Askiteksen ja sen komplikaatioiden hoito

Teema : hepatologia. English summaryPeer reviewe

Vatsan alueen elinsiirroista

Teema : elinsiirrotVatsanalueen elinsiirrot ovat lisääntyneet, mistä kiitos kuuluu elinluovuttajia tunnistaville ja hoitaville tahoille. Tarvitaan kuitenkin edelleen aktiivisia toimia, jotta luovuttajien määrä saataisiin lisääntymään nykyisestä

Value of posttransplant protocol biopsies in 2 biliary autoimmune liver diseases A step toward personalized immunosuppressive treatment

The value of protocol liver graft biopsies with good liver function was evaluated in patients with primary sclerosing cholangitis (PSC) or primary biliary cholangitis (PBC). A total of 250 protocol liver biopsy reports from 182 PSC and PBC patients were compared. Overall histopathological findings and those leading to changes in immunosuppression therapy were retrospectively analyzed. The mean time to first protocol biopsy after transplantation was 5.5 (+/- 4.5) years for PSC patients and 9.3 (+/- 6.6) years for PBC patients. More than 1 abnormal histopathological parameter was found in 43% and 62% of PSC and PBC patients, respectively. However, the histology was interpreted as normal by the pathologist in 78% of PSC and 60% of PBC patients. Immunosuppression therapy was reduced in 10% and increased in 6% patients due to protocol biopsy findings. Biopsies leading to increased immunosuppression therapy had more portal (P = .004), endothelial (P = .008), interphase (P = .021), and lobular (P = .000) inflammation. Mild histopathological findings were frequently found in the protocol biopsies despite the normal biochemistry. PBC patients had more histological abnormalities than those transplanted due to PSC; however, PBC patients had longer follow-up times. Immunosuppression therapy could be safely increased or decreased according to protocol biopsy findings after multidisciplinary meeting discussions.Peer reviewe

Outcomes and quality of life after major bile duct injury in long-term follow-up

Introduction Recently new standards for reporting outcomes of bile duct injury (BDI) have been proposed. It is unclear how these treatment outcomes are reflected in quality of life (QOL). The aim of this study was to report outcomes and QOL after repair of major BDI and compare repairs by hepatobiliary surgeon to repairs by non-hepatobiliary surgeons. Methods This was a retrospective study of patients treated for major (Strasberg E-type) BDI after cholecystectomy at a tertiary hepatobiliary center. Outcomes were assessed using Cho-Strasberg proposed standards. QOL was assessed using Short Form Health Survey (SF-36) and the gastrointestinal QOL-index (GIQLI). Patients undergoing uneventful cholecystectomy matched by age, urgency, and duration of follow-up were used as controls. Results Fifty-two patients with major BDI treated between 2000 and 2016 were included (42% male, median age 53 years). Thirty-seven (71%) patients attained primary patency (29 (83%) if primarily operated by a hepatobiliary surgeon). Actuarial primary patency rate (grade A result) at 1, 3, and 5 years was 58%, 56%, and 53% in the whole cohort, and 83%, 80%, and 80% in patients primary treated by a hepatobiliary surgeon, respectively. At 3-year follow-up 6 (11.5%) patients obtained grade B, 10 (19.2%) grade C, and 7 (13.5%) grade D result. QOL was similar in patients with BDI and controls (median SF-36 physical component 51.7 and 53.6,p = 1.0, mental component 53.3 and 53.4,p = 1.0, GIQLI 109.0 and 123.0,p = 0.174, respectively) at median 90 (IQR 70-116) months from cholecystectomy. QOL was similar regardless of outcome grade. Conclusion First attempt to repair a severe BDI should be undertaken by a hepatobiliary surgeon. However, long-term QOL is not affected even by severe BDI, and QOL is not associated with the grade of the outcome.Peer reviewe

Role of autoimmunity in patients transplanted for acute liver failure of unknown origin: a clinical and graft-biopsy analysis

