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Vaghiri S, Lehwald-Tywuschik N, Prassas D, Safi SA, Kalmuk S, Knoefel WT, Dizdar L, Alexander A. Predictive factors of 90-day mortality after curative hepatic resection for hepatocellular carcinoma: a western single-center observational study. Langenbecks Arch Surg 2024; 409:149. [PMID: 38698255 PMCID: PMC11065924 DOI: 10.1007/s00423-024-03337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE The aim of this study was to identify predictive risk factors associated with 90-day mortality after hepatic resection (HR) in hepatocellular carcinoma (HCC). METHODS All patients undergoing elective resection for HCC from a single- institutional and prospectively maintained database were included. Multivariate regression analysis was conducted to identify pre- and intraoperative as well as histopathological predictive factors of 90-day mortality after elective HR. RESULTS Between August 2004 and October 2021, 196 patients were enrolled (148 male /48 female). The median age of the study cohort was 68.5 years (range19-84 years). The rate of major hepatectomy (≥ 3 segments) was 43.88%. Multivariate analysis revealed patient age ≥ 70 years [HR 2.798; (95% CI 1.263-6.198); p = 0.011], preoperative chronic renal insufficiency [HR 3.673; (95% CI 1.598-8.443); p = 0.002], Child-Pugh Score [HR 2.240; (95% CI 1.188-4.224); p = 0.013], V-Stage [HR 2.420; (95% CI 1.187-4.936); p = 0.015], and resected segments ≥ 3 [HR 4.700; (95% 1.926-11.467); p = 0.001] as the major significant determinants of the 90-day mortality. CONCLUSION Advanced patient age, pre-existing chronic renal insufficiency, Child-Pugh Score, extended hepatic resection, and vascular tumor involvement were identified as significant predictive factors of 90-day mortality. Proper patient selection and adjustment of treatment strategies could potentially reduce short-term mortality.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Nadja Lehwald-Tywuschik
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
- Department of Surgery, Katholisches Klinikum Essen, Philippusstift, Teaching Hospital of Duisburg-Essen University, Huelsmannstrasse 17, 45355, Essen, Germany
| | - Sami Alexander Safi
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Sinan Kalmuk
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany.
| | - Levent Dizdar
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andrea Alexander
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
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Tomita K, Koganezawa I, Nakagawa M, Ochiai S, Gunji T, Yokozuka K, Ozawa Y, Hikita K, Kobayashi T, Sano T, Chiba N, Kawachi S. A New Preoperative Risk Score for Predicting Postoperative Complications in Elderly Patients Undergoing Hepatectomy. World J Surg 2021; 45:1868-1876. [PMID: 33598726 PMCID: PMC8093153 DOI: 10.1007/s00268-021-05985-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative complications are not rare in the elderly population after hepatectomy. However, predicting postoperative risk in elderly patients undergoing hepatectomy is not easy. We aimed to develop a new preoperative evaluation method to predict postoperative complications in patients above 65 years of age using biological impedance analysis (BIA). METHODS Clinical data of 59 consecutive patients (aged 65 years or older) who underwent hepatectomy at our institution between 2017 and 2020 were retrospectively analyzed. Risk factors for postoperative complications (Clavien-Dindo ≥ III) were evaluated using multivariate regression analysis. Additionally, a new preoperative risk score was developed for predicting postoperative complications. RESULTS Fifteen patients (25.4%) had postoperative complications, with biliary fistula being the most common complication. Abnormal skeletal muscle mass index from BIA and type of surgical procedure were found to be independent risk factors in the multivariate analysis. These two variables and preoperative serum albumin levels were used for developing the risk score. The postoperative complication rate was 0.0% with a risk score of ≤ 1 and 57.1% with a risk score of ≥ 4. The area under the receiver operating characteristic curve of the risk score was 0.810 (p = 0.001), which was better than that of other known surgical risk indexes. CONCLUSION Decreased skeletal muscle and the type of surgical procedure for hepatectomy were independent risk factors for postoperative complications after elective hepatectomy in elderly patients. The new preoperative risk score is simple, easy to perform, and will help in the detection of high-risk elderly patients undergoing elective hepatectomy.
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Affiliation(s)
- Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Itsuki Koganezawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Masashi Nakagawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Shigeto Ochiai
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Kei Yokozuka
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Yosuke Ozawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Kosuke Hikita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Toshimichi Kobayashi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, 193-0998, Japan.
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Qi Y, LeVan TD, Haynatzki G, Are C, Farazi PA. Development of an Integer-based Risk Score to Predict 90-Day Mortality After Hepatectomy in Patients With Hepatocellular Carcinoma. Am J Clin Oncol 2020; 43:640-647. [PMID: 32889834 DOI: 10.1097/coc.0000000000000724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of liver cancer has more than tripled since 1980. Hepatectomy represents the major curative treatment for liver cancer. The risk factors associated with 90-day mortality after hepatectomy are not well understood and there are currently no good prediction models for this outcome. The objectives of the current study were to identify risk factors of 90-day mortality after hepatectomy in patients with hepatocellular carcinoma and to develop an integer-based risk score using the National Cancer Database. METHODS Hepatectomies recorded in the National Cancer Database during 2004-2012 were reviewed for 90-day mortality. Risk factors were identified by multivariate logistic regression models. An integer-based risk score was developed using the β coefficients derived from the logistic regression model and tested for discriminatory ability. According to the total risk score, patients were grouped into 4 risk groups. RESULTS The overall 90-day mortality was 10.2%. Ten risk factors were identified, which included sex, age, race/ethnicity, insurance status, education, annual hospital volume, stage, tumor grade, Charlson-Deyo Score, and surgical procedure. The risk of 90-day mortality was stratified into 4 groups. The calculated 90-day mortality rates were 2.47%, 5.88%, 12.58%, and 24.67% for low-risk, medium-risk, high-risk, and excessive-risk groups, respectively. An area under the receiver operating characteristic curve of 0.69 was obtained for model discrimination. CONCLUSIONS The integer-based risk score we developed could easily quantify each patient's risk level and predict 90-day mortality after hepatectomy. The stratified risk score could be a useful addition to perioperative risk management and a tool to improve 90-day mortality after hepatectomy.
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Santambrogio R, Farina G, D'Alessandro V, Iacob G, Gemma M, Zappa MA. Guidelines Adaptation to the COVID-19 Outbreak for the Management of Hepatocellular Carcinoma. J Laparoendosc Adv Surg Tech A 2020; 31:266-272. [PMID: 32810426 DOI: 10.1089/lap.2020.0559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: COVID-19 pandemic rendered the surgical approach as well as the surgical indication very complex due to the outstanding consumption of public health system' resources, especially in the intensive care subdivision. A multidisciplinary team-based strategy is necessary to adapt guidelines and medical practices to the actual situation. The aim of this study is to evaluate the changes in the therapeutic algorithm in a small group of patients with hepatocellular carcinoma (HCC) enlisted for surgery during the COVID-19 outbreak. Materials and Methods: A multidisciplinary strategy has been adopted to allocate HCC patients to a treatment that permitted to reduce the risk of complications and the hospital stay, thus preventing contamination by the virus. Nasopharyngeal swab and a chest radiograph were performed in all patients within 48 hours before the surgical procedure: in the suspected cases with negative COVID tests, we prudently postponed surgery and repeated the diagnostic tests after 15 days. Results: During the emergency state, 11 HCC patients were treated (8 laparoscopic ablations and 3 hepatic resections). We reported only 1 postoperative complication (hemothorax) and 1 death during the follow-up for COVID pneumonia. Comparing our performances with those in the same time frame in the past 4 years, we treated a similar number of HCC patients, obtaining a decrease in operative timing (P = .0409) and hospital stay (P = .0412) (Fig. 2b) with similar rates of immediate postoperative complications, without ICU admissions. Conclusions: An adapted algorithm for the treatment of HCC to COVID outbreak permitted to manage safely these patients by identifying those most at risk of evolution of the neoplastic disease.
