151
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Luo X, Chen L, Liu W, Dong S, Luo H, Zhang B, Chen X. A propensity score analysis of two methods of hepatic vascular occlusion in hepatectomy. J Surg Res 2017; 213:184-190. [DOI: 10.1016/j.jss.2017.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/13/2017] [Accepted: 02/20/2017] [Indexed: 01/14/2023]
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152
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Abstract
Objective: To establish a reliable equation to predict hepatic venous pressure gradient (HVPG) using serological tests for surgical patients with hepatocellular carcinoma (HCC). Background: Accurate assessment of portal pressure for surgical patients with HCC is important for safe hepatic resection (HR). The HVPG is regarded as the most reliable method to detect portal hypertension. However, HVPG is not utilized in many medical centers due to invasiveness of procedure. Methods: Between 2006 and 2008, 171 patients (Correlation cohort), who underwent liver surgery in a tertiary hospital, were enrolled. Preoperative measurements of the HVPG and serological tests were performed simultaneously. Correlation between the HVPG and serological tests were analyzed to establish an equation for calculated HVPG (cHVPG). Between 2008 and 2013, 510 surgical patients (Application cohort) were evaluated, and HR recommended when cHVPG < 10 mm Hg. The outcomes of HR were analyzed to evaluate reliability of the cHVPG for HR. Results: In the correlation cohort, the equation for cHVPG was established using multivariate linear regression analysis; cHVPG (mm Hg) = 0.209 × [ICG-R15 (%)] − 1.646 × [albumin (g/dL)] − 0.01×[platelet count (103)] + 1.669 × [PT-INR] + 8.911. In the application cohort, 425 patients with cHVPG < 10 mm Hg underwent HR. Among them, 357 had favorable value of ICG-R15 < 20% (group A), and 68 had unfavorable value of ICG-R15 ≥ 20% (group B). There was no significant difference in patient demographics, tumor characteristics, operative outcome, and survival rates between group A and B. Conclusions: The equation for cHVPG of this study was established on statistical reliability. The cHVPG could be useful to predict portal pressure quantitatively for surgical patients with HCC using serological tests.
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153
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Pure Laparoscopic Hepatectomy Versus Open Hepatectomy for Hepatocellular Carcinoma in 110 Patients With Liver Cirrhosis: A Propensity Analysis at a Single Center. Ann Surg 2017; 264:612-20. [PMID: 27433917 DOI: 10.1097/sla.0000000000001848] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the long-term outcomes of pure laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma (HCC) with background cirrhosis. BACKGROUND Laparoscopic hepatectomy has been gaining popularity, but has not been widely accepted, because published data were gathered from small numbers of patients. METHODS Data of patients diagnosed with HCC and cirrhosis treated by hepatectomy were reviewed. The outcomes of pure laparoscopic hepatectomy were compared with those of open hepatectomy. Propensity score matching of patients in a ratio of 1:3 was conducted. RESULTS There were 110 patients and 330 patients in the laparoscopic group and the open group, respectively. The laparoscopic group had less blood loss (150 vs 400 mL; P < 0.001), shorter operation time (185 vs 255 minutes; P < 0.001), and shorter hospital stay (4vs 7 days; P < 0.001). The median overall survival was 136 months in the laparoscopic group and 120 months in the open group. The 1, 3, and 5-year overall survival rates were 98.9%, 89.8%, and 83.7%, respectively, in the laparoscopic group, and 94%, 79.3%, and 67.4%, respectively, in the open group (P = 0.033). The median disease-free survival was 66.37 months in the laparoscopic group and 52.4 months in the open group. The 1, 3, and 5-year disease-free survival rates were 87.7%, 65.8%, and 52.2%, respectively, in the laparoscopic group, and 75.2%, 56.3%, and 47.9%, respectively, in the open group (P = 0.141). CONCLUSIONS Pure laparoscopic hepatectomy for HCC can be carried out safely with favorable short-term and long-term outcomes even in cirrhotic patients at high-volume liver cancer centers.
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154
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Ruzzenente A, Conci S, Ciangherotti A, Campagnaro T, Valdegamberi A, Bertuzzo F, Bagante F, Mantovani G, De Angelis M, Dorna AE, Piccino M, Pedrazzani C, Guglielmi A, Iacono C. Impact of age on short-term outcomes of liver surgery: Lessons learned in 10-years' experience in a tertiary referral hepato-pancreato-biliary center. Medicine (Baltimore) 2017; 96:e6955. [PMID: 28514317 PMCID: PMC5440154 DOI: 10.1097/md.0000000000006955] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We investigate the surgical outcomes of patients undergoing hepatectomy according to different age intervals, identify the clinical factors related to surgical outcomes, and propose clinical risk scores for severe morbidity and mortality based on the clinical factors.Eight hundred three patients undergoing liver resection were divided into 3 groups: young patients (YP), <65 years (n = 387), elderly patients (EP), from 65 to 74 years (n = 279); very-elderly patients (VEP), ≥75 years (n = 137).Severe morbidity was 10.6%, 12.2%, and 17.5% (P = .103), and mortality was 0.3%, 1.4%, and 4.4% (P = .002) in group YP, EP, and VEP, respectively. Ischemic heart disease, cirrhosis, major hepatectomy, biliary tract-associated procedure, and red blood cells (RBC) transfusion ≥3 U were related with severe morbidity. Ischemic heart disease, cirrhosis, major hepatectomy, and RBC transfusion were independent risk factors for postoperative mortality. Age did not result an independent factor related to mortality and severe morbidity. Two different scores were developed and have proved to be statistically related with severe morbidity and mortality. Moreover, in patients with score ≥2, severe morbidity increased from 24.2% in YP, to 29.3% in EP, and to 40.0% in VEP, P = .047. Likewise, mortality increased from 2.3% in YP, to 7.0% in EP, and to 22.7% in VEP, in patients with score ≥2, P = .017.Age alone should not be considered a contraindication for hepatectomy. We identified factors and proposed 2 scores that can be useful to stratify the risk of morbidity and mortality after hepatectomy. Moreover, severe morbidity and mortality increases according to the different age intervals in patients with scores ≥2.
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155
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Fromer MW, Gaughan JP, Atabek UM, Spitz FR. Primary Malignancy is an Independent Determinant of Morbidity and Mortality after Liver Resection. Am Surg 2017. [DOI: 10.1177/000313481708300515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although outcomes after liver resection have improved, there remains considerable perioperative morbidity and mortality with these procedures. Studies suggest a primary liver cancer diagnosis is associated with poorer outcomes, but the extent to which this is attributable to a higher degree of hepatic dysfunction is unclear. To better delineate this, we performed a matched pair analysis of primary versus metastatic malignancies using a national database. The American College of Surgeons National Surgical Quality Improvement Program (2005–2013) was analyzed to select elective liver resections. Diagnoses were sorted as follows: 1) primary liver cancers and 2) metastatic neoplasms. A literature review identified factors known to impact hepatectomy outcomes; these variables were evaluated by a univariate analysis. The most predictive factors were used to create similar groups from each diagnosis category via propensity matching. Multivariate regression was used to validate results in the wider study population. Outcomes were compared using chi-squared test and Fisher exact test. Matched groups of 4838 patients were similar by all variables, including indicators of liver function. A number of major complications were significantly more prevalent with a primary diagnosis; overall major morbidity rates in the metastatic and primary groups were 29.3 versus 41.6 per cent, respectively. The mortality rate for primary neoplasms was 4.6 per cent (vs 1.6%); this represents a risk of death nearly three-times greater (95% confidence interval = 2.20–3.81, P < 0.0001) in cancers of hepatic origin. Hepatectomy carries substantially higher perioperative risk when performed for primary liver cancers, independent of hepatic function and resection extent. This knowledge will help to improve treatment planning, patient education, and resource allocation in oncologic liver resection.
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Affiliation(s)
- Marc W. Fromer
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - John P. Gaughan
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - Umur M. Atabek
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - Francis R. Spitz
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
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156
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Labgaa I, Joliat GR, Kefleyesus A, Mantziari S, Schäfer M, Demartines N, Hübner M. Is postoperative decrease of serum albumin an early predictor of complications after major abdominal surgery? A prospective cohort study in a European centre. BMJ Open 2017; 7:e013966. [PMID: 28391235 PMCID: PMC5775466 DOI: 10.1136/bmjopen-2016-013966] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes. DESIGN Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS). SETTING Department of abdominal surgery in a European tertiary centre. PARTICIPANTS Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded. RESULTS The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p<0.001). ΔAlb also correlated to overall complications (r=0.485, p<0.001), CCI (r=0.383, p<0.001) and LoS (r=0.468, p<0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1% and a specificity of 67.2% (AUC: 78.3%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications. CONCLUSIONS Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk.