Abstract Background The etiology and prognosis of acute liver failure (ALF) remains unknown in a significant proportion of cases. Signs of autoimmunity may be present, but no consistent pattern has been observed. We aimed to analyse if pretransplant immunological findings, HLA haplotypes and clinical features among patients with unknown etiology differ from those of autoimmune or other known etiology. We also analysed whether such signs impact post-transplant biopsy findings or complications. Methods All adult ALF patients undergoing liver transplantation (LT) in Finland during 1987-2015 were followed to 2016. Data were from the LT registry, pathology database and patient records. 124 patients were included in the analysis. Study subgroups were acute autoimmune hepatitis (AIH) (n=25), known non-AIH etiology (n=54), and unknown etiology (n=45). Results The unknown etiology group differed from the known non-AIH group with regard to the following pretransplant autoimmunity-associated features: positive pANCA (35% vs 8%; P=0.02), higher mean IgA (3.2±1.7 vs 2.1±1.4, P=0.006) and IgG (12.7±4.3 vs 8.5±3.6, P=0.001). AIH-associated HLA haplotypes B8, DR3 and B8DR3 were more common in the AIH group (40%, 44% and 36%) and in the unknown group (29%, 33% and 29%) than in the known non-AIH group (11%, 17% and 11%) or in the Finnish general population (17%, 18% and 8%). However, these findings had no association with protocol biopsies, extrahepatic autoimmune diseases or survival. Patients with ≥1 rejection episode had higher pretransplant IgA (3.7±2.3 vs 2.6±1.2, P=0.02) and IgG (16.4±10.2 vs 12.4±6.8, P=0.03) than those without rejections. Conclusions Autoimmunity-associated pretransplant laboratory findings and HLA haplotypes were common in ALF of unknown etiology, but showed minimal predictive value for post-transplant biopsy findings, clinical complications or survival.Peer reviewe

Pre- vs. postoperative initiation of thromboprophylaxis in liver surgery

Background: Thromboprophylaxis protocols in liver surgery vary greatly worldwide. Due to limited research, there is no consensus whether the administration of thromboprophylaxis should be initiated pre-or postoperatively. Methods: Patients undergoing liver resection in Helsinki University Hospital between 2014 and 2017 were reviewed retrospectively. Initiation of thromboprophylaxis was changed in the institution in the beginning of 2016 from postoperative to preoperative. Patients were classified into two groups for analyses: thromboprophylaxis initiated preoperatively (Preop-group) or postoperatively (Postop-group). The incidences of VTE and haemorrhage within 30 days of surgery were compared between these groups. Patients with permanent anticoagulation were excluded. Results: A total of 512 patients were included to the study (Preop, n = 253, Postop, n = 259). The incidence of VTE was significantly lower in the Preop-group compared to the Postop-group (3 (1.2%) vs. 25 (9.7%), P =Peer reviewe

Postoperative CEA is a better prognostic marker than CA19-9, hCGβ or TATI after resection of colorectal liver metastases

Liver metastases of colorectal cancer can be operated with a curative intent in selected cases. However, more than half of the patients have a recurrence. The aim of this study was to evaluate the prognostic and predictive value of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), human chorionic gonadotropin ? (hCG?) and tumour-associated trypsin-inhibitor (TATI) in colorectal cancer patients before and 3?months after resection of liver metastases. Marker concentrations were determined in blood samples from 168 colorectal cancer patients, who underwent liver resection between the years 1998 and 2007 at Helsinki University Hospital, Finland. The samples were taken before and 3?months after curative resection. Increased concentrations of CEA (>5?µg/L) and hCG? (>1?pmol/L) 3?months after liver resection correlated with recurrence and impaired overall survival and increased CA19-9 (>26?kU/L) with impaired overall survival, but postoperative TATI was not prognostic. Preoperatively elevated CEA and CA19-9 correlated with impaired overall survival, but not with recurrence. Neither preoperative hCG? nor TATI was prognostic. In conclusion, CEA is a useful prognostic marker, when measured 3?months after resection of colorectal liver metastases. CA19-9 also has prognostic significance and may have additional value.Peer reviewe

