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Boubaddi M, Marichez A, Adam JP, Lapuyade B, Debordeaux F, Tlili G, Chiche L, Laurent C. Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR. Ann Surg Oncol 2024:10.1245/s10434-024-16108-9. [PMID: 39230854 DOI: 10.1245/s10434-024-16108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/16/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR). OBJECTIVE The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy. METHOD We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques. RESULTS The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization). CONCLUSION There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.
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Affiliation(s)
- Mehdi Boubaddi
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France.
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Bordeaux University, Bordeaux, France.
| | - Arthur Marichez
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Bordeaux University, Bordeaux, France
| | - Jean-Philippe Adam
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Bruno Lapuyade
- Radiology Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Frederic Debordeaux
- Nuclear Medicine Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Ghoufrane Tlili
- Nuclear Medicine Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Laurence Chiche
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
| | - Christophe Laurent
- Hepatobiliary and Pancreatic Surgery Department, Bordeaux University Hospital Center, Bordeaux, France
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, Bordeaux University, Bordeaux, France
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Wells AB, Butano VW, Phillips MC, Mckillop IH, Martinie JB, Baker EH, Iannitti DA. Outcomes after Surgical Microwave Ablation for the Treatment of Colorectal Liver Metastasis. J Am Coll Surg 2024; 239:276-285. [PMID: 38651746 DOI: 10.1097/xcs.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most common cause of cancer mortality worldwide. Of these, approximately 25% will have liver metastasis. We performed 394 microwave ablations (MWAs) and analyzed outcomes for survival and ablation failure. STUDY DESIGN We conducted a retrospective review of patients who underwent a surgical MWA at a single-center high-volume institution from October 2006 to September 2022 using a prospectively maintained database. The primary outcome was overall survival. RESULTS A total of 394 operations were performed on 328 patients with 842 tumors undergoing MWA. Median tumor size was 1.5 cm (range 0.4 to 7.0 cm), with the median number of tumors ablated per operation being 1 (range 1 to 11). A laparoscopic approach was used 77.9% of the time. Concomitant procedures were performed 63% of the time, most commonly hepatectomy (22.3%), cholecystectomy (17.5%), and colectomy (6.6%). Clavien-Dindo grade III or IV complication occurred in 12 patients (3.6%), and all of these patients had undergone concomitant procedures. Mortality within 30 days occurred in 4 patients (1.2%). The rate of incomplete ablation was 1.5% per tumor. Local recurrence occurred at a rate of 6.3% per tumor. Black patients were found to have a higher incidence of incomplete ablation and local recurrence. One-year survival probability was 91% (95% CI 87.9 to 94.3), with a mean overall survival of 57.6 months (95% CI 49.9 to 65.4 months). CONCLUSIONS Surgical MWA offers a low-morbidity approach to treatment of colorectal liver metastasis, with low rate of failure. This large series reviews the outcomes of MWA as definitive treatment for colorectal liver metastasis.
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Affiliation(s)
- Alexandra B Wells
- From the Division of HPB Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
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Blackburn KW, Brubaker LS, Van Buren Ii G, Feng E, Mohamed S, Ramamurthy U, Ramanathan V, Wood AL, Navarro Cagigas ME, Fisher WE. Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application. Jt Comm J Qual Patient Saf 2024; 50:449-455. [PMID: 38565473 DOI: 10.1016/j.jcjq.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data. METHODS The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses. RESULTS When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article. CONCLUSION The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.
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Jehan FS, Ganguli S, Hase NE, Seth A, Kwon Y, Hemming AW, Aziz H. Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database. Am Surg 2024:31348241246175. [PMID: 38820223 DOI: 10.1177/00031348241246175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.
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Affiliation(s)
- Faisal S Jehan
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sangrag Ganguli
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Niklas E Hase
- Tufts University School of Medicine, Boston, MA, USA
| | - Abhinav Seth
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Yong Kwon
- Division of Transplant and Hepatobiliary Surgery, University of Washington, Seattle, WA, USA
| | - Alan W Hemming
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Hassan Aziz
- Division of Transplant and Hepatobiliary Surgery, University of Iowa Hospital and Clinics, Iowa City, IA, USA
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Turan C, Kovács EH, Szabó L, Atakan I, Dembrovszky F, Ocskay K, Váncsa S, Hegyi P, Zubek L, Molnár Z. The Effect of Preoperative Administration of Glucocorticoids on the Postoperative Complication Rate in Liver Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2024; 13:2097. [PMID: 38610862 PMCID: PMC11012757 DOI: 10.3390/jcm13072097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/16/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Glucocorticoids may grant a protective effect against postoperative complications. The evidence on their efficacy, however, has been inconclusive thus far. We investigated the effects of preoperatively administered glucocorticoids on the overall postoperative complication rate, and on liver function recovery in patients undergoing major liver surgery. Methods: We performed a systematic literature search on PubMed, Embase, and CENTRAL in October 2021, and repeated the search in April 2023. Pre-study protocol was registered on PROSPERO (ID: CRD42021284559). Studies investigating patients undergoing liver resections or transplantation who were administered glucocorticoids preoperatively and reported postoperative complications were eligible. Meta-analyses were performed using META and DMETAR packages in R with a random effects model. Risk of bias was assessed using RoB2. Results: The selection yielded 11 eligible randomized controlled trials (RCTs) with 964 patients. Data from nine RCTs (n = 837) revealed a tendency toward a lower overall complication rate with glucocorticoid administration (odds ratio: 0.71; 95% confidence interval: 0.38-1.31, p = 0.23), but it was not statistically significant. Data pooled from seven RCTs showed a significant reduction in wound infections with glucocorticoid administration [odds ratio: 0.64; 95% confidence interval: 0.45-0.92 p = 0.02]. Due to limited data availability, meta-analysis of liver function recovery parameters was not possible. Conclusions: The preoperative administration of glucocorticoids did not significantly reduce the overall postoperative complication rate. Future clinical trials should investigate homogenous patient populations with a specific focus on postoperative liver recovery.
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Affiliation(s)
- Caner Turan
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
| | - Emőke Henrietta Kovács
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, 1085 Budapest, Hungary
| | - László Szabó
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
| | - Işıl Atakan
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
| | - Fanni Dembrovszky
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
| | - Klementina Ocskay
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
| | - Szilárd Váncsa
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, 1085 Budapest, Hungary
| | - László Zubek
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 61-701 Poznan, Poland
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Moretto R, Germani MM, Borelli B, Conca V, Rossini D, Boraschi P, Donati F, Urbani L, Lonardi S, Bergamo F, Cerma K, Ramondo G, D'Amico FE, Salvatore L, Valente G, Barbaro B, Giuliante F, Di Maio M, Masi G, Cremolini C. Predicting early recurrence after resection of initially unresectable colorectal liver metastases: the role of baseline and pre-surgery clinical, radiological and molecular factors in a real-life multicentre experience. ESMO Open 2024; 9:102991. [PMID: 38631269 PMCID: PMC11027482 DOI: 10.1016/j.esmoop.2024.102991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Advances in surgical techniques and systemic treatments have increased the likelihood of achieving radical surgery and long-term survival in metastatic colorectal cancer (mCRC) patients with initially unresectable colorectal liver metastases (CRLMs). Nonetheless, roughly half of the patients resected after an upfront systemic therapy experience disease relapse within 6 months from surgery, thus leading to the question whether surgery is actually beneficial for these patients. MATERIALS AND METHODS A real-world dataset of mCRC patients with initially unresectable liver-limited disease treated with conversion chemotherapy followed by radical resection of CRLMs at three high-volume Italian institutions was retrospectively assessed with the aim of investigating the association of baseline and pre-surgical clinical, radiological and molecular factors with the risk of relapse within 6 or 12 months from surgery. RESULTS Overall, 268 patients were included in the analysis and 207 (77%) experienced recurrence. Ninety-six (46%) of them had disease relapse within 6 months after CRLM resection and in spite of several variables associated with early recurrence at univariate analyses, only primary tumour resection at diagnosis [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.32-0.89, P = 0.02] remained significant in the multivariable model. Among patients with resected primary tumours, pN+ stage was associated with higher risk of disease relapse within 6 months (OR 3.02, 95% CI 1.23-7.41, P = 0.02). One hundred and forty-nine patients (72%) had disease relapse within 12 months after CRLMs resection but none of the analysed variables was independently associated with outcome. CONCLUSIONS Clinical, radiological and molecular factors assessed before and after conversion chemotherapy do not reliably predict early recurrence after secondary resection of initially unresectable CRLMs. While novel markers are needed to optimize the cost/efficacy balance of surgical procedures, CRLM resection should be offered as soon as metastases become resectable during first-line chemotherapy to all patients eligible for surgery.
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Affiliation(s)
- R Moretto
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa
| | - M M Germani
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa; Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa
| | - B Borelli
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa; Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa
| | - V Conca
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa; Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa
| | - D Rossini
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa; Department of Health Sciences, Section of Clinical Pharmacology and Oncology, University of Florence, Pisa
| | - P Boraschi
- Department of Diagnostic and Interventional Radiology, and Nuclear Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa
| | - F Donati
- Department of Diagnostic and Interventional Radiology, and Nuclear Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa
| | - L Urbani
- General Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa
| | - S Lonardi
- Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua
| | - F Bergamo
- Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua
| | - K Cerma
- Department of Oncology, Veneto Institute of Oncology IOV - IRCCS, Padua
| | - G Ramondo
- Radiology Unit, Veneto Institute of Oncology IOV - IRCCS, Padua
| | - F E D'Amico
- General Surgery 2, Department of Surgical Oncological and Gastroenterological Sciences (DISCOG), University of Padua, Padua
| | - L Salvatore
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome; Medical Oncology Unit, Università Cattolica del Sacro Cuore, Rome
| | - G Valente
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome; Medical Oncology Unit, Università Cattolica del Sacro Cuore, Rome
| | - B Barbaro
- Diagnostic and General Interventional Radiology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome
| | - F Giuliante
- General and Hepatobiliary Surgery, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome
| | - M Di Maio
- Department of Oncology, Università degli Studi di Torino, Turin, Italy
| | - G Masi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa; Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa
| | - C Cremolini
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa; Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa.
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Hirpara DH, Irish J, Rashid M, Martin T, Zhu A, Hunter A, Jayaraman S, Wei AC, Coburn NG, Wright FC. Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes. J Am Coll Surg 2024; 238:157-165. [PMID: 37796140 DOI: 10.1097/xcs.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
BACKGROUND In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada. STUDY DESIGN This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends. RESULTS A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization. CONCLUSIONS Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.
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Affiliation(s)
- Dhruvin H Hirpara
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
| | - Jonathan Irish
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of Head and Neck Oncology and Reconstructive Surgery, University Health Network, Toronto, Ontario, Canada (Irish)
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Mohammed Rashid
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Tharsiya Martin
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Alice Zhu
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
| | - Amber Hunter
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
| | - Shiva Jayaraman
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of General Surgery, Unity Health, St Joseph's Health Center, Toronto, Ontario, Canada (Jayaraman)
| | - Alice C Wei
- Memorial Sloan Kettering Cancer Center, New York, NY (Wei)
| | - Natalie G Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- the Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (Coburn, Wright)
| | - Frances C Wright
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada (Hirpara, Irish, Zhu, Jayaraman, Coburn, Wright)
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada (Irish, Rashid, Martin, Hunter, Wright)
- the Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (Coburn, Wright)
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Ren Q, Wu M, Li HY, Li J, Zeng ZH. Failure of enhanced recovery after surgery in liver surgery: a systematic review and meta analysis. Front Med (Lausanne) 2023; 10:1159960. [PMID: 37497275 PMCID: PMC10366385 DOI: 10.3389/fmed.2023.1159960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/14/2023] [Indexed: 07/28/2023] Open
Abstract
Purpose This study aimed to conduct a systematic review of the literature to identify and summarize the existing evidence regarding ERAS failure and related risk factors after hepatic surgery. The objective was to provide physicians with a better understanding of these factors so that they can take appropriate action to minimize ERAS failure and improve patient outcomes. Method A literature search of the PubMed MEDLINE, OVID, EMBASE, Cochrane Library, and Web of Science was performed. The search strategy involved terms related to ERAS, failure, and hepatectomy. Result A meta-analysis was conducted on four studies encompassing a total of 1,535 patients, resulting in the identification of 20 risk factors associated with ERAS failure after hepatic surgery. Four of these risk factors were selected for pooling, including major resection, ASA classification of ≥3, advanced age, and male gender. Major resection and ASA ≥ 3 were identified as statistically significant factors of ERAS failure. Conclusion The comprehensive literature review results indicated that the frequently identified risk factors for ERAS failure after hepatic surgery are linked to operative and anesthesia factors, including substantial resection and an American Society of Anesthesiologists score of 3 or higher. These insights will assist healthcare practitioners in taking prompt remedial measures. Nevertheless, there is a requirement for future high-quality randomized controlled trials with standardized evaluation frameworks for ERAS programs.