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Affiliation(s)
- Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Amaniel Kefleyesus
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Markus Schäfer
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
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157
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Neethirajan SM, Rachapoodivenkata RR. Oral glucose tolerance test for preoperative assessment of liver function in liver resection. Ann Hepatobiliary Pancreat Surg 2017; 21:1-10. [PMID: 28317039 PMCID: PMC5353905 DOI: 10.14701/ahbps.2017.21.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/22/2016] [Accepted: 09/26/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUNDS/AIMS We intended to determine the role of the Oral glucose tolerance test (OGTT), in addition to volumetry, in preoperative assessment of patients undergoing liver resection. METHODS This was a prospective study conducted at a tertiary care hospital, between February 2009 and February 2011. OGTT curve (parabolic/linear), linearity index (LI) and Parenchymal Hepatic Resection Rate (PHRR) were correlated with postoperative outcomes in terms of postoperative liver failure (PLF), by 50-50 criteria, morbidity, mortality and hospital stay. RESULTS Of the 33 patients included in the study, 23 (69.7%) patients underwent major liver resections. Hepatocellular carcinoma (30.3%) was the leading indication. The overall postoperative morbidity rate was 72.7%, but major complications occurred in 3 (9.1%) patients only. There was no 90-day mortality. The 50-50 criteria were met by 3 patients undergoing major resection. Significant correlation was noted between the linear OGTT curve and the overall hospital stay (12.1 days vs. 9.6 days in parabolic; p=0.04). Patients with linear OGTT met the 50-50 criteria more often (18%) than those having a parabolic curve (4.5%; p=0.25). Although the OGTT was more often linear with occurrence of morbidity (41.7% vs 11.1%), major morbidity (66.7% vs 30%) and PLF by 50-50 criteria (66.7% vs 30%), it was not statistically significant. The linearity index was marginally lower (0.9 vs 1.2) in the presence of major morbidity and PLF by 50-50 criteria. CONCLUSIONS Linear OGTT affects the PLF and major morbidity, therein impacting the hospital stay. OGTT LI and PHRR can help predict postoperative outcome for a given extent of liver resection.
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Affiliation(s)
- Saravanan Manickam Neethirajan
- Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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158
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Li EL, Feng Q, Yang QP, Liao WJ, Liu WW, Huang Y, Wu LQ, Yin XB, Shao JH. Effectiveness of hepatic parenchyma lithotomy of hepatolithiasis: A single-center experience. Medicine (Baltimore) 2017; 96:e6134. [PMID: 28272201 PMCID: PMC5348149 DOI: 10.1097/md.0000000000006134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
To investigate the clinical significance of hepatic parenchyma incision by lithotomy near the second hepatic portal area for the treatment of complex hepatolithiasis.A retrospective study was conducted with 35 patients who had complicated hepatolithiasis in our hospital from January 2008 to December 2013, who underwent hepatic parenchyma incision by lithotomy near the second hepatic portal area. The perioperative and long-term outcomes included the stone clearance rate, operative morbidity and mortality, and the stone recurrence rate. Patients with a preoperative diagnosis of cholangiocarcinoma were excluded from the study.All patients with hepatic duct stones were mainly located at S2, S4, and S8 regions. Surgical methods included were hepatic parenchyma incision by lithotomy near the second hepatic portal area, or by combined partial hepatectomy. The mean follow-up period was 51 months. One patient died during hospitalization. The surgical morbidity was 17.6%, stone clearance rate was 88.2%, and final clearance rate was 94.1% followed by postoperative choledochoscopic lithotripsy. The stone recurrence rate was 15.6% and the occurrence of postoperative cholangitis was 11.8% during the follow-up period.Hepatic parenchyma incision by lithotomy near the second hepatic portal area is safe with satisfactory short and long-term outcome results for complicated hepatolithiasis.
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Affiliation(s)
- En Liang Li
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Qian Feng
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Qing Ping Yang
- Center of Assisted Reproduction, the First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wen Jun Liao
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Wang Wei Liu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Yong Huang
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Lin Quan Wu
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Xiang Bao Yin
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
| | - Jiang Hua Shao
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Nanchang University
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159
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Establishing a Porcine Model of Small for Size Syndrome following Liver Resection. Can J Gastroenterol Hepatol 2017; 2017:5127178. [PMID: 28951864 PMCID: PMC5603121 DOI: 10.1155/2017/5127178] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 08/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Small for size syndrome (SFSS) is responsible for a high proportion of mortalities and morbidities following extended liver resection. AIM The aim of this study was to establish a porcine model of SFSS. METHODS Twenty-four Landrace pigs underwent liver resection with a remnant liver volume of 50% (group A, n = 8), 25% (group B, n = 8), and 15% (group C, n = 8). After resection, the animals were followed up for 8 days and clinical, laboratory, and histopathological outcomes were evaluated. RESULTS The survival rate was significantly lower in group C compared with the other groups (p < 0.001). The international normalized ratio, bilirubin, aspartate transaminase, alanine transaminase, and alkaline phosphatase levels increased shortly after surgery in groups B and C, but no change was observed in group A (p < 0.05 for all analyses). The histopathological findings in group A were mainly mild mitoses, in group B severe mitoses and hepatocyte ballooning, moderate congestion, and hemorrhage, along with mild necrosis, and in group C extended tissue damage with severe necrosis, hemorrhage, and congestion. CONCLUSIONS Combination of clinical, laboratory, and histopathological evaluations is needed to confirm the diagnosis of SFSS. 75% liver resection in porcine model results in SFSS. 85% liver resection causes irreversible liver failure.
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160
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Ma KW, Cheung TT. Surgical resection of localized hepatocellular carcinoma: patient selection and special consideration. J Hepatocell Carcinoma 2016; 4:1-9. [PMID: 28097107 PMCID: PMC5207474 DOI: 10.2147/jhc.s96085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Localized hepatocellular carcinoma (HCC) refers to a solitary or few tumors located within either the left or right hemiliver without evidence of bilobar or extrahepatic spread. This term encompasses a heterogeneous morphology with no regard to stage of prognosis of the disease. Surgical resection remains the mainstay of curative treatment for the localized HCC. Various biochemical and radiological tests constitute an indispensible part of preoperative assessment. Emergence of laparoscopic hepatectomy has brought liver resection into a new era. Improved understanding of the pathophysiology of HCC allows more aggressive surgical resection without compromising outcomes. New insights into the management of special situations, such as ruptured HCC, pyogenic transformation of HCC, and HCC with portal vein tumor thrombus, rekindle the hopes of curative resection in these terminal events. Amalgamating salvage liver transplantation into the surgical management of resectable HCC has revolutionized the treatment paradigm of this deadly disease.
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Affiliation(s)
- Ka Wing Ma
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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161
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The influence of PEEP and positioning on central venous pressure and venous hepatic hemodynamics in patients undergoing liver resection. J Clin Monit Comput 2016; 31:1221-1228. [DOI: 10.1007/s10877-016-9970-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022]
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162
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Karanicolas PJ, Lin Y, Tarshis J, Law CHL, Coburn NG, Hallet J, Nascimento B, Pawliszyn J, McCluskey SA. Major liver resection, systemic fibrinolytic activity, and the impact of tranexamic acid. HPB (Oxford) 2016; 18:991-999. [PMID: 27765582 PMCID: PMC5144548 DOI: 10.1016/j.hpb.2016.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/19/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection. METHODS In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration. RESULTS No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA. CONCLUSIONS There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182.
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Affiliation(s)
- Paul J Karanicolas
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Calvin H L Law
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barto Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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163
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Yokoo H, Miyata H, Konno H, Taketomi A, Kakisaka T, Hirahara N, Wakabayashi G, Gotoh M, Mori M. Models predicting the risks of six life-threatening morbidities and bile leakage in 14,970 hepatectomy patients registered in the National Clinical Database of Japan. Medicine (Baltimore) 2016; 95:e5466. [PMID: 27930526 PMCID: PMC5265998 DOI: 10.1097/md.0000000000005466] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To construct a robust morbidity risk-prediction model based on a Japanese nationwide web-based database of patients who underwent liver surgery.Although liver resection has become safer, patient mortality and morbidity still occur. This study investigated postoperative morbidity risks in patients who underwent hepatectomy in Japan at institutions registered in the National Clinical Database.This analysis involved 14,970 patients who underwent hepatectomy of more than 1 section, except for left lateral sectionectomy, during 2011 and 2012 at 1192 hospitals in Japan. Patients were randomized into 2 subsets, with 80% of patients analyzed for model development and the remaining 20% for model validation.Rates of 90-day inhospital mortality and overall morbidity were 3.7% and 25.7%, respectively. Rates of surgical site infection and bile leakage were 9.0% and 8.0%, respectively, but these morbidities showed little association with mortality. Rates of nonsurgical complications, including postoperative transfusion over 5 units, unexpected intubation, renal failure, cardiac events, septic shock, and postoperative pneumonia, ranged from 0.2% to 2.6%. These complications were highly associated with mortality, suggesting they were life-threatening. Risk models for morbidity yielded high C-indices for transfusion of over 5 units (0.758), unplanned intubation (0.755), renal failure (0.80), cardiac events (0.779), septic shock (0.783), pneumonia (0.768), and bile leakage (0.676).Preoperative parameters/comorbidities can accurately predict life-threatening complications after hepatectomy. These models allow early identification of patients at risk of mortality and may be useful in deciding on surgical interventions and in improving surgical quality.
