Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection

Outcomes of Laparoscopic Versus Open Liver Resection: A Case-control Study With Propensity Score Matching

BACKGROUND

This study aimed to evaluate the perioperative outcomes of patients with benign and malignant liver lesions scheduled for laparoscopic and open surgery using a propensity score-matched approach to analyze additional cofactors influencing outcomes.

PATIENTS AND METHODS

In this study, we retrospectively reviewed 270 patients who underwent laparoscopic or open liver resection at our institute between October 2016 and November 2021. Patients were divided into open and laparoscopic liver resection groups and compared according to the intention to treat principle. In the purification process for the nonrandom nature of the study, a matching analysis was performed at a 1:1 case-control ratio. The PS model included selected data on body mass index, additional data on the American Society of Anesthesiology score, cirrhosis, lesion <2 cm from the hilum, lesion <2 cm from the hepatic vein or inferior vena cava, and type of neoadjuvant chemotherapy.

RESULTS

The operation time and 30- and 90-day mortality rates were similar between the groups. The average length of hospital stay was 11 days in the open surgery group and 9 days in the laparoscopic surgery group after matching ( P =0.011). The 30-day morbidity rate was statistically different between the groups before and after matching, favoring the laparoscopic group ( P =0.001 and 0.006, respectively). After the propensity score-matched approch, the open group's Pringle time was shorter than that of the laparoscopic group. The total operative time was longer in the laparoscopic than in the open surgery group. This did not change after matching (300 vs. 240 min).

CONCLUSIONS

Laparoscopic surgery is a feasible and safe treatment option for patients with liver tumors, with promising results in terms of morbidity and hospital stay.

Surgery-related disseminated intravascular coagulation predicts postoperative complications

PURPOSE

The rate of postoperative morbidity, including infectious complications, is still high after major hepatobiliary pancreatic (HBP) surgery. Although surgery-related disseminated intravascular coagulation (DIC) occurs in some cases, its significance has not been elucidated in HBP surgery. This study aimed to evaluate the influence of surgery-related DIC on the complication severity after HBP surgery.

METHODS

We analyzed the records of 100 patients with hepatectomy in two or more segments, hepatectomy with biliary tract reconstruction, and pancreaticoduodenectomy. The baseline characteristics and complications were compared between patients with and without surgery-related DIC on postoperative day 1 (POD1) after HBP surgery between 2010 and 2018. Complication severity was assessed using the Comprehensive Complication Index (CCI).

RESULTS

The DIC group (surgery-related DIC on POD1) had predictive factors, such as larger bleeding volume and higher liver enzyme levels. The DIC group exhibited significantly elevated rates of surgical site infection, sepsis, prolonged intensive care unit stay, more frequent blood transfusions, and higher CCI. Furthermore, compared with and without adjustment of DIC, odds ratio (OR) of AST level and operation time for  the risk of high CCI decreased (OR of AST level: 1.25 to 1.19 and OR of operation time: 1.30 to 1.23) and the significant differences had vanished.

CONCLUSIONS

Surgery-related DIC on POD1 could be a partial mediator between AST level, operation time and higher CCI. The prevention or proper management of surgery-related DIC on POD1 can be an important target to reduce the severity of postoperative complications.

Impact of perioperative blood transfusion on long-term survival in patients with different stages of perihilar cholangiocarcinoma treated with curative resection: A multicentre propensity score matching study

Background & aim

The association of perioperative blood transfusion (PBT) with long-term survival in perihilar cholangiocarcinoma (pCCA) patients after surgical resection with curative intent is controversial and may differ among different stages of the disease. This study aimed to investigate the impact of PBT on long-term survival of patients with different stages of pCCA.

Methods

Consecutive pCCA patients from three hospitals treated with curative resection from 2012 to 2019 were enrolled and divided into the PBT and non-PBT groups. Propensity score matching (PSM) was used to balance differences in baseline characteristics between the PBT and non-PBT groups. Kaplan–Meier curves and log-rank test were used to compare overall survival (OS) and recurrence-free survival (RFS) between patients with all tumor stages, early stage (8th AJCC stage I), and non-early stage (8th AJCC stage II-IV) pCCA in the PBT and non-PBT groups. Cox regression analysis was used to determine the impact of PBT on OS and RFS of these patients.

