Second Generation of a Fast-track Liver Resection Programme

Learning curves in robot-assisted minimally invasive liver surgery at a high-volume center in Denmark: Report of the first 100 patients and review of literature

BACKGROUND AND OBJECTIVE

Minimally invasive liver surgery is evolving worldwide, and robot-assisted liver surgery (RLS) can deliver obvious benefits for patients. However, so far no large case series have documented the learning curve for RLS.

METHODS

We conducted a retrospective study for robotic liver surgery (RLS) from June 2019 to June 2022 where 100 patients underwent RLS by the same surgical team. Patients' variables, short-term follow-up, and the learning curve were analyzed. A review of the literature describing the learning curve in RLS was also conducted.

RESULTS

Mean patient age was 63.1 years. The median operating time was 246 min and median estimated blood loss was 100 mL. Thirty-two patients underwent subsegmentectomy, 18 monosegmentectomies, 25 bisegmentectomies, and 25 major hepatectomies. One patient (1.0%) required conversion to open surgery. Five patients (5%) experienced postoperative major complications, and no mortalities occurred. Median length of hospital stay was 3 days. R0 resection was achieved in 93.4% of the malignant cases. The learning curve consisted of three stages; there were no significant differences in operative time, transfusion rate, or complication rate among the three groups. Postoperative complications were similar in each group despite an increase in surgical difficulty scores. The learning effect was highlighted by significantly shorter hospital stays in cohorts I, II, and III, respectively. The included systematic review suggested that the learning curve for RLS is similar to, or shorter, than that of laparoscopic liver surgery.

CONCLUSIONS

In our experience, RLS has achieved good clinical results, albeit in the short term. Standardization of training leads to increasing proficiency in RLS with reduced blood loss and low complication rates even in more advanced liver resections. Our study suggests that a minimum of 30 low-to-moderate difficulty robotic procedures should be performed before proceeding to more difficult resections.

Impact of high-dose glucocorticoid on endothelial damage after liver resection - a double-blinded randomized substudy

OBJECTIVES

Postoperative endothelial damage potentially results in increased vascular leakage, tissue edema and subsequent complications. The preventive effect of glucocorticoids on endothelial damage after surgery is sparsely described, including the relation between endothelial damage and the postoperative inflammatory response. Thus, we aimed to assess the preventive effect of high-dose glucocorticoids on postoperative endothelial damage, and the association between endothelial damage and inflammation after surgery.

METHODS

This was a predefined substudy of a randomized double-blinded clinical trial of methylprednisolone 10 mg/kg (high dose) vs. dexamethasone 8 mg (low dose) in patients undergoing liver resection at Rigshospitalet, Copenhagen. In total 25 patients undergoing major liver resection (11 in the high-dose group and 14 in the low-dose group) were included. The primary outcome was changed in five endothelial biomarkers and the secondary outcome was changes in inflammation [C-reactive protein (CRP)] for the first three postoperative days.

RESULTS

No statistically significant difference was found for any endothelial biomarkers postoperatively between the two groups (P > 0.15, for all). High-dose glucocorticoids significantly reduced CRP on day 3 compared to low-dose glucocorticoids [median difference on a postoperative day 3, 59.6 g/L, (84.2; 27.1), P < 0.002]. No significant correlation between endothelial damage and CRP levels was seen.

CONCLUSIONS

No significant effect of high- vs. low-dose glucocorticoids on development in endothelial biomarkers after major liver resection was observed. High-dose glucocorticoids reduce the inflammatory response though without correlation to endothelial damage. Future studies should assess the clinical impact of increased endothelial biomarkers for clinical perioperative outcomes.

Enhanced recovery after surgery is feasible and safe in liver transplantation: a cohort study

BACKGROUND

The principles of enhanced recovery after surgery (ERAS) are being applied to still more advanced procedures. Liver transplantation offers a unique opportunity for a multimodal approach including donor care as well. Our objective was to determine if ERAS was applicable and safe in orthotopic liver transplantation (OLT).

METHODS

A national single centre retrospective study showing the implementation of ERAS from 2013 to 2019 with the proceeding 2 years serving as baseline. The primary endpoints were mortality, length of stay (LOS) in the ward and intensive care unit stay. Secondary endpoints were complications estimated by Dindo-Clavien classification, comprehensive complication index (CCI®) and re-admissions.

