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Otsubo T, Kobayashi S, Sano K, Misawa T, Katagiri S, Nakayama H, Suzuki S, Watanabe M, Ariizumi S, Unno M, Tanabe M, Nagano H, Kokudo N, Hirano S, Nakamura M, Shirabe K, Suzuki Y, Yoshida M, Takada Y, Nakagohri T, Horiguchi A, Ohdan H, Eguchi S, Ohtsuka M, Sho M, Rikiyama T, Hatano E, Taketomi A, Fujii T, Yamaue H, Miyazaki M, Yamamoto M, Takada T, Endo I. A nationwide certification system to increase the safety of highly advanced hepatobiliary-pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:60-71. [PMID: 35611453 DOI: 10.1002/jhbp.1186] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/04/2022] [Accepted: 04/15/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND To ensure that highly advanced hepatobiliary-pancreatic surgery (HBPS) is performed safely, the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons established a safety committee to monitor surgical safety. METHODS We investigated postoperative mortality rates based on summary reports of numbers and outcomes of highly advanced HBPS submitted annually by the board-certified training institutions from 2012 to 2019. We also analyzed summary reports on mortality cases submitted by institutions with high 90-day post-HBPS mortality rates and recommended site visits and surveys as necessary. RESULTS Highly advanced HBPS was performed in 121 518 patients during the 8-year period. Thirty-day mortality rates from 2012 to 2019 were 0.92%, 0.8%, 0.61%, 0.63%, 0.70%, 0.59%, 0.48%, and 0.52%, respectively (P < .001). Ninety-day mortality rates were 2.1%, 1.82%, 1.62%, 1.28%, 1.46%, 1.22%, 1.19%, and 0.98%, respectively (P < .001). Summary reports were submitted by 20 hospitals between 2015 and 2019. Mortality rates before and after the start of report submission and audit were 5.72% and 2.79%, respectively (odds ratio 0.690, 95% confidence interval 0.487-0.977; P = .037). CONCLUSIONS Development of a system for designation of board-certified expert surgeons and safety management improved the mortality rate associated with highly advanced HBPS.
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Affiliation(s)
- Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shinjiro Kobayashi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takeyuki Misawa
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Satoshi Katagiri
- Department of Surgery, Tokyo Women's Medical University Yachiyo Medical Center, Chiba, Japan
| | - Hisashi Nakayama
- Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shuji Suzuki
- Department of Gastroenterological Surgery, Tokyo Medical University Ibaraki Medical Center, Ibaraki, Japan
| | - Manabu Watanabe
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Shunichi Ariizumi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Minoru Tanabe
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Norihiro Kokudo
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Takamatsu, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yasutsugu Takada
- Department of Hepato-Pancreatic-Biliary and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Japan
| | - Toshio Nakagohri
- Department of Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masaru Miyazaki
- Digestive Diseases Center, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Masakazu Yamamoto
- Department of Gastroenterological Surgery, Utsunomiya Memorial Hospital, Utsunomiya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Dan Y, Meng W, Li W, Chen Z, Lyu Y, Yu T. Transarterial Chemoembolization Combined With Radiofrequency Ablation Versus Hepatectomy for Hepatocellular Carcinoma: A Meta-Analysis. Front Surg 2022; 9:948355. [PMID: 35898584 PMCID: PMC9309475 DOI: 10.3389/fsurg.2022.948355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although many studies reported the effectiveness of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) or surgical resection (SR) in the treatment of hepatocellular carcinoma (HCC), the efficacy of these two strategies remains controversial. Therefore, this meta-analysis aimed to evaluate and compare the efficacy of sequential use of TACE plus RFA (TACE + RFA) and SR alone in treating HCC. Methods Relevant studies with unmatched and propensity score-matched patients were identified by comprehensive search of MEDLINE, PubMed, EMBASE, Web of Science, and Cochrane electronic databases. Meta-analysis was conducted using Review Manager (RevMan) software version 5.4.1. Finally, 12 eligible studies were included in this study, including 11 case–control studies and 1 randomized controlled trial. The primary outcome of interest for this study was to compare the 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS), major complications, 5-year OS in different tumor diameters between the two treatment strategies, and hospital stay time. Results HCC patients who received TACE + RFA had a lower incidence of complication rates and shorter hospital stay time than those who received SR alone. Among these studies using propensity score-matched cohorts, SR had better 3- and 5-year OS than TACE + RFA, whereas there were no significant differences between TACE + RFA and SR regarding the 1-, 3-, and 5-year DFS. When the tumor diameter is longer than 3 cm, the 5-year OS rate is better when SR is selected. Conclusion There was no significant difference in the short-term survival outcomes between TACE + RFA and SR in HCC patients. Moreover, SR is superior to TACE + RFA in terms of long-term beneficial effects but may result in a higher risk of major complications and a longer hospital stay time.
