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Lester W, Bent C, Alikhan R, Roberts L, Gordon-Walker T, Trenfield S, White R, Forde C, Arachchillage DJ. A British Society for Haematology guideline on the assessment and management of bleeding risk prior to invasive procedures. Br J Haematol 2024; 204:1697-1713. [PMID: 38517351 DOI: 10.1111/bjh.19360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Will Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Clare Bent
- Department of Radiology, University Hospitals Dorset, Dorset, UK
| | - Raza Alikhan
- Department of Haematology, University Hospitals of Cardiff, Cardiff, UK
| | - Lara Roberts
- Department of Haematology, King College London, London, UK
| | - Tim Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sarah Trenfield
- Department of Anaesthesia and Critical Care, Royal Brompton Hospital, London, UK
| | - Richard White
- Department of Radiology, Cardiff and Vale UHB, Cardiff, UK
| | - Colm Forde
- Department of Radiology, University Hospitals Birmingham, Birmingham, UK
| | - Deepa J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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Neuberger J, Patel J, Caldwell H, Davies S, Hebditch V, Hollywood C, Hubscher S, Karkhanis S, Lester W, Roslund N, West R, Wyatt JI, Heydtmann M. Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology. Gut 2020; 69:1382-1403. [PMID: 32467090 PMCID: PMC7398479 DOI: 10.1136/gutjnl-2020-321299] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several approaches to liver biopsy but predominantly percutaneous or transvenous approaches are used. A wide choice of needles is available and the approach and type of needle used will depend on the clinical state of the patient and local expertise but, for non-lesional biopsies, a 16-gauge needle is recommended. Many patients with liver disease will have abnormal laboratory coagulation tests or receive anticoagulation or antiplatelet medication. A greater understanding of the changes in haemostasis in liver disease allows for a more rational, evidence-based approach to peri-biopsy management. Overall, liver biopsy is safe but there is a small morbidity and a very small mortality so patients must be fully counselled. The specimen must be of sufficient size for histopathological interpretation. Communication with the histopathologist, with access to relevant clinical information and the results of other investigations, is essential for the generation of a clinically useful report.
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Affiliation(s)
- James Neuberger
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jai Patel
- Department of Vascular Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Helen Caldwell
- Liver Unit, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Susan Davies
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Coral Hollywood
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Stefan Hubscher
- Department of Pathology, University of Birmingham, Birmingham, UK
| | - Salil Karkhanis
- Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - Judith I Wyatt
- Department of Pathology, St James University Hospital, Leeds, UK
| | - Mathis Heydtmann
- Department of Gastroenterology, Royal Alexandra Hospital, Glasgow, UK
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Characterization of the immune cell landscape of patients with NAFLD. PLoS One 2020; 15:e0230307. [PMID: 32168345 PMCID: PMC7069622 DOI: 10.1371/journal.pone.0230307] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple factors are involved in the pathogenesis of non-alcoholic fatty liver disease (NAFLD), but the exact immunological mechanisms that cause inflammation and fibrosis of the liver remain enigmatic. In this current study, cellular samples of a cohort of NAFLD patients (peripheral blood mononuclear cells (PBMC): n = 27, liver samples: n = 15) and healthy individuals (PBMC: n = 26, liver samples: n = 3) were analyzed using 16-color flow cytometry, and the frequency and phenotype of 23 immune cell subtypes was assessed. PBMC of NAFLD patients showed decreased frequencies of total CD3+, CD8+ T cells, CD56dim NK cells and MAIT cells, but elevated frequencies of CD4+ T cells and Th2 cells compared to healthy controls. Intrahepatic lymphocytes (IHL) of NAFLD patients showed decreased frequencies of total T cells, total CD8+ T cells, Vd2+γδ T cells, and CD56bright NK cells, but elevated frequencies of Vδ2-γδ T cells and CD56dim NK cells compared to healthy controls. The activating receptor NKG2D was significantly less frequently expressed among iNKT cells, total NK cells and CD56dim NK cells of PBMC of NAFLD patients compared to healthy controls. More strikingly, hepatic fibrosis as measured by fibroscan elastography negatively correlated with the intrahepatic frequency of total NK cells (r2 = 0,3737, p = 0,02). Hepatic steatosis as measured by controlled attenuation parameter (CAP) value negatively correlated with the frequency of circulating NKG2D+ iNKT cells (r2 = 0,3365, p = 0,0047). Our data provide an overview of the circulating and intrahepatic immune cell composition of NAFLD patients, and point towards a potential role of NK cells and iNKT cells for the regulation of hepatic fibrosis and steatosis in NAFLD.