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Affiliation(s)
- Qiuping Ren
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Nursing Key Laboratory of Sichuan Province, West China Medical Center, Sichuan Medical University, Chengdu, China
| | - Menghang Wu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong Yu Li
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiafei Li
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zi Hang Zeng
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Recknagel S, Rademacher S, Höhne C, Lederer AA, Lange UG, Herta T, Seehofer D, Sucher R, Scheuermann U. Prediction of the Postoperative Outcome in Liver Resection Using Perioperative Serum Lactate Levels. J Clin Med 2023; 12:jcm12062100. [PMID: 36983103 PMCID: PMC10051976 DOI: 10.3390/jcm12062100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/10/2023] Open
Abstract
Background: The aim of our study was to analyze perioperative lactate levels and their predictive value for postoperative mortality and morbidity after liver resection. Methods: The clinicopathological characteristics and outcomes of 152 patients who underwent liver resection for benign and malign diagnoses were analyzed retrospectively. Lactate concentrations at three different time points, (1) before liver resection (LAC-PRE), (2) after liver resection on day 0 (LAC-POST), and (3) on day one after the operation (LAC-POD1) were assessed regarding the prognostic value in predicting postoperative complications and mortality according to the Clavien–Dindo (CD) classification. Results: The rates of postoperative complications (CD ≥ IIIb) and mortality rates were 19.7% (N = 30) and 4.6% (N = 7), respectively. The LAC-PRE levels showed no correlation with the postoperative outcome. The ROC curve analysis showed that LCT-POST and LCT-POD1 values were moderately strong in predicting postoperative morbidity (0.681 and 0.768, respectively) and had strong predictive accuracies regarding postoperative mortality (0.800 and 0.838, respectively). The multivariate analysis revealed LAC-POST as a significant predictor of postoperative complications (CD ≥ IIIb: OR 9.28; 95% CI: 2.88–29.9; p < 0.001) and mortality (OR 11.69; 95% CI: 1.76–77.7; p = 0.011). Conclusion: Early postoperative lactate levels are a useful and easily practicable predictor of postoperative morbidity and mortality in patients after liver resection.
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Affiliation(s)
- Sebastian Recknagel
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Claudia Höhne
- Department of Anesthesiology, Pain Therapy, Intensive Care and Emergency Medicine, DRK Hospital Berlin-Koepenick, 12559 Berlin, Germany
| | - Andri A. Lederer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Undine G. Lange
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Toni Herta
- Department of Gastroenterology and Oncology, Division of Hepatology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
| | - Uwe Scheuermann
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany
- Correspondence:
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10
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Aramaki O, Takayama T, Matsuyama Y, Kubo S, Kokudo N, Kurosaki M, Murakami T, Shiina S, Kudo M, Sakamoto M, Nakashima O, Fukumoto T, Iijima H, Eguchi S, Soejima Y, Makuuchi M. Reevaluation of Makuuchi's criteria for resecting hepatocellular carcinoma: A Japanese nationwide survey. Hepatol Res 2023; 53:127-134. [PMID: 36181504 DOI: 10.1111/hepr.13844] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
AIM Although Makuuchi's criteria are widely used to determine the cut-off for safe liver resection, there have been few reports of concrete data supporting their validity. Here, we verified the utility of Makuuchi's criteria by comparing the operative mortality rates associated with liver resection between hepatocellular carcinoma (HCC) patients meeting or exceeding the criteria. METHODS A database was built using data from 15 597 patients treated between 2000 and 2007 for whom values for all three variables included in Makuuchi's criteria for liver resection (clinical ascites, serum bilirubin, and indocyanine green clearance) were available. The patients were divided into those fulfilling (n = 12 175) or exceeding (n = 3422) the criteria. The postoperative mortality (death for any reason within 30 days) and long-term survival were compared between the two groups. RESULTS The operative mortality rate was significantly lower in patients meeting the criteria than in those exceeding the criteria (1.07% vs. 2.01%, respectively; p < 0.001). On multivariate analysis, exceeded the criteria was significantly associated with the risk for operative mortality (relative risk 2.08; 95% confidence interval (CI), 1.23-3.52; p = 0.007). Surgical indication meeting or exceeding the criteria was an independent factor for overall survival (hazard ratio 1.27; 95% CI, 1.18-1.36; p < 0.001). CONCLUSION Makuuchi's criteria are suitable for determining the indication for resection of HCC due to the reduction in risk of operative mortality.
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Affiliation(s)
- Osamu Aramaki
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Tadatoshi Takayama
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | | | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino, Japan
| | - Takamichi Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Kobe, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Nakashima
- Laboratory Services Center, St. Mary's Hospital, Kurume, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroko Iijima
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuji Soejima
- Department of Surgery, Division of Gastroenterological, Hapato-Biliary-Pancreatic, Transplantation, and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masatoshi Makuuchi
- Department of Hepato-Biliary-Pancreatic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
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11
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Abstract
Hepatoblastoma is the most common primary malignant paediatric liver tumour and surgery remains the cornerstone of its management. The aim of this article is to present the principles of surgical treatment of hepatoblastoma. All aspects of surgery in hepatoblastoma are discussed, from biopsy, through conventional and laparoscopic liver resections, to extreme resection with adjacent structures, staged hepatectomy and transplantation.
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Affiliation(s)
- Maciej Murawski
- Department of Pediatric Surgery and Urology, Medical University of Gdansk, Gdansk, Poland.
- Department of Surgery and Urology for Children and Adolescents, Medical University of Gdansk, 1-6 Nowe Ogrody St., 80-803, Gdansk, Poland.
| | - Viola B Weeda
- Department of Surgery, University Academic Medical Centre Groningen, University of Amsterdam, Amsterdam, The Netherlands
| | - Piotr Czauderna
- Department of Pediatric Surgery and Urology, Medical University of Gdansk, Gdansk, Poland
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12
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Otsubo T, Kobayashi S, Sano K, Misawa T, Katagiri S, Nakayama H, Suzuki S, Watanabe M, Ariizumi S, Unno M, Tanabe M, Nagano H, Kokudo N, Hirano S, Nakamura M, Shirabe K, Suzuki Y, Yoshida M, Takada Y, Nakagohri T, Horiguchi A, Ohdan H, Eguchi S, Ohtsuka M, Sho M, Rikiyama T, Hatano E, Taketomi A, Fujii T, Yamaue H, Miyazaki M, Yamamoto M, Takada T, Endo I. A nationwide certification system to increase the safety of highly advanced hepatobiliary-pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:60-71. [PMID: 35611453 DOI: 10.1002/jhbp.1186] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/04/2022] [Accepted: 04/15/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND To ensure that highly advanced hepatobiliary-pancreatic surgery (HBPS) is performed safely, the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons established a safety committee to monitor surgical safety. METHODS We investigated postoperative mortality rates based on summary reports of numbers and outcomes of highly advanced HBPS submitted annually by the board-certified training institutions from 2012 to 2019. We also analyzed summary reports on mortality cases submitted by institutions with high 90-day post-HBPS mortality rates and recommended site visits and surveys as necessary. RESULTS Highly advanced HBPS was performed in 121 518 patients during the 8-year period. Thirty-day mortality rates from 2012 to 2019 were 0.92%, 0.8%, 0.61%, 0.63%, 0.70%, 0.59%, 0.48%, and 0.52%, respectively (P < .001). Ninety-day mortality rates were 2.1%, 1.82%, 1.62%, 1.28%, 1.46%, 1.22%, 1.19%, and 0.98%, respectively (P < .001). Summary reports were submitted by 20 hospitals between 2015 and 2019. Mortality rates before and after the start of report submission and audit were 5.72% and 2.79%, respectively (odds ratio 0.690, 95% confidence interval 0.487-0.977; P = .037). CONCLUSIONS Development of a system for designation of board-certified expert surgeons and safety management improved the mortality rate associated with highly advanced HBPS.
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Affiliation(s)
- Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shinjiro Kobayashi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takeyuki Misawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Satoshi Katagiri
- Department of Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Hisashi Nakayama
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shuji Suzuki
- Department of Gastroenterological Surgery, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Manabu Watanabe
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Shunichi Ariizumi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Minoru Tanabe
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Norihiro Kokudo
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Takamatsu, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yasutsugu Takada
- Department of Hepato-Pancreatic-Biliary and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Toshio Nakagohri
- Department of Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masaru Miyazaki
- Digestive Diseases Center, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Masakazu Yamamoto
- Department of Gastroenterological Surgery, Utsunomiya Memorial Hospital, Utsunomiya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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13
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Textbook outcome among voluntary donors undergoing major living donor hepatectomy. Langenbecks Arch Surg 2022; 407:2905-2913. [PMID: 35670859 PMCID: PMC9171097 DOI: 10.1007/s00423-022-02578-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
Purpose Textbook outcome (TO) is a composite measure of outcome and provides superior assessment of quality of care after surgery. TO after major living donor hepatectomy (MLDH) has not been assessed. The objective of this study was to determine the rate of TO and its associated factors, after MLDH. Methods This was a single center retrospective review of living liver donors who underwent MLDH between 2012 and 2021 (n = 1022). The rate of TO and its associated factors was determined. Results Among 1022 living donors (of whom 693 [67.8%] were males, median age 26 [range, 18–54] years), TO was achieved in 714 (69.9%) with no donor mortality. Majority of donors met the cutoffs for individual outcome measures: 908 (88.8%) for no major complications, 904 (88.5%) for ICU stay ≤ 2 days, 900 (88.1%) for hospital stay ≤ 10 days, 990 (96.9%) for no perioperative blood transfusion, 1004 (98.2%) for no 30-day re-admission, and 1014 (99.2%) for no post-hepatectomy liver failure. Early donation era (before streamlining of donor operative pathways) was associated with failure to achieve TO [OR 1.4, CI 1.1–1.9, P = 0.006]. TO was achieved in 506/755 (67%) donors in the early donation era versus 208/267 (77.9%) in the later period (P = 0.001). Conclusion Despite zero mortality and low complication rate, TO was achieved in approximately 70% donors. TO was modifiable and improved with changes in donor operative pathway.
