Preoperative Total Bilirubin Level Research Articles

Recurrence of common bile duct stones after choledocholithotomy in elderly patients: risk factor analysis and clinical prediction model development.

The reasons for the recurrence of common bile duct stones (CBDS) in elderly patients after choledocholithotomy are still unclear. This study aims to establish a prediction model for CBDS recurrence by identifying risk factors. We conducted a retrospective analysis of 1804 elderly patients aged 65 years and above who were diagnosed to have CBDS and were admitted to Nanjing First Hospital between January 1, 2010, and January 1, 2021. According to inclusion and exclusion criteria, 706 patients were selected for the final analysis. The patients were assigned to two groups according to the presence or absence of CBDS recurrence, and their clinical data were then statistically analyzed. Subsequently, a prediction model and nomogram were developed, evaluating effectiveness using the concordance index (C-index). Of the 706 elderly patients, 62 patients experienced CBDS recurrence after surgery, resulting in a recurrence rate of 8.8%. The multivariate Cox analysis showed that prior history of cholecystectomy (hazard ratio [HR] = 1.931, 95% confidence interval [CI]: 1.051-3.547, p = 0.034), white blood cell (WBC) count ≥11.0 × 109/L (HR = 2.923, 95% CI: 1.723-4.957, p < 0.001), preoperative total bilirubin (TBIL) level ≥ 36.5 mmol/L (HR = 2.172, 95% CI: 1.296-3.639, p = 0.003), number of stones ≥2 (HR = 2.093, 95% CI: 1.592-5.294, p = 0.001), maximum stone diameter ≥ 0.85 cm (HR = 1.940, 95% CI: 1.090-3.452, p = 0.024), and T-tube drainage (HR = 2.718, 95% CI: 1.230-6.010, p = 0.013) were independent risk factors of CBDS recurrence in elderly patients after choledocholithotomy. A postoperative CBDS recurrence prediction model was constructed with a C-index value of 0.758 (95% CI: 0.698-0.818) and internal validation value of 0.758 (95% CI: 0.641-0.875). A history of cholecystectomy, WBC count ≥11.0 × 109/L, preoperative TBIL level ≥ 36.5 mmol/L, number of stones ≥2, maximum stone diameter ≥ 0.85 cm, and T-tube drainage are the independent risk factors of CBDS recurrence after choledocholithotomy in elderly patients. Our developed prediction model for CBDS recurrence has good predictive ability and can help predict the prognosis of patients with CBDS.

Impact of patent foramen ovale on short-term outcomes in children with biliary atresia undergoing living donor liver transplantation: a retrospective cohort study

ObjectiveTo investigate the impact of patent foramen ovale (PFO) on the short-term outcomes of living donor liver transplantation (LDLT) in children with biliary atresia.MethodsWith the approval of the hospital ethics committee, 304 children with biliary atresia who underwent LDLT in our center from January 2020 to December 2021 were enrolled. According to the results of echocardiography before the operation, the subjects were divided into the PFO group (n = 73) and the NoPFO group (n = 231). The baseline characteristics; intraoperative recipient-related data and donor-related data; incidence of postreperfusion syndrome (PRS); postoperative mechanical ventilation time; ICU stay duration; postoperative hospital stay duration; liver function index; incidences of postoperative complications including acute renal injury (AKI), graft dysfunction, hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT); and one-year survival rate were compared between the two groups.ResultsThe median age in the PFO group was 6 months and that in the NoPFO group was 9 months (P < 0.001), and the median height (65 cm) and weight (6.5 kg) in the PFO group were significantly lower than those in the NoPFO group (68 cm, 8.0 kg) (P < 0.001). The preoperative total bilirubin level (247 vs. 202 umol/L, P = 0.007) and pediatric end-stage liver disease (PELD) score (21 vs. 16, P = 0.001) in the PFO group were higher than those in the NoPFO group. There were no significant differences in the intraoperative PRS incidence (46.6% vs. 42.4%, P = 0.533 ), postoperative mechanical ventilation time (184 vs. 220 min, P = 0.533), ICU stay duration (3.0 vs. 2.5 d, P = 0.267), postoperative hospital stay duration (22 vs. 21 d, P = 0.138), AKI incidence (19.2% vs. 24.7%, P = 0.333), graft dysfunction incidence (11.0% vs. 12.6%, P = 0.716), HAT incidence (5.5% vs. 4.8%, P = 0.762), PVT incidence (2.7% vs. 2.2%, P = 0.675) or one-year survival rate (94.5% vs. 95.7%, P = 0.929) between the two groups.ConclusionThe presence of PFO has no negative impact on short-term outcomes in children with biliary atresia after LDLT.