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Keller S, Aigner A, Zenouzi R, Kim AC, Meijer A, Weidemann SA, Krech T, Lohse AW, Adam G, Schramm C, Yamamura J. Association of gadolinium-enhanced magnetic resonance imaging with hepatic fibrosis and inflammation in primary sclerosing cholangitis. PLoS One 2018. [PMID: 29513767 PMCID: PMC5841815 DOI: 10.1371/journal.pone.0193929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate magnetic resonance imaging (MRI) parameters T2 signal, contrast enhancement (CE), and relative liver enhancement (RLE) of extracellular gadolinium-based contrast agent (GBCA)-enhanced MRI as a marker for hepatic fibrosis and inflammation in patients with primary sclerosing cholangitis (PSC). Methods 3.0-Tesla MRI scans and liver biopsies of 40 patients (41.2 ± 17.1 years) were retrospectively reviewed. Biopsies were obtained within a mean time of 54 ± 55 days to MRI scans and specimens were categorized according to Ishak modified hepatic activity index (mHAI) and Scheuer staging of fibrosis. T2 signal (N = 40), CE alterations (N = 29), and RLE (N = 29) were assessed by two raters. Mixed-effects regression models were applied to estimate the association between histopathology and MRI parameters. Results No significant association was observed between T2 signal or CE alterations with stages of fibrosis or mHAI grading. Regression models revealed significant positive associations of portal venous phase RLE with mHAI grade ≥ 7 points [β = 25.5; 95% CI (2.53; 48.62); p = 0.04] and delayed phase RLE with stages of fibrosis [stage 2: β = 35.13; 95% CI (11.35; 58.87); p = 0.007; stage 3/4: β = 69.24; 95% CI (45.77; 92.75); p < 0.001]. The optimal cut-off value of 66.6% delayed phase RLE distinguished fibrosis stages 0–2 from 3–4 with a sensitivity of 0.833 and specificity of 0.972. Inter-rater reliability (IRR) for quantification of RLE was ‘excellent’ (r = 0.90–0.98). IRR was ‘substantial’ for detection of T2 signal in the right liver lobe (RL) (Kappa = 0.77) and ‘almost perfect’ for T2 signal of the left liver lobe (LL) and CE of both lobes (Kappa = 0.87–1.0). Conclusion The simple and reproducible method of RLE quantification on standard extracellular GBCA-enhanced MRI may provide a correlate measure of advanced stages of hepatic fibrosis and potentially also inflammation in PSC patients, if validated in larger cohorts.
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Affiliation(s)
- Sarah Keller
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- * E-mail:
| | - Annette Aigner
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Roman Zenouzi
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Anne C. Kim
- Department Stroke and Neurovascular Imaging, The Permanente Medical Group, San Francisco, California, United States of America
| | - Arnoud Meijer
- Department of Radiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Sören A. Weidemann
- Institute of Pathology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Till Krech
- Institute of Pathology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Ansgar W. Lohse
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Jin Yamamura
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Ehlken H, Wroblewski R, Corpechot C, Arrivé L, Rieger T, Hartl J, Lezius S, Hübener P, Schulze K, Zenouzi R, Sebode M, Peiseler M, Denzer UW, Quaas A, Weiler-Normann C, Lohse AW, Chazouilleres O, Schramm C. Validation of Transient Elastography and Comparison with Spleen Length Measurement for Staging of Fibrosis and Clinical Prognosis in Primary Sclerosing Cholangitis. PLoS One 2016; 11:e0164224. [PMID: 27723798 PMCID: PMC5056739 DOI: 10.1371/journal.pone.0164224] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/21/2016] [Indexed: 12/15/2022] Open
Abstract
Background Patients with primary sclerosing cholangitis (PSC) develop progressive liver fibrosis and end-stage liver disease. Non-invasive and widely available parameters are urgently needed to assess disease stage and the risk of clinical progression. Transient elastography (TE) has been reported to predict fibrosis stage and disease progression. However, these results have not been confirmed in an independent cohort and comparison of TE measurement to other non-invasive means is missing. Methods In a retrospective study we collected data from consecutive PSC patients receiving TE measurements from 2006 to 2014 (n = 139). Data from 62 patients who also underwent a liver biopsy were used to assess the performance of TE and spleen length (SL) measurement for the staging of liver fibrosis. Follow-up data from this cohort (n = 130, Hamburg) and another independent cohort (n = 80, Paris) was used to compare TE and SL as predictors of clinical outcome applying Harrel’s C calculations. Results TE measurement had a very good performance for the diagnosis and exclusion of higher fibrosis stages (≥F3: AUROC 0.95) and an excellent performance for the diagnosis and exclusion of cirrhosis (F4 vs. < F4: AUROC 0.98). Single-point TE measurement had very similar predictive power for patient outcome as previously published. In a combined cohort of PSC patients (n = 210), SL measurements had a similar performance as TE for the prediction of patient outcome (5 x cross-validated Harrel’s C 0.76 and 0.72 for SL and TE, respectively). Conclusions Baseline TE measurement has an excellent performance to diagnose higher fibrosis stages in PSC. Baseline measurements of SL and TE have similar usefulness as predictive markers for disease progression in patients with PSC.
