Administration of Rifaximin to Improve Liver Regeneration and Outcome Following Major Liver Resection

Phase 2TerminatedNCT02555293

RWTH Aachen University96 enrolled

Overview

Surgery is in almost all cases the only potentially curative treatment option for patients with primary or secondary malignancies of the liver. However, in most cases oncological resections ("R0-resections") can only be achieved by performing major liver resections (4 or more liver segments), which is related to considerable postoperative complications such as systemic infections and postoperative liver insufficiency (postresectional liver failure (PRLF)). Despite optimized preoperative and postoperative strategies of care presently, up to 32-55% of patients display severs postoperative complications (Clavien score ≥ 3a) and 5% even suffer from a severe PRLF. Recent observations in murine disease models as well as human patients suggested that postoperative alterations of hemodynamics within the portal vein tract as well as postoperative modulations of the immune response facilitates the translocation of gut bacteria in the blood, leading to systemic infections and sepsis. Moreover it became apparent that inflammatory mediators, released by the gut microbiota might negatively affect postoperative liver regeneration. Rifaximin (Xifaxan®) is a novel and potent, semisynthetic antibiotic that efficiently acts against most enteric bacteria and significantly reduced liver inflammation and liver fibrosis in animal studies. Moreover, Rifaximin is very well tolerated, even in patients with liver insufficiency.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

NONE

Enrollment

Conditions

Malignant Liver Disease

Eligibility

Sex: ALLMin age: 18 YearsMax age: 80 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Patients undergoing a liver resection of at least 4 segments 2. Age \> 18 years \< 80 years 3. BMI 18-40 4. Patients with ASA (American Society of Anesthesiologists) I-III 5. Written informed consent prior to study participation Exclusion Criteria: 1. Patients with ASA IV-V 2. Contraindication for MRI (see 5.4.3) 3. Underlying chronic liver disease such as severe fibrosis or liver cirrhosis 4. Need for procedures additive to partial liver resection 5. Participation in other liver related trials 6. BMI \> 40 7. Previous liver transplantation or porto-systemic shunt 8. Concomitant acute infectious diseases 9. Renal insufficiency 10. Hypersensitivity to Rifaximin 11. Concomitant HIPEC (hypertherme intraperitoneale chemoperfusion) treatment 12. ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) 13. Pregnant females as determined by positive \[serum or urine\] hCG (human chorionic gonadotropin) test at Screening or prior to dosing. Participants of child-bearing age should use adequate contraception as defined in the study protocol. 14. Lactating females 15. The subject has a history of any other illness, which, in the opinion of the investigator, might pose an unacceptable risk by administering study medication. 16. The subject received an investigational drug within 30 days prior to inclusion into this study 17. The subject has any current or past medical condition and/or required medication to treat a condition that could affect the evaluation of the study 18. The subject is unwilling or unable to follow the procedures outlined in the protocol 19. The subject is mentally or legally incapacitated

Outcomes

Primary Outcomes

Effect of Rifaximin on postoperative liver function

LiMAx liver function percentage increase on postoperative day 7 in relation to LiMAx value on postoperative day 4 compared to a control group without Rifaximin treatment. LiMAx will be made after at least 14 days but up to 28 days of treatment (control group analogue) dependent on the need for a PVE and the period between PVE or randomization and surgery

Time frame: Postoperative day 7 in relation to postoperative day 4

Secondary Outcomes

postoperative morbidity/Complications

Complications will be scored using the Clavien-Dindo scoring system and a liver-specific-composite-endpoint for the duration of hospital stay, an expected average of minimum 14 days

Time frame: minimum 14 days after liver resection

Liver volume percentage increase

MRI volumetry: pre- and postoperative comperative measurements mainly based on suitable, preoperatively and routinely done MRI/CT-images. On postoperative day 7 as tudy related MRI will be done if no CT/MRI images available routinely done 1 day before or one day after visit 5

Time frame: 14 up to 21 days before liver resection at baseline and 7 days after the operation

liver function percentage increase

LiMAx-test: LiMAx liver function testing will be performed before surgery and on postoperative days 4 and 7 to evaluate functional recovery after liver resection.

Time frame: 14 up to 21 days before liver resection at baseline (all), on preoperative day 1 (PVE group only) and on postoperative day 4 and day 7 (all)

Time to functional recovery

The evaluation of time to functional recovery will start on POD 0 and will be scored daily until discharge from the hospital with the following criteria * Adequate pain control on oral analgesics only * Eating and drinking properly without the need of IV fluids * Independently mobile or mobile at preoperative level * Standard laboratory tests and liver function returning to normal level When all of these criteria are met, we consider a patient functional recovered.

Time frame: minimum 14 days starting on operation day