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Rajagopalan A, Aroori S, Russell TB, Labib PL, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Croagh D. Five-year recurrence/survival after pancreatoduodenectomy for pancreatic adenocarcinoma: does pre-existing diabetes matter? Results from the Recurrence After Whipple's (RAW) study. HPB (Oxford) 2024:S1365-182X(24)01276-0. [PMID: 38755085 DOI: 10.1016/j.hpb.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/27/2024] [Accepted: 04/19/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Diabetes mellitus (DM) has a complex relationship with pancreatic cancer. This study examines the impact of preoperative DM, both recent-onset and pre-existing, on long-term outcomes following pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). METHODS Data were extracted from the Recurrence After Whipple's (RAW) study, a multi-centre cohort of PD for pancreatic head malignancy (2012-2015). Recurrence and five-year survival rates of patients with DM were compared to those without, and subgroup analysis performed to compare patients with recent-onset DM (less than one year) to patients with established DM. RESULTS Out of 758 patients included, 187 (24.7%) had DM, of whom, 47 of the 187 (25.1%) had recent-onset DM. There was no difference in the rate of postoperative pancreatic fistula (DM: 5.9% vs no DM 9.8%; p = 0.11), five-year survival (DM: 24.1% vs no DM: 22.9%; p = 0.77) or five-year recurrence (DM: 71.7% vs no DM: 67.4%; p = 0.32). There was also no difference between patients with recent-onset DM and patients with established DM in postoperative outcomes, recurrence, or survival. CONCLUSION We found no difference in five-year recurrence and survival between diabetic patients and those without diabetes. Patients with pre-existing DM should be evaluated for PD on a comparable basis to non-diabetic patients.
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Affiliation(s)
| | | | | | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Labib PL, Russell TB, Denson JL, Puckett MA, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Bhogal RH, Marangoni G, Thomasset SC, Frampton AE, Spalding DR, Lykoudis P, Bellotti R, Alhaboob N, Srinivasan P, Bari H, Smith A, Dominguez-Rosado I, Croagh D, Thakkar RG, Gomez D, Silva MA, Lapolla P, Mingoli A, Davidson BR, Porcu A, Shah NS, Hamady ZZ, Al-Sarireh BA, Serrablo A, Aroori S. Patterns, timing and predictors of recurrence following pancreaticoduodenectomy for distal cholangiocarcinoma: An international multicentre retrospective cohort study. Eur J Surg Oncol 2024; 50:108353. [PMID: 38701690 DOI: 10.1016/j.ejso.2024.108353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/21/2024] [Accepted: 04/16/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION Patients undergoing pancreaticoduodenectomy for distal cholangiocarcinoma (dCCA) often develop cancer recurrence. Establishing timing, patterns and risk factors for recurrence may help inform surveillance protocol strategies or select patients who could benefit from additional systemic or locoregional therapies. This multicentre retrospective cohort study aimed to determine timing, patterns, and predictive factors of recurrence following pancreaticoduodenectomy for dCCA. MATERIALS AND METHODS Patients who underwent pancreaticoduodenectomy for dCCA between June 2012 and May 2015 with five years of follow-up were included. The primary outcome was recurrence pattern (none, local-only, distant-only or mixed local/distant). Data were collected on comorbidities, investigations, operation details, complications, histology, adjuvant and palliative therapies, recurrence-free and overall survival. Univariable tests and regression analyses investigated factors associated with recurrence. RESULTS In the cohort of 198 patients, 129 (65%) developed recurrence: 30 (15%) developed local-only recurrence, 44 (22%) developed distant-only recurrence and 55 (28%) developed mixed pattern recurrence. The most common recurrence sites were local (49%), liver (24%) and lung (11%). 94% of patients who developed recurrence did so within three years of surgery. Predictors of recurrence on univariable analysis were cancer stage, R1 resection, lymph node metastases, perineural invasion, microvascular invasion and lymphatic invasion. Predictors of recurrence on multivariable analysis were female sex, venous resection, advancing histological stage and lymphatic invasion. CONCLUSION Two thirds of patients have cancer recurrence following pancreaticoduodenectomy for dCCA, and most recur within three years of surgery. The commonest sites of recurrence are the pancreatic bed, liver and lung. Multiple histological features are associated with recurrence.
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Affiliation(s)
- Peter Lz Labib
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Thomas B Russell
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Jemimah L Denson
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Mark A Puckett
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ambareen Kausar
- East Lancashire Hospital NHS Trust, Blackburn, United Kingdom
| | - Vasileios K Mavroeidis
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom; The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Ricky H Bhogal
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Gabriele Marangoni
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | | | - Adam E Frampton
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | - Pavlos Lykoudis
- Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | | | | | - Parthi Srinivasan
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | - Andrew Smith
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | | | - Rohan G Thakkar
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Andrea Mingoli
- Policlinico Umberto I Sapienza University of Rome, Rome, Italy
| | | | - Alberto Porcu
- Cliniche San Pietro, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Zaed Z Hamady
- University Hospital Southampton Foundation Trust, Southampton, United Kingdom
| | | | | | - Somaiah Aroori
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom; University of Plymouth, Plymouth, United Kingdom.
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3
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Malik AK, Davidson BR, Manas DM. Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma. Eur J Surg Oncol 2024:108248. [PMID: 38467524 DOI: 10.1016/j.ejso.2024.108248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.
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Affiliation(s)
- Abdullah K Malik
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK.
| | - Brian R Davidson
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK; NHS Blood and Transplant, Bristol, UK
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Halle-Smith JM, Pathak S, Frampton A, Pandanaboyana S, Sutcliffe RP, Davidson BR, Smith AM, Roberts KJ. Current postoperative nutritional practice after pancreatoduodenectomy in the UK: national survey and snapshot audit. BJS Open 2024; 8:zrae021. [PMID: 38513279 PMCID: PMC10957164 DOI: 10.1093/bjsopen/zrae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/10/2023] [Accepted: 11/18/2023] [Indexed: 03/23/2024] Open
Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Samir Pathak
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Adam Frampton
- Department of Hepato-Pancreato-Biliary Surgery, Royal Surrey County Hospital, Guildford, UK
| | - Sanjay Pandanaboyana
- Hepatobiliary and Pancreatic Surgery Unit, Newcastle Upon Tyne Teaching Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Brian R Davidson
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free London NHS Foundation Trust, London, UK
- Department of Surgical Innovation, Organ Regeneration and Transplant, University College London, London, UK
| | - Andrew M Smith
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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5
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Russell TB, Labib PL, Murphy P, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Aroori S. Do some patients receive unnecessary parenteral nutrition after pancreatoduodenectomy? Results from an international multicentre study. Ann Hepatobiliary Pancreat Surg 2024; 28:70-79. [PMID: 38092429 PMCID: PMC10896679 DOI: 10.14701/ahbps.23-071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 02/21/2024] Open
Abstract
Backgrounds/Aims After pancreatoduodenectomy (PD), an early oral diet is recommended; however, the postoperative nutritional management of PD patients is known to be highly variable, with some centers still routinely providing parenteral nutrition (PN). Some patients who receive PN experience clinically significant complications, underscoring its judicious use. Using a large cohort, this study aimed to determine the proportion of PD patients who received postoperative nutritional support (NS), describe the nature of this support, and investigate whether receiving PN correlated with adverse perioperative outcomes. Methods Data were extracted from the Recurrence After Whipple's study, a retrospective multicenter study of PD outcomes. Results In total, 1,323 patients (89%) had data on their postoperative NS status available. Of these, 45% received postoperative NS, which was "enteral only," "parenteral only," and "enteral and parenteral" in 44%, 35%, and 21% of cases, respectively. Body mass index < 18.5 kg/m2 (p = 0.03), absence of preoperative biliary stenting (p = 0.009), and serum albumin < 36 g/L (p = 0.009) all correlated with receiving postoperative NS. Among those who did not develop a serious postoperative complication, i.e., those who had a relatively uneventful recovery, 20% received PN. Conclusions A considerable number of patients who had an uneventful recovery received PN. PN is not without risk, and should be reserved for those who are unable to take an oral diet. PD patients should undergo pre- and postoperative assessment by nutrition professionals to ensure they are managed appropriately, and to optimize perioperative outcomes.
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Affiliation(s)
- Thomas B. Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Peter L. Labib
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Paula Murphy
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Fabio Ausania
- Department of HPB Surgery, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Keith J. Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ambareen Kausar
- Department of HPB Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Vasileios K. Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gabriele Marangoni
- Department of HPB Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Adam E. Frampton
- Department of HPB Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Pavlos Lykoudis
- Department of HPB Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Manuel Maglione
- Department of HPB Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nassir Alhaboob
- Department of HPB Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | - Hassaan Bari
- Department of HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | - Andrew M. Smith
- Department of HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Spalding
- Department of HPB Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Parthi Srinivasan
- Department of HPB Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Brian R. Davidson
- Department of HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ricky H. Bhogal
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Croagh
- Department of HPB Surgery, Monash Medical Centre, Melbourne, Australia
| | - Ismael Dominguez
- Department of HPB Surgery, Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Department of HPB Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Department of HPB Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A. Silva
- Department of HPB Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Pierfrancesco Lapolla
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Andrea Mingoli
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Department of HPB Surgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S. Shah
- Department of HPB Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z. R. Hamady
- Department of HPB Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bilal Al-Sarrieh
- Department of HPB Surgery, Swansea Bay University Health Board, Swansea, UK
| | - Alejandro Serrablo
- Department of HPB Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Rushbrook SM, Kendall TJ, Zen Y, Albazaz R, Manoharan P, Pereira SP, Sturgess R, Davidson BR, Malik HZ, Manas D, Heaton N, Prasad KR, Bridgewater J, Valle JW, Goody R, Hawkins M, Prentice W, Morement H, Walmsley M, Khan SA. British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma. Gut 2023; 73:16-46. [PMID: 37770126 PMCID: PMC10715509 DOI: 10.1136/gutjnl-2023-330029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Abstract
These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.
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Affiliation(s)
- Simon M Rushbrook
- Department of Hepatology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | - Timothy James Kendall
- Division of Pathology, University of Edinburgh, Edinburgh, UK
- University of Edinburgh MRC Centre for Inflammation Research, Edinburgh, UK
| | - Yoh Zen
- Department of Pathology, King's College London, London, UK
| | - Raneem Albazaz
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Richard Sturgess
- Digestive Diseases Unit, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Brian R Davidson
- Department of Surgery, Royal Free Campus, UCL Medical School, London, UK
| | - Hassan Z Malik
- Department of Surgery, University Hospital Aintree, Liverpool, UK
| | - Derek Manas
- Department of Surgery, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Nigel Heaton
- Department of Hepatobiliary and Pancreatic Surgery, King's College London, London, UK
| | - K Raj Prasad
- John Goligher Colorectal Unit, St. James University Hospital, Leeds, UK
| | - John Bridgewater
- Department of Oncology, UCL Cancer Institute, University College London, London, UK
| | - Juan W Valle
- Department of Medical Oncology, The Christie NHS Foundation Trust/University of Manchester, Manchester, UK
| | - Rebecca Goody
- Department of Oncology, St James's University Hospital, Leeds, UK
| | - Maria Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Wendy Prentice
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Shahid A Khan
- Hepatology and Gastroenterology Section, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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7
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Russell TB, Labib PL, Denson J, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Rajagopalan A, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Perra T, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Aroori S. Does an extensive diagnostic workup for upfront resectable pancreatic cancer result in a delay which affects survival? Results from an international multicentre study. Ann Hepatobiliary Pancreat Surg 2023; 27:403-414. [PMID: 37661767 DOI: 10.14701/ahbps.23-042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 09/05/2023] Open
Abstract
Backgrounds/Aims Pancreatoduodenectomy (PD) is recommended in fit patients with a carcinoma (PDAC) of the pancreatic head, and a delayed resection may affect survival. This study aimed to correlate the time from staging to PD with long-term survival, and study the impact of preoperative investigations (if any) on the timing of surgery. Methods Data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD outcomes. Only PDAC patients who underwent an upfront resection were included. Patients who received neoadjuvant chemo-/radiotherapy were excluded. Group A (PD within 28 days of most recent preoperative computed tomography [CT]) was compared to group B (> 28 days). Results A total of 595 patents were included. Compared to group A (median CT-PD time: 12.5 days, interquartile range: 6-21), group B (49 days, 39-64.5) had similar one-year survival (73% vs. 75%, p = 0.6), five-year survival (23% vs. 21%, p = 0.6) and median time-todeath (17 vs. 18 months, p = 0.8). Staging laparoscopy (43 vs. 29.5 days, p = 0.009) and preoperative biliary stenting (39 vs. 20 days, p < 0.001) were associated with a delay to PD, but magnetic resonance imaging (32 vs. 32 days, p = 0.5), positron emission tomography (40 vs. 31 days, p > 0.99) and endoscopic ultrasonography (28 vs. 32 days, p > 0.99) were not. Conclusions Although a treatment delay may give rise to patient anxiety, our findings would suggest this does not correlate with worse survival. A delay may be necessary to obtain further information and minimize the number of PD patients diagnosed with early disease recurrence.
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Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Peter L Labib
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jemimah Denson
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Fabio Ausania
- Department of HPB Surgery, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Keith J Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ambareen Kausar
- Department of HPB Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gabriele Marangoni
- Department of HPB Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Adam E Frampton
- Department of HPB Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Pavlos Lykoudis
- Department of HPB Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Manuel Maglione
- Department of HPB Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nassir Alhaboob
- Department of HPB Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | - Hassaan Bari
- Department of HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | - Andrew M Smith
- Department of HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Spalding
- Department of HPB Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Parthi Srinivasan
- Department of HPB Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Brian R Davidson
- Department of HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ricky H Bhogal
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Croagh
- Department of HPB Surgery, Monash Medical Centre, Melbourne, Australia
| | | | - Ismael Dominguez
- Department of HPB Surgery, Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Department of HPB Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Department of HPB Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Department of HPB Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Pierfrancesco Lapolla
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Andrea Mingoli
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Department of HPB Surgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Teresa Perra
- Department of HPB Surgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Department of HPB Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- Department of HPB Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bilal Al-Sarrieh
- Department of HPB Surgery, Swansea Bay University Health Board, Swansea, UK
| | - Alejandro Serrablo
- Department of HPB Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Russell TB, Labib PL, Denson J, Streeter A, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh BA, Serrablo A, Aroori S. Postoperative complications after pancreatoduodenectomy for malignancy: results from the Recurrence After Whipple's (RAW) study. BJS Open 2023; 7:zrad106. [PMID: 38036696 PMCID: PMC10689345 DOI: 10.1093/bjsopen/zrad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 08/04/2023] [Accepted: 08/27/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is associated with significant postoperative morbidity. Surgeons should have a sound understanding of the potential complications for consenting and benchmarking purposes. Furthermore, preoperative identification of high-risk patients can guide patient selection and potentially allow for targeted prehabilitation and/or individualized treatment regimens. Using a large multicentre cohort, this study aimed to calculate the incidence of all PD complications and identify risk factors. METHOD Data were extracted from the Recurrence After Whipple's (RAW) study, a retrospective cohort study of PD outcomes (29 centres from 8 countries, 2012-2015). The incidence and severity of all complications was recorded and potential risk factors for morbidity, major morbidity (Clavien-Dindo grade > IIIa), postoperative pancreatic fistula (POPF), post-pancreatectomy haemorrhage (PPH) and 90-day mortality were investigated. RESULTS Among the 1348 included patients, overall morbidity, major morbidity, POPF, PPH and perioperative death affected 53 per cent (n = 720), 17 per cent (n = 228), 8 per cent (n = 108), 6 per cent (n = 84) and 4 per cent (n = 53), respectively. Following multivariable tests, a high BMI (P = 0.007), an ASA grade > II (P < 0.0001) and a classic Whipple approach (P = 0.005) were all associated with increased overall morbidity. In addition, ASA grade > II patients were at increased risk of major morbidity (P < 0.0001), and a raised BMI correlated with a greater risk of POPF (P = 0.001). CONCLUSION In this multicentre study of PD outcomes, an ASA grade > II was a risk factor for major morbidity and a high BMI was a risk factor for POPF. Patients who are preoperatively identified to be high risk may benefit from targeted prehabilitation or individualized treatment regimens.