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14
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Thormann M, Omari J, Pech M, Damm R, Croner R, Perrakis A, Strobel A, Wienke A, Surov A. Low skeletal muscle mass and post-operative complications after surgery for liver malignancies: a meta-analysis. Langenbecks Arch Surg 2022; 407:1369-1379. [PMID: 35583832 PMCID: PMC9283156 DOI: 10.1007/s00423-022-02541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/29/2022] [Indexed: 12/03/2022]
Abstract
Purpose To assess the influence of low skeletal muscle mass (LSMM) on post-operative complications in patients with hepatic malignancies grade (Clavien Dindo ≥ 3) undergoing resection. Methods MEDLINE, Cochrane, and SCOPUS databases were screened for associations between sarcopenia and major post-operative complications (≥ grade 3 according to Clavien-Dindo classification) after resection of different malignant liver tumors. RevMan 5.3 software was used to perform the meta-analysis. The methodological quality of the included studies was assessed according to the QUIPS instrument. Results The analysis included 17 studies comprising 3157 patients. Subgroup analyses were performed for cholangiocarcinoma (CCC), colorectal cancer (CRC) liver metastases, and hepatocellular carcinoma (HCC). LSMM as identified on CT was present in 1260 patients (39.9%). Analysis of the overall sample showed that LSMM was associated with higher post-operative complications grade Clavien Dindo ≥ 3 (OR 1.56, 95% CI 1.25–1.95, p < 0.001). In the subgroup analysis, LSMM was associated with post-operative complications in CRC metastases (OR 1.60, 95% CI 1.11–2.32, p = 0.01). In HCC and CCC sub-analyses, LSMM was not associated with post-operative complications in simple regression analysis. Conclusion LSMM is associated with major post-operative complications in patients undergoing surgery for hepatic metastases and it does not influence major post-operative complications in patients with HCC and CCC.
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Affiliation(s)
- Maximilian Thormann
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Jazan Omari
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Maciej Pech
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Robert Damm
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Roland Croner
- Department of General-, Visceral-, Vascular- and Transplantation Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Aristotelis Perrakis
- Department of General-, Visceral-, Vascular- and Transplantation Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Alexandra Strobel
- Institute of Medical Epidemiology, Biometry, and Informatics, Martin Luther University, Halle-Wittenberg, Germany
- Profile Area Clinical Studies & Biostatistics, Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University, Halle-Wittenberg, Halle, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biometry, and Informatics, Martin Luther University, Halle-Wittenberg, Germany
- Profile Area Clinical Studies & Biostatistics, Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University, Halle-Wittenberg, Halle, Germany
| | - Alexey Surov
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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15
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Faria LLD, Darce GF, Bordini AL, Herman P, Jeismann VB, de Oliveira IS, Ortega CD, Rocha MDS. Liver Surgery: Important Considerations for Pre- and Postoperative Imaging. Radiographics 2022; 42:722-740. [PMID: 35363553 DOI: 10.1148/rg.210124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Liver surgery may be a curative treatment option not only for primary liver neoplasms but also for liver metastases in selected patients. The number of liver surgeries performed worldwide has increased, but surgical morbidity associated with these surgeries remains significant. Therefore, radiologists need to understand the terminology, surgical techniques, resectability and unresectability criteria, and possible postoperative complications as these are part of the decision-making process. Because vascular and biliary variations are common, an adequate preoperative anatomic evaluation determines the best surgical technique, helps identify patients in whom additional surgical steps will be required, and reduces the risk of inadvertent injury. The surgeon must ensure that the future liver remnant is sufficient to maintain adequate function, aided by the radiologist who can provide valuable information such as the presence of steatosis, biliary dilatation, signs of cirrhosis, and portal hypertension, in addition to the volume of the future liver remnant. Postoperative complications must also be understood and evaluated. The most common postoperative complications are vascular (bleeding, thrombosis, and ischemia), biliary (fistulas, bilomas, and strictures), infectious (incisional or deep), those related to liver failure, and even tumor recurrence. An invited commentary by Winslow is available online. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Luisa Leitão de Faria
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - George Felipe Darce
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - André Leopoldino Bordini
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - Paulo Herman
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - Vagner Birk Jeismann
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - Iraí Santana de Oliveira
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - Cinthia D Ortega
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
| | - Manoel de Souza Rocha
- From the Department of Radiology (L.L.d.F., A.L.B., I.S.d.O., C.D.O., M.d.S.R.) and Liver Surgery Unit, Discipline of Digestive Surgery, Department of Gastroenterology (G.F.D., P.H., V.B.J.), University of São Paulo School of Medicine, Ovídio Pires de Campos 75, São Paulo 05403-010, Brazil
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16
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Long-Term Survival Impact of High-Grade Complications after Liver Resection for Hepatocellular Carcinoma: A Retrospective Single-Centre Cohort Study. Medicina (B Aires) 2022; 58:medicina58040534. [PMID: 35454372 PMCID: PMC9024755 DOI: 10.3390/medicina58040534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 01/27/2023] Open
Abstract
Background and Objectives: Although complications after liver resection for hepatic cancer are common, the long-term impact of these complications on oncological outcomes remains unclear. This study aimed to investigate the potential effect of high-grade postoperative complications on long-term mortality and cancer recurrence after surgical resection of hepatocellular carcinoma. Materials and Methods: In a retrospective cohort study, patients undergoing curative liver resection for primary hepatocellular carcinoma between 2005 and 2016 were evaluated. The Clavien–Dindo (CD) grading system was used to classify patients into two groups of either high-grade complications (grade III or IV) or none or low-grade complications (grade 0 to II) within 30 days after surgery. The primary endpoint was all-cause mortality. Secondary endpoints were cancer-specific mortality and cancer recurrence. Weighted Cox proportional hazards regression models were used to calculate the adjusted hazard ratio (aHR) with a 95% confidence interval (CI) for the outcomes of interest. Results: A total of 1419 patients with a median follow-up time of 46.6 months were analysed. Among them, 93 (6.6%) developed high-grade complications after surgery. The most common complications were bile leakage (n = 30) in CD grade III and respiratory failure (n = 13) in CD grade IV. High-grade complications were significantly associated with all-cause mortality (aHR: 1.78, 95% CI: 1.55–2.06) and cancer-specific mortality (aHR: 1.34, 95% CI: 1.13–1.60), but not cancer recurrence (aHR: 0.92, 95% CI: 0.84–1.02). Independent influential factors for complications were sex, diabetes mellitus, clinically significant portal hypertension, oesophageal varices, multifocal cancer, intraoperative blood loss, and anaesthesia duration. Conclusions: Patients who had high-grade postoperative complications had a greater risk of long-term mortality after liver resection for hepatocellular carcinoma. Prevention of postoperative complications may serve as an effective strategy for improving long-term survival.
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Naito S, Fujikawa T, Kouno N, Hasegawa S. Is laparoscopic liver resection safe for super-elderly patients (aged ≥80)? A propensity score-matched analysis. Asian J Endosc Surg 2022; 15:279-289. [PMID: 34612004 DOI: 10.1111/ases.12994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/13/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE The safety of laparoscopic liver resection in super-elderly patients with comorbidities is unknown. We used propensity score matching to evaluate the utility and safety of laparoscopic liver resection in super-elderly patients. METHODS Two-hundred and five patients who underwent laparoscopic liver resection were retrospectively reviewed. They were classified into two groups based on age: ≥80 years (elderly group, n = 49) and <80 years (control group, n = 156). Propensity score matching (PSM) was performed based on preoperative clinical parameters. The intraoperative and postoperative outcomes were compared. RESULTS After matching, 45 patients were included in each group. The intraoperative blood loss was identical between the control and elderly groups (60 vs 60 mL, respectively, P = .588); the frequency of serious postoperative complications (Clavien-Dindo class ≥3, 1/45 vs 1/45, P = 1.00) was also similar. There was no significant difference in terms of the exacerbation of malignancy (22.2% vs 11.1%, P = .258) or other diseases (8.9% vs 22.2%, P = .144). There was no difference in overall survival before and after PSM. However, 5-year overall survival excluding primary cancer-related death showed a difference after PSM (90.7% vs 70.4%; P = .048). CONCLUSIONS Laparoscopic liver resection is feasible and safe in super-elderly patients. The long-term prognosis was poor in patients affected by other illnesses compared to the younger population with similar risk profiles, but there was no difference in overall survival.
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Affiliation(s)
- Shigetoshi Naito
- Department of Surgery, Kokura Memorial Hospital, Fukuoka, Japan.,Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
| | | | - Nobuji Kouno
- Department of Surgery, Kokura Memorial Hospital, Fukuoka, Japan
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Fukuoka University, Fukuoka, Japan
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Germani MM, Borelli B, Boraschi P, Antoniotti C, Ugolini C, Urbani L, Morelli L, Fontanini G, Masi G, Cremolini C, Moretto R. The management of colorectal liver metastases amenable of surgical resection: How to shape treatment strategies according to clinical, radiological, pathological and molecular features. Cancer Treat Rev 2022; 106:102382. [PMID: 35334281 DOI: 10.1016/j.ctrv.2022.102382] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 02/05/2023]
Abstract
Metastatic colorectal cancer (mCRC) patients have poor chances of long term survival, being < 15% of them still alive after 5 years from diagnosis. Nonetheless, patients with colorectal liver metastases (CRLM) may be eligible for metastases resection thus being able to achieve long-term disease remission and survival. The likelihood for patients with CRLM of being or becoming eligible for liver metastasectomy is increasing, thanks to the evolution of surgical techniques, the availability of active systemic treatments and the widespread diffusion of experienced multidisciplinary boards to manage these patients. However, disease relapse after liver surgery is common and occurs in two-thirds of resected patients. Therefore, adequate radiological staging and risk stratification is crucial for the optimal selection of patients candidate to surgery in order to maximize the benefit-risk ratio of liver metastasectomy and to individualize the treatment strategy. Based on the multidimensional assessment, three possible approaches are available: upfront liver surgery followed by adjuvant chemotherapy, perioperative chemotherapy preceding and following liver surgery, and an upfront systemic treatment including chemotherapy plus a targeted agent, both chosen according to patients' and tumours' characteristics, then followed by liver surgery if indicated. In this review, we describe the most important factors impacting the therapeutic choices in patients with resectable and potentially resectable CRLM, and we discuss the most promising factors that may reshape the future decision-making process of these patients.
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Affiliation(s)
- Marco Maria Germani
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Beatrice Borelli
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Piero Boraschi
- Department of Diagnostic and Interventional Radiology, and Nuclear Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Carlotta Antoniotti
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Clara Ugolini
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Lucio Urbani
- Unit of General Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Luca Morelli
- General Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gabriella Fontanini
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Gianluca Masi
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Chiara Cremolini
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Roberto Moretto
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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The Prevalence and the Impact of Frailty in Hepato-Biliary Pancreatic Cancers: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11041116. [PMID: 35207389 PMCID: PMC8878959 DOI: 10.3390/jcm11041116] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/13/2022] [Accepted: 02/17/2022] [Indexed: 11/27/2022] Open
Abstract
Background: Frailty has been associated with increased mortality among hepatobiliary pancreatic (HBP) cancer patients. Nevertheless, estimates of frailty prevalence in HBP cancers and the precise average effect regarding mortality remains uncertain. The present systematic review and meta-analysis aimed to quantify: (1) the prevalence of frailty in patients with liver and pancreatic cancers and (2) the impact of frailty on mortality in patients affected by liver and pancreatic cancers. Methods: MEDLINE/PubMed database search was conducted from inception until 1 November 2021, the pooled prevalence and relative risk (RR) estimate were calculated. Results: A total of 34,276 patients were identified and the weighted prevalence of frailty was 39%; (95% [C.I.] 23–56; I2 = 99.9%, p < 0.0001). Frailty was significantly associated with increased mortality RR 1.98 (95% [C.I.] 1.49–2.63; I2 = 75.9%, p = 0.006). Conclusions: Frailty prevalence is common among HBP cancer patients and exerts a significant negative impact on survival. These findings are characterized by significant heterogeneity and caution is warranted on their interpretation. However, stratification of patients with HBP cancer by frailty status may provide prognostic information and may inform priorities for decision-making strategy.
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20
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Piątek B, Majos A, Grząsiak O, Strzelczyk J. Evaluation of bile sterility in patients undergoing liver resection. POLISH JOURNAL OF SURGERY 2022. [DOI: 10.5604/01.3001.0015.7343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction: Surgery remains the mainstay of treatment for liver tumors. Significant differences in complication rates between liver surgery centers have been reported ranging from 4.1% up to 47.7%. There have been little papers or studies on the impact of bile infection on postoperative complications in patients undergoing surgery for liver cancer.