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Affiliation(s)
- Hideki Yokoo
- The Japanese Society of Gastroenterological Surgery (JSGS)
| | - Hiroaki Miyata
- Database Committee, The Japanese Society of Gastroenterological Surgery (JSGS)
- National Clinical Database, Sapporo, Tokyo, Japan
| | - Hiroyuki Konno
- Database Committee, The Japanese Society of Gastroenterological Surgery (JSGS)
| | - Akinobu Taketomi
- Database Committee, The Japanese Society of Gastroenterological Surgery (JSGS)
| | | | | | - Go Wakabayashi
- Database Committee, The Japanese Society of Gastroenterological Surgery (JSGS)
| | - Mitsukazu Gotoh
- Database Committee, The Japanese Society of Gastroenterological Surgery (JSGS)
| | - Masaki Mori
- The Japanese Society of Gastroenterological Surgery (JSGS)
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164
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Zakaria HM, Gad EH, Nada A, Abdelaleem AA, Maher D, Abdel Samea ME, Sabry A. Hepatic resection for hepatocellular carcinoma in cirrhotic patients with portal hypertension. SURGICAL PRACTICE 2016. [DOI: 10.1111/1744-1633.12215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Hazem M. Zakaria
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery; Menoufia University; Menoufia Egypt
| | - Emad H. Gad
- Department of Hepatopancreatobiliary and Liver Transplantation Surgery; Menoufia University; Menoufia Egypt
| | - Ali Nada
- Department of Hepatology, National Liver Institute; Menoufia University; Menoufia Egypt
| | - Anwar A. Abdelaleem
- Department of Hepatology, National Liver Institute; Menoufia University; Menoufia Egypt
| | - Doha Maher
- Department of Pathology, National Liver Institute; Menoufia University; Menoufia Egypt
| | - Mohammad E. Abdel Samea
- Department of Diagnostic and Intervention Radiology, National Liver Institute; Menoufia University; Menoufia Egypt
| | - Alyaa Sabry
- Department of Hepatology, National Liver Institute; Menoufia University; Menoufia Egypt
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165
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Xu Y, Chen J, Wang H, Zheng H, Feng D, Zhang A, Leng J, Duan W, Yang Z, Chen M, Shi X, Cai S, Ji W, Jiang K, Zhang W, Chen Y, Gu W, Dong J, Lu S. Perioperative and long-term outcomes of liver resection for hepatitis B virus-related hepatocellular carcinoma without versus with hepatic inflow occlusion: study protocol for a prospective randomized controlled trial. Trials 2016; 17:492. [PMID: 27724929 PMCID: PMC5057253 DOI: 10.1186/s13063-016-1621-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 09/24/2016] [Indexed: 02/06/2023] Open
Abstract
Background The high prevalence of hepatitis B virus (HBV) imposes a huge burden of hepatocellular carcinoma (HCC) in Asia. Surgical resection remains an important therapeutic strategy for HCC. Hepatic inflow occlusion, known as the Pringle maneuver, is the most commonly used method of reducing blood loss during liver parenchymal transection. A major issue with this maneuver is ischemia-reperfusion injury to the remnant liver, and the hemodynamic disturbance it induces in the tumor-bearing liver raises an oncological concern. Given the technical advances in living donor liver transplantation, vascular occlusion in liver resection can be avoided in experienced hands. The aim of this study is to compare the perioperative and long-term outcomes of liver resection for HBV-related HCC without versus with hepatic inflow occlusion. Methods/design This study will include eligible patients with HBV-related HCC elected for liver resection. Fifty-seven patients will be enrolled in each randomization arm to detect a 20 % difference in the serum level of total bilirubin on postoperative day 5 (80 % power and α = 0.05). The secondary endpoints include procedural parameters, perioperative liver function and inflammatory response, postoperative morbidity and mortality, and long-term outcomes. Patients will be followed for up to 5 years. Data will be statistically analyzed on an intention-to-treat basis. Discussion This prospective randomized controlled trial is designed to compare the perioperative and long-term outcomes of liver resection for HBV-related HCC without versus with vascular occlusion. The clinical implications of these outcomes may change current surgical practice and fill the oncological gaps therein. Trial registration Clinicaltrials.gov identifier NCT02563158. Registered on 28 September 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1621-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yinzhe Xu
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China.,Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Jiye Chen
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Hongguang Wang
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, 50 Staniford Street, Boston, MA, 02114, USA
| | - Dan Feng
- Division of Standard Operational Management, Institute of Hospital Management, Chinese PLA General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Aiqun Zhang
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Jianjun Leng
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Weidong Duan
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Zhanyu Yang
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Mingyi Chen
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Xianjie Shi
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Shouwang Cai
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Wenbin Ji
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Kai Jiang
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Wenzhi Zhang
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Yongliang Chen
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Wanqing Gu
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Jiahong Dong
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China
| | - Shichun Lu
- Department of Hepatobiliary Surgery, Chinese People's Liberation Army General Hospital, 28 Fuxing Road, Haidian, Beijing, 100853, China.
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166
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The utility of 5-aminolevulinic acid-mediated photodynamic diagnosis in the detection of intraoperative bile leakage. Am J Surg 2016; 213:1077-1082. [PMID: 27871684 DOI: 10.1016/j.amjsurg.2016.09.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/24/2016] [Accepted: 09/30/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of this retrospective study was to evaluate the utility of the new intraoperative bile leakage test as a preventive measure of postoperative bile leakage. METHOD 737 patients were retrospectively analyzed with respect to the management of intra- and post-operative bile leakage. RESULTS Nine (8.3%) of 109 patients evaluated using conventional white light fluorescent imaging were recognized as having intra-operative bile leakage. However, performance of 5-aminolevulinic acid (5-ALA)-mediated PDD detected bile leakage intraoperatively not only in these 9 patients, but also in an additional 6 patients, such that 'red fluorescence' at the cut surface of the liver, was visualized in a total of 15 patients. The postoperative courses of most patients were uneventful, and postoperative bile leakages occurred in only one (0.9%) patient. CONCLUSION 5-ALA fluorescence imaging may be needed to prevent postoperative bile leakage in patients at high risk for this surgical complication after hepatic resection.
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167
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Quesada R, Poves I, Berjano E, Vilaplana C, Andaluz A, Moll X, Dorcaratto D, Grande L, Burdio F. Impact of monopolar radiofrequency coagulation on intraoperative blood loss during liver resection: a prospective randomised controlled trial. Int J Hyperthermia 2016; 33:135-141. [PMID: 27633068 DOI: 10.1080/02656736.2016.1231938] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To evaluate the impact of using monopolar thermal coagulation based on radiofrequency (RF) currents on intraoperative blood loss during liver resection. MATERIALS AND METHODS A prospective randomised controlled trial was planned. Patients undergoing hepatectomy were randomised into two groups. In the control group (n = 10), hemostasis was obtained with a combination of stitches, vessel-sealing bipolar RF systems, sutures or clips. In the monopolar radiofrequency coagulation (MRFC) group (n = 18), hemostasis was mainly obtained using an internally cooled monopolar RF electrode. RESULTS No differences in demographic or clinical characteristics were found between groups. Mean blood loss during liver resection in the control group was more than twice that of the MRFC group (556 ± 471 ml vs. 225 ± 313 ml, p = .02). The adjusted mean bleeding/transection area was also significantly higher in the control group (7.0 ± 3.3 ml/cm2 vs. 2.8 ± 4.0 ml/cm2, p = .006). No significant differences were observed in the rate of complications between the groups. CONCLUSIONS The findings suggest that the monopolar electrocoagulation created with an internally cooled RF electrode considerably reduces intraoperative blood loss during liver resection.
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Affiliation(s)
- Rita Quesada
- a Cancer Research Group HBP , Fundación Instituto Mar de Investigaciones Médicas , Barcelona , Spain.,b Apeiron Medical , Valencia , Spain
| | - Ignasi Poves
- c General Surgery Department , Hospital del Mar , Barcelona , Spain
| | - Enrique Berjano
- d Department of Electronic Engineering , Universitat Politècnica de València , Valencia , Spain
| | - Carles Vilaplana
- e Clinical Chemistry , Laboratori de Referència de Catalunya, Hospital del Mar , Barcelona , Spain
| | - Anna Andaluz
- f Medicine and Surgery of Animals Department, Facultat de Veterinària , Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - Xavier Moll
- f Medicine and Surgery of Animals Department, Facultat de Veterinària , Universitat Autònoma de Barcelona , Bellaterra , Spain
| | - Dimitri Dorcaratto
- g Hepatobiliary and Liver Transplant Surgical Unit , St. Vincent's University Hospital , Dublin , Ireland
| | - Luis Grande
- c General Surgery Department , Hospital del Mar , Barcelona , Spain
| | - Fernando Burdio
- c General Surgery Department , Hospital del Mar , Barcelona , Spain
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168
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Rekman J, Wherrett C, Bennett S, Gostimir M, Saeed S, Lemon K, Mimeault R, Balaa FK, Martel G. Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections. Surgery 2016; 161:650-657. [PMID: 27712877 DOI: 10.1016/j.surg.2016.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 07/22/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations. METHODS Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H2O). The target phlebotomy volume was 7-10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison. RESULTS A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3 cm H2O (0-15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications. CONCLUSION Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.
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Affiliation(s)
- Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Miso Gostimir
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Sara Saeed
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON
| | - Kristina Lemon
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Richard Mimeault
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
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169
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Modern Technical Approaches in Hepatic Surgery for Colorectal Metastases. CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0327-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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170
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Martínez-Mier G, Esquivel-Torres S, Alvarado-Arenas R, Ortiz-Bayliss A, Lajud-Barquín F, Zilli-Hernandez S. Liver resection morbidity, mortality, and risk factors at the departments of hepatobiliary surgery in Veracruz, Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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171
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Eshmuminov D, Raptis DA, Linecker M, Wirsching A, Lesurtel M, Clavien PA. Meta-analysis of associating liver partition with portal vein ligation and portal vein occlusion for two-stage hepatectomy. Br J Surg 2016; 103:1768-1782. [PMID: 27633328 DOI: 10.1002/bjs.10290] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/04/2016] [Accepted: 07/06/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Discussion is ongoing regarding whether associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) or portal vein occlusion is better in staged hepatectomy. The aim of this study was to compare available strategies using a two-stage approach in extended hepatectomy. METHODS A literature search was performed in MEDLINE, Scopus, the Cochrane Library and Embase, and additional articles were identified by hand searching. Data from the international ALPPS registry were extracted. Clinical studies reporting volumetric changes, mortality, morbidity, feasibility of the second stage and tumour-free resection margins (R0) in two-stage hepatectomy were included. RESULTS Ninety studies involving 4352 patients, including 320 from the ALPPS registry, met the inclusion criteria. Among these, nine studies (357 patients) reported on comparisons with other strategies. In the comparison of ALPPS versus portal vein embolization (PVE), ALPPS was associated with a greater increase in the future liver remnant (76 versus 37 per cent; P < 0·001) and more frequent completion of stage 2 (100 versus 77 per cent; P < 0·001). Compared with PVE, ALPPS had a trend towards higher morbidity (73 versus 59 per cent; P = 0·16) and mortality (14 versus 7 per cent; P = 0·19) after stage 2. In the non-comparative studies, complication rates were 39 per cent in the PVE group, 47 per cent in the portal vein ligation (PVL) group and 70 per cent in the ALPPS group. After stage 2, mortality rates were 5, 7 and 12 per cent respectively. CONCLUSION ALPPS is associated with greater future liver remnant hypertrophy and a higher rate of completion of stage 2, but this may be at the price of greater morbidity and mortality.