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Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Peter L Labib
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jemimah Denson
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Adam Streeter
- Department of Medical Statistics, University of Muenster, Muenster, Germany
- Department of Medical Statistics, University of Plymouth, Plymouth, UK
| | - Fabio Ausania
- Department of HPB Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elizabeth Pando
- Department of HPB Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Keith J Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ambareen Kausar
- Department of HPB Surgery, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Gabriele Marangoni
- Department of HPB Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Adam E Frampton
- Department of HPB Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Pavlos Lykoudis
- Department of HPB Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Manuel Maglione
- Department of HPB Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Nassir Alhaboob
- Department of HPB Surgery, Ibn Sina Specialized Hospital, Khartoum, Sudan
| | - Hassaan Bari
- Department of HPB Surgery, Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | - Andrew M Smith
- Department of HPB Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Duncan Spalding
- Department of HPB Surgery, Imperial College Healthcare NHS Trust, London, UK
| | - Parthi Srinivasan
- Department of HPB Surgery, King’s College Hospital NHS Foundation Trust, London, UK
| | - Brian R Davidson
- Department of HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Ricky H Bhogal
- Department of HPB Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Croagh
- Department of HPB Surgery, Monash Medical Centre, Melbourne, Australia
| | - Ismael Dominguez
- Department of HPB Surgery, Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Department of HPB Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Department of HPB Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Department of HPB Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Pierfrancesco Lapolla
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Andrea Mingoli
- Department of HPB Surgery, Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Department of HPB Surgery, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Department of HPB Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- Department of HPB Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bilal A Al-Sarrieh
- Department of HPB Surgery, Swansea Bay University Health Board, Swansea, UK
| | - Alejandro Serrablo
- Department of HPB Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
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9
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Staubli SM, Raptis DA, Ghani S, Davidson BR, Fusai GK, Imber C, Iype S, Nasralla D, Pissanou T, Rahman S, Sharma D, Tinguely P, Haddad F, Dodd M, Dann C, Walker D, Pollok JM. Author Correction: Management of patients at the hepatopancreatobiliary unit of a London teaching hospital during the COVID-19 pandemic. Sci Rep 2023; 13:17549. [PMID: 37845246 PMCID: PMC10579231 DOI: 10.1038/s41598-023-44594-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Affiliation(s)
- Sebastian M Staubli
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Dimitri A Raptis
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Shahi Ghani
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Brian R Davidson
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Giuseppe K Fusai
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Charles Imber
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Sateesh Iype
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - David Nasralla
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Theodora Pissanou
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Sakhawat Rahman
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Dinesh Sharma
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Pascale Tinguely
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Fares Haddad
- Division of Surgery and Interventional Science, University College London, London, UK
- The Princess Grace Hospital (HCA Healthcare UK), London, UK
- Institute for Sport Exercise and Health (ISEH), University College Hospital London, London, UK
- Department of Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, London, UK
| | - Miranda Dodd
- The Princess Grace Hospital (HCA Healthcare UK), London, UK
| | - Chris Dann
- Department of Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, London, UK
| | - David Walker
- Division of Surgery and Interventional Science, University College London, London, UK
- The Princess Grace Hospital (HCA Healthcare UK), London, UK
| | - Joerg-Matthias Pollok
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK.
- Division of Surgery and Interventional Science, University College London, London, UK.
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10
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Russell TB, Labib PL, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Aroori S. Serious complications of pancreatoduodenectomy correlate with lower rates of adjuvant chemotherapy: Results from the recurrence after Whipple's (RAW) study. Eur J Surg Oncol 2023; 49:106919. [PMID: 37330348 DOI: 10.1016/j.ejso.2023.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/29/2023] [Accepted: 04/24/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Adjuvant chemotherapy (AC) can prolong overall survival (OS) after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). However, fitness for AC may be influenced by postoperative recovery. We aimed to investigate if serious (Clavien-Dindo grade ≥ IIIa) postoperative complications affected AC rates, disease recurrence and OS. MATERIALS AND METHODS Data were extracted from the Recurrence After Whipple's (RAW) study (n = 1484), a retrospective study of PD outcomes (29 centres from eight countries). Patients who died within 90-days of PD were excluded. The Kaplan-Meier method was used to compare OS in those receiving or not receiving AC, and those with and without serious postoperative complications. The groups were then compared using univariable and multivariable tests. RESULTS Patients who commenced AC (vs no AC) had improved OS (median difference: (MD): 201 days), as did those who completed their planned course of AC (MD: 291 days, p < 0.0001). Those who commenced AC were younger (mean difference: 2.7 years, p = 0.0002), more often (preoperative) American Society of Anesthesiologists (ASA) grade I-II (74% vs 63%, p = 0.004) and had less often experienced a serious postoperative complication (10% vs 18%, p = 0.002). Patients who developed a serious postoperative complication were less often ASA grade I-II (52% vs 73%, p = 0.0004) and less often commenced AC (58% vs 74%, p = 0.002). CONCLUSION In our multicentre study of PD outcomes, PDAC patients who received AC had improved OS, and those who experienced a serious postoperative complication commenced AC less frequently. Selected high-risk patients may benefit from targeted preoperative optimisation and/or neoadjuvant chemotherapy.
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Affiliation(s)
- Thomas B Russell
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK
| | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vasileios K Mavroeidis
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Somaiah Aroori
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK.
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11
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Staubli SM, Raptis DA, Ghani S, Davidson BR, Fusai GK, Imber C, Iype S, Nasralla D, Pissanou T, Rahman S, Sharma D, Tinguely P, Haddad F, Dodd M, Dann C, Walker D, Pollok JM. Management of patients at the hepatopancreatobiliary unit of a London teaching hospital during the COVID-19 pandemic. Sci Rep 2023; 13:13432. [PMID: 37596332 PMCID: PMC10439108 DOI: 10.1038/s41598-023-40264-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023] Open
Abstract
To mitigate COVID-19-related shortage of treatment capacity, the hepatopancreatobiliary (HPB) unit of the Royal Free Hospital London (RFHL) transferred its practice to independent hospitals in Central London through the North Central London Cancer Alliance. The aim of this study was to critically assess this strategy and evaluate perioperative outcomes. Prospectively collected data were reviewed on all patients who were treated under the RFHL HPB unit in six hospitals between November 2020 and October 2021. A total of 1541 patients were included, as follows: 1246 (81%) at the RFHL, 41 (3%) at the Chase Farm Hospital, 23 (2%) at the Whittington Hospital, 207 (13%) at the Princess Grace Hospital, 12 (1%) at the Wellington Hospital and 12 (1%) at the Lister Hospital, Chelsea. Across all institutions, overall complication rate were 40%, major complication (Clavien-Dindo grade ≥ 3a) rate were 11% and mortality rates were 1.4%, respectively. In COVID-19-positive patients (n = 28), compared with negative patients, complication rate and mortality rates were increased tenfold. Outsourcing HPB patients, including their specialist care, to surrounding institutions was safe and ensured ongoing treatment with comparable outcomes among the institutions during the COVID-19 pandemic. Due to the lack of direct comparison with a non-pandemic cohort, these results can strictly only be applied within a pandemic setting.
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Affiliation(s)
- Sebastian M Staubli
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Dimitri A Raptis
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Shahi Ghani
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Brian R Davidson
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Giuseppe K Fusai
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Charles Imber
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Sateesh Iype
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - David Nasralla
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Theodora Pissanou
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Sakhawat Rahman
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Dinesh Sharma
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Pascale Tinguely
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK
| | - Fares Haddad
- Division of Surgery and Interventional Science, University College London, London, UK
- The Princess Grace Hospital (HCA Healthcare UK), London, UK
- Institute for Sport Exercise and Health (ISEH), University College Hospital London, London, UK
- Department of Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, London, UK
| | - Miranda Dodd
- The Princess Grace Hospital (HCA Healthcare UK), London, UK
| | - Chris Dann
- Department of Trauma and Orthopaedics, University College London Hospitals NHS Foundation Trust, London, London, UK
| | - David Walker
- Division of Surgery and Interventional Science, University College London, London, UK
- The Princess Grace Hospital (HCA Healthcare UK), London, UK
| | - Joerg-Matthias Pollok
- Department of HPB Surgery and Liver Transplantation, Clinical Service of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, UCL Partners, Pond Street, London, NW3 2QG, UK.
- Division of Surgery and Interventional Science, University College London, London, UK.
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12
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Rai ZL, Magbagbeola M, Doyle K, Lindenroth L, Dwyer G, Gander A, Stilli A, Stoyanov D, Davidson BR. Ex Vivo Perfusion of Porcine Pancreas and Liver Sourced from Commercial Abattoirs after Circulatory Death as a Research Resource: A Methodological Study. Methods Protoc 2023; 6:66. [PMID: 37489433 PMCID: PMC10366747 DOI: 10.3390/mps6040066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 07/04/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Machine perfusion (MP) is increasingly used for human transplant organ preservation. The use of MP for research purposes is another opportunity for this technology. The porcine pancreas and liver are similar in anatomical size and function to their human counterparts, making them an excellent resource for research, but they have some important differences from human organs which can influence their research use. In this paper, we describe a technique developed and tested for the retrieval of porcine organs for use in research on perfused viable organs. METHODS Whole-organ porcine pancreata and livers were harvested at a commercial abattoir, following standard slaughterhouse processes. The standard slaughterhouse process involved a thoracotomy and mid-line laparotomy, and all the thoracoabdominal organs were removed. The pancreas, fixed in the retroperitoneum, was carefully dissected from its attachments to the surrounding structures, and tissue planes between the pancreas, spleen, duodenum, and colon were meticulously identified and dissected. Vessel exposure and division: The aorta, portal vein (PV), hepatic vein (HV), and hepatic artery (HA) were dissected and isolated, preserving the input and output channels for the liver and pancreas. A distal 3 cm of the aorta was preserved and divided and served as the input for the pancreas perfusions. The liver, PV, HV, and HA were preserved and divided to preserve the physiological channels of the input (PV and HA) and output (HV) for the liver perfusions. The porcine hepatic and pancreas anatomy shares significant resemblance with the gross anatomy found in humans, and this was taken into consideration when designing the perfusion circuitry. The porcine pancreas and spleen shared a common blood supply, with branches arising from the splenic artery. The organs were flushed with cold, heparinised normal saline and transported in a temperature-regulated receptacle maintained at a core temperature between 4 and 8 °C, in line with the standards of static cold storage (SCS), to a dedicated perfusion lab and perfused using our novel perfusion machine with autologous, heparinised porcine blood, also collected at the abattoir.
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Affiliation(s)
- Zainab L Rai
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
- Centre for Surgical Innovation, Organ Repair and Transplantation (CSIORT), University College London, London NW3 2PS, UK
- Department of HPB & Liver Transplantation Surgery, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Morenike Magbagbeola
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
| | - Katie Doyle
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
| | - Lukas Lindenroth
- Department of Surgical & Interventional Engineering, School of Biomedical Engineering & Imaging Sciences, King's College, London SE1 1UL, UK
| | - George Dwyer
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
| | - Amir Gander
- Centre for Surgical Innovation, Organ Repair and Transplantation (CSIORT), University College London, London NW3 2PS, UK
- Department of HPB & Liver Transplantation Surgery, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
| | - Agostino Stilli
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
| | - Brian R Davidson
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London W1W 7TY, UK
- Centre for Surgical Innovation, Organ Repair and Transplantation (CSIORT), University College London, London NW3 2PS, UK
- Department of HPB & Liver Transplantation Surgery, Royal Free London NHS Foundation Trust, Pond Street, London NW3 2QG, UK
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13
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Doyle K, Magbagbeola M, Rai ZL, Waterhouse D, Lindenroth L, Dwyer G, Gander A, Stilli A, Davidson BR, Stoyanov D. The Application of Machine Perfusion as an Enhanced ex vivo Model for Optical Imaging. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-7. [PMID: 38083568 DOI: 10.1109/embc40787.2023.10341091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Optical imaging techniques such as spectral imaging show promise for the assessment of tissue health during surgery; however, the validation and translation of such techniques into clinical practise is limited by the lack of representative tissue models. In this paper, we demonstrate the application of an organ perfusion machine as an ex vivo tissue model for optical imaging. Three porcine livers are perfused at stepped blood oxygen saturations. Over the duration of each perfusion, spectral data of the tissue are captured via diffuse optical spectroscopy and multispectral imaging. These data are synchronised with blood oxygen saturation measurements recorded by the perfusion machine. Shifts in the optical properties of the tissue are demonstrated over the duration of the each perfusion, as the tissue becomes reperfused and as the oxygen saturation is varied.