Postoperative pancreatic fistula after pancreaticoduodenectomy: if you lack knowledge of what to search for, you will be unable to locate what you desire.

Postoperative pancreatic fistula (POPF) is the most common and critical complication of pancreatoduodenectomy (PD). In this study, we aimed to define preoperative, perioperative, and postoperative conditions that may cause POPF and examine the predictive value of drain fluid amylase (DFA) values in showing the clinical severity of POPF. Between December 2018 and December 2019, 49 patients who underwent PD for malignant reasons by a single team were retrospectively analyzed. Patients with benign indications, vascular reconstruction, preoperative biliary drainage catheterization, resectable liver metastases, POPF that occurred after reoperation, and patients undergoing neoadjuvant oncological treatment were excluded from the study. The patients were divided into two groups developing (FP) and non-developing (FN) POPF. There was no difference between the groups in terms of gender (p=0.781), age (p=0.219), American Society of Anesthesiologists (ASA) score (p=0.338), and comorbidity status (p=0.219). The mean body mass index (BMI) kg/m2 values of the patients in the FN and FP groups were 25.2±4.0 kg/m2 and 27.4±2.6 kg/m2, respectively (p=0.042). An increased BMI increases the risk of POPF. Preoperative prognostic nutritional index (PNI) score (p=0.588), preoperative total bilirubin level (p=0.707), pancreatic duct diameter (p=0.334), pancreatic texture (p=0.334), operation time (p=0.659) do not pose a risk for POPF. Increased perioperative bleeding amounted to a risk for POPF (123.8±46.7 ml, 244.7±66.3 ml in FN and FP groups, respectively, p=0.024). Drain fluid amylase (DFA) values (p<0.001, p=0.043, p=0.019, respectively) were found to be high in patients with POPF on postoperative days 1, 4, and 7. Increased BMI and excess perioperative blood loss increase the risk of POPF. DFA level is an easily applicable method that provides early diagnosis for POPF.

Hyperbilirubinemia has Predictive Potential for the Diagnosis of Appendiceal Perforation

Background: Acute appendicitis is an inflammation of the vermiform appendix. Usually, the diagnosis is made on clinical evaluation and elevated leukocyte count (TLC). But in cases when the clinical diagnosis is indeterminate, additional assessment needs imaging. Despite the increased use of modern diagnostic modalities such as Sonography, computed tomography (CT), and diagnostic laparoscopy, the frequency of misdiagnosis of appendicitis has remained constant (15%) as has the rate of appendiceal rupture. Presently, some serum markers such as C-reactive protein (CRP), lactate, and bilirubin have been proposed as a diagnostic tools for appendicitis. When compared CRP, TLC and lactate are found less explicit than bilirubin as predictive markers for acute appendicitis and its complications. Objective: To determine the diagnostic accuracy of hyperbilirubinemia in diagnosing perforated appendix by taking per-operative findings as the gold standard. Material &amp; methods: It is a cross-sectional survey conducted at the Surgery department at PAF Hospital Mushaf, Sargodha. The duration of the study was from 1st June 2018 to 1st December 2018. A total of 160 patients of both gender with acute appendicitis with Alvarado Score ≥ 7 were included. Patients with age less than 12 years, HBsAg &amp; anti-HCV positive, history of jaundice, history of liver disease (e.g.: Crigler-Najjar, Gilbert syndrome, cirrhosis, hepatitis), the patient is alcoholic, history of hemolytic disorders (e.g.: thalassemia, spherocytosis), history of the biliary disease (e.g.: biliary stones, worm infestation, atresia, etc), history of gastrointestinal&amp; hepato-pancreato biliary malignancy, patient with appendicular mass per-operatively and appendectomy performed incidentally or for other indications were excluded. All patients were tested by routine laboratory investigations including LFTs hyperbilirubinemia was recorded. All cases underwent appendectomy by the same surgical team&amp; peri-operative findings were recorded &amp; compared with pre-operative total bilirubin levels. Patients were categorized as true positive, true negative, false positive &amp; false negative. Results: The age range in this study was from 12 to 60 years with a mean age of 35.231± 8.63 years and mean Pre-Op Bilirubin Levels was 0.812±0.72 mg/dl. Laboratory Findings (Bilirubin levels ≥ 1mg/dl) diagnosed 44(27.5%) patients and Per Operative Findings diagnosed 60(37.5%) patients with Perforated Appendix. Laboratory Findings (Bilirubin levels ≥ 1mg/dl) have shown a sensitivity of 50%, specificity of 86%, the diagnostic accuracy of 73%, PPV 68.18%, NPV 74.4%, (p=0.000) in the diagnosis of Perforated Appendix. Conclusion: It is concluded that serum bilirubin level was higher in patients with appendiceal perforation, it s a definite predictive potential in these cases. Therefore, acquiring SB values upon admission can be used in combination with more recent diagnostic tests such as CT scans n, ultrasonography to help determine the presence of perforation and thus assist in timely clinical management. Keywords: Perforated appendix, Hyperbilirubinemia, Diagnostic accuracy

Hyperbilirubinemia after surgical repair for acute type a aortic dissection: A propensity score-matched analysis.