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Affiliation(s)
- D Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - D A Raptis
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Linecker
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - A Wirsching
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
| | - M Lesurtel
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland.,Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France
| | - P-A Clavien
- Department of Surgery, Swiss HPB and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
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172
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Maurer CA, Walensi M, Käser SA, Künzli BM, Lötscher R, Zuse A. Liver resections can be performed safely without Pringle maneuver: A prospective study. World J Hepatol 2016; 8:1038-1046. [PMID: 27648156 PMCID: PMC5002500 DOI: 10.4254/wjh.v8.i24.1038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/04/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate liver resections without Pringle maneuver, i.e., clamping of the portal triad.
METHODS Between 9/2002 and 7/2013, 175 consecutive liver resections (n = 101 major anatomical and n = 74 large atypical > 5 cm) without Pringle maneuver were performed in 127 patients (143 surgeries). Accompanying, 37 wedge resections (specimens < 5 cm) and 43 radiofrequency ablations were performed. Preoperative volumetric calculation of the liver remnant preceeded all anatomical resections. The liver parenchyma was dissected by water-jet. The median central venous pressure was 4 mmHg (range: 5-14). Data was collected prospectively.
RESULTS The median age of patients was 60 years (range: 16-85). Preoperative chemotherapy was used in 70 cases (49.0%). Liver cirrhosis was present in 6.3%, and liver steatosis of ≥ 10% in 28.0%. Blood loss was median 400 mL (range 50-5000 mL). Perioperative blood transfusions were given in 22/143 procedures (15%). The median weight of anatomically resected liver specimens was 525 g (range: 51-1850 g). One patient died postoperatively. Biliary leakages (n = 5) were treated conservatively. Temporary liver failure occurred in two patients.
CONCLUSION Major liver resections without Pringle maneuver are feasible and safe. The avoidance of liver inflow clamping might reduce liver damage and failure, and shorten the hospital stay.
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173
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Martínez-Mier G, Esquivel-Torres S, Alvarado-Arenas RA, Ortiz-Bayliss AB, Lajud-Barquín FA, Zilli-Hernandez S. Liver resection morbidity, mortality, and risk factors at the departments of hepatobiliary surgery in Veracruz, Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:195-201. [PMID: 27527529 DOI: 10.1016/j.rgmx.2016.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 03/23/2016] [Accepted: 05/04/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Liver resection has been associated with high morbidity and mortality, and the most serious complication is liver failure. Patient evaluation is limited to risk scales. The 50-50 criteria and bilirubin peak>7mg/dl have been used as mortality predictors. AIM The aim of this study was to determine the risk factors associated with morbidity and mortality for liver resection in our population. MATERIAL AND METHODS A retrospective study was carried out on 51 patients that underwent liver resection. Sociodemographic variables, pathology, and the surgical act were analyzed, together with morbidity and mortality and their associated factors. RESULTS Fifty-one patients, 23 men and 28 women, were analyzed. They had a mean age of 51.4±19.13 years, 64.7% had concomitant disease, and their mean MELD score was 7.49±1.79. The mean size of the resected lesions was 7.34±3.47cm, 51% were malignant, and 34 minor resections were performed. The Pringle maneuver was used in 64.7% of the cases and the mean blood loss was 1,090±121.76ml. Morbidity of 25.5% was associated with viral hepatitis infection, greater blood loss, transfusion requirement, the Pringle maneuver, lower hemoglobin and PTT values, and higher MELD, INR, bilirubin, and glucose values. A total 3.9% mortality was associated with hyperbilirubinemia, hyperglycemia, and greater blood loss and transfusions. CONCLUSIONS The main risk factors associated with the morbidity and mortality of liver resection in our population were those related to the preoperative biochemical parameters of the patient and the factors that occurred during the surgical act.
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Affiliation(s)
- G Martínez-Mier
- Departamento de Cirugía Hepatobiliar, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México; Departamento de Cirugía Hepatobiliar, Hospital de Alta Especialidad de Veracruz, Veracruz, México.
| | - S Esquivel-Torres
- Departamento de Cirugía Hepatobiliar, Hospital de Alta Especialidad de Veracruz, Veracruz, México
| | - R A Alvarado-Arenas
- Departamento de Cirugía Hepatobiliar, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
| | - A B Ortiz-Bayliss
- Departamento de Cirugía Hepatobiliar, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
| | - F A Lajud-Barquín
- Departamento de Investigación, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
| | - S Zilli-Hernandez
- Departamento de Investigación, Unidad Médica de Alta Especialidad, Hospital de Especialidades No 14 Centro Médico Nacional "Adolfo Ruiz Cortinez", Instituto Mexicano del Seguro Social, Veracruz, México
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174
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Hutchinson KM, Shaw SP. A Review of Central Venous Pressure and Its Reliability as a Hemodynamic Monitoring Tool in Veterinary Medicine. Top Companion Anim Med 2016; 31:109-121. [PMID: 27968811 DOI: 10.1053/j.tcam.2016.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/04/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To review the current literature regarding central venous pressure (CVP) in veterinary patients pertaining to placement (of central line), measurement, interpretation, use in veterinary medicine, limitations, and controversies in human medicine. ETIOLOGY CVP use in human medicine is a widely debated topic, as numerous sources have shown poor correlation of CVP measurements to the volume status of a patient. Owing to the ease of placement and monitoring in veterinary medicine, CVP remains a widely used modality for evaluating the hemodynamic status of a patient. A thorough evaluation of the veterinary and human literature should be performed to evaluate the role of CVP measurements in assessing volume status in veterinary patients. DIAGNOSIS Veterinary patients that benefit from accurate CVP readings include those suffering from hypovolemic or septic shock, heart disease, or renal disease or all of these. Other patients that may benefit from CVP monitoring include high-risk anesthetic patients undergoing major surgery, trending of fluid volume status in critically ill patients, patients with continued shock, and patients that require rapid or large amounts of fluids. THERAPY The goal of CVP use is to better understand a patient's intravascular volume status, which would allow early goal-directed therapy. PROGNOSIS CVP would most likely continue to play an important role in the hemodynamic monitoring of the critically ill veterinary patient; however, when available, cardiac output methods should be considered the first choice for hemodynamic monitoring.
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Affiliation(s)
| | - Scott P Shaw
- VCA, Specialty Regional Medical Director; Northeast Los Angeles, CA, USA
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175
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She WH, Chan ACY, Cheung TT, Chok KSH, Dai WC, Chan SC, Lo CM. Short- and long-term impact of reoperation for complications after major hepatectomy for hepatocellular carcinoma. Surgery 2016; 160:1236-1243. [PMID: 27498301 DOI: 10.1016/j.surg.2016.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 06/02/2016] [Accepted: 06/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of reoperation for complications after major liver resection for hepatocellular carcinoma was evaluated. METHODS In this retrospective study covering 25 years, patients with reoperation for complications after major liver resection for hepatocellular carcinoma were compared with patients without reoperation in terms of demographics, tumor characteristics, operative details, postoperative results, oncologic outcomes, and survival. Reasons for reoperation were also investigated. RESULTS Forty-nine out of 1,092 patients underwent reoperation within a median of 0.2 days (range, 0-6.9 days) after hepatectomy. Patients with and without reoperation had similar baseline characteristics and liver function. Nonetheless, patients with reoperation had a higher indocyanine green retention rate at 15 minutes (12.55% vs 10.5%, P = .015), more operative blood loss (1.4 L vs 1 L, P = .012), a higher blood transfusion rate (44.9% vs 29.2%, P = .029), longer hospital stay (21 days vs 11 days, P < .001), a higher hospital mortality (38.8% vs 3.0%, P < .001), and a higher 90-day mortality (38.8% vs 4.7%, P < .001). Hemorrhage was the most common cause for reoperation (26/49, 53.1%), mainly resulting from coagulopathic bleeding from raw areas (12/26, 46.2%) and bleeding from diaphragmatic veins (6/26, 23.1%). However, reoperation did not affect 5-year overall survival (50.2% vs 48.3%, P = .468). CONCLUSION Postoperative hemorrhage was associated with a high mortality, signifying the importance of meticulous hemostasis and careful perioperative management. Oncologic outcomes, however, were not affected by reoperation.
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Affiliation(s)
- Wong Hoi She
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Albert C Y Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, China.