Aim: The aim of our study was to assess the etiology of bile infections in patients following liver resection and to evaluate its impact on complications and perioperative mortality.
Materials and methods: The studied material consisted of 69 patients undergoing surgery for liver tumors at the Department of General and Transplant Surgery of the Medical University of Lodz between 2011 and 2013, when the intraoperative bile cultures were available.
Results: The intraoperative bile cultures were positive for bacteria in 12 cases (18.75%), while in other cases the bile was sterile (n = 52). In 41.61% of cases, a methicillin-resistant strain was identified. Two patients presented with jaundice, associated with abdominal pain in one patient; other patients complained of abdominal pain only (jaundice: 16.67%; abdominal pain: 91.67%). In both cases, jaundice was not accompanied by any other typical symptoms of cholangitis; also, palliative surgery was performed in both cases.
In patients with confirmed bile infection, jaundice was significantly more common (16.67% vs 0.00%; p = 0.033). Patients with sterile bile cultures reported weight loss significantly more often compared to patients with bile infection (26.90% vs 0.00%; p = 0.042). The hospital stay was longer in patients with bile infection (p = 0.138), whereas the hospitalization was significantly longer in patients infected with methicillin-resistant strains compared to both patients with sterile bile and those with bile infection with non-resistant strains.
Conclusions: The causes and real incidence of asymptomatic bile infection remain unknown. Routine bile cultures in patients undergoing liver surgery may prevent complications by early modification of antibiotic regime considering the antibiogram, and identification of the most common causes of asymptomatic bile infection may translate to better preoperative antibiotic prophylaxis.
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Kawaguchi C, Hokuto D, Yasuda S, Yoshikawa T, Kamitani N, Matsuo Y, Sho M. Advantages of skin closure with subcuticular suture for liver resection on postoperative and cosmetic outcomes: a propensity matched analysis. Langenbecks Arch Surg 2022; 407:1121-1129. [PMID: 34988640 DOI: 10.1007/s00423-021-02388-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The effects of subcuticular sutures on postoperative and cosmetic outcomes in patients who underwent liver resection have not been well studied. Here, we investigated the advantages of subcuticular suture compared to skin stapler regarding open liver resection. METHODS We assessed 342 patients who underwent liver resection at Nara Medical University between 2008 and 2015. They were divided into two groups: subcuticular suture and staple groups. Baseline characteristics and perioperative outcomes were retrospectively compared using one-to-one propensity score matching analysis. RESULTS In this period, 179 patients underwent skin closure with subcuticular sutures and 163 patients underwent skin closure with staples. After propensity matching, 85 pairs of cases were matched. The incidence of wound infection was similar in the two groups (3.5% in the subcuticular suture group and 9.4% in the staple group; p = 0.119). The length of hospital stay was significantly shorter in the subcuticular suture group than in the staple group (10 days vs 15 days; p < 0.001). In addition, the rate of patients who were discharged within 7 days after surgery was statistically higher in the subcuticular group (21.1% vs 3.5%, p = 0.001). Hypertrophic scar 6 months after surgery was significantly less frequent in the subcuticular group (9.4% vs 25.9%, p = 0.010). CONCLUSION Subcuticular sutures might be advantageous for liver surgery reducing length of hospital stay and proportion of hypertrophic scar.
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Affiliation(s)
- Chihiro Kawaguchi
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan.
| | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Takahiro Yoshikawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Naoki Kamitani
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho Kashihara-shi, Nara, 634-8522, Japan
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22
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Bile Leakage After Hepatic Resection for Hepatocellular Carcinoma: Does It Impact the Short- and Long-term Outcomes? J Gastrointest Surg 2022; 26:2070-2081. [PMID: 36002785 PMCID: PMC9568438 DOI: 10.1007/s11605-022-05433-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bile leakage (BL) is one of the commonest morbidities after hepatic resection for hepatocellular carcinoma (HCC). The current study was conducted to evaluate the incidence and different predictive factors for BL after hepatic resection for HCC, and to evaluate of the impact of BL on the long-term survival outcomes. METHODS We reviewed the patients' data who underwent hepatic resection for HCC during the period between June 2010 and June 2019. RESULTS A total of 293 patients were included in the study. BL occurred in 17 patients (5.8%). More Child-Pugh class B patients were found in BL group. There were no significant differences between the two groups except for tumor site, macroscopic portal vein invasion, extent of liver resection, Pringle maneuver use, intraoperative blood loss, and transfusions. Longer hospital stay, higher grades of post-hepatectomy liver failure, and abdominal collections were noted in BL group. After median follow-up duration of 17 months (4-110 months), there were no significant differences between BL and non-BL group regarding overall survival (log-rank, p = 0.746) and disease-free survival (log-rank, p = 0.348). In multivariate analysis, Child-Pugh class, macroscopic portal vein invasion, liver resection extent (minor/major), and Pringle's maneuver use were the only significant predictors of BL. CONCLUSION BL did not significantly impair the long-term outcomes after hepatic resection for HCC. Child-Pugh class, macroscopic portal vein invasion, liver resection extent (minor/major), and Pringle's maneuver use were the main risk factors of BL in the current study.
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23
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Chua DW, Sim D, Syn N, Abdul Latiff JB, Lim KI, Sim YE, Abdullah HR, Lee SY, Chan CY, Goh BKP. Impact of introduction of an enhanced recovery protocol on the outcomes of laparoscopic liver resections: A propensity-score matched study. Surgery 2021; 171:413-418. [PMID: 34417027 DOI: 10.1016/j.surg.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/04/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Presently, data on the impact of enhanced recovery protocols on the outcomes of laparoscopic liver resection remain limited. We performed propensity matched analysis comparing the outcomes between patients undergoing laparoscopic liver resection before and after the introduction of an enhanced recovery protocol. METHODS Between 2013 and 2019, 462 consecutive patients underwent laparoscopic liver resection by 3 surgeons of which 360 met the study inclusion criteria. There were 89 patients who underwent surgery under an enhanced recovery protocol and 271 without an enhanced recovery protocol. One-to-one propensity matched analysis was performed for 84 enhanced recovery protocol patients and 84 nonenhanced recovery protocol patients. RESULTS Comparisons between propensity matched cohorts revealed that patients who received laparoscopic liver resection with enhanced recovery protocol had reduced median blood loss (200 vs 300 mL, P = .013), postoperative stay (3 vs 4 days, P = .003), and lower open conversion rates (0% vs 8.3%, P = .008). There was no difference in other key perioperative outcomes such as operation time, postoperative morbidity, postoperative major morbidity, and 30-day readmission rates. CONCLUSION A combined approach of enhanced recovery protocol and laparoscopic liver resection was associated with improved perioperative outcomes as opposed to laparoscopic liver resection alone.
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Affiliation(s)
- Darren W Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Dayna Sim
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Kai-Inn Lim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Yilin Eileen Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Hairil Rizal Abdullah
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, Duke-National University of Singapore Transplant Center, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, Duke-National University of Singapore Transplant Center, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, Duke-National University of Singapore Transplant Center, Singapore.
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Beane JD, Hyer M, Mehta R, Onuma AE, Gleeson EM, Thompson VM, Pawlik TM, Pitt HA. Optimal hepatic surgery: Are we making progress in North America? Surgery 2021; 170:1741-1748. [PMID: 34325906 DOI: 10.1016/j.surg.2021.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/13/2021] [Accepted: 06/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this analysis was to determine whether optimal outcomes have increased in recent years. Hepatic surgery is high risk, but regionalization and minimally invasive approaches have evolved. Best practices also have been defined with the goal of improving outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried. Analyses were performed separately for partial (≤2 segments), major (≥3 segments), and all hepatectomies. Optimal hepatic surgery was defined as the absence of mortality, serious morbidity, need for a postoperative invasive procedure or reoperation, prolonged length of stay (<75th percentile) or readmission. Tests of trend, χ2, and multivariable analyses were performed. RESULTS From 2014 to 2018, 17,082 hepatectomies, including 11,862 partial hepatectomies and 5,220 major hepatectomies, were analyzed. Minimally invasive approaches increased from 25.6% in 2014 to 29.6% in 2018 (P < .01) and were performed more frequently for partial hepatectomies (34.2%) than major hepatectomies (14.4%) (P < .01). Operative time decreased from 220 minutes in 2014 to 208 minutes in 2018 (P < .05) and was lower in partial hepatectomies (189 vs 258 minutes for major hepatectomies) (P < .01). Mortality (0.7%) and length of stay (4 days) were lower for partial hepatectomies compared with major hepatectomies (1.9%; 6 days), and length of stay decreased for both partial hepatectomies (5 days in 2014 to 4 days in 2018) and major hepatectomies (6 days in 2014 to 6 days in 2018) (all P < .01). Postoperative sepsis (2.9% in 2014 and 2.4% in 2018), bile leaks (6% in 2014 and 4.8% in 2018), and liver failure (3.7% in 2014 and 3.3% in 2018) decreased for all patients (<.05). On multivariable analyses, overall morbidity decreased for major hepatectomies (OR 0.95, 95% CI 0.91-0.99) and all hepatectomies (OR 0.97, 95% CI 0.94-0.99, both P < .01), and optimal hepatic surgery increased over time for partial hepatectomies (OR 1.05, 95% CI 1.02-1.09) and all hepatectomies (OR 1.04, 95% CI 1.02-1.07, both P < .01). CONCLUSION Over a 5-year period in North America, minimally invasive hepatectomies have increased, while operative time, postoperative sepsis, bile leaks, liver failure, and prolonged length of stay have decreased. Optimal hepatic surgery has increased for partial and all hepatectomies and is achieved more often in partial than in major resections.
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Affiliation(s)
- Joal D Beane
- Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH.
| | - Madison Hyer
- Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH
| | - Rittal Mehta
- Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH
| | - Amblessed E Onuma
- Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH
| | - Elizabeth M Gleeson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Timothy M Pawlik
- Department of Surgery, The James Cancer Center, Ohio State University, Columbus, OH
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Milliken D, Curtis S, Melikian C. Predicting morbidity in liver resection surgery: external validation of the revised frailty index and development of a novel predictive model. HPB (Oxford) 2021; 23:954-961. [PMID: 33168438 DOI: 10.1016/j.hpb.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/21/2020] [Accepted: 10/19/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Perioperative complications of liver resection surgery are common but individual patient-level prediction is difficult. Most risk models are unvalidated and may not be clinically useful. We aimed to validate a risk prediction model for complications of liver resection, the Revised Frailty Index (rFI), at a high volume centre. We also aimed to derive a predictive model for complications in our cohort. METHODS Records were reviewed for 300 patients undergoing liver resection. The rFI's discrimination of 90-day major complications was assessed by receiver operating curve analysis. Logistic regression analysis was then used to fit rFI covariates to our dataset. A further analysis produced a model with optimal discrimination of 90-day major complications. RESULTS The rFI was a poor discriminator of 90-day major complications (AUROC 0.562) among patients at our centre. The rFI optimised fit model demonstrated improved discrimination of 90-day major complications (AUROC 0.685). We developed a novel model with improved fit and similar discrimination (AUROC 0.710). CONCLUSION We were unable to validate the rFI as a predictor of complications. We developed a novel model with discrimination at least equal to other published risk models. However, there is an unmet need for well-validated, clinically useful risk tools in this area.
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Affiliation(s)
- Don Milliken
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.
| | - Sam Curtis
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Clare Melikian
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
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The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery. Anesth Analg 2021; 134:357-368. [PMID: 33999011 DOI: 10.1213/ane.0000000000005571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity. METHODS This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching. RESULTS A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes. CONCLUSIONS Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.