Background: Inflammation and oxidative stress are known to participate in the pathogenesis of hyperbilirubinemia. It has been known that acute type A aortic dissection (ATAAD) surgical repair often associates with complications which might affect the long-term prognosis. However, the clinical significance of postoperative hyperbilirubinemia (PH) has not been evaluated. Here in this study, we examined the incidence, risk factors, and prognosis of PH after ATAAD surgery. Methods: This retrospective study enrolled a total of 970 patients who received ATAAD surgical repair from January 2014 to December 2019. PH was defined as serum total bilirubin >3.0 mg/dl within the first week after the surgery. Propensity score matching was used to reduce selection bias and eliminate potential confounding factors. Kaplan–Meier survival and Cox proportional hazards regression analyses were conducted to explore the association between PH and postoperative long-term survival. Results: Development of PH (183 patients) was associated with a higher 30-Day mortality (20.8% vs. 9.0%, p < 0.001). Advanced age [odds ratio (OR) 1.538, p = 0.006], higher baseline total bilirubin level (OR 1.735, p = 0.026), preoperative pericardial tamponade (OR 3.192, p = 0.024), prolonged cardiopulmonary bypass (CPB) duration (OR 2.008, p = 0.005), and elevated postoperative central venous pressure (CVP) level (OR 2.183, p < 0.001) were associated with PH. The Kaplan-Meier analysis showed patients who developed PH were associated with poor long-term survival (p = 0.044). Cox analysis showed that the presence of PH (hazard ratio 2.006, p = 0.003) was an independent risk factor for increased mortality. Conclusion: PH is a common complication in patients undergoing ATAAD surgical repair that associates with worse short- and long-term prognosis. Our data indicated that age, preoperative total bilirubin level, pericardial tamponade, CPB duration, and postoperative CVP level were risk factors for the development of PH.

Analysis of the Bacterial Spectrum and Key Clinical Factors of Biliary Tract Infection in Patients with Malignant Obstructive Jaundice after PTCD.

Objective To analyze the bacterial spectrum and key clinical factors associated with biliary tract infections following percutaneous transhepatic cholangial drainage (PTCD) for malignant obstructive jaundice (MOJ). Methods This retrospective study comprised patients with MOJ who were treated with PTCD from 1st June 2016 to 31st December 2020. Patient clinical data, development of postprocedure biliary tract infections, spectrum of pathogenic bacteria, and drug sensitivity were analyzed, focusing on antibiotic drug resistance and identifying key associated risk factors for postoperative biliary tract infections. Results Of the 528 study patients, 80 were diagnosed with postoperative biliary tract infections, 58 of whom had pathogenic bacteria detected in their bile samples. A total of 90 strains of pathogenic bacteria and 3 strains of fungi were detected; the top 4 were Escherichia coli, Klebsiella pneumoniae, Enterococcus faecium, and Pseudomonas aeruginosa. By univariate analysis, a positive bile culture following PTCD was closely correlated with both the location and degree of preoperative obstruction and the preoperative bilirubin level. Moreover, the results of logistic regression analysis concluded that complete obstruction and a high preoperative total bilirubin level prior to PTCD were independent risk factors for a positive bile culture following PTCD. Conclusion Biliary tract infections following PTCD for MOJ were principally due to Escherichia coli, and bacteria in the bile were statistically more likely to be detected in patients with complete obstruction and high preoperative bilirubin levels.

A Non-Linear Relationship between Preoperative Total Bilirubin Level and Postoperative Delirium Incidence after Liver Transplantation.

This study aimed to explore the correlation between preoperative total bilirubin (TBil) level and postoperative delirium (POD) in orthotopic liver transplantation (OLT). All the OLT consecutively performed between April 2019 and March 2021 were retrospectively reviewed with data retrieved from a prospectively collected database. Logistic regression model and generalized additive model were used to identify both linear and non-linear relationships between TBil and POD. A two-piecewise regression model was performed to calculate the saturation effect. Subgroup analyses were performed using stratified logistic regression models. A total of 402 recipients were enrolled. After fully adjusted for covariates, TBil was indicated to have a non-linear relationship with POD. The two-piecewise regression model showed the inflection point was 20 mg/dL. On the left side of the inflection point, the incidence of POD increased by 5% per 1 mg/dL increment of TBil (p = 0.026). On the right side of the inflection point, the effect size had no statistical significance (OR, 0.97; 95% CI, 0.90–1.05; p = 0.482). The relationship between preoperative TBil level and POD incidence is non-linear in OLT recipients. The incidence of POD is positively correlated with TBil level when it is below 20 mg/dL. A saturation effect is observed when TBil level reaches 20 mg/dL.