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Affiliation(s)
- Hanno Ehlken
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.,Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Raluca Wroblewski
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Christophe Corpechot
- Service d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, Assistance Publique, Hôpitaux de Paris, Faculté de Médecine et Université Pierre et Marie Curie, site Saint-Antoine, Paris, France
| | - Lionel Arrivé
- Service de Radiologie, Hôpital Saint-Antoine, Assistance Publique, Hôpitaux de Paris, Faculté de Médecine et Université Pierre et Marie Curie, site Saint-Antoine, Paris, France
| | - Tim Rieger
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Johannes Hartl
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Susanne Lezius
- Department of Medical Biometry and Epidemiology, Martinistr. 52, 20246 Hamburg, Germany
| | - Peter Hübener
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Kornelius Schulze
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Roman Zenouzi
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Marcial Sebode
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Moritz Peiseler
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Ulrike W Denzer
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Alexander Quaas
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Christina Weiler-Normann
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Ansgar W Lohse
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Olivier Chazouilleres
- Service d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, Assistance Publique, Hôpitaux de Paris, Faculté de Médecine et Université Pierre et Marie Curie, site Saint-Antoine, Paris, France
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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Micro-laparoscopic colectomy: initial experience. J Gastrointest Surg 2015; 19:344-9. [PMID: 25385072 DOI: 10.1007/s11605-014-2689-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 10/22/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Single-port surgery (SPS) has been growing in acceptance as an alternative to traditional laparoscopic surgery. With SPS, there are technical skills required that are not routine to standard laparoscopy. We explored the feasibility of micro-laparoscopic colectomy (MLC) using 3 mm instruments in patients eligible for standard laparoscopic surgery. METHODS We performed an IRB approved retrospective review of all segmental colectomy performed by a single surgeon in selected patients using a micro-laparoscopic technique. We utilized two 3-mm trocars and one 12-mm Hasson umbilical incision, which was later widen for specimen extraction. RESULTS Eighty patients underwent MLC: Twenty-six for diverticulitis, 26 for cancer, 22 for polyps, 3 for Crohn's disease, and 3 for volvulus. Eight patients were converted into either laparotomy or hand port (10 %) and three patients required the addition of one 5-mm trocar. Mean final extraction incision length was 3.9 cm. In cancer patients, the average lymph node harvest was 26 (range 13-70). The 30-day mortality was zero and the anastomotic leak rate was 1.3 %. CONCLUSIONS MLC is safe and feasible when performing colon resections for benign and oncologic pathology. Extraction incision length is small and offers similar cosmesis to SPS without the steep learning curve needed to learn this technique.
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Hilgard P, Dechene A, Canbay A, Herzer K, Schlaak JF, Treichel U, Gassel AM, Baba H, Zoepf T. Mini-laparoscopy is superior in detecting liver cirrhosis and metastases in liver cancer: an over 10-year experience in 1,788 cases. Digestion 2014; 89:156-64. [PMID: 24577116 DOI: 10.1159/000354829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/02/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Mini-laparoscopy has, since its first description in 1998, proven to be a valuable diagnostic method in liver diseases. We re-evaluated the significance of mini-laparoscopy for diagnosis and staging of liver disease and primary liver and bile duct cancer. PATIENTS AND METHODS 1,788 consecutive patients who received a diagnostic mini-laparoscopy between 10/1998 and 06/2011 were included in this retrospective cohort study. RESULTS In chronic liver disease, cirrhosis was detected by mini-laparoscopy in 27% of cases. A comparison of microscopic versus macroscopic diagnosis of cirrhosis revealed a sampling error for histology alone of 21%. Macroscopic inspection of the liver surface contributed to the diagnosis of unknown liver diseases in approximately 38%. In patients with bile duct or liver cancer, mini-laparoscopy led to upstaging of the disease in 33 and 23%, respectively. Major complications (bowel perforation and delayed bleeding) occurred in 0.39% of cases. CONCLUSIONS Mini-laparoscopy is a valuable procedure with significant diagnostic impact in known and unknown inflammatory and malignant liver diseases. It can be safely performed even in patients with acute liver failure and severe coagulopathy and the diagnostic value does not differ from diagnostic laparoscopy performed with standard instruments.
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Affiliation(s)
- Philip Hilgard
- Department for Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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Tannapfel A, Dienes, Lohse. In reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:60. [PMID: 23413393 PMCID: PMC3570959 DOI: 10.3238/arztebl.2013.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Dienes
- **Institut für Pathologie, Köln
| | - Lohse
- ***I. Medizinische Klinik und Poliklinik, UKE Hamburg
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