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Affiliation(s)
| | | | | | - Giulio Iacob
- UOC di Chirurgia Generale, ASST Fatebenefratelli Sacco, Milano, Italy
| | - Marco Gemma
- UOC di Anestesia e Rianimazione, ASST Fatebenefratelli Sacco, Milano, Italy
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Noda C, Williams GA, Foltz G, Kim H, Sanford DE, Hammill CW, Fields RC. The safety of hepatectomy after transarterial radioembolization: Single institution experience and review of the literature. J Surg Oncol 2020; 122:1114-1121. [PMID: 32662066 DOI: 10.1002/jso.26115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The liver is a frequent site of malignancy, both primary and metastatic. The treatment goal of patients with liver cancer may include transarterial radioembolization (TARE). There are limited reports on the safety of hepatectomy following TARE. Our study's purpose is to review patients who have received TARE followed by hepatectomy. METHODS A retrospective study was performed on patients diagnosed with any liver cancer from 2013 to 2019 who underwent TARE followed by hepatectomy. Postoperative complications were prospectively collected. Descriptive statistics and the Kaplan-Meier test were used to assess survival outcomes. RESULTS Twelve patients were treated with a TARE followed by a hepatectomy (nine with ≥4 segments resected). Diagnoses included: six HCC, four cholangiocarcinoma, one metastatic neuroendocrine tumor, and one metastatic colorectal cancer. There were no 90-day post-hepatectomy mortalities and the overall morbidity was 66% (16% severe ≥MAGS 3). Hepatectomy-specific complications after hepatectomy included two (16%) bile leaks and no post-hepatectomy liver failures. The median recurrence free survival was 26 months. Overall survival at 1-year was 78% and at 3 years was 47%. CONCLUSIONS Our results support the safety of hepatectomy in select patients after TARE. Additional comparison to patients who receive hepatectomy as a first-line treatment for liver cancers should be investigated.
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Affiliation(s)
- Christopher Noda
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Gretchen Foltz
- Department of Radiology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Hyun Kim
- Department of Radiation Oncology, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri
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Risk prediction of 30-day mortality after lower extremity major amputation. J Vasc Surg 2019; 70:1868-1876. [DOI: 10.1016/j.jvs.2019.03.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/04/2019] [Indexed: 12/21/2022]
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Feng J, Zhu R, Feng D, Yu L, Zhao D, Wu J, Yuan C, Chen J, Zhang Y, Zheng X. Prediction of Early Recurrence of Solitary Hepatocellular Carcinoma after Orthotopic Liver Transplantation. Sci Rep 2019; 9:15855. [PMID: 31676847 PMCID: PMC6825189 DOI: 10.1038/s41598-019-52427-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/17/2019] [Indexed: 02/07/2023] Open
Abstract
Hepatocellular carcinomas(HCC) consisted of heterogeneous subtypes with different recurrence probabilities after liver transplantation(LT). Our study aimed to develop an improved model for predicting the recurrence of solitary HCC after LT. In this retrospective study, 151 solitary HCC patients who received orthotopic LT over a period of 10 consecutive years were included. All recipients received graft from deceased donors. The first eligible 50 patients were used as validation cohort and others were utilized to construct the model. A two-tailed P < 0.05 was considered to indicate statistical significance for all analysis. Based on the maximisation of the Youden’s index, the optimal cutoff values for alpha-fetoprotein(AFP) and tumor diameter were 261.6 ng/mL and 3.6 cm, respectively. Vascular involvement includes gross and microscopic vascular invasion. Variables potentially affecting recurrence-free survival(RFS) were examined using univariate and multivariate Cox regression analysis. Univariate and multivariate analysis revealed that AFP, tumor diameter, vascular invasion and cytokeratin-19/glypican-3 sub-typing were independent prognostic factors for RFS, thus comprised the risk scoring model. The AUC values of the model in the cohorts were significantly higher than that of the Milan, UCSF, Fudan and Hangzhou criteria. These findings suggest the model has high performance in predicting early recurrence of solitary HCC patients after LT.
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Affiliation(s)
- Jiliang Feng
- Clinical-Pathology Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China.
| | - Ruidong Zhu
- General Surgical Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dezhao Feng
- Vantage College, University of British Columbia, Vancouver, Canada
| | - Lu Yu
- Clinical-Pathology Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Dawei Zhao
- Medical Imaging Department, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jushan Wu
- General Surgical Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China.
| | - Chunwang Yuan
- Department of Interventional Therapy, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Junmei Chen
- Medical Laboratory Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yan Zhang
- Clinical-Pathology Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiu Zheng
- Clinical-Pathology Center, Bejing You-An Hospital, Capital Medical University, Beijing, People's Republic of China
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9
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Lassen K, Nymo LS, Olsen F, Brudvik KW, Fretland ÅA, Søreide K. Contemporary practice and short-term outcomes after liver resections in a complete national cohort. Langenbecks Arch Surg 2018; 404:11-19. [PMID: 30519886 DOI: 10.1007/s00423-018-1737-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Improved outcome after liver resections have been reported in several series, but outcomes from national cohorts are scarce. Our aim was to evaluate nationwide practice and short-term outcomes after liver surgery in a universal healthcare system. METHODS A complete 5-year cohort of all liver resections from the Norwegian Patient Registry (NPR). Short-term outcomes were aggregated length of stay (a-LoS), reoperation and 90-day mortality. RESULTS Of 2118 liver resections, 605 (28.6%) were major, median age was 65 years and 1184 (55%) were male. Most common indication was metastatic disease (n = 1554; 73.4%) and primary malignancy (n = 328; 15.3%). Laparoscopy was performed in 513 (33.9%) of minor and 37 (6.1%) of major liver resections and increased over time to 39.1% of minor resections in 2016. Median a-LoS was 12 days for major resections, 8 days for open minor and 3 days for laparoscopic minor resections. Reoperation was reported for 159 (7.4%) and 90-day mortality for 44 (2.1%). Primary malignancy, male gender, elderly patients and major resections were associated with poorer outcome. CONCLUSIONS In a national cohort, laparoscopy is used for a substantial proportion of minor resections and was associated with reduced a-LoS. Risk factors for reoperation and mortality were male gender, increased age and major resection for primary malignancy.
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Affiliation(s)
- Kristoffer Lassen
- Department of HPB Surgery, Oslo University Hospital at Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway. .,Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway. .,Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway.
| | - Linn Såve Nymo
- Department of Gastrointestinal Surgery, University Hospital of North Norway, Tromsø, Norway.,Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Bodo, Norway
| | - Kristoffer Watten Brudvik
- Department of HPB Surgery, Oslo University Hospital at Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Åsmund Avdem Fretland
- Department of HPB Surgery, Oslo University Hospital at Rikshospitalet, Sognsvannsveien 20, 0372, Oslo, Norway.,The Intervention Centre, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kjetil Søreide
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
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Shen J, Li C, Yan L, Li B, Xu M, Yang J, Wang W, Wen T. Short- and Long-term Outcomes between Young and Older HCC Patients Exceeding The Milan Criteria after Hepatectomy. Ann Hepatol 2018; 17:134-143. [PMID: 29311397 DOI: 10.5604/01.3001.0010.7545] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM The objective of this study was to evaluate short- and long-term survival after surgical treatment between young and older hepatocellular carcinoma (HCC) patients beyond the Milan criteria. MATERIAL AND METHODS One hundred fifty-seven HCC patients (≤ 55 years old) were categorized into group A, and one hundred fifty-eight HCC patients (> 55 years old) were categorized into group B. Postoperative complications and overall survival were retrospectively analyzed. RESULTS Older HCC patients had a higher rate of delayed extubation after surgery and suffered more complications after surgery, especially major complications. Intraoperative blood transfusion, liver fibrosis/cirrhosis and delayed extubation were risk factors related to postoperative complications. Microvascular invasion (MVI), tumor diameter, postoperative alpha-fetoprotein and the presence of satellites were independent risk factors for long-term survival. Young patients had more advanced tumors. Overall survival rates at 1, 3 and 5-years were 78.1%, 45.1% and 27.4% for young patients, respectively, and 86.5%, 57.5% and 42.4% for older patients, respectively (p = 0.007). CONCLUSION The category A group had poorer tumor characteristics and worse prognoses than the category B group.