Results

302 pCCA patients treated with curative resection were enrolled into this study. Before PSM, 68 patients (22 patients in the PBT group) were in the early stage and 234 patients (108 patients in the PBT group) were in the non-early stage. Patients with early stage pCCA in the PBT group had significantly lower OS and RFS rates than those in the non-PBT group. However, there were with no significant differences between the 2 groups with all tumor stages and non-early stage pCCA. After PSM, there were 18 matched pairs of patients with early stage and 72 matched pairs of patients with non-early stage. Similar results were obtained in the pre- and post-PSM cohorts: patients with early stage pCCA in the PBT group showed significantly lower OS and RFS rates than those in the non-PBT group, but there were no significant differences between the 2 groups for patients with all tumor stages and non-early stage pCCA. Cox regression analysis demonstrated that PBT was independently associated with worse OS and RFS for patients with early stage pCCA.

Conclusions

PBT had a negative impact on long-term survival in patients with early stage pCCA after curative resection, but not in patients with non-early stage pCCA.

Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist

BACKGROUND

The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery.

METHODS

To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions.

RESULTS

NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703).

CONCLUSION

An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.

Impact of perioperative blood transfusions on postoperative renal function and survival after resection of colorectal liver metastases

Background and aims

Recent studies focusing on thoracic surgery suggest postoperative kidney injury depending on the amount of perioperative blood transfusions. Data investigating similar effects after resection of colorectal liver metastases (CRLM) are not available. Aim of this study was therefore to evaluate the influence of perioperative blood transfusions on postoperative renal function and survival after resection of CRLM.

Methods

Seven hundred twenty-seven cases of liver resection for CRLM were retrospectively analyzed. Renal function was measured via estimated glomerular filtration rate (eGFR) and a postoperative decline of ≥ 10% was considered substantial. Potential influences on postoperative kidney function were assessed using univariable and multivariable logistic regression analyses. Cox-regression analyses were performed to estimate the impact on overall survival (OS).

Results

Preoperative impaired kidney function (p = 0.001, OR 2.477) and transfusion of > 2 units of packed red blood cells (PRBC) (p = 0.046; OR 1.638) were independently associated with an increased risk for ≥ 10% loss of renal function. Neither a pre-existing renal impairment, nor the additional loss of renal function were associated with reduced survival. Chemotherapies in the context of primary colorectal cancer treatment (p = 0.002), age > 70 years at liver resection (p = 0.005), number (p = 0.001), and size of metastases > 50 mm (p = 0.018), duration of resection > 120 min (p = 0.006) and transfusions of > 2 units of PRBC (p = 0.039) showed a negative independent influence on OS.

Conclusion

The results demonstrate a negative impact of perioperative blood transfusions on the postoperative renal function and OS. Hence, efforts to reduce blood transfusions should be intensified.

Intraoperative autologous transfusion and oncologic outcomes in liver transplantation for hepatocellular carcinoma: a propensity matched analysis

BACKGROUND

Intraoperative autologous transfusion (IAT) of salvaged blood is a common method of resuscitation during liver transplantation (LT), however concern for recurrence in recipients with hepatocellular carcinoma (HCC) has limited widespread adoption.

METHODS

A review of patients undergoing LT for HCC between 2008 and 2018 was performed. Clinicopathologic and intraoperative characteristics associated with inferior recurrence-free (RFS) and overall survival (OS) were identified using Kaplan-Meier analysis and uni-/multi-variable Cox proportional hazards modeling. Propensity matching was utilized to derive clinicopathologically similar groups for subgroup analysis.

RESULTS

One-hundred-eighty-six patients were identified with a median follow up of 65 months. Transplant recipients receiving IAT (n = 131, 70%) also had higher allogenic transfusions (median 5 versus 0 units, P < 0.001). There were 14 recurrences and 46 deaths, yielding an estimated 10-year RFS and OS of 89% and 67%, respectively. IAT was not associated with RFS (HR 0.89/liter, P = 0.60), or OS (HR 0.98/liter, P = 0.83) pre-matching, or with RFS (HR 0.97/liter, P = 0.92) or OS (HR 1.04/liter, P = 0.77) in the matched cohort (n = 49 per group).

CONCLUSION

IAT during LT for HCC is not associated with adverse oncologic outcomes. Use of IAT should be encouraged to minimize the volume of allogenic transfusion in patients undergoing LT for HCC.