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14
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Kosti A, Borakati A, Varma A, Gupta A, Mustafa A, Hakeem A, Quddus A, Sahl AB, Beniwal A, Adesuyi A, Krzak AM, Brooks A, Frampton A, Gadhvi A, Talbot A, Elnogoomi A, Mahgoub A, Naqvi A, Pervez A, Bodla AS, Taha A, Tawfik A, Prabhu A, Puri A, Belgaumkar A, Gupta A, McCrorie A, Findlay A, Healey A, De Prendergast A, Farrugia A, Dosis A, Adiamah A, Sallam A, Wong A, Bradley A, Martin A, Collins A, Awan A, Bond A, Koh A, Kourdouli A, Patel AG, Dhannoon A, Khalil A, Banerjee A, Khan A, Elserafy A, Alamassi A, Owen A, Benjafield A, Zuccarrelli A, Luhmann A, Jones A, Kennedy-Dalby A, Smith AM, Kaul A, Kumar A, White A, Baker A, Minicozzi A, Bardoli A, Golpe AL, Manzelli A, Sivakumar A, Saha A, Shajpal A, Lango A, Cotton A, Nair A, Brown A, Menon A, Tandon A, Afza A, Hassan A, Shamali A, Khalid A, Regan A, Piramanayagam B, Oyewole B, Ibrahim B, Murphy B, Clayton B, Jenkins B, Kumar B, Rybinski B, Khor BY, Davidson BR, Lees B, Blacklock C, Johnstone C, Salinas CH, Boven C, Wolstenholme C, Chin C, Gilmore C, Sharp C, Walker C, Harris C, Khanna C, Ferguson C, Kyriakides C, Bee C, Currow C, Parmar C, Collins C, Halloran C, Smart CJ, Neophytou C, Delaney C, Anele C, Heugh C, Choh CTP, Kenington C, Wyatt C, Borg CM, Mole D, Arumugam D, Gunia D, Porter D, Berry D, Griffith D, Hou D, Longbotham D, Mitton D, Strachan D, Di Mauro D, Worku D, Heaphy D, Dunne D, Yeung D, Arambepola D, Leswas DA, Pournaras DJ, Damaskos D, Saleh D, Osilli D, Pearman D, Whitelaw D, Haq EU, Mack E, Spurring E, Jamieson E, Lenzi E, Gemmill E, Gammeri E, Bota E, Britton E, Farrow E, Lloyd E, Moran E, Itobi E, Craig E, Tanaka E, Chohda E, Muhammad FU, Youssef F, Roslan F, Amir F, Froghi F, Di Franco F, Abbadessa F, DiMaggio F, Gurung G, Faulkner G, Choa G, Kerans G, Davis GN, Galanopoulos G, Karagiannidis G, McCabe G, Mohammadi-Zaniani G, Nawaz G, Van Boxel G, Bond-Smith G, Tierney GM, Muthukumarasamy G, Grey G, Wong G, Finch G, Khan H, Bourne H, Javanmard-Emamghissi H, Murray H, Rottenburg H, Wright H, Khalil H, Spiers HVM, Bashiti H, Shanti H, Ebied H, Ng HJ, Hamid HKS, Kim H, Wilson I, Rajendran I, Gerogiannis I, Patel I, El-Abbassy I, Burridge I, Caldwll J, Jackman J, Clark J, Duncan J, Milburn J, O’Kelly J, Olivier J, Rink J, Royle J, Rai J, Latif J, Ahmad J, Maliyil J, Carr J, Coles J, McGarry J, Apollos J, Lim J, Gray J, Thomas J, Bennett J, Findlay J, Spearman J, Young J, Lund JN, Meilak J, Alfred J, Welsh J, Chan JH, Martin J, Patel K, Ko KYK, Isand K, Razi K, Sarathy K, Powezka K, Foster K, Peleki K, Bevan K, Fox K, Edwards K, Larsen K, Spellar K, Oh KE, Kong K, Brown K, Roberts KJ, Seymour K, Beatson K, Etherson K, Willis K, Mann K, Nizami K, Rajput K, Lavery L, Sawdon L, Nip L, Al-Hamed L, Fagan L, Watton L, Saint-Grant AL, Convie L, Girard LP, Huppler L, Marsh L, Seretny L, Newton L, Buksh M, Sallam M, Mathew M, Prasanth MN, Nayar M, Wijeyaratne M, Hollyman M, Ransome M, Popa M, Galea M, Taylor M, Gismondi M, Michel M, Wadley M, Al-Azzawi M, Claxton M, Kuzman M, Bonomaully M, Newman M, Bhandari M, Courtney M, Jones M, Rarity M, Wilson M, Ebraheem M, Elnaghi M, Mohamed MSN, Al-Hijaji M, Al-Rashedy M, Qayum MK, Zourob M, Gaber M, Rao M, Islam MA, Rashid MU, Zafar M, Naqvi M, Ahmad MN, Telfah M, Merali N, Hanbali N, Gulnaz N, Kumar N, Husain N, Angamuthu N, Murali N, Kirmani N, Assaf N, Doshi N, Shah NS, Basra N, Menezes N, Dai N, Schuijtvlot N, Kansal N, Chidumije N, Yassin N, Babalola O, Oyende O, Williams O, Pawlik O, O'Connor O, Jalil OA, Ryska O, Vaz O, Sarmah P, Jayawardena P, Patel P, Hart P, Cromwell P, Manby P, Marriott P, Needham P, Ghaneh P, Rao PKD, Eves P, Coe PO, May-Miller P, Szatmary P, Ireland P, Seta P, Ravi P, Janardhanan P, Patil P, Mistry P, Heer P, Patel P, Nunes Q, Ain Q, Clifford R, Brindle R, Lee RXN, Lim RQH, Rahman R, Kumar RM, Lunevicius R, Mukherjee R, Lahiri R, Behmida R, Rajebhosale R, Levy R, Chhabra R, Oliphant R, Freeman R, Jones RM, Elkalbash R, Brignall R, Bell R, Byrom R, Laing RW, Patel R, Buhain R, Clark R, Sutton R, Presa R, Lawther R, Patel R, Zakeri R, Mashar R, Wei R, Baron R, Tasleem S, Kadambot SS, Azam S, Wajed S, Ali S, Body S, Saeed S, Bandyopadhyay S, Mohamed S, Pandanaboyana S, Hassasing S, Dyer S, Small S, Seeralakandapalan S, Arumugam S, Chakravartty S, Ong SL, Ooi SZY, Nazir S, Zafar S, Shirazi S, Bharucha S, Majid S, Ahmed S, Rajamanickam SK, Albalkiny S, Ng S, Chowdhury S, Yahia S, Handa S, Fallis S, Fisher S, Jones S, Phillips S, Mitra S, Aroori S, Thanki S, Rozwadowski S, Tucker S, Conroy S, Barman S, Bhat S, McCallion S, Knight SR, Tezas S, van Laarhoven S, Cowie S, Rao S, Sellahewa S, Bhatti S, Kaistha S, Moug SJ, Argyropoulos S, Virupaksha S, Difford T, Shikh-Bahaei T, Saafan T, Lo T, Magro T, Gala T, Katbeh T, Athwal T, Lo T, Fraser T, Anyomih T, Chase TJG, Walker T, Ward T, Gallagher TK, Richardson T, Wiggins T, Ali U, Patnam V, Kanakala V, Beynon V, Hudson VE, Morrison-Jones V, Korwar V, Massella V, Parekh V, Ng V, Toh WH, Toh W, Hawkins W, Cambridge W, Harrison W, Tan YY, Aal YA, Malam Y, Toumi Z, Khaddar ZA, Bleything Z. PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK. BJS Open 2023; 7:zrad008. [PMID: 37161673 PMCID: PMC10170253 DOI: 10.1093/bjsopen/zrad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/01/2022] [Accepted: 01/04/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. METHODS All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. RESULTS A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. CONCLUSION Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.
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Dowrick T, Xiao G, Nikitichev D, Dursun E, van Berkel N, Allam M, Koo B, Ramalhinho J, Thompson S, Gurusamy K, Blandford A, Stoyanov D, Davidson BR, Clarkson MJ. Evaluation of a calibration rig for stereo laparoscopes. Med Phys 2023; 50:2695-2704. [PMID: 36779419 PMCID: PMC10614700 DOI: 10.1002/mp.16310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Accurate camera and hand-eye calibration are essential to ensure high-quality results in image-guided surgery applications. The process must also be able to be undertaken by a nonexpert user in a surgical setting. PURPOSE This work seeks to identify a suitable method for tracked stereo laparoscope calibration within theater. METHODS A custom calibration rig, to enable rapid calibration in a surgical setting, was designed. The rig was compared against freehand calibration. Stereo reprojection, stereo reconstruction, tracked stereo reprojection, and tracked stereo reconstruction error metrics were used to evaluate calibration quality. RESULTS Use of the calibration rig reduced mean errors: reprojection (1.47 mm [SD 0.13] vs. 3.14 mm [SD 2.11], p-value 1e-8), reconstruction (1.37 px [SD 0.10] vs. 10.10 px [SD 4.54], p-value 6e-7), and tracked reconstruction (1.38 mm [SD 0.10] vs. 12.64 mm [SD 4.34], p-value 1e-6) compared with freehand calibration. The use of a ChArUco pattern yielded slightly lower reprojection errors, while a dot grid produced lower reconstruction errors and was more robust under strong global illumination. CONCLUSION The use of the calibration rig results in a statistically significant decrease in calibration error metrics, versus freehand calibration, and represents the preferred approach for use in the operating theater.
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Affiliation(s)
- Thomas Dowrick
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Guofang Xiao
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Daniil Nikitichev
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Eren Dursun
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Niels van Berkel
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Moustafa Allam
- Royal Free CampusUCL Medical SchoolRoyal Free HospitalLondonUK
| | - Bongjin Koo
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Joao Ramalhinho
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Stephen Thompson
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | | | - Ann Blandford
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
| | - Danail Stoyanov
- Wellcome EPSRC Centre for Interventional and Surgical SciencesUCLLondonUK
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16
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Magbagbeola M, Rai ZL, Doyle K, Lindenroth L, Dwyer G, Gander A, Stilli A, Davidson BR, Stoyanov D. An adaptable research platform for ex vivo normothermic machine perfusion of the liver. Int J Comput Assist Radiol Surg 2023:10.1007/s11548-023-02903-4. [PMID: 37095316 DOI: 10.1007/s11548-023-02903-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/31/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE This paper presents an assessment of a low-cost organ perfusion machine designed for use in research settings. The machine is modular and versatile in nature, built on a robotic operating system (ROS2) pipeline allowing for the addition of specific sensors for different research applications. Here we present the system and the development stages to achieve viability of the perfused organ. METHODS The machine's perfusion efficacy was assessed by monitoring the distribution of perfusate in livers using methylene blue dye. Functionality was evaluated by measuring bile production after 90 min of normothermic perfusion, while viability was examined using aspartate transaminase assays to monitor cell damage throughout the perfusion. Additionally, the output of the pressure, flow, temperature, and oxygen sensors was monitored and recorded to track the health of the organ during perfusion and assess the system's capability of maintaining the quality of data over time. RESULTS The results show the system is capable of successfully perfusing porcine livers for up to three hours. Functionality and viability assessments show no deterioration of liver cells once normothermic perfusion had occurred and bile production was within normal limits of approximately 26 ml in 90 min showing viability. CONCLUSION The developed low-cost perfusion system presented here has been shown to keep porcine livers viable and functional ex vivo. Additionally, the system is capable of easily incorporating several sensors into its framework and simultaneously monitor and record them during perfusion. The work promotes further exploration of the system in different research domains.
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Affiliation(s)
- M Magbagbeola
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK.
| | - Z L Rai
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Centre for Surgical Innovation, Organ Repair and Transplantation (CSIORT), UCL, London, UK
- Royal Free Hospital NHS Trust, London, UK
| | - K Doyle
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - L Lindenroth
- Department of Surgical and Interventional Engineering, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - G Dwyer
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - A Gander
- Centre for Surgical Innovation, Organ Repair and Transplantation (CSIORT), UCL, London, UK
- Royal Free Hospital NHS Trust, London, UK
| | - A Stilli
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | - B R Davidson
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Centre for Surgical Innovation, Organ Repair and Transplantation (CSIORT), UCL, London, UK
- Royal Free Hospital NHS Trust, London, UK
| | - D Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
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17
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Russell TB, Labib PL, Denson J, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Aroori S. Predictors of actual five-year survival and recurrence after pancreatoduodenectomy for ampullary adenocarcinoma: results from an international multicentre retrospective cohort study. HPB (Oxford) 2023:S1365-182X(23)00096-5. [PMID: 37149485 DOI: 10.1016/j.hpb.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 03/15/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence/survival. METHODS Data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD patients with a confirmed head of pancreas or periampullary malignancy (June 1st, 2012-May 31st, 2015). Patients with AA who developed recurrence/died within five-years were compared to those who did not. RESULTS 394 patients were included and actual five-year survival was 54%. Recurrence affected 45% and the median time-to-recurrence was 14 months. Local only, local and distant, and distant only recurrence affected 34, 41 and 94 patients, respectively (site unknown: 7). Among those with recurrence, the most common sites were the liver (32%), local lymph nodes (14%) and lung/pleura (13%). Following multivariable tests, number of resected nodes, histological T stage > II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin correlated with increased recurrence and reduced survival. Furthermore, ≥1 positive margin, PPFI and PNI were all associated with reduced time-to-recurrence. CONCLUSIONS This multicentre retrospective study of PD outcomes identified numerous histopathological predictors of AA recurrence. Patients with these high-risk features might benefit from adjuvant therapy.
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Affiliation(s)
- Thomas B Russell
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK
| | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK
| | | | | | - Elizabeth Pando
- Hospital Clinic de Barcelona, Barcelona, Spain; Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vasileios K Mavroeidis
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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18
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Kostakis ID, Raptis DA, Davidson BR, Iype S, Nasralla D, Imber C, Sharma D, Pissanou T, Pollok JM. Donor-Recipient Body Surface Area Mismatch and the Outcome of Liver Transplantation in the UK. Prog Transplant 2023; 33:61-68. [PMID: 36537056 DOI: 10.1177/15269248221145035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Too small or too big liver grafts for recipient's size has detrimental effects on transplant outcomes. Research Questions: The purpose was to correlate donor-recipient body surface area ratio or body surface area index with recipient survival, graft survival, hepatic artery or portal vein, or vena cava thrombosis. High and low body surface area index cut-off points were determined. Design: There were 11,245 adult recipients of first deceased donor whole liver-only grafts performed in the UK from January 2000 until June 2020. The transplants were grouped according to the body surface area index and compared to complications, graft and recipient survival. Results: The body surface area index ranged from 0.491 to 1.691 with a median of 0.988. The body surface area index > 1.3 was associated with a higher rate of portal vein thrombosis within the first 3 months (5.5%). This risk was higher than size-matched transplants (OR: 2.878, 95% CI: 1.292-6.409, P = 0.01). Overall graft survival was worse in transplants with body surface area index ≤ 0.85 (HR: 1.254, 95% CI: 1.051-1.497, P = 0.012) or body surface area index > 1.4 (HR: 3.704, 95% CI: 2.029-6.762, P < 0.001) than those with intermediate values. The graft survival rates were reduced by 2% for cases with body surface area index ≤ 0.85 but were decreased by 20% for cases with body surface area index > 1.4. These findings were confirmed by bootstrap internal validation. No statistically significant differences were detected for hepatic artery thrombosis, occlusion of hepatic veins/inferior vena cava or recipient survival. Conclusions: Donor-recipient size mismatch affects the rates of portal vein thrombosis within the first 3 months and overall graft survival in deceased-donor liver transplants.
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Affiliation(s)
- Ioannis D Kostakis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Dimitri Aristotle Raptis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Brian R Davidson
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Satheesh Iype
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - David Nasralla
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Charles Imber
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Dinesh Sharma
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Theodora Pissanou
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
| | - Joerg Matthias Pollok
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Royal Free Hospital, 4965Royal Free London NHS Foundation Trust, London, UK
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19
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Pallett LJ, Swadling L, Diniz M, Maini AA, Schwabenland M, Gasull AD, Davies J, Kucykowicz S, Skelton JK, Thomas N, Schmidt NM, Amin OE, Gill US, Stegmann KA, Burton AR, Stephenson E, Reynolds G, Whelan M, Sanchez J, de Maeyer R, Thakker C, Suveizdyte K, Uddin I, Ortega-Prieto AM, Grant C, Froghi F, Fusai G, Lens S, Pérez-Del-Pulgar S, Al-Akkad W, Mazza G, Noursadeghi M, Akbar A, Kennedy PTF, Davidson BR, Prinz M, Chain BM, Haniffa M, Gilroy DW, Dorner M, Bengsch B, Schurich A, Maini MK. Tissue CD14 +CD8 + T cells reprogrammed by myeloid cells and modulated by LPS. Nature 2023; 614:334-342. [PMID: 36697826 DOI: 10.1038/s41586-022-05645-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/12/2022] [Indexed: 01/26/2023]
Abstract
The liver is bathed in bacterial products, including lipopolysaccharide transported from the intestinal portal vasculature, but maintains a state of tolerance that is exploited by persistent pathogens and tumours1-4. The cellular basis mediating this tolerance, yet allowing a switch to immunity or immunopathology, needs to be better understood for successful immunotherapy of liver diseases. Here we show that a variable proportion of CD8+ T cells compartmentalized in the human liver co-stain for CD14 and other prototypic myeloid membrane proteins and are enriched in close proximity to CD14high myeloid cells in hepatic zone 2. CD14+CD8+ T cells preferentially accumulate within the donor pool in liver allografts, among hepatic virus-specific and tumour-infiltrating responses, and in cirrhotic ascites. CD14+CD8+ T cells exhibit increased turnover, activation and constitutive immunomodulatory features with high homeostatic IL-10 and IL-2 production ex vivo, and enhanced antiviral/anti-tumour effector function after TCR engagement. This CD14+CD8+ T cell profile can be recapitulated by the acquisition of membrane proteins-including the lipopolysaccharide receptor complex-from mononuclear phagocytes, resulting in augmented tumour killing by TCR-redirected T cells in vitro. CD14+CD8+ T cells express integrins and chemokine receptors that favour interactions with the local stroma, which can promote their induction through CXCL12. Lipopolysaccharide can also increase the frequency of CD14+CD8+ T cells in vitro and in vivo, and skew their function towards the production of chemotactic and regenerative cytokines. Thus, bacterial products in the gut-liver axis and tissue stromal factors can tune liver immunity by driving myeloid instruction of CD8+ T cells with immunomodulatory ability.