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Affiliation(s)
- Junyi Shen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Chuan Li
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Lvnan Yan
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Bo Li
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Mingqing Xu
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Jiayin Yang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Wentao Wang
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
| | - Tianfu Wen
- Department of Liver Surgery & Liver Transplantation Center, West China Hospital, Sichuan University. China
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11
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Samim M, Mungroop TH, AbuHilal M, Isfordink CJ, Molenaar QI, van der Poel MJ, Armstrong TA, Takhar AS, Pearce NW, Primrose JN, Harris S, Verkooijen HM, van Gulik TM, Hagendoorn J, Busch OR, Johnson CD, Besselink MG. Surgeons' assessment versus risk models for predicting complications of hepato-pancreato-biliary surgery (HPB-RISC): a multicenter prospective cohort study. HPB (Oxford) 2018; 20:809-814. [PMID: 29678364 DOI: 10.1016/j.hpb.2018.02.635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/17/2018] [Accepted: 02/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several studies advise the use of risk models when counseling patients for hepato-pancreato-biliary (HPB) surgery, but studies comparing these models to the surgeons' assessment are lacking. The aim of this study was to assess whether risk prediction models outperform surgeons' assessment for the risk of complications in HPB surgery. METHODS This prospective study included adult patients scheduled for HPB surgery in three centers in the UK and the Netherlands. Primary outcome was the rate of postoperative major complications. Surgeons assessed the risk prior to surgery while blinded for the formal risk scores. Risk prediction models were retrieved via a systematic review and risk scores were calculated. For each model, discrimination and calibration were evaluated. RESULTS Overall, 349 patients were included. The rate of major complications was 27% and in-hospital mortality 3%. Surgeons' assessment resulted in an AUC of 0.64; 0.71 for liver and 0.56 for pancreas surgery (P = 0.020). The AUCs for nine existing risk prediction models ranged between 0.57 and 0.73 for liver surgery and between 0.51 and 0.57 for pancreas surgery. CONCLUSION In HPB surgery, existing risk prediction models do not outperform surgeons' assessment. Surgeons' assessment outperforms most risk prediction models for liver surgery although both have a poor predictive performance for pancreas surgery. REGISTRATION INFORMATION REC reference number (13/SC/0135); IRAS ID (119370). TRIALREGISTER.NL: NTR4649.
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Affiliation(s)
- Morsal Samim
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands; Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Mohammed AbuHilal
- Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - Cas J Isfordink
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Quintus I Molenaar
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Marcel J van der Poel
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Thomas A Armstrong
- Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - Arjun S Takhar
- Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - Neil W Pearce
- Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - John N Primrose
- Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - Scott Harris
- Department of Epidemiology, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | | | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Colin D Johnson
- Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, The Netherlands; Department of Surgery, University Hospital Southampton NHS Trust Foundation, United Kingdom.
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12
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Fruscione M, Kirks R, Cochran A, Murphy K, Baker EH, Martinie JB, Iannitti DA, Vrochides D. Developing and validating a center-specific preoperative prediction calculator for risk of outcomes following major hepatectomy procedures. HPB (Oxford) 2018; 20:721-728. [PMID: 29550269 DOI: 10.1016/j.hpb.2018.02.634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/15/2018] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The American College of Surgeons NSQIP® Surgical Risk Calculator (SRC) was developed to estimate postoperative outcomes. Our goal was to develop and validate an institution-specific risk calculator for patients undergoing major hepatectomy at Carolinas Medical Center (CMC). METHODS Outcomes generated by the SRC were recorded for 139 major hepatectomies performed at CMC (2008-2016). Novel predictive models for seven postoperative outcomes were constructed and probabilities calculated. Brier score and area under the curve (AUC) were employed to assess accuracy. Internal validation was performed using bootstrap logistic regression. Logistic regression models were constructed using bivariate and multivariate analyses. RESULTS Brier scores showed no significant difference in the predictive ability of the SRC and CMC model. Significant differences in the discriminative ability of the models were identified at the individual level. Both models closely predicted 30-day mortality (SRC AUC: 0.867; CMC AUC: 0.815). The CMC model was a stronger predictor of individual postoperative risk for six of seven outcomes (SRC AUC: 0.531-0.867; CMC AUC: 0.753-0.970). CONCLUSION Institution-specific models provide superior outcome predictions of perioperative risk for patients undergoing major hepatectomy. If properly developed and validated, institution-specific models can be used to deliver more accurate, patient-specific care.
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Affiliation(s)
- Mike Fruscione
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Russell Kirks
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Allyson Cochran
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Keith Murphy
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - John B Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study. J Gastrointest Surg 2018; 22:650-660. [PMID: 29235004 DOI: 10.1007/s11605-017-3648-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/27/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm). METHODS We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival. RESULTS Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival. CONCLUSION Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.
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14
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Spaulding TP, Martin RCG. Predicting adverse events in patients undergoing hepatectomy-validation of preoperative nomogram and risk score. HPB (Oxford) 2017; 19:1112-1118. [PMID: 28882456 DOI: 10.1016/j.hpb.2017.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 07/28/2017] [Accepted: 08/13/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE Much research exists on preoperative measures of postoperative mortality in the surgical treatment of liver malignancies, but little on morbidity, a more common outcome. This study aims (i) to validate the published calculations as acceptable measures of postoperative mortality and (ii) to assess the value of these published measures in predicting postoperative morbidity. METHODS Data were collected from a prospectively managed dataset of 1059 hepatectomies performed in Louisville, Kentucky from December 1990 to April 2014. Preoperative data were used to assign scores for each of two published measures and the scores were sorted into clinically relevant groups with corresponding ordinal scores, according to the previously published literature (Dhir nomogram and Simons risk score). RESULTS After selection, 851 hepatectomies were analyzed. Both the Dhir nomogram (p = 0.0004) and Simons risk score (p = 0.0017) were acceptable predictors of postoperative mortality. In the analysis of morbidity, Dhir scores were a poor predictor of morbidity. The Simons ordinal risk score was predictive of complications (p = 0.0029), the number of complications (p = 0.0028), complication grade (p = 0.0033), and hepatic-specific complications (p = 0.0003). CONCLUSION The Simons ordinal risk score can be useful in assessing postoperative morbidity among hepatectomy patients.
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Affiliation(s)
- Travis P Spaulding
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 315 East Broadway, Louisville, KY, 40202, USA
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, 315 East Broadway, Louisville, KY, 40202, USA.
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15
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Abbas A, Brar TS, Zori A, Estores DS. Role of early endoscopic evaluation in decreasing morbidity, mortality, and cost after caustic ingestion: a retrospective nationwide database analysis. Dis Esophagus 2017; 30:1-11. [PMID: 28475747 DOI: 10.1093/dote/dox010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 01/26/2017] [Indexed: 12/11/2022]
Abstract
Caustic substance ingestion (CSI) is a serious medical problem with potentially devastating short- and long-term consequences. Early upper gastrointestinal endoscopy (EaEn) is recommended to evaluate the extent of injury and guide management but there has been controversy about the timing. There is no nationwide study evaluating adherence to EaEn and outcomes following CSI.Nationwide Inpatient Sample database 2003-2011 was used to identify all-age, nonreferral, urgent/emergent admissions with E-International Classification of Diseases Ninth Revision codes for CSI. We evaluated the association of undergoing late endoscopy (LaEn, >48 hours since admission) with poor clinical (death or systemic complications) and economic (cost for admission and length of stay above the 75th percentile) outcomes after controlling for other demographic and clinical factors using a multivariate analysis.We identified 21,682 patients with a median age of 37 years, 51% males, 43% Caucasians, with suicidal ingestion reported in 40%. Endoscopy was performed in 6011 patients (37%). The majority had EaEn (43% within 24, and 40% within 24-48 hours), whereas 17% had LaEn.Compared to EaEn group, the LaEn group was associated with a three-fold increase (OR = 2.7, P < 0.001) in the risk for poor clinical outcome: a fourfold increase (OR = 4.6, P < 0.001) in high cost admissions, and a fivefold increase (OR = 4.9, P < 0.001) in prolonged hospitalization. There was no significant difference in clinical outcomes based on endoscopy within 24, and 24-48 hours of admission.In this retrospective nationwide database analysis, undergoing LaEn was associated with both negative clinical and economic outcomes. More studies are needed to further examine the reasons for delaying endoscopy and subsequent management pathways based on the endoscopic findings. Early endoscopic evaluation could potentially improve the clinical outcomes and reduce costs of these admissions.
