Primary biliary cirrhosis(PBC),which is characterised by progressive destruction of intrahepatic bile ducts,is not a rare disease since both prevalence and incidence are increasing during the last years mainly due to ...Primary biliary cirrhosis(PBC),which is characterised by progressive destruction of intrahepatic bile ducts,is not a rare disease since both prevalence and incidence are increasing during the last years mainly due to the improvement of case finding strategies.The prognosis of the disease has improved due to both the recognition of earlier and indolent cases,and to the wide use of ursodeoxycholic acid(UDCA).New indicators of prog-nosis are available that will be useful especially for the growing number of patients with less severe disease.Most patients are asymptomatic at presentation.Pruri-tus may represent the most distressing symptom and,when UDCA is ineffective,cholestyramine represents the mainstay of treatment.Complications of long-standing cholestasis may be clinically relevant only in very ad-vanced stages.Available data on the effects of UDCA on clinically relevant end points clearly indicate that the drug is able to slow but not to halt the progression of the disease while,in advanced stages,the only thera-peutic option remains liver transplantation.展开更多
Indocyanine green(ICG)fluorescence imaging is widely used in abdominal surgery.The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of op...Indocyanine green(ICG)fluorescence imaging is widely used in abdominal surgery.The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems.In that setting,ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow.The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery.Each type of use has been separately addressed and the evidence was investigated.During rectal resection,ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks.In addition,ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury.This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed.This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature.Although further studies are need to investigate the real clinical benefits,these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.展开更多
BACKGROUND The T-cell costimulation blocking agent belatacept has been identified as a possible substitute for calcineurin inhibitors,however,no consensus has been established against its use over the standard care ag...BACKGROUND The T-cell costimulation blocking agent belatacept has been identified as a possible substitute for calcineurin inhibitors,however,no consensus has been established against its use over the standard care agent Tacrolimus.AIM To evaluate the effectiveness of belatacept based maintenance immunosuppressive regimens in comparison to tacrolimus in renal transplantion.METHODS We did extensive search of all the available literature comparing the role of belatacept to tacrolimus in renal transplant recipients by searching the PubMed,Embase,Cochrane,Crossref,Scopus,clinical trials registry on October 5,2020.RESULTS The literature search identified four randomized controlled trials(n=173 participants)comparing belatacept with tacrolimus.There was no significant difference in estimated renal function at 12 mo[mean difference 4.12 mL/min/1.73 m^(2),confidence interval(CI):-2.18 to 10.42,P=0.20].Further,belatacept group was associated with significant increase in biopsy proven acute rejection[relative risk(RR)=3.27,CI:0.88 to 12.11,P=0.08]and worse 12 mo allograft survival(RR=4.51,CI:1.23 to 16.58,P=0.02).However,incidence of new onset diabetes mellitus was lower with belatacept at 12 mo(RR=0.26,CI:0.07 to 0.99,P=0.05).CONCLUSION The evidence reviewed in this meta-analysis suggested that belatacept-based maintenance immunosuppression regimens were associated with an increased risk allograft loss in renal transplant recipients with equivalent renal functioning against standard tacrolimus;however,observed significantly reduced new onset diabetes mellitus after transplantation incidence and lower serum low density lipid profile levels in belatacept group.In addition,the adaptation of belatacept in renal transplantation has been forestalled by increased rates of rejection and resistance owing to development of various effector memory T cells through,parallel differentiation and immunological plasticity.展开更多