RESULTS

A total of 334 patients were included. LOS was significantly reduced from a median of 22.5 days at introduction to 14 days at 2019. Cold ischaemia time was reduced from a mean of 10.7 to 6.0 h and the use of blood products (erythrocytes, plasma and thrombocytes) from a median of 28 to 6 units. Complications were reduced in severity. Mortality and readmission rates were not affected.

CONCLUSION

ERAS principles are safe and recommended in patients undergoing OLT resulting in reduced severity of complications and LOS without affecting re-admissions or mortality.

Impact of high-dose glucocorticoid on endothelial damage after liver resection - a double-blinded randomized substudy

OBJECTIVES

Postoperative endothelial damage potentially results in increased vascular leakage, tissue edema and subsequent complications. The preventive effect of glucocorticoids on endothelial damage after surgery is sparsely described, including the relation between endothelial damage and the postoperative inflammatory response. Thus, we aimed to assess the preventive effect of high-dose glucocorticoids on postoperative endothelial damage, and the association between endothelial damage and inflammation after surgery.

METHODS

This was a predefined substudy of a randomized double-blinded clinical trial of methylprednisolone 10 mg/kg (high dose) vs. dexamethasone 8 mg (low dose) in patients undergoing liver resection at Rigshospitalet, Copenhagen. In total 25 patients undergoing major liver resection (11 in the high-dose group and 14 in the low-dose group) were included. The primary outcome was changed in five endothelial biomarkers and the secondary outcome was changes in inflammation [C-reactive protein (CRP)] for the first three postoperative days.

RESULTS

No statistically significant difference was found for any endothelial biomarkers postoperatively between the two groups (P > 0.15, for all). High-dose glucocorticoids significantly reduced CRP on day 3 compared to low-dose glucocorticoids [median difference on a postoperative day 3, 59.6 g/L, (84.2; 27.1), P < 0.002]. No significant correlation between endothelial damage and CRP levels was seen.

CONCLUSIONS

No significant effect of high- vs. low-dose glucocorticoids on development in endothelial biomarkers after major liver resection was observed. High-dose glucocorticoids reduce the inflammatory response though without correlation to endothelial damage. Future studies should assess the clinical impact of increased endothelial biomarkers for clinical perioperative outcomes.

High-dose preoperative glucocorticoid for prevention of emergence and postoperative delirium in liver resection: A double-blinded randomized clinical trial substudy

BACKGROUND

Emergence delirium (ED) and postoperative delirium (POD) are associated with increased morbidity and mortality and occur in up to one-third of patients undergoing major non-cardiac surgery, where the underlying pathogenesis is multifactorial, including increased inflammation. We aimed to assess the effect of pre-operative high- versus low-dose glucocorticoid on the occurrence of ED and POD.

METHODS

This was a substudy from a randomized, double-blinded clinical trial. Patients ≥18 years, undergoing open liver resection were randomized 1:1 to high-dose (HD, 10 mg/kg methylprednisolone) or low-dose (LD, 8 mg dexamethasone) glucocorticoid and assessed for ED and POD for a maximum of 4 days during hospitalization. The 3-min Diagnostic Interview for CAM-defined delirium (3D-CAM) was used for assessment, 15 and 90 min after arrival in the post-anesthesia care unit (PACU), and subsequently once daily in the ward.

RESULTS

Fifty-three patients were included in this secondary substudy (26 HD-group and 27 LD-group). ED occurred in n = 5 HD versus n = 6 LD patients 15 min after PACU arrival. At 90 min after PACU arrival, 4 patients had ED, all from LD-group, and resulted in significantly longer PACU admission, 273 versus 178 min in ED versus Non-ED patients. During the first 4 days in the ward, n = 5 patients had at least one occurrence of POD, all from LD-group.

CONCLUSIONS

The primary finding of the current substudy was a lower occurrence of ED/POD in the PACU 90 min after arrival and during the first four postoperative days in patients receiving high-dose glucocorticoid compared with patients receiving low-dose glucocorticoid. The two study groups were not evenly balanced concerning known explanatory factors, i.e., age and size of surgery, which calls for larger studies to elucidate the matter.