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Affiliation(s)
| | | | - A Zori
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - D S Estores
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
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16
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Santambrogio R, Barabino M, Scifo G, Costa M, Giovenzana M, Opocher E. Effect of Age (over 75 Years) on Postoperative Complications and Survival in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma. J Gastrointest Surg 2017; 21:657-665. [PMID: 28083840 DOI: 10.1007/s11605-016-3354-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/31/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Thanks to technical advancement in surgery for hepatocellular carcinoma (HCC), hepatic resection (HR) for elderly HCC patients has become safer. However, elderly patients may have shorter long-term survival after surgery if compared with younger patients because of their expected life span. The aim of the present study was to evaluate clinical outcomes and safety after HR in HCC patients aged >75 years (older) compared with HCC patients aged <75 years (younger). METHOD One hundred sixty-eight patients who underwent HR for HCC from 1998 to 2015 in our Center were analyzed using a prospective database. Complications, disease-free survival rates, and cumulative survival rates were compared between the two groups. RESULTS During the immediate postoperative period, no differences were found about liver-related complications, hospital stay and 90-day mortality. However, older patients had more complications in class II or higher (Clavien classification) (p = 0.017). Although disease-free survival in both groups was similar (p = 0.099), overall survival was worse in the elderly group (p = 0.024). On multivariate analysis, only age ≥75 years was significantly related to overall survival. CONCLUSION If elderly patients with liver cirrhosis and HCC are appropriately selected and evaluated, they might have favorable prognoses after HR.
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Affiliation(s)
- Roberto Santambrogio
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy.
| | - Matteo Barabino
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Giovanna Scifo
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Mara Costa
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Marco Giovenzana
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
| | - Enrico Opocher
- UOC di Chirurgia Epato-bilio-pancreatica e Digestiva, Ospedale San Paolo, Università di Milano, via A. di Rudini' 8, 20142, Milan, Italy
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Santambrogio R, Bruno S, Kluger MD, Costa M, Salceda J, Belli A, Laurent A, Barabino M, Opocher E, Azoulay D, Cherqui D. Laparoscopic ablation therapies or hepatic resection in cirrhotic patients with small hepatocellular carcinoma. Dig Liver Dis 2016; 48:189-96. [PMID: 26675381 DOI: 10.1016/j.dld.2015.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 11/12/2015] [Accepted: 11/16/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Barcelona Clinic Liver Cancer staging system recommends radiofrequency ablation as treatment of choice for patients with "small" (up to 2 cm in size) hepatocellular carcinoma. AIMS Aim of the study was to assess whether laparoscopic ablation therapies or hepatic resection could be proposed as alternative option if percutaneous approach is not feasible. METHODS Overall survival and tumour recurrence rate were compared in a retrospective cohort of 176 consecutive patients with small hepatocellular carcinoma on cirrhosis treated by laparoscopic ablation therapies or surgery. To balance the covariates between the two groups, a propensity case-matched analysis was developed to generate a matched sample, which included 76 patients in each arm. RESULTS Local tumour progression (p=0.005), intra-segmental recurrence (p=0.0001), and 5-year recurrence rates (80% vs. 60%; p=0.0014) were significantly higher in the ablation therapies group. The 5-year survival rate were 48% after ablation therapies and 69% after hepatic resection (p=0.0006). Multivariate analysis showed that MELD score, alpha-fetoprotein value, procedure category and intraoperative restaging were associated with survival, while the surgery was the only independent predictor of intra-hepatic recurrence. CONCLUSIONS The present study suggests that, if percutaneous ablation is not feasible, hepatic resection may be considered as a sound option in the treatment of small hepatocellular carcinoma.
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Affiliation(s)
- Roberto Santambrogio
- Surgical Unit 2, Hepatobiliary-Pancreatic and Digestive, San Paolo Hospital, University of Milan, Italy.
| | - Savino Bruno
- Humanitas University Medicine and Humanitas Research Hospital, Rozzano, Milano, Italy
| | - Michael D Kluger
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Division of Gastrointestinal and Endocrine Surgery, Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA
| | - Mara Costa
- Surgical Unit 2, Hepatobiliary-Pancreatic and Digestive, San Paolo Hospital, University of Milan, Italy; Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Juan Salceda
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Andrea Belli
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Department of Oncological Abdominal Surgery, National Tumour Institute "G. Pascale", Naples, Italy
| | - Alexis Laurent
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Matteo Barabino
- Surgical Unit 2, Hepatobiliary-Pancreatic and Digestive, San Paolo Hospital, University of Milan, Italy
| | - Enrico Opocher
- Surgical Unit 2, Hepatobiliary-Pancreatic and Digestive, San Paolo Hospital, University of Milan, Italy
| | - Daniel Azoulay
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Daniel Cherqui
- Department of Digestive and Hepatobiliary Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; Hepato-Biliary Centre, AP-HP Hospital Paul Brousse, Villejuif, France
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Bauschke A, Altendorf-Hofmann A, Mothes H, Rauchfuß F, Settmacher U. Partial liver resection results in a significantly better long-term survival than locally ablative procedures even in elderly patients. J Cancer Res Clin Oncol 2016; 142:1099-108. [PMID: 26782669 DOI: 10.1007/s00432-016-2115-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/04/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE The number of elderly patients with HCC will increase worldwide in the next years. Therefore, surgeons need to reassess clinical algorithms for the treatment of patients with HCC. We reevaluated a cohort of patients treated in the last 10 years at our hospital, with emphasis on long-term results and age. METHOD A prospectively recorded consecutive series of all patients treated in between January 1995 and December 2014 with curative intent either by partial liver resection or by ablative therapy was analysed. RESULTS At the time of diagnosis, 232 patients were younger than 70 years and 127 patients were aged 70 years and over. In the latter group, solitary tumours, absence of liver cirrhosis and resection therapy were more frequent compared to younger patients. Charlson index, AFP-negative tumours and CLIP score were equally distributed in both groups. Observed survival of older and younger patients was similar but after partial liver resection, younger patients had a better survival than elderly patients, whereas survival in patients treated with ablation was similar in both groups. In the univariate analysis, long-term survival of patients aged 70 years and over was influenced by treatment procedure, number of lesions, liver cirrhosis, Child's stage and CLIP score. In the multivariate analysis, only treatment procedure and CLIP score were identified as independent predictors of observed survival, and comorbidity was not. CONCLUSION In patients aged 70 years and over, long-term prognosis is independently influenced by CLIP score and treatment procedure and other findings have only minor influence on long-term survival.
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Affiliation(s)
- A Bauschke
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Street 104, 07740, Jena, Germany.
| | - A Altendorf-Hofmann
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Street 104, 07740, Jena, Germany
| | - H Mothes
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Street 104, 07740, Jena, Germany
| | - F Rauchfuß
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Street 104, 07740, Jena, Germany
| | - U Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Erlanger Street 104, 07740, Jena, Germany
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Thirty-day mortality leads to underestimation of postoperative death after liver resection: A novel method to define the acute postoperative period. Surgery 2015; 158:1530-7. [PMID: 26298028 DOI: 10.1016/j.surg.2015.07.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/18/2015] [Accepted: 07/04/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative mortality commonly is defined as death occurring within 30 days of surgery or during hospitalization. After resection for liver malignancies, this definition may result in underreporting, because mortality caused by postoperative complications can be delayed as the result of improved critical care. The aim of this study was to estimate statistically the acute postoperative period (APP) after partial hepatectomy and to compare mortality within this phase to standard timestamps. METHODS From a prospective database, 784 patients undergoing resection for primary and secondary hepatic malignancies between 2003 and 2013 were reviewed. For estimation of APP, a novel statistical method applying tests for a constant postoperative hazard was implemented. Multivariable mortality analysis was performed. RESULTS The APP was determined to last for 80 postoperative days (95% confidence interval 40-100 days). Within this period, 55 patients died (7.0%; 80-day mortality). In comparison, 30-day mortality (N = 32, 4.0%) and in-hospital death (N = 39, 5.0%) were relevantly less. No patient died between postoperative days 80 and 90. The causes of mortality within 30 days and from days 30-80 did not greatly differ, especially regarding posthepatectomy liver failure (44% vs 39%, P = .787). Septic complications, however, tended to cause late deaths more frequently (43% vs 25%, P = .255). Comorbidities (Charlson comorbidity index ≥ 3; P = .046), increased preoperative alanine aminotransferase activity (P = .030), and major liver resection (P = .035) were independent risk factors of 80-day mortality. CONCLUSION After liver resection for primary and secondary malignancies, 90-day rather than 30-day or in-hospital mortality should be used to avoid underreporting of deaths.