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Kenneth S H Chok
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Wing Chiu Dai
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - See Ching Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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176
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Muangkaew P, Cho JY, Han HS, Yoon YS, Choi Y, Jang JY, Choi H, Jang JS, Kwon SU. Defining Surgical Difficulty According to the Perceived Complexity of Liver Resection: Validation of a Complexity Classification in Patients with Hepatocellular Carcinoma. Ann Surg Oncol 2016; 23:2602-2609. [DOI: 10.1245/s10434-015-5058-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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177
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Peres LAB, Bredt LC, Cipriani RFF. Acute renal injury after partial hepatectomy. World J Hepatol 2016; 8:891-901. [PMID: 27478539 PMCID: PMC4958699 DOI: 10.4254/wjh.v8.i21.891] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 06/02/2016] [Accepted: 06/27/2016] [Indexed: 02/06/2023] Open
Abstract
Currently, partial hepatectomy is the treatment of choice for a wide variety of liver and biliary conditions. Among the possible complications of partial hepatectomy, acute kidney injury (AKI) should be considered as an important cause of increased morbidity and postoperative mortality. Difficulties in the data analysis related to postoperative AKI after liver resections are mainly due to the multiplicity of factors to be considered in the surgical patients, moreover, there is no consensus of the exact definition of AKI after liver resection in the literature, which hampers comparison and analysis of the scarce data published on the subject. Despite this multiplicity of risk factors for postoperative AKI after partial hepatectomy, there are main factors that clearly contribute to its occurrence. First factor relates to large blood losses with renal hypoperfusion during the operation, second factor relates to the occurrence of post-hepatectomy liver failure with consequent distributive circulatory changes and hepatorenal syndrome. Eventually, patients can have more than one factor contributing to post-operative AKI, and frequently these combinations of acute insults can be aggravated by sepsis or exposure to nephrotoxic drugs.
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Affiliation(s)
- Luis Alberto Batista Peres
- Luis Alberto Batista Peres, Department of Nephrology, University Hospital of Western Paraná, State University of Western Paraná, Cascavel, Paraná 85819-110, Brazil
| | - Luis Cesar Bredt
- Luis Alberto Batista Peres, Department of Nephrology, University Hospital of Western Paraná, State University of Western Paraná, Cascavel, Paraná 85819-110, Brazil
| | - Raphael Flavio Fachini Cipriani
- Luis Alberto Batista Peres, Department of Nephrology, University Hospital of Western Paraná, State University of Western Paraná, Cascavel, Paraná 85819-110, Brazil
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178
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Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy. J Surg Res 2016; 206:106-112. [PMID: 27916348 DOI: 10.1016/j.jss.2016.07.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/26/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. MATERIALS AND METHODS Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. RESULTS Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). CONCLUSIONS Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.
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Abstract
This study aimed to clarify the predictive factors for bile leakage after hepatectomy for liver tumor in terms of the International Study Group of Liver Surgery (ISGLS) definition. Between August 2006 and July 2012, 242 patients with a diagnosis of liver tumor underwent hepatectomy in our department, and the total bilirubin level of peritoneal drainage fluid prior to removal of the abdominal drains was examined. The data on all of the patients were analyzed retrospectively to identify the factors that might significantly affect the postoperative bile leakage. There was no grade C bile leakage, and grade A was documented in 65 patients (26.9%) and grade B in 7 patients (2.9%) in terms of the ISGLS definition. Although there was no significant difference in postoperative hospital stay between grade A bile leakage only and those without bile leakage (P = 0.933), a significant difference was noted between grades A and B (median, 11.0 versus 21.0 days; P < 0.001). Multivariate analysis revealed 4 independent significant predictive factors: prolonged operation time (P = 0.040), cholecystectomy (P = 0.048), non–portal vein embolization (P = 0.010), and preoperative chemotherapy (P = 0.021). The ISGLS definition of bile leakage is clinically useful. Prolonged operation time, cholecystectomy, non–portal vein embolization, and preoperative chemotherapy were significant independent risk factors of bile leakage in this study.
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Fromer MW, Aloia TA, Gaughan JP, Atabek UM, Spitz FR. The utility of the MELD score in predicting mortality following liver resection for metastasis. Eur J Surg Oncol 2016; 42:1568-75. [PMID: 27365199 DOI: 10.1016/j.ejso.2016.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The MELD score has been demonstrated to be predictive of hepatectomy outcomes in mixed patient samples of primary and secondary liver cancers. Because MELD is a measure of hepatic dysfunction, prior conclusions may rely on the high prevalence of cirrhosis observed with primary lesions. This study aims to evaluate MELD score as a predictor of mortality and develop a risk prediction model for patients specifically undergoing hepatic metastasectomy. METHODS ACS-NSQIP 2005-2013 was analyzed to select patients who had undergone liver resections for metastases. A receiver operating characteristic (ROC) analysis determined the MELD score most associated with 30-day mortality. A literature review identified variables that impact hepatectomy outcomes. Significant factors were included in a multivariable analysis (MVA). A risk calculator was derived from the final multivariable model. RESULTS Among the 14,919 patients assessed, the mortality rate was 2.7%, and the median MELD was 7.3 (range = 34.4). A MELD of 7.24 was identified by ROC (sensitivity = 81%, specificity = 51%, c-statistic = 0.71). Of all patients above this threshold, 4.4% died at 30 days vs. 1.1% in the group ≤7.24. This faction represented 50.1% of the population but accounted for 80.3% of all deaths (p < 0.001). The MVA revealed mortality to be increased 2.6-times (OR = 2.55, 95%CI 1.69-3.84, p < 0.001). A risk calculator was successfully developed and validated. CONCLUSIONS MELD>7.24 is an important predictor of death following hepatectomy for metastasis and may prompt a detailed assessment with the provided risk calculator. Attention to MELD in the preoperative setting will improve treatment planning and patient education prior to oncologic liver resection.
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Affiliation(s)
- M W Fromer
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - T A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, TX, 77030, USA.
| | - J P Gaughan
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - U M Atabek
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - F R Spitz
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
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181
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Liver surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it. Updates Surg 2016; 68:135-42. [PMID: 27294278 DOI: 10.1007/s13304-016-0373-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/17/2016] [Indexed: 12/29/2022]
Abstract
During the last decades, liver surgery had an extraordinary evolution and diffusion thanks to a drastic reduction of operative mortality and morbidity rates. A debate is ongoing about the need for centralization of liver resections in tertiary referral centers. Robust evidences showed that complex surgical procedures have lower mortality rates when performed in high-volume centers. The present expert group reviewed the literature data and proposed guidelines to identify surgical units that should be entitled to perform liver surgery in Italy. Three separate types of requirements were identified. First, the hospital requirements that include the following criteria: (1) a hospital of 1st level according to the Italian law; (2) the presence of a dedicated hepatobiliary or hepatobiliopancreatic unit or a team dedicated to liver surgery into a general surgery unit; (3) the mandatory presence of oncology, hepatology, radiology, interventional radiology, digestive endoscopy, intensive care, and pathology units; (4) the availability of a liver transplant team into the hospital or into another hospital within an established partnership; (5) a periodic multidisciplinary meeting. Second, the volume requirements: the unit has to perform more than 20 liver resections per year for malignant liver diseases with a 90-day mortality rate < 3 %. Finally, the organization requirements: the presence of specific diagnostic-therapeutic flowcharts for liver diseases.
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182
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Lim C, Audureau E, Salloum C, Levesque E, Lahat E, Merle JC, Compagnon P, Dhonneur G, Feray C, Azoulay D. Acute kidney injury following hepatectomy for hepatocellular carcinoma: incidence, risk factors and prognostic value. HPB (Oxford) 2016; 18:540-8. [PMID: 27317959 PMCID: PMC4913133 DOI: 10.1016/j.hpb.2016.04.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/19/2016] [Accepted: 04/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following hepatectomy remains understudied in terms of diagnosis, severity, recovery and prognostic value. The aim of this study was to assess the risk factors and prognostic value of AKI on short- and long-term outcomes following hepatectomy for hepatocellular carcinoma (HCC). METHOD This is a retrospective analysis of a single-center cohort of 457 consecutive patients who underwent hepatectomy for HCC. The KDIGO criteria were used for AKI diagnosis. The incidence, risk factors, and prognostic value of AKI were investigated. RESULTS AKI occurred in 67 patients (15%). The mortality and major morbidity rates were significantly higher in patients with AKI (37% and 69%) than in those without (6% and 22%; p < 0.001). Renal recovery was complete in 35 (52%), partial in 25 (37%), and absent in 7 (11%) patients. Advanced age, an increased MELD score, major hepatectomy and prolonged duration of operation were identified as independent predictors of AKI. AKI was identified as the strongest independent predictor of postoperative mortality but did not impact survival. CONCLUSION AKI is a common complication after hepatectomy for HCC. Although its development is associated with poor short-term outcomes, it does not appear to be predictive of impaired long-term survival.
