Nevin Manimala

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S315. doi: 10.14701/ahbps.EP-117.

ABSTRACT

INTRODUCTION: The purpose of this study is to recommend an optimal indication of single incision laparoscopic cholecystectomy (SILC).

METHODS: We retrospectively reviewed the 1,405 consecutive patients who underwent SILC at a single institution between April 2010 and June 2020. We defined difficult surgery (DS; conversion to multiport or open, adjacent organ injury, operation time ≥ 90 minutes, or estimated blood loss ≥ 100 milliliters) and poor postoperative outcomes (PPO; postoperative hospital stays ≥ 5 days, or postoperative complication ≥ grade II Clavien-Dindo classification). Subgroup analysis of acute cholecystitis (AC) was conducted according to the Tokyo guideline 18.

RESULTS: Of the 1,405 patients, 338 were for gallbladder (GB) stone, 121 were for GB polyp, 478 were for chronic cholecystitis, and 423 were for AC. The conversion and postoperative complication rate were 2.4% and 3.5%, the mean operation time and length of postoperative hospital stay were 51.8 minutes and 2.5 days. 89 and 94 patients were included in DS group and PPO group, respectively. In multivariable analysis, both grade I or grade II/III AC, and body mass index ≥ 30 kg/m² were statistically significant predictors of DS. Grade II/III AC and age ≥ 70 years were statistically significant predictors of PPO. In subgroup analysis of AC, grade II/III AC group had longer operation time (57.2 vs. 67.4 minutes, p < 0.001), postoperative hospital stays (2.7 vs. 3.7 days, p = 0.001), higher complication rate (4.2 vs. 15.8%, p < 0.001), and conversion rate (3.9 vs. 15.8%, p < 0.001) than grade I AC group.

CONCLUSIONS: SILC should be avoided in patients with grade II/III AC for better surgical outcomes.

PMID:34230380 | DOI:10.14701/ahbps.EP-117

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S269. doi: 10.14701/ahbps.EP-68.

ABSTRACT

INTRODUCTION: Hepatic artery (HA) reconstruction during living donor liver transplantation (LDLT) is the key step due to the small diameter of the artery and risk of HA thrombosis (HAT). To overcome this risky procedure, it has been preferred to using microscope during HA reconstruction by experienced microsurgeon. However, it takes long time to complete the procedure and has long and steep learning curve. To make this procedure simple, some transplant surgeons recently try the procedure using surgical loupe. We conduct this study to compare the outcomes after HA reconstruction using conventional microscope versus surgical loupe.

METHODS: We retrospectively reviewed outcomes of 300 LDLTs at our institution from April 2014 to July 2020. From April 2014 to September 2017 (era 1), HA reconstruction was performed with conventional microscope by an experienced plastic surgeon. From September 2017 to end date (era 2), it was performed using surgical loupe (× 5.0) by an experienced transplantation surgeon.

RESULTS: There was no difference in most perioperative outcomes between two groups including major postoperative complications: HAT (2/150 versus 1/150, p-value = 0.562), postoperative bleeding (13/150 versus 6/150, p-value = 0.097) and biliary leak (18/150 versus 13/150, p-value = 0.343). It was statistically significant between two groups for total operation time (436.66 ± 83.91 versus 415.35 ± 68.55, p-value = 0.035). Multivariable regression modeling to adjust for baseline differences showed that the use of surgical loupe was not associated with HAT.

CONCLUSIONS: HA reconstruction with surgical loupe makes results as good as with microscope for the transplant surgeon and contributes to reducing operating time.

PMID:34230374 | DOI:10.14701/ahbps.EP-68

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S255. doi: 10.14701/ahbps.EP-54.

ABSTRACT

INTRODUCTION: Tacrolimus (TAC) is a main therapy for liver transplantation (LT) patients, but it has side effects such as chronic nephrotoxicity that progressively aggravate renal function. The purpose of this study was to retrospectively compare the renal function between a TAC group and a combination of everolimus and reduced TAC (EVR-TAC) group after deceased donor liver transplantation (DDLT).

METHODS: The study comprised 131 patients who underwent DDLT between January 2013 and April 2018 at our institution. They received TAC or EVR-TAC after DDLT. EVR was introduced between one and six months after DDLT.