Impact of Postoperative Complications on Long-Term Survival of Hepatocellular Carcinoma Patients After Liver Resection

Objective

The effect of postoperative complications including red blood cell transfusion (BT) on long-term survival for hepatocellular carcinoma (HCC) is unknown. The purpose of this study was to define the relationship between postoperative complications and long-term survival in patients with HCC.

Methods

Postoperative complications of 1251 patients who underwent curative liver resection for HCC were classified, and their recurrence-free survival (RFS) and cumulative overall survival (OS) were investigated.

Results

Any complications occurred in 503 patients (40%). Five-year RFS and 5-year OS in the complication group were 21% and 56%, respectively, significantly lower than the respective values of 32% (P &lt; 0.001) and 68% (P &lt; 0.001) in the no-complication group (n = 748). Complications related to RFS were postoperative BT [hazard ratio (HR): 1.726, 95% confidence interval (CI): 1.338–2.228, P &lt; 0.001], pleural effusion (HR: 1.434, 95% CI: 1.200–1.713, P &lt; 0.001) using Cox proportional-hazard model. Complications related to OS were postoperative BT (HR: 1.843, 95% CI: 1.380–2.462, P &lt; 0.001), ascites (HR: 1.562, 95% CI: 1.066–2.290, P = 0.022), and pleural effusion (HR: 1.421, 95% CI: 1.150–1.755, P = 0.001).

Conclusions

Postoperative complications were factors associated with poor long-term survival. Postoperative BT and pleural effusion were noticeable complications that were prognostic factors for both RFS and OS.

Treatment of intrahepatic recurrence after hepatectomy for hepatocellular carcinoma

BACKGROUND

Prognostic factors after treatment for intrahepatic recurrent hepatocellular carcinoma (RHCC) after hepatic resection (Hx) are controversial. The current study aimed to examine the impact of treatment modality on the prognosis of intrahepatic RHCC following Hx.

METHODS

For control of variables, the subjects were 56 patients who underwent treatment for intrahepatic RHCC, three or fewer tumors, each measuring ≤3 cm in diameter without macroscopic vascular invasion (MVI), between 2000 and 2011. Retreatment consisted of repeat Hx (n = 23), local ablation therapy (n = 11) and transarterial chemoembolization or transcatheter arterial infusion (TACE/TAI) (n = 22). We retrospectively investigated the relation between type of treatment for RHCC and overall survival (OS) as well as disease-free survival (DFS).

RESULTS

In multivariate (MV) analysis, the poor prognostic factors in DFS after retreatment consisted of disease-free interval (DFI) (≤1.5 y) (P = .011), type of retreatment (TACE/TAI) (P = .002), age (<65 y old) (P = .0022), perioperative RBC transfusion (P = .025), while those in OS after retreatment were DFI (≤1.5 y) (P < .0001). In evaluation of stratification for type of retreatment, DFS in the repeat Hx group was significantly better than those in the local ablation therapy group or the TACE/TAI group (P = .023 or P < .0001, respectively).

CONCLUSIONS

DFI (≤1.5 y) was an independent poor prognostic factor in both DFS and OS, and repeat Hx for intrahepatic RHCC, few in number and size without MVI, seems to achieve the most reliable local control.

Robotic liver surgery: literature review and future perspectives

INTRODUCTION

Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations.

EVIDENCE ACQUISITION

A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR.

EVIDENCE SYNTHESIS

The literature review results are presented and our additional remarks on the topic are discussed.

CONCLUSIONS

Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

Prediction of Post-hepatectomy Liver Failure in Patients With Hepatocellular Carcinoma Based on Radiomics Using Gd-EOB-DTPA-Enhanced MRI: The Liver Failure Model

Objectives: Preoperative prediction of post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) is significant for developing appropriate treatment strategies. We aimed to establish a radiomics-based clinical model for preoperative prediction of PHLF in HCC patients using gadolinium-ethoxybenzyl-diethylenetriamine (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI).

Methods: A total of 144 HCC patients from two medical centers were included, with 111 patients as the training cohort and 33 patients as the test cohort, respectively. Radiomics features and clinical variables were selected to construct a radiomics model and a clinical model, respectively. A combined logistic regression model, the liver failure (LF) model that incorporated the developed radiomics signature and clinical risk factors was then constructed. The performance of these models was evaluated and compared by plotting the receiver operating characteristic (ROC) curve and calculating the area under the curve (AUC) with 95% confidence interval (CI).

