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Gon H, Komatsu S, Soyama H, Tanaka M, Fukushima K, Urade T, So S, Yoshida T, Arai K, Ishida J, Nanno Y, Tsugawa D, Yanagimoto H, Toyama H, Kido M, Fukumoto T. Impact of bile leak on the prognosis of patients with hepatocellular carcinoma who have undergone liver resection. Langenbecks Arch Surg 2024; 409:233. [PMID: 39078441 DOI: 10.1007/s00423-024-03430-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 07/23/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE The impact of postoperative bile leak on the prognosis of patients with hepatocellular carcinoma who underwent liver resection is controversial. This study aimed to investigate the prognostic impact of bile leak for patients with hepatocellular carcinoma who underwent liver resection. METHODS Patients with hepatocellular carcinoma who underwent liver resection between 2009 and 2019 at Kobe University Hospital and Hyogo Cancer Center were included. After propensity score matching between the bile leak and no bile leak groups, differences in 5-year recurrence-free and overall survival rates were evaluated using the Kaplan-Meier method. RESULTS A total of 781 patients, including 43 with postoperative bile leak, were analyzed. In the matched cohort, 40 patients were included in each group. The 5-year recurrence-free survival rates after liver resection were 35% and 32% for the bile leak and no bile leak groups, respectively (P = 0.857). The 5-year overall survival rates were 44% and 54% for the bile leak and no bile leak groups, respectively (P = 0.216). CONCLUSION Overall, bile leak may not have a profound negative impact on the prognosis of patients with hepatocellular carcinoma who have undergone liver resection.
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Affiliation(s)
- Hidetoshi Gon
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hirotoshi Soyama
- Department of Surgery, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, 673-8558, Japan
| | - Motofumi Tanaka
- Department of Surgery, Hyogo Cancer Center, 13-70 Kitaoji-cho, Akashi, 673-8558, Japan
| | - Kenji Fukushima
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takeshi Urade
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinichi So
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Toshihiko Yoshida
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Keisuke Arai
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Jun Ishida
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yoshihide Nanno
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Daisuke Tsugawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hirochika Toyama
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Masahiro Kido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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Procopio F, Branciforte B, Galvanin J, Costa G, Franchi E, Cimino M, Torzilli G. Anatomical liver resection using the ultrasound-guided compression technique in minimal access surgery. Surg Endosc 2024; 38:193-201. [PMID: 37957299 DOI: 10.1007/s00464-023-10523-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/08/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Segmental or subsegmental anatomical resection (AR) of hepatocellular carcinoma (HCC) in minimal access liver surgery (MALS) has been technically proposed. The Glissonean approach or dye injection technique are generally adopted. The tumor-feeding portal pedicle compression technique (C-AR) is an established approach in open surgery, but its feasibility in the MALS environment has never been described. METHODS Eligible patients were prospectively enrolled to undergo laparoscopic or robotic ultrasound-guided C-AR based on HCC location and preoperative identification of a single tumor-feeding portal pedicle. Initial C-AR experience was gained with laparoscopic cases in the beginning of 2020. Following our progressive experience in laparoscopic C-AR, patients requiring AR for HCC were consecutively selected for robotic C-AR. RESULTS A total of 10 patients underwent minimal access C-AR. All patients had Child-Pugh A HCC. The surgical procedures included 6 laparoscopic and 4 robotic C-AR. Median tumor size was 3.1 cm (range 2-7 cm). All procedures had R0 margin. Postoperative complications were nil. CONCLUSION C-AR technique is a feasible and promising technique for patients eligible for laparoscopic and robotic AR for HCC. Further data are necessary to validate its applicability to more complex minimal access AR.
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Affiliation(s)
- Fabio Procopio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Bruno Branciforte
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jacopo Galvanin
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Guido Costa
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Eloisa Franchi
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Guido Torzilli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy.
- Division of Hepatobiliary & General Surgery, Department of Surgery - IRCCS, Humanitas Research Hospital, via Manzoni 56, Rozzano, 20089, Milan, Italy.
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3
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Laino ME, Fiz F, Morandini P, Costa G, Maffia F, Giuffrida M, Pecorella I, Gionso M, Wheeler DR, Cambiaghi M, Saba L, Sollini M, Chiti A, Savevsky V, Torzilli G, Viganò L. A virtual biopsy of liver parenchyma to predict the outcome of liver resection. Updates Surg 2023; 75:1519-1531. [PMID: 37017906 DOI: 10.1007/s13304-023-01495-7] [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: 10/25/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
The preoperative risk assessment of liver resections (LR) is still an open issue. Liver parenchyma characteristics influence the outcome but cannot be adequately evaluated in the preoperative setting. The present study aims to elucidate the contribution of the radiomic analysis of non-tumoral parenchyma to the prediction of complications after elective LR. All consecutive patients undergoing LR between 2017 and 2021 having a preoperative computed tomography (CT) were included. Patients with associated biliary/colorectal resection were excluded. Radiomic features were extracted from a virtual biopsy of non-tumoral liver parenchyma (a 2 mL cylinder) outlined in the portal phase of preoperative CT. Data were internally validated. Overall, 378 patients were analyzed (245 males/133 females-median age 67 years-39 cirrhotics). Radiomics increased the performances of the preoperative clinical models for both liver dysfunction (at internal validaton, AUC = 0.727 vs. 0.678) and bile leak (AUC = 0.744 vs. 0.614). The final predictive model combined clinical and radiomic variables: for bile leak, segment 1 resection, exposure of Glissonean pedicles, HU-related indices, NGLDM_Contrast, GLRLM indices, and GLZLM_ZLNU; for liver dysfunction, cirrhosis, liver function tests, major hepatectomy, segment 1 resection, and NGLDM_Contrast. The combined clinical-radiomic model for bile leak based on preoperative data performed even better than the model including the intraoperative data (AUC = 0.629). The textural features extracted from a virtual biopsy of non-tumoral liver parenchyma improved the prediction of postoperative liver dysfunction and bile leak, implementing information given by standard clinical data. Radiomics should become part of the preoperative assessment of candidates to LR.
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Affiliation(s)
- Maria Elena Laino
- Artificial Intelligence Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesco Fiz
- Department of Nuclear Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Pierandrea Morandini
- Artificial Intelligence Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Guido Costa
- Division of Hepatobiliary and General Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Fiore Maffia
- Artificial Intelligence Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Mario Giuffrida
- Division of Hepatobiliary and General Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ilaria Pecorella
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Matteo Gionso
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Dakota Russell Wheeler
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Martina Cambiaghi
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Luca Saba
- Department of Radiology, University of Cagliari, Cagliari, Italy
| | - Martina Sollini
- Department of Nuclear Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Arturo Chiti
- Department of Nuclear Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Victor Savevsky
- Artificial Intelligence Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy
| | - Luca Viganò
- Department of Biomedical Sciences, Humanitas University, Viale Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milan, Italy.
- Hepatobiliary Unit, Department of Minimally Invasive General and Oncologic Surgery, Humanitas Gavazzeni University Hospital, Viale M. Gavazzeni 21, 24125, Bergamo, Italy.
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Xue S, Wang H, Chen X, Zeng Y. Risk factors of postoperative bile leakage after liver resection: A systematic review and meta-analysis. Cancer Med 2023; 12:14922-14936. [PMID: 37326370 PMCID: PMC10417307 DOI: 10.1002/cam4.6128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 04/26/2023] [Accepted: 05/14/2023] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE Postoperative bile leakage (POBL) is one of the most common complications after liver resection. However, current studies on the risk factors for POBL and their impacts on surgical outcomes need to be more consistent. This study aims to conduct a meta-analysis to analyze the risk factors for POBL after hepatectomy. METHODS We incorporated all eligible studies from Embase, PubMed, and the Web of Science database (until July 2022) into this study. RevMan and STATA software were used to analyze the extracted data. RESULTS A total of 39 studies, including 43,824 patients, were included in this meta-analysis. We found that gender, partial hepatectomy, repeat of hepatectomy, extended hepatectomy, abdominal drain, diabetes, Child≥B, solitary tumor, and chemotherapy are the factors of grade B and C POBL. Some recognized risk factors were considered potential risk factors for grade B and C bile leakage because no subgroup analysis was performed, like HCC, cholangiocarcinoma, major resection, posterior sectionectomy, bi-segmentectomy, S4 involved, S8 involved, central hepatectomy, and bile duct resection/reconstruction. Meanwhile, cirrhosis, benign diseases, left hepatectomy, and Segment 1 resection were not significant for grade B and C bile leakage. The influence of lateral sectionectomy, anterior sectionectomy, S1 involved, S3 involved, high-risk procedure, laparoscope, and blood loss>1000 mL on POBL of ISGLS needs further research. Meanwhile, POBL significantly influenced overall survival (OS) after liver resection. CONCLUSIONS We identified several risk factors for POBL after hepatectomy, which could prompt the clinician to decrease POBL rates and make more beneficial decisions for patients who underwent the hepatectomy.