Medical disease and ambulatory surgery, new insights in patient selection based on medical disease

PURPOSE OF REVIEW

Improvements in perioperative care contributed to enlarge the eligibility criteria for day case surgery and more and more patients with comorbidities may be concerned. However, underlying medical diseases may influence postoperative outcomes, and therefore, must be considered when selecting patients to undergo ambulatory surgery.

RECENT FINDINGS

To limit postoperative complications, rigid patient selection criteria are often applied in ambulatory surgery. In practice, however, most of these criteria predict the occurrence of treatable perioperative adverse events but not the need for unanticipated admission or readmission.

SUMMARY

The underlying medical diseases should not be considered as sole criteria but they should rather be regarded as a dynamic process, which includes the surgical procedure as well as the experience and expertise of the perioperative setting.

Predictors of discharge timing and unplanned readmission after laparoscopic liver resection

BACKGROUND

The aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR).

METHODS

Consecutive LLR performed at the "Institut Mutualiste Montsouris" between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission.

RESULTS

Early discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75-125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98-12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60-11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12-15.8, p = 0.045).

CONCLUSION

Concomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.

Enhanced Recovery After Surgery in the Patients With Hepatocellular Carcinoma Undergoing Hemihepatectomy

BACKGROUND

This study aims to compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing hemihepatectomy.

METHODS

From January 2017 to June 2019, 54 and 56 patients were enrolled into the control and ERAS group, retrospectively. All the indicators related to operation, liver functions, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) analysis identified 72 patients for further analysis.

RESULTS

The clinicopathological characteristics were well-matched after PSM, and there were no significant differences in the operative duration, blood loss, blood transfusion, hospital costs, and most postoperative indicators in these 2 groups. In the ERAS group, D-dimer and fibrin degradation product values were significantly reduced (3.57 (2.874.60) μg/ml vs 4.81 (3.948.29) μg/ml and 11.90 (10.0418.02) μg/ml vs 15.80 (11.5529.24) μg/ml; P = .002 and P = .023, respectively). The days that semiliquid diet was allowed after surgery (2.00 (2.003.00) days vs 5.00 (4.006.00) days, P < .001), abdominal drainage tube indwelling duration (5.00 (4.005.00) days vs 5.00 (4.756.25) days, P = .004), and hospital stay after surgery (6.00 (6.007.00) days vs 8.00 (7.0010.00) days, P < .001) were also significantly shorter. The proportion of patients requiring analgesic treatment was significantly lower in the postoperative day 2 and day 4 (P < .001 and P = .025, respectively). The morbidity was significantly less (36.11% vs 69.44%, P = .005).

CONCLUSIONS

ERAS programs are feasible and safe in HCC patients undergoing hemihepatectomy. Postoperative anticoagulant therapy may be one of the necessary steps.

Enhanced Recovery After Surgery in Patients With Hepatocellular Carcinoma Undergoing Laparoscopic Hepatectomy

Objective: To compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy.

Methods: From September 2016 to June 2019, 282 patients were enrolled, and ERAS was implemented since March 2018. All indicators related to surgery, liver function, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) identified 174 patients for further comparison.

Results: After PSM, the clinicopathological baselines were well-matched. The group showed significantly less intraoperative blood loss (100.00 [100.00–200.00] vs. 200.00 [100.00–300.00] ml, P = 0.001), fewer days before abdominal drainage tube removal (4.00 [3.00–4.00] days vs. 4.00 [3.00–5.00] days, P = 0.023), shorter hospital stay after surgery (6.00 [5.00–6.00] days vs. 6.00 [6.00–7.00] days, P < 0.001), and reduced postoperative morbidity (18.39 vs. 34.48%, P = 0.026). The proportion of patients with a pain score ≥ 4 was significantly lower in the ERAS group within the first 2 days after surgery (1.15 vs. 13.79% and 8.05 vs. 26.44%, P = 0.002 and P = 0.001, respectively). Pringle maneuver was performed more frequently in the ERAS group (70.11 vs. 18.39%, P < 0.001), and a significantly higher postoperative alanine aminotransferase level was also observed (183.40 [122.85–253.70] vs. 136.20 [82.93–263.40] U/l, P = 0.026). The 2-year recurrence-free survival was similar between the two groups (72 vs. 71%, P = 0.946).