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Key Words
- aki, acute kidney injury
- kdigo, kidney disease improving global outcomes
- hcc, hepatocellular carcinoma
- scr, serum creatinine
- rrt, renal replacement therapy
- cki, chronic kidney injury
- egfr, estimated glomerula filtration rate
- icu, intensive care unit
- auroc, area under the receiver operating curve
- os, overall survival
- meld, model for end stage liver disease
- or, odds ratio
- ci, confidence interval
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U965, Paris, France
| | - Etienne Audureau
- Department of Public Health, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Jean Claude Merle
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Gilles Dhonneur
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Cyrille Feray
- INSERM, U955, Créteil, France,Department of Hepatology, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France,Correspondence: Daniel Azoulay, Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor hospital, 51 avenue de Lattre de Tassigny, 94010 Créteil, France. Tel: + 33 1 49 81 25 48. Fax. + 33 1 49 81 24 32.Department of Hepatobiliary and Pancreatic Surgery and Liver TransplantationHenri Mondor hospital51 avenue de Lattre de TassignyCréteil94010France
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Kajiwara T, Midorikawa Y, Yamazaki S, Higaki T, Nakayama H, Moriguchi M, Tsuji S, Takayama T. Clinical score to predict the risk of bile leakage after liver resection. BMC Surg 2016; 16:30. [PMID: 27154038 PMCID: PMC4859985 DOI: 10.1186/s12893-016-0147-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 04/30/2016] [Indexed: 12/12/2022] Open
Abstract
Background In liver resection, bile leakage remains the most common cause of operative morbidity. In order to predict the risk of this complication on the basis of various factors, we developed a clinical score system to predict the potential risk of bile leakage after liver resection. Methods We analyzed the postoperative course in 518 patients who underwent liver resection for malignancy to identify independent predictors of bile leakage, which was defined as “a drain fluid bilirubin concentration at least three times the serum bilirubin concentration on or after postoperative day 3,” as proposed by the International Study Group of Liver Surgery. To confirm the robustness of the risk score system for bile leakage, we analyzed the independent series of 289 patients undergoing liver resection for malignancy. Results Among 81 (15.6 %) patients with bile leakage, 76 had grade A bile leakage, and five had grade C leakage and underwent reoperation. The median postoperative hospital stay was significantly longer in patients with bile leakage (median, 14 days; range, 8 to 34) than in those without bile leakage (11 days; 5 to 62; P = 0.001). There was no hepatic insufficiency or in-hospital death. The risk score model was based on the four independent predictors of postoperative bile leakage: non-anatomical resection (odds ratio, 3.16; 95 % confidence interval [CI], 1.72 to 6.07; P < 0.001), indocyanine green clearance rate (2.43; 1.32 to 7.76; P = 0.004), albumin level (2.29; 1.23 to 4.22; P = 0.01), and weight of resected specimen (1.97; 1.11 to 3.51; P = 0.02). When this risk score system was used to assign patients to low-, middle-, and high-risk groups, the frequency of bile leakage in the high-risk group was 2.64 (95 % CI, 1.12 to 6.41; P = 0.04) than that in the low-risk group. Among the independent series for validation, 4 (5.7 %), 16 (10.0 %), and 10 (16.6 %) patients in low-, middle, and high-risk groups were given a diagnosis of bile leakage after operation, respectively (P = 0.144). Conclusions Our risk score model can be used to predict the risk of bile leakage after liver resection.
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Affiliation(s)
- Takahiro Kajiwara
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yutaka Midorikawa
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Shintaro Yamazaki
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Tokio Higaki
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hisashi Nakayama
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Masamichi Moriguchi
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Shingo Tsuji
- Genome Science Division, Research Center for Advanced Science and Technologies, University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo, 153-8904, Japan
| | - Tadatoshi Takayama
- Department of Digestive Surgery, Nihon University School of Medicine, 30-1 Oyaguchikami-cho, Itabashi-ku, Tokyo, 173-8610, Japan
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184
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Labgaa I, Joliat GR, Demartines N, Hübner M. Serum albumin is an early predictor of complications after liver surgery. Dig Liver Dis 2016; 48:559-561. [PMID: 26818186 DOI: 10.1016/j.dld.2016.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/15/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The morbidity associated with liver surgery remained substantially high despite considerable surgical and anesthetic improvements. The unmet need of accurate biomarkers to predict postoperative complications is widely accepted. AIMS This pilot study aimed to assess serum albumin as a surrogate marker of surgical stress and to test its potential predictive role for postoperative complications. METHODS This retrospective pilot study included 106 patients who underwent liver surgery between 2010 and 2014. Serum albumin levels were measured pre- and post-operatively. Maximal albumin decrease (AlbΔmin) was correlated with complications. RESULTS Serum albumin rapidly dropped after surgery. AlbΔmin was significantly increased in patients with complications (14.5±6.0g/L vs. 10.3±7.2, p=0.009). On multivariate analysis, ASA III/IV (p=0.016) and AlbΔmin (p=0.037) were the only predictors of overall complications. CONCLUSION Early postoperative drop of serum albumin reflects the intensity of the surgical stress and may predict complications after liver surgery. Serum albumin is a biomarker displaying precious features and deserving further prospective investigations.
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Affiliation(s)
- Ismail Labgaa
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland
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185
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A Conceptual Technique for Laparoscopic Right Hepatectomy Based on Facts and Oncologic Principles: The Caudal Approach. Ann Surg 2016; 261:1226-31. [PMID: 24854453 DOI: 10.1097/sla.0000000000000737] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate a new conceptual technique of laparoscopic right hepatectomy. BACKGROUND Despite significant improvements in surgical care in the last decades, morbidity is still high after major hepatectomy. Blood loss and transfusions are known to significantly increase the risk of postoperative complications and cancer recurrence after liver resection. A laparoscopic approach may improve perioperative outcomes in these cases, but data in literature are limited and the surgical technique is not yet standardized. METHODS A new conceptual technique of right hepatectomy was designed using evidence-based facts and oncologic rules: laparoscopy with pneumoperitoneum, low central venous pressure, intermittent pedicle clamping, anterior approach without mobilization, and parenchymal section with ultrasonic dissector. Thirty patients were prospectively enrolled between October 2011 and September 2013. Primary endpoint was intraoperative blood loss. RESULTS Eighty percent of patients underwent surgery for malignant disease and cirrhosis was present in 11 patients. Benign lesions accounted for 13% of indications, whereas living liver donation was performed in 2 cases. Median blood loss was 100 mL (50-700) and transfusion rate was 7%. Five patients (16.6%) required conversion to laparotomy, including 2 using hybrid technique. The median operative time was 360 minutes (210-510). R0 resection rate was 87% (21/24). Postoperative morbidity rate was 23% (7/30) with 8 complications including 6 Clavien III-IV. No respiratory complication occurred. The median hospital stay was 8 days. No patient died. CONCLUSIONS This study showed that several evidence-based facts could be combined to define a new conceptual technique of laparoscopic right hepatectomy allowing for low blood loss and morbidity.
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186
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Preoperative thrombocytopenia and outcomes of hepatectomy for hepatocellular carcinoma. J Surg Res 2016; 201:498-505. [DOI: 10.1016/j.jss.2015.08.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 07/25/2015] [Accepted: 08/21/2015] [Indexed: 02/08/2023]
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187
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Symptomatic Perihepatic Fluid Collections After Hepatic Resection in the Modern Era. J Gastrointest Surg 2016; 20:748-56. [PMID: 26643300 PMCID: PMC4830382 DOI: 10.1007/s11605-015-3041-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/23/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Improvements in liver surgery have led to decreased mortality rates. Symptomatic perihepatic collections (SPHCs) requiring percutaneous drainage remain a significant source of morbidity. STUDY DESIGN A single institution's prospectively maintained hepatic resection database was reviewed to identify patients who underwent hepatectomy between January 2004 and February 2012. RESULTS Data from 2173 hepatectomies performed in 2040 patients were reviewed. Overall, 200 (9%) patients developed an SPHC, the majority non-bilious (75.5%) and infected (54%). Major hepatic resections, larger than median blood loss (≥360 ml), use of surgical drains, and simultaneous performance of a colorectal procedure were associated with an SPHC on multivariate analysis. Non-bilious, non-infected (NBNI) collections were associated with lower white blood cell (WBC) counts, absence of a bilio-enteric anastomosis, use of hepatic arterial infusion pump (HAIP), and presence of metastatic disease, and resolved more frequently with a single interventional radiology (IR) procedure (85 vs. 46.5%, p < 0.001) more quickly (15 vs. 30 days, p = 0.001). CONCLUSIONS SPHCs developed in 9% of patients in a modern series of hepatic resections, and in one third were non-bilious and non-infected. In the era of modern interventional radiology, the need for re-operation for SPHC is exceedingly rare. A significant proportion of minimally symptomatic SPHC patients may not require drainage, and strategies to avoid unnecessary drainage are warranted.
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188
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Abstract
The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.
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Affiliation(s)
- Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, Building C, 2nd Floor, Atlanta, GA 30322, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, 1365C Clifton Road NE, Building C, 2nd Floor, Atlanta, GA 30322, USA.
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189
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Margonis GA, Amini N, Buettner S, Besharati S, Kim Y, Sobhani F, Kamel IR, Pawlik TM. Impact of early postoperative platelet count on volumetric liver gain and perioperative outcomes after major liver resection. Br J Surg 2016; 103:899-907. [DOI: 10.1002/bjs.10120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/13/2015] [Accepted: 01/05/2016] [Indexed: 12/17/2022]
Abstract
Abstract
Background
Although perioperative platelet count has been associated with postoperative morbidity and mortality, its impact on liver regeneration has not been examined directly. This study sought to determine the impact of platelet count on liver regeneration after major liver resection using cross-sectional imaging volumetric assessment.
Methods
Patients who underwent major liver resection between 2004 and 2015 and had available data on immediate postoperative platelet count, as well as preoperative and postoperative CT images, were identified retrospectively. Resected liver volume was subtracted from total liver volume (TLV) to define postoperative remnant liver volume (RLVp). The liver regeneration index was defined as the relative increase in liver volume within 2 months ((RLV2m – RLVp)/RLVp, where RLV2m is the remnant liver volume around 2 months after surgery). The association between platelet count, liver regeneration and outcomes was assessed.