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Affiliation(s)
- Shuai Xue
- Division of Liver Surgery, Department of General Surgery and Laboratory of Liver Surgery, and State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Haichuan Wang
- Division of Liver Surgery, Department of General Surgery and Laboratory of Liver Surgery, and State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Xiangzheng Chen
- Division of Liver Surgery, Department of General Surgery and Laboratory of Liver Surgery, and State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, West China HospitalSichuan UniversityChengduChina
| | - Yong Zeng
- Division of Liver Surgery, Department of General Surgery and Laboratory of Liver Surgery, and State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, West China HospitalSichuan UniversityChengduChina
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Patkar S, Kunte A, Sundaram S, Goel M. Post-hepatectomy biliary leaks: analysis of risk factors and development of a simplified predictive scoring system. Langenbecks Arch Surg 2023; 408:63. [PMID: 36692605 DOI: 10.1007/s00423-023-02776-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 12/14/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Most studies identifying risk factors for post-hepatectomy biliary leaks (PHBLs) have relatively small proportions of major hepatectomies. A simplified predictive score to identify high risk patients is necessary in order to investigate the efficacy of mitigation strategies. METHODS A retrospective analysis of a prospectively maintained database of liver resections from a high-volume cancer center was performed. Multivariate regression was utilized for identification of risk factors and development of the predictive score. RESULTS A total of 862 patients underwent a curative hepatic resection over 10 years, of whom 146 (16.9%) developed a biliary leak; 85 (9.86%), 52 (6.03%), and 9 (1.04%) patients had a grade A, B, and C leak respectively. A biliary-enteric anastomosis [OR 5.1 (95% CI 2.45-10.58); p < 0.001], a central [OR 4.33 (95% CI 1.25-14.95); p = 0.021] or an extended hepatectomy [OR 4.29 (95% CI 1.52-12.12); p = 0.006], liver steatosis [OR 2.28 (95% CI 1.09-4.77); p = 0.027], and blood loss of ≥ 2000 mL [OR 2.219 (95% CI 1.15-4.27); p = 0.017] were identified as independent predictors of a clinically significant biliary leak and were assigned 1 point each to develop the biliary leak score. Clinically significant biliary leaks were seen in 11 (2.79%), 20 (6.38%), 19 (15.4%), 9 (56.3%), and 1 (100%) patients with scores of 0, 1, 2, 3, and 4 respectively (p < 0.001). CONCLUSION A biliary-enteric anastomosis, a central or extended hepatectomy, liver steatosis, and blood loss ≥ 2L combined result in a simple predictive score for clinically significant biliary leaks.
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Affiliation(s)
- Shraddha Patkar
- GI & HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Aditya Kunte
- GI & HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Mahesh Goel
- GI & HPB Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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Calamia S, Barbara M, Cipolla C, Grassi N, Pantuso G, Li Petri S, Pagano D, Gruttadauria S. Risk factors for bile leakage after liver resection for neoplastic disease. Updates Surg 2022; 74:1581-1587. [PMID: 35841529 DOI: 10.1007/s13304-022-01326-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/29/2022] [Indexed: 11/29/2022]
Abstract
Biliary leakage (BL) remains the most frequent and feared complication after hepatoresective surgery. Placement of the abdominal drainage at the end of liver surgery remains controversial due to the delicate balance between risks and potential benefits in case of BL. The study was aimed to detect possible risk factors for BL occurrence after liver surgery. We enrolled all oncologic patients who underwent liver resection from June 2016 to March 2021. BL was diagnosed according to the ISGLS definition. We have examined demographic characteristics of the patients, type of neoplasia, presence of cirrhosis, neoadjuvant chemotherapy and type of intervention. Uni- and multivariable analyses were performed to assess the predictive value of potential predictor of BL. A total of 379 patients were enrolled in the study, 16 (4.2%) of which developed BL. Among others, at univariate analysis the occurrence of BL was found to be associated with bilio-digestive anastomosis (OR: 9.75, C.I. 2.7-34.7, p < 0.001) and neoadjuvant chemotherapy (OR: 0.09, C.I 0.01,-0.88, p = 0.039). Multivariable analysis selected the body mass index (OR: 1.21, 95%C.I.: 1.04-1.41, p = 0.015), anatomical resection (OR: 8.35, 95% C.I.: 2.01-34.74, p = 0.004), and blood loss (OR: 1.09, 95%C.I.: 1.05-1.13, p < 0.001). Identification of patients at greater risk of BL can help in the choice of positioning the drainage at the end of liver surgery.
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Affiliation(s)
- Sergio Calamia
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
- Department of Surgical Oncological and Oral Sciences, University of Palermo, 90127, Palermo, Italy
| | - Marco Barbara
- Research Department, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Calogero Cipolla
- Department of Surgical Oncological and Oral Sciences, University of Palermo, 90127, Palermo, Italy
| | - Nello Grassi
- Department of Surgical Oncological and Oral Sciences, University of Palermo, 90127, Palermo, Italy
| | - Gianni Pantuso
- Department of Surgical Oncological and Oral Sciences, University of Palermo, 90127, Palermo, Italy
| | - Sergio Li Petri
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Duilio Pagano
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto di Ricovero e Cura a Carattere Scientifico Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy.
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, 95123, Catania, Italy.
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Liver drains after surgery: what is the real practice? An international snapshot from the Li.DR.A.S. survey. Updates Surg 2022; 74:1317-1326. [PMID: 35657558 DOI: 10.1007/s13304-022-01301-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
Despite current evidence, the use of drains in liver surgery is still controversial. We conducted an international survey to investigate the clinical use of drains in the E-AHPBA, A-HPBA and A-PHPBA communities. An open survey of 30 questions was prepared on Google-Form and distributed by email to all members. One hundred and ninety-one HPB surgeons responded to the survey. One hundred and twelve surgeons (58.6%) reported routine use of abdominal drains after liver resections. Eighty-eight (46.1%) responded that removal was driven by low volume and low bilirubin levels in the drains. For minor liver resection, 97 (50.8%) surgeons reported using drains selectively; in contrast, 134 (70.2%) surgeons prefer to use a drain always after major procedures. Among patients with cirrhosis, 87 (45.5%) surgeons reported routine drains placement, while 84 (44.0%) considered drains selectively. A no-drain policy was most prevalent among surgeons from North America (80%) versus Asian-Pacific (70.0%), European and African (60.8%), and South American (61.5%) surgeons. Among minimally invasive surgeons, 74.2% reported drain use only in selected cases versus 35.0% among surgeons who performed open surgery. The practice of draining after liver surgery is still highly variable among centers and surgeons around the world, with a high variability according to the underlying liver condition and planned surgical approach.
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8
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Watanabe G, Kawaguchi Y, Ichida A, Ishizawa T, Akamatsu N, Kaneko J, Arita J, Hasegawa K. Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay. HPB (Oxford) 2022; 24:226-233. [PMID: 34312059 DOI: 10.1016/j.hpb.2021.06.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND After liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time. METHODS Surgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed. RESULTS Of 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection. CONCLUSION Conditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.
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Affiliation(s)
- Genki Watanabe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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9
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Tan L, Liu F, Liu ZL, Xiao JW. Meta-Analysis of Risk Factors for Bile Leakage After Hepatectomy Without Biliary Reconstruction. Front Surg 2021; 8:764211. [PMID: 34790696 PMCID: PMC8591075 DOI: 10.3389/fsurg.2021.764211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Background and Aim: The risk factors for bile leakage after hepatectomy without biliary reconstruction are controversial. This study investigated the risk factors for bile leakage after hepatectomy without biliary reconstruction. Methods: We searched databases (Embase (Ovid), Medline (Ovid), PubMed, Cochrane Library, and Web of Science) for articles published between January 1, 2000, and May 1, 2021, to evaluate the risk factors for bile leakage after hepatectomy without biliary reconstruction. Results: A total of 16 articles were included in this study, and the overall results showed that sex (OR: 1.21, 95% CI: 1.04–1.42), diabetes (OR: 1.21, 95% CI: 1.05–1.38), left trisectionectomy (OR: 3.53, 95% CI: 2.32–5.36), central hepatectomy (OR: 3.28, 95% CI: 2.63–4.08), extended hemihepatectomy (OR: 2.56, 95% CI: 1.55–4.22), segment I hepatectomy (OR: 2.56, 95% CI: 1.50–4.40), intraoperative blood transfusion (OR:2.40 95%CI:1.79–3.22), anatomical hepatectomy (OR: 1.70, 95% CI: 1.19–2.44) and intraoperative bleeding ≥1,000 ml (OR: 2.46, 95% CI: 2.12–2.85) were risk factors for biliary leakage. Age >75 years, cirrhosis, underlying liver disease, left hepatectomy, right hepatectomy, benign disease, Child–Pugh class A/B, and pre-operative albumin <3.5 g/dL were not risk factors for bile leakage after hepatectomy without biliary reconstruction. Conclusion: Comprehensive research in the literature revealed that sex, diabetes, left trisectionectomy, central hepatectomy, extended hemihepatectomy, segment I hepatectomy, intraoperative blood transfusion, anatomical hepatectomy and intraoperative bleeding ≥1,000 ml were risk factors for biliary leakage.