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Borzio M, Dionigi E, Parisi G, Raguzzi I, Sacco R. Management of hepatocellular carcinoma in the elderly. World J Hepatol 2015; 7:1521-1529. [PMID: 26085911 PMCID: PMC4462690 DOI: 10.4254/wjh.v7.i11.1521] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/09/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Mean age of hepatocellular carcinoma (HCC) patients has been progressively increasing over the last decades and ageing of these patients is becoming a real challenge in every day clinical practice. Unfortunately, international guidelines on HCC management do not address this problem exhaustively and do not provide any specific recommendation. We carried out a literature search in MEDLINE database for studies reporting on epidemiology, clinical characteristics and treatment outcome of HCC in elderly patients. Available data seem to indicate that in elderly patients the outcome of HCC is mostly influenced by liver function and tumor stage rather than by age and the latter should not influence treatment allocation. Age is not a risk for resection and older patients with resectable HCC and good liver function could gain benefit from surgery. Mild comorbidities do not seem a contraindication for surgery in aged patients. Conversely, major resection in elderly, even when performed in experienced high-volume centres, should be avoided. Both percutaneous ablation and transarterial chemoembolization are not contraindicated in aged patients and safety profile of these procedures is acceptable. Sorafenib is a viable option for advanced HCC in elderly provided that a careful evaluation of concomitant comorbidities, particularly cardiovascular ones, is taken into account. Available data seem to suggest that in either elderly and younger, treatment is a main predictor of outcome. Consequently, a nihilistic attitude of physicians towards under- or no-treatment of aged patients should not be longer justified.
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Lim C, Dejong CH, Farges O. Improving the quality of liver resection: a systematic review and critical analysis of the available prognostic models. HPB (Oxford) 2015; 17:209-21. [PMID: 25322917 PMCID: PMC4333781 DOI: 10.1111/hpb.12346] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/28/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver resection is considered to offer the only hope of cure for patients with liver malignancy. However, there are concerns about its safety, particularly in view of the increasing efficacy of less invasive strategies. No systematic review of prognostic research in liver resections has yet been performed. METHODS A systematic search identified articles published between 1999 and 2012 that performed a risk prediction analysis in patients undergoing liver resection. Studies were included if an outcome occurring within 90 days of surgery was identified, multivariable analysis performed and regression coefficients provided. The main endpoints were the outcomes and predictors chosen by the investigators, their definition, the performance and validity of the models, and the quality of the study as assessed using the QUIPS (quality in prognosis studies) tool. RESULTS A total of 91 studies were included. Eleven were prospective, but only two of these were registered. Twenty-eight endpoints were identified. These focused on postoperative morbidity or mortality, but many were redundant or ill defined and other relevant patient-reported outcomes were lacking. Predictors were not standardized, were poorly defined and overlapped. Only nine studies assessed the performance of their models and seven made an internal or temporal validation, but none reported an external validation or impact analysis. The median QUIPS score was 34 out of 50, indicating a high risk for bias. CONCLUSION Prognostic research in liver resection is still at the developmental stage.
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Affiliation(s)
- Chetana Lim
- Department of Surgery, Assistance Publique Hôpitaux de Paris (AP-HP), Henri Mondor Hospital, Faculty of Medicine, University of Paris EstCreteil, France
| | - Cornelius H Dejong
- Department of Surgery, University of MaastrichtMaastricht, the Netherlands
| | - Oliver Farges
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, University of Paris 7Clichy, France
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Oishi K, Itamoto T, Kohashi T, Matsugu Y, Nakahara H, Kitamoto M. Safety of hepatectomy for elderly patients with hepatocellular carcinoma. World J Gastroenterol 2014; 20:15028-36. [PMID: 25386051 PMCID: PMC4223236 DOI: 10.3748/wjg.v20.i41.15028] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 05/11/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023] Open
Abstract
The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing. Characteristics of elderly HCC patients are a higher proportion of females, a lower rate of positive hepatitis B surface antigen, and a higher rate of positive hepatitis C antibodies. Careful patient selection is vital for performing hepatectomy safely in elderly HCC patients. Treatment strategy should be decided by not only considering tumor stage and hepatic functional reserve, but also physiological status, including comorbid disease. Various assessment tools have been applied to predict the risk of hepatectomy. The reported mortality and morbidity rates after hepatectomy in elderly HCC patients ranged from 0% to 42.9% and from 9% to 51%, respectively. Overall survival rate after hepatectomy in elderly HCC patients at 5 years ranged from 26% to 75.9%. Both short-term and long-term results after hepatectomy for strictly selected elderly HCC patients are almost the same as those for younger patients. However, considering physiological characteristics and the high prevalence of comorbid disease in elderly patients, it is important to assess patients more meticulously and to select them strictly if scheduled to undergo major hepatectomy.
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Abbas A, Medvedev S, Shores N, Bazzano L, Dehal A, Hutchings J, Balart L. Epidemiology of metastatic hepatocellular carcinoma, a nationwide perspective. Dig Dis Sci 2014; 59:2813-20. [PMID: 24903653 DOI: 10.1007/s10620-014-3229-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 05/26/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver. AIMS The aim of this study was to describe the prevalence, trends, and predictors of metastatic HCC on a national scale. METHODS We used two nationwide datasets for our study: the University Health Consortium (UHC) and the Nationwide Inpatient Sample (NIS) databases. We included adults with a primary diagnosis of HCC from 2000 to 2011. We collected information regarding demographics, insurance, HCC risk factors, liver decompensation, and the sites and frequencies of metastases. Multivariable regression analysis was used to examine predictors of metastatic HCC. Trend analysis was performed to examine the change in metastatic HCC prevalence over time. RESULTS We included 25,671 and 26,054 HCC patients from UHC and NIS, respectively. Prevalence of metastatic HCC was 18 % with lung being the most frequent site (31 %). Compared with Caucasian, African American ethnicity was an independent predictor of metastasis in both the NIS [OR 1.13 (1.02-1.25)] and UHC [OR 1.4 (1.3-1.6)] databases. Lack of long-term insurance was associated with significantly higher prevalence of metastasis in both the NIS [OR 1.6 (1.4-1.9)] and UHC [OR 1.9 (1.6-2.2)] databases. There has been an increased prevalence of metastatic HCC over the last decade with an annual percentage change of +1.25 and +1.60 % (p = 0.03 and p = 0.08) for the NIS and UHC databases, respectively. CONCLUSIONS Metastasis is not rare among HCC patients and is rising in prevalence over the last decade. Lungs were the most common metastatic site. Ethnicity and insurance status are independent predictors of metastasis.