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Affiliation(s)
- Laura J Pallett
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK.
| | - Leo Swadling
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Mariana Diniz
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | | | | | | | - Jessica Davies
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Stephanie Kucykowicz
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | | | - Niclas Thomas
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Nathalie M Schmidt
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Oliver E Amin
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Upkar S Gill
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Kerstin A Stegmann
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Alice R Burton
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Emily Stephenson
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Gary Reynolds
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Matt Whelan
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Jenifer Sanchez
- School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Roel de Maeyer
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Clare Thakker
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Kornelija Suveizdyte
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Imran Uddin
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | | | | | - Farid Froghi
- Division of Surgery, University College London, London, UK
| | - Giuseppe Fusai
- Division of Surgery, University College London, London, UK
| | - Sabela Lens
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
- Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Sofia Pérez-Del-Pulgar
- Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Walid Al-Akkad
- Institute for Liver & Digestive Health, University College London, London, UK
| | - Giuseppe Mazza
- Institute for Liver & Digestive Health, University College London, London, UK
| | - Mahdad Noursadeghi
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Arne Akbar
- Division of Medicine, University College London, London, UK
| | - Patrick T F Kennedy
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Marco Prinz
- Institute of Neuropathology, University of Freiburg, Freiburg, Germany
- Center for Basics in NeuroModulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany
| | - Benjamin M Chain
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
- Department of Computer Science, University College London, London, UK
| | - Muzlifah Haniffa
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Derek W Gilroy
- Division of Medicine, University College London, London, UK
| | - Marcus Dorner
- Department of Medicine, Imperial College London, London, UK
| | - Bertram Bengsch
- Signalling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, Clinic for Internal Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Disease, University Medical Center Freiburg, Freiburg, Germany
| | - Anna Schurich
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
- School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Mala K Maini
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK.
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20
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Bell RJ, Hakeem AR, Pandanaboyana S, Davidson BR, Prasad RK, Dasari BVM. Portal vein embolization versus dual vein embolization for management of the future liver remnant in patients undergoing major hepatectomy: meta-analysis. BJS Open 2022; 6:6832521. [PMID: 36398754 PMCID: PMC9673134 DOI: 10.1093/bjsopen/zrac131] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/31/2022] [Accepted: 09/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background This meta-analysis aimed to compare progression to surgery, extent of liver hypertrophy, and postoperative outcomes in patients planned for major hepatectomy following either portal vein embolization (PVE) or dual vein embolization (DVE) for management of an inadequate future liver remnant (FLR). Methods An electronic search was performed of MEDLINE, Embase, and PubMed databases using both medical subject headings (MeSH) and truncated word searches. Articles comparing PVE with DVE up to January 2022 were included. Articles comparing sequential DVE were excluded. ORs, risk ratios, and mean difference (MD) were calculated using fixed and random-effects models for meta-analysis. Results Eight retrospective studies including 523 patients were included in the study. Baseline characteristics between the groups, specifically, age, sex, BMI, indication for resection, and baseline FLR (ml and per cent) were comparable. The percentage increase in hypertrophy was larger in the DVE group, 66 per cent in the DVE group versus 27 per cent in the PVE group, MD 39.07 (9.09, 69.05) (P = 0.010). Significantly fewer patients failed to progress to surgery in the DVE group than the PVE group, 13 per cent versus 25 per cent respectively OR 0.53 (0.31, 0.90) (P = 0.020). Rates of post-hepatectomy liver failure 13 per cent versus 22 per cent (P = 0.130) and major complications 20 per cent versus 28 per cent (Clavien–Dindo more than IIIa) (P = 0.280) were lower. Perioperative mortality was lower with DVE, 1 per cent versus 10 per cent (P = 0.010) Conclusion DVE seems to produce a greater degree of hypertrophy of the FLR than PVE alone which translates into more patients progressing to surgery. Higher quality studies are needed to confirm these results.
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Affiliation(s)
- Richard J Bell
- Department of Hepatobiliary and Transplant Surgery, St James’s University Hospital , Leeds , UK
| | - Abdul R Hakeem
- Department of Hepatobiliary and Transplant Surgery, St James’s University Hospital , Leeds , UK
| | - Sanjay Pandanaboyana
- Department of Hepato-Pancreato-Biliary (HPB) and Transplant Surgery, Freeman Hospital , Newcastle upon Tyne , UK
| | - Brian R Davidson
- Department of Hepato-Pancreato-Biliary (HPB) and Transplant Surgery, Royal Free Hospital , London , UK
| | - Raj K Prasad
- Department of Hepatobiliary and Transplant Surgery, St James’s University Hospital , Leeds , UK
| | - Bobby V M Dasari
- Department of Hepato-Pancreato-Biliary (HPB) and Transplant Surgery, University Hospital Birmingham , Birmingham , UK
- School of Medicine, University of Birmingham , Birmingham , UK
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21
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Shaker TM, Eason JD, Davidson BR, Barth RN, Pirenne J, Imventarza O, Spiro M, Raptis DA, Fung J. Which cava anastomotic techniques are optimal regarding immediate and short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14681. [PMID: 35567584 PMCID: PMC10078200 DOI: 10.1111/ctr.14681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND It has long been debated whether cava anastomosis should be performed with the piggyback technique or cava replacement, with or without veno-venous bypass (VVB), with or without temporary portocaval shunt (PCS) in the setting of liver transplantation. OBJECTIVES To identify whether different cava anastomotic techniques and other maneuvers benefit the recipient regarding short-term outcomes and to provide international expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021240979). RESULTS Of 3205 records screened, 307 publications underwent full-text assessment for eligibility and 47 were included in qualitative synthesis. Four studies were randomized control trials. Eighteen studies were comparative. The remaining 25 were single-center retrospective noncomparative studies. CONCLUSION Based on existing data and expert opinion, the panel cannot recommend one cava reconstruction technique over another, rather the surgical approach should be based on surgeon preference and center dependent, with special consideration toward patient circumstances (Quality of evidence: Low | Grade of Recommendation: Strong). The panel recommends against routine use of vevo-venous bypass (Quality of evidence: Very Low | Grade of Recommendation: Strong) and against the routine use of temporary porto-caval shunt (Quality of evidence: Very Low | Grade of Recommendation: Strong).
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Affiliation(s)
- Tamer M Shaker
- Division of Transplant, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - James D Eason
- James D. Eason Transplant Institute, University of Tennessee, Memphis, Tennessee, USA
| | - Brian R Davidson
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London, United Kingdom of Great Britain and Northern Ireland
| | - Rolf N Barth
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
| | - Jacques Pirenne
- Department of Microbiology, Immunology, and Transplantation, Lab of Abdominal Transplantation, Transplantation Research Group, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplantation Surgery and Coordination, University Hospitals of Leuven, Leuven, Belgium
| | - Oscar Imventarza
- Liver Transplant Unit, Hospital Argerich, Hospital Garrahan, Stalyc Representative, Buenos Aires, Argentina
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - John Fung
- Department of Surgery, Transplantation Institute, University of Chicago, Chicago, Illinois, USA
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22
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Beaton L, Tregidgo HFJ, Znati SA, Forsyth S, Counsell N, Clarkson MJ, Bandula S, Chouhan M, Lowe HL, Thin MZ, Hague J, Sharma D, Pollok JM, Davidson BR, Raja J, Munneke G, Stuckey DJ, Bascal ZA, Wilde PE, Cooper S, Ryan S, Czuczman P, Boucher E, Hartley JA, Atkinson D, Lewis AL, Jansen M, Meyer T, Sharma RA. Phase 0 Study of Vandetanib-Eluting Radiopaque Embolics as a Preoperative Embolization Treatment in Patients with Resectable Liver Malignancies. J Vasc Interv Radiol 2022; 33:1034-1044.e29. [PMID: 35526675 DOI: 10.1016/j.jvir.2022.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 04/03/2022] [Accepted: 04/21/2022] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To assess the safety and tolerability of a vandetanib-eluting radiopaque embolic (BTG-002814) for transarterial chemoembolization (TACE) in patients with resectable liver malignancies. MATERIALS AND METHODS The VEROnA clinical trial was a first-in-human, phase 0, single-arm, window-of-opportunity study. Eligible patients were aged ≥18 years and had resectable hepatocellular carcinoma (HCC) (Child-Pugh A) or metastatic colorectal cancer (mCRC). Patients received 1 mL of BTG-002814 transarterially (containing 100 mg of vandetanib) 7-21 days prior to surgery. The primary objectives were to establish the safety and tolerability of BTG-002814 and determine the concentrations of vandetanib and the N-desmethyl vandetanib metabolite in the plasma and resected liver after treatment. Biomarker studies included circulating proangiogenic factors, perfusion computed tomography, and dynamic contrast-enhanced magnetic resonance imaging. RESULTS Eight patients were enrolled: 2 with HCC and 6 with mCRC. There was 1 grade 3 adverse event (AE) before surgery and 18 after surgery; 6 AEs were deemed to be related to BTG-002814. Surgical resection was not delayed. Vandetanib was present in the plasma of all patients 12 days after treatment, with a mean maximum concentration of 24.3 ng/mL (standard deviation ± 13.94 ng/mL), and in resected liver tissue up to 32 days after treatment (441-404,000 ng/g). The median percentage of tumor necrosis was 92.5% (range, 5%-100%). There were no significant changes in perfusion imaging parameters after TACE. CONCLUSIONS BTG-002814 has an acceptable safety profile in patients before surgery. The presence of vandetanib in the tumor specimens up to 32 days after treatment suggests sustained anticancer activity, while the low vandetanib levels in the plasma suggest minimal release into the systemic circulation. Further evaluation of this TACE combination is warranted in dose-finding and efficacy studies.
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Affiliation(s)
- Laura Beaton
- University College London Cancer Institute, University College London, London, United Kingdom.
| | - Henry F J Tregidgo
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Sami A Znati
- University College London Cancer Institute, University College London, London, United Kingdom
| | - Sharon Forsyth
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom
| | - Nicholas Counsell
- Cancer Research UK and University College London Cancer Trials Centre, University College London, London, United Kingdom
| | - Matthew J Clarkson
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Steven Bandula
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Manil Chouhan
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Helen L Lowe
- University College London Experimental Cancer Medicine Centre Good Clinical Laboratory Practice Facility, University College London, London, United Kingdom
| | - May Zaw Thin
- Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
| | - Julian Hague
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Dinesh Sharma
- Division of Transplantation and Immunology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joerg-Matthias Pollok
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Hepatopancreatobiliary Surgery and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Hepatopancreatobiliary Surgery and Liver Transplantation, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Jowad Raja
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Graham Munneke
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Daniel J Stuckey
- Centre for Advanced Biomedical Imaging, University College London, London, United Kingdom
| | - Zainab A Bascal
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Paul E Wilde
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Sarah Cooper
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Samantha Ryan
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Peter Czuczman
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Eveline Boucher
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - John A Hartley
- University College London Cancer Institute, University College London, London, United Kingdom; University College London Experimental Cancer Medicine Centre Good Clinical Laboratory Practice Facility, University College London, London, United Kingdom
| | - David Atkinson
- University College London Centre for Medical Imaging, University College London, London, United Kingdom
| | - Andrew L Lewis
- Biocompatibles UK Ltd, Lakeview, Riverside Way, Watchmoor Park, Camberley, Surrey, United Kingdom
| | - Marnix Jansen
- University College London Cancer Institute, University College London, London, United Kingdom; University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Tim Meyer
- University College London Cancer Institute, University College London, London, United Kingdom; Department of Oncology, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Ricky A Sharma
- National Institute for Health Research University College London Hospitals Biomedical Centre, University College London Cancer Institute, London, United Kingdom
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23
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Bricogne C, Halliday N, Fernando R, Tsochatzis EA, Davidson BR, Harber M, Westbrook RH. Donor-recipient human leukocyte antigen A mismatching is associated with hepatic artery thrombosis, sepsis, graft loss, and reduced survival after liver transplant. Liver Transpl 2022; 28:1306-1320. [PMID: 35313059 PMCID: PMC9541857 DOI: 10.1002/lt.26458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 01/13/2023]
Abstract
Human leukocyte antigen (HLA) matching is not routinely performed for liver transplantation as there is no consistent evidence of benefit; however, the impact of HLA mismatching remains uncertain. We explored the effect of class I and II HLA mismatching on graft failure and mortality. A total of 1042 liver transplants performed at a single center between 1999 and 2016 with available HLA typing data were included. The median follow-up period was 9.38 years (interquartile range 4.9-14) and 350/1042 (33.6%) transplants resulted in graft loss and 280/1042 (26.9%) in death. Graft loss and mortality were not associated with the overall number of mismatches at HLA-A, HLA-B, HLA-C, HLA-DR, and HLA-DQ loci. However, graft failure and mortality were both increased in HLA mismatching on graft failure and mortality the presence of one (p = 0.004 and p = 0.01, respectively) and two (p = 0.01 and p = 0.04, respectively) HLA-A mismatches. Elevated hazard ratios for graft failure and death were observed with HLA-A mismatches in univariate and multivariate Cox proportional hazard models. Excess graft loss with HLA-A mismatch (138/940 [14.7%] mismatched compared with 6/102 [5.9%] matched transplants) occurred within the first year following transplantation (odds ratio 2.75; p = 0.02). Strikingly, transplants performed at a single all grafts lost due to hepatic artery thrombosis were in HLA-A-mismatched transplants (31/940 vs. 0/102), as were those lost due to sepsis (35/940 vs. 0/102). In conclusion, HLA-A mismatching was associated with increased graft loss and mortality. The poorer outcome for the HLA-mismatched group was due to hepatic artery thrombosis and sepsis, and these complications occurred exclusively with HLA-A-mismatched transplants. These data suggest that HLA-A mismatching is important for outcomes following liver transplant. Therefore, knowledge of HLA-A matching status may potentially allow for enhanced surveillance, clinical interventions in high-risk transplants or stratified HLA-A matching in high-risk recipients.