RESULTS: Thirty-six of 131 patients (27.5%) received EVR-TAC. The incidence of chronic kidney disease (CKD) (eGFR <60 mL/1.73 m²) in the EVR-TAC group was higher than in the TAC group (25% vs. 8.4%; p = 0.019). Increasing serum creatinine (n = 23, 63.9%) was the most common cause for adding EVR to treatment of the post-transplant patients. There were no statistical differences in acute rejection and CKD between the two groups. The TAC trough level was significantly lower in the EVR-TAC group than in the TAC group, and the renal function of the EVR-TAC group was worse than that of the TAC group until one year after DDLT. However, the renal function of the EVR-TAC group improved and became similar to that of TAC group at 3 years post-transplant.

CONCLUSIONS: The present study suggests that EVR should be introduced as soon as possible after DDLT to reduce exposure to high doses of TAC to improve the renal function.

PMID:34230360 | DOI:10.14701/ahbps.EP-54

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S251. doi: 10.14701/ahbps.EP-50.

ABSTRACT

INTRODUCTION: Laparoscopic minor liver resections (LLR) of the posterosuperior (PS) segments have been increasingly performed at our institution. The aim of this study was to compare the surgical outcomes of LLR and open minor liver resection (OLR) of hepatocellular carcinoma (HCC) located in the PS segments.

METHODS: We included 113 patients: 55 who underwent LLR, and 58 OLR for HCC in the PS segments from January 2008 to August 2019. Propensity score matching in a 1:1 ratio was conducted. The perioperative and long-term outcomes of 37 matched patients were retrospectively analyzed.

RESULTS: There was no intra-operative mortality or reoperation in either group. One conversion to open surgery was necessary due to severe post-operative adhesions. The LLR group compared to OLR had statistically significantly shorter operative time (215.16 vs. 251.41 min, p = 0.025), lesser blood loss (218.11 vs. 358.92 mL, p = 0.046), lower complication rate (8.1% vs. 29.7%, p = 0.018), and shorter hospital stay (7.03 vs. 11.78 days, p = 0.001). Intraoperative transfusion, R0 resection, resection margin, 5-year disease-free survival and 5-year overall survival were comparable.

CONCLUSIONS: Our standardized LLR for HCC in the PS segments provided improved short-term outcomes and similar long-term outcomes compared with OLR.

PMID:34230356 | DOI:10.14701/ahbps.EP-50

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S248. doi: 10.14701/ahbps.EP-47.

ABSTRACT

INTRODUCTION: Portal vein embolization (PVE) has been documented as an essential strategy for patient with small future liver remnant, to minimize postoperative morbidity and mortality. The majority of hepatectomy requiring preoperative PVE is approached using conventional operation because of the anticipated complexity of the case. Laparoscopic liver resection (LLR) has been gradually increased and similar outcomes have been reported when compared to open hepatectomy. However, it is very difficult to find the reports about LLR after PVE. Hence, we will present our experiences and outcomes for LLR after PVE in hepatocellular carcinoma (HCC) patients with significant technical tips.

METHODS: We performed laparoscopic right hepatectomy after PVE in 8 HCC patients from 2016 to 2020. The operation was performed within 3 weeks after PVE. We confirmed the atrophy of resected liver and compensatory hypertrophy of future liver remnant using preoperative computed tomography scan. During surgery, individual inflow control was easier because right portal vein had been already occluded.

RESULTS: There was no blood transfusion and open conversion. There was no statistical difference in operation time, intraoperative complications and postoperative morbidity including hospital stay, compared to open hepatectomy.

CONCLUSIONS: PVE is very useful procedure even in laparoscopic right hepatectomy as in open hepatectomy. However, caution is needed when PVE is applied cirrhotic livers. Therefore, adequate candidate selection for PVE and technical refinement are needed to decrease morbidity and increase surgical outcomes.

PMID:34230353 | DOI:10.14701/ahbps.EP-47

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S226. doi: 10.14701/ahbps.EP-25.