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Affiliation(s)
- Ling Tan
- Department of Gastrointestinal Surgery, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Fei Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Zi-Lin Liu
- Department of Gastrointestinal Surgery, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Jiang-Wei Xiao
- Department of Gastrointestinal Surgery, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, China
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10
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Harimoto N, Araki K, Yamanaka T, Hagiwara K, Ishii N, Tsukagoshi M, Watanabe A, Shirabe K. Direct Bilirubin in Drainage Fluid 3 days after Hepatectomy Is Useful for Detecting Severe Bile Leakage. Eur Surg Res 2021; 63:33-39. [PMID: 34515111 DOI: 10.1159/000518267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The International Study Group of Liver Surgery (ISGLS) definition of bile leakage is an elevated total bilirubin concentration in the drainage fluid after post-operative day (POD) 3, which has been widely accepted. However, there were no reports about direct bilirubin in drainage fluid to predict bile leakage. METHODS Data from 257 patients who underwent hepatectomy were retrospectively reviewed. The optimal cut-off value was investigated using receiver-operating characteristic curves. The predictive power of drainage fluid total bilirubin (dTB) and drainage fluid direct bilirubin (dDB) to predict bile leakage, which was defined using ISGLS grade B or grade C, were compared. RESULTS ISGLS grade B bile leakage occurred in 16 patients (6.2%). Area under the curve (AUC) of dDB was always higher than that of dTB on each POD. The AUC of dDB was >0.75 on PODs 2, 3, and 5, and then it increased with the increasing POD. The dDB on POD 5 showed the highest accuracy (0.91) and positive predictive value (PPV) (0.67), which was followed by dTB/serum total bilirubin (sTB) on POD 3 (accuracy, 0.91; PPV, 0.33). Because the PPV of dDB increased as the POD increased, dDB was better than dTB for predicting clinically significant bile leakage. dDB on POD 3 showed the highest negative predictive value (0.97). The positive likelihood of dDB increased and the negative likelihood of dDB decreased on the basis of the POD. Among patients with dTB/sTB ≤3 on POD 3, 19.1% of these patients had bile leakage when dDB was >0.44 on POD 3. CONCLUSIONS Measurement of both dDB and dTB, which are easy to perform, can be used to effectively predict clinically significant bile leakage.
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Affiliation(s)
- Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takahiro Yamanaka
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Mariko Tsukagoshi
- Department of Innovative Cancer Immunotherapy, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
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11
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Giustiniano E, Nisi F, Rocchi L, Zito PC, Ruggieri N, Cimino MM, Torzilli G, Cecconi M. Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist. Cancers (Basel) 2021; 13:cancers13092203. [PMID: 34063684 PMCID: PMC8125060 DOI: 10.3390/cancers13092203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Major high-risk surgery (HRS) exposes patients to potential perioperative adverse events. Hepatic resection of colorectal metastases can surely be included into the HRS class of operations. Limiting such risks is the main target of the perioperative medicine. In this context the collaboration between the anesthetist and the surgeon and the sharing of management protocols is of utmost importance and represents the key issue for a successful outcome. In our institution, we have been adopting consolidated protocols for patients undergoing this type of surgery for decades; this made our mixed team (surgeons and anesthetists) capable of achieving a safe outcome for the majority of our surgical population. In this narrative review, we report the most recent state of the art of perioperative management of hepatic resection of colorectal metastases along with our experience in this field, trying to point out the main issues. Abstract Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Correspondence: (E.G.); (F.N.); Tel.: +39-02-8224-7459 (E.G.); +39-02-8224-4115 (F.N.); Fax: +39-02-8224-4190 (E.G. & F.N.)
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Correspondence: (E.G.); (F.N.); Tel.: +39-02-8224-7459 (E.G.); +39-02-8224-4115 (F.N.); Fax: +39-02-8224-4190 (E.G. & F.N.)
| | - Laura Rocchi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Paola C. Zito
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Matteo M. Cimino
- Hepato-Biliary & Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (M.M.C.); (G.T.)
| | - Guido Torzilli
- Hepato-Biliary & Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (M.M.C.); (G.T.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
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12
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Del Fabbro D, Cimino MM, Procopio F, Torzilli G. Stent-free duct-to-duct biliary reconstruction after hepatectomy for liver tumors involving biliary confluence at the hepatic hilum: a monocentric experience. Updates Surg 2021; 73:2017-2022. [PMID: 33768448 DOI: 10.1007/s13304-021-00987-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Abstract
Roux-en-Y hepaticojejunostomy (HJ) is the standard of care for biliary reconstruction. Its weaknesses are the loss of the sphincter functionality, which could lead to repeated cholangitis, and the reduced endoscopic accessibility to the biliary tree. In the context of liver transplantation it has been shown that duct-to-duct biliary anastomosis may be suitable as an alternative to HJ, significantly reducing the risk of cholangitis. Here we present our experience on stent-free duct-to-duct reconstruction, performed in six patients receiving hepatectomy with resection of the biliary confluence. Operative mortality was nil. Anastomotic leak occurred in four patients and resolved spontaneously in all cases. One patient developed anastomotic stricture 17 months after surgery and only one patient developed tumor recurrence at the anastomotic site; in both cases the endoscopic stenting succeeded in restoring the ducts patency. With a median follow-up of 24 months (range 19-28 months), no cholangitis or other biliary-related complications were observed. Our experience, although limited, shows satisfactory oncological and functional outcomes, confirming all previously published results.
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Affiliation(s)
- Daniele Del Fabbro
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Matteo Maria Cimino
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary Surgery, Department of Surgery, IRCCS Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy.
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13
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Citterio D, Vaiani M, Sposito C, Rossi RE, Flores M, Battiston C, Mazzaferro V. Improved management of grade B biliary leaks after complex liver resections using gadoxetic acid disodium-enhanced magnetic resonance cholangiography. Surgery 2021; 170:499-506. [PMID: 33745732 DOI: 10.1016/j.surg.2021.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bile leaks occurring after complex liver resection and lasting >1 week (grade B) usually are managed by means of invasive cholangiography either endoscopic or percutaneous, with a substantial risk of procedure-related complications. The aim of this study was to investigate the ability of gadoxetic acid disodium-enhanced magnetic resonance cholangiography to detect postoperative biliary leaks and avoid invasive cholangiography in case of peripheral location of the fistula. METHODS Patients with grade B biliary leak after complex liver resection from January 2018 to March 2020 underwent magnetic resonance cholangiography to guide the management of the leak (study group). The primary endpoint was the ability of magnetic resonance cholangiography to reduce the need for invasive cholangiography with respect to similar posthepatectomy leaks collected in the previous 2 years and approached with upfront invasive cholangiography (controls). A series of in-hospital outcomes also were compared. RESULTS Out of 533 liver resections, 11 study patients versus 11 control patients with grade B leaks were compared. Magnetic resonance cholangiography achieved 100% accuracy in detection and location of the leak. Five out of 6 peripheral leaks healed without invasive cholangiography. Overall, 50% reduction in the use of invasive cholangiography was observed in the study versus control patients. Median healing time and hospital stay were 38 and 40 days in patients undergoing invasive cholangiography versus 10 and 11 days in patients treated conservatively (P = .007 and 0.012, respectively). Infection rate and other complications rate were 82% vs 20% (P = .01) and 35% vs 40% (P = .5), respectively. CONCLUSION Magnetic resonance cholangiography is a safe, precise, noninvasive tool to detect posthepatectomy bile leaks that can help clinicians in decision-making on conservative versus invasive treatment of fistulas.
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Affiliation(s)
- Davide Citterio
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Marta Vaiani
- Department of Radiology, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Carlo Sposito
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Roberta Elisa Rossi
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Maria Flores
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Carlo Battiston
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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14
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Gentile D, Donadon M, Civilini E, Torzilli G. Total upper transversal hepatectomy with outflow reconstruction for advanced mass-forming cholangiocarcinoma. Updates Surg 2021; 73:769-773. [PMID: 33625678 DOI: 10.1007/s13304-020-00946-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
We describe a complex case of extended hepatectomy with venous outflow reconstruction for the treatment of advanced mass-forming cholangiocarcinoma (MFCCC) invading the three main hepatic veins (HVs). A 50-year-old woman who received a diagnosis of MFCCC and judged unresectable, was referred to our hospital. After multidisciplinary team evaluation, the patient underwent abdominal computed tomography, gadoxetic acid-enhanced magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography. The radiological examinations showed a large mass located in S4s-8 and S1, in contact with the right hepatic vein (RHV), the inferior right hepatic vein, the anterior wall of the inferior vena cava (IVC), infiltrating the middle and left hepatic veins (MHV, LHV). Several communicating veins between the RHV, MHV and LHV were detected. The case was further investigated, and the surgical strategy planned by means of using three-dimensional simulation software. A total upper transversal hepatectomy with resection of the main HVs and outflow reconstruction was performed. The outflow of the remnant liver was restored performing a vascular anastomosis between the parenchymal stump of the RHV and the IVC. Meticulous review of pre-operative imaging techniques with three-dimensional simulation of hepatectomy together with advanced use of intra-operative ultrasound allowed us to offer the chance of cure to a patient otherwise considered unresectable.