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Predictors of complications after liver surgery: a systematic review of the literature. HPB (Oxford) 2021; 23:645-655. [PMID: 33485797 DOI: 10.1016/j.hpb.2020.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/21/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Numerous potential predictors of adverse outcomes have been reported but their performance and utilization in practice seem heterogenous. This study aimed to systematically review the literature on the role and value of predictors of complications after hepatectomy. METHODS A systematic review following the PRISMA guidelines was performed. Studies on liver transplant were excluded. Only studies assessing overall or major complications were included. RESULTS A total of 10'965 abstracts were screened. After application of exclusion criteria, 72 articles including 68'480 patients were included. A total of 72 markers with 48 pre-, 9 intra- and 15 postoperative factors were identified as predictors of complications. Preoperative and intraoperative predictive markers retrieved several times with the highest odds ratios (OR) were ASA score (OR range: 1.3-7.5, significant in 8 studies) and intraoperative need for red blood cell transfusion (OR range: 1.2-17.1, significant in 24 studies), respectively. CONCLUSION Numerous markers have been described to predict the complication risk after hepatectomy. Because of their intrinsic characteristics, most markers such as ASA score and need for red blood cell transfusion are of limited clinical interest. There is a clear need to identify new biomarkers and to develop scores that could easily be implemented in clinical practice.
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Spyropoulos AC, Giannis D, Cohen J, John S, Myrka A, Inlall D, Qiu M, Akgul S, Hyman RJ, Wang JJ. Implementation of the Management of Anticoagulation in the Periprocedural Period App Into an Electronic Health Record: A Prospective Cohort Study. Clin Appl Thromb Hemost 2021; 26:1076029620925910. [PMID: 32633538 PMCID: PMC7495935 DOI: 10.1177/1076029620925910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Appropriate perioperative management of patients on chronic oral anticoagulation (OAC)—including warfarin and the direct oral anticoagulants—is a poorly defined yet important clinical issue with potentially severe consequences in the postoperative period. We sought to prospectively evaluate the effect of the Management of Anticoagulation in the Periprocedural Period (MAPPP) mobile app as a clinical decision tool in the management of patients on chronic OAC undergoing elective procedures or surgeries. Between January 1, 2018, and January 31, 2019, 642 patients treated in our health system were included. Eligible patients met the following criteria: age >18 years old, creatinine clearance ≥15 mL/min, and on chronic OAC with adequate information regarding baseline characteristics. Our study outcome was patient’s emergency department (ED) visits within 30 days postprocedure. The MAPPP app was integrated into the electronic health record (EHR), and the end user was free to accept or decline recommended evidence-based perioperative anticoagulation management guidance. Analysis revealed that acceptance was more common in younger patients (P = .0137), patients on oral anticoagulants other than warfarin (P < .0001), and patients undergoing increased bleeding risk procedures (P = .0068). Acceptance of the MAPPP app recommendation was significantly associated with fewer ED visits (acceptance group: 4.0% vs rejection group: 8.3%, P = .0205). Logistic regression showed that intervention acceptance and female gender were significantly associated with fewer—while age ≥80 with more—30-day ED visits. Our findings indicate that newer technologies, such as the MAPPP app, integrated into clinical EHR workflow, can significantly augment evidence-based perioperative anticoagulation management and potentially result in a reduction of adverse outcomes.
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Affiliation(s)
- Alex C Spyropoulos
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Dimitrios Giannis
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Jessica Cohen
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Northwell Health at North Shore University Hospital, Manhasset, NY, USA
| | - Suja John
- Northwell Health at North Shore University Hospital, Manhasset, NY, USA
| | | | - Damian Inlall
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Michael Qiu
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Saydi Akgul
- Decker College of Health Sciences, Binghamton University, Binghamton, NY, USA
| | - Roger J Hyman
- SC Johnson College of Business, Cornell University, Ithaca, NY, USA
| | - Jason J Wang
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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29
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Ivashchenko OV, Kuhlmann KFD, van Veen R, Pouw B, Kok NFM, Hoetjes NJ, Smit JN, Klompenhouwer EG, Nijkamp J, Ruers TJM. CBCT-based navigation system for open liver surgery: Accurate guidance toward mobile and deformable targets with a semi-rigid organ approximation and electromagnetic tracking of the liver. Med Phys 2021; 48:2145-2159. [PMID: 33666243 PMCID: PMC8251891 DOI: 10.1002/mp.14825] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 12/21/2022] Open
Abstract
Purpose The surgical navigation system that provides guidance throughout the surgery can facilitate safer and more radical liver resections, but such a system should also be able to handle organ motion. This work investigates the accuracy of intraoperative surgical guidance during open liver resection, with a semi‐rigid organ approximation and electromagnetic tracking of the target area. Methods The suggested navigation technique incorporates a preoperative 3D liver model based on diagnostic 4D MRI scan, intraoperative contrast‐enhanced CBCT imaging and electromagnetic (EM) tracking of the liver surface, as well as surgical instruments, by means of six degrees‐of‐freedom micro‐EM sensors. Results The system was evaluated during surgeries with 35 patients and resulted in an accurate and intuitive real‐time visualization of liver anatomy and tumor's location, confirmed by intraoperative checks on visible anatomical landmarks. Based on accuracy measurements verified by intraoperative CBCT, the system’s average accuracy was 4.0 ± 3.0 mm, while the total surgical delay due to navigation stayed below 20 min. Conclusions The electromagnetic navigation system for open liver surgery developed in this work allows for accurate localization of liver lesions and critical anatomical structures surrounding the resection area, even when the liver was manipulated. However, further clinically integrating the method requires shortening the guidance‐related surgical delay, which can be achieved by shifting to faster intraoperative imaging like ultrasound. Our approach is adaptable to navigation on other mobile and deformable organs, and therefore may benefit various clinical applications.
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Affiliation(s)
- Oleksandra V Ivashchenko
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Koert F D Kuhlmann
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Ruben van Veen
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Bas Pouw
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Niels F M Kok
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Nikie J Hoetjes
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Jasper N Smit
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Elisabeth G Klompenhouwer
- Department of Radiology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Jasper Nijkamp
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Theodoor J M Ruers
- Department of Surgical Oncology, The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Faculty of Science and Technology (TNW), University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands
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30
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Xiao J, Caan BJ, Cespedes Feliciano EM, Meyerhardt JA, Peng PD, Baracos VE, Lee VS, Ely S, Gologorsky RC, Weltzien E, Kroenke CH, Kwan ML, Alexeeff SE, Castillo AL, Prado CM. Association of Low Muscle Mass and Low Muscle Radiodensity With Morbidity and Mortality for Colon Cancer Surgery. JAMA Surg 2021; 155:942-949. [PMID: 32805015 DOI: 10.1001/jamasurg.2020.2497] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Given the risks of postoperative morbidity and its consequent economic burden and impairment to patients undergoing colon resection, evaluating risk factors associated with complications will allow risk stratification and the targeting of supportive interventions. Evaluation of muscle characteristics is an emerging area for improving preoperative risk stratification. Objective To examine the associations of muscle characteristics with postoperative complications, length of hospital stay (LOS), readmission, and mortality in patients with colon cancer. Design, Setting, and Participants This population-based retrospective cohort study was conducted among 1630 patients who received a diagnosis of stage I to III colon cancer from January 2006 to December 2011 at Kaiser Permanente Northern California, an integrated health care system. Preliminary data analysis started in 2017. Because major complication data were collected between 2018 and 2019, the final analysis using the current cohort was conducted between 2019 and 2020. Exposures Low skeletal muscle index (SMI) and/or low skeletal muscle radiodensity (SMD) levels were assessed using preoperative computerized tomography images. Main Outcomes and Measures Length of stay, any complication (≥1 predefined complications) or major complications (Clavien-Dindo classification score ≥3), 30-day mortality and readmission up to 30 days postdischarge, and overall mortality. Results The mean (SD) age at diagnosis was 64.0 (11.3) years and 906 (55.6%) were women. Patients with low SMI or low SMD were more likely to remain hospitalized 7 days or longer after surgery (odds ratio [OR], 1.33; 95% CI, 1.05-1.68; OR, 1.39; 95% CI, 1.05-1.84, respectively) and had higher risks of overall mortality (hazard ratio, 1.40; 95% CI, 1.13-1.74; hazard ratio, 1.44; 95% CI, 1.12-1.85, respectively). Additionally, patients with low SMI were more likely to have 1 or more postsurgical complications (OR, 1.31; 95% CI, 1.04-1.65) and had higher risk of 30-day mortality (OR, 4.85; 95% CI, 1.23-19.15). Low SMD was associated with higher odds of having major complications (OR, 2.41; 95% CI, 1.44-4.04). Conclusions and Relevance Low SMI and low SMD were associated with longer LOS, higher risk of postsurgical complications, and short-term and long-term mortality. Research should evaluate whether targeting potentially modifiable factors preoperatively, such as preserving muscle mass, could reverse the observed negative associations with postoperative outcomes.
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Affiliation(s)
- Jingjie Xiao
- Covenant Health Palliative Institute, Edmonton, Alberta, Canada.,Human Nutrition Research Unit, Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Bette J Caan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Jeffrey A Meyerhardt
- Dana Farber Cancer Institute, Department of Medical Oncology, Harvard Medical School, Boston, Massachusetts
| | - Peter D Peng
- Medical Center and Redwood City Medical Center, Kaiser Permanente Northern California, Oakland, California
| | - Vickie E Baracos
- Department of Oncology, University of Alberta Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Valerie S Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sora Ely
- Department of Surgery, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California.,UCSF East Bay Surgery, Highland Hospital, Oakland, California
| | - Rebecca C Gologorsky
- Department of Surgery, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California.,UCSF East Bay Surgery, Highland Hospital, Oakland, California
| | - Erin Weltzien
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Candyce H Kroenke
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Stacey E Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Carla M Prado
- Human Nutrition Research Unit, Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
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31
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Nagata S, Maeda S, Nagamatsu S, Kai S, Fukuyama Y, Korematsu S, Orita H, Anai H, Kuwano H, Korenaga D. Prognostic Nutritional Index Considering Resection Range Is Useful for Predicting Postoperative Morbidity of Hepatectomy. J Gastrointest Surg 2021; 25:2788-2795. [PMID: 33420654 PMCID: PMC8602222 DOI: 10.1007/s11605-020-04893-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Poor preoperative nutritional and immunological status are major risk factors for postoperative complications in patients with various malignancies. Lower preoperative prognostic nutrition index (PNI) is associated with higher rates of postoperative complications and poorer prognosis in those patients. The aim of this study was to analyze the predictive value of the PNI for post-hepatectomy complications in patients with hepatocellular carcinoma (HCC), and evaluate its utility in the surgical procedure. METHODS This retrospective study included 510 patients who underwent open hepatectomies for HCC. The predictive value of the preoperative nutritional and immunological status for postoperative complications was assessed using the PNI. Postoperative complications were defined as grade II or higher per the Clavien-Dindo classification. Postoperative complication rates were compared according to surgical procedure (major hepatectomy vs minor hepatectomy). RESULTS Patients with postoperative complications had significantly lower PNIs than those without (43.1 ± 5.5 vs 47.0 ± 5.7, P < 0.001). In the multivariate analysis, low preoperative PNI (< 45) was an independent risk factor for postoperative complications after hepatectomy (hazard ratio, 3.85). When patients were classified per their PNI (high vs low) and extent of surgical procedures (major vs minor), there were more complications among patients with low PNI than those with high PNI, regardless of the extent of surgical procedures. Specifically, the group of patients with low PNI who underwent major hepatectomy had significantly higher rates of postoperative complications than the other groups. CONCLUSIONS Adding the resection range to the PNI is useful for predicting the postoperative morbidities of hepatectomy patients.