Conclusions: ERAS programs are feasible and safe and do not influence mid-term recurrence in HCC patients undergoing laparoscopic hepatectomy.

Morbidity and mortality after liver surgery for colorectal liver metastases: a cohort study in a high-volume fast-track programme

BACKGROUND

For colorectal liver metastases, surgery is a high-risk procedure due to perioperative morbidity. The objective was to assess severity of complications after fast-track liver surgery for colorectal liver metastases and their impact on morbidity and mortality.

METHODS

All patients were treated according to the same fast-track programme. Complications were graded according to the Clavien-Dindo classification for patients undergoing surgery from 2013 to 2015. Correlation between complications and length of stay was analysed by multivariate linear regression.

RESULTS

564 patient cases were included of which three patients died within 3 months (0.53%, 95% CI: 0.17-1.64%). Complications were common with Grade ≤ 2 in 167 patients (30%) and ≥ Grade 3a in 93 (16%). Patients without complications had a mean length of stay of 4.1 days, which increased with complications: 1.4 days (95% CI: 1.3-1.5) for Grade 2, 1.7 days (1.5-2.0) for Grade 3a, 2.3 days (1.7-3.0) for Grade 3b, 2.6 days (1.6-4.2) for Grade 4a, and 2.9 days (2.8-3.1) for Grade 4b. Following were associated with increased length of stay: complication severity grade, liver insufficiency, ascites, biliary, cardiopulmonary, and infectious complications.

CONCLUSIONS

Complications after liver surgery for colorectal liver metastases, in a fast track setting, were associated with low mortality, and even severe complications only prolonged length of stay to a minor degree.

Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial

BACKGROUND

Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery.

METHODS

This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity.

RESULTS

A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups.

CONCLUSION

A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).

Possible Preventable Causes of Unplanned Readmission After Elective Liver Resection, Results from a Non-academic Referral HPB Center

INTRODUCTION

Unplanned readmission is a common event after liver resection, and it is a burden for both patients and healthcare policy makers. This study evaluates the incidence of and reasons for unplanned readmission after liver resection, in order to identify possible preventable causes.

METHODS

In this single-center cohort study, data from patients who underwent liver resection for both malignant and benign indications from 2001 to 2016 at our institute were collected from a database with prospective data. Readmissions were analyzed for their reasons and risk factors. Patients with general complaints with no specific complications were categorized as failure to thrive.

RESULTS

In 406 patients, the readmission rate was 11.6%. Most patients were readmitted because of failure to thrive (35%), deep and superficial surgical site infection (28%), or cardiopulmonary complications (15%). A multivariate analysis revealed that unplanned readmission was associated with the occurrence of complications during index admission-with an odds ratio of 4.69 (CI 2.41-9.12, p < 0.001).

CONCLUSION

Readmission occurs in more than 1 in 10 patients after liver resection, and it is associated with a complicated course during index admission. One-third of readmissions occur because of failure to thrive and might be preventable. Future research in strategies to reduce readmission rates should focus on both the prevention of complications during index admission and programs at the interface between primary and secondary care.

Impact of the Enhanced Recovery Program after Hepato-Pancreato-Biliary Surgery

Enhanced Recovery after Surgery (ERAS) is a multicentric program that includes the fields of nursing and anesthesia, nutrition and fluid management, and minimally invasive surgery. ERAS protocols focus on reducing the postoperative complications and stress response, optimizing the postoperative recovery. They have been implemented in many surgical fields, such as cardiac, gastric, and urologic, as they were shown to be effective in reducing morbidity and the overall health costs and in improving patient satisfaction. The aim of this minireview was to investigate the impact of ERAS programs on patients' postoperative outcome after hepato-pancreato-biliary surgery.

Analysis of the postoperative hemostatic profile of colorectal cancer patients subjected to liver metastasis resection surgery

BACKGROUND

Liver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas.

AIM

To study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia).

METHODS

A prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed.

RESULTS

A total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge.

CONCLUSION

Epidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.