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Hepatobiliary & Pancreatic Diseases... Jun 2023Post-hepatectomy liver failure (PHLF) is the Achilles' heel of hepatic resection for colorectal liver metastases. The most commonly used procedure to generate... (Meta-Analysis)
Meta-Analysis
Simultaneous portal and hepatic vein embolization is better than portal embolization or ALPPS for hypertrophy of future liver remnant before major hepatectomy: A systematic review and network meta-analysis.
BACKGROUND
Post-hepatectomy liver failure (PHLF) is the Achilles' heel of hepatic resection for colorectal liver metastases. The most commonly used procedure to generate hypertrophy of the functional liver remnant (FLR) is portal vein embolization (PVE), which does not always lead to successful hypertrophy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed to overcome the limitations of PVE. Liver venous deprivation (LVD), a technique that includes simultaneous portal and hepatic vein embolization, has also been proposed as an alternative to ALPPS. The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy, effectiveness, and safety of the three regenerative techniques.
DATA SOURCES
A systematic search for literature was conducted using the electronic databases Embase, PubMed (MEDLINE), Google Scholar and Cochrane.
RESULTS
The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days, respectively. Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts. There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort, but non-significant differences were observed when compared to the LVD cohort. Notably, the LVD cohort demonstrated a significantly better FLR/body weight (BW) ratio compared to both the ALPPS and PVE cohorts. Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort. The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.
CONCLUSIONS
LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy. Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.
Topics: Humans; Hepatectomy; Hepatic Veins; Network Meta-Analysis; Treatment Outcome; Liver; Portal Vein; Liver Neoplasms; Hepatomegaly; Hypertrophy; Embolization, Therapeutic; Ligation
PubMed: 36100542
DOI: 10.1016/j.hbpd.2022.08.013 -
United European Gastroenterology Journal Oct 2023Transjugular intrahepatic portosystemic shunts (TIPS) in patients with hepatocellular carcinoma (HCC) may improve access to curative therapies, treat portal hypertension...
BACKGROUND/AIMS
Transjugular intrahepatic portosystemic shunts (TIPS) in patients with hepatocellular carcinoma (HCC) may improve access to curative therapies, treat portal hypertension (PH)-related complications without worsening liver function, and increase overall survival. Data on the efficacy and safety of TIPS to treat PH complications in HCC patients, as well as the HCC treatment response, were evaluated.
METHODS
Studies reporting efficacy in controlling bleeding/ascites or response to HCC therapy, safety, and survival in patients with HCC and TIPS were searched systematically on PubMed and Embase. An extraction of articles using predefined data fields and quality indicators was used.
RESULTS
We selected 19 studies and found 937 patients treated for ascites/bleeding and 177 evaluating HCC treatment response. Over half were under 5 cm and solitary lesions, and most studies included tumours with portal vein thrombosis. Regarding PH studies, TIPS resolved bleeding/ascites in >60% of patients, more effective for bleeding. There were no lethal complications reported and procedural bleeding occurred in <5%. Hepatic encephalopathy occurred in 15%-30% within three months. In the HCC treatment-response studies, major complication rates were low with no mortality. In the studies that evaluated the response to transarterial chemoembolization, complete response rate of patients with TIPS varied from 16% to 75%. Liver transplantation rate varied from 8% to 80%, with >40% rate in half of the studies.
CONCLUSIONS
In the published studies, TIPS is effective in treating PH complications in patients with HCC. Prospective studies on TIPS placement in patients with HCC are urgently needed to evaluate the efficacy and safety of TIPS in this setting.