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Affiliation(s)
- Yuan Dan
- Department of Hepatobiliary Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Wenjun Meng
- Department of Gastrointestinal Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
- Department of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenke Li
- Department of Hepatobiliary Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Zhiliang Chen
- Department of Hepatobiliary Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Yongshuang Lyu
- Department of Hepatobiliary Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
| | - Tianwu Yu
- Department of Hepatobiliary Surgery, Yongchuan Hospital, Chongqing Medical University, Chongqing, China
- Correspondence: Tianwu Yu
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Teo ZH, Huey CWT, Low JK, Junnarkar SP, Vishalkumar GS. Impact of COVID-19 pandemic on Hepatobiliary and Pancreatic surgical services in Singapore: Experience Paper. JMIR Perioper Med 2022; 5:e29045. [PMID: 35486909 PMCID: PMC9128730 DOI: 10.2196/29045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 12/29/2021] [Accepted: 04/29/2022] [Indexed: 01/22/2023] Open
Abstract
Background At the height of the COVID-19 pandemic, the hepatopancreatobiliary (HPB) unit had to reorganize its surgical case volume due to the rationing of health care resources. We report on a local audit evaluating the impact of COVID-19 on the HPB unit and the HPB surgical oncology practice. Objective The aim of this study was to review the impact of the COVID-19 pandemic on the HPB unit’s elective and emergency surgical cases. The secondary aims were to investigate the impact on the HPB surgical oncology operative case volume. Methods We performed a comparative audit of the HPB unit surgical case volume for January-June 2019 (baseline) and 2020 (COVID-19). Elective and emergency cases performed under general anesthesia were audited. Elective cases included hernia and gallbladder operations and liver and pancreatic resections. Emergency cases included cholecystectomies and laparotomies performed for general surgical indications. We excluded endoscopies and procedures done under local anesthesia. The retrospective data collected during the 2 time periods were compared. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000040265). Results The elective surgical case volume decreased by 41.8% (351 cases in 2019 compared to 204 cases in 2020) during the COVID-19 pandemic. The number of hernia operations decreased by 63.9% (155 in 2019 compared to 56 in 2020; P<.001) and cholecystectomies decreased by 40.1% (157 in 2019 compared to 94 in 2020; P=.83). The liver and pancreatic resection volume increased by 16.7% (30 cases in 2019 compared to 35 cases in 2020; P=.004) and 111.1% (9 cases in 2019 compared to 19 cases in 2020; P=.001), respectively. The emergency surgical workload decreased by 40.9% (193 cases in 2019 compared to 114 cases in 2020). The most significant reduction in the emergency workload was observed in March (41 to 23 cases, a 43.9% reduction; P=.94), April (35 to 8 cases, a 77.1% reduction; P=.01), and May (32 to 14 cases, a 56.3% reduction; P=.39); however, only April had a statistically significant reduction in workload (P=.01). Conclusions The reallocation of resources due to the COVID-19 pandemic did not adversely impact elective HPB oncology work. With prudent measures in place, essential surgical services can be maintained during a pandemic. Trial Registration Chinese Clinical Trial Registry (ChiCTR2000040265); https://tinyurl.com/ms9kpr6x
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Affiliation(s)
- Zhe Hao Teo
- Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, SG
| | | | - Jee Keem Low
- Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, SG