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Affiliation(s)
- Christopher Bricogne
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Neil Halliday
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Raymond Fernando
- The Anthony Nolan Research InstituteRoyal Free London NHS Foundation TrustLondonUK
| | - Emmanuel A. Tsochatzis
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Brian R. Davidson
- UCL Division of Surgery and Interventional SciencesRoyal Free HospitalLondonUK
| | - Mark Harber
- Kidney UnitRoyal Free London NHS Foundation TrustLondonUK
| | - Rachel H. Westbrook
- Sheila Sherlock Liver UnitRoyal Free London NHS Foundation Trust and Institute for Liver and Digestive HealthUniversity College LondonLondonUK
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24
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Wiggins BG, Pallett LJ, Li X, Davies SP, Amin OE, Gill US, Kucykowicz S, Patel AM, Aliazis K, Liu YS, Reynolds GM, Davidson BR, Gander A, Luong TV, Hirschfield GM, Kennedy PTF, Huang Y, Maini MK, Stamataki Z. The human liver microenvironment shapes the homing and function of CD4 + T-cell populations. Gut 2022; 71:1399-1411. [PMID: 34548339 PMCID: PMC9185819 DOI: 10.1136/gutjnl-2020-323771] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 08/19/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Tissue-resident memory T cells (TRM) are vital immune sentinels that provide protective immunity. While hepatic CD8+ TRM have been well described, little is known about the location, phenotype and function of CD4+ TRM. DESIGN We used multiparametric flow cytometry, histological assessment and novel human tissue coculture systems to interrogate the ex vivo phenotype, function and generation of the intrahepatic CD4+ T-cell compartment. We also used leukocytes isolated from human leukocyte antigen (HLA)-disparate liver allografts to assess long-term retention. RESULTS Hepatic CD4+ T cells were delineated into three distinct populations based on CD69 expression: CD69-, CD69INT and CD69HI. CD69HICD4+ cells were identified as tissue-resident CD4+ T cells on the basis of their exclusion from the circulation, phenotypical profile (CXCR6+CD49a+S1PR1-PD-1+) and long-term persistence within the pool of donor-derived leukcoocytes in HLA-disparate liver allografts. CD69HICD4+ T cells produced robust type 1 polyfunctional cytokine responses on stimulation. Conversely, CD69INTCD4+ T cells represented a more heterogenous population containing cells with a more activated phenotype, a distinct chemokine receptor profile (CX3CR1+CXCR3+CXCR1+) and a bias towards interleukin-4 production. While CD69INTCD4+ T cells could be found in the circulation and lymph nodes, these cells also formed part of the long-term resident pool, persisting in HLA-mismatched allografts. Notably, frequencies of CD69INTCD4+ T cells correlated with necroinflammatory scores in chronic hepatitis B infection. Finally, we demonstrated that interaction with hepatic epithelia was sufficient to generate CD69INTCD4+ T cells, while additional signals from the liver microenvironment were required to generate liver-resident CD69HICD4+ T cells. CONCLUSIONS High and intermediate CD69 expressions mark human hepatic CD4+ TRM and a novel functionally distinct recirculating population, respectively, both shaped by the liver microenvironment to achieve diverse immunosurveillance.
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Affiliation(s)
- Benjamin G Wiggins
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Immunity and Transplantation, Division of Infection and Immunity, University College London, London, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Laura J Pallett
- Institute of Immunity and Transplantation, Division of Infection and Immunity, University College London, London, UK
| | - Xiaoyan Li
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Infectious Diseases and Guangdong Provincial Key Laboratory of Liver Disease Research, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Scott P Davies
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Oliver E Amin
- Institute of Immunity and Transplantation, Division of Infection and Immunity, University College London, London, UK
| | | | - Stephanie Kucykowicz
- Institute of Immunity and Transplantation, Division of Infection and Immunity, University College London, London, UK
| | - Arzoo M Patel
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Konstantinos Aliazis
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Yuxin S Liu
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Gary M Reynolds
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | | | - Amir Gander
- Tissue Access for Patient Benefit, University College London, London, UK
| | - Tu Vinh Luong
- Department of Cellular Pathology, Royal Free Hospital, London, UK
| | - Gideon M Hirschfield
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- Centre for Liver Research, National Institute for Health Research Biomedical Research Unit, University of Birmingham, Birmingham, UK
| | | | - Yuehua Huang
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Liver Disease Research, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Mala K Maini
- Division of Infection and Immunity, Rayne Institute, University College London, London, UK
| | - Zania Stamataki
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
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25
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Magbagbeola M, Doyle K, Rai ZL, Lindenroth L, Dwyer G, Stilli A, Davidson BR, Stoyanov D. Evaluation of A Novel Organ Perfusion Research Platform. Annu Int Conf IEEE Eng Med Biol Soc 2022; 2022:2565-2568. [PMID: 36086012 DOI: 10.1109/embc48229.2022.9871028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This paper presents a novel, low cost, organ perfusion machine designed for use in research. The modular and versatile nature of the system allows for additional sensing equipment to be added or adapted for specific use. Here we introduce the system and present its preliminary evaluation by assessing its ability to maintain a predetermined input pressure. A proportional-integral-derivative (PID) controller was implemented and tested on a porcine liver to maintain input pressure to the hepatic artery and compared to bench tests. The results confirmed the effectiveness of the controller for maintaining input through the hepatic artery (HA) in a timely manner. Clinical Relevance-Machine Perfusion (MP) is proving to be an invaluable adjunct in clinical practice. With its ongoing success in the transplant arena, we propose MP for use in research. A cost-effective, versatile system that can be modified for specific research use to test new pharmacological therapies, imaging techniques or develop simulation training would be beneficial.
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26
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Rai ZL, Ranieri V, Palmer DH, Littler P, Ghaneh P, Gurusamy K, Manas D, Pizzo E, Psarelli EE, Gilmore R, Peddu P, Bartlett DC, de Liguori Carino N, Davidson BR. Treatment of unresectable locally advanced pancreatic cancer with percutaneous irreversible electroporation (IRE) following initial systemic chemotherapy (LAP-PIE) trial: study protocol for a feasibility randomised controlled trial. BMJ Open 2022; 12:e050166. [PMID: 35551086 PMCID: PMC9109032 DOI: 10.1136/bmjopen-2021-050166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 01/17/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Approximately 30% of patients with pancreas cancer have unresectable locally advanced disease, which is currently treated with systemic chemotherapy. A new treatment option of irreversible electroporation (IRE) has been investigated for these patients since 2005. Cohort studies suggest that IRE confers a survival advantage, but with associated, procedure-related complications. Selection bias may account for improved survival and there have been no prospective randomised trials evaluating the harms and benefits of therapy. The aim of this trial is to evaluate the feasibility of a randomised comparison of IRE therapy with chemotherapy versus chemotherapy alone in patients with locally advanced pancreatic cancer (LAPC). METHODS AND ANALYSIS Eligible patients with LAPC who have undergone first-line 5-FluoroUracil, Leucovorin, Irinotecan and Oxaliplatin chemotherapy will be randomised to receive either a single session of IRE followed by (if indicated) further chemotherapy or to chemotherapy alone (standard of care). Fifty patients from up to seven specialist pancreas centres in the UK will be recruited over a period of 15 months. Trial follow-up will be 12 months. The primary outcome measure is ability to recruit. Secondary objectives include practicality and technical success of treatment, acceptability of treatment to patients and clinicians and safety of treatment. A qualitative study has been incorporated to evaluate the patient and clinician perspective of the locally advanced pancreatic cancer with percutaneous irreversible electroporation trial. It is likely that the data obtained will guide the structure, the primary outcome measure, the power and the duration of a subsequent multicentre randomised controlled trial aimed at establishing the clinical efficiency of pancreas IRE therapy. Indicative procedure-related costings will be collected in this feasibility trial, which will inform the cost evaluation in the subsequent study on efficiency. ETHICS AND DISSEMINATION The protocol has received approval by London-Brent Research Ethics Committee reference number 21/LO/0077.Results will be analysed following completion of trial recruitment and follow-up. Results will be presented to international conferences with an interest in oncology, hepatopancreaticobiliary surgery and interventional radiology and be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN14986389.
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Affiliation(s)
- Zainab L Rai
- Division of Surgery and Interventional Science, University College London, London, UK
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Veronica Ranieri
- Research & Development, Tavistock and Portman NHS Foundation Trust, London, UK
- Science & Technology Studies, University College London, London, UK
| | - Daniel H Palmer
- Hepato-Pancreatco-Biliary Disease, University of Liverpool, Liverpool, Merseyside, UK
| | - Peter Littler
- Hepato-Pancreatico-Biliary Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Pauleh Ghaneh
- Hepato-Pancreatco-Biliary Disease, University of Liverpool, Liverpool, Merseyside, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Derek Manas
- Hepato-Pancreatico-Biliary Surgery, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Elena Pizzo
- Applied Health Research, University College London, London, UK
| | | | - Roopinder Gilmore
- Division of Surgery and Interventional Science, University College London, London, UK
- Oncology, Royal Free London NHS Foundation Trust, London, UK
| | - Praveen Peddu
- Department of Radiology, King's College Hospital NHS Trust, London, UK
| | - David C Bartlett
- Hepato-Pancreatico-Biliary Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
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Sims JM, Lawrence E, Glazer K, Gander A, Fuller B, Davidson BR, Garibaldi J, Quinlan PR. Lessons learned from the COVID-19 pandemic about sample access for research in the UK. BMJ Open 2022; 12:e047309. [PMID: 35428611 PMCID: PMC9013782 DOI: 10.1136/bmjopen-2020-047309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Annotated clinical samples taken from patients are a foundation of translational medical research and give mechanistic insight into drug trials. Prior research by the Tissue Directory and Coordination Centre (TDCC) indicated that researchers, particularly those in industry, face many barriers in accessing patient samples. The arrival of the COVID-19 pandemic to the UK produced an immediate and extreme shockwave, which impacted on the ability to undertake all crucial translational research. As a national coordination centre, the TDCC is tasked with improving efficiency in the biobanking sector. Thus, we took responsibility to identify and coordinate UK tissue sample collection organisations (biobanks) able to collect COVID-19-related samples for researchers between March and September 2020. FINDINGS Almost a third of UK biobanks were closed during the first wave of the UK COVID-19 pandemic. Of the remainder, 43% had limited capabilities while 26% maintained normal activity. Of the nationally prioritised COVID-19 interventional studies, just three of the five that responded to questioning were collecting human samples. Of the 41 requests for COVID-19 samples received by the TDCC, only four could be fulfilled due to a lack of UK coordinated strategy. Meanwhile, in the background there are numerous reports that sample collections in the UK remain largely underutilised. CONCLUSION The response to a pandemic demands high level co-ordinated research responses to reduce mortality. Our study highlights the lack of efficiency and coordination between human sample collections and clinical trials across the UK. UK sample access is not working for researchers, clinicians or patients. A radical change is required in the strategy for sample collection and distribution to maximise this valuable resource of human-donated samples.
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Affiliation(s)
- Jessica M Sims
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emma Lawrence
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Katy Glazer
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Amir Gander
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Barry Fuller
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
- HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan Garibaldi
- School of Computer Science, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Philip R Quinlan
- Digital Health, School of Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
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Borakati A, Froghi F, Shetye A, Fusai GK, Davidson BR, Mirnezami R. Assessing the Impact of Primary Tumour Location on Survival After Resection of Colorectal Liver Metastases: A Propensity Weighted Retrospective Cohort Study. World J Surg 2022; 46:1734-1755. [PMID: 35325347 DOI: 10.1007/s00268-022-06514-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Right-sided colonic tumours appear to have poorer survival after resection of colorectal liver metastases, although this may be confounded by various factors including advanced stage and emergency presentation. METHODS Medical records of consecutive patients undergoing resection of colorectal liver metastases at a single centre from 2008 to 2015 were retrospectively reviewed. Cases were categorised by primary tumour location (right colon, left colon, rectum). Each primary location was weighted using propensity scores to balance covariates, including staging and mode of presentation. Cox regression was then applied to derive multivariable hazard ratios (HR) of survival after liver resection. Primary outcomes were 10-year overall survival (OS) and 5-year disease-free survival (DFS) after liver resection based on PTL. RESULTS 414 patients were included in the analysis. Left colonic tumours were significantly associated with higher rates of bilobar liver metastasis (36.2% vs. 20.1% and 30.1%) and larger maximum size of liver metastases compared with rectal and right-sided tumours, respectively. There was no difference in rates of extra-hepatic metastases, recurrence in the liver after resection or RAS, BRAF or p53 mutational status. After propensity weighting and Cox-regression, right-sided tumours were independently associated with significantly reduced 10 year OS (HR 1.56, 95% CI 1.03-2.36, p = 0.04) but not 5 year DFS (HR 1.36, 95% CI 0.89-2.08, p = 0.15). CONCLUSIONS Compared with left colonic and rectal tumours, right-sided colonic tumours are independently associated with inferior OS after resection of CRLM. This is despite higher rates of bilobar liver metastases and larger metastases with left-sided tumours.
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Affiliation(s)
- Aditya Borakati
- University Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Farid Froghi
- University Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Alysha Shetye
- University Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
| | - Giuseppe K Fusai
- University Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Brian R Davidson
- University Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Reza Mirnezami
- University Department of Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
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Zakeri N, Hall A, Swadling L, Pallett LJ, Schmidt NM, Diniz MO, Kucykowicz S, Amin OE, Gander A, Pinzani M, Davidson BR, Quaglia A, Maini MK. Characterisation and induction of tissue-resident gamma delta T-cells to target hepatocellular carcinoma. Nat Commun 2022; 13:1372. [PMID: 35296658 PMCID: PMC8927126 DOI: 10.1038/s41467-022-29012-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
Immunotherapy is now the standard of care for advanced hepatocellular carcinoma (HCC), yet many patients fail to respond. A major unmet goal is the boosting of T-cells with both strong HCC reactivity and the protective advantages of tissue-resident memory T-cells (TRM). Here, we show that higher intratumoural frequencies of γδ T-cells, which have potential for HLA-unrestricted tumour reactivity, associate with enhanced HCC patient survival. We demonstrate that γδ T-cells exhibit bona fide tissue-residency in human liver and HCC, with γδTRM showing no egress from hepatic vasculature, persistence for >10 years and superior anti-tumour cytokine production. The Vγ9Vδ2 T-cell subset is selectively depleted in HCC but can efficiently target HCC cell lines sensitised to accumulate isopentenyl-pyrophosphate by the aminobisphosphonate Zoledronic acid. Aminobisphosphonate-based expansion of peripheral Vγ9Vδ2 T-cells recapitulates a TRM phenotype and boosts cytotoxic potential. Thus, our data suggest more universally effective HCC immunotherapy may be achieved by combining aminobisphosphonates to induce Vγ9Vδ2TRM capable of replenishing the depleted pool, with additional intratumoural delivery to sensitise HCC to Vγ9Vδ2TRM-based targeting.
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Affiliation(s)
- Nekisa Zakeri
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Andrew Hall
- Institute for Liver & Digestive Health, Royal Free London NHS Foundation Trust, London, UK
| | - Leo Swadling
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Laura J Pallett
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Nathalie M Schmidt
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Mariana O Diniz
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Stephanie Kucykowicz
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Oliver E Amin
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK
| | - Amir Gander
- Division of Surgery, University College London, London, UK
| | - Massimo Pinzani
- Institute for Liver & Digestive Health, Royal Free London NHS Foundation Trust, London, UK
| | | | - Alberto Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Cancer Institute, London, UK
| | - Mala K Maini
- Division of Infection & Immunity, Institute of Immunity & Transplantation, University College London, London, UK.