Topics: Humans; Carcinoma, Hepatocellular; Portasystemic Shunt, Transjugular Intrahepatic; Liver Neoplasms; Ascites; Prospective Studies; Esophageal and Gastric Varices; Treatment Outcome; Chemoembolization, Therapeutic; Hypertension, Portal
PubMed: 37736854
DOI: 10.1002/ueg2.12454 -
Clinical and Applied... 2023Splanchnic vein thrombosis (SVT) is not rare in patients with acute pancreatitis. It remains unclear about whether anticoagulation should be given for acute... (Meta-Analysis)
Meta-Analysis
Splanchnic vein thrombosis (SVT) is not rare in patients with acute pancreatitis. It remains unclear about whether anticoagulation should be given for acute pancreatitis-associated SVT. The PubMed, EMBASE, and Cochrane Library databases were searched. Rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were pooled and compared between patients with acute pancreatitis-associated SVT who received and did not receive therapeutic anticoagulation. Pooled rates and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Heterogeneity among studies was evaluated. Overall, 16 studies including 698 patients with acute pancreatitis-associated SVT were eligible. After therapeutic anticoagulation, the pooled rates of SVT recanalization, any bleeding, death, intestinal ischemia, portal cavernoma, and gastroesophageal varices were 44.3% (95%CI = 32.3%-56.6%), 10.7% (95%CI = 4.9%-18.5%), 13.3% (95%CI = 6.9%-21.4%), 16.8% (95%CI = 6.9%-29.9%), 21.2% (95%CI = 7.5%-39.5%), and 29.1% (95%CI = 16.1%-44.1%), respectively. Anticoagulation therapy significantly increased the rate of SVT recanalization (RR = 1.69; 95%CI = 1.29-2.19; < .01), and marginally increased the risk of bleeding (RR = 1.98; 95%CI = 0.93-4.22; = .07). The rates of death (RR = 1.42; 95%CI = 0.62-3.25; = .40), intestinal ischemia (RR = 2.55; 95%CI = 0.23-28.16; = .45), portal cavernoma (RR = 0.51; 95%CI = 0.21-1.22; = .13), and gastroesophageal varices (RR = 0.71; 95%CI = 0.38-1.32; = .28) were not significantly different between patients who received and did not receive anticoagulation therapy. Heterogeneity was statistically significant in the meta-analysis of intestinal ischemia, but not in those of SVT recanalization, any bleeding, death, portal cavernoma, or gastroesophageal varices. Anticoagulation may be effective for recanalization of acute pancreatitis-associated SVT, but cannot improve the survival. Randomized controlled trials are warranted to further investigate the clinical significance of anticoagulation therapy in such patients.
Topics: Humans; Pancreatitis; Acute Disease; Venous Thrombosis; Hemorrhage; Anticoagulants; Ischemia; Varicose Veins; Portal Vein; Splanchnic Circulation
PubMed: 37461391
DOI: 10.1177/10760296231188718 -
International Journal of Surgery... Aug 2022External beam radiation therapy (EBRT) and surgery are local treatment modalities for patients with hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT).... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
External beam radiation therapy (EBRT) and surgery are local treatment modalities for patients with hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT). This meta-analysis aims to evaluate the effectiveness and feasibility of these treatment modalities.
METHODS
PubMed, Medline, Embase, and Cochrane Library databases were systematically searched until April 2021. The primary endpoint was overall survival (OS) of the patients; the adverse effects of the treatment were also investigated.
RESULTS
A total of 59 studies involving 9525 patients with HCC and PVT were included in this meta-analysis. All studies were non-randomized series, including seven comparative studies, and the remainder were single-arm studies or studies with comparative groups other than surgery or EBRT. The pooled rates of Child-Pugh class A were 74.6% and 95.3% in the EBRT and surgery arms, respectively, and the pooled main PVT rates were 40.7% and 15.5% in the EBRT and surgery arms, respectively (p < 0.001). Pooled 1- and 2-year OS rates of the EBRT arm were 44.1% (95% CI:40.3-48.0) and 21.7% (95% CI:18.9-24.8), respectively. In the subgroup of EBRT studies without main PVT, pooled 1- and 2-year OS rates were 59.9% (95% CI:48.9-70.1) and 30.5% (95% CI:15.2-51.8), respectively. In the surgery arm, the correlation rates were 62.8% (95% CI:55.0-70.0) and 42.5% (95% CI:34.4-51.0), respectively. The pooled 1-, and 2-year OS rates of surgery arm were significantly higher than those of EBRT arm (ps < 0.001), and not significantly different with the EBRT subgroup without main PVT (p = 0.762, 0.353, respectively). In studies of surgery accompanied by EBRT, the 1- and 2-year OS rates were 77.1% (95% CI:69.6-83.2) and 45.4% (95% CI:19.8-73.7), respectively. The pooled rates of grade≥3 toxicities ranged from 1.8 to 4.3%, depending on the type.