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Sheriff S, Madhavan S, Lei GY, Chan YH, Junnarkar SP, Huey CW, Low JK, Shelat VG. Predictors of mortality within the first year post-hepatectomy for hepatocellular carcinoma. J Egypt Natl Canc Inst 2022; 34:14. [PMID: 35368234 DOI: 10.1186/s43046-022-00113-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/06/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hepatic resection (HR) for hepatocellular carcinoma (HCC) is safe with good perioperative and long-term oncologic outcomes. There is a paucity of data with regards to intermediate-term outcomes (i.e., beyond 90-day and within 1-year mortality). This paper studies the risk factors for within 1-year mortality after elective HR with curative intent in patients with HCC. METHODS An audit of patients who underwent curative HR for HCC from January 2007 to April 2016 was conducted. Univariate and multivariate analysis were sequentially performed on perioperative variables using Cox-regression analysis to identify factors predicting intermediate-term outcomes defined as within 1-year mortality. Kaplan-Meier survival curves and hazard ratios were obtained. RESULTS Three hundred forty-eight patients underwent HR during the study period and 163 patients had curative hepatectomy for HCC. Fifteen patients (9.2%) died within 1-year after HR. Multivariate analysis identified Child-Pugh class B/C (HR 5.5, p = 0.035), multinodularity (HR 7.1, p = 0.001), macrovascular invasion (HR 4.2, p = 0.04) postoperative acute renal failure (HR 5.8, p = 0.049) and posthepatic liver failure (HR 9.6, p = 0.009) as significant predictors of 1-year mortality. CONCLUSION One-year mortality following HR for HCC remains high and can be predicted preoperatively by multinodularity, Child-Pugh class, and macrovascular invasion. Postoperative acute renal failure and liver failure are associated with 1-year mortality.
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Affiliation(s)
| | | | | | - Yiong Huak Chan
- Biostatistics Unit, National University Health System, Singapore, Singapore
| | - Sameer P Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Cheong Wei Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Hai HH, Aw P, Teng TZJ, Shelat VG. Perioperative steroid administration reduces overall complications in patients undergoing liver resection: A meta-analysis. World J Gastrointest Surg 2021; 13:1079-1094. [PMID: 34621482 PMCID: PMC8462075 DOI: 10.4240/wjgs.v13.i9.1079] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/03/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatic resection (HR) results in an inflammatory response that can be modified by perioperative steroid administration. However, it remains to be determined if this response's attenuation translates to a reduction in complications.
AIM To evaluate if perioperative administration of steroids reduces complications following HR.
METHODS A systematic review of randomized controlled trials (RCTs) was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials to evaluate the effect of perioperative steroid (compared to placebo or no intervention) use in patients undergoing HR. Clinical outcomes were extracted, and meta-analysis was performed.
RESULTS 8 RCTs including 590 patients were included. Perioperative steroid administration was associated with significant reduction in postoperative complications [odds ratios: 0.58; 95% confidence intervals (CI): 0.35-0.97, P = 0.04]. There was also improvement in biochemical and inflammatory markers, including serum bilirubin on postoperative day 1 [MD: -0.27; 95%CI: (-0.47, -0.06), P = 0.01], C-reactive protein on postoperative day 3 [MD: -4.89; 95%CI: (-5.83, -3.95), P < 0.001], and interleukin-6 on postoperative day 1 [MD: -54.84; 95%CI: (-63.91, -45.76), P < 0.001].
CONCLUSION Perioperative steroids administration in HR may reduce overall complications, postoperative bilirubin, and inflammation. Further studies are needed to determine the optimal dose and duration and patient selection.