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Froghi F, Gopalan V, Anastasiou Z, Koti R, Gurusamy K, Eastgate C, McNeil M, Filipe H, Pinto M, Singh J, Longworth L, Mallett S, Schofield N, Thorburn D, Martin D, Davidson BR. Effect of post-operative goal-directed fluid therapy (GDFT) on organ function after orthotopic liver transplantation: Secondary outcome analysis of the COLT randomised control trial. Int J Surg 2022; 99:106265. [PMID: 35181556 DOI: 10.1016/j.ijsu.2022.106265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/28/2021] [Accepted: 02/09/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Goal-directed fluid therapy (GDFT) has been shown to reduce the complications following a variety of major surgical procedures, possibly mediated by improved organ perfusion and function. We have shown that it is feasible to randomise patients to GDFT or standard fluid management following liver transplant in the cardiac-output optimisation following liver transplantation (COLT) trial. The current study compares end organ function in patients from the COLT trial who received GDFT in comparison to those receiving standard care (SC) following liver transplant. METHODS Adult patients with liver cirrhosis undergoing liver transplantation were randomised to GDFT or SC for the first 12 h following surgery as detailed in a published trial protocol. GDFT protocol was based on stroke volume (SV) optimisation using 250 ml crystalloid boluses. Total fluid administration and time to extubation were recorded. Hourly SV and cardiac output (CO) readings were recorded from the non-invasive cardiac output monitoring (NICOM) device in both groups. Pulmonary function was assessed by arterial blood gas (ABG) and ventilatory parameters. Lung injury was assessed using PaO2:FiO2 ratios and calculated pulmonary compliance. The KDIGO score was used for determining acute kidney injury. Renal and liver graft function were assessed during the post-operative period and at 3 months and 1-year. RESULTS 60 patients were randomised to GDFT (n = 30) or SC (n = 30). All patients completed the 12 h intervention period. GDFT group received a significantly higher total volume of fluid during the 12 h trial intervention period (GDFT 5317 (2335) vs. SC 3807 (1345) ml, p = 0.003); in particular crystalloids (GDFT 3968 (2073) vs. SC 2510 (1027) ml, p = 0.002). There was no evidence of significant difference between the groups in SV or CO during the assessment periods. Time to extubation, PaO2: FIO2 ratios, pulmonary compliance, ventilatory or blood gas measurements were similar in both groups. There was a significant rise in serum creatinine from baseline (77 μmol/L) compared to first (87 μmol/L, p = 0.039) and second (107 μmol/L, p = 0.001) post-operative days. There was no difference between GDFT and SC in the highest KDIGO scores for the first 7 days post-LT. At 1-year follow-up, there was no difference in need for renal replacement therapy or graft function. CONCLUSIONS In this randomised trial of fluid therapy post liver transplant, GDFT was associated with an increased volume of crystalloids administered but did not alter early post-operative pulmonary or renal function when compared with standard care.
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Affiliation(s)
- Farid Froghi
- UCL Division of Surgery & Interventional Sciences, HPB and Liver Transplantation, London, United Kingdom UCL Joint Research Office, Biostatistics Group, London, United Kingdom Royal Free Hospital, Critical Care Unit, London, United Kingdom PHMR Limited, London, United Kingdom UCL Institute for Liver and Digestive Health, London, United Kingdom UCL Division of Surgery & Interventional Sciences, London, United Kingdom Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
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Fabes J, Ambler G, Shah B, Williams NR, Martin D, Davidson BR, Spiro M. Protocol for a prospective double-blind, randomised, placebo-controlled feasibility trial of octreotide infusion during liver transplantation. BMJ Open 2021; 11:e055864. [PMID: 34857585 PMCID: PMC8640665 DOI: 10.1136/bmjopen-2021-055864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Liver transplantation is a complex operation that can provide significant improvements in quality of life and survival to the recipients. However, serious complications are common and include major haemorrhage, hypotension and renal failure. Blood transfusion and the development of acute kidney injury lead to both short-term and long-term poor patient outcomes, including an increased risk of death, graft failure, length of stay and reduced quality of life. Octreotide may reduce the incidence of renal dysfunction, perioperative haemorrhage and enhance intraoperative blood pressure. However, octreotide does have risks, including resistant bradycardia, hyperglycaemia and hypoglycaemia and QT prolongation. Hence, a randomised controlled trial of octreotide during liver transplantation is needed to determine the cost-efficacy and safety of its use; this study represents a feasibility study prior to this trial. METHODS AND ANALYSIS We describe a multicentre, double-blind, randomised, placebo-controlled feasibility study of continuous infusion of octreotide during liver transplantation surgery. We will recruit 30 adult patients at two liver transplant centres. A blinded infusion during surgery will be administered in a 2:1 ratio of octreotide:placebo. The primary outcomes will determine the feasibility of this study design. These include the recruitment ratio, correct administration of blinded study intervention, adverse event rates, patient and clinician enrolment refusal and completion of data collection. Secondary outcome measures of efficacy and safety will help shape future trials by assessing potential primary outcome measures and monitoring safety end points. No formal statistical tests are planned. This manuscript represents study protocol number 1.3, dated 2 June 2021. ETHICS AND DISSEMINATION This study has received Research Ethics Committee approval. The main study outcomes will be submitted to an open-access journal. TRIAL SPONSOR The Joint Research Office, University College London, UK.Neither the sponsor nor the funder have any role in study design, collection, management, analysis and interpretation of data, writing of the study report or the decision to submit the report for publication. TRIAL REGISTRATION The study is registered with ClinicalTrials.gov (NCT04941911) with recruitment due to start in August 2021 with anticipated completion in July 2022. CLINICAL TRIALS UNIT Surgical and Interventional Group, Division of Surgery & Interventional Science, University College London.
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Affiliation(s)
- Jeremy Fabes
- Peninsula Medical School, University of Plymouth, Plymouth, Devon, UK
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Bina Shah
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Norman R Williams
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Daniel Martin
- Peninsula Medical School, University of Plymouth, Plymouth, Devon, UK
| | - Brian R Davidson
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Michael Spiro
- Division of Surgery & Interventional Science, University College London, London, UK
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32
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Gurusamy KS, Mehta N, Davidson BR. Techniques of biliary reconstruction for liver transplantation. Hippokratia 2021. [DOI: 10.1002/14651858.cd007055.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Naimish Mehta
- Liver Transplantation & Surgical Gastroenterology; Sir Ganga Ram Hospital; New Dehli India
| | - Brian R Davidson
- Division of Surgery and Interventional Science; University College London; London UK
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Gurusamy KS, Tapuria N, Davidson BR. Methods of gallbladder dissection for laparoscopic cholecystectomy. Hippokratia 2021. [DOI: 10.1002/14651858.cd007054.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Brian R Davidson
- Division of Surgery and Interventional Science; University College London; London UK
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Leung J, Leong J, Au Yeung K, Hao BZ, McCluskey A, Kayani Y, Davidson BR, Gurusamy KS. Can you trust clinical practice guidelines for laparoscopic surgery? A systematic review of clinical practice guidelines for laparoscopic surgery. Updates Surg 2021; 74:391-401. [PMID: 34519972 PMCID: PMC8995291 DOI: 10.1007/s13304-021-01168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/05/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Clinical practice guidelines aim to support clinicians in providing clinical care and should be supported by evidence. There is currently no information on whether clinical practice guidelines in laparoscopic surgery are supported by evidence. METHODS We performed a systematic review and identified clinical practice guidelines of laparoscopic surgery published in PubMed and Embase between March 2016 and February 2019. We performed an independent assessment of the strength of recommendation based on the evidence provided by the guideline authors. We used the 'Appraisal of Guidelines for Research & Evaluation II' (AGREE-II) Tool's 'rigour of development', 'clarity of presentation', and 'editorial independence' domains to assess the quality of the guidelines. We performed a mixed-effects generalised linear regression modelling. RESULTS We retrieved 63 guidelines containing 1905 guideline statements. The median proportion of 'difference in rating' of strength of recommendation between the guideline authors and independent assessment was 33.3% (quartiles: 18.3%, 55.8%). The 'rigour of development' domain score (odds ratio 0.06; 95% confidence intervals 0.01-0.48 per unit increase in rigour score; P value = 0.0071) and whether the strength of recommendation was 'strong' by independent evaluation (odds ratio 0.09 (95% confidence intervals 0.06-0.13; P value < 0.001) were the only determinants of difference in rating between the guideline authors and independent evaluation. CONCLUSION A considerable proportion of guideline statements in clinical practice guidelines in laparoscopic surgery are not supported by evidence. Guideline authors systematically overrated the strength of the recommendation (i.e., even when the evidence points to weak recommendation, guideline authors made strong recommendations).
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Affiliation(s)
- Jeffrey Leung
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.
| | - Jonathan Leong
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Kenneth Au Yeung
- Medical School, University of Birmingham, Birmingham, B296QU, UK
| | - Bo Zhen Hao
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Aled McCluskey
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Yusuf Kayani
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Brian R Davidson
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK
| | - Kurinchi S Gurusamy
- Division of Surgery and Interventional Science, Hampstead Campus, University College London, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, NW3 2PF, UK.,Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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35
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Schneider C, Allam M, Stoyanov D, Hawkes DJ, Gurusamy K, Davidson BR. Performance of image guided navigation in laparoscopic liver surgery - A systematic review. Surg Oncol 2021; 38:101637. [PMID: 34358880 DOI: 10.1016/j.suronc.2021.101637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/04/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Compared to open surgery, minimally invasive liver resection has improved short term outcomes. It is however technically more challenging. Navigated image guidance systems (IGS) are being developed to overcome these challenges. The aim of this systematic review is to provide an overview of their current capabilities and limitations. METHODS Medline, Embase and Cochrane databases were searched using free text terms and corresponding controlled vocabulary. Titles and abstracts of retrieved articles were screened for inclusion criteria. Due to the heterogeneity of the retrieved data it was not possible to conduct a meta-analysis. Therefore results are presented in tabulated and narrative format. RESULTS Out of 2015 articles, 17 pre-clinical and 33 clinical papers met inclusion criteria. Data from 24 articles that reported on accuracy indicates that in recent years navigation accuracy has been in the range of 8-15 mm. Due to discrepancies in evaluation methods it is difficult to compare accuracy metrics between different systems. Surgeon feedback suggests that current state of the art IGS may be useful as a supplementary navigation tool, especially in small liver lesions that are difficult to locate. They are however not able to reliably localise all relevant anatomical structures. Only one article investigated IGS impact on clinical outcomes. CONCLUSIONS Further improvements in navigation accuracy are needed to enable reliable visualisation of tumour margins with the precision required for oncological resections. To enhance comparability between different IGS it is crucial to find a consensus on the assessment of navigation accuracy as a minimum reporting standard.
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Affiliation(s)
- C Schneider
- Department of Surgical Biotechnology, University College London, Pond Street, NW3 2QG, London, UK.
| | - M Allam
- Department of Surgical Biotechnology, University College London, Pond Street, NW3 2QG, London, UK; General surgery Department, Tanta University, Egypt
| | - D Stoyanov
- Department of Computer Science, University College London, London, UK; Centre for Medical Image Computing (CMIC), University College London, London, UK
| | - D J Hawkes
- Centre for Medical Image Computing (CMIC), University College London, London, UK; Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK
| | - K Gurusamy
- Department of Surgical Biotechnology, University College London, Pond Street, NW3 2QG, London, UK
| | - B R Davidson
- Department of Surgical Biotechnology, University College London, Pond Street, NW3 2QG, London, UK
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Komolafe O, Buzzetti E, Linden A, Best LM, Madden AM, Roberts D, Chase TJ, Fritche D, Freeman SC, Cooper NJ, Sutton AJ, Milne EJ, Wright K, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Nutritional supplementation for nonalcohol-related fatty liver disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 7:CD013157. [PMID: 34280304 PMCID: PMC8406904 DOI: 10.1002/14651858.cd013157.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of non-alcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases risks of liver cirrhosis, hepatocellular carcinoma, and the requirement for liver transplantation. Uncertainty surrounds relative benefits and harms of various nutritional supplements in NAFLD. Currently no nutritional supplement is recommended for people with NAFLD. OBJECTIVES • To assess the benefits and harms of different nutritional supplements for treatment of NAFLD through a network meta-analysis • To generate rankings of different nutritional supplements according to their safety and efficacy SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, the World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) for people with NAFLD, irrespective of method of diagnosis, age and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods whenever possible and calculated differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios with 95% credible intervals (CrIs) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included in the review a total of 202 randomised clinical trials (14,200 participants). Nineteen trials were at low risk of bias. A total of 32 different interventions were compared in these trials. A total of 115 trials (7732 participants) were included in one or more comparisons. The remaining trials did not report any of the outcomes of interest for this review. Follow-up ranged from 1 month to 28 months. The follow-up period in trials that reported clinical outcomes was 2 months to 28 months. During this follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. We did not calculate effect estimates for mortality because of sparse data (zero events for at least one of the groups in the trial). None of the trials reported that they measured overall health-related quality of life using a validated scale. The evidence is very uncertain about effects of interventions on serious adverse events (number of people or number of events). We are very uncertain about effects on adverse events of most of the supplements that we investigated, as the evidence is of very low certainty. However, people taking PUFA (polyunsaturated fatty acid) may be more likely to experience an adverse event than those not receiving an active intervention (network meta-analysis results: OR 4.44, 95% CrI 2.40 to 8.48; low-certainty evidence; 4 trials, 203 participants; direct evidence: OR 4.43, 95% CrI 2.43 to 8.42). People who take other supplements (a category that includes nutritional supplements other than vitamins, fatty acids, phospholipids, and antioxidants) had higher numbers of adverse events than those not receiving an active intervention (network meta-analysis: rate ratio 1.73, 95% CrI 1.26 to 2.41; 6 trials, 291 participants; direct evidence: rate ratio 1.72, 95% CrI 1.25 to 2.40; low-certainty evidence). Data were sparse (zero events in all groups in the trial) for liver transplantation, liver decompensation, and hepatocellular carcinoma. So, we did not perform formal analysis for these outcomes. The evidence is very uncertain about effects of other antioxidants (antioxidants other than vitamins) compared to no active intervention on liver cirrhosis (HR 1.68, 95% CrI 0.23 to 15.10; 1 trial, 99 participants; very low-certainty evidence). The evidence is very uncertain about effects of interventions in any of the remaining comparisons, or data were sparse (with zero events in at least one of the groups), precluding formal calculations of effect estimates. Data were probably because of the very short follow-up period (2 months to 28 months). It takes follow-up of 8 to 28 years to detect differences in mortality between people with NAFLD and the general population. Therefore, it is unlikely that differences in clinical outcomes are noted in trials providing less than 5 to 10 years of follow-up. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about effects of nutritional supplementation compared to no additional intervention on all clinical outcomes for people with non-alcohol-related fatty liver disease. Accordingly, high-quality randomised comparative clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (study design in which multiple interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice) comparing interventions such as vitamin E, prebiotics/probiotics/synbiotics, PUFAs, and no nutritional supplementation. The reason for the choice of interventions is the impact of these interventions on indirect outcomes, which may translate to clinical benefit. Outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource utilisation measures including costs of intervention and decreased healthcare utilisation after minimum follow-up of 8 years (to find meaningful differences in clinically important outcomes).