Results: The radiomics model showed a higher AUC than the clinical model in the training cohort and the test cohort for predicting PHLF in HCC patients. Moreover, the LF model had the highest AUCs in both cohorts [0.956 (95% CI: 0.955–0.962) and 0.844 (95% CI: 0.833–0.886), respectively], compared with the radiomics model and the clinical model.

Conclusions: We evaluated quantitative radiomics features from MRI images and presented an externally validated radiomics-based clinical model, the LF model for the prediction of PHLF in HCC patients, which could assist clinicians in making treatment strategies before surgery.

Decrease in the Risk of Posttransplant Hepatocellular Carcinoma Recurrence After the Conversion to Prestorage Leukoreduction for Transfused Red Blood Cells

BACKGROUND

Prestorage leukoreduction has the advantage over poststorage leukoreduction in reducing leukocyte-derived molecules in red blood cells (RBC) unit, which induce immunomodulation. Our institution newly introduced prestorage leukoreduction, instead of conventional poststorage leukoreduction, for liver transplant recipients since March 2012. In this study, we aimed to evaluate the risk of posttransplant hepatocellular carcinoma (HCC) recurrence after the conversion of poststorage leukoreduction into prestorage leukoreduction for transfused allogeneic RBCs.

METHODS

Among 220 patients who underwent living-donor liver transplantation for HCC, 83 of 113 who received only poststorage-leukoreduced RBCs were matched with 83 of 107 who received only prestorage-leukoreduced RBCs using 1:1 propensity score matching based on factors like tumor biology. The primary outcome was overall HCC recurrence. Survival analysis was performed with death as a competing risk event.

RESULTS

In the matched cohort, recurrence probability at 1, 2, and 5 years posttransplant was 9.6%, 15.6%, and 18.1% in prestorage group and 15.6%, 21.6%, and 33.7% in poststorage group (hazard ratio [HR], 0.52; 0.28-0.97; P = 0.040). Multivariable analysis confirmed a significance of prestorage leukoreduction (HR, 0.29; 0.15-0.59; P < 0.001). Overall death risk was also lower with prestorage leukoreduction (HR, 0.51; 0.26-0.99; P = 0.049). In subgroup analysis for the unmatched cohort, recurrence risk was significantly lower in prestorage group within the patients who underwent surgery 2 years (HR, 0.24; 0.10-0.61; P = 0.002), 1 year (HR, 0.16; 0.03-0.92; P = 0.040), and 6 months (HR, 0.13; 0.02-0.85; P = 0.034), respectively, before and after the conversion to prestorage leukoreduction.

CONCLUSIONS

Our findings suggest a potential benefit of prestorage leukoreduction in reducing the risk of HCC recurrence in liver transplant recipients who received allogeneic RBCs during the perioperative period.

Links between Inflammation and Postoperative Cancer Recurrence

Despite complete resection, cancer recurrence frequently occurs in clinical practice. This indicates that cancer cells had already metastasized from their organ of origin at the time of resection or had circulated throughout the body via the lymphatic and vascular systems. To obtain this potential for metastasis, cancer cells must undergo essential and intrinsic processes that are supported by the tumor microenvironment. Cancer-associated inflammation may be engaged in cancer development, progression, and metastasis. Despite numerous reports detailing the interplays between cancer and its microenvironment via the inflammatory network, the status of cancer-associated inflammation remains difficult to recognize in clinical settings. In the current paper, we reviewed clinical reports on the relevance between inflammation and cancer recurrence after surgical resection, focusing on inflammatory indicators and cancer recurrence predictors according to cancer type and clinical indicators.

D-dimer-based screening for early diagnosis of venous thromboembolism after hepatectomy

PURPOSE

The aim of this study was to evaluate the clinical utility of a novel diagnostic algorithm based on serum D-dimer levels for venous thromboembolism (VTE) after hepatectomy.

METHODS

We retrospectively analyzed 742 consecutive patients who underwent hepatectomy in our hospital from 2009 to 2019. From 2015, we routinely measured serum D-dimer level postoperatively and computed tomography was performed when D-dimer level was ≥ 20 μg/mL.

RESULTS

VTE was diagnosed in 26 patients and pulmonary embolism (PE) was diagnosed in 18 patients. Multivariate analysis revealed that resected liver weight ≥ 120 g is a significant predictor of VTE (P = 0.011). The incidence of VTE from 2015 to 2019 was greater than that from 2009 to 2014 (5.0% versus 2.1%, P = 0.044). The number of low-risk PE patients between 2015 and 2019 was significantly greater than that between 2009 and 2014 (P = 0.013). There was no in-hospital mortality of patients with PE from 2015 to 2019.