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Affiliation(s)
- Hao-Han Hai
- NUS Yong Loo Lin School of Medicine, Singapore 119228, Singapore
| | - Phoebe Aw
- NUS Yong Loo Lin School of Medicine, Singapore 119228, Singapore
| | | | - Vishal G Shelat
- NTU Lee Kong Chian School of Medicine, Singapore 308232, Singapore
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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6
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Milliken D, Curtis S, Melikian C. Predicting morbidity in liver resection surgery: external validation of the revised frailty index and development of a novel predictive model. HPB (Oxford) 2021; 23:954-961. [PMID: 33168438 DOI: 10.1016/j.hpb.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/21/2020] [Accepted: 10/19/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Perioperative complications of liver resection surgery are common but individual patient-level prediction is difficult. Most risk models are unvalidated and may not be clinically useful. We aimed to validate a risk prediction model for complications of liver resection, the Revised Frailty Index (rFI), at a high volume centre. We also aimed to derive a predictive model for complications in our cohort. METHODS Records were reviewed for 300 patients undergoing liver resection. The rFI's discrimination of 90-day major complications was assessed by receiver operating curve analysis. Logistic regression analysis was then used to fit rFI covariates to our dataset. A further analysis produced a model with optimal discrimination of 90-day major complications. RESULTS The rFI was a poor discriminator of 90-day major complications (AUROC 0.562) among patients at our centre. The rFI optimised fit model demonstrated improved discrimination of 90-day major complications (AUROC 0.685). We developed a novel model with improved fit and similar discrimination (AUROC 0.710). CONCLUSION We were unable to validate the rFI as a predictor of complications. We developed a novel model with discrimination at least equal to other published risk models. However, there is an unmet need for well-validated, clinically useful risk tools in this area.
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Affiliation(s)
- Don Milliken
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.
| | - Sam Curtis
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Clare Melikian
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
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Lei GY, Shen L, Junnarkar SP, Huey CT, Low J, Shelat VG. Predictors of 90-Day Mortality following Hepatic Resection for Hepatocellular Carcinoma. Visc Med 2021; 37:102-109. [PMID: 33981750 PMCID: PMC8077452 DOI: 10.1159/000510811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/10/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND/PURPOSE 90-day mortality is a key performance indicator for short-term perioperative outcome of hepatic resection (HR). Although many preoperative, intraoperative, and postoperative variables predict 90-day mortality following elective HR, only few are specific to hepatocellular carcinoma (HCC). This study aims to determine the predictors of 90-day mortality following elective HR for HCC. METHODS We report a retrospective analysis of patients who underwent elective HR between January 1, 2007, and December 31, 2017. Health status, perioperative variables, and the presence of post-hepatectomy liver failure (PHLF) were studied. Cox's regression evaluated factors predicting 90-day mortality. RESULTS Two hundred and forty-four patients diagnosed with HCC underwent HR; 102 (41.8%) underwent a major HR. The postoperative 90-day mortality rate was 5.3%. Multivariate analysis demonstrated that Child-Pugh score (p < 0.001), intraoperative blood loss (p = 0.013), the 50-50 criteria for PHLF (p < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (p = 0.007) on postoperative day 3 predict 90-day mortality. CONCLUSION In patients with HCC undergoing HR, Child-Pugh score, intraoperative blood loss, the 50-50 criteria for PHLF on postoperative day 5, and peak serum bilirubin >119 µmol/L on postoperative day 3 predict 90-day mortality following elective HR for HCC.
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Affiliation(s)
- Geraldine Yanlei Lei
- Department of General Surgery, Ministry of Health Holdings, Singapore, Singapore
| | - Liang Shen
- Department of Biostatistics Unit, National University Health System, Singapore, Singapore
| | - Sameer P. Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - CheongWei Terence Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - JeeKeem Low
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G. Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Pang Q, Liu S, Wang L, Pan H, Wang C, Zhou L, Lu Y, Liu H. The Significance of Platelet-Albumin-Bilirubin (PALBI) Grade in Hepatocellular Carcinoma Patients Stratified According to Platelet Count. Cancer Manag Res 2020; 12:12811-12822. [PMID: 33364830 PMCID: PMC7751793 DOI: 10.2147/cmar.s277013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/02/2020] [Indexed: 01/27/2023] Open
Abstract
Background Platelet–albumin–bilirubin (PALBI) has been demonstrated to be superior to conventional Child–Pugh (C-P) grade in evaluating liver function and prognosis of HCC patients. However, both thrombocytosis and thrombocytopenia are unfavorable for HCC survival. The aim of this study was to preliminarily investigate the prognostic value of PALBI in HCC patients with thrombocytopenia and excluding thrombocytopenia. Methods In this retrospective cohort study, we reviewed 465 cases of HCC patients who underwent radical surgery. PALBI grade was calculated based on preoperative serological examinations. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS), which were assessed by Kaplan–Meier method and Cox regression. The prognostic performances of PALBI and other models were estimated by using the concordance index (C-index). Results During a median follow-up time of 28 months, 31.6% (147/465) of patients died and 33.5% (156/465) experienced recurrence. Multivariate analyses revealed that both thrombocytosis and thrombocytopenia were independently associated with poor OS and RFS compared with normal platelet count (PLT) in HCC patients. Stratified analysis further revealed that PALBI was a significant predictor for HCC survival in patients excluding thrombocytopenia but not in patients with thrombocytopenia. In particular, in HCC patients excluding thrombocytopenia, the combination of tumor size with PALBI (C-index = 0.730, 95% CI: 0.674–0.786) may be superior to the classical Barcelona Clinic Liver Cancer (BCLC) and Cancer of Liver Italian Program (CLIP) staging systems in predicting survival. Conclusion In conclusion, PALBI grade, in particular the combination with tumor size, is an effective model for discriminating survival in HCC patients excluding thrombocytopenia but not in thrombocytopenic HCC patients.