The impact of preoperative biliary drainage on postoperative outcomes in patients with malignant obstructive jaundice: a retrospective analysis of 290 consecutive cases at a single medical center

BackgroundThe efficacy of preoperative biliary drainage (PBD) has been debated for several decades, and yet indications for PBD remain controversial. The aim of this study was to compare the postoperative morbidity and mortality in patients with malignant obstructive jaundice undergoing direct surgery versus surgery with PBD.MethodsAll consecutive patients with malignant obstructive jaundice who underwent radical resection between June 2017 and December 2019 at Zhongshan Hospital were analyzed retrospectively. The study population was divided into two groups: PBD group (PG) and direct surgery group (DG). The subgroups were chosen based on the site of obstruction. Perioperative indicators and postoperative complications were compared and analyzed.ResultsA total of 290 patients were analyzed. Postoperative complications occurred in 134 patients (46.4%). Patients in the PG group had a lower overall rate of postoperative complications compared with the DG group, with perioperative total bilirubin (TB) identified as an independent risk factor in multivariate analysis (hazard ratio = 1.004; 95% confidence interval 1.001–1.007; P = 0.017). Subgroup analysis showed that PBD reduced the complication rate in patients with proximal obstruction. In the proximal-obstruction subgroup, a preoperative TB level > 162 μmol/L predicted postoperative complications.ConclusionsPBD may reduce the overall rate of postoperative complications among patients with proximal malignant obstructive jaundice.Trial registrationClinicalTrials.gov, 2018ZSLC 24. Registered May 17, 2018, https://clinicaltrials.gov/.

Risk factors analysis of hyperbilirubinemia after off-pump coronary artery bypass grafting: a retrospective observational study

BackgroundHyperbilirubinemia is a common complication after off-pump coronary artery bypass grafting (OPCAB), but the incidence and the risk factors are unclear. This study aimed to analyze the incidence and risk factors of postoperative hyperbilirubinemia in patients undergoing OPCAB.MethodsFrom December 2016 to March 2019, a total of 416 consecutive patients undergoing OPCAB were enrolled in this single-center retrospective study. Patients were divided into the normal serum total bilirubin group and the hyperbilirubinemia group based on the serum total bilirubin levels. Perioperative variables between the two groups were compared by univariate logistic regression analysis. Then, multivariate binary logistic regression analysis was used to analyze the independent risk factors of developing hyperbilirubinemia in patients underwent OPCAB. P < 0.05 was considered as statistically significant.ResultsThirty two of 416 (7.7%) patients developed postoperative hyperbilirubinemia. Univariate regression analysis showed significant differences in gender (73.96% vs. 93.75%, P = 0.012), preoperative total bilirubin levels (11.92 ± 4.52 vs. 18.28 ± 7.57, P < 0.001), perioperative IABP implantation (22.66% vs. 43.75%, P = 0.008), perioperative blood transfusion (37.50% vs. 56.25%, P = 0.037) between the two groups. Multivariate logistic regression analysis revealed that elevated preoperative serum total bilirubin levels (OR = 1.225, 95% CI 1.145–1.310, P < 0.001), perioperative blood transfusion (OR = 4.488, 95% CI 1.876–10.737, P = 0.001) and perioperative IABP implantation (OR = 4.016, 95% CI 1.709–9.439, P = 0.001) were independent risk factors for hyperbilirubinemia after OPCAB.ConclusionsHyperbilirubinemia is also a common complication after OPCAB. Elevated preoperative serum total bilirubin levels, perioperative blood transfusion, and perioperative IABP implantation were independent risk factors for patients developing hyperbilirubinemia after OPCAB. Further studies need to be conducted to confirm the risk factors of hyperbilirubinemia after OPCAB procedure.

Retrospective non-inferiority study of preoperative bilirubin level on surgical outcomes in hepatectomy with hilar resection

Elevated preoperative bilirubin affects the morbidity and mortality significantly in biliary tract surgery. Routine preoperative biliary drainage has been suggested and bilirubin level has been kept lower than 3 mg/dL before a major hepatectomy with hilar resection. However, the serum bilirubin may affected with the undrained liver lobe. The target bilirubin level less than 3 mg/dL probably unnecessary in all patients. To study the association of preoperative bilirubin level with post-operative complications and mortality. There were 51 and 30 patients in group A and B. The operative blood loss was higher in group B but there was no significant difference. The incidence of post hepatectomy liver failure was comparable in group A and B [3.92% vs. 3.33% (p = 0.898)]. There was no significant different of 30-day mortality and 1-year survival between group A and B [3.92% vs. 6.67% (p = 0.624) and 76.47 vs. 73.33 (p = 0.536)]. Multivariate analysis revealed significant factors that associated with mortality were post hepatectomy liver failure adjusted hazard ratio = 93.70 (p < 0.001). The surgical outcome in patients who have preoperative total bilirubin level between 3 and 10 mg/dL are non-inferior to bilirubin less than 3 mg/dL. Post hepatectomy liver failure is the independent factor that associated with postoperative mortality which relate to other factors such as future remnant liver volume or major complication.