CONCLUSION

Patients who undergo hepatectomy are at high risk for VTE, especially when the resected liver weight is high. The proposed diagnostic algorithm based on serum D-dimer levels for VTE after hepatectomy can be useful for early diagnosis.

A self-designed liver circle for on-demand Pringle's manoeuver in laparoscopic liver resection

BACKGROUND

Laparoscopic liver resection (LLR) allows minimal incisions and relatively quicker post-operative recovery, while intraoperative massive haemorrhage led to conversion to laparotomy. This study aimed to introduce a new, safe and convenient device to serve as Pringle's manoeuver according to the demand in LLR.

METHODS

A liver circle consisting of a hole and a round stem with an obtuse small head was made by medical silica gel. It was applied in LLR to perform on-demand Pringle's manoeuver and developed its function in inferior vena cava (IVC) occlusion. The time of performing Pringle's manoeuver by liver circle, extracorporeal tourniquet and endo intestinal clip under laparoscopic simulator and LLR was compared.

RESULTS

The liver circle was successfully applied to perform Pringle's manoeuver, IVC exposure and occlusion. It took less time in the occluding step of Pringle's manoeuver than the extracorporeal tourniquet (4.15 ± 0.35 s vs. 9.90 ± 1.15 s, P < 0.05) and the endo intestinal clip (4.15 ± 0.35 s vs. 47.91 ± 3.98 s, P < 0.05) under LLR. The total manipulating time for Pringle's manoeuver with liver circle remained the shortest, and the advantages were more obvious with increased frequencies of intermittent Pringle's manoeuver.

CONCLUSION

The new-designed liver circle is more convenient compared to other techniques in performing Pringle's manoeuver, especially the intermittent Pringle's manoeuver in LLR. It can be used to perform on-demand hepatic blood inflow occlusion in every LLR by pre-circling the hepatoduodenal ligament to control bleeding during surgery. It can also be applied to expose the surgical field of vision and perform IVC occlusion to reduce intraoperative blood loss.

Intraoperative Transfusion of Fresh Frozen Plasma Predicts Morbidity Following Partial Liver Resection for Hepatocellular Carcinoma

BACKGROUND

The reduction of perioperative morbidity is a main surgical goal in patients undergoing partial hepatectomy for hepatocellular carcinoma (HCC). Here, we investigated clinical determinants of perioperative morbidity in a European cohort of patients undergoing surgical resection for HCC.

METHODS

A total 136 patients who underwent partial hepatectomy for HCC between 2011 and 2017 at our institution were included in this analysis. The associations between major surgical complications (Clavien-Dindo ≥ 3) and overall morbidity (Clavien-Dindo ≥ 1) with clinical variables were assessed using univariate and multivariable binary logistic regression analysis.

RESULTS

Multivariable analysis identified the Child-Pugh-Score (CPS, HR = 3.23; p = 0.040), operative time (HR = 5.63; p = 0.003), and intraoperatively administered fresh frozen plasma (FFP, HR = 5.62; p = 0.001) as independent prognostic markers of major surgical complications, while only FFP (HR = 6.52; p = 0.001) was associated with morbidity in the multivariable analysis. The transfusion of FFP was not associated with perioperative liver functions tests.

CONCLUSIONS

The intraoperative administration of FFP is an important independent predictor of perioperative morbidity in patients undergoing partial hepatectomy for HCC.

Impact of perioperative blood transfusion on survival in pancreatic neuroendocrine tumor patients: analysis from the US Neuroendocrine Study Group

BACKGROUND

Packed red blood cell (PRBC) transfusion has been associated with worse survival in multiple malignancies but its impact on pancreatic neuroendocrine tumors (PNETs) is unknown. The aim of this study was to determine the impact of PRBC transfusion on survival following PNET resection.

METHODS

A retrospective cohort study of PNET patients was performed using the US Neuroendocrine Tumor Study Group database. Demographic and clinical factors were compared. Kaplan-Meier and log-rank analyses were performed. Factors associated with transfusion, overall (OS), recurrence-free (RFS) and progression-free survival (PFS) were assessed by logistic regression.