BACKGROUND Hepatobiliary manifestations occur in ulcerative colitis(UC)patients.The effect of laparoscopic restorative proctocolectomy(LRP)with ileal pouch anal anastomosis(IPAA)on hepatobiliary manifestations is deba...BACKGROUND Hepatobiliary manifestations occur in ulcerative colitis(UC)patients.The effect of laparoscopic restorative proctocolectomy(LRP)with ileal pouch anal anastomosis(IPAA)on hepatobiliary manifestations is debated.AIM To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.METHODS Between June 2013 and June 2018,167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study.Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study.The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.RESULTS The patients'mean age was 36±8 years,and males predominated(67.1%).The most common hepatobiliary diagnostic method was liver biopsy(85.6%),followed by Magnetic resonance cholangiopancreatography(63.5%),Antineutrophil cytoplasmic antibodies(62.5%),abdominal ultrasonography(35.9%),and Endoscopic retrograde cholangiopancreatography(6%).The most common hepatobiliary symptom was Primary sclerosing cholangitis(PSC)(62.3%),followed by fatty liver(16.8%)and gallbladder stone(10.2%).66.4%of patients showed a stable course after surgery.Progressive or regressive courses occurred in 16.8%of each.Mortality was 6%,and recurrence or progression of symptoms required surgery for 15%.Most PSC patients(87.5%)had a stable course,and only 12.5%became worse.Two-thirds(64.3%)of fatty liver patients showed a regressive course,while one-third(35.7%)showed a stable course.Survival rates were 98.8%,97%,95.8%,and 94%at 12 mo,24 mo,36 mo,and at the end of the follow-up.CONCLUSION In patients with UC who had LRP,there is a positive impact on hepatobiliary disease.It caused an improvement in PSC and fatty liver disease.The most prevalent unchanged course was PSC,while the most common improvement was fatty liver disease.展开更多
BACKGROUND Hydatid cyst disease(HCD)is common in certain locations.Surgery is associated with postoperative biliary fistula(POBF)and recurrence.The primary aim of this study was to identify whether occult cysto-biliar...BACKGROUND Hydatid cyst disease(HCD)is common in certain locations.Surgery is associated with postoperative biliary fistula(POBF)and recurrence.The primary aim of this study was to identify whether occult cysto-biliary communication(CBC)can predict recurrent HCD.The secondary aim was to assess the role of cystic fluid bilirubin and alkaline phosphatase(ALP)levels in predicting POBF and recurrent HCD.AIM To identify whether occult CBC can predict recurrent HCD.The secondary aim was to assess the role of cystic fluid bilirubin and ALP levels in predicting POBF and recurrent HCD.METHODS From September 2010 to September 2016,a prospective multicenter study was undertaken involving 244 patients with solitary primary superficial stage cystic echinococcosis 2 and cystic echinococcosis 3b HCD who underwent laparoscopic partial cystectomy with omentoplasty.Univariable logistic regression analysis assessed independent factors determining biliary complications and recurrence.RESULTS There was a highly statistically significant association(P≤0.001)between cystic fluid biochemical indices and the development of biliary complications(of 16 patients with POBF,15 patients had high cyst fluid bilirubin and ALP levels),where patients with high bilirubin-ALP levels were 3405 times more likely to have biliary complications.There was a highly statistically significant association(P≤0.001)between biliary complications,biochemical indices,and the occurrence of recurrent HCD(of 30 patients with recurrent HCD,15 patients had high cyst fluid bilirubin and ALP;all 16 patients who had POBF later developed recurrent HCD),where patients who developed biliary complications and high bilirubin-ALP were 244.6 and 214 times more likely to have recurrent hydatid cysts,respectively.CONCLUSION Occult CBC can predict recurrent HCD.Elevated cyst fluid bilirubin and ALP levels predicted POBF and recurrent HCD.展开更多
Primary biliary cirrhosis(PBC)is a chronic cholestatic liver disease for which an autoimmune pathogenesis is supported by clinical and experimental data,including the presence of autoantibodies and autoreactive T cell...Primary biliary cirrhosis(PBC)is a chronic cholestatic liver disease for which an autoimmune pathogenesis is supported by clinical and experimental data,including the presence of autoantibodies and autoreactive T cells.The etiology remains to be determined,yet data suggest that both a susceptible genetic background and unknown environmental factors determine disease onset.Multiple infectious and chemical candidates have been proposed to trigger the disease in a genetically susceptible host,mostly by molecular mimicry.Most recently,several murine models have been reported,including genetically determined models as well as models induced by immunization with xenobiotics and bacteria.展开更多