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Affiliation(s)
- Damiano Gentile
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Via Manzoni, 56, 20089, Rozzano, Milano, Italy
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Via Manzoni, 56, 20089, Rozzano, Milano, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Efrem Civilini
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Vascular Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Via Manzoni, 56, 20089, Rozzano, Milano, Italy. .,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy.
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15
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Drain Placement After Uncomplicated Hepatic Resection Increases Severe Postoperative Complication Rate: A Japanese Multi-institutional Randomized Controlled Trial (ND-trial). Ann Surg 2021; 273:224-231. [PMID: 33064385 DOI: 10.1097/sla.0000000000004051] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the clinical impact of a no-drain policy after hepatic resection. SUMMARY OF BACKGROUND DATA Previous randomized controlled trials addressing no-drain policy after hepatic resection seem inconclusive because they did not adopt appropriate study design to validate its true clinical impact. METHODS This unblinded, randomized controlled trial was done at 7 Japanese institutions. Patients undergoing hepatic resection without biliary reconstruction were randomized to either D group or ND group. When the risk of postoperative bile leakage or hemorrhage were considered high, the patients were excluded during the operation. Primary endpoint was the postoperative complication of C-D grade 3 or higher within 90 postoperative days. A noninferiority of ND group to D group was assessed, and if it was confirmed, a superiority was assessed. RESULTS Between May 2015 and July 2017, a total of 400 patients were finally included in the per-protocol set analysis: 199 patients in D group and 201 patients in ND group. Intraoperatively, 37 patients were excluded from the final enrollment because of high risk of bile leakage or hemorrhage. Postoperative complication rate of C-D grade 3 or higher was 8.0% (16/199) in the D group and 2.5% (5/201) in the ND group. The risk difference was -5.5% (95% confidence interval: -9.9% to -1.2%) and fulfilled the prescribed noninferiority margin of 4%. No postoperative mortality was experienced in both groups. Bile leakage was diagnosed in 8.0% (16/199) of the D group and none in the ND group (P < 0.001). In none of the subgroups classified based on 8 potentially relevant factors, drain placement was favored in terms of C-D grade 3 or higher complication. CONCLUSIONS Drains should not be placed after uncomplicated hepatic resections.
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16
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Smith AA, Monlezun DJ, Martinie J, Iannitti D, Konstantinidis I, Darden M, Parker G, Fong Y, Buell JF. Bile Leak Reduction with Laparoscopic Versus Open Liver Resection: A Multi-institutional Propensity Score-Adjusted Multivariable Regression Analysis. World J Surg 2021; 44:1578-1585. [PMID: 31897695 DOI: 10.1007/s00268-019-05343-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The reported rate of postoperative bile leak is variable between 3 and 33%. Recent data would suggest a minimally invasive approach to liver surgery has decreased this incidence. METHODS This multi-institutional case-control study utilized databases from three high-volume surgeons. All consecutive open and minimally invasive liver resection cases were analyzed in a propensity score-adjusted multivariable regression. A p value < 0.05 was considered significant. RESULTS In 1388 consecutive liver resections, the average age was 56.9 ± 14.0 years, 730 (52.59%) were male gender, and 599 (43.16%) underwent minimally invasive liver resection. Thirty-nine (2.81%) in the series were identified with post-resection bile duct leaks. Leaks were associated with major resections and increased blood loss (p < 0.05). Propensity score-adjusted multivariable regression identified minimally invasive liver resection significantly and independently reduced the odds of bile duct leak (OR 0.48, p = 0.046) even controlling for BMI, ASA, cirrhosis, major resection, and resection year. CONCLUSIONS Our data suggest the incidence of bile leaks in a large-volume center series is far less than previously reported and that a minimally invasive approach to liver resection reduces the incidence of postoperative bile leak.
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Affiliation(s)
- Alison A Smith
- Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL-22, New Orleans, LA, 70112, USA.
| | - Dominique J Monlezun
- Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL-22, New Orleans, LA, 70112, USA
| | - John Martinie
- Division of HPB Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - David Iannitti
- Division of HPB Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | - Michael Darden
- Carey Business School, Johns Hopkins University, Baltimore, MD, USA
| | - Geoffrey Parker
- Thayer School of Engineering, Dartmouth College, Hanover, USA
| | - Yuman Fong
- City of Hope National Medical Center, Los Angeles, CA, USA
| | - Joseph F Buell
- Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL-22, New Orleans, LA, 70112, USA
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17
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Viganò L, Torzilli G, Aldrighetti L, Ferrero A, Troisi R, Figueras J, Cherqui D, Adam R, Kokudo N, Hasegawa K, Guglielmi A, Majno P, Toso C, Krawczyk M, Abu Hilal M, Pinna AD, Cescon M, Giuliante F, De Santibanes E, Costa-Maia J, Pawlik T, Urbani L, Zugna D. Stratification of Major Hepatectomies According to Their Outcome: Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis. Ann Surg 2020; 272:827-833. [PMID: 32925253 DOI: 10.1097/sla.0000000000004338] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To stratify major hepatectomies (MajHs) according to their outcomes. SUMMARY OF BACKGROUND DATA MajHs are associated with non-negligible operative risks, but they include a wide range of procedures. Detailed depiction of the outcomes of different MajHs is the basis for a new classification of liver resections. METHODS We retrospectively considered patients that underwent hepatectomy in 17 high-volume centers. Patients with an associated digestive/biliary resection were excluded. We analyzed open MajHs in non-cirrhotic patients. MajHs were classified according to the Brisbane nomenclature. Right hepatectomies (RHs) were reference standards. Outcomes were adjusted for potential confounders, including indication, liver function, preoperative portal vein embolization, and enrolling center. RESULTS We analyzed a series of 2212 patients. In comparison with RH, left hepatectomy had lower mortality [0.6% vs 2.2%, odds ratio (OR) = 0.25], severe morbidity (11.7% vs 14.4%, OR = 0.62), and liver failure rates (2.1% vs 11.6%, OR = 0.16). Left hepatectomy+Sg1 and mesohepatectomy+/-Sg1 had outcomes similar to RH, except for higher bile leak rate (31.3% and 13.5% vs 6.7%, OR = 4.36 and OR = 2.29). RH + Sg1 had slightly worse outcomes than RH. Right and left trisectionectomies had higher mortality (5.0% and 7.3% vs 2.2%, OR = 2.07 and OR = 2.71) and liver failure rates than RH (19.0% and 22.0% vs 11.6%, OR = 2.03 and OR = 2.21). Left trisectionectomy had even higher severe morbidity (25.6% vs 14.4%, OR = 2.07) and bile leak rates (14.6% vs 6.7%, OR = 2.31). CONCLUSIONS The term "major hepatectomy" includes resections having heterogeneous outcome. Different MajHs can be stratified according to their mortality, severe morbidity, liver failure, and bile leak rates.
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Affiliation(s)
- Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano - Milan, Italy.,Humanitas University, Department of Biomedical Sciences, Pieve Emanuele - Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano - Milan, Italy.,Humanitas University, Department of Biomedical Sciences, Pieve Emanuele - Milan, Italy
| | | | | | | | | | | | - René Adam
- Paul Brousse Hospital, Villejuif, France
| | | | | | | | - Pietro Majno
- University Hospital of Geneva, Geneva, Switzerland.,Ospedale Regionale di Lugano, Lugano, Switzerland
| | | | | | | | | | | | | | | | | | - Timothy Pawlik
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lucio Urbani
- Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Daniela Zugna
- Department of Medical Sciences, Cancer Epidemiology Unit, University of Torino and CPO-Piemonte, Torino, Italy
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18
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Ellis RJ, Brajcich BC, Ko CY, Cohen ME, Bilimoria KY, Yopp AC, D’Angelica MI, Merkow RP. Hospital variation in use of prophylactic drains following hepatectomy. HPB (Oxford) 2020; 22:1471-1479. [PMID: 32173175 PMCID: PMC8385641 DOI: 10.1016/j.hpb.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use. METHODS Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed. RESULTS Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level. CONCLUSION Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.
