RESUMEN
OBJECTIVE: This study aims at establishing benchmark values for best achievable outcomes following open major anatomic hepatectomy for liver tumors of all dignities. BACKGROUND: Outcomes after open major hepatectomies vary widely lacking reference values for comparisons among centers, indications, types of resections, and minimally invasive procedures. METHODS: A standard benchmark methodology was used covering consecutive patients, who underwent open major anatomic hepatectomy from 44 high-volume liver centers from 5 continents over a 5-year period (2016-2020). Benchmark cases were low-risk non-cirrhotic patients without significant comorbidities treated in high-volume centers (≥30 major liver resections/year). Benchmark values were set at the 75th percentile of median values of all centers. Minimum follow-up period was 1 year in each patient. RESULTS: Of 8044 patients, 2908 (36%) qualified as benchmark (low-risk) cases. Benchmark cutoffs for all indications include R0 resection ≥78%; liver failure (grade B/C) ≤10%; bile leak (grade B/C) ≤18%; complications ≥grade 3 and CCI ® ≤46% and ≤9 at 3 months, respectively. Benchmark values differed significantly between malignant and benign conditions so that reference values must be adjusted accordingly. Extended right hepatectomy (H1, 4-8 or H4-8) disclosed a higher cutoff for liver failure, while extended left (H1-5,8 or H2-5,8) were associated with higher cutoffs for bile leaks, but had superior oncologic outcomes, when compared to formal left hepatectomy (H1-4 or H2-4). The minimal follow-up for a conclusive outcome evaluation following open anatomic major resection must be 3 months. CONCLUSION: These new benchmark cutoffs for open major hepatectomy provide a powerful tool to convincingly evaluate other approaches including parenchymal-sparing procedures, laparoscopic/robotic approaches, and alternative treatments, such as ablation therapy, irradiation, or novel chemotherapy regimens.
Asunto(s)
Laparoscopía , Fallo Hepático , Neoplasias Hepáticas , Humanos , Hepatectomía/métodos , Benchmarking , Complicaciones Posoperatorias/etiología , Neoplasias Hepáticas/cirugía , Neoplasias Hepáticas/etiología , Fallo Hepático/etiología , Laparoscopía/métodos , Estudios Retrospectivos , Tiempo de InternaciónRESUMEN
Complications related to cholecystectomy occur in <3% of patients. Endoclip migration after laparoscopic cholecystectomy with hepatolithiasis is an extremely rare complication. We report a case of hepatolithiasis secondary to endoclip migration after laparoscopic cholecystectomy treated successfully via right hepatectomy. A 35-year-old female presented with upper abdominal pain, fever and vomiting 9 years after laparoscopic cholecystectomy for chronic calculus cholecystitis. Laboratory investigation revealed gamma-glutamyl transpeptidase of 550 U/L and alkaline phosphatase of 350 U/L. Magnetic resonance cholangiopancreatography revealed a dilated intrahepatic bile duct in segment 6 filled with stones. After preoperative evaluation, a right hepatectomy was performed using the intermittent Pringle maneuver. The postoperative recovery was uneventful and the patient was well after 4 months of follow-up. Although rare, endoclip migration should be considered in patients presenting with intrahepatic lithiasis even many years after laparoscopic cholecystectomy. Liver resection may be necessary in cases of failure of endoscopic extraction.
RESUMEN
PURPOSE: The purpose of the study is to compare the clearance of procalcitonin (PCT-c) in the first 24 and 48 hours of treatment of severe sepsis and septic shock with another early prognostic marker represented by the 48-hour Δ Sequential Organ Failure Assessment (SOFA). MATERIALS AND METHODS: Prospective, observational cohort study conducted in a general intensive care unit including patients with severe sepsis and septic shock. The PCT-c was determined at the diagnosis of sepsis and after 24 and 48 hours. The SOFA score was determined at the time of intensive care unit admission and after 48 hours. RESULTS: One hundred thirty adult patients with severe sepsis and septic shock were studied over an 18-month period. The 24- and 48-hour PTC-c scores were significantly higher in survivors (P < .0001). In nonsurvivors, the initial SOFA was significantly higher, and the 48-hour Δ SOFA was significantly smaller (P = .01). The area under the receiver operating characteristic curve was 0.68 for Δ SOFA and 0.76 for 24- and 48-hour PCT-c. CONCLUSIONS: The 48-hour Δ SOFA score and the clearance of 24- and 48-hour PCT are useful markers of prognosis in patients with severe sepsis and septic shock. A decrease in PCT-c in the first 24 hours of treatment should prompt the reassessment of the appropriateness and adequacy of treatment.