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Affiliation(s)
- Shigeyuki Nagata
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan.
| | - Shohei Maeda
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Satoko Nagamatsu
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Seiichiro Kai
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Yasuro Fukuyama
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Seigo Korematsu
- Department of Pediatrics, Nakatsu Municipal Hospital, Oita, Japan
| | - Hiroyuki Orita
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
| | - Hideaki Anai
- Department of Surgery, Oita Medical Center, Oita, Japan
| | - Hiroyuki Kuwano
- Department of Surgery, Fukuoka City Hospital, Fukuoka, Japan
| | - Daisuke Korenaga
- Department of Surgery, Nakatsu Municipal Hospital, 173 Shimoikenaga, Nakatsu, Oita, 871-8511, Japan
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Ito T, Sugiura T, Okamura Y, Yamamoto Y, Ashida R, Ohgi K, Yasui H, Yamazaki K, Uesaka K. The Safety and Survival Outcome of Hepatectomy with Combined Bile Duct Resection for Colorectal Liver Metastasis. World J Surg 2020; 44:1231-1243. [PMID: 31832703 DOI: 10.1007/s00268-019-05326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Biliary confluence is sometimes involved in colorectal liver metastasis (CRLM), and therefore bile duct resection (BDR) is occasionally necessary for complete resection. However, the utility of hepatectomy with combined BDR is unclear. The safety and survival outcome of hepatectomy with combined BDR for CRLM was assessed. METHODS Patients who underwent hepatectomy for CRLM between 2002 and 2017 were identified from a prospectively compiled database. Postoperative outcomes were compared between patients undergoing hepatectomy alone and with combined BDR for CRLM. RESULTS A total of 734 patients who underwent hepatectomy for CRLM were included. Hepatectomy with combined BDR was performed in 16 (2.1%) patients. The postoperative complications rate (Clavien-Dindo ≥ 3) of patients undergoing hepatectomy with BDR was 31.2%, which was higher than that without BDR (P = 0.001) for CRLM. The mortality rate of surgery for CRLM was 0%. The 5- and 10-year relapse-free survival (RFS) rates for hepatectomy with BDR were 45.0% and 30.0%, respectively. Patients undergoing hepatectomy with BDR had a similar RFS to those without BDR for CRLM (P = 0.351). The 5- and 10-year overall survival (OS) rates for hepatectomy with BDR were 62.6% and 62.6%, respectively. Patients undergoing hepatectomy with BDR had a similar OS to those without BDR for CRLM (P = 0.738). CONCLUSIONS In conclusion, hepatectomy with combined BDR was a potentially feasible treatment option that obtained favorable survival outcomes in patients with invasion of the biliary confluence by CRLM, although BDR with hepatectomy for CRLM was associated with a high rate of morbidity.
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Affiliation(s)
- Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hirofumi Yasui
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Kentaro Yamazaki
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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Effect of liver fibrosis on survival in patients with intrahepatic cholangiocarcinoma: a SEER population-based study. Oncotarget 2020; 11:4438-4447. [PMID: 33315979 PMCID: PMC7720776 DOI: 10.18632/oncotarget.27820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (iCCA) is a biliary tract malignancy with rising incidence in recent decades. While the causative role of cirrhosis in the development of iCCA is well established, the role of cirrhosis as a prognostic factor in iCCA is debatable. MATERIALS AND METHODS The study population consisted of 512 patients diagnosed with iCCA between 2004-2016 collected from the Surveillance, Epidemiology and End Results (SEER) database. The impact of fibrosis on overall and cancer-specific survival 12, 36 and 60 months following diagnosis, was evaluated in the entire cohort and in sub-groups stratified according to treatment approach and the American Joint Committee on Cancer (AJCC) tumor stage using a Cox proportional-hazards model. RESULTS After adjusting for age, sex, race, year of diagnosis, AJCC stage, and surgical treatment strategy, advanced fibrosis was associated with worse cancer-specific survival across follow up periods (HR 1.49 (1.13-1.96, p = 0.005); HR 1.44 (1.14-1.83, p = 0.002) and HR 1.45 (1.15-1.83, p = 0.002) for 12, 36 and 60 months, respectively). Similar effects were observed for overall survival. Among patients that underwent surgical resection, advanced fibrosis was associated with worse overall survival and cancer-specific survival across follow up periods. Fibrosis was associated with worse overall and cancer-specific survival in patients with a later stage (III-IV) at diagnosis but this effect was not demonstrated in early stages. CONCLUSIONS Patients with iCCA and advanced liver fibrosis have an increased risk of both overall and cancer-specific mortality compared to patients with earlier stages of fibrosis.
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Berardi G, Antonelli G, Colasanti M, Meniconi R, Guglielmo N, Laurenzi A, Ferretti S, Levi Sandri GB, Spagnoli A, Moschetta G, Schininà V, Antonini M, Marignani M, Ettorre GM. Association of Sarcopenia and Body Composition With Short-term Outcomes After Liver Resection for Malignant Tumors. JAMA Surg 2020; 155:e203336. [PMID: 32965483 DOI: 10.1001/jamasurg.2020.3336] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Previous retrospective studies have shown that sarcopenia substantially alters the postoperative and oncological outcomes after liver resection for malignant tumors. However, the evidence is limited to small retrospective studies with heterogeneous results and the lack of standardized measurements of sarcopenia. Objective To investigate the role of sarcopenia as a risk factor associated with 90-day morbidity after liver resection for malignant tumors. Design, Setting, and Participants This cohort study included 234 consecutive patients undergoing liver resection for malignant tumors at San Camillo Forlanini Hospital, Rome, Italy, between June 1, 2018, and December 15, 2019. Muscle mass and strength were assessed using the skeletal muscle index (SMI) on preoperative computed tomographic scans and the handgrip strength test, respectively. Patients were then divided into the following 4 groups: group A (normal muscle mass and strength), group B (reduced muscle strength), group C (reduced muscle mass), and group D (reduced muscle mass and strength). Main Outcomes and Measures The primary outcome of the study was 90-day morbidity. The following secondary outcomes were investigated: 90-day mortality, hospital stay, and readmission rate. Results Sixty-four major and 170 minor hepatectomies were performed in 234 patients (median age, 66.50 [interquartile range, 58.00-74.25] years; 158 men [67.5%]). The median SMI of the entire population was 46.22 (interquartile range, 38.60-58.20) cm/m2. The median handgrip strength was 30.80 (interquartile range, 22.30-36.90) kg. Patients in group D had a statistically significantly higher rate of 90-day morbidity than patients in the other groups (51.5% [35 of 68] vs 38.7% [29 of 75] in group C, 23.1% [3 of 13] in group B, and 6.4% [5 of 78] in group A; P < .001). Compared with patients in the other groups, those in group D had a longer hospital stay (10 days vs 8 days in group C, 9 days in group B, and 6 days in group A; P < .001), and more patients in this group were readmitted to the hospital (8.8% [6 of 68] vs 5.3% [4 of 75] in group C, 7.7% [1 of 13] in group B, and 0% [0 of 78] in group A; P = .02). Sarcopenia, portal hypertension, liver cirrhosis, and biliary reconstruction were independent risk factors associated with 90-day morbidity. Conclusions and Relevance Sarcopenia appears to be associated with adverse outcomes after liver resection for malignant tumors. Both muscle mass measurements on computed tomographic scans and muscle strength assessments with the handgrip strength test should be performed at the first clinical encounter to better classify patients and to minimize the risk of morbidity.
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Affiliation(s)
- Giammauro Berardi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Giulio Antonelli
- Department of Digestive and Liver Diseases, University Sapienza, Rome, Italy
| | - Marco Colasanti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Roberto Meniconi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Nicola Guglielmo
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Andrea Laurenzi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Stefano Ferretti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Alessandra Spagnoli
- Statistics Section, Department of Public Health and Infectious Diseases, University Sapienza, Rome, Italy
| | - Giovanni Moschetta
- Department of Radiology, San Camillo Forlanini Hospital, Rome, Italy.,Department of General Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Vincenzo Schininà
- Department of Radiology, San Camillo Forlanini Hospital, Rome, Italy
| | - Mario Antonini
- Department of Radiology, San Camillo Forlanini Hospital, Rome, Italy.,Department of Anesthesiology and Intensive Care, San Camillo Forlanini Hospital, Rome, Italy
| | - Massimo Marignani
- Department of Digestive and Liver Diseases, University Sapienza, Rome, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
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Kobayashi K, Uldry E, Demartines N, Halkic N. Liver resections between 2014 and 2020 in the Lausanne University Hospital, Switzerland. Glob Health Med 2020; 2:337-342. [PMID: 33330829 DOI: 10.35772/ghm.2020.01059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Abstract
Lausanne University Hospital is in the Francophone part of Switzerland and services a catchment population of about 1 million people. We recorded and analyzed baseline characteristics and surgical outcomes for 400 consecutive patients who underwent liver resection there between January 2014 and February 2020. Their pathological results were primary liver cancer (including hepatocellular carcinoma and intrahepatic cholangiocarcinoma): 21.8%, extrahepatic cholangiocarcinoma (including perihilar cholangiocarcinoma and gallbladder cancer): 5.3%, liver metastases: 51.8%, echinococcosis: 10.8%, adenoma: 3.0%, and other diagnoses: 7.5%. Global morbidity rate (Clavien-Dindo classification ≥ 1) was 45.5% with major complication (Clavien-Dindo classification ≥ 3) identified in 81 patients (20.3%). Of the 400 patients, two died within 30 days of surgery (0.5%) and five died within 90 days (1.3%). The 2017-2019 subgroup had a significantly greater percentage of patients aged ≥ 75 years (20.5%) than did the 2014-2016 subgroup (10.9%; p = 0.011) and a higher percentage of laparoscopic procedures than the earlier subgroup (2014-2016: 9.2%, 2017-2019: 32.5%; p < 0.001). We conclude that as the patient population ages, preoperative management and surgical techniques should be constantly improved.
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Affiliation(s)
- Kosuke Kobayashi
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emilie Uldry
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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36
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Abreu P, Ferreira R, Bussyguin DS, DaCás E, Venkatasamy VV, Tomasich FDS, Szutan LA. Liver resections for metastasis: surgical outcomes of a single center academic institution. BMC Surg 2020; 20:254. [PMID: 33109145 PMCID: PMC7590712 DOI: 10.1186/s12893-020-00920-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatic metastasis are frequent and liver resection may be an option for some cases, despite the high complexity of the procedure and the possibility of postoperative complications. METHODS This retrospective comparative descriptive study aims to evaluate a series of 86 consecutive liver resections (LRs) performed for the treatment of metastatic liver tumors, comparing the results between patients undergoing major and minor LR. All patients submitted to LR from October 2010 to July 2015 at the Erasto Gaertner Hospital in Curitiba-PR were included. Quantitative numerical variables were analyzed with the Student t-test. The nonparametric Mann-Whitney U test was used for numerical variables of non-normal distribution. Categorical variables were analyzed with the Chi-square test with Fisher's correction. The data were analyzed with the SPSS 23.0 and STATA 15 programs, being p < 0.05 considered statistically significant. RESULTS Eighty-six LR were performed, 56 cases by colorectal metastasis. The major LR corresponded to 68 cases, with 13.2% of Clavien-Dindo III-V complications and 2.9% of reoperation rate. Eighteen minor LR were performed and one patient had a postoperative complication requiring reoperation. CONCLUSION Preoperative elevation of transaminases and jaundice negatively influence surgical outcomes in patients undergoing LR. Tumors greater than 3 cm presented worse postoperative survival. Major LR did not significantly increase the surgical morbidity rate. INSTITUTIONAL REVIEW BOARD REGISTRATION 1.122.319/2015.