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Affiliation(s)
| | - Elena Buzzetti
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Audrey Linden
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Angela M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Thomas Jg Chase
- Department of General Surgery, Homerton University Hospital NHS Foundation Trust, London, UK
| | | | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Kathy Wright
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Buzzetti E, Linden A, Best LM, Madden AM, Roberts D, Chase TJG, Freeman SC, Cooper NJ, Sutton AJ, Fritche D, Milne EJ, Wright K, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Lifestyle modifications for nonalcohol-related fatty liver disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD013156. [PMID: 34114650 PMCID: PMC8193812 DOI: 10.1002/14651858.cd013156.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of nonalcohol-related fatty liver disease (NAFLD) varies between 19% and 33% in different populations. NAFLD decreases life expectancy and increases the risks of liver cirrhosis, hepatocellular carcinoma, and requirement for liver transplantation. There is uncertainty surrounding the relative benefits and harms of various lifestyle interventions for people with NAFLD. OBJECTIVES To assess the comparative benefits and harms of different lifestyle interventions in the treatment of NAFLD through a network meta-analysis, and to generate rankings of the different lifestyle interventions according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, World Health Organization International Clinical Trials Registry Platform, and trials registers until February 2021 to identify randomised clinical trials in people with NAFLD. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in people with NAFLD, whatever the method of diagnosis, age, and diabetic status of participants, or presence of non-alcoholic steatohepatitis (NASH). We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We planned to perform a network meta-analysis with OpenBUGS using Bayesian methods and to calculate the differences in treatments using hazard ratios (HRs), odds ratios (ORs), and rate ratios (RaRs) with 95% credible intervals (CrIs) based on an available-participant analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. However, the data were too sparse for the clinical outcomes. We therefore performed only direct comparisons (head-to-head comparisons) with OpenBUGS using Bayesian methods. MAIN RESULTS We included a total of 59 randomised clinical trials (3631 participants) in the review. All but two trials were at high risk of bias. A total of 33 different interventions, ranging from advice to supervised exercise and special diets, or a combination of these and no additional intervention were compared in these trials. The reference treatment was no active intervention. Twenty-eight trials (1942 participants) were included in one or more comparisons. The follow-up ranged from 1 month to 24 months. The remaining trials did not report any of the outcomes of interest for this review. The follow-up period in the trials that reported clinical outcomes was 2 months to 24 months. During this short follow-up period, clinical events related to NAFLD such as mortality, liver cirrhosis, liver decompensation, liver transplantation, hepatocellular carcinoma, and liver-related mortality were sparse. This is probably because of the very short follow-up periods. It takes a follow-up of 8 years to 28 years to detect differences in mortality between people with NAFLD and the general population. It is therefore unlikely that differences by clinical outcomes will be noted in trials with less than 5 years to 10 years of follow-up. In one trial, one participant developed an adverse event. There were no adverse events in any of the remaining participants in this trial, or in any of the remaining trials, which seemed to be directly related to the intervention. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effects of the lifestyle interventions compared with no additional intervention (to general public health advice) on any of the clinical outcomes after a short follow-up period of 2 months to 24 months in people with nonalcohol-related fatty liver disease. Accordingly, high-quality randomised clinical trials with adequate follow-up are needed. We propose registry-based randomised clinical trials or cohort multiple randomised clinical trials (a study design in which multiple interventions are trialed within large longitudinal cohorts of participants to gain efficiencies and align trials more closely to standard clinical practice), comparing aerobic exercise and dietary advice versus standard of care (exercise and dietary advice received as part of national health promotion). The reason for the choice of aerobic exercise and dietary advice is the impact of these interventions on indirect outcomes which may translate to clinical benefit. The outcomes in such trials should be mortality, health-related quality of life, decompensated liver cirrhosis, liver transplantation, and resource use measures including costs of intervention and decreased healthcare use after a minimum follow-up of eight years, to find meaningful differences in the clinically important outcomes.
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Affiliation(s)
- Elena Buzzetti
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Audrey Linden
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Angela M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Thomas J G Chase
- Department of General Surgery, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | | | - Kathy Wright
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Kostakis ID, Iype S, Nasralla D, Davidson BR, Imber C, Sharma D, Pollok JM. Combining Donor and Recipient Age With Preoperative MELD and UKELD Scores for Predicting Survival After Liver Transplantation. EXP CLIN TRANSPLANT 2021; 19:570-579. [PMID: 34085606 DOI: 10.6002/ect.2020.0513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The end-stage liver disease scoring systems MELD, UKELD, and D-MELD (donor age × MELD) have had mediocre results for survival assessment after orthotopic liver transplant. Here, we introduced new indices based on preoperative MELD and UKELDscores and assessed their predictive ability on survival posttransplant. MATERIALS AND METHODS We included 1017 deceased donor orthotopic liver transplants that were performed between 2008 (the year UKELD was introduced) and 2019. Donor and recipient characteristics, liver disease scores, transplant characteristics, and outcomes were collected for analyses. D-MELD, D-UKELD (donor age × UKELD),DR-MELD[(donor age + recipient age) × MELD], and DR-UKELD [(donor age + recipient age) × UKELD] were calculated. RESULTS No score had predictive value for graft survival. For patient survival,DR-MELD and DR-UKELD provided the best results but with low accuracy. The highest accuracy was observed at 1 year posttransplant (areas under the curve of 0.598 [95% CI, 0.529-0.667] and 0.609 [95% CI, 0.549-0.67]forDR-MELDandDR-UKELD). Addition of donor and recipient age significantly improved the predictive abilities of MELD and UKELD for patient survival, but addition of donor age alone did not. For 1-year mortality (using receiver operating characteristic curves), optimal cut-off points were DR-MELD>2345 and DR-UKELD>5908. Recipients with DR-MELD >2345 (P < .001) and DR-UKELD >5908 (P = .002) had worse patient survival within the first year, but only DR-MELD >2345 remained significant after multivariable analysis (P = .007). CONCLUSIONS DR-MELD and DR-UKELD scores provided the best, albeit mediocre, predictive ability among the 6 tested models, especially at 1 year after posttransplant, although only for patient but not for graft survival. A DR-MELD >2345 was considered to be an additional independent risk factor for worse recipient survival within the first postoperative year.
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Affiliation(s)
- Ioannis D Kostakis
- From the Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK; and the Division of Surgery and Interventional Science, University College London, London, UK
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Rai ZL, Feakins R, Pallett LJ, Manas D, Davidson BR. Irreversible Electroporation (IRE) in Locally Advanced Pancreatic Cancer: A Review of Current Clinical Outcomes, Mechanism of Action and Opportunities for Synergistic Therapy. J Clin Med 2021; 10:1609. [PMID: 33920118 PMCID: PMC8068938 DOI: 10.3390/jcm10081609] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) accounts for 30% of patients with pancreatic cancer. Irreversible electroporation (IRE) is a novel cancer treatment that may improve survival and quality of life in LAPC. This narrative review will provide a perspective on the clinical experience of pancreas IRE therapy, explore the evidence for the mode of action, assess treatment complications, and propose strategies for augmenting IRE response. A systematic search was performed using PubMed regarding the clinical use and safety profile of IRE on pancreatic cancer, post-IRE sequential histological changes, associated immune response, and synergistic therapies. Animal data demonstrate that IRE induces both apoptosis and necrosis followed by fibrosis. Major complications may result from IRE; procedure related mortality is up to 2%, with an average morbidity as high as 36%. Nevertheless, prospective and retrospective studies suggest that IRE treatment may increase median overall survival of LAPC to as much as 30 months and provide preliminary data justifying the well-designed trials currently underway, comparing IRE to the standard of care treatment. The mechanism of action of IRE remains unknown, and there is a lack of data on treatment variables and efficiency in humans. There is emerging data suggesting that IRE can be augmented with synergistic therapies such as immunotherapy.
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Affiliation(s)
- Zainab L. Rai
- Centre of Surgical Innovation, Organ Regeneration and Transplantation, University College London (UCL), London NW3 2QG, UK;
- Wellcome/EPSRC Center for Interventional and Surgical Sciences (WEISS), London W1W 7TY, UK
- Royal Free NHS Foundation Trust, London NW3 2QG, UK;
| | - Roger Feakins
- Royal Free NHS Foundation Trust, London NW3 2QG, UK;
| | - Laura J. Pallett
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, London WC1E 6BT, UK;
| | - Derek Manas
- Newcastle Upon Tyne NHS Foundation Trust, Newcastle-Upon-Tyne NE7 7DN, UK;
| | - Brian R. Davidson
- Centre of Surgical Innovation, Organ Regeneration and Transplantation, University College London (UCL), London NW3 2QG, UK;
- Royal Free NHS Foundation Trust, London NW3 2QG, UK;
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Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013155. [PMID: 33837526 PMCID: PMC8094233 DOI: 10.1002/14651858.cd013155.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments. OBJECTIVES To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices. SELECTION CRITERIA We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details. MAIN RESULTS We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.
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Affiliation(s)
- Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Dana Walshaw
- Acute Medicine, Barts and The London NHS Trust, London, UK
| | | | | | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Roccarina D, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Benmassaoud A, Plaz Torres MC, Iogna Prat L, Csenar M, Arunan S, Begum T, Milne EJ, Tapp M, Pavlov CS, Davidson BR, Tsochatzis E, Williams NR, Gurusamy KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013121. [PMID: 33822357 PMCID: PMC8092414 DOI: 10.1002/14651858.cd013121.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR), and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details. MAIN RESULTS We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. AUTHORS' CONCLUSIONS Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.
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Affiliation(s)
- Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | | | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Plaz Torres MC, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Roccarina D, Benmassaoud A, Iogna Prat L, Williams NR, Csenar M, Fritche D, Begum T, Arunan S, Tapp M, Milne EJ, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 3:CD013122. [PMID: 33784794 PMCID: PMC8094621 DOI: 10.1002/14651858.cd013122.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.
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Affiliation(s)
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Swadling L, Pallett LJ, Diniz MO, Baker JM, Amin OE, Stegmann KA, Burton AR, Schmidt NM, Jeffery-Smith A, Zakeri N, Suveizdyte K, Froghi F, Fusai G, Rosenberg WM, Davidson BR, Schurich A, Simon AK, Maini MK. Human Liver Memory CD8 + T Cells Use Autophagy for Tissue Residence. Cell Rep 2021; 30:687-698.e6. [PMID: 31968246 PMCID: PMC6988113 DOI: 10.1016/j.celrep.2019.12.050] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/04/2019] [Accepted: 12/13/2019] [Indexed: 12/11/2022] Open
Abstract
Tissue-resident memory T cells have critical roles in long-term pathogen and tumor immune surveillance in the liver. We investigate the role of autophagy in equipping human memory T cells to acquire tissue residence and maintain functionality in the immunosuppressive liver environment. By performing ex vivo staining of freshly isolated cells from human liver tissue, we find that an increased rate of basal autophagy is a hallmark of intrahepatic lymphocytes, particularly liver-resident CD8+ T cells. CD8+ T cells with increased autophagy are those best able to proliferate and mediate cytotoxicity and cytokine production. Conversely, blocking autophagy induction results in the accumulation of depolarized mitochondria, a feature of exhausted T cells. Primary hepatic stellate cells or the prototypic hepatic cytokine interleukin (IL)-15 induce autophagy in parallel with tissue-homing/retention markers. Inhibition of T cell autophagy abrogates tissue-residence programming. Thus, upregulation of autophagy adapts CD8+ T cells to combat mitochondrial depolarization, optimize functionality, and acquire tissue residence. An increased rate of basal autophagy is a hallmark of liver-resident CD8+ T cells Enhanced T cell autophagy can be imprinted by IL-15 or hepatic stellate cells Autophagy induction is required for tissue-residence programming in vitro Enhanced autophagy maintains TRM mitochondrial fitness in the liver
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Affiliation(s)
- Leo Swadling
- Division of Infection and Immunity, University College London, London, UK.
| | - Laura J Pallett
- Division of Infection and Immunity, University College London, London, UK
| | - Mariana O Diniz
- Division of Infection and Immunity, University College London, London, UK
| | - Josephine M Baker
- Division of Infection and Immunity, University College London, London, UK
| | - Oliver E Amin
- Division of Infection and Immunity, University College London, London, UK
| | - Kerstin A Stegmann
- Division of Infection and Immunity, University College London, London, UK
| | - Alice R Burton
- Division of Infection and Immunity, University College London, London, UK
| | - Nathalie M Schmidt
- Division of Infection and Immunity, University College London, London, UK
| | - Anna Jeffery-Smith
- Division of Infection and Immunity, University College London, London, UK; Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Nekisa Zakeri
- Division of Infection and Immunity, University College London, London, UK
| | | | - Farid Froghi
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Giuseppe Fusai
- Institute for Liver and Digestive Health, University College London, London, UK
| | - William M Rosenberg
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Brian R Davidson
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Anna Schurich
- Division of Infection and Immunity, University College London, London, UK; Department of Infectious Diseases, Kings College London, London, UK
| | - A Katharina Simon
- The Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Mala K Maini
- Division of Infection and Immunity, University College London, London, UK.
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Labib PL, Yaghini E, Davidson BR, MacRobert AJ, Pereira SP. 5-Aminolevulinic acid for fluorescence-guided surgery in pancreatic cancer: Cellular transport and fluorescence quantification studies. Transl Oncol 2021; 14:100886. [PMID: 33059124 PMCID: PMC7566921 DOI: 10.1016/j.tranon.2020.100886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 12/30/2022] Open
Abstract
5-Aminolevulinic acid (ALA) is a potential contrast agent for fluorescence-guided surgery in pancreatic ductal adenocarcinoma (PDAC). However, factors influencing ALA uptake in PDAC have not been adequately assessed. We investigated ALA-induced porphyrin fluorescence in PDAC cell lines CFPAC-1 and PANC-1 and pancreatic ductal cell line H6c7 following incubation with 0.25-1.0 mM ALA for 4-48 h. Fluorescence was assessed qualitatively by microscopy and quantitatively by plate reader and flow cytometry. Haem biosynthesis enzymes and transporters were measured by quantitative polymerase chain reaction (qPCR). CFPAC-1 cells exhibited intense fluorescence under microscopy at low concentrations whereas PANC-1 cells and pancreatic ductal cell line H6c7 showed much lower fluorescence. Quantitative fluorescence studies demonstrated fluorescence saturation in the two PDAC cell lines at 0.5 mM ALA, whereas H6c7 cells showed increasing fluorescence with increasing ALA. Based on the PDAC:H6c7 fluorescence ratio studies, lower ALA concentrations provide better contrast between PDAC and benign pancreatic cells. Studies with qPCR showed upregulation of ALA influx transporter PEPT1 in CFPAC-1, whereas PANC-1 upregulated the efflux transporter ABCG2. We conclude that PEPT1 and ABCG2 expression may be key contributory factors for variability in ALA-induced fluorescence in PDAC.
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Affiliation(s)
- P L Labib
- UCL Institute for Liver & Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom of Great Britain and Northern Ireland.
| | - E Yaghini
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom of Great Britain and Northern Ireland.
| | - B R Davidson
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom of Great Britain and Northern Ireland.
| | - A J MacRobert
- UCL Division of Surgery & Interventional Science, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom of Great Britain and Northern Ireland.
| | - S P Pereira
- UCL Institute for Liver & Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, United Kingdom of Great Britain and Northern Ireland.
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Schneider C, Nikitichev D, Xia W, Gurusamy K, Desjardins AE, Davidson BR. Multispectral tissue mapping: developing a concept for the optical evaluation of liver disease. J Med Imaging (Bellingham) 2020; 7:066001. [PMID: 33376759 PMCID: PMC7757517 DOI: 10.1117/1.jmi.7.6.066001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/01/2020] [Indexed: 11/14/2022] Open
Abstract
Purpose: Alterations in the optical absorption behavior of liver tissue secondary to pathological processes can be evaluated by multispectral analysis, which is increasingly being explored as an imaging adjunct for use in liver surgery. Current methods are either invasive or have a limited wavelength spectrum, which restricts utility. This proof of concept study describes the development of a multispectral imaging (MSI) method called multispectral tissue mapping (MTM) that addresses these issues. Approach: The imaging system consists of a tunable excitation light source and a near-infrared camera. Following the development stage, proof of concept experiments are carried out where absorption spectra from colorectal cancer liver metastasis (CRLM), hepatocellular carcinoma (HCC), and liver steatosis specimen are acquired and compared to controls. Absorption spectra are compared to histopathology examination as the current gold standard for tissue assessment. Generalized linear mixed modeling is employed to compare absorption characteristics of individual pixels and to select wavelengths for false color image processing with the aim of visually enhancing cancer tissue. Results: Analysis of individual pixels revealed distinct absorption spectra therefore suggesting that MTM is possible. A prominent absorption peak at 1210 nm was found in lipid-rich animal tissues and steatotic liver specimen. Liver cancer tissue had a heterogeneous appearance on MSI. Subsequent statistical analysis suggests that measuring changes in absorption behavior may be a feasible method to estimate the pixel-based probability of cancer being present. In CRLM, this was observed throughout 1100 to 1700 nm, whereas in HCC it was concentrated around 1140 and 1430 nm. False color image processing visibly enhances contrast between cancer and normal liver tissues. Conclusions: The system's ability to enable no-touch MSI at 1100 to 1700 nm was demonstrated. Preliminary data suggest that MTM warrants further exploration as a potential imaging tool for the detection of liver cancer during surgery.