ABSTRACT

INTRODUCTION: Chronic hepatitis B is still an infectious disease that is a major problem in Asia. The success of antiviral therapy against hepatitis B infection has been widely supported by very sensitive laboratory tests to monitor hepatitis B virus (HBV)-DNA. However, in developing countries like Indonesia, the measurement of HBV-DNA level is still a challenge. Apart from limited access, a limited health insurance system contributes to this obstacle. Potential markers are transaminase enzymes (ALT and AST) although not all studies show a strong association. This study aims to analyze the relationship between HBV-DNA viral load and transaminase enzymes (ALT and AST) in hepatitis B patients in a low setting area.

METHODS: This study was funded by Deputi Bidang Penguatan Riset dan Pengembangan, Kemenristek/BRIN. This study using observational research with secondary data from January to November 2020 in hepatitis B patients at Dr. Sardjito Hospital. This study has been approved by the Committee of Ethics Committee of the Faculty of Medicine, Public Health and Nursing (FK-KMK), Universitas Gadjah Mada.

RESULTS: The subjects of this study were 139 hepatitis B patients. The median of HBV-DNA level was 4.56 log IU/mL (0.84-8.20 IU/mL). The median ALT and AST levels were 41.0 U/L (6.0-1041.0 U/L) and 43.0 U/L (13.0-1058.0 U/L), respectively. Correlation analysis showed that there was a weak but statistically significant relationship between HBV-DNA and both ALT and AST levels (r = 0.383; p < 0.01; r = 0.334; p < 0.01).

CONCLUSIONS: This study demonstrates the possibility of using transaminase enzymes to monitor hepatitis B patients in a low setting area.

PMID:34230331 | DOI:10.14701/ahbps.EP-25

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S397. doi: 10.14701/ahbps.EP-198.

ABSTRACT

INTRODUCTION: Although molecular insights about biliary tract cancer (BTC) increased in the last decade, new therapeutic strategy like inhibition of histone deacetylases (HDACs) could additionally improve the still dismal outcome of this tumor entity.

METHODS: Therefore, we performed comprehensive investigation of HDAC expression and pharmacological inhibition in a panel of eight established BTC cell lines and in a cohort resected native BTC specimens (n = 78).

RESULTS: HDAC profiling revealed a heterogeneous expression of HDACs across the studied cell lines and the BTC cancer specimen. Cytotoxicity of six established HDAC inhibitors (HDACi) covering pan- and class-specific HDACis was dose- as well as cell line-dependent and did not show a statistical correlation with HDAC isoform expression. Romidepsin (a class II HDACi), induced the highest reduction of cell viability and apoptosis in BTC cells which was paralleled by reducing HDAC1/2 activity and increasing histone 3 lysine 9 acetylation. Furthermore, non-toxic concentrations of romidepsin could augment the cytotoxic effect of the standard chemotherapeutic cisplatin. Related to the clinical tumor specimen, HDAC expression pattern correlated with the tumor grading and the survival of BTC patients.

CONCLUSIONS: In conclusion, in-vitro-experiments provide clear evidence that the HDAC class I inhibitor romidepsin is effective for BTC alone and acts supportively in combination with standard chemotherapeutics. Additionally, the observed HDAC expression in BTC specimens could serve as a predictive and prognostic biomarker for BTC patients.

PMID:34230294 | DOI:10.14701/ahbps.EP-198

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S393. doi: 10.14701/ahbps.EP-194.

ABSTRACT

INTRODUCTION: Surgical site infection (SSI) is an infection occurs after surgery in the part of the body where the surgery took place within 30 days and a significant portion of healthcare-associated infections. Distal pancreatectomy (DP) is a major surgery associated with a relatively high incidence of SSI. The aim of this study is to investigate risk factors of SSI after distal pancreatectomy.

METHODS: In total, 159 patients who underwent DP from January 2002 to December 2019 were identified and included in this study. We retrospectively collected clinical data based on the medical records of the patients. The risk factors were analyzed by logistic regression analysis.

RESULTS: A total of 14 patients (8.8%) developed SSI after DP. Four patient (2.5%) experienced deep incisional SSI and 10 patient (6.3%) had organ space SSI. Male sex was associated with SSI. Hypertension and combined surgery were associated with organ space SSI in univariate analysis. Male sex and hypertension were significant risk factor of organ space SSI in multivariate analysis (p = 0.040, p = 0.032, respectively). Male sex and combined surgery were associated with overall complication (p = 0.039, p = 0.026, respectively). However, age, body mass index, diabetes, diagnosis, type of antibiotics administered, laparoscopic surgery, and spleen preservation were not associated with SSI.