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Affiliation(s)
- Qing Pang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China.,Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province 710061, People's Republic of China
| | - Shuangchi Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
| | - Luyao Wang
- Clinical Medical College of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
| | - Huadong Pan
- Clinical Medical College of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
| | - Chunfang Wang
- Clinical Medical College of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
| | - Lei Zhou
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
| | - Yimin Lu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
| | - Huichun Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province 233000, People's Republic of China
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Chan KS, Chia CLK, Ng FKL, Seow WHJ, Leong DY, Shelat VG. Impaired Handgrip Strength Does Not Predict Postoperative Morbidity in Major Hepatobiliary Surgery. J Surg Res 2020; 256:549-556. [PMID: 32799004 DOI: 10.1016/j.jss.2020.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 06/18/2020] [Accepted: 07/11/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Assessment of preoperative handgrip strength (HGS) is an objective and inexpensive bedside tool, which has been investigated to predict morbidity risk in elective surgery. However, its use is not validated in patients undergoing major elective hepatobiliary surgery (MEHS). The aim of this study is to investigate the use of HGS to predict morbidity in patients undergoing MEHS. METHODS This is a single-center prospective study involving 81 patients who underwent MEHS over 21 mo from July 2014 to March 2016. MEHS was defined as any hepatobiliary surgery expected to last more than 2 h and/or with an anticipated blood loss of ≥500 mL. HGS was assessed in both dominant and nondominant hands with standardization and subsequently recorded and expressed as a percentage of a general, age- and gender-matched normative values. RESULTS The mean age was 65.2 ± 9.5 y with male predominance (n = 52, 64.2%). Approximately, half of the patients underwent liver resection (n = 43, 53.1%). There was no difference in the incidence of Clavien-Dindo ≥ grade IIIA in both dominant HGS (impaired HGS 8/33 [24.2%], normal HGS 6/48 [12.5%]; P = 0.170) and nondominant HGS (impaired HGS 8/33 [21.1%], normal HGS 6/43 [14%]; P = 0.399). Dominant and nondominant HGS showed poor discriminatory ability in the prediction of Clavien-Dindo ≥ grade IIIA complications (dominant HGS area under the curve [AUC] = 0.572; nondominant HGS AUC 0.545). However, the use of dominant HGS showed moderate discriminatory ability to predict the length of hospital stay ≥21 d (AUC = 0.759). CONCLUSIONS The use of HGS may not predict Clavien-Dindo ≥ grade IIIA complications, but predicts a prolonged length of hospital stay ≥21 d.
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Affiliation(s)
- Kai Siang Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Felicia Kai Lin Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore.