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Affiliation(s)
- Phillipe Abreu
- Erasto Gaertner Hospital, Centro de Projetos de Estudo E Pesquisa (CEPEP), Curitiba, PR, Brazil. .,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Área de Fígado e Hipertensão Portal, São Paulo, SP, Brazil. .,Department of Surgery, University of Miami, Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL, USA.
| | - Raphaella Ferreira
- Erasto Gaertner Hospital, Centro de Projetos de Estudo E Pesquisa (CEPEP), Curitiba, PR, Brazil.,Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Área de Fígado e Hipertensão Portal, São Paulo, SP, Brazil
| | | | - Eduardo DaCás
- Erasto Gaertner Hospital, Centro de Projetos de Estudo E Pesquisa (CEPEP), Curitiba, PR, Brazil
| | | | | | - Luiz Arnaldo Szutan
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, Departamento de Cirurgia, Área de Fígado e Hipertensão Portal, São Paulo, SP, Brazil
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Qi Y, LeVan TD, Haynatzki G, Are C, Farazi PA. Development of an Integer-based Risk Score to Predict 90-Day Mortality After Hepatectomy in Patients With Hepatocellular Carcinoma. Am J Clin Oncol 2020; 43:640-647. [PMID: 32889834 DOI: 10.1097/coc.0000000000000724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of liver cancer has more than tripled since 1980. Hepatectomy represents the major curative treatment for liver cancer. The risk factors associated with 90-day mortality after hepatectomy are not well understood and there are currently no good prediction models for this outcome. The objectives of the current study were to identify risk factors of 90-day mortality after hepatectomy in patients with hepatocellular carcinoma and to develop an integer-based risk score using the National Cancer Database. METHODS Hepatectomies recorded in the National Cancer Database during 2004-2012 were reviewed for 90-day mortality. Risk factors were identified by multivariate logistic regression models. An integer-based risk score was developed using the β coefficients derived from the logistic regression model and tested for discriminatory ability. According to the total risk score, patients were grouped into 4 risk groups. RESULTS The overall 90-day mortality was 10.2%. Ten risk factors were identified, which included sex, age, race/ethnicity, insurance status, education, annual hospital volume, stage, tumor grade, Charlson-Deyo Score, and surgical procedure. The risk of 90-day mortality was stratified into 4 groups. The calculated 90-day mortality rates were 2.47%, 5.88%, 12.58%, and 24.67% for low-risk, medium-risk, high-risk, and excessive-risk groups, respectively. An area under the receiver operating characteristic curve of 0.69 was obtained for model discrimination. CONCLUSIONS The integer-based risk score we developed could easily quantify each patient's risk level and predict 90-day mortality after hepatectomy. The stratified risk score could be a useful addition to perioperative risk management and a tool to improve 90-day mortality after hepatectomy.
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Liver resections in patients with prior bilioenteric anastomosis are predisposed to develop organ/space surgical site infections and biliary leakage: results from a propensity score matching analysis. Surg Today 2020; 51:526-536. [PMID: 32785844 DOI: 10.1007/s00595-020-02105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE The aims of this study were to compare the perioperative outcomes after hepatectomy with prior bilioenteric anastomosis to those without prior anastomosis, and to elucidate the mechanisms and preventative measures of its characteristic complications. METHODS The demographic data and perioperative outcomes of 525 hepatectomies performed between January 2007 and December 2018, including 40 hepatectomies with prior bilioenteric anastomosis, were retrospectively analyzed. RESULTS A propensity score matching analysis demonstrated that hepatectomies with prior bilioenteric anastomosis were associated with a higher frequency of major complications (p = 0.015), surgical site infection (p = 0.005), organ/space surgical site infection (p = 0.003), and bile leakage (p = 0.007) compared to those without. A multivariate analysis also elucidated that prior bilioenteric anastomosis was one of the independent risk factors of organ/space surgical site infection. In the patients with prior bilioenteric anastomosis, bile leakage was associated with organ/space surgical site infection at a significantly higher rate than those without prior bilioenteric anastomosis (p < 0.001). CONCLUSIONS Prior bilioenteric anastomosis is a strong risk factor for organ/space surgical site infections, which might be induced by bile leakage. To prevent infectious complications after hepatectomy with prior bilioenteric anastomosis, meticulous liver transection to reduce bile leakage rate is thus considered to be mandatory.
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Resectability and Ablatability Criteria for the Treatment of Liver Only Colorectal Metastases: Multidisciplinary Consensus Document from the COLLISION Trial Group. Cancers (Basel) 2020; 12:cancers12071779. [PMID: 32635230 PMCID: PMC7407587 DOI: 10.3390/cancers12071779] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023] Open
Abstract
The guidelines for metastatic colorectal cancer crudely state that the best local treatment should be selected from a ‘toolbox’ of techniques according to patient- and treatment-related factors. We created an interdisciplinary, consensus-based algorithm with specific resectability and ablatability criteria for the treatment of colorectal liver metastases (CRLM). To pursue consensus, members of the multidisciplinary COLLISION and COLDFIRE trial expert panel employed the RAND appropriateness method (RAM). Statements regarding patient, disease, tumor and treatment characteristics were categorized as appropriate, equipoise or inappropriate. Patients with ECOG≤2, ASA≤3 and Charlson comorbidity index ≤8 should be considered fit for curative-intent local therapy. When easily resectable and/or ablatable (stage IVa), (neo)adjuvant systemic therapy is not indicated. When requiring major hepatectomy (stage IVb), neo-adjuvant systemic therapy is appropriate for early metachronous disease and to reduce procedural risk. To downstage patients (stage IVc), downsizing induction systemic therapy and/or future remnant augmentation is advised. Disease can only be deemed permanently unsuitable for local therapy if downstaging failed (stage IVd). Liver resection remains the gold standard. Thermal ablation is reserved for unresectable CRLM, deep-seated resectable CRLM and can be considered when patients are in poor health. Irreversible electroporation and stereotactic body radiotherapy can be considered for unresectable perihilar and perivascular CRLM 0-5cm. This consensus document provides per-patient and per-tumor resectability and ablatability criteria for the treatment of CRLM. These criteria are intended to aid tumor board discussions, improve consistency when designing prospective trials and advance intersociety communications. Areas where consensus is lacking warrant future comparative studies.
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Comprehensive Complication Index Validates Improved Outcomes Over Time Despite Increased Complexity in 3707 Consecutive Hepatectomies. Ann Surg 2020; 271:724-731. [PMID: 30339628 DOI: 10.1097/sla.0000000000003043] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate trends over time in perioperative outcomes for patients undergoing hepatectomy. BACKGROUND As perioperative care and surgical technique for hepatectomy have improved, the indications for and complexity of liver resections have evolved. However, the resulting effect on the short-term outcomes over time has not been well described. METHODS Consecutive patients undergoing hepatectomy during 1998 to 2015 at 1 institution were analyzed. Perioperative outcomes, including the comprehensive complication index (CCI), were compared between patients who underwent hepatectomy in the eras 1998 to 2003, 2004 to 2009, and 2010 to 2015. RESULTS The study included 3707 hepatic resections. The number of hepatectomies increased in each era (794 in 1998 to 2003, 1402 in 2004 to 2009, and 1511 in 2010 to 2015). Technical complexity increased over time as evidenced by increases in the rates of major hepatectomy (20%, 23%, 30%, P < 0.0001), 2-stage hepatectomy (0%, 3%, 4%, P < 0.001), need for portal vein embolization (5%, 9%, 9%, P = 0.001), preoperative chemotherapy for colorectal liver metastases (70%, 82%, 89%, P < 0.001) and median operative time (180, 175, 225 minutes, P < 0.001). Significant decreases over time were observed in median blood loss (300, 250, 200 mL, P < 0.001), transfusion rate (19%, 15%, 5%, P < 0.001), median length of hospitalization (7, 7, 6 days, P < 0.001), rates of CCI ≥26.2 (20%, 22%, 16%, P < 0.001) and 90-day mortality (3.1%, 2.6%, 1.3%, P < 0.01). On multivariable analysis, hepatectomy in the most recent era 2010 to 2015 was associated with a lower incidence of CCI ≥26.2 (odds ratio 0.7, 95% confidence interval 0.6-0.8, P < 0.0001). CONCLUSION Despite increases in complexity over an 18-year period, continued improvements in surgical technique and perioperative outcomes yielded a resultant decrease in CCI in the most current era.
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Tsilimigras DI, Sahara K, Moris D, Mehta R, Paredes AZ, Ratti F, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Workneh A, Guglielmi A, Hugh T, Aldrighetti L, Weiss M, Bauer TW, Maithel SK, Pulitano C, Shen F, Koerkamp BG, Endo I, Pawlik TM. Assessing Textbook Outcomes Following Liver Surgery for Primary Liver Cancer Over a 12-Year Time Period at Major Hepatobiliary Centers. Ann Surg Oncol 2020; 27:3318-3327. [DOI: 10.1245/s10434-020-08548-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Indexed: 12/14/2022]
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Tsilimigras DI, Pawlik TM. ASO Author Reflections: Assessing the Outcomes of Liver Cancer Patients Undergoing Surgery Over the Last Decade—Are We Doing Better? Ann Surg Oncol 2020; 27:3328-3329. [DOI: 10.1245/s10434-020-08549-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Indexed: 11/18/2022]
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Correlation of Relative Value Units With Surgical Complexity and Physician Workload in Urology. Urology 2020; 139:71-77. [DOI: 10.1016/j.urology.2019.12.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/07/2019] [Accepted: 12/16/2019] [Indexed: 11/23/2022]
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Kuan LL, Mavilakandy A, Oyebola T, Bhardwaj N, Dennison AR, Garcea G. Indeterminate liver lesions - a virtual epidemic: a cohort study over 8 years. ANZ J Surg 2020; 90:791-795. [PMID: 32086883 DOI: 10.1111/ans.15685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/03/2019] [Accepted: 12/12/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Within the last decade, advances and availability in radiological imaging have led to an increase in the detection of incidental liver lesions (ILLs) in the asymptomatic patient population. This poses a diagnostic conundrum. This study was undertaken to review the outcome of liver lesions labelled as 'indeterminate' in asymptomatic patients without a biopsy-proven concomitant primary tumour. The secondary aim was to assess the impact on healthcare resources and cost-effectiveness with regards to the frequency and modality of radiological scans, multidisciplinary team discussions and clinic reviews. METHODS The study consisted of a retrospective analysis of prospectively collected data from the University Hospitals of Leicester multidisciplinary team database. The study period ranged from 2010 to 2015. All patients were followed-up for 3 years to ensure no late re-occurrences with malignancy. RESULTS A total of 92 patients with ILL were identified. The median age was 72 years. The median size of these ILLs was 10 mm. Eighty-seven patients required supplementary imaging and 42 required a third imaging. Ninety-one patients had benign lesions. Only one case was biopsy proven to be malignant. CONCLUSION Small (<15 mm) hepatic lesions discovered incidentally in patients with no known primary malignancy and risk factors are virtually always benign, with a 1% risk of malignancy. There is a need for a classification system, which stratifies ILLs by malignant potential based on a standardized and evidence-based approach. This is important to prevent unnecessary investigations. A multidisciplinary approach in an experienced hepatobiliary and pancreatic centre is recommended until such a classification exists.
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Affiliation(s)
- Li Lian Kuan
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Akash Mavilakandy
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Taiwo Oyebola
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Neil Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Giuseppe Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
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Ishii M, Itano O, Shinoda M, Kitago M, Abe Y, Hibi T, Yagi H, Takeuchi A, Tsujikawa H, Abe T, Kitagawa Y. Pre-hepatectomy type IV collagen 7S predicts post-hepatectomy liver failure and recovery. World J Gastroenterol 2020; 26:725-739. [PMID: 32116420 PMCID: PMC7039827 DOI: 10.3748/wjg.v26.i7.725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/11/2020] [Accepted: 01/18/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver resection is an effective treatment for benign and malignant liver tumors. However, a method for preoperative evaluation of hepatic reserve has not yet been established. Previously reported assessments of preoperative hepatic reserve focused only on liver failure in the early postoperative period and did not consider the long-term recovery of hepatic reserve. When determining eligibility for hepatectomy, the underlying pathophysiology needs to be considered to determine if the functional hepatic reserve can withstand both surgery and any postoperative therapy.