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Affiliation(s)
- Ali Abbas
- Department of Internal Medicine, Shands Hospital, University of Florida, 1600 SW Archer Road, PO BOX 100277, Gainesville, FL, 32610, USA,
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Rosero EB, Cheng GS, Khatri KP, Joshi GP. Evaluation of epidural analgesia for open major liver resection surgery from a US inpatient sample. Proc AMIA Symp 2014; 27:305-12. [PMID: 25484494 PMCID: PMC4255849 DOI: 10.1080/08998280.2014.11929141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to assess the nationwide use of epidural analgesia (EA) and the incidence of postoperative complications in patients undergoing major liver resections (MLR) with and without EA in the United States. The 2001 to 2010 Nationwide Inpatient Sample was queried to identify adult patients undergoing MLR. A 1:1 matched cohort of patients having MLR with and without EA was assembled using propensity-score matching techniques. Differences in the rate of postoperative complications were compared between the matched groups. We identified 68,028 MLR. Overall, 5.9% of patients in the database had procedural codes for postoperative EA. A matched cohort of 802 patients per group was derived from the propensity-matching algorithm. Although use of EA was associated with more blood transfusions (relative risk, 1.36; 95% confidence interval, 1.12-1.65; P = 0.001) and longer hospital stay (median [interquartile range], 6 [5-8] vs 6 [4-8] days), the use of coagulation factors and the incidence of postoperative hemorrhage/hematomas or other postoperative complications were not higher in patients receiving EA. In conclusion, the use of EA for MLR is low, and EA does not seem to influence the incidence of postoperative complications. EA, however, was associated with an increased use of blood transfusions and a longer hospital stay.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gloria S Cheng
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kinnari P Khatri
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
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Chang CM, Yin WY, Su YC, Wei CK, Lee CH, Juang SY, Chen YT, Chen JC, Lee CC. Preoperative risk score predicting 90-day mortality after liver resection in a population-based study. Medicine (Baltimore) 2014; 93:e59. [PMID: 25211044 PMCID: PMC4616270 DOI: 10.1097/md.0000000000000059] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The impact of important preexisting comorbidities, such as liver and renal disease, on the outcome of liver resection remains unclear. Identification of patients at risk of mortality will aid in improving preoperative preparations. The purpose of this study is to develop and validate a population-based score based on available preoperative and predictable parameters predicting 90-day mortality after liver resection using data from a hepatitis endemic country.We identified 13,159 patients who underwent liver resection between 2002 and 2006 in the Taiwan National Health Insurance Research Database. In a randomly selected half of the total patients, multivariate logistic regression analysis was used to develop a prediction score for estimating the risk of 90-day mortality by patient demographics, preoperative liver disease and comorbidities, indication for surgery, and procedure type. The score was validated with the remaining half of the patients.Overall 90-day mortality was 3.9%. Predictive characteristics included in the model were age, preexisting cirrhosis-related complications, ischemic heart disease, heart failure, cerebrovascular disease, renal disease, malignancy, and procedure type. Four risk groups were stratified by mortality scores of 1.1%, 2.2%, 7.7%, and 15%. Preexisting renal disease and cirrhosis-related complications were the strongest predictors. The score discriminated well in both the derivation and validation sets with c-statistics of 0.75 and 0.75, respectively.This population-based score could identify patients at risk of 90-day mortality before liver resection. Preexisting renal disease and cirrhosis-related complications had the strongest influence on mortality. This score enables preoperative risk stratification, decision-making, quality assessment, and counseling for individual patients.
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Affiliation(s)
- Chun-Ming Chang
- Department of Surgery (C-MC, W-YY, C-KW, C-HL, J-CC); Department of Otolaryngology (C-CL); Center for Clinical Epidemiology and Biostatistics (S-YJ, C-CL); Division of Hematology-Oncology, Department of Internal Medicine (Y-CS); Cancer Center (Y-CS, C-CL), Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi; School of Medicine, Tzu Chi University, Hualian (C-MC, W-YY, C-KW, C-HL, J-CC, C-CL); and Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan City (Y-TC), Taiwan
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Abstract
OBJECTIVE Hip fractures are a common source of morbidity and mortality among the elderly. Although multiple prior studies have identified risk factors for poor outcomes, few studies have presented a validated risk stratification calculator. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 4331 patients undergoing surgery for hip fracture between 2005 and 2010. Patient demographics, comorbidities, laboratory values, and operative characteristics were compared in a univariate analysis, and a multivariate logistic regression analysis was then used to identify independent predictors of 30-day morbidity and mortality. Weighted values were assigned to each independent risk factor and used to create predictive models of 30-day morbidity, minor complication risk, major complication risk, and total complication risk. The models were internally validated with randomly partitioned 80%/20% cohort groups. RESULTS Thirty-day mortality was 5.9% and morbidity was 30.0%. Patient age, especially age greater than 80 years [mortality: odds ratio (OR): 2.41, 95% confidence interval (CI): 1.17-4.99); morbidity: OR: 1.43, 95% CI: 1.05-1.94], and male gender (mortality: OR: 2.28, 95% CI: 1.61-3.22; morbidity: OR: 1.26, 95% CI: 1.03-1.54) were associated with both increased mortality and morbidity. An increased American Society of Anesthesia class had the highest negative impact on total complication incidence in the scoring models. Additionally, complete functional dependence, active malignancy, patient race, cardiopulmonary disease, laboratory derangements, prolonged operating time, and open versus percutaneous surgery independently influenced outcomes. Risk scores, based on weighted models, which included the aforementioned variables, predicted mortality (P < 0.001, C index: 0.702) and morbidity (P < 0.001, C index: 0.670) after hip fracture surgery. CONCLUSIONS In this study, we have developed an internally validated method for risk stratifying patients undergoing hip fracture surgery, and this model is predictive of both 30-day morbidity and mortality. Our model could be useful for identifying high-risk individuals, for obtaining informed consent, and for risk-adjusted comparisons of outcomes between institutions. LEVEL OF EVIDENCE Prognostic level II. See instructions for authors for a complete description of levels of evidence.
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Li GZ, Speicher PJ, Lidsky ME, Darrabie MD, Scarborough JE, White RR, Turley RS, Clary BM. Hepatic resection for hepatocellular carcinoma: do contemporary morbidity and mortality rates demand a transition to ablation as first-line treatment? J Am Coll Surg 2014; 218:827-34. [PMID: 24655879 DOI: 10.1016/j.jamcollsurg.2013.12.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Despite the rising incidence of hepatocellular carcinoma (HCC), challenges and controversy persist in optimizing treatment. As recent randomized trials suggest that ablation can have oncologic equivalence compared with resection for early HCC, the relative morbidity of the 2 approaches is a central issue in treatment decisions. Although excellent contemporary perioperative outcomes have been reported by a few hepatobiliary units, it is not clear that they can be replicated in broader practice. Our objective was to help inform this treatment dilemma by defining perioperative outcomes in a broader set of patients as represented in NSQIP-participating institutions. STUDY DESIGN Mortality and morbidity data were extracted from the 2005-2010 NSQIP Participant Use Data Files based on Current Procedural Terminology (hepatectomy and ablation) and ICD-9 (HCC). Perioperative outcomes were reviewed, and factors associated with morbidity and mortality were identified with multivariable logistic regression. RESULTS Eight hundred and thirty-seven (52%) underwent minor hepatectomy, 444 (28%) underwent major hepatectomy, and 323 (20%) underwent surgical ablation. Mortality rates were 3.4% for minor hepatectomy, 3.7% for ablation, and 8.3% for major hepatectomy (p < 0.01). Major complication rates were 21.3% for minor hepatectomy, 9.3% for ablation, and 35.1% for major hepatectomy (p < 0.01). When controlling for confounders, ablation was associated with decreased mortality (adjusted odds ratio = 0.20; 95% CI, 0.04-0.97; p = 0.046) and major complications (adjusted odds ratio = 0.34; 95% CI, 0.22-0.52; p < 0.001). CONCLUSIONS Exceedingly high complication rates after major hepatectomy for HCC exist in the broader NSQIP treatment environment. These data strongly support the use of parenchymal-sparing minor resections or ablation over major hepatectomy for early HCC when feasible.
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Affiliation(s)
- George Z Li
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Paul J Speicher
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Michael E Lidsky
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Marcus D Darrabie
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - John E Scarborough
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Rebekah R White
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Ryan S Turley
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC
| | - Bryan M Clary
- Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
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Cauble S, Abbas A, Balart L, Bazzano L, Medvedev S, Shores N. United States women receive more curative treatment for hepatocellular carcinoma than men. Dig Dis Sci 2013; 58:2817-25. [PMID: 23812858 PMCID: PMC8717408 DOI: 10.1007/s10620-013-2731-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 05/29/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Previous database studies have found gender disparities favoring men in rates of liver transplantation, which resolve in cohorts examining only patients with hepatocellular carcinoma (HCC). AIMS Our study aims to use two large, multicenter United States (US) databases to assess for gender disparity in HCC treatment regardless of transplant listing status. METHODS We performed a retrospective database analysis of inpatient admission data from the University Health Consortium (UHC) and the Nationwide Inpatient Sample (NIS), over a 9- and 10-year period, respectively. Adults with a primary discharge diagnosis of HCC, identified using the International Classification of Diseases 9th Edition (ICD-9) code, were included. Series of univariate and multivariate analyses were performed to examine gender disparities in metastasis, liver decompensation, treatment type, and inpatient mortality after controlling for other possible predictors. RESULTS We included 26,054 discharges from the NIS database and 25,671 patients from the UHC database in the analysis. Women with HCC appear to present less often with decompensated liver disease (OR = 0.79, p < 0.001). Furthermore they are more likely to receive invasive HCC treatment, with significantly higher rates of resection across race and diagnoses (OR = 1.34 and 1.44, p < 0.001). Univariate analyses show that US women have lower unadjusted rates of transplant; however, the disparity resolves after controlling for other clinical and demographic factors. CONCLUSIONS US women more often receive invasive treatment for HCC (especially resection) than US men with no observed disparity in transplantation rates when adjusted for pre-treatment variables.