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Donadon M, Galvanin J, Branciforte B, Palmisano A, Procopio F, Cimino M, Del Fabbro D, Torzilli G. Assessment of the American College of Surgeons surgical risk calculator of outcomes after hepatectomy for liver tumors: Results from a cohort of 950 patients. Int J Surg 2020; 84:102-108. [PMID: 33099020 DOI: 10.1016/j.ijsu.2020.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/01/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) calculator has been endorsed to counsel patients regarding complications. The aim of this study was to assess its ability to predict outcomes after hepatectomy. METHODS Outcomes generated by the ACS-NSQIP were recorded in a consecutive cohort of patients. By using established classifications of complications, post-hepatectomy insufficiency and bile leak, the calculator was tested by the comparison of expected versus observed rates of events. The performance of the calculator was tested by using c-statistic and Brier score. RESULTS 950 patients who underwent hepatectomy between January 2014 and June 2019 were included. Predicted rates were significantly lower than actual rates: the mean ACS-NSQIP morbidity was 17.97% ± 8.4 vs. actual 37.01% ± 0.56 (P < 0.001); the mean ACS-NSQIP mortality was 0.91% ± 1.48 vs. actual 1.76% ± 0.11 (P < 0.001). Predicted length of stay (LOS) was significantly shorter: mean ACS-NSQIP was 5.81 ± 1.66 days vs. actual 10.91 ± 4.6 days (P < 0.001). Post-hepatectomy liver insufficiency and bile leak were recorded in 6.8% and 11.9% of patients, respectively. These events were not expressed by the calculator. C-statistic and Brier scores showed low performance of the calculator. CONCLUSION The calculator underestimates the risks of complications, mortality and LOS after hepatectomy. Refinements of the ACS-NSQIP model that account for organ-specific risks should be considered.
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Affiliation(s)
- Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Jacopo Galvanin
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Bruno Branciforte
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Angela Palmisano
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Fabio Procopio
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Daniele Del Fabbro
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, 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, Rozzano, Milan, Italy.
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Wang B, Shelat VG, Chow JJL, Huey TCW, Low JK, Woon WWL, Junnarkar SP. Prehabilitation Program Improves Outcomes of Patients Undergoing Elective Liver Resection. J Surg Res 2020; 251:119-125. [PMID: 32135382 DOI: 10.1016/j.jss.2020.01.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/22/2019] [Accepted: 01/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Preoperative phase can be effectively used by multidisciplinary teams to optimize the surgical candidate to improve perioperative outcomes. The aim of our study was to evaluate the impact of prehabilitation program (PP) in patients undergoing elective liver resection (LR). METHODS This was a prospective study including patients undergoing elective LR from February 2016 to October 2017. Outcomes of patients enrolled into PP were compared with patients receiving standard care. PP involved physiotherapist, dietitian, and case managers along with surgical and anesthetic services. Postoperative morbidity, length of stay, 90-day mortality, readmission rate, quality of life, and cost were measured. RESULTS Seventy patients were enrolled into PP and compared with 34 patients receiving standard care. Median Charlson comorbidity index was higher in PP group (4 versus 3, P = 0.03). PP showed reduction in overall morbidity (30% versus 52.9%, P = 0.02) and social issues (nil versus 3, P = 0.03). Quality of life survey showed improved social well-being. A tendency to cost savings was observed in prehabilitation group with 16.5% ($1359) cost reduction (median cost $6892 versus $8251, P = 0.07). CONCLUSIONS PP improves outcomes in patients undergoing elective LR.
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Affiliation(s)
- Bei Wang
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
| | | | | | | | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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12
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Gui CH, Baey S, D'cruz RT, Shelat VG. Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma - A meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:763-771. [PMID: 31937433 DOI: 10.1016/j.ejso.2020.01.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/09/2019] [Accepted: 01/02/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR. AIM To compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC. MATERIALS AND METHODS A systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM). RESULTS Eight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62-0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58-0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05-5.86, p = 0.04) compared to SR but IDR and DM rates were not significant. DISCUSSION AND CONCLUSION TACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.
