = 71 per cent). There were no signs of an increase in potential steroid-induced adverse events, namely infectious complications, thromboembolic events, or bleeding.

CONCLUSIONS

Perioperative steroid administration significantly reduces the overall complication rate after elective liver resection without an increased risk of adverse effects.

Effect of rapid rehabilitation nursing on inflammation and liver function after laparoscopic radical resection of primary liver cancer

OBJECTIVE

To explore the effect of rapid rehabilitation nursing on inflammation and liver function in patients with primary liver cancer (PLC) after laparoscopic radical resection.

METHODS

A total of 124 PLC patients who underwent laparoscopic radical surgery in the Zhuji People's Hospital of Zhejiang Province from April 2019 to July 2021 were enrolled in this retrospective study. Among them, 65 patients who received rapid rehabilitation nursing were assigned into the observation group (OG), and the other 59 with routine nursing were considered to be the control group (CG). The pain before operation (T0), 3 days after operation (T1) and 7 days after operation (T2) was evaluated by visual analogue scale (VAS). The perioperative related indexes and nursing satisfaction were compared. The levels of liver function indexes alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and inflammatory factors C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured before operation, 1 day and 7 days after operation. Finally, the incidence of postoperative complications was counted, the 6-month survival rate of both groups of patients was compared.

RESULTS

There was no obvious difference in VAS scores between the two groups at T0 (P>0.050), but the VAS scores at T1 and T2 in the OG were lower than those in the CG (P<0.001). There was no marked difference in the total operation time. Compared with the CG, the time to first exhaust, catheter indwelling and hospitalization in the OG were shorter (P<0.001) and the nursing satisfaction rate was higher (P<0.05). There was no obvious difference in ALT, AST and TBIL on the 1st day after operation (P>0.05); however, on the 7th day after operation, ALT and AST were lower while TBIL was higher in the OG (all P<0.05). There was no marked difference in CRP, IL-6 and TNF-α between the two groups on postoperative day 1 (P>0.05), but the levels were lower in the OG than those in the CG on postoperative day 7 (all P<0.05), and the total incidence of adverse reactions in the OG was lower (P<0.05). There was no statistical difference in the postoperative survival rate between both groups of patients (P>0.05). Age, number of lesions, tumor size, Child-Pugh grade, AST, TBIL, CRP, IL-6, TNF-α were associated with the survival rate of patients.

CONCLUSION

Rapid rehabilitation nursing can effectively reduce adverse reactions after laparoscopic radical resection of PLC. Thus, it has a high application value in future clinical treatment.

Current evidence on posthepatectomy liver failure: comprehensive review

INTRODUCTION

Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF.

METHODS

A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022.

RESULTS

Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited.

DISCUSSION

Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.

Impact of high-dose glucocorticoid on endothelial damage after liver resection - a double-blinded randomized substudy

OBJECTIVES

Postoperative endothelial damage potentially results in increased vascular leakage, tissue edema and subsequent complications. The preventive effect of glucocorticoids on endothelial damage after surgery is sparsely described, including the relation between endothelial damage and the postoperative inflammatory response. Thus, we aimed to assess the preventive effect of high-dose glucocorticoids on postoperative endothelial damage, and the association between endothelial damage and inflammation after surgery.

METHODS

This was a predefined substudy of a randomized double-blinded clinical trial of methylprednisolone 10 mg/kg (high dose) vs. dexamethasone 8 mg (low dose) in patients undergoing liver resection at Rigshospitalet, Copenhagen. In total 25 patients undergoing major liver resection (11 in the high-dose group and 14 in the low-dose group) were included. The primary outcome was changed in five endothelial biomarkers and the secondary outcome was changes in inflammation [C-reactive protein (CRP)] for the first three postoperative days.

RESULTS

No statistically significant difference was found for any endothelial biomarkers postoperatively between the two groups (P &gt; 0.15, for all). High-dose glucocorticoids significantly reduced CRP on day 3 compared to low-dose glucocorticoids [median difference on a postoperative day 3, 59.6 g/L, (84.2; 27.1), P &lt; 0.002]. No significant correlation between endothelial damage and CRP levels was seen.

CONCLUSIONS

No significant effect of high- vs. low-dose glucocorticoids on development in endothelial biomarkers after major liver resection was observed. High-dose glucocorticoids reduce the inflammatory response though without correlation to endothelial damage. Future studies should assess the clinical impact of increased endothelial biomarkers for clinical perioperative outcomes.

Impact of high-dose glucocorticoid on endothelial damage after liver resection - a double-blinded randomized substudy

OBJECTIVES

Postoperative endothelial damage potentially results in increased vascular leakage, tissue edema and subsequent complications. The preventive effect of glucocorticoids on endothelial damage after surgery is sparsely described, including the relation between endothelial damage and the postoperative inflammatory response. Thus, we aimed to assess the preventive effect of high-dose glucocorticoids on postoperative endothelial damage, and the association between endothelial damage and inflammation after surgery.

METHODS

This was a predefined substudy of a randomized double-blinded clinical trial of methylprednisolone 10 mg/kg (high dose) vs. dexamethasone 8 mg (low dose) in patients undergoing liver resection at Rigshospitalet, Copenhagen. In total 25 patients undergoing major liver resection (11 in the high-dose group and 14 in the low-dose group) were included. The primary outcome was changed in five endothelial biomarkers and the secondary outcome was changes in inflammation [C-reactive protein (CRP)] for the first three postoperative days.

RESULTS

No statistically significant difference was found for any endothelial biomarkers postoperatively between the two groups (P > 0.15, for all). High-dose glucocorticoids significantly reduced CRP on day 3 compared to low-dose glucocorticoids [median difference on a postoperative day 3, 59.6 g/L, (84.2; 27.1), P < 0.002]. No significant correlation between endothelial damage and CRP levels was seen.

CONCLUSIONS

No significant effect of high- vs. low-dose glucocorticoids on development in endothelial biomarkers after major liver resection was observed. High-dose glucocorticoids reduce the inflammatory response though without correlation to endothelial damage. Future studies should assess the clinical impact of increased endothelial biomarkers for clinical perioperative outcomes.

High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double-blinded randomized clinical trial substudy

BACKGROUND

Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of pre-operative high- versus low-dose glucocorticoid on the occurrence of ED and POD.

METHODS

This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward.

RESULTS

Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group.

CONCLUSIONS

The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.