CONCLUSION
Surgery can yield a favorable survival outcome, whereas EBRT can be widely considered for patients, including those with inferior clinical profiles. Further studies are warranted to determine the possibility of improving the clinical outcomes of surgery accompanied by EBRT.
Topics: Carcinoma, Hepatocellular; Feasibility Studies; Humans; Liver Neoplasms; Portal Vein; Venous Thrombosis
PubMed: 35798205
DOI: 10.1016/j.ijsu.2022.106753 -
Canadian Journal of Surgery. Journal... Mar 2021Portal vein arterialization (PVA) is a possible option when hepatic artery reconstruction is impossible during liver resection. The aim of this study was to review the...
BACKGROUND
Portal vein arterialization (PVA) is a possible option when hepatic artery reconstruction is impossible during liver resection. The aim of this study was to review the literature on the clinical application of PVA in hepatopancreatobiliary (HPB) surgery.
METHODS
We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the PubMed, Embase and Web of Science databases until December 2019. Experimental (animal) studies, review articles and letters were excluded.
RESULTS
Twenty studies involving 57 patients were included. Cholangiocarcinoma was the most common indication for surgery (40 patients [74%]). An end-to-side anastomosis between a celiac trunk branch and the portal vein was the main PVA technique (35 patients [59%]). Portal hypertension was the most common longterm complication (12 patients [21%] after a mean of 4.1 mo). The median followup period was 12 (range 1-87) months. The 1-, 3- and 5-year survival rates were 64%, 27% and 20%, respectively.
CONCLUSION
Portal vein arterialization can be considered as a rescue option to improve the outcome in patients with acute liver de-arterialization when arterial reconstruction is not possible. To prevent portal hypertension and liver injuries due to thrombosis or overarterialization, vessel calibre adjustment and timely closure of the anastomosis should be considered. Further prospective experimental and clinical studies are needed to investigate the potential of this procedure in patients whose liver is suddenly de-arterialized during HPB procedures.
Topics: Bile Ducts; Digestive System Surgical Procedures; Humans; Liver; Pancreas; Portal Vein
PubMed: 33739801
DOI: 10.1503/cjs.012419 -
Research and Practice in Thrombosis and... Oct 2019Portal vein thrombosis (PVT) is common in cirrhosis. PVT is associated with high morbidity and mortality. Individual reports suggest that PVT occurs more frequently in...
BACKGROUND
Portal vein thrombosis (PVT) is common in cirrhosis. PVT is associated with high morbidity and mortality. Individual reports suggest that PVT occurs more frequently in patients with cirrhosis and inherited thrombophilia. The relationship between cirrhosis, PVT development, and inherited thrombophilia was explored in this study. The aim of the study was to determine whether cirrhotic patients with nontumoral PVT have an increased rate of inherited thrombophilia.
METHODS
Studies were identified by searching electronic databases up to October 2017 with English language and human subject restrictions. Two independent reviewers screened citations and extracted data. Magnitude of effect was calculated to obtain aggregate estimates of effect size and 95% confidence intervals (CIs). Between-study variability and heterogeneity were assessed.