Results
A total of 99 patients met the inclusion criteria. Overall, 25 patients (25 per cent) had a low platelet count (less than 150 × 109/l), whereas 74 had a normal–high platelet count (at least 150 × 109/l). Despite having comparable clinicopathological characteristics and RLVp/TLV at surgery (P = 0·903), the relative increase in liver volume within 2 months was considerably lower in the low-platelet group (3·9 versus 16·5 per cent; P = 0·043). Patients with a low platelet count had an increased risk of postoperative complications (72 versus 38 per cent; P = 0·003), longer hospital stay (8 versus 6 days; P = 0·004) and worse median overall survival (24·5 versus 67·3 months; P = 0·005) than those with a normal or high platelet count.
Conclusion
After major liver resection, a low postoperative platelet count was associated with inhibited liver regeneration, as well as worse short- and long-term outcomes. Immediate postoperative platelet count may be an early indicator to identify patients at increased risk of worse outcomes.
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Affiliation(s)
- G A Margonis
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - N Amini
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Buettner
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S Besharati
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Y Kim
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - F Sobhani
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - I R Kamel
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - T M Pawlik
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hu WH, Chen HH, Lee KC, Liu L, Eisenstein S, Parry L, Cosman B, Ramamoorthy S. Assessment of the Addition of Hypoalbuminemia to ACS-NSQIP Surgical Risk Calculator in Colorectal Cancer. Medicine (Baltimore) 2016; 95:e2999. [PMID: 26962812 PMCID: PMC4998893 DOI: 10.1097/md.0000000000002999] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The aim of this study was to evaluate the benefit of adding hypoalbuminemia to the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator when predicting postoperative outcomes in colorectal cancer patients.The ACS-NSQIP Surgical Risk Calculator offers qualified risk evaluation in surgical decision-making and informed patient consent. To date, malnutrition defined as hypoalbuminemia, an important independent surgical risk factor in colorectal cancer, is not included.This is a retrospective, multi-institutional study of ACS-NSQIP patients (n = 18,532) who received colorectal surgery from 2009 to 2012. Models were constructed for predicting postoperative mortality and morbidity using the risk factors of the ACS-NSQIP Surgical Risk Calculator before and after adding hypoalbuminemia as a risk factor. The 2 models' performance was then compared using c-statistics and Brier scores. The ACS-NSQIP database in 2008 was used for validation of the created models.The prevalence of hypoalbuminemia (27.8%) is higher in colorectal cancer, when compared with other most common cancers. In univariate analyses, hypoalbuminemia was significantly associated with postoperative mortality and morbidity in colorectal cancer patients. In multivariate logistic regression analyses, 15 postoperative complications, including mortality and serious morbidities, were significantly predicted by hypoalbuminemia. Most of the models with hypoalbuminemia showed better performance and validation in predicting postoperative complications than those without hypoalbuminemia.In colorectal cancer, hypoalbuminemia, with levels below 3.5 g/dL, serves as an excellent assessment tool and preoperative predictor of postoperative outcomes. When combined with hypoalbuminemia as a risk factor, the ACS-NSQIP Surgical Risk Calculator offers more accurate information and estimation of surgical risks to patients and surgeons when choosing treatment options.
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Affiliation(s)
- Wan-Hsiang Hu
- From the Department of Surgery (W-HH, SE, LP, BC, SR) and Rebecca and John Moores Cancer Center (W-HH, SE, LP, SR), University of California San Diego Health System, La Jolla, CA; Department of Colorectal Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan (W-HH, H-HC, K-CL); Department of Surgery, Veteran's Administration San Diego Healthcare System, La Jolla (BC); and Division of Biostatistics and Bioinformatics, School of Medicine, University of California, San Diego (LL), CA
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Nishio T, Taura K, Koyama Y, Tanabe K, Yamamoto G, Okuda Y, Ikeno Y, Seo S, Yasuchika K, Hatano E, Okajima H, Kaido T, Tanaka S, Uemoto S. Prediction of posthepatectomy liver failure based on liver stiffness measurement in patients with hepatocellular carcinoma. Surgery 2016. [DOI: 10.1016/j.surg.2015.06.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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192
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Hughes MJ, Chong J, Harrison E, Wigmore S. Short-term outcomes after liver resection for malignant and benign disease in the age of ERAS. HPB (Oxford) 2016; 18:177-182. [PMID: 26902137 PMCID: PMC4814591 DOI: 10.1016/j.hpb.2015.10.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 08/29/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Enhanced Recovery After Surgery protocols have been implemented effectively after liver resection and provide benefits in terms of general morbidity rates. In order to optimise peri-operative care protocols and minimise morbidity, further investigation is required to identify factors associated with poor outcome after liver resection. METHODS A retrospective analysis of patients undergoing liver resection and enhanced recovery care between January 2006 and September 2012 was conducted. Data were collected on patient outcome and demographics, operative and pathological details. Univariate and multivariate analyses were performed to determine independent predictors of adverse outcome. RESULTS 603 patients underwent liver resection during the study period. Morbidity and mortality rates were 34.3% and 1.5% respectively. The only predictor of major morbidity was extended resection (OR 4.079; 95% CI 2.177-7.642). CONCLUSIONS Extended resection is associated with major morbidity. When determining optimum peri-operative care, ERAS protocols must incorporate care components that can mitigate against morbidity associated with extended resection.
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Affiliation(s)
- Michael J. Hughes
- Correspondence Michael J. Hughes, Department of Clinical Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK. Tel: +44 (0)7734429759. Fax: +44 (0)131 242 3617.
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193
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Guo T, Xiao Y, Liu Z, Liu Q. The impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels: A systematic review and meta-analysis. Int J Surg 2016; 27:99-104. [PMID: 26827893 DOI: 10.1016/j.ijsu.2016.01.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/14/2016] [Accepted: 01/21/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIMS Intraoperative vascular occlusion techniques during liver surgeries have been performed and refined for decades. However, the impact of these techniques on postoperative peak ALT levels remains uncertain. Thus, we performed a literature review and meta-analysis to determine the impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels. METHODS A systematic literature search of the PubMed database was conducted to discover relevant controlled clinical trials. Studies that reported postoperative peak ALT values for both an observation group and a control group were included. The Q statistic and the I(2) index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test and Orwin's fail-safe N test. RESULTS Of the 281 retrieved articles, 10 articles fulfilled the inclusion criteria. These 10 articles involved 12 randomized controlled trials with a total of 1443 records. The pooled estimation results indicated that intraoperative vascular occlusion significantly elevated postoperative peak ALT levels (test for SMD: Z = 4.09, P < 0.001; 95% CI: 0.59-1.68), with high heterogeneity (I(2) = 93.8%). Subgroup analysis revealed that intermittent inflow occlusion and Pringle's maneuver vascular occlusions may be the potential crucial factors. No obvious publication bias was detected by Egger's test (P = 0.541) or Orwin's fail-safe N test (Nfs0.05 = 2059.19). CONCLUSIONS Intraoperative vascular occlusion, especially intermittent inflow occlusion and Pringle's maneuver vascular occlusions, may be a potential risk factor that could lead higher postoperative peak ALT values than non-occlusion procedures for liver surgeries.
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Affiliation(s)
- Tao Guo
- Department of General Surgery, Zhongnan Hospital, Wuhan University, Wuhan, 430071, PR China
| | - Yusha Xiao
- Department of General Surgery, Zhongnan Hospital, Wuhan University, Wuhan, 430071, PR China
| | - Zhisu Liu
- Department of General Surgery, Zhongnan Hospital, Wuhan University, Wuhan, 430071, PR China
| | - Quanyan Liu
- Department of General Surgery, Zhongnan Hospital, Wuhan University, Wuhan, 430071, PR China.
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194
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Current strategies for preoperative conditioning of the liver to expand criteria for resectability of hepatic metastases. Eur Surg 2016. [DOI: 10.1007/s10353-015-0381-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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195
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Belli A, Cioffi L, Russo G, Belli G. Liver resection for hepatocellular carcinoma in patients with portal hypertension: the role of laparoscopy. Hepatobiliary Surg Nutr 2016; 4:417-21. [PMID: 26734627 DOI: 10.3978/j.issn.2304-3881.2015.12.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is a major issue since patients are at risk of serious intraoperative and postoperative complications. The current EASL/AASLD guidelines recommend LR only in case of patients with stage A HCC with well-preserved liver function and consider the presence of portal hypertension (PHT) as a contraindication to surgery. Nevertheless, the literature on this topic is conflicting. Recently several studies reported that favorable outcomes can be achieved with a careful patients' selection in high volume centers. Laparoscopic LR, when performed by well-trained surgeons and with appropriate indications, proved to be a valid option for the surgical treatment of HCC on cirrhosis offering similar oncologic outcomes but a reduction in surgical related morbidities. Laparoscopic LR thanks to a reduction in the incidence of post-operative liver failure and ascites development in comparison to standard open LR could, in selected cases challenge alternative treatments in the treatment of HCC patients with preserved liver function and clinical signs of mild PHT.