First-day plasma amylase detects patients at risk of complications after simultaneous pancreas-kidney transplantation

Background Simultaneous pancreas-kidney transplantation (SPK) carries a high risk of major postoperative complications, but knowledge on early warning signs and surrogate markers for postoperative complications is scarce. Aims Our aim was to analyze the complication-predictive value of different laboratory tests in pancreas transplantation. Materials & Methods All SPKs in Finland between January 2010 and February 2020 were retrospectively analyzed. Levels of first three-day plasma amylase, drain fluid amylase, C-reactive protein, C-peptide, plasma trypsinogen, and white blood cell count were assessed for their performance predicting cumulative postoperative complications (assessed using the Comprehensive Complication Index) within 90 days from transplantation by using ROC analyses. Results Of the 164 SPK patients included, 39 suffered at least one complication requiring laparotomy. First-day plasma amylase had the best value in predicting complications based on its high AUC value and easy clinical applicability, with an optimum cutoff of six times the upper normal limit. Negative predictive values (NPVs) and positive predictive values of this cutoff were 0.81 and 0.71 for any relaparotomy, and 0.91 and 0.71 for the Comprehensive Complication Index >47.7 (which equals the morbidity of two relaparotomies), respectively. Conclusion In conclusion, first-day plasma amylase could be able to detect patients at risk of complications after SPK.Peer reviewe

First-day plasma amylase detects patients at risk of complications after simultaneous pancreas-kidney transplantation

Background Simultaneous pancreas-kidney transplantation (SPK) carries a high risk of major postoperative complications, but knowledge on early warning signs and surrogate markers for postoperative complications is scarce. Aims Our aim was to analyze the complication-predictive value of different laboratory tests in pancreas transplantation. Materials & Methods All SPKs in Finland between January 2010 and February 2020 were retrospectively analyzed. Levels of first three-day plasma amylase, drain fluid amylase, C-reactive protein, C-peptide, plasma trypsinogen, and white blood cell count were assessed for their performance predicting cumulative postoperative complications (assessed using the Comprehensive Complication Index) within 90 days from transplantation by using ROC analyses. Results Of the 164 SPK patients included, 39 suffered at least one complication requiring laparotomy. First-day plasma amylase had the best value in predicting complications based on its high AUC value and easy clinical applicability, with an optimum cutoff of six times the upper normal limit. Negative predictive values (NPVs) and positive predictive values of this cutoff were 0.81 and 0.71 for any relaparotomy, and 0.91 and 0.71 for the Comprehensive Complication Index >47.7 (which equals the morbidity of two relaparotomies), respectively. Conclusion In conclusion, first-day plasma amylase could be able to detect patients at risk of complications after SPK.Peer reviewe

The risk of incidental gallbladder cancer is negligible in macroscopically normal cholecystectomy specimens

Background: Cholecystectomy is usually carried out for benign indications. Most perform routine histopathologic examination to detect incidental gallbladder cancer (GBC). Methods: Cholecystectomies performed at four hospitals in the Helsinki Metropolitan Area during 2010-2012 were analyzed retrospectively. Patients with preoperative suspicion of neoplasia, active malignancy, or in whom cholecystectomy was performed as a secondary procedure were excluded. Results: A total of 2034 cholecystectomies were included. In ten patients (0.5%), GBC was identified, each with an associated macroscopic finding, including local hardness (n = 1), a thickened wall (n = 5), acute inflammation and necrosis (n = 1), or suspected neoplasia (n = 3). No GBC was found in macroscopically normal gallbladders (n = 1464). Of the ten patients with GBC, five underwent subsequent liver resection, four had metastatic disease, and one had locally advanced inoperable disease. Three of the five patients who underwent liver resection were alive and disease-free at final follow-up (median 48 months). The remaining seven patients with GBC died of the disease, with a median survival of 14 months (range 10-48 months). Conclusions: Routine histopathologic examination of a macroscopically normal gallbladder does not improve diagnosis of GBC. A histopathological examination is, however, mandatory when a macroscopic abnormality is present.Peer reviewe