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Affiliation(s)
- Crispin Schneider
- University College London, Division of Surgery and Interventional Science, Royal Free Campus, London, United Kingdom
| | - Daniil Nikitichev
- University College London, Wellcome/EPSRC Centre for Surgical and Interventional Sciences, London, United Kingdom.,University College London, Department of Medical Physics and Bioengineering, London, United Kingdom
| | - Wenfeng Xia
- University College London, Wellcome/EPSRC Centre for Surgical and Interventional Sciences, London, United Kingdom.,University College London, Department of Medical Physics and Bioengineering, London, United Kingdom
| | - Kurinchi Gurusamy
- University College London, Division of Surgery and Interventional Science, Royal Free Campus, London, United Kingdom.,University College London, Wellcome/EPSRC Centre for Surgical and Interventional Sciences, London, United Kingdom
| | - Adrien E Desjardins
- University College London, Wellcome/EPSRC Centre for Surgical and Interventional Sciences, London, United Kingdom.,University College London, Department of Medical Physics and Bioengineering, London, United Kingdom
| | - Brian R Davidson
- University College London, Division of Surgery and Interventional Science, Royal Free Campus, London, United Kingdom.,University College London, Wellcome/EPSRC Centre for Surgical and Interventional Sciences, London, United Kingdom
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46
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Diaz-Nieto R, Lykoudis P, Robertson F, Sharma D, Moore K, Malago M, Davidson BR. A simple scoring model for predicting early graft failure and postoperative mortality after liver transplantation. Ann Hepatol 2020; 18:902-912. [PMID: 31405576 DOI: 10.1016/j.aohep.2019.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/15/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Graft failure and postoperative mortality are the most serious complications after liver transplantation. The aim of this study is to establish a prognostic scoring system to predict graft and patient survival based on serum transaminases levels that are routinely used during the postoperative period in human cadaveric liver transplants. PATIENTS AND METHODS Postoperative graft failure and patient mortality after liver transplant were analyzed from a consecutive series of 1299 patients undergoing cadaveric liver transplantation. This was correlated with serum liver function tests and the rate of reduction in transaminase levels over the first postoperative week. A cut-off transaminase level correlating with graft and patient survival was calculated and incorporated into a scoring system. RESULTS Aspartate-aminotransferase (AST) on postoperative day one showed significant correlation with early graft failure for levels above 723U/dl and early postoperative mortality for levels above 750U/dl. AST reduction rate (day 1 to 3) greater than 1.8 correlated with reduced graft failure and greater than 2 with mortality. Alanine-aminotransferase (ALT) reduction in the first 48h post transplantation also correlated with outcomes. CONCLUSION A scoring system with these three variables allowed us to classify our patients into three groups of risk for early graft failure and mortality.
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Affiliation(s)
- Rafael Diaz-Nieto
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom.
| | - Panagis Lykoudis
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
| | - Francis Robertson
- Royal Free Campus, University College London, London, United Kingdom
| | - Dinesh Sharma
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Kevin Moore
- Royal Free Campus, University College London, London, United Kingdom
| | - Massimo Malago
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Brian R Davidson
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
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47
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Pallett LJ, Burton AR, Amin OE, Rodriguez-Tajes S, Patel AA, Zakeri N, Jeffery-Smith A, Swadling L, Schmidt NM, Baiges A, Gander A, Yu D, Nasralla D, Froghi F, Iype S, Davidson BR, Thorburn D, Yona S, Forns X, Maini MK. Longevity and replenishment of human liver-resident memory T cells and mononuclear phagocytes. J Exp Med 2020; 217:e20200050. [PMID: 32602903 PMCID: PMC7478732 DOI: 10.1084/jem.20200050] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/07/2020] [Accepted: 05/15/2020] [Indexed: 12/13/2022] Open
Abstract
The human liver contains specialized subsets of mononuclear phagocytes (MNPs) and T cells, but whether these have definitive features of tissue residence (long-term retention, lack of egress) and/or can be replenished from the circulation remains unclear. Here we addressed these questions using HLA-mismatched liver allografts to discriminate the liver-resident (donor) from the infiltrating (recipient) immune composition. Allografts were rapidly infiltrated by recipient leukocytes, which recapitulated the liver myeloid and lymphoid composition, and underwent partial reprogramming with acquisition of CD68/CD206 on MNPs and CD69/CD103 on T cells. The small residual pool of donor cells persisting in allografts for over a decade contained CX3CR1hi/CD163hi/CD206hi Kupffer cells (KCs) and CXCR3hi tissue-resident memory T cells (TRM). CD8+ TRM were found in the local lymph nodes but were not detected egressing into the hepatic vein. Our findings inform organ transplantation and hepatic immunotherapy, revealing remarkably long-lived populations of KCs and TRM in human liver, which can be additionally supplemented by their circulating counterparts.
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Affiliation(s)
- Laura J. Pallett
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
| | - Alice R. Burton
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
| | - Oliver E. Amin
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
| | - Sergio Rodriguez-Tajes
- Liver Unit, Hospital Clinic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Amit A. Patel
- Division of Medicine, University College London, London, UK
| | - Nekisa Zakeri
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
| | - Anna Jeffery-Smith
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
- Barts Liver Centre, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Leo Swadling
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
| | - Nathalie M. Schmidt
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
| | - Anna Baiges
- Liver Unit, Hospital Clinic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Amir Gander
- Division of Surgery, University College London, London, UK
| | - Dominic Yu
- Liver Transplant Unit, Royal Free Hospital, London, UK
| | | | - Farid Froghi
- Division of Surgery, University College London, London, UK
| | - Satheesh Iype
- Liver Transplant Unit, Royal Free Hospital, London, UK
| | | | | | - Simon Yona
- Institute of Dental Sciences, Hebrew University, Jerusalem, Israel
| | - Xavier Forns
- Liver Unit, Hospital Clinic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Mala K. Maini
- Division of Infection and Immunity, Institute of Immunity and Transplantation, University College London, UK
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Teo JY, Ho AFW, Bulluck H, Gao F, Chong J, Koh YX, Tan EK, Abdul Latiff JB, Chua SH, Goh BKP, Chan CY, Chung AYF, Lee SY, Cheow PC, Ooi LLPJ, Davidson BR, Jevaraj PR, Hausenloy DJ. Effect of remote ischemic preConditioning on liver injury in patients undergoing liver resection: the ERIC-LIVER trial. HPB (Oxford) 2020; 22:1250-1257. [PMID: 32007393 DOI: 10.1016/j.hpb.2019.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/11/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Novel hepatoprotective strategies are needed to improve clinical outcomes during liver surgery. There is mixed data on the role of remote ischemic preconditioning (RIPC). We investigated RIPC in partial hepatectomy for primary hepatocellular carcinoma (HCC). METHODS This was a Phase II, single-center, sham-controlled, randomized controlled trial (RCT). The primary hypothesis was that RIPC would reduce acute liver injury following surgery indicated by serum alanine transferase (ALT) 24 h following hepatectomy in patients with primary HCC, compared to sham. Patients were randomized to receive either four cycles of 5 min/5 min arm cuff inflation/deflation immediately prior to surgery, or sham. Secondary endpoints included clinical, biochemical and pathological outcomes. Liver function measured by Indocyanine Green pulse densitometry was performed in a subset of patients. RESULTS 24 and 26 patients were randomized to RIPC and control groups respectively. The groups were balanced for baseline characteristics, except the duration of operation was longer in the RIPC group. Median ALT at 24 h was similar between groups (196 IU/L IQR 113.5-419.5 versus 172.5 IU/L IQR 115-298 respectively, p = 0.61). Groups were similar in secondary endpoints. CONCLUSION This RCT did not demonstrate beneficial effects with RIPC on serum ALT levels 24 h after partial hepatectomy.
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Affiliation(s)
- Jin Yao Teo
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Andrew F W Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore; SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore; Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore; National Heart Research Institute Singapore, National Heart Centre, Singapore
| | | | - Fei Gao
- National Heart Research Institute Singapore, National Heart Centre, Singapore; Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore
| | - Jun Chong
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore; National Heart Research Institute Singapore, National Heart Centre, Singapore
| | - Ye Xin Koh
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ek Khoon Tan
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Julianah B Abdul Latiff
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Siew H Chua
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Chung Yip Chan
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Alexander Y F Chung
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ser Yee Lee
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Peng Chung Cheow
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - London L P J Ooi
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian R Davidson
- Division of Surgery and Intervention Science, Royal Free Campus, University College London, UK; Department of Hepato Pancreato Biliary Surgery and Liver Transplantation, Royal Free Hospital Foundation Trust, UK
| | - Prema Raj Jevaraj
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Derek J Hausenloy
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore; National Heart Research Institute Singapore, National Heart Centre, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore; The Hatter Cardiovascular Institute, University College London, London, UK; Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taiwan; Tecnologico de Monterrey, Centro de Biotecnologia-FEMSA, Nuevo Leon, Mexico.
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Gurusamy K, Vale CL, Pizzo E, Bhanot R, Davidson BR, Mould T, Mughal M, Saunders M, Aziz O, O'Dwyer S. Cytoreductive surgery (CRS) with hyperthermic intraoperative peritoneal chemotherapy (HIPEC) versus standard of care (SoC) in people with peritoneal metastases from colorectal, ovarian or gastric origin: protocol for a systematic review and individual participant data (IPD) meta-analyses of effectiveness and cost-effectiveness. BMJ Open 2020; 10:e039314. [PMID: 32404398 PMCID: PMC7228534 DOI: 10.1136/bmjopen-2020-039314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION There is uncertainty about whether cytoreductive surgery (CRS)+hyperthermic intraoperative peritoneal chemotherapy (HIPEC) improves survival and/or quality of life compared with standard of care (SoC) in people with peritoneal metastases who can withstand major surgery. PRIMARY OBJECTIVES To compare the relative benefits and harms of CRS+HIPEC versus SoC in people with peritoneal metastases from colorectal, ovarian or gastric cancers eligible to undergo CRS+HIPEC by a systematic review and individual participant data (IPD) meta-analysis. SECONDARY OBJECTIVES To compare the cost-effectiveness of CRS+HIPEC versus SoC from a National Health Service (NHS) and personal social services perspective using a model-based cost-utility analysis. METHODS AND ANALYSIS We will perform a systematic review of literature by updating the searches from MEDLINE, Embase, Cochrane library, Science Citation Index as well as trial registers. Two members of our team will independently screen the search results and identify randomised controlled trials comparing CRS+HIPEC versus SoC for inclusion based on full texts for articles shortlisted during screening. We will assess the risk of bias in the trials and obtain data related to baseline prognostic characteristics, details of intervention and control, and outcome data related to overall survival, disease progression, health-related quality of life, treatment related complications and resource utilisation data. Using IPD, we will perform a two-step IPD, that is, calculate the adjusted effect estimate from each included study and then perform a random-effects model meta-analysis. We will perform various subgroup analyses, meta-regression and sensitivity analyses. We will also perform a model-based cost-utility analysis to assess whether CRS+HIPEC is cost-effective in the NHS setting. ETHICS AND DISSEMINATION This project was approved by the UCL Research Ethics Committee (Ethics number: 16023/001). We aim to present the findings at appropriate international meetings and publish the review, irrespective of the findings, in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42019130504.
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Affiliation(s)
- Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Claire L Vale
- Meta-analysis Group, MRC Clinical Trials Unit at UCL, London, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - R Bhanot
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of HPB Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - Tim Mould
- Gynaecological Oncology, University College London Hospitals NHS Trust, London, UK
| | - Muntzer Mughal
- Surgery, University College London Hospital NHS Foundation Trust, London, UK
| | - Mark Saunders
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Omer Aziz
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Sarah O'Dwyer
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
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Benmassaoud A, Freeman SC, Roccarina D, Plaz Torres MC, Sutton AJ, Cooper NJ, Iogna Prat L, Cowlin M, Milne EJ, Hawkins N, Davidson BR, Pavlov CS, Thorburn D, Tsochatzis E, Gurusamy KS. Treatment for ascites in adults with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2020; 1:CD013123. [PMID: 31978257 PMCID: PMC6984622 DOI: 10.1002/14651858.cd013123.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Approximately 20% of people with cirrhosis develop ascites. Several different treatments are available; including, among others, paracentesis plus fluid replacement, transjugular intrahepatic portosystemic shunts, aldosterone antagonists, and loop diuretics. However, there is uncertainty surrounding their relative efficacy. OBJECTIVES To compare the benefits and harms of different treatments for ascites in people with decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for ascites according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until May 2019 to identify randomised clinical trials in people with cirrhosis and ascites. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and ascites. We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 49 randomised clinical trials (3521 participants) in the review. Forty-two trials (2870 participants) were included in one or more outcomes in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies, without other features of decompensation, having mainly grade 3 (severe), recurrent, or refractory ascites. The follow-up in the trials ranged from 0.1 to 84 months. All the trials were at high risk of bias, and the overall certainty of evidence was low or very low. Approximately 36.8% of participants who received paracentesis plus fluid replacement (reference group, the current standard treatment) died within 11 months. There was no evidence of differences in mortality, adverse events, or liver transplantation in people receiving different interventions compared to paracentesis plus fluid replacement (very low-certainty evidence). Resolution of ascites at maximal follow-up was higher with transjugular intrahepatic portosystemic shunt (HR 9.44; 95% CrI 1.93 to 62.68) and adding aldosterone antagonists to paracentesis plus fluid replacement (HR 30.63; 95% CrI 5.06 to 692.98) compared to paracentesis plus fluid replacement (very low-certainty evidence). Aldosterone antagonists plus loop diuretics had a higher rate of other decompensation events such as hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding compared to paracentesis plus fluid replacement (rate ratio 2.04; 95% CrI 1.37 to 3.10) (very low-certainty evidence). None of the trials using paracentesis plus fluid replacement reported health-related quality of life or symptomatic recovery from ascites. FUNDING the source of funding for four trials were industries which would benefit from the results of the study; 24 trials received no additional funding or were funded by neutral organisations; and the source of funding for the remaining 21 trials was unclear. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, there is considerable uncertainty about whether interventions for ascites in people with decompensated liver cirrhosis decrease mortality, adverse events, or liver transplantation compared to paracentesis plus fluid replacement in people with decompensated liver cirrhosis and ascites. Based on very low-certainty evidence, transjugular intrahepatic portosystemic shunt and adding aldosterone antagonists to paracentesis plus fluid replacement may increase the resolution of ascites compared to paracentesis plus fluid replacement. Based on very low-certainty evidence, aldosterone antagonists plus loop diuretics may increase the decompensation rate compared to paracentesis plus fluid replacement.
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Affiliation(s)
- Amine Benmassaoud
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Suzanne C Freeman
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Davide Roccarina
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | | | - Alex J Sutton
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Nicola J Cooper
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Laura Iogna Prat
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | | | | | - Neil Hawkins
- University of GlasgowHEHTAUniversity Ave Glasgow G12 8QQGlasgowUK
| | - Brian R Davidson
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2QG
| | - Chavdar S Pavlov
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
| | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Kurinchi Selvan Gurusamy
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2QG
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
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