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Affiliation(s)
- Stephanie Cauble
- Department of Medicine, Section of Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, LA, USA,
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Yu DC, Chen WB, Jiang CP, Ding YT. Risk assessment in patients undergoing liver resection. Hepatobiliary Pancreat Dis Int 2013; 12:473-9. [PMID: 24103276 DOI: 10.1016/s1499-3872(13)60075-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection is still a risky procedure with high morbidity and mortality. It is significant to predict the morbidity and mortality with some models after liver resection. DATA SOURCES The MEDLINE/PubMed, Web of Science, Google Scholar, and Cochrane Library databases were searched using the terms "hepatectomy" and "risk assessment" for relevant studies before August 2012. Papers published in English were included. RESULTS Thirty-four original papers were included finally. Some models, such as MELD, APACHE II, E-PASS, or POSSUM, widely used in other populations, are useful to predict the morbidity and mortality after liver resection. Some special models for liver resection are used to predict outcomes after liver resection, such as mortality, liver dysfunction, transfusion, or acute renal failure. However, there is no good scoring system to predict or classify surgical complications because of shortage of internal or external validation. CONCLUSION It is important to validate the models for the major complications after liver resection with further internal or external databases.
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Affiliation(s)
- De-Cai Yu
- Department of Hepatobiliary Surgery, Drum Tower Hospital, the Affiliated Medical School of Nanjing University, Nanjing 210008, China.
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Hsu YC, Ho HJ, Wu MS, Lin JT, Wu CY. Postoperative peg-interferon plus ribavirin is associated with reduced recurrence of hepatitis C virus-related hepatocellular carcinoma. Hepatology 2013; 58:150-7. [PMID: 23389758 DOI: 10.1002/hep.26300] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 01/18/2013] [Indexed: 12/15/2022]
Abstract
UNLABELLED Hepatocellular carcinoma (HCC) frequently recurs after surgical resection. This population-based research aimed to investigate the association between postoperative antiviral treatment and risk of recurrent HCC in patients with hepatitis C virus (HCV) infection. By analyzing the Taiwan National Health Insurance Research Database, we initially screened a total of 100,938 patients diagnosed with HCC for the first time between October 2003 and December 2010. Among 2,237 antiviral-naïve HCV-infected patients with curatively resected HCC, there were 213 patients receiving antiviral treatment with pegylated interferon plus ribavirin for 16 weeks or more after surgery (treated cohort). These treated patients were matched 1:4 with 852 controls who were never treated for HCV infection (untreated cohort) by age, gender, cirrhosis, and the elapsed time between surgery and antiviral therapy. Cumulative incidences of and hazard ratios for recurrent HCC were calculated after adjusting for competing mortality. The recurrence rate of HCC was significantly lower in the treated than untreated cohort, with 52.1% (95% confidence interval [CI], 42.0-62.2%) and 63.9% (95% CI, 58.9-68.8%) after 5 years of follow-up, respectively (P = 0.001). The number needed to treat for one fewer recurrent HCC at 5 years was 8. The association between postoperative antiviral treatment and risk of recurrent HCC was independent of adjustment for multiple covariates, with an adjusted hazard ratio of 0.64 (95% CI, 0.50-0.83). Stratified analyses revealed that the attenuation in recurrence risk was greater in patients younger than 60 years and those without cirrhosis or diabetes. CONCLUSION Postoperative pegylated interferon plus ribavirin is associated with reduced recurrence of HCC in patients with HCV infection. Age, liver cirrhosis, and diabetes mellitus appear to modify this association.
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Affiliation(s)
- Yao-Chun Hsu
- Graduate Institute of Clinical Medicine, China Medical University, Taichung, Taiwan
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McPhee JT, Nguyen LL, Ho KJ, Ozaki CK, Conte MS, Belkin M. Risk prediction of 30-day readmission after infrainguinal bypass for critical limb ischemia. J Vasc Surg 2013; 57:1481-8. [DOI: 10.1016/j.jvs.2012.11.074] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 11/09/2012] [Accepted: 11/14/2012] [Indexed: 11/25/2022]
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Ragulin-Coyne E, Carroll JE, Smith JK, Witkowski ER, Ng SC, Shah SA, Zhou Z, Tseng JF. Perioperative mortality after pancreatectomy: A risk score to aid decision-making. Surgery 2012; 152:S120-7. [DOI: 10.1016/j.surg.2012.05.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 01/26/2023]
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Dhir M, Reddy SK, Smith LM, Ullrich F, Marsh JW, Tsung A, Geller DA, Are C. External validation of a pre-operative nomogram predicting peri-operative mortality risk after liver resections for malignancy. HPB (Oxford) 2011; 13:817-22. [PMID: 21999596 PMCID: PMC3238017 DOI: 10.1111/j.1477-2574.2011.00373.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM A pre-operative nomogram using a population-based database to predict peri-operative mortality risk after liver resections for malignancy has recently been developed. The aim of the present study was to perform an external validation of the nomogram using data from a high volume institution. METHODS The National Inpatient Sample (NIS) database (2000-2004) was used initially to construct the nomogram. The dataset for external validation was obtained from a high volume centre specializing in hepatobiliary surgery. Validation was performed using calibration plots and concordance index. RESULTS A total of 794 patients who underwent liver resection from the years 2000-2010 at the external institute were included in the validation set with an observed mortality rate of 1.6%. The mean total points for this sample of patients was 124.9 [standard error (SE) 1.8, range 0-383] which translates to a nomogram predicted mortality rate of 1.5%, similar to the actual observed overall mortality rate. The nomogram concordance index was 0.65 [95% confidence interval (CI) 0.46-0.82] and calibration plots stratified by quartiles revealed good agreement between the predicted and observed mortality rates. CONCLUSIONS The present study provides an external validation of the pre-operative nomogram to predict the risk of peri-operative mortality after liver resection for malignancy.
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Affiliation(s)
| | | | | | | | | | - Allan Tsung
- University of Pittsburgh Medical CenterPittsburgh, PA
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Mayo SC, Shore AD, Nathan H, Edil BH, Hirose K, Anders RA, Wolfgang CL, Schulick RD, Choti MA, Pawlik TM. Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion. HPB (Oxford) 2011; 13:473-82. [PMID: 21689231 PMCID: PMC3133714 DOI: 10.1111/j.1477-2574.2011.00326.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 04/08/2011] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Defining perioperative mortality as death that occurs within 30 days of surgery may underestimate 'true' mortality among patients undergoing hepatic resection. To better define perioperative mortality, trends in the risk for death during the first 90 days after hepatectomy were assessed. METHODS Surveillance, Epidemiology and End Results (SEER) Medicare data were used to identify 2597 patients who underwent hepatic resection during 1991-2006. Data on their clinicopathological characteristics, surgical management and perioperative mortality were collected and survival was assessed at 30, 60 and 90 days post-surgery. RESULTS Overall, 5.7% of patients died within the first 30 days. Postoperative mortality at 60 and 90 days were 8.3% and 10.1%. In-hospital mortality after hepatic resection was greater among patients with hepatocellular carcinoma (HCC) than among those with colorectal liver metastases (CRLM) (8.9% and 3.8%, respectively; P < 0.001). In CRLM patients, mortality increased from 4.3% at 30 days to 8.4% at 90 days, whereas mortality in HCC patients increased from 9.7% at 30 days to 15.0% at 90 days (both P < 0.05). Patients with HCC were twice as likely as CRLM patients to die within 30 days [odds ratio (OR) 2.03], 60 days (OR = 1.74) and 90 days (OR = 1.71) (all P < 0.001). Differences in 30- and 90-day mortality were greatest among HCC patients undergoing major hepatic resection (P < 0.05). CONCLUSIONS Reporting deaths that occur within a maximum of 30 days of surgery underestimates the mortality associated with hepatic resection. Traditional 30-day definitions of mortality are misleading and surgeons should report all perioperative outcomes that occur within 90 days of hepatic resection.
