Saboor Khan

The value of the aggregate data approach in meta-analysis with time-to-event outcomes

Collecting individual patient data has been described as the ‘gold standard’ for undertaking meta‐analysis. If studies involve time‐to‐event outcomes, conducting a meta‐analysis based on aggregate data can be problematical. Two meta‐analyses of randomized controlled trials with time‐to‐event outcomes are used to illustrate the practicality and value of several proposed methods to obtain summary statistic estimates. In the first example the results suggest that further effort should be made to find unpublished trials. In the second example the use of aggregate data for trials where no individual patient data have been supplied allows the totality of evidence to be assessed and indicates previously unrecognized heterogeneity.

Conventional versus piggyback technique of caval implantation; without extra-corporeal veno-venous bypass. A comparative study.

Conventional orthotopic liver transplantation (CON‐LT) involves resection of recipient cava, usually with extra‐corporeal circulation (veno‐venous bypass, VVB), while in the piggyback technique (PC‐LT) the cava is preserved. Along with a temporary portacaval shunt (TPCS), better haemodynamic maintenance is purported with PC‐LT. A prospective, consecutive series of 384 primary transplants (2000–2003) were analysed, 138 CON‐LT (with VVB) and 246 PC‐LT (54 without TPCS). Patient/donor characteristics were similar in the two groups. PC‐LT required less usage of fresh‐frozen plasma and platelets, intensive care stay, number of patients requiring ventilation after day 1 and total days spent on ventilator. The results were not different when comparing, total operating and warm ischaemia time (WIT), red cell usage, requirement for renal support, day 3 serum creatinine and total hospital stay. TPCS had no impact on outcome other than WIT (P = 0.02). Three patients in PC‐LT group (three of 246;1.2%) developed caval outflow obstruction (P = 0.02). There was no difference in short‐ or long‐term graft or patient survival. PC‐LT has an advantage over CON‐LT unsing VVB with respect to intraoperative blood product usage, postoperative ventilation requirement and ITU stay. VVB is no longer required and TPCS may be used selectively in adult transplantation.

Multivariate and Univariate Analysis of Prognostic Factors following Resection in HCC: The Birmingham Experience

Background: The aim of this study was to look into our experience of resection for hepatocellular carcinomas (HCCs) in a tertiary Hepatobiliary and Liver Transplant Unit in the UK. Methods: A retrospective analysis of our prospective database was carried out. Results: 715 cases of HCC were seen. 100 (13.9%) underwent hepatic resection and 159 (22.2%) orthotopic liver transplant. The 1-, 3- and 5-year overall survival following resection was 75.3, 37.0 and 21.5% respectively. Factors affecting long-term survival included resection margin (p < 0.001), recurrence (p < 0.007), α-fetoprotein >50 (p < 0.001) and serum albumin (p < 0.03). On multivariate analysis, recurrence (p < 0.001) and histological grade (p < 0.044) were significant. The 1- and 3-year recurrence rates were 27.3 and 72.5% respectively. Histological grade (p < 0.007), α-fetoprotein >50 (p < 0.033), female gender (p < 0.016) and portal vein involvement (p < 0.016) were significant in recurrence. Conclusions: Resection data from the East may not be comparable to the West owing to the higher transplant activity in the latter. Liver function tests and imaging would be sufficient to assess liver function prior to hepatic resection. HCC with cirrhosis should be assessed by a transplant unit prior to any treatment. The MELD (Model for End-Stage Liver Disease) score would be a valuable preoperative tool in the assessment of cirrhotics.

Screening for malnutrition in patients with gastro-entero-pancreatic neuroendocrine tumours: a cross-sectional study

Objectives To investigate whether screening for malnutrition using the validated malnutrition universal screening tool (MUST) identifies specific characteristics of patients at risk, in patients with gastro-entero-pancreatic neuroendocrine tumours (GEP-NET). Design Cross-sectional study. Setting University Hospitals Coventry & Warwickshire NHS Trust; European Neuroendocrine Tumour Society Centre of Excellence. Participants Patients with confirmed GEP-NET (n=161) of varying primary tumour sites, functioning status, grading, staging and treatment modalities. Main outcome measure To identify disease and treatment-related characteristics of patients with GEP-NET who score using MUST, and should be directed to detailed nutritional assessment. Results MUST score was positive (≥1) in 14% of outpatients with GEP-NET. MUST-positive patients had lower faecal elastase concentrations compared to MUST-negative patients (244±37 vs 383±20 µg/g stool; p=0.018), and were more likely to be on treatment with long-acting somatostatin analogues (65 vs 38%, p=0.021). MUST-positive patients were also more likely to have rectal or unknown primary NET, whereas, frequencies of other GEP-NET including pancreatic NET were comparable between MUST-positive and MUST-negative patients. Conclusions Given the frequency of patients identified at malnutrition risk using MUST in our relatively large and diverse GEP-NET cohort and the clinical implications of detecting malnutrition early, we recommend routine use of malnutrition screening in all patients with GEP-NET, and particularly in patients who are treated with long-acting somatostatin analogues.