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Affiliation(s)
- Ryan J. Ellis
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian C. Brajcich
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, IL,Department of Surgery, University of Chicago Medicine, Chicago, IL,Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | | | - Karl Y. Bilimoria
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Adam C. Yopp
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael I. D’Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ryan P. Merkow
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Camerlo A, Magallon C, Vanbrugghe C, Chiche L, Gaudon C, Rinaldi Y, Fara R. Robotic hepatic parenchymal transection: a two-surgeon technique using ultrasonic dissection and irrigated bipolar coagulation. J Robot Surg 2020; 15:539-546. [PMID: 32779132 DOI: 10.1007/s11701-020-01138-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023]
Abstract
Liver transection is the most challenging part of hepatectomy due to the risk of hemorrhage which is associated with postoperative morbidity and mortality and reduced long-term survival. Parenchymal ultrasonic dissection (UD) with bipolar coagulation (BPC) has been widely recognized as a safe, effective, and standard technique during open and laparoscopic hepatectomy. We here introduce our technique of robotic liver transection using UD with BPC and report on short-term perioperative outcomes. From a single-institution prospective liver surgery database, we identified patients who underwent robotic liver resection. Demographic, anesthetic, perioperative, and oncologic data were analyzed. Fifty patients underwent robotic liver resection using UD and BPC for liver malignancies (n = 42) and benign lesions (n = 8). The median age of the patients was 67 years and 28 were male. According to the difficulty scoring system, 60% (n = 30) of liver resection were considered difficult. Three cases (6%) were converted to open surgery. The median operative time was 240 min, and the median estimated blood loss was 200 ml; 2 patients required operative transfusions. The overall complication rate was 38% (grade I, 29; grade II, 15; grade III, 3; grade IV, 1). Seven patients (14%) experienced biliary leakage. The median length of hospital stay post-surgery was 7 (range 3-20) days. The R0 resection rate was 92%. Robotic parenchymal transection using UD and irrigated BPC appears a simple, safe, and effective technique. However, our results must be confirmed in larger series or in randomized controlled trials.
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Affiliation(s)
- Antoine Camerlo
- Department of Digestive Surgery Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France.
| | - Cloé Magallon
- Department of Digestive Surgery Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France
| | - Charles Vanbrugghe
- Department of Digestive Surgery Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France
| | - Laurent Chiche
- Department of Clinical Research Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France
| | - Chloé Gaudon
- Department of Radiology Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France
| | - Yves Rinaldi
- Department of Digestive Surgery Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France
| | - Régis Fara
- Department of Digestive Surgery Hôpital Européen, 6 rue désirée Clary, 13003, Marseille, France
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20
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Donadon M, Lanza E, Branciforte B, Muglia R, Lisi C, Pedicini V, Poretti D, Famularo S, Balzarini L, Torzilli G. Hepatic uptake index in the hepatobiliary phase of gadolinium ethoxybenzyl diethylenetriamine penta acetic acid-enhanced magnetic resonance imaging estimates functional liver reserve and predicts post-hepatectomy liver failure. Surgery 2020; 168:419-425. [PMID: 32600880 DOI: 10.1016/j.surg.2020.04.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent evidence suggests that gadolinium ethoxybenzyl diethylenetriamine penta acetic acid-enhanced (Gd-EOB-DTPA) magnetic resonance imaging may be used to evaluate liver function. The aim of this study was to assess whether the signal intensity of Gd-EOB-DTPA magnetic resonance imaging may be used to predict functional liver reserve and posthepatectomy liver failure in patients undergoing hepatectomy for liver tumors. METHODS This is an observational retrospective study on 137 preoperative Gd-EOB-DTPA magnetic resonance imaging of patients undergoing hepatectomy between 2015 and 2018. Mean signal intensity of liver (L20) and spleen (S20) were measured on T1-weighted single-breath-hold 3-dimensional fat-saturated gradient echo sequences acquired 20 minutes after Gd-EOB-DTPA administration. The hepatocellular uptake index of liver volume (VL) was calculated with the formula VL([L20/S20] - 1) and was tested with several score systems for liver diseases and to the occurrence of post-hepatectomy liver failure. RESULTS Patients with diseased liver had significantly lower values of hepatic uptake index in comparison with those with normal function. This was found for a Model for End-Stage Liver Disease score ≤9 versus >9 (P = .04), combination of bilirubin and cholinesterases levels score ≤2 versus >2 (P = .02), albumin to bilirubin grades (P = .03), and Humanitas score ≤6 versus >6 (P = .03). Twenty-two patients (16%) developed posthepatectomy liver failure, and 2 (1.4%) died within 90 days. The hepatocellular uptake index was significantly lower in those patients with posthepatectomy liver failure (P < .01). Receiver operating characteristics curve analysis revealed valuable hepatocellular uptake index ability in predicting post-hepatectomy liver failure (area under the curve = 0.84; 95% confidence interval, 0.71-0.92; P < .01), with a cutoff value of 574.33 (98% sensitivity; 83% specificity). CONCLUSION The hepatocellular uptake index hepatocellular uptake index measured on preoperative Gd-EOB-DTPA magnetic resonance imaging identifies patients with diseased liver and predicts posthepatectomy liver failure. This index could be used to discern those patients at higher risk of complications after hepatectomy.
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Affiliation(s)
- Matteo Donadon
- Department of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ezio Lanza
- Department of Radiology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Bruno Branciforte
- Department of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Riccardo Muglia
- Department of Radiology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Costanza Lisi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Vittorio Pedicini
- Department of Radiology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Dario Poretti
- Department of Radiology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Simone Famularo
- Department of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Luca Balzarini
- Department of Radiology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
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Yamamoto M, Kobayashi T, Kuroda S, Hamaoka M, Honmyo N, Yamaguchi M, Takei D, Ohdan H. Impact of postoperative bile leakage on long‐term outcome in patients following liver resection for hepatocellular carcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:931-941. [DOI: 10.1002/jhbp.750] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Masateru Yamamoto
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Michinori Hamaoka
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Naruhiko Honmyo
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Megumi Yamaguchi
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Daisuke Takei
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan
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Minor Hepatectomies: Focusing a Blurred Picture: Analysis of the Outcome of 4471 Open Resections in Patients Without Cirrhosis. Ann Surg 2020; 270:842-851. [PMID: 31569127 DOI: 10.1097/sla.0000000000003493] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To elucidate minor hepatectomy (MiH) outcomes. SUMMARY BACKGROUND DATA Liver surgery has moved toward a parenchyma-sparing approach, favoring MiHs over major resections. MiHs encompass a wide range of procedures. METHODS We retrospectively evaluated consecutive patients who underwent open liver resections in 17 high-volume centers. EXCLUSION CRITERIA cirrhosis and associated digestive/biliary resections. Resections were classified as (Brisbane nomenclature): limited resections (LR); (mono)segmentectomies/bisegmentectomies (Segm/Bisegm); right anterior and right posterior sectionectomies (RightAnteriorSect/RightPosteriorSect). Additionally, we defined: complex LRs (ComplexLR = LRs with exposed vessels); postero-superior segmentectomies (PosteroSuperiorSegm = segment (Sg)7, Sg8, and Sg7+Sg8 segmentectomies); and complex core hepatectomies (ComplexCoreHeps = Sg1 segmentectomies and combined resections of Sg4s+Sg8+Sg1). Left lateral sectionectomies (LLSs, n = 442) and right hepatectomies (RHs, n = 1042) were reference standards. Outcomes were adjusted for potential confounders. RESULTS Four thousand four hundred seventy-one MiHs were analyzed. Compared with RHs, MiHs had lower 90-day mortality (0.5%/2.2%), severe morbidity (8.6%/14.4%), and liver failure rates (2.4%/11.6%, P < 0.001), but similar bile leak rates. LR and LLS had similar outcomes. ComplexLR and Segm/Bisegm of anterolateral segments had higher bile leak rates than LLS rates (OR = 2.35 and OR = 3.24), but similar severe morbidity rates. ComplexCoreHeps had higher bile leak rates than RH rates (OR = 1.94); the severe morbidity rate approached that of RH. PosteroSuperiorSegm, RightAnteriorSect, and RightPosteriorSect had severe morbidity and bile leak rates similar to RH rates. MiHs had low liver failure rates, except RightAnteriorSect (vs LLS OR = 4.02). CONCLUSIONS MiHs had heterogeneous outcomes. Mortality was low, but MiHs could be stratified according to severe morbidity, bile leak, and liver failure rates. Some MiHs had postoperative outcomes similar to RH.
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23
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Maulat C, Regimbeau JM, Buc E, Boleslawski E, Belghiti J, Hardwigsen J, Vibert E, Delpero JR, Tournay E, Arnaud C, Suc B, Pessaux P, Muscari F. Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial. Br J Surg 2020; 107:824-831. [DOI: 10.1002/bjs.11405] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/22/2019] [Accepted: 09/27/2019] [Indexed: 01/15/2023]
Abstract
Abstract
Background
Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.
Methods
This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.
Results
A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.
