Lactate: the Black Peter in high-risk gastrointestinal surgery patients

Severe Intra- and Post-Operative Lactic Acidosis in a Patient Who Underwent Robotic Thoracoscopic Surgery

Background/Objectives: Lactic acidosis is one of the most common causes of metabolic acidosis in hospitalized patients. It happens when lactic acid production exceeds lactic acid clearance. The elevation of lactate was commonly improved after the restoration of tissue perfusion. However, there are rare cases of severe lactate elevation (greater than 8 mmol/L) in the intraoperative period of thoracoscopic surgery. A poor prognosis with high morbidity and mortality characterizes these cases. Case Description: A 72-year-old man was admitted to the Soroka University Medical Center for thoracoscopic robotic left upper lobe lobectomy due to squamous cell carcinoma. At the end of surgery (overall, 8.5 h), the lactate level reached 10.2 mmol/L with the development of severe lactic metabolic acidosis. Thiamine was successfully given to patients to stimulate lactate clearance towards the cycle of tricarboxylic acids via pyruvate. Conclusions: Though the pathogenesis of this state in our case is not fully clear, it may have been induced by chemotherapy and during tumor manipulation by a surgeon. The successful recovery of blood lactic levels after thiamine treatment is suggestive of thiamine deficiency as a possible cause of lactic acidosis in our patient. Although we do not have data on the plasma thiamine level, we suggest that its determination in the perioperative period would be beneficial for excluding a probable thiamine deficiency in the case of severe lactic acidosis.

Elevated lactate impairs the efficacy of antiviral treatment on post-hepatectomy survival for advanced stage hepatitis B virus - related hepatocellular carcinoma

BACKGROUND

Nucleoside and nucleotide analogues (NAs) have a risk of mitochondrial toxicity and then inducing the increase of lactate. We aim to evaluate the impact of lactate on the effects of NAs therapy in hepatitis B virus-related hepatocellular carcinoma (HCC) patients after curative liver resection.

MATERIALS AND METHODS

Five hundred and fifty-seven HBV-related HCC patients were divided into the treatment and control group according to whether they received NAs therapy or not. Perioperative and prognosis data were retrospectively reviewed.

RESULTS

The treatment group had a better overall survival rate (OS) than the control group (P = 0.017). The recurrence-free survival rate (RFS) did not significantly differ between the two groups (P = 0.174). NAs could improve the OS of early stage HCC patients (P = 0.028), as well as the OS of advanced stage HCC patients with low level of lactate in subgroup analysis stratified against the level of lactate (P = 0.037). Advanced stage HCC patients in the treatment group had a higher value of lactate than those in the control group (P = 0.024). Besides, advanced stage HCC patients had a higher value of lactate than early stage HCC patients in the treatment group (P < 0.001), as well as in the control group (P < 0.001).

CONCLUSIONS

NAs could improve the long-term outcomes of HBV-related HCC patients after curative liver resection. However, the improvement effect of NAs therapy is counteracted by the adverse effect of elevated lactate in advanced stage HBV-related HCC patients.