Alpha-fetoprotein level to total tumor volume as a predictor of hepatocellular carcinoma recurrence after resection. A retrospective cohort study

BackgroundTotal tumor volume (TTV) and serum alfa fetoprotein (AFP) level are important risk factors linked with the high possibility of hepatocellular carcinoma (HCC) recurrence. The aim of the study was to evaluate the role of AFP/TTV ratio, as a prognostic marker, in the prediction of HCC recurrence after resection. MethodsPatients who underwent liver resection for HCC between 2010 and 2018 were retrospectively analyzed. Patients were divided into 2 groups; a group with AFP/TTV ≤2 and another group with AFP/TTV >2. Risk factors for HCC recurrence were recorded. ResultsA total of 286 HCC patients underwent liver resection (184 patients with AFP/TTV ≤ 2, and 102 patients with AFP/TTV > 2). There was a significant difference between the 2 groups in the preoperative total bilirubin level, serum AFP level, mean tumor diameter, TTV, operative blood loss, microvascular invasion and hospital stay (all P values < 0.05). The 1-, 3-, and 5-year tumor recurrence rates were 24.1%, 43%, and 57.6% respectively. The independent risk factors for tumor recurrence were AFP/TTV >2 (HR = 1.62, 95% CI = 1.29–1.98, P = 0.042), Macrovascular invasion (HR = 2.03, 95% CI = 2.17–2.38, P = 0.021, and microvascular invasion (HR = 1.36, 95% CI = 1.08–1.77, P = 0.019). ConclusionAFP/TTV ratio is a feasible prognostic marker for prediction of HCC recurrence after resection so, it can help in providing an intensive postoperative surveillance program to high risk patients for early detection and management of any recurrence.

Surgery for Hepatolithiasis: Single Center Experience of 12 Patients

Hepatolithiasis is the presence of stones within the intrahepatic bile ducts, regardless of common bile duct and gallbladder stones. It is rarely seen in our country and has been presented only as case reports in the literature. There are many treatment methods ranging from percutaneous drainage to liver transplantation. In this study, we aimed to present our relevant surgical experience to the literature, as a hepatobiliary center. Twelve patients operated for hepatolithiasis between 2013–2019 were included in this study. Data were obtained retrospectively by scanning patient files. Of the 12 patients included in the study, ten (83%) were female and two (17%) were male. The median age was 59 (31–78) years. The mean length of stay in hospital was 24.1 (7–54) days. ERCP was performed in five (45%) patients before the operation due to choledocholithiasis. Preoperative PTC was performed in one patient due to elevated bilirubin. This patient underwent choledochoduedenostomy and ERCP because of biliary stenosis following previous gallbladder operation. Preoperative total bilirubin levels were normal in all the patients except one patient (8.3%) with elevated level (3.3 mg/dl). Preoperative CRP level was found to be high in ten (83%) patients with a mean value of 79.5 (1–438) mg/L. Hepatolithiasis is most commonly seen in the left lateral segment, although it may involve any segment of the liver. Residual stones were observed in one patient (8.3%). In this patient, postoperative PTC was performed and the stones were pushed down to the bowel lumen. Removal of the stones and resection of the affected liver segment is the best choice in the treatment of hepatolithiasis. However, residual stone fragments may remain in the early postoperative period or recurrence may occur later during follow up period. ERCP and/or PTC may be needed for the treatment of such conditions. For this reason, a multidisciplinary approach is required for the surgical treatment of hepatolithiasis patients, involving gastroenterology and interventional radiology.