Purpose: Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of an...Purpose: Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. Methods: A systematic literature review searched "liver trauma" , "hepatic trauma" , "conservative management" , "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs;studies reported NOM complications together with those post-intervention;case reports;studies including less than 5 cases;studies not written in English;and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. Results: A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. Conclusion: NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.展开更多
We have read with great interest the study by Liang et al.addressing the role of radical resection combined with intestinal autotransplantation for locally advanced pancreatic cancer after neoadjuvant therapy(1).The s...We have read with great interest the study by Liang et al.addressing the role of radical resection combined with intestinal autotransplantation for locally advanced pancreatic cancer after neoadjuvant therapy(1).The study may attract the attention of the pancreato-biliary oncological and surgical community.展开更多
文摘Primary biliary cirrhosis(PBC),which is characterised by progressive destruction of intrahepatic bile ducts,is not a rare disease since both prevalence and incidence are increasing during the last years mainly due to the improvement of case finding strategies.The prognosis of the disease has improved due to both the recognition of earlier and indolent cases,and to the wide use of ursodeoxycholic acid(UDCA).New indicators of prog-nosis are available that will be useful especially for the growing number of patients with less severe disease.Most patients are asymptomatic at presentation.Pruri-tus may represent the most distressing symptom and,when UDCA is ineffective,cholestyramine represents the mainstay of treatment.Complications of long-standing cholestasis may be clinically relevant only in very ad-vanced stages.Available data on the effects of UDCA on clinically relevant end points clearly indicate that the drug is able to slow but not to halt the progression of the disease while,in advanced stages,the only thera-peutic option remains liver transplantation.
文摘Indocyanine green(ICG)fluorescence imaging is widely used in abdominal surgery.The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems.In that setting,ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow.The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery.Each type of use has been separately addressed and the evidence was investigated.During rectal resection,ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks.In addition,ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury.This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed.This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature.Although further studies are need to investigate the real clinical benefits,these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.
文摘BACKGROUND The T-cell costimulation blocking agent belatacept has been identified as a possible substitute for calcineurin inhibitors,however,no consensus has been established against its use over the standard care agent Tacrolimus.AIM To evaluate the effectiveness of belatacept based maintenance immunosuppressive regimens in comparison to tacrolimus in renal transplantion.METHODS We did extensive search of all the available literature comparing the role of belatacept to tacrolimus in renal transplant recipients by searching the PubMed,Embase,Cochrane,Crossref,Scopus,clinical trials registry on October 5,2020.RESULTS The literature search identified four randomized controlled trials(n=173 participants)comparing belatacept with tacrolimus.There was no significant difference in estimated renal function at 12 mo[mean difference 4.12 mL/min/1.73 m^(2),confidence interval(CI):-2.18 to 10.42,P=0.20].Further,belatacept group was associated with significant increase in biopsy proven acute rejection[relative risk(RR)=3.27,CI:0.88 to 12.11,P=0.08]and worse 12 mo allograft survival(RR=4.51,CI:1.23 to 16.58,P=0.02).However,incidence of new onset diabetes mellitus was lower with belatacept at 12 mo(RR=0.26,CI:0.07 to 0.99,P=0.05).CONCLUSION The evidence reviewed in this meta-analysis suggested that belatacept-based maintenance immunosuppression regimens were associated with an increased risk allograft loss in renal transplant recipients with equivalent renal functioning against standard tacrolimus;however,observed significantly reduced new onset diabetes mellitus after transplantation incidence and lower serum low density lipid profile levels in belatacept group.In addition,the adaptation of belatacept in renal transplantation has been forestalled by increased rates of rejection and resistance owing to development of various effector memory T cells through,parallel differentiation and immunological plasticity.