RESULTS
Of 2893 citations identified, 9 studies composed of 1929 subjects with cirrhosis were included. The overall prevalence of PVT was 6.5% (n = 125). Both prothrombin G20210A mutation (odds ratio [OR], 2.43; 95% CI, 1.07-5.53; = 0.03) and factor V Leiden (FVL) (OR, 1.98; 95% CI, 1.06-3.68; = 0.03) were significantly associated with PVT risk. Methyltetrahydrofolate reductase C677T mutation was not associated with increased PVT risk. No heterogeneity or publication bias was observed. One important study with opposite findings could not be included due to lack of primary data.
CONCLUSIONS
FVL and PTG20210A mutation were associated with increased PVT risk in patients with cirrhosis. This finding reframes the role of inherited thrombophilia in PVT development in patients with cirrhosis. Future prospective studies investigating screening for inherited thrombophilia in all cirrhosis patients with PVT seem warranted.
PubMed: 31624785
DOI: 10.1002/rth2.12253 -
BJS Open Nov 2022Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone.
METHODS
A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase.
RESULTS
Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients).
CONCLUSION
Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.
Topics: Humans; Portal Vein; Hepatic Veins; Retrospective Studies; Liver Neoplasms; Hypertrophy
PubMed: 36437731
DOI: 10.1093/bjsopen/zrac141 -
Digestive Diseases (Basel, Switzerland) 2022Transjugular intrahepatic portosystemic shunt (TIPS) is technically challenging in the treatment of portal vein cavernous transformation (PVCT), and there is no... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Transjugular intrahepatic portosystemic shunt (TIPS) is technically challenging in the treatment of portal vein cavernous transformation (PVCT), and there is no high-quality evidence regarding whether it is an option for patients with PVCT. We carried out a systematic review and meta-analysis to assess the feasibility and safety of TIPS for PVCT.
METHODS
Systematic search of PubMed, Chinese National Knowledge Infrastructure (CNKI) database, Cochrane Library, Embase, and Wanfang database through December 2021 for appropriate studies reporting efficacy and safety in patients with PVCT undergoing TIPS. The main outcome included the technical success rate, postoperative rebleeding rate, postoperative hepatic encephalopathy rate, stent patency rate, preoperative, and postoperative portal pressure.
RESULTS
Ten studies, including 292 patients were included. Our results showed that TIPS was technically successful in 82.97% (95% confidence interval [CI]: 77.14%-88.41%, p = 0.297) with low heterogeneity (I2 = 18.39%, p = 0.279). Postoperative rebleeding occurred in 9.56% (95% CI: 4.55%-16.77%, p = 0.073) with moderate heterogeneity (I2 = 46.45%, p = 0.06). Postoperative hepatic encephalopathy occurred in 18.55% (95% CI: 9.23%-27.05%, p = 0.343) with moderate heterogeneity (I2 = 48.62%, p = 0.049). Stent patency during follow-up was in 78.43% (95% CI: 70.74%-85.20%, p = 0.805) with low heterogeneity (I2 = 0%, p = 0.654). Postoperative portal pressure significantly reduced (WMD = 12.79 mm Hg, 95% CI: 12.09-13.48 mm Hg, p < 0.00001) with high heterogeneity (I2 = 61.4%, p = 0.02). Both Begg test and funnel plot showed that there was no significant publication bias.
CONCLUSIONS
TIPS is feasible and safe in patients with PVCT and PVCT should not be considered an absolute contraindication to TIPS.
Topics: Humans; Portal Vein; Portasystemic Shunt, Transjugular Intrahepatic; Hepatic Encephalopathy; Portal Pressure; Treatment Outcome; Retrospective Studies
PubMed: 35130546
DOI: 10.1159/000522313 -
Current Oncology (Toronto, Ont.) Jan 2023Background: Transarterial chemoembolization (TACE) combined with tyrosine kinase inhibitors (TKIs) may enhance the efficacy of treatment for hepatocellular carcinoma... (Meta-Analysis)
Meta-Analysis Review
Efficacy of Transarterial Chemoembolization Combined with Tyrosine Kinase Inhibitors for Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombus: A Systematic Review and Meta-Analysis.