Conclusion
This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- C Maulat
- Department of Digestive Surgery and Liver Transplantation, Toulouse University Hospital, Toulouse, France
| | - J-M Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France
- Simplifications des Soins Patients Chirurgicaux Complexes (SSPC), Unit of Clinical Research, University of Picardie Jules Verne, Amiens, France
| | - E Buc
- Department of Digestive Surgery and Liver Transplantation, Hôtel Dieu, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - E Boleslawski
- Department of Digestive Surgery and Liver Transplantation, Claude Huriez Hospital, Lille, France
| | - J Belghiti
- Department of Digestive Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - J Hardwigsen
- Department of Digestive Surgery, La Conception University Hospital, Marseille, France
| | - E Vibert
- Department of Digestive Surgery and Liver Transplantation, Centre Hépato-Biliaire, Paul Brousse Hospital, Villejuif, France
| | - J-R Delpero
- Department of Digestive Surgery, Paoli Calmettes Institute, Marseille, France
| | - E Tournay
- Department of Epidemiology and Clinical Research, Toulouse University Hospital, Toulouse, France
| | - C Arnaud
- Department of Epidemiology and Clinical Research, Toulouse University Hospital, Toulouse, France
| | - B Suc
- Department of Digestive Surgery and Liver Transplantation, Toulouse University Hospital, Toulouse, France
| | - P Pessaux
- Department of Digestive Surgery, Strasbourg University Hospital, IRCAD, Strasbourg, France
| | - F Muscari
- Department of Digestive Surgery and Liver Transplantation, Toulouse University Hospital, Toulouse, France
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Kannappan O, Keditsu K, Bhagat M, Shrimal A, Polnaya A, Kulkarni S, Qureshi SS. Portal Vein Embolization for Future Liver Remnant Enhancement and Combined Modality Treatment for the Management of Post-hepatic Resection Biliary Fistula in an 18-Month Old Child With Hepatoblastoma. Front Surg 2019; 6:54. [PMID: 31608285 PMCID: PMC6758928 DOI: 10.3389/fsurg.2019.00054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/30/2019] [Indexed: 12/22/2022] Open
Abstract
Hepatic resection is the mainstay of treatment for hepatoblastoma. However, the presence of adequate future liver remnant (FLR) is essential to prevent postoperative liver failure. Portal vein embolization (PVE) is commonly utilized in adults for promoting hypertrophy of FLR, however, it is sparingly used in children. Secondly, bile leak after liver resections is a well-defined complication. Apart from conservative treatment such as drainage and antibiotic, several management strategies including endoscopic, percutaneous, and surgical approaches have been described for its management. We present an 18-month old child with hepatoblastoma for whom PVE was performed to enhance the FLR so that an extended right hepatectomy could be accomplished. The same patient endured delayed postoperative biliary leak wherein the conservative, and non-operative interventional procedure failed, however, surgery combined with intraoperative interventional radiology procedure was utilized with a favorable outcome.
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Affiliation(s)
- Odaiyappan Kannappan
- Division of Pediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Keduovinuo Keditsu
- Division of Pediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Monica Bhagat
- Division of Pediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Anurag Shrimal
- Division of Pediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Ashwin Polnaya
- Department of Interventional Radiology, Tata Memorial Centre, Mumbai, India
| | - Suyash Kulkarni
- Department of Interventional Radiology, Tata Memorial Centre, Mumbai, India
| | - Sajid S Qureshi
- Division of Pediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
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López de la Torre Molina B, Caso Maestro O, García Conde Delgado M, Manrique Municio A, Loinaz Segurola C. Fistulo-jejunostomy as an alternative treatment in the repair of a complex biliary leak. Cir Esp 2019; 98:166-168. [PMID: 31500847 DOI: 10.1016/j.ciresp.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/02/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Oscar Caso Maestro
- Unidad Hepatobiliar y Trasplante, Hospital Universitario 12 de Octubre, Madrid, España
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Costa G, Donadon M, Torzilli G. Post-hepatectomy biliary fistula: from risk factors to the role of drain placement and management-still a lot to be answered. Hepatobiliary Surg Nutr 2019; 8:417-418. [PMID: 31489319 DOI: 10.21037/hbsn.2019.06.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Guido Costa
- Department of Hepatobiliary and General Surgery, Humanitas University & Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Matteo Donadon
- Department of Hepatobiliary and General Surgery, Humanitas University & Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas University & Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
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Donadon M, Fontana A, Procopio F, Del Fabbro D, Cimino M, Viganò L, Palmisano A, Torzilli G. Dissecting the multinodular hepatocellular carcinoma subset: is there a survival benefit after hepatectomy? Updates Surg 2019; 71:57-66. [DOI: 10.1007/s13304-019-00626-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/22/2019] [Indexed: 02/07/2023]
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Braunwarth E, Primavesi F, Göbel G, Cardini B, Oberhuber R, Margreiter C, Maglione M, Schneeberger S, Öfner D, Stättner S. Is bile leakage after hepatic resection associated with impaired long-term survival? Eur J Surg Oncol 2019; 45:1077-1083. [PMID: 30803908 DOI: 10.1016/j.ejso.2019.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/31/2019] [Accepted: 02/17/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Bile leakage (BL) is a frequent and severe complication following liver surgery. The aim of this study was to evaluate risk factors for BL, related other complications and association with long-term survival. METHODS This study included all patients undergoing hepatectomy in a single centre from 2005 to 2016. Perioperative risk factors related to BL were identified using univariable and multivariable analysis. Kaplan-Meier method was used for survival analysis. RESULTS BL occurred in 48 of 458 patients (11%). BLs were more frequent in patients after major hepatectomy (p = 0.001). Portal vein embolization, bilioenteric-anastomosis, lymphadenectomy, vascular reconstruction and operative time were significant factors for developing BL. Comparing patients with or without BL, BL was more commonly associated with other postoperative complications (p = 0.001), especially acute kidney failure and surgical-site-infections. There was no difference in 90-day-mortality (p = 0.124). The median disease-free survival was comparable (17 vs. 15 months, p = 0.976), also no difference was observed when stratifying for different tumour entities. There was no difference in median overall survival (OS) among malignant disease (35 vs. 47 months, p = 0.200) and in 3-year OS (46% vs. 59%). Multivariate analysis confirmed that postoperative liver failure and major hepatectomy were risk factors for reduced OS (p = 0.010). CONCLUSIONS Many concerns have been raised regarding tumour progression after major complications. In this study, we only found a relevant influence of BL on OS in pCC, whereas no association was seen in other cancer types, indicating that tumour progression might be triggered by BL in cancer types arising from the bile ducts itself.
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Affiliation(s)
- Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Göbel
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.
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30
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Donadon M, Terrone A, Procopio F, Cimino M, Palmisano A, Viganò L, Del Fabbro D, Di Tommaso L, Torzilli G. Is R1 vascular hepatectomy for hepatocellular carcinoma oncologically adequate? Analysis of 327 consecutive patients. Surgery 2019; 165:897-904. [PMID: 30691871 DOI: 10.1016/j.surg.2018.12.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/23/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND R1 vascular resection for liver tumors was introduced in the early twenty-first century. However, its oncologic adequacy remains controversial. The aim of this study was to determine the oncologic adequacy of R1 vascular hepatectomy in hepatocellular carcinoma patients. METHODS A prospective cohort of patients with hepatocellular carcinoma resected between the years 2005 and 2015 was reviewed. R0 was any resection with a minimum 1 mm of negative margin. R1 vascular was any resection with tumor exposure attributable to the detachment from major intrahepatic vessel. R1 parenchymal was any resection with tumor exposure at parenchymal margin. The end points were the calculation of the local recurrence of R0, R1 parenchymal, and R1 vascular hepatectomy and their prognostic significances. RESULTS We analyzed 327 consecutive patients with 532 hepatocellular carcinoma and 448 resection areas. We found that 205 (63%) resulted R0, 56 (17%) resulted R1 parenchymal, 50 (15%) resulted R1 vascular, and 16 (5%) resulted both R1 parenchymal and R1 vascular. After a median follow-up of 33.5 months (range 6.1-107.6), the 5-year overall survival rates were 54%, 30%, 65%, and 36%, respectively for R0, R1 parenchymal, R1 vascular, and R1 parenchymal + R1 vascular (P = .031). Local recurrence rates were 3%, 14%, 4%, and 19%, respectively for R0, R1 parenchymal, R1 vascular, and R1 parenchymal + R1 vascular (P = .001) per patient, and 4%, 4%, 12%, and 18%, respectively for R0, R1 vascular, R1 parenchymal, and R1 parenchymal + R1 vascular (P = .001) per resection area. At multivariate analysis R1 parenchymal and R1 vascular + R1 parenchymal were independent detrimental factors. CONCLUSION R1 vascular hepatectomy for hepatocellular carcinoma is not associated with increased local recurrence or decreased survival. Thus, detachment of hepatocellular carcinoma from intrahepatic vessels should be considered oncologically adequate.
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Affiliation(s)
- Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy; Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Alfonso Terrone
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Angela Palmisano
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy; Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Daniele Del Fabbro
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Luca Di Tommaso
- Humanitas University and Research Hospital, Rozzano, Milan, Italy; Department of Pathology, Humanitas University and Research Hospital, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University and Research Hospital, Rozzano, Milan, Italy; Humanitas University and Research Hospital, Rozzano, Milan, Italy.