Analysis of the curative effect and prognosis factors of surgical treatment for hilar cholangiocarcinoma

Objective To exlore and analyze the curative effect and pognostic factors of surgical treatment for hilar cholangiocarcinoma. Methods The clinical data and prognosis of 92 patients with hilar cholangiocarcinoma admitted to Anhui Provincial Hospital Affiliated to Anhui Medical University from January 2010 to January 2018 were retrospectively analyzed. There were 58 males and 34 females, with an age range of 35-81 years and average age of 61.3 years. Among them, 50 patients underwent radical resection of tumors (radical operation group), and 42 patients were discussed to undergo radical operation before operation, but only palliative resection of tumors or simple biliary drainage (palliative operation group) were performed because of the high location of tumors or distant metastasis during operation. Of the 50 patients who received radical surgery, 27 underwent simple perihepatic portectomy (perihepatic hilar resection group), and 23 underwent combined hepatic lobectomy (extended hepatectomy group). The incidence of perioperative complications, perioperative mortality and long-term survival rate of all patients were collected. The data of clinical cases included in the study were analyzed by univariate and multivariate analysis, and the relationship between perioperative mortality and prognosis survival time was discussed. The measurement data that accord with normal distribution were expressed by (Mean±SD). The comparison between the two groups was performed by t-test, the comparison between multiple groups was performed by one-way ANOVA; Measurement data with non-normal distribution were described as M(P25, P75), and comparison between groups was done using Mann-Whitney U test. The comparison between counting data groups was performed by chi-square test. Results Ninety-two patients included in this study successfully completed the operation. One patient died during the perioperative period, with a mortality rate of 1.09%. The incidence of complications was 35.87%. Biliary tract infection and bile leakage were the most common complications. The incidence of complications was 14.13%(13/92) and 9.78%(9/92) respectively. The survival time of patients in the radical operation group 34.23(13.00, 52.25) months was significantly different from that in the palliative operation group 4.75(2.88, 7.25) months (Z=-6.708, P=0.000). There was no significant difference in the survival time between the extended hepatectomy group 33.87(13.00, 56.00) months and the simple perihepatectomy group 34.54(13.00, 51.00) months (Z=-0.156, P=0.876). Univariate analysis showed that the factors related to the prognosis of hilar cholangiocarcinoma were preoperative history of calculi, tumor size, preoperative highest serum total bilirubin level, preoperative CA19-9 level, surgical modality and tumor differentiation(HR=0.200, 2.692, 2.942, 4.350, 3.740, 0.198; 95%CI: 0.043-0.938, 0.995-7.283, 1.022-8.469, 1.174-16.114, 1.229-11.382, 0.049~0.806, P<0.05). Multivariate analysis showed that tumor size, tumor differentiation and surgical modality were related to hilar cholangiocarcinoma. Surgical prognosis of patients with cholangiocarcinoma was significantly correlated(OR=1.034, 6.444, 12.527; 95%CI: 1.007-1.062, 1.012-41.037, 3.187-49.243, P<0.05). Conclusions Radical resection is an effective way to improve the survival of patients with hilar cholangiocarcinoma. The effective grasp of surgical indications can improve the overall treatment prognosis. Key words: Bile duct neoplasms; Surgical procedures, operative; Prognosis; Treatment outcome; Complications

Five-year native liver survival analysis in biliary atresia from a single large Chinese center: The death/liver transplantation hazard change and the importance of rapid early clearance of jaundice

PurposeThis study aimed to analyze the change of death/liver transplantation hazard and biochemical indexes over time after Kasai procedure (KP) based on a retrospective biliary atresia (BA) cohort, and to evaluate the predictive value of early jaundice clearance rate to 5-year native liver survival (NLS). MethodsA retrospective cohort with follow-up results of 139 BA patients from January 2009 to December 2012 was established, and the pre- and postoperative data were collected. NLS rates were estimated with Kaplan–Meier curves, and any differences between groups were tested by log-rank test. Hazard curve of death/liver transplantation was fitted with Weibull distribution, and hazards at certain time points were calculated. Trend charts of biochemical indexes were drawn to show any changes over time. Rate of jaundice clearance was indicated as the proportion of decreased total bilirubin level at a certain postoperative time point to preoperative total bilirubin level. In multivariate analysis for prediction of 5-year NLS, COX proportional hazard regression model was used and results were expressed as hazard ratios with 95% confidence intervals (CIs). The predictive value of early jaundice clearance rates for 5-year NLS was analyzed by receiver operating characteristic (ROC) curve, and a cut-off value of 4-week jaundice clearance rate was determined. ResultsThe estimated 5-year NLS rate of the 139 patients was 58.0%. The patients had a high hazard of death/liver transplantation early after KP, which gradually decreased and stabilized at a lower level 1 year later. Most death/liver transplantation events occurred within 1 year after KP. The total bilirubin (TBIL), direct bilirubin (DBIL) and total bile acid (TBA) levels of successful Kasai group decreased continuously after KP, and the biggest decline was seen in the first month. The aspartate aminotransferase (AST), alanine aminotransferase (ALT) and γ-glutamyl transpeptidase (GGT) levels increased during the first month after KP and decreased continuously thereafter. All the biochemical indexes of successful Kasai group tended to stabilize within/close to normal range 1 year after KP. On the contrary, all the biochemical indexes of failed Kasai group fluctuated at obvious abnormal levels after KP. The estimated 5-year NLS rates of successful Kasai group and failed Kasai group were 90.1% and 10.7% (p = 0.000). The most significant clinical protective factor of 5-year NLS was 4-week jaundice clearance rate, revealed by COX proportional hazard regression model, and the HR was 0.089 (95%CI 0.018–0.432, p = 0.003). In predicting 5-year native liver survival, the largest area under ROC (AUROC) curve belonged to 4-week jaundice clearance rate, which was 0.731 (p = 0.000). A cut-off value of 0.457 was determined, with sensitivity 0.827, specificity 0.552, positive predictive value 0.720, and negative predictive value 0.696. NLS rates of patients divided by cut-off value showed significant statistical difference demonstrated by Kaplan–Meier curve and log-rank test (p = 0.000). ConclusionsThe 5-year death/liver transplantation hazard of biliary atresia patients reduces greatly and stabilizes 1 year after KP. A successful KP enables patients to achieve long-term stable normal biochemical indexes. A rapid clearance of jaundice is of great positive significance to 5-year NLS, and the 4-week jaundice clearance rate is of some predictive value. Type of studyPrognosis study. Level of evidenceLevel II, retrospective study.