Background: Transarterial chemoembolization (TACE) combined with tyrosine kinase inhibitors (TKIs) may enhance the efficacy of treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT); however, it remains unclear. We aim to evaluate the efficacy of TACE combined with TKIs. Methods: A thorough literature search was performed on major databases since their inception until October 2022. Based on the eligibility criteria, eight studies (2103 patients) were included. Results: Meta-analysis showed that TACE+sorafenib/apatinib had a better tumor response (objective response rate (ORR): RR = 4.85, 95% CI 2.68−8.75, disease control rate (DCR): RR = 3.23, 95% CI 1.88−5.56), and prolonged OS (HR = 0.50, 95%CI 0.42−0.60, p < 0.00001) than TACE alone. TACE+lenvatinib was stronger than TACE+sorafenib in ORR (60.7% vs. 38.9%) and TTP (HR = 0.61, 95% CI 0.43−0.86), whereas it was similar in DCR (96.4% vs. 96.3%) and OS (HR = 0.70 95% CI 0.46−1.05). Conclusions: TACE plus sorafenib or apatinib was superior to TACE alone for hepatocellular carcinoma with PVTT; no significant advantage was found between TACE+lenvatinib and TACE+sorafenib, although TACE+lenvatinib performed better in terms of ORR and TTP.
Topics: Humans; Carcinoma, Hepatocellular; Sorafenib; Tyrosine Kinase Inhibitors; Liver Neoplasms; Portal Vein; Chemoembolization, Therapeutic; Treatment Outcome; Thrombosis
PubMed: 36661745
DOI: 10.3390/curroncol30010096 -
The Turkish Journal of Gastroenterology... Jul 2022Portal vein thrombosis is considered to be an indicator of worse outcomes in patients with hepatic cirrhosis. More and more evidence shows that metabolic disorders are... (Meta-Analysis)
Meta-Analysis
Portal vein thrombosis is considered to be an indicator of worse outcomes in patients with hepatic cirrhosis. More and more evidence shows that metabolic disorders are noticeable pro-thrombotic factors. However, whether or not metabolic disorders increase the risk of cirrhotic portal vein thrombosis is controversial. We aim to quantify the magnitude of the association between metabolic disorders and the risk of cirrhotic portal vein thrombosis. Databases were searched for papers to identify studies in which metabolic disorders were compared in liver cirrhosis with or without portal vein thrombosis. Based on data from the eligible studies, metabolic disorders related to portal vein thrombosis included diabetes mellitus, nonalcoholic fatty liver disease, hypercholesterolemia, and body mass index. Pooled adjusted odds ratios with 95% CIs were calculated. Data for 22 studies with a total of 57 371 portal vein thrombosis cases and 3 979 015 participants were included. Statistically significant pooled odds ratios for portal vein thrombosis were obtained for diabetes mel- litus (odds ratio 1.80, 95% CI 1.42-2.28), nonalcoholic fatty liver disease (odds ratio 1.61, 95% CI 1.34-1.95), and hypercholesterolemia (odds ratio 3.59, 95% CI 1.83-7.03). Body mass index was likely irrelevant with cirrhotic portal vein thrombosis (odds ratio 1.01, 95% CI 0.87-1.17), both in overall and subgroup meta-analyses. Significant heterogeneities among studies were observed, except for the hypercholesterolemia group. Metabolic disorders, such as diabetes mellitus, nonalcoholic fatty liver disease, and hypercholesterolemia, increased the risk of portal vein thrombosis in cirrhotic patients by 1.80-fold, 1.61-fold, and 3.59-fold, respectively. Body mass index did not appear to be a risk predictor of cirrhotic portal vein thrombosis. Further, well-designed clinical and mechanistic studies are required to strengthen the arguments, especially in obese patients.
Topics: Humans; Hypercholesterolemia; Liver Cirrhosis; Non-alcoholic Fatty Liver Disease; Portal Vein; Venous Thrombosis
PubMed: 35879911
DOI: 10.5152/tjg.2022.211022