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13
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Chan KS, Low JK, Shelat VG. Associated liver partition and portal vein ligation for staged hepatectomy: a review. Transl Gastroenterol Hepatol 2020; 5:37. [PMID: 32632388 PMCID: PMC7063517 DOI: 10.21037/tgh.2019.12.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
Outcomes of liver resection have improved with advances in surgical techniques, improvements in critical care and expansion of resectability criteria. However, morbidity and mortality following liver resection continue to plague surgeons. Post-hepatectomy liver failure (PHLF) due to inadequate future liver remnant (FLR) is an important cause of morbidity and mortality following liver resection. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel two-staged procedure described in 2012, which aims to induce rapid hypertrophy of the FLR unlike conventional two-stage hepatectomy, which require a longer time for FLR hypertrophy. Careful patient selection and modifications in surgical technique has improved morbidity and mortality rates in ALPPS. Colorectal liver metastases (CRLM) confers the best outcomes post-ALPPS. Patients <60 years old and low-grade fibrosis with underlying hepatocellular carcinoma (HCC) are also eligible for ALPPS. Evidence for other types of cancers is less promising. Current studies, though limited, demonstrate that ALPPS has comparable oncological outcomes with conventional two-stage hepatectomy. Modifications such as partial-ALPPS and mini-ALPPS have shown improved morbidity and mortality compared to classic ALPPS. ALPPS may be superior to conventional two-stage hepatectomy in carefully selected groups of patients and has a promising outlook in liver surgery.
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Affiliation(s)
- Kai Siang Chan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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14
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Dong KS, Liang BY, Zhang ZY, Zhang EL, Yang G, Xia SL, Chen XP, Huang ZY. Histologic severity of liver cirrhosis: A key factor affecting surgical outcomes of hepatocellular carcinoma in patients with portal hypertension. Asian J Surg 2019; 42:981-989. [DOI: 10.1016/j.asjsur.2019.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/06/2019] [Accepted: 01/22/2019] [Indexed: 02/08/2023] Open
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15
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Melstrom L. Hepatectomy: more complex operations and improved perioperative outcomes. Hepatobiliary Surg Nutr 2019; 8:389-391. [PMID: 31489310 DOI: 10.21037/hbsn.2019.03.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Laleh Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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Chen YW, Huang MT, Chang TC. Long term outcomes of simultaneous laparoscopic versus open resection for colorectal cancer with synchronous liver metastases. Asian J Surg 2018; 42:217-223. [PMID: 29804706 DOI: 10.1016/j.asjsur.2018.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND/OBJECTIVE Because of the advancements in the surgical techniques of liver resection and improvements in anesthesia and postoperative critical care, the simultaneous resection of synchronous colorectal cancer with liver metastasis either by the laparoscopic procedure or by the open resection method has been considered as a safe and acceptable option. However, there is limited information on the comparison of postoperative outcomes between laparoscopic surgery and open surgery. This study investigated the clinical results and postoperative outcomes of laparoscopic simultaneous resection of synchronous colorectal cancer with liver metastasis in comparison with those of open surgery. METHODS Patients with synchronous colorectal cancer and liver metastasis who underwent simultaneous resection at Shuang Ho Hospital from 2009 to 2017 were identified. The patient demographics, perioperative morbidity, and survival rates were analyzed. RESULTS A total of 38 patients underwent simultaneous resection of synchronous colorectal cancer with liver metastasis. Laparoscopic procedure was performed for 16 patients, and the remaining 22 patients underwent open surgery. No significant differences were observed in the patient characteristics between the two groups. There was no perioperative mortality in both groups. The 1- and 3-year disease-free survival rates were 56% and 35% in the laparoscopic group and 70% and 15% in the open surgery group, respectively. The 1- and 3-year overall survival rates were 100% and 84% in the laparoscopic group and 73% and 48% in the open surgery group, respectively. CONCLUSION In selected patients, laparoscopic surgery for simultaneous resection of synchronous colorectal cancer with liver metastasis seems to be safe and had a similar outcome to that of open surgery.
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Affiliation(s)
- Ying-Wei Chen
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taiwan; Division of General Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taipei, Taiwan; Department of surgery, Taipei Medical University Shuang-Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City. 235, Taiwan.
| | - Ming-Te Huang
- Division of General Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taipei, Taiwan; Department of surgery, Taipei Medical University Shuang-Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City. 235, Taiwan.
| | - Tung-Cheng Chang
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, Taiwan; Graduate Institute of Clinical Medicine, Taipei Medical University, Taiwan; Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taiwan; Department of surgery, Taipei Medical University Shuang-Ho Hospital, Number 291, Zhongzheng Road, Zhonghe District, New Taipei City. 235, Taiwan.
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