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Affiliation(s)
- Andrea Belli
- 1 Division of Surgical Oncology, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione G. Pascale"-IRCCS, Naples 80131, Italy ; 2 Department of General and Hepato-Pancreato-Biliary Surgery, S. M. Loreto Nuovo Hospital, Naples 80142, Italy
| | - Luigi Cioffi
- 1 Division of Surgical Oncology, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione G. Pascale"-IRCCS, Naples 80131, Italy ; 2 Department of General and Hepato-Pancreato-Biliary Surgery, S. M. Loreto Nuovo Hospital, Naples 80142, Italy
| | - Gianluca Russo
- 1 Division of Surgical Oncology, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione G. Pascale"-IRCCS, Naples 80131, Italy ; 2 Department of General and Hepato-Pancreato-Biliary Surgery, S. M. Loreto Nuovo Hospital, Naples 80142, Italy
| | - Giulio Belli
- 1 Division of Surgical Oncology, Department of Abdominal Oncology, "Istituto Nazionale Tumori Fondazione G. Pascale"-IRCCS, Naples 80131, Italy ; 2 Department of General and Hepato-Pancreato-Biliary Surgery, S. M. Loreto Nuovo Hospital, Naples 80142, Italy
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196
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de Ridder JAM, Lemmens VEPP, Overbeek LIH, Nagtegaal ID, de Wilt JHW. Liver Resection for Metastatic Disease; A Population-Based Analysis of Trends. Dig Surg 2016; 33:104-13. [PMID: 26730988 DOI: 10.1159/000441802] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 10/13/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The study aims to evaluate all patients who underwent liver resection for metastatic disease for demographics, characteristics of the primary tumor and metastasis, volume of liver resection specimens per pathology laboratory and to describe trends in surgical treatment. METHODS Data were prospectively collected using the Dutch nationwide pathology network. All pathology reports containing details on liver resections for metastatic disease between January 2001 and December 2010 were evaluated. RESULTS A total of 3,916 liver resections were performed in 3,699 patients with a median age of 63 years (range 1-91). The primary tumor was mainly colorectal (n = 3,256; 88.0%). The number of 'high volume liver centers' increased from 2 to 12 in the study period, whereas the number of 'low volume centers' decreased. The number of liver resections increased from 224 to 596 per year (p ≤ 0.0001). A significant increase was demonstrated in elderly patients, patients with multiple metastases, liver resections for smaller metastases and minor liver resections. CONCLUSION Although the majority of patients were young and had solitary metastasis, indications for liver resection are expanding as indicated by increasing numbers of elderly and patients with multiple liver metastases. Patients with non-colorectal liver metastases were seldom candidates for resection.
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Affiliation(s)
- J A M de Ridder
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
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197
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Civil O, Kement M, Okkabaz N, Haksal M, Gezen C, Oncel M. The Feasibility of Hepatic Resections Using a Bipolar Radiofrequency Device (Habib®). Indian J Surg 2015; 77:276-82. [PMID: 26702234 DOI: 10.1007/s12262-015-1295-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 05/26/2015] [Indexed: 11/29/2022] Open
Abstract
The bipolar radiofrequency device (Habib®) has been recently introduced in order to reduce intraoperative bleeding for a safe hepatic resection as an alternative to the conventional tools. However, indications, perioperative findings, and outcome of the device for hepatic resections remain and deserve to be analyzed. The current study aims to analyze the feasibility of the bipolar radiofrequency device (Habib®) for hepatic resections. Information of the patients that underwent hepatic resection using with the Habib® device between 2007 and 2011 was abstracted. Patient, disease, and operation-related findings and perioperative data were investigated. A total of 71 cases (38 [53.5 %] males, mean age was 56.8 ± 11.9) were analyzed. Metastatic disease (n = 55; 77.5 %) was the leading indication followed by primary liver and biliary malignancies (n = 7; 9.9 %), hemangioma (n = 5; 7 %), hydatid disease (n = 3; 2.8 %), and hepatic gunshot trauma (n = 1; 1.4 %). Metastasectomy was the most commonly performed procedure (n = 31; 56.3 %), but in 24 (77.4 %) cases, it was performed in addition to extended resections. Other procedures in the study patients include segmentectomy in 17, bisegmentectomy in 19, trisegmentectomy in 17, right or left hepatectomy in 8, and extended right/left hepatectomy in 3. The mean (±SD) operation time was 241.7 ± 78.2 min. The median amount of bleeding was 300 cc (range 25-2500), and 23 (32.4 %) cases required perioperative transfusion. The median hospitalization period was 5 days (range 1-47). Lengthened drainage (n = 9, 12.7 %) and intraabdominal abscess (n = 8, 11.23 %) were the most common problems. Hepatic resections using the Habib® device seem to be feasible in cases with primary and metastatic hepatic lesions and benign liver masses and even those with hepatic trauma. It may lessen the amount of intraoperative hemorrhage, although lengthened drainage and intraabdominal abscess were the major postoperative problems in these cases.
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Affiliation(s)
- Osman Civil
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Metin Kement
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Nuri Okkabaz
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Haksal
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Cem Gezen
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Oncel
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey ; Department of General Surgery, Medipol University Hospital, Istanbul, Turkey
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198
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The anterior hanging-approach improves postoperative course after right hepatectomy in patients with colorectal liver metastases. Results of a prospective study with propensity-score matching comparison. Eur J Surg Oncol 2015; 42:176-83. [PMID: 26710993 DOI: 10.1016/j.ejso.2015.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 11/01/2015] [Accepted: 11/09/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To establish the role of the anterior approach with liver hanging maneuver for right hepatectomy in patients with colorectal liver metastases (CRLM). SUMMARY BACKGROUND DATA The indications for hepatectomy in patients with CRLM are expanding. The liver remnant must be protected to avoid morbidity. METHODS We prospectively enrolled all patients with the diagnosis of CRLM requiring right hepatectomy from 2009 to 2012. In all cases right hepatectomy with an anterior-hanging maneuver approach was attempted. We compared the group of patients who underwent this procedure with a group of patients who had previously undergone a conventional right hepatectomy. To minimize selection bias, propensity score matching was performed, based on baseline patient characteristics. RESULTS A right hepatectomy was planned in 57 cases. The anterior-hanging approach was feasible in 85% of cases. Overall morbidity was similar. In-hospital mortality due to hepatic insufficiency was 2.3% in anterior-hanging group compared to 9% in the conventional group (p = 0.30). The incidence of ascites was significantly greater in the conventional group (AH: 18% vs Conv: 54%; p = 0.002), and hospital stay was longer (AH: 10.9 ± 5.7 vs Conv: 14.4 ± 8.1 days; p = 0.05). Bilirubin levels were significantly lower in anterior-hanging group in day 1 and 3. There were no differences on recurrence nor survival. CONCLUSIONS The anterior-hanging approach for right hepatectomy in patients with CRLM can be used safely with a high feasibility rate. Its use contributes to improve postoperative course.
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199
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Abstract
BACKGROUND Various clamping procedures are used to decrease bleeding during liver resections but their effect on central venous pressure (CVP) remains unclear. The aim of this study was to assess the variations of the CVP during two different clamping procedures. METHODS We retrospectively reviewed 29 patients (19 males, 10 females) who had Pringle maneuver (PM) and clamping of the inferior vena cava below the liver (IVCC) during major liver resections. RESULTS Mean decrease of the CVP after PM, IVCC, and PM+IVCC was 0.84 ± 1.37, 2.17 ± 2.13 and 3.17 ± 2.56 cmH20, respectively (P=0.02, P<0.0001 and P<0.0001, respectively). IVCC was more effective in inducing a decrease of the CVP than PM alone (P<0.05). The combination of both PM and IVCC induced the greatest decrease but not to a level of significance compared to IVCC alone (P=0.25). CONCLUSION IVCC remains the more efficient procedure to lower the CVP. However, although PM is commonly used to control vascular inflow within the liver its significant influence on the CVP could participate to the reduction of bleeding during liver resections.
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200
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Day RW, Brudvik KW, Vauthey JN, Conrad C, Gottumukkala V, Chun YS, Katz MH, Fleming JB, Lee JE, Aloia TA. Advances in hepatectomy technique: Toward zero transfusions in the modern era of liver surgery. Surgery 2015; 159:793-801. [PMID: 26584854 DOI: 10.1016/j.surg.2015.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/26/2015] [Accepted: 10/01/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Perioperative blood transfusions suppress immunity and increase hospital costs. Despite multiple improvements in perioperative care, rates of transfusion during/after hepatectomy are reported to range from 25 to 50%. The purpose of this study was to determine the current risk factors for perihepatectomy transfusion by assessing the impact of recent technical advances in liver surgery on transfusion rates. METHODS Using our prospectively maintained hepatobiliary tumor database from a high-volume center, a modern cohort of 2,249 hepatectomies (2004-2013) were identified. Patient and operative characteristics were compared between 2 time periods, 2004-2008 (n = 1,139) and 2009-2013 (n = 1,110). Throughout the study interval, transfusions were given based on clinical assessment and not triggered by laboratory thresholds. RESULTS Compared with the early cohort, the recent cohort had more patients with an American Society of Anesthesiologists score of ≥ 3 (79 vs 74%), preoperative chemotherapy (73 vs 68%), and a lesser median preoperative hemoglobin (12.9 vs 13.1 mg/dL) and platelet (215,000 vs 243,000) values (all P < .001). Despite these adverse risk factors, with an increasing use of the 2-surgeon resection technique (63 vs 50%), estimated blood loss (309 vs 394 mL), transfusion rates (6 vs 15%), and duration of stay (7.0 vs 8.4 days) were decreased (all P < .001) with no change in overall morbidity or mortality. Multivariate analysis of the recent cohort determined that the independent risk factors associated with transfusion were preoperative anemia and >350 mL of blood loss. The only independent factor associated with less transfusion was use of the 2-surgeon technique for hepatic parenchymal transection. CONCLUSION With the exception of patients with moderate to severe preoperative anemia requiring major hepatectomy, recent technical advances have decreased significantly the need for transfusion in liver surgery.
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Affiliation(s)
- Ryan W Day
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kristoffer W Brudvik
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vijaya Gottumukkala
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yun-Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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