文摘BACKGROUND Hepatobiliary manifestations occur in ulcerative colitis(UC)patients.The effect of laparoscopic restorative proctocolectomy(LRP)with ileal pouch anal anastomosis(IPAA)on hepatobiliary manifestations is debated.AIM To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.METHODS Between June 2013 and June 2018,167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study.Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study.The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.RESULTS The patients'mean age was 36±8 years,and males predominated(67.1%).The most common hepatobiliary diagnostic method was liver biopsy(85.6%),followed by Magnetic resonance cholangiopancreatography(63.5%),Antineutrophil cytoplasmic antibodies(62.5%),abdominal ultrasonography(35.9%),and Endoscopic retrograde cholangiopancreatography(6%).The most common hepatobiliary symptom was Primary sclerosing cholangitis(PSC)(62.3%),followed by fatty liver(16.8%)and gallbladder stone(10.2%).66.4%of patients showed a stable course after surgery.Progressive or regressive courses occurred in 16.8%of each.Mortality was 6%,and recurrence or progression of symptoms required surgery for 15%.Most PSC patients(87.5%)had a stable course,and only 12.5%became worse.Two-thirds(64.3%)of fatty liver patients showed a regressive course,while one-third(35.7%)showed a stable course.Survival rates were 98.8%,97%,95.8%,and 94%at 12 mo,24 mo,36 mo,and at the end of the follow-up.CONCLUSION In patients with UC who had LRP,there is a positive impact on hepatobiliary disease.It caused an improvement in PSC and fatty liver disease.The most prevalent unchanged course was PSC,while the most common improvement was fatty liver disease.
文摘BACKGROUND Hydatid cyst disease(HCD)is common in certain locations.Surgery is associated with postoperative biliary fistula(POBF)and recurrence.The primary aim of this study was to identify whether occult cysto-biliary communication(CBC)can predict recurrent HCD.The secondary aim was to assess the role of cystic fluid bilirubin and alkaline phosphatase(ALP)levels in predicting POBF and recurrent HCD.AIM To identify whether occult CBC can predict recurrent HCD.The secondary aim was to assess the role of cystic fluid bilirubin and ALP levels in predicting POBF and recurrent HCD.METHODS From September 2010 to September 2016,a prospective multicenter study was undertaken involving 244 patients with solitary primary superficial stage cystic echinococcosis 2 and cystic echinococcosis 3b HCD who underwent laparoscopic partial cystectomy with omentoplasty.Univariable logistic regression analysis assessed independent factors determining biliary complications and recurrence.RESULTS There was a highly statistically significant association(P≤0.001)between cystic fluid biochemical indices and the development of biliary complications(of 16 patients with POBF,15 patients had high cyst fluid bilirubin and ALP levels),where patients with high bilirubin-ALP levels were 3405 times more likely to have biliary complications.There was a highly statistically significant association(P≤0.001)between biliary complications,biochemical indices,and the occurrence of recurrent HCD(of 30 patients with recurrent HCD,15 patients had high cyst fluid bilirubin and ALP;all 16 patients who had POBF later developed recurrent HCD),where patients who developed biliary complications and high bilirubin-ALP were 244.6 and 214 times more likely to have recurrent hydatid cysts,respectively.CONCLUSION Occult CBC can predict recurrent HCD.Elevated cyst fluid bilirubin and ALP levels predicted POBF and recurrent HCD.
文摘Primary biliary cirrhosis(PBC)is a chronic cholestatic liver disease for which an autoimmune pathogenesis is supported by clinical and experimental data,including the presence of autoantibodies and autoreactive T cells.The etiology remains to be determined,yet data suggest that both a susceptible genetic background and unknown environmental factors determine disease onset.Multiple infectious and chemical candidates have been proposed to trigger the disease in a genetically susceptible host,mostly by molecular mimicry.Most recently,several murine models have been reported,including genetically determined models as well as models induced by immunization with xenobiotics and bacteria.
文摘Purpose: Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. Methods: A systematic literature review searched "liver trauma" , "hepatic trauma" , "conservative management" , "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs;studies reported NOM complications together with those post-intervention;case reports;studies including less than 5 cases;studies not written in English;and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. Results: A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. Conclusion: NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
文摘We have read with great interest the study by Liang et al.addressing the role of radical resection combined with intestinal autotransplantation for locally advanced pancreatic cancer after neoadjuvant therapy(1).The study may attract the attention of the pancreato-biliary oncological and surgical community.