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Kato H, Usui M, Nakatsuka A, Hayasaki A, Ito T, Iizawa Y, Murata Y, Tanemura A, Kuriyama N, Azumi Y, Kishiwada M, Mizuno S, Sakurai H, Isaji S. Isolated Biliary Fistula After Donor Right Hepatectomy and Its Novel Interventional Treatment: Isolated Liver-Punctured Drainage. Transplant Proc 2018; 50:2885-2888. [PMID: 30401417 DOI: 10.1016/j.transproceed.2018.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/06/2018] [Indexed: 11/27/2022]
Abstract
Isolated biliary leakage is difficult to manage, and afflicted patients often develop refractory fistula. The present case was a 43-year-old male donor whose wife developed acute fulminant liver failure. Computed tomography (CT) volumetry showed that the estimated remnant liver volume was only 394 mL (31%) if his right lobe would be harvested. Since remnant liver volume was marginal, our proposed cut line for the right hepatectomy was set in order to preserve branches of the middle hepatic vein draining segments 4b+8 and 5. Right hepatectomy was performed, but on postoperative day 14, the donor developed fever and right back pain, and enhanced CT showed a 6 cm intra-abdominal abscess at the site of cutting, and we diagnosed it as an isolated biliary fistula since the isolated segment 5/8 was receiving arterial blood supply and exhibiting regrowth. A transabdominal abscess drainage was performed, after which the patient lost 30 to 50 mL of bile juice per day in drainage until 2 months after the drainage procedure. Ethanol injection, acetic acid injection, and transarterial or portal embolization for the isolated liver were proposed, but these all were impossible to carry out because there were no accessible routes. Thus, re-abscess drainage with a 7-French drainage catheter was performed through the isolated liver on postoperative day 53, and the isolated functional liver was punctured to induce liver atrophy. After this drainage, the isolated liver started to shrink and bile output had been stopped. In conclusion, our punctured-liver drainage could be effective for the treatment of isolated biliary fistula, allowing physicians to avoid an invasive additional liver resection or other invasive percutaneous approach using chemical reagents.
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Affiliation(s)
- H Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan.
| | - M Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - A Nakatsuka
- Department of Radiology, Mie University School of Medicine, Mie, Japan
| | - A Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - T Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Y Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Y Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - A Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - N Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Y Azumi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - M Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - S Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - H Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - S Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
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Viganò L, Procopio F, Mimmo A, Donadon M, Terrone A, Cimino M, Fabbro DD, Torzilli G. Oncologic superiority of anatomic resection of hepatocellular carcinoma by ultrasound-guided compression of the portal tributaries compared with nonanatomic resection: An analysis of patients matched for tumor characteristics and liver function. Surgery 2018; 164:1006-1013. [PMID: 30195402 DOI: 10.1016/j.surg.2018.06.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 06/07/2018] [Accepted: 06/12/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The superiority of anatomic resection compared with nonanatomic resection for hepatocellular carcinoma remains a matter of debate. Further, the technique for anatomic resection (dye injection) is difficult to reproduce. Anatomic resection using a compression technique is an easy and reversible procedure based on liver discoloration after ultrasound-guided compression of the tumor-feeding portal tributaries. We compared the oncologic efficacy of compression technique anatomic resection with that of nonanatomic resection. METHODS Among patients with resected hepatocellular carcinoma, patients who underwent compression technique anatomic resection were matched 1-to-2 with nonanatomic resection cases based on the Child-Pugh class, Model for End-Stage Liver Disease score, cirrhosis, hepatocellular carcinoma number (1/>1), and hepatocellular carcinoma size (>30, 30-50, and >50 mm). The exclusion criteria were nonanatomic resection because of severe cirrhosis, major hepatectomy, 90-day mortality (0 compression technique anatomic resection), non-cancer-related death, and follow-up <12 months. A total of 47 patients who underwent compression technique anatomic resection were matched with 94 nonanatomic resection cases. RESULTS All patients were Child-Pugh A, and 53% were cirrhotic. Liver function tests and signs of portal hypertension were similar between the groups. There was 1 hepatocellular carcinoma in 81% of the patients, and the hepatocellular carcinoma was ≥30 mm in 68%. Patients undergoing anatomic resection with compression had better 5-year survival (77% vs 60%; risk ratio = 0.423; P = .032; multivariable analysis), less local recurrences (4% vs 20%; P = .012), and better 2-year local recurrence-free survival (94% vs 78%; P = .012). Nonlocal recurrence-free survival was similar between the groups. The compression technique anatomic resection group more often had repeat radical treatment for recurrence (68% vs 28%; P = .0004) and had better 3-year survival after recurrence (65% vs 42%; P = .043). CONCLUSION Compression technique anatomic resection appears to provide a more complete removal of the hepatocellular carcinoma-bearing portal territory. Local disease control and survival are better with compression technique anatomic resection than with nonanatomic resection.
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Affiliation(s)
- Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Antonio Mimmo
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Alfonso Terrone
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Daniele Del Fabbro
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Reseach Hospital, Humanitas University, Rozzano, Milan, Italy.
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Huynh F, Junnarkar SP, Huey TCW, Punamiya SJ, Woon WWL. Spontaneous hepaticoduodenal fistula following extended right hemihepatectomy. ANZ J Surg 2018; 89:1659-1661. [PMID: 30203433 DOI: 10.1111/ans.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 07/01/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Frederick Huynh
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sameer P Junnarkar
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Terence C W Huey
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sundeep J Punamiya
- Vascular and Interventional Radiology, Department of Radiology, Tan Tock Seng Hospital, Singapore
| | - Winston W L Woon
- Hepato-Pancreato-Biliary Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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34
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Donadon M, Mimmo A, Cosola D, Terrone A, Procopio F, Del Fabbro D, Cimino M, Viganò L, Torzilli G. Hepatectomy with or without the thoraco-abdominal approach: impact on perioperative outcome. HPB (Oxford) 2018; 20:752-758. [PMID: 29615370 DOI: 10.1016/j.hpb.2018.02.639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/26/2018] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatectomy using the thoraco-abdominal approach (TAA) compared to the abdominal approach (AA) remains under debate. This study assessed the perioperative outcomes of patients operated with or without TAA. METHODS 1:1 propensity score-matched analysis was applied in 744 patients operated between 2007 and 2013, identifying 246 patients who underwent hepatectomy with TAA compared to 246 patients with AA. These groups were matched for demographics, liver disease, comorbidity, tumor features, and extent of resection. Rates of morbidity and mortality were the study endpoints. RESULTS The rates of morbidity or mortality were not different. With the TAA length of the operations (P = 0.002), length of the Pringle maneuver (P = 0.012), and rate of blood transfusions (P = 0.041) were significantly different. Hospital stay was similar. Independent significant prognostic factors for adverse perioperative outcome were: renal comorbidity (OR = 2.7; P = 0.001), extent of the resection (OR = 3.7; P = 0.001), and increased BILCHE score (OR = 2.4; P = 0.002). CONCLUSIONS Hepatectomy using the TAA was not associated with adverse perioperative outcome. The associations with length of operation, Pringle maneuver and blood transfusions may have reflected the complexity of the tumor presentation rather than the technical approach.
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Affiliation(s)
- Matteo Donadon
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.
| | - Antonio Mimmo
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Davide Cosola
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Alfonso Terrone
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Fabio Procopio
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Daniele Del Fabbro
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Matteo Cimino
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Luca Viganò
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
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35
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Khaoudy I, Rebibo L, Regimbeau JM. Is bariatric surgery a potential new treatment for large inflammatory hepatocellular adenomas in obese patients? Surg Obes Relat Dis 2018; 14:535-538. [DOI: 10.1016/j.soard.2018.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 01/02/2018] [Accepted: 01/05/2018] [Indexed: 02/06/2023]
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36
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Mohkam K, Farges O, Vibert E, Soubrane O, Adam R, Pruvot FR, Regimbeau JM, Adham M, Boleslawski E, Mabrut JY, Ducerf C, Pradat P, Darnis B, Cazauran JB, Lesurtel M, Dokmak S, Aussilhou B, Dondero F, Allard MA, Ciacio O, Pittau G, Cherqui D, Castaing D, Sa Cunha A, Truant S, Hardwigsen J, Le Treut YP, Grégoire E, Scatton O, Brustia R, Sepulveda A, Cosse C, Laurent C, Adam JP, El Bechwaty M, Perinel J. Risk score to predict biliary leakage after elective liver resection. Br J Surg 2017; 105:128-139. [DOI: 10.1002/bjs.10647] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 05/29/2017] [Accepted: 06/11/2017] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL.
Methods
In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated.
Results
A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P < 0·001; 15 versus 3·1 per cent in the validation cohort, P < 0·001).
Conclusion
The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.