AIM To identify pre-hepatectomy factors associated with both early postoperative liver failure and long-term postoperative liver function recovery.
METHODS This study was a retrospective cohort study. We retrospectively investigated 215 patients who underwent hepatectomy at our hospital between May 2013 and December 2016. Early post-hepatectomy liver failure (PHLF) was defined using the International Study Group of Liver Surgery’s definition of PHLF. Long-term postoperative recovery of liver function was defined as the time taken for serum total bilirubin and albumin levels to return to levels of < 2 mg/dL and > 2.8 g/dL, respectively, and the time taken for Child-Pugh score to return to Child-Pugh class A.
RESULTS Preoperative type IV collagen 7S was identified as a significant independent factor associated with both PHLF and postoperative long-term recovery of liver function. Further analysis revealed that the time taken for the recovery of Child-Pugh scores and serum total bilirubin and albumin levels was significantly shorter in patients with type IV collagen 7S ≤ 6 ng/mL than in those with type IV collagen 7S > 6 ng/mL. In additional analyses, similar results were observed in patients without chronic viral hepatitis associated with fibrosis.
CONCLUSION Preoperative type IV collagen 7S is a preoperative predictor of PHLF and long-term postoperative liver function recovery. It can also be used in patients without chronic hepatitis virus.
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Affiliation(s)
- Masatsugu Ishii
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Osamu Itano
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba 286-8686, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University, Kumamoto 860-8556, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Ayano Takeuchi
- Department of Public Health, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Hanako Tsujikawa
- Department of Pathology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Tokiya Abe
- Department of Pathology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo 160-8582, Japan
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Kamarajah SK, Wilson CH, Bundred JR, Lin A, Sen G, Hammond JS, French JJ, Manas DM, White SA. A systematic review and network meta-analysis of parenchymal transection techniques during hepatectomy: an appraisal of current randomised controlled trials. HPB (Oxford) 2020; 22:204-214. [PMID: 31668587 DOI: 10.1016/j.hpb.2019.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/21/2019] [Accepted: 09/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Major liver resection can lead to significant morbidity and mortality. Blood loss is one of the most important factors predicting a good outcome. Although various transection methods have been reported, there is no consensus on the best technique. This systematic review and network meta-analysis aims to characterise and identify the best reported technique for elective parenchymal liver transection based on published randomised controlled trials (RCT's). METHODS A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Central to identify RCT's up to 5th June 2019 that examined parenchymal transection for liver resection. Data including study characteristics and outcomes including intraoperative (blood loss, operating time) and postoperative measures (overall and major complications, bile leaks) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials. RESULTS This study identified 22 RCT's involving 2360 patients reporting ten parenchymal transection techniques. Bipolar cautery has lower blood loss and shorter operating time than stapler (mean difference: 85 mL; 22min) and Tissue Link (mean difference: 66 mL; 29min). Bipolar cautery was ranked first for blood loss and operating time followed by stapler and TissueLink. Harmonic scalpel is associated with lower overall complications than Hydrojet (Odds ratio (OR): 0.48), BiClamp forceps (OR: 0.46) and clamp crushing (OR: 0.41). CONCLUSION Bipolar cautery techniques appear to best at reducing blood loss and associated with shortest operating time. In contrast, Harmonic scalpel appears best for overall and major complications. Given the paucity of data and selective outcome reporting, it is still hard to identify what is the best technique for liver resection. Therefore, further high-quality large-scale RCT's are still needed.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, United Kingdom.
| | - Colin H Wilson
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gourab Sen
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - John S Hammond
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Jeremy J French
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Derek M Manas
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom
| | - Steven A White
- Department of HPB and Transplant Surgery, The Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, United Kingdom; Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, Tyne and Wear, United Kingdom
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Wee IJY, Syn N, Lee LS, Tan SS, Chiow AKH. A systematic review and meta-analysis on the quality of life after hepatic resection. HPB (Oxford) 2020; 22:177-186. [PMID: 32008917 DOI: 10.1016/j.hpb.2019.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Quality of life (QoL) after hepatic resection is a pertinent issue that has been poorly studied. The aim of this study was to compare changes in QoL before and after hepatic resection. METHODS A systematic review was performed using Medline, EMBASE, and the Cochrane library. Whenever possible, pooled mean differences of survey scores pre- and post-operatively were calculated. RESULTS 22 studies were included comprising a total of 1785 participants. Using the EORTC-QLQ 30C survey, patients with benign disease tend to have better QoL post-surgery than those with malignant disease. There were post-operative improvements in the following FACT-HEP domains: physical at 9 months (MD 3.14, 95%CI 2.70 to 3.58, P < 0.001), social and family at 3 (MD 1.45, 95%CI 0.12 to 2.77, p = 0.030), 6 (MD 1.12, 95%CI 0.21 to 2.04, p = 0.020), 9 (MD 0.66, 95%CI 0.03 to 1.28, p = 0.040), and 12 (MD 0.58, 95%CI 0.12 to 1.03, p = 0.010) months, emotional at 9 (P < 0.001) and 24 months (P < 0.001), hepatobiliary at 24 months (p < 0.001), and global health status at 9 months (p = 0.002). CONCLUSION QoL scores tend to deteriorate post-surgery, but recover to baseline in the long-term at 9-months. Patients with malignant disease, and those who underwent major hepatectomy, have poorer QoL scores.
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Affiliation(s)
- Ian J Y Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lip Seng Lee
- Department of General Surgery, Hepatopancreatobiliary Service, Changi General Hospital, Singapore
| | - Siong San Tan
- Department of General Surgery, Hepatopancreatobiliary Service, Changi General Hospital, Singapore
| | - Adrian K H Chiow
- Department of General Surgery, Hepatopancreatobiliary Service, Changi General Hospital, Singapore.
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Simpson RE, Carpenter KL, Wang CY, Schmidt CM, Kilbane EM, Colgate CL, House MG, Zyromski NJ, Schmidt CM, Nakeeb A, Ceppa EP. Is resident assistance equivalent to fellows during hepatectomy? Surg Endosc 2020; 35:260-269. [PMID: 31993809 DOI: 10.1007/s00464-020-07388-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hepatectomy is a complex operative procedure frequently performed at academic institutions with trainee participation. The aim of this study was to determine the effect of assistant's training level on outcomes following hepatectomy. METHODS A retrospective review of a prospective, single-institution ACS-NSQIP database was performed for patients that underwent hepatectomy (2013-2016). Patients were divided by trainee assistant level: hepatopancreatobiliary (HPB) fellow versus general surgery resident (PGY 4-5). Demographic, perioperative, and 30-day outcome variables were compared using Chi-Square/Fisher's exact, Mann-Whitney U test, and multivariable regression. Cases involving a senior-level general surgery resident or HPB fellow as first assistant were included (n = 352). Those with a second attending, junior-level resident, or no documented assistant were excluded (n = 39). RESULTS Patients undergoing hepatectomy with an HPB fellow as primary assistant had more frequent preoperative biliary stenting, longer operative time, and more concomitant procedures including biliary reconstruction, resulting in a higher rate of post-hepatectomy liver failure (PHLF) (15% vs. 8%, P = 0.044). However, trainee level did not impact PHLF on multivariable analysis (OR 0.60, 95% CI [0.29-1.25], P = 0.173). Fellows assisted with proportionally more major hepatectomies (45% vs. 31%; P = 0.010) and resections for hepatobiliary cancers (31% vs. 19%, P = 0.014). On stratified analysis of major and minor hepatectomies, outcomes were similar between trainee groups. CONCLUSION Fellows performed higher complexity cases with longer operative time. Despite these differences, outcomes were similar regardless of assistant training level. Resident and HPB fellow participation in operations requiring liver resection provide comparable quality of care.
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Affiliation(s)
- Rachel E Simpson
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Kyle L Carpenter
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Christine Y Wang
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Christian M Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - E Molly Kilbane
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Cameron L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA.
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Fujio A, Miyagi S, Tokodai K, Nakanishi W, Nishimura R, Mitsui K, Unno M, Kamei T. Effects of a new perioperative enhanced recovery after surgery protocol in hepatectomy for hepatocellular carcinoma. Surg Today 2019; 50:615-622. [PMID: 31797128 DOI: 10.1007/s00595-019-01930-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/18/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols are becoming the standard of care in many surgical procedures, although data on their use following hepatectomy for hepatocellular carcinoma (HCC) are scarce. This study aimed to evaluate the effects of a new ERAS pathway in terms of the patient nutrition status after hepatectomy for HCC. METHODS This is a retrospective analysis of 97 consecutive patients treated with open or laparoscopic hepatectomy for HCC between January 2011 and August 2014. We compared the perioperative outcomes between patients whose treatment incorporated the ERAS pathway and control patients. The nutritional status was evaluated using the controlling nutritional status score. RESULTS The length of hospital stay (LOS) after both open and laparoscopic hepatectomy was shorter for the ERAS group than the control group. The days of ambulation and cessation of intravenous infusion were earlier and the postoperative nutrition status was statistically better in the ERAS group than in the control group. A multivariate analysis showed that being in the non-ERAS group was a risk factor of delayed discharge. There were no marked differences in the rate of severe complications between the two groups. CONCLUSIONS The ERAS pathway seems feasible and safe and results in a faster recovery, reduced LOS, improved nutrition status, and fewer severe complications.
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Affiliation(s)
- Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan.
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Wataru Nakanishi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Ryuichi Nishimura
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Kazuhiro Mitsui
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
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Dili A, Bertrand C, Lebrun V, Pirlot B, Leclercq IA. Hypoxia protects the liver from Small For Size Syndrome: A lesson learned from the associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure in rats. Am J Transplant 2019; 19:2979-2990. [PMID: 31062475 DOI: 10.1111/ajt.15420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 02/07/2023]
Abstract
Portal hyperperfusion and "dearterialization" of the liver remnant are the main pathogenic mechanisms for Small For Size syndrome (SFSS). Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces rapid remnant hypertrophy. We hypothesized a similar increase in portal pressure/flow into the future liver remnant in ALPPS and SFSS-setting hepatectomies. In a rodent model, ALPPS was compared to SFSS-setting hepatectomy. We assessed mortality, remnant hypertrophy, hepatocyte proliferation, portal and hepatic artery flow, hypoxia-induced response, and liver sinusoidal morphology. SFSS-hepatectomy rats were subjected to local (hepatic artery ligation) or systemic (Dimethyloxalylglycine) hypoxia. ALLPS prevented mortality in SFSS-setting hepatectomies. Portal hyperperfusion per liver mass was similar in ALLPS and SFSS. Compared to SFSS, efficient arterial perfusion of the remnant was significantly lower in ALPPS causing pronounced hypoxia confirmed by pimonidazole immunostaining, activation of hypoxia sensors and upregulation of neo-angiogenic genes. Liver sinusoids, larger in ALPPS, collapsed in SFSS. Induction of hypoxia in SFSS reduced mortality. Hypoxia had no impact on hepatocyte proliferation but contributed to the integrity of sinusoidal morphology. ALPPS hemodynamically differ from SFSS by a much lower arterial flow in ALPPS's FLR. We show that the ensuing hypoxic response is essential for the function of the regenerating liver by preserving sinusoidal morphology.
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Affiliation(s)
- Alexandra Dili
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium.,Department of Surgery, Centre Hospitalier Universitaire UCLouvain-Namur, Yvoir, Belgium
| | - Claude Bertrand
- Department of Surgery, Centre Hospitalier Universitaire UCLouvain-Namur, Yvoir, Belgium
| | - Valérie Lebrun
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
| | - Boris Pirlot
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
| | - Isabelle A Leclercq
- Institut de Recherche Expérimentale et Clinique, Laboratory of Hepato-Gastroenterology, Université Catholique de Louvain, Brussels, Belgium
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