Hepato-biliary clinical trials and their inclusion in the Cochrane Hepato-Biliary Group register and reviews

Background and Aims:  The Cochrane Hepato‐Biliary Group (CHBG) is one of the 52 collaborative review groups within The Cochrane Collaboration. The activities of the CHBG focus on collecting hepato‐biliary randomized clinical trials (RCT) and controlled clinical trials (CCT), and including them in systematic reviews with meta‐analyses of the trials. In this overview, we present the growth of The CHBG Controlled Trials Register, as well as the systematic reviews that have been produced since March 1996.

Prognostic potential of hepatocyte volume and cytokine expression in cirrhotic portal hypertension

Background:  Differentiating the prognosis of Child‐Pugh A and B patients is difficult, particularly following an acute variceal hemorrhage. We have examined the prognostic significance of hepatocyte volume (HV) and the expression of selected cytokines controlling liver repair and regeneration.

Novel Prediction of Pancreatic Anastomotic Failure After Pancreatoduodenectomy Using Preoperative CT Imaging With the Evaluation of Remnant Pancreatic Volume and Body Composition

INTRODUCTION: An increased body mass index (BMI) and pancreatic duct size are known predictors of pancreatic anastomotic failure (PAF) after pancreatoduodenectomy (PD). However, the impact of anthropomorphic measurements (remnant pancreatic (parenchymal) volume (RPV) and body composition on PAF) are unknown. The aim was to determine if pancreatic remnant volume, subcutaneous/visceral adipose tissue (SAT/VAT) area, and skeletal muscle (SM) area calculated from the preoperative computed tomography (CT) predict PAF after PD. METHODS: In173 patients undergoing preoperative CT and PD at a single institution between 2004 and 2009, SM area and SAT/VAT cross-sectional area at the 3rd lumbar vertebra were quantitated using the preoperative CT. Muscle and adipose tissue were identified semi-automatically using the CT Hounsfield threshold method and remnant pancreatic volume as a volumetric sum of pancreatic parenchymal area to the left of the surgical margin (left border of SMA) over multiple cuts. Pancreatic duct size and parenchymal hardness were assessed by surgeon. The definition of PAF was the International Study Group of Pancreatic Fistula (ISGPF) Classification System; Grades B and C PAF were considered clinically-relevant PAF. Patient demographics of those with clinically relevant PAF were compared to those without PAF. Associations with PAF by univariate logistic regression models were summarized with odds ratios and 95% confidence intervals (CI). The predictive ability for several models was described using a concordance index (c-index). RESULTS: PAF occurred in 22 patients (13%); Grades B and C were present in 15 (9%) and 7 (4%) patients resp. In univariate logistic regression analysis, RPV, VAT, SM, BMI, SAT, pancreatic duct size, and pancreatic texture (soft or hard) were all predictors of PAF with P values of <0.001, <0.001, 0.001, 0.001, 0.02, 0.03, and 0.04, resp. A multivariate model with the known predictors using BMI and duct size had a c-index of 0.75 (BMI; Odds ratio (OR): 1.13, 95%CI: 1.04−1.24, P =0.005, duct size; OR: 0.71, 95%CI: 0.51−0.95, P =0.036). A better multivariate model included preoperative CT factors VAT and SM with a c-index = 0.96 (VAT; OR: 1.24, 95%CI: 1.16−1.37, P <.001, SM; OR: 0.02, 95%CI: 0.01−0.08, P <0.001). CONCLUSIONS: Compared to established risk factors for PAF, RPV and VAT were better predictors of PAF after PD. Prediction of the risk of PAF after PD may be best estimated by including these anthropomorphic measures from the preoperative CT as well as using intraoperative findings.