CONCLUSIONS: Male sex, hypertension, and other concomitant organ resections were statistically associated with SSI. The type of prophylactic antibiotics used was not related to SSI. Organ space SSI is associated with significant complications and the effort to reduce SSI is important.

PMID:34230290 | DOI:10.14701/ahbps.EP-194

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S390. doi: 10.14701/ahbps.EP-191.

ABSTRACT

INTRODUCTION: The oncological effects of adjuvant chemotherapy after surgery for resected ampulla of Vater cancer (AoVCa) remain controversial. This study was conducted to confirm the oncological effects of adjuvant chemotherapy after surgery in patients who underwent radical surgery with AoVCa.

METHODS: For this study, data about clinical pathological characteristics, postoperative chemotherapy, and long-term survival from 306 AoVCa patients who underwent surgical pancreaticoduodenal resection from 2005 to 2019 were retrospectively and reviewed.

RESULTS: Patients were classified into groups that received adjuvant chemotherapy (n = 124, 40.5%) and those who did not (n = 182, 59.5%). There were significant differences in Cancer stage (p < 0.001), lymph node involvement (p < 0.001), PNI (p < 0.001), LVI (p < 0.001), and cancer differentiation (p = 0.010). As a result, relatively low long-term survival (p < 0.001) was found in the group received adjuvant chemotherapy. As a result of multivariate analysis based on univariate analysis of patient’s survival, factors affecting the patient’s prognosis include cancer progression, Lymph node involvement (HR = 3.50 [95% CI: 1.76-6.93], p < 0.001), PNI (HR = 1.90 [95% CI: 1.07-3.40], p = 0.029), LVI (HR = 1.83 [95% CI: 1.00-3.36], p = 0.052), cancer differentiation, but the presence of adjuvant chemotherapy does not have a significantly affect the patient’s long-term survival rate. The regimen of chemotherapy did not show any significant statistics related to patient survival (p = 0.629).

CONCLUSIONS: The oncological effect of adjuvant chemotherapy after surgery in resected AoVCa patients is not clear and will remain controversial in the future. In order to improve the therapeutic outcome of resected AoVCa, it is urgent to develop effective anticancer treatment methods for patients with risk factors.

PMID:34230287 | DOI:10.14701/ahbps.EP-191

Ann Hepatobiliary Pancreat Surg. 2021 Jun 30;25(Suppl 1):S296. doi: 10.14701/ahbps.EP-95.

ABSTRACT

INTRODUCTION: Avicularin is a flavonoidal class chemical basically composed with quercetin-3-α-l-arabino furanoside present in Lindera erythrocarpa, Rhododendron schlipenbachii and Psidium guajava. Avicularin protect hepatocytes against oxidative stress.

METHODS: Various literature databases have been searched to collect the needed information of avicularin for their biological importance against chronic and hepatic complication. All the literature data’s have been evaluated statistically for their protective role in liver disorders through different experimental models. Avicularin has been considered as a potent anti-inflammatory agent, so here in this study scientific literature databases analysis have been performed to know their biological importance on liver complication. Biological importance interleukin (IL-1β, IL-6) and tumor necrosis factor alpha (TNF-alpha) for the development of better drug against liver disorders have been also investigated through literature databases analysis.

RESULTS: Biological importance of avicularin on various model of inflammation were studied and found to be significant against various types of inflammatory disorders through literature databases analysis. Molecular study revealed the biological importance of IL-1β and IL-6 in the medicine for the treatment of liver disorders. Further importance of TNF-alpha in the medicine supports the molecular mechanism for their anti-inflammatory properties. From the literature data analysis, avicularin showed anti-inflammatory and anti-oxidant activities which are the main parameter for the treatment of inflammatory disorders of the liver.

CONCLUSIONS: Present work describes the biological importance of avicularin and their efficacy in chronic inflammatory disorders of Hepatic system. This work also describes mechanistic study of the anti-inflammatory properties of avicularin in biological system.

PMID:34230252 | DOI:10.14701/ahbps.EP-95