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Affiliation(s)
- Skye C Mayo
- Department of Surgery, School of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Maithel SK, Kneuertz PJ, Kooby DA, Scoggins CR, Weber SM, Martin RCG, McMasters KM, Cho CS, Winslow ER, Wood WC, Staley CA. Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis. J Am Coll Surg 2011; 212:638-48; discussion 648-50. [PMID: 21463803 DOI: 10.1016/j.jamcollsurg.2011.01.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 01/05/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection. STUDY DESIGN Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as <150 × 10(3)/μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality. RESULTS A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p = 0.031), PLI (30% versus 6%, p = 0.001), and 60-day mortality (22% versus 6%, p = 0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p = 0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p = 0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p = 0.009). CONCLUSIONS LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.
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Affiliation(s)
- Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Maithel SK, Kneuertz PJ, Kooby DA, Scoggins CR, Weber SM, Martin RCG, McMasters KM, Cho CS, Winslow ER, Wood WC, Staley CA. Importance of low preoperative platelet count in selecting patients for resection of hepatocellular carcinoma: a multi-institutional analysis. J Am Coll Surg 2011. [PMID: 21463803 DOI: 10.1016/j.jamollsurg.2011.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Low platelet count is a marker of portal hypertension but is not routinely included in the standard preoperative evaluation of patients with hepatocellular carcinoma (HCC) because it pertains to liver function (Child/model for end-stage liver disease [MELD] score) and tumor burden (Milan criteria). We hypothesized that low platelet count would be independently associated with increased perioperative morbidity and mortality after resection. STUDY DESIGN Patients treated with liver resection for HCC between January 2000 and January 2010 at 3 institutions were eligible. Preoperative platelet count, Child/MELD score, and tumor extent were recorded. Low preoperative platelet count (LPPC) was defined as <150 × 10(3)/μL. Postoperative liver insufficiency (PLI) was defined as peak bilirubin >7 mg/dL or development of ascites. Univariate and multivariate regression was performed for predictors of major complications, PLI, and 60-day mortality. RESULTS A total of 231 patients underwent resection, of whom 196 (85%) were classified as Child A and 35 (15%) as Child B; median MELD score was 8. Overall, 168 (71%) had tumors that exceeded Milan criteria and 134 (58%) had major hepatectomy (≥3 Couinaud segments). Overall and major complication rates were 55% and 17%, respectively. PLI occurred in 25 patients (11%), and 21 (9%) died within 60 days of surgery. Patients with LPPC (n = 50) had a significantly increased number of major complications (28% versus 14%, p = 0.031), PLI (30% versus 6%, p = 0.001), and 60-day mortality (22% versus 6%, p = 0.001). When adjusted for Child/MELD score and tumor burden, LPPC remained independently associated with increased number of major complications (odds ratio [OR] 2.8, 95% confidence intervals [CI] 1.1 to 6.8, p = 0.026), PLI (OR 4.0, 95% CI 1.4 to 11.1, p = 0.008), and 60-day mortality (OR 4.6, 95% CI 1.5 to 14.6, p = 0.009). CONCLUSIONS LPPC is independently associated with increased major complications, PLI, and mortality after resection of HCC, even when accounting for standard criteria, such as Child/MELD score and tumor extent, used to select patients for resection. Patients with LPPC may be better served with transplantation or liver-directed therapy.
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Affiliation(s)
- Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Kirkland LL, Kashiwagi DT, Burton MC, Cha S, Varkey P. The Charlson Comorbidity Index Score as a Predictor of 30-Day Mortality After Hip Fracture Surgery. Am J Med Qual 2011; 26:461-7. [DOI: 10.1177/1062860611402188] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This study is a retrospective chart review to determine the association of Charlson Comorbidity Index (CCI), age, body mass index (BMI), and admission glucose with the incidence of postoperative 30-day mortality in older patients undergoing hip fracture surgery from January 1, 2000, to June 30, 2002. A total of 40 (8%) of 485 eligible patients died within 30 days after hip fracture surgery. The factors associated with 30-day mortality were age > 90 years (odds ratio [OR] = 2.74; confidence interval [CI] = 1.27-5.95; P = .012), BMI < 18.5 (OR = 3.98; CI 1.48-10.65; P = .006), and CCI ≥ 6 (OR = 2.6; CI = 1.20-5.65; P = .015). There was no relationship between admission glucose concentration and 30-day mortality. Advanced age, low BMI, and high CCI can be identified prospectively and are independently associated with postoperative 30-day mortality in older, chronically ill patients.
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Dhir M, Smith LM, Ullrich F, Leiphrakpam PD, Ly QP, Sasson AR, Are C. Pre-operative nomogram to predict risk of peri-operative mortality following liver resections for malignancy. J Gastrointest Surg 2010; 14:1770-81. [PMID: 20824363 DOI: 10.1007/s11605-010-1352-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/23/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The majority of liver resections for malignancy are performed in older patient with major co-morbidities. There is currently no pre-operative, patient-specific method to determine the likely peri-operative mortality for each individual patient. The aim of this study was to develop a pre-operative nomogram based on the presence of co-morbidities to predict risk of peri-operative mortality following liver resections for malignancy. METHODS The Nationwide Inpatient Sample database was queried to identify adult patients that underwent liver resection for malignancy. The pre-operative co-morbidities, identified as predictors were used and a nomogram was created with multivariate regression using Taylor expansion method in SAS software, surveylogistic procedure. Training set (years 2000-2004) was utilized to develop the model and validation set (year 2005) was utilized to validate this model. RESULTS A total of 3,947 and 972 patients were included in training and validation sets, respectively. The overall actual-observed peri-operative mortality rates for training and validation sets were 4.1% and 3.2%, respectively. The decile-based calibration plots for the training set revealed good agreement between the observed probabilities and nomogram-predicted probabilities. Similarly, the quartile-based calibration plot for the validation set revealed good agreement between the observed and predicted probabilities. The accuracy of the nomogram was further reinforced by a good concordance index of 0.80 with a 95% confidence interval of 0.72 and 0.87. CONCLUSIONS This pre-operative nomogram may be utilized to predict the risk of peri-operative mortality following liver resection for malignancy.
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Affiliation(s)
- Mashaal Dhir
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Eppley Cancer Center, Omaha, NE 68198, USA
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Hill JS, Zhou Z, Simons JP, Ng SC, McDade TP, Whalen GF, Tseng JF. A simple risk score to predict in-hospital mortality after pancreatic resection for cancer. Ann Surg Oncol 2010; 17:1802-7. [PMID: 20155401 DOI: 10.1245/s10434-010-0947-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pancreatectomy for cancer continues to have substantial perioperative risk, and the factors affecting mortality are ill defined. An integer-based risk score based on national data might help clarify the risk of in-hospital mortality in patients undergoing pancreatic resection. METHODS Records with the diagnosis of pancreatic cancer were queried from the Nationwide Inpatient Sample for 1998-2006. Procedures were categorized as proximal, distal, or nonspecified pancreatectomies on the basis of ICD-9 codes. Logistic regression and bootstrap methods were used to create an integer risk score for estimating the risk of in-hospital mortality using patient demographics, comorbidities (Charlson comorbidity score), procedure, and hospital type. A random sample of 80% of the cohort was used to create the risk score with a 20% internal validation set. RESULTS A total of 5715 patient discharges were identified. Composite in-hospital mortality was 5.8%. Predictors used for the final model were age group, Charlson score, sex, type of pancreatectomy, and hospital volume status (low-, medium-, or high-volume center). Integer values were assigned to these characteristics and then used for calculating an additive score. Three clinically useful score groups were defined to stratify the risk of in-hospital mortality (mortality was 2.0, 6.2, and 13.9%, respectively; P < 0.0001), with a 6.95-fold difference between the low- and high-risk groups. There was sufficient discrimination of both the derivation set and the validation set, with c statistics of 0.71 and 0.72, respectively. CONCLUSIONS An integer-based risk score can be used to accurately predict in-hospital mortality after pancreatectomy and may be useful for preoperative risk stratification and patient counseling.
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Affiliation(s)
- Joshua S Hill
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
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