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Affiliation(s)
- K Mohkam
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Ecole Doctorale Interdisciplinaire Sciences Santé 205 – Equipe Mixte de Recherche 3738, Université Lyon 1, Lyon, France
| | - O Farges
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France
| | - E Vibert
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Paul Brousse, Villejuif, France
| | - O Soubrane
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France
| | - R Adam
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Paul Brousse, Villejuif, France
| | - F-R Pruvot
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Claude Huriez, Lille, France
| | - J-M Regimbeau
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - M Adham
- Department of Hepatopancreatobiliary Surgery, Hôpital Edouard Herriot, Lyon, France
| | - E Boleslawski
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Claude Huriez, Lille, France
| | - J-Y Mabrut
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Ecole Doctorale Interdisciplinaire Sciences Santé 205 – Equipe Mixte de Recherche 3738, Université Lyon 1, Lyon, France
| | - C Ducerf
- Hôpital de la Croix-Rousse, Lyon, France
| | - P Pradat
- Hôpital de la Croix-Rousse, Lyon, France
| | - B Darnis
- Hôpital de la Croix-Rousse, Lyon, France
| | | | - M Lesurtel
- Hôpital de la Croix-Rousse, Lyon, France
| | | | | | | | | | - O Ciacio
- Hôpital Paul Brousse, Villejuif, France
| | - G Pittau
- Hôpital Paul Brousse, Villejuif, France
| | - D Cherqui
- Hôpital Paul Brousse, Villejuif, France
| | | | | | - S Truant
- Hôpital Claude Huriez, Lille, France
| | | | | | | | - O Scatton
- Hôpital de la Pitié-Salpétrière, Paris, France
| | - R Brustia
- Hôpital de la Pitié-Salpétrière, Paris, France
| | - A Sepulveda
- Hôpital de la Pitié-Salpétrière, Paris, France
| | - C Cosse
- Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - C Laurent
- Hôpital Haut-Lévêque, Bordeaux, France
| | - J-P Adam
- Hôpital Haut-Lévêque, Bordeaux, France
| | | | - J Perinel
- Hôpital Edouard Herriot, Lyon, France
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Donadon M, Fontana A, Palmisano A, Viganò L, Procopio F, Cimino M, Del Fabbro D, Torzilli G. Individualized risk estimation for postoperative morbidity after hepatectomy: the Humanitas score. HPB (Oxford) 2017; 19:910-918. [PMID: 28743491 DOI: 10.1016/j.hpb.2017.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/01/2017] [Accepted: 06/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Estimation of postoperative morbidity after hepatectomy remains challenging. The aim of this prospective study was to develop a surgical score to predict an individual risk of post-hepatectomy complications. METHODS All consecutive patients scheduled for hepatectomy from February 2012 to September 2015 were included and randomly assigned into a derivation or validation cohort. We developed a score based on preoperative variables, and we tested them using multivariate analyses. Odds-ratio (OR) values were used to build the score. RESULTS 340 patients were included, 240 in the derivation and 100 in the validation cohort. Multivariate analysis showed that major hepatectomy (OR = 1.62; 95% CI 1.39-3.51), liver stiffness ≥9.7 kPa (OR = 2.46; 95% CI 1.16-5.28), BILCHE score (combination of serum bilirubin and cholinesterase) ≥2 (OR = 2.76; 95% CI 0.82-4.28) and esophageal varices (OR = 1.59; 95% CI 1.51-3.61) were independent complications predictors. A 10-point scoring system was introduced. Patients with a score ≤4 did not experience complications, whereas patients with ≥7 points experienced up to 54% of complications (P < 0.001). CONCLUSIONS A new, easy and clinically reliable surgical score based on the liver stiffness, BILCHE score, type of hepatectomy, and presence of varices may be used to predict post-hepatectomy morbidity. CLINICAL TRIAL NUMBER NCT02454686 (https://www.clinicaltrials.gov/).
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Affiliation(s)
- Matteo Donadon
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Andrea Fontana
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Angela Palmisano
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Luca Viganò
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Fabio Procopio
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Matteo Cimino
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Daniele Del Fabbro
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy
| | - Guido Torzilli
- Department of Hepatobiliary and General Surgery, Humanitas University, Humanitas Research Hospital IRCCS, Via Manzoni 56, 20089, Milan, Rozzano, Italy.
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38
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Torzilli G, Viganò L, Gatti A, Costa G, Cimino M, Procopio F, Donadon M, Del Fabbro D. Twelve-year experience of "radical but conservative" liver surgery for colorectal metastases: impact on surgical practice and oncologic efficacy. HPB (Oxford) 2017. [PMID: 28625391 DOI: 10.1016/j.hpb.2017.05.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver surgery for colorectal metastases (CLM) is moving toward parenchyma-sparing approaches. The authors reported the technical feasibility of parenchyma-sparing hepatectomy for deeply located tumors, but its impact on daily practice and long-term outcomes remain unclear. METHODS The patients undergoing liver resection (LR) for CLM with vascular contact (first-/second-order pedicle or hepatic vein (HV) trunk) were considered. Those undergoing major hepatectomy were excluded. The authors' technique included tumor-vessel detachment, partial resection of marginally infiltrated HVs, and detection of communicating vessels (CVs) among HVs to preserve outflow after HV resection. RESULTS Among 169 patients with major vascular contact, parenchyma-sparing LR was feasible in 146 (86%). Twenty-eight SERPS, 13 transversal hepatectomies, 6 mini-mesohepatectomies, and 4 liver tunnels were performed. Sixty-six (45%) patients underwent CLM-vessel detachment, 25 (17%) underwent partial HV resection, and 30 (21%) achieved outflow preservation by CV identification. The mortality and severe morbidity rates were 1.4% and 8.2%, respectively. The 5-year survival rate was 30.7%. The parenchyma-sparing strategy failed in 14 (7%) patients because of recurrence in the spared parenchyma or cut edge; 13 were radically retreated. CONCLUSION Ultrasound-guided parenchyma-sparing surgery is feasible in most patients with ill-located CLMs. This procedure is safe and achieves adequate oncologic outcomes.
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Affiliation(s)
- Guido Torzilli
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.
| | - Luca Viganò
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Andrea Gatti
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Guido Costa
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Matteo Cimino
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Fabio Procopio
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Matteo Donadon
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Daniele Del Fabbro
- Department of Surgery - Division of Hepatobiliary & General Surgery, Humanitas University, School of Medicine, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
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Techniques of parenchyma-sparing hepatectomy for the treatment of tumors involving the hepatocaval confluence: A reliable way to assure an adequate future liver remnant volume. Surgery 2017; 162:483-499. [DOI: 10.1016/j.surg.2017.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 02/15/2017] [Accepted: 02/15/2017] [Indexed: 01/19/2023]
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Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge. Dig Liver Dis 2017; 49:893-897. [PMID: 28457903 DOI: 10.1016/j.dld.2017.03.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bile leakage is a common complication after hepatic resection [1-4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5-9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). METHODS Considering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. RESULTS We performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8-42 months). CONCLUSIONS The described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.
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Operative Site Drainage after Hepatectomy: A Propensity Score Matched Analysis Using the American College of Surgeons NSQIP Targeted Hepatectomy Database. J Am Coll Surg 2016; 223:774-783.e2. [PMID: 27793459 DOI: 10.1016/j.jamcollsurg.2016.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/07/2016] [Accepted: 09/07/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Operative site drainage (OSD) after elective hepatectomy remains widely used despite data suggesting limited benefit. Multi-institutional, quality-driven databases and analytic techniques offer a unique source from which the utility of OSD can be assessed. STUDY DESIGN Elective hepatectomies from the 2014 American College of Surgeons (ACS) NSQIP Targeted Hepatectomy Database were propensity score matched on the use of OSD using preoperative and intraoperative variables. The influence of OSD on the diagnosis of postoperative bile leaks, rates of subsequent intervention, and other outcomes within 30 days were assessed using paired testing. RESULTS Operative site drainage was used in 42.2% of 2,583 eligible hepatectomies. There were 1,868 cases matched, with 7.2% experiencing a post-hepatectomy bile leak. The incidence of bile leak initially requiring intervention was no different between the OSD and no OSD groups (n = 32 vs n = 24, p = 0.278), and OSD was associated with a greater number of drainage procedures to manage post-hepatectomy bile leak (n = 27 in the OSD group, n = 13 in the no OSD group, p = 0.034, relative risk [RR] 2.1 [95% CI 1.1 to 4.0]). The OSD group had a greater mean length of stay (+0.8 days, p = 0.004) and more 30-day readmissions (p < 0.001, RR 1.6 [95% CI 1.2 to 2.1]). On multivariate analysis, post-hepatectomy bile leak and receipt of additional drainage procedures were stronger predictors of increased length of stay and readmissions than OSD. CONCLUSIONS In a propensity score matched cohort, OSD did not improve the rate of diagnosis of major bile leaks and was associated with increased interventions, greater length of stay, and more 30-day readmissions. These data suggest that routine OSD after elective hepatectomy may not be helpful in capturing clinically relevant bile leaks and has additional consequences.
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Pharmacological Modulation of Ischemic-Reperfusion Injury during Pringle Maneuver in Hepatic Surgery. A Prospective Randomized Pilot Study. World J Surg 2016; 40:2202-12. [DOI: 10.1007/s00268-016-3506-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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