Evolution of surgery for Klatskin tumor demonstrates improved outcome: a single center analysis.

The rapid development of the Chinese economy has enabled advances to be made in the surgical treatment of Klatskin tumors. We retrospectively reviewed the surgical outcomes of hilar cholangiocarcinoma at a single Chinese center, focusing on the surgical procedures, radicality of the operative procedure (R0, R1 or R2), survival rates, and independent prognostic factors. This objective of the analysis was to evaluate improvements in perioperative and long-term outcomes of surgical resection of Klatskin tumors. Between January 1998 and December 2007, 131 consecutive patients underwent operative resection for Klatskin tumor at Tianjin Medical University General Hospital, Tianjin, China. Clinicopathological data were analyzed to assess their impact on survival. The overall 3- and 5-year survival rates were 46% and 22%, respectively. Median overall survival for the entire cohort was 35 months. Survival increased progressively between 1998 and 2007. Preoperative biliary drainage represents a safe strategy before hepatectomy for hilar cholangiocarcinoma in patients with jaundice. Patients who underwent liver resection achieved significantly higher R0 rates than those undergoing biliary resection only. Preoperative total bilirubin level, lymph node metastasis and degree of radicality (R1 and 2 vs R0) were found to be independent factors that negatively affected overall survival. Surgical resection remains the mainstay of treatment for hilar cholangiocarcinoma. Development in surgical equipment, techniques, and perioperative management have increased long-term survival after curative liver resection, despite the more aggressive surgical procedures that are being performed.

Acute kidney injury after pediatric liver transplantation: incidence, risk factors, and association with outcome.

Data on the incidence of, risk factors for, and association with outcomes of acute kidney injury (AKI) after pediatric liver transplantation are scarce. We conducted a retrospective cohort study to determine the incidence of AKI after pediatric liver transplantation. In addition, we examined risk factors for AKI and association of AKI with outcomes. This study included 156 children aged between 3months and 18years undergoing liver transplantation at Kyoto University Hospital. AKI was defined according to the Kidney Disease: Improving Global Outcomes guidelines based on serum creatinine and urine output. We used multivariable logistic regression with stepwise variable selection to identify independent risk factors for AKI. AKI occurred in 72 patients (46.2%); 34 (21.8%) had stage 1, 32 (20.5%) had stage 2, and 6 (3.8%) had stage 3 AKI. Factors independently associated with the development of AKI were increased preoperative total bilirubin level (adjusted odds ratio, 1.04 per 1mg/dl; 95% confidence interval, 1.01-1.09; P=0.026) and increased intraoperative blood loss (adjusted odds ratio, 1.03 per 10ml/kg; 95% confidence interval, 1.00-1.06; P=0.022). AKI was significantly associated with prolonged hospitalization (median, 61 vs. 46days; P=0.028). In-hospital mortality rate was 4.2% in patients with AKI and 3.6% in those without AKI (P=1.000). The incidence of AKI after pediatric liver transplantation was 46.2%. Increased preoperative total bilirubin level and increased intraoperative blood loss were independently associated with the development of AKI. AKI was associated with prolonged hospitalization.

Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma

The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA. This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at 2 centers, from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of hepatic insufficiency and liver failure-related death. The study included 133 patients with right or left major (n= 67) or extended (n= 66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III to IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them from liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p < 0.05) were preoperative cholangitis (odds ratio [OR] 3.2), future liver remnant (FLR) volume < 30% (OR 3.5), preoperative total bilirubin level >3 mg/dL (OR 4), and albumin level <3.5 mg/dL (OR 3.3). Only preoperative cholangitis (OR 7.5, p= 0.016) and FLR volume <30% (OR 7.2, p= 0.019) predicted postoperative liver failure-related death. Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure-related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.

Risk factors of morbidity and predictors of long-term survival after hepatopancreatoduodenectomy for biliary cancer.

Hepatopancreatoduodenectomy (HPD) is performed to achieve radical resection of malignant biliary tumors. We reviewed clinical outcomes to evaluate the utility of HPD in terms of morbidity and mortality. A retrospective analysis was conducted on 17 patients underwent HPD between August 1991 and May 2013; 9 bile duct cancer, 5 advanced gallbladder and 3 pancreatic tumor with liver metastasis. The morbidity and mortality rates were 88.3% and 0%, respectively. Univariate analysis showed that a body mass index of ≥22 and preoperative total bilirubin level ≥0.8 mg/dl were significantly associated with severe complications. One-, 3- and 5-year survival rate were 73.3%, 60.0% and 30.0%. In 14 patients with biliary carcinoma, univariate analysis showed that a histological grade of G1 was significantly associated with survival. Patients without pancreatic invasion or portal vein invasion tended to survive longer than patients with these types of invasion, although the difference was not significant. HPD can be performed with no mortality and provides a survival benefit for some patients with biliary carcinoma undergoing curative resection. In patients with grade G1 biliary carcinoma without pancreatic or portal vein invasion in particular, this aggressive surgery might offer a chance of long-term survival.

Postoperative hepatitis B virus reactivation and surgery-induced immunosuppression in patients with hepatitis B-related hepatocellular carcinoma.

Hepatectomy in hepatocellular carcinoma (HCC) patients lead to postoperative hepatitis B virus (HBV) reactivation (PHR) as well as immunosuppression. This prospective study involved 135 HBV-related HCC patients and 42 control hepatic hemangioma patients. Among HCC patients, 26 (19.3%) suffered PHR. Risk factors for PHR were HBV-cAg S1 positivity [hazard ratio (HR) = 404.82, P = 0.004], high preoperative total bilirubin level (HR = 186.38, P = 0.036), small preoperative proportions of CD3-CD16 + CD56 + cells (HR = 0.01, P = 0.014) and CD19 + B cells (HR = 0.02, P = 0.016), blood transfusion (HR = 157.03, P = 0.006) and high liver cirrhosis S score (HR = 270.45, P = 0.004). On postoperative day (POD) 3, PHR patients showed much greater immunosuppression than non-PHR patients based on proportions of T cells (CD3+, CD3 + CD4+, CD3 + CD8+), B cells (CD19+) and on levels of IgG, IgA antibodies, complement proteins C3, and C4. By POD 7, PHR patients had partially recovered but not as quickly as non-PHR patients: PHR patients still showed deficits in T cells (CD3+, CD3 + CD4+), CD3-CD16 + CD56+ cells and in levels of IgM, C3, C4, and C-reactive protein. PHR may be associated with resection-induced immunosuppression in patients with HBV-related HCC.

Liver transplantation from living donors with Gilbert's syndrome is a safe procedure for both donors and recipients.

Liver transplantation (LT) has become a favorable therapeutic option for patients with end-stage liver diseases. Gilbert's syndrome (GS) is a benign condition characterized by intermittent mild jaundice due to unconjugated hyperbilirubinemia. It is not obvious whether living-donor liver transplantation (LDLT) from a donor with GS could result in a normal outcome for both the recipient and the donor. We aimed to determine whether right lobe hepatectomy is a safe procedure for living donors with GS and LT recipients. Between September 2011 and March 2015, 305 LDLT procedures using right lobe grafts were performed at Atasehir Memorial Hospital, Istanbul, Turkey. Nineteen of 305 LT candidates who had been diagnosed with GS were included in the current study. After a 12-h overnight fast, total and indirect bilirubin levels of donors and recipients were measured. The median follow-up after transplant was 16 months (range 3-36 months). The median age of donors was 25 (range 20-55 yr). Four donors (21%) were female, and 15 donors (89%) were male. The median age of donors was 51 (range 23-68 yr). Eleven recipients (57%) were female, and 8 (43%) were male. The median preoperative total bilirubin level of donors was 1.69 mg/dL (range 1.26-2.43 mg/dL) (normal range <1.2 mg/dL). The median total bilirubin level of donors on postoperative day 7 was 1.04 mg/dL (range 0.71-3.23 mg/dL). As our study has included a large number of donors with GS, it produced reliable evidence that right lobe hepatectomy is a safe procedure for living donors with GS and LT recipients.