RESULTS

Of 1129 patients with surgically resected PNETs, 156 (13.8%) received perioperative PRBC transfusion. Transfused patients had higher ASA Class, lower preoperative hemoglobin, larger tumors, more nodal involvement, and increased major complications (all p < 0.010). Transfused patients had worse median OS (116 vs 150 months, p < 0.001), worse RFS (83 vs 128 months, p < 0.01) in curatively resected (n = 1047), and worse PFS (11 vs 24 months, p = 0.110) in non-curatively resected (n = 82) patients. On multivariable analysis, transfusion was associated with worse OS (HR 1.80, p = 0.011) when controlling for TNM stage, tumor grade, final resection status, and pre-operative anemia.

CONCLUSION

PRBC transfusion is associated with worse survival for patients undergoing PNET resection.

Perioperative blood transfusion has distinct postsurgical oncologic impact on patients with different stage of hepatocellular carcinoma

Background

The influence of perioperative blood transfusion (PBT) on postsurgical survival of patients with different stage of hepatocellular carcinoma (HCC) is not well clarified. This study aimed to evaluate the impact of PBT on survival outcomes of different stage of HCC patients.

Methods

Consecutive patients who underwent liver resection for HCC between January 2009 and November 2015 were identified from an HCC prospective database in authors’ center. The survival outcomes were compared between patients receiving PBT and those without PBT before and after propensity score matching (PSM) in different stage subsets. Cox regression analysis was performed to verify the impact of PBT on outcomes of HCC.

Results

Among 1255 patients included, 804 (64.1%) were Barcelona Clinic Liver Cancer (BCLC) stage 0-A, and 347 (27.6%) received PBT. Before PSM, patients with PBT had worse disease free survival (DFS) and overall survival (OS) compared with those without PBT in both BCLC 0-A subset and BCLC B-C subset (all P < 0.05). After PSM, 288 pairs of patients (with and without PBT) were created. In the subset of BCLC 0-A, the median DFS of patients with PBT was shorter than those without PBT (12.0 months vs. 36.0 months, P = 0.001) Similar result was observed for OS (36.0 months vs. 96.0 months, P = 0.001). In the subset of BCLC B-C, both DFS and OS were comparable between patients with PBT and those without PBT. Cox regression analysis showed that PBT involved an increasing risk of DFS (HR = 1.607; P < 0.001) and OS (HR = 1.756; P < 0.001) for this subset. However, PBT had no impact on DFS (P = 0.126) or OS (P = 0.139) for those with stage B-C HCC.

Conclusions

PBT negatively influenced oncologic outcomes of patient with BCLC stage 0-A HCC, but not those with stage B-C after curative resection.

A comparison between robotic, laparoscopic and open hepatectomy: A systematic review and network meta-analysis

BACKGROUND

The evidence of pairwise meta-analysis of Robotic Hepatectomy (RH) vs Laparoscopic Hepatectomy (LH) and RH vs Open Hepatectomy (OH) is inconclusive. Therefore, the aim of this study, was to compare the outcomes of RH, LH and OH by performing a network meta-analysis.

METHODS

A systematic literature search was performed in the following databases: Pubmed, Google scholar, EMBASE and Cochrane library. Cost-effectiveness and survival benefits were selected as primary outcomes.

RESULTS

The cost was less in OH compared to both minimally invasive procedures, LH demonstrated lower cost compared to RH, but the differences were not statistically significant. Both the RH and LH cohorts demonstrated significantly lower estimated blood loss, reduced major morbidity rate and shorter length of stay compared to OH cohort. The LH and OH cohorts demonstrated significantly shorter operative time and duration of clamping compared to the RH cohort. The LH cohort included significantly smaller tumours compared to the OH cohort.

CONCLUSION

The present network meta-analysis, demonstrated that both RH and LH in malignant and benign conditions were associated with lower morbidity rates, shorter hospital stay and the procedure related costs were statistically nonsignificant between RH, LH and OH.

A novel exposure maneuver in laparoscopic right hepatectomy

BACKGROUND AND OBJECTIVES

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver.

METHODS

Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon.

RESULTS

The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases.

CONCLUSIONS

The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

Packed Red Blood Cell Transfusion Modulates Myeloid Dendritic Cell Activation and Inflammatory Response In Vitro

Transfusion of packed red blood cells (PRBCs) modulates patients' immune responses and clinical outcomes; however, the underpinning mechanism(s) remain unknown. The potential for PRBC to modulate myeloid dendritic cells (mDC) and blood DC antigen 3 was assessed using an in vitro transfusion model. In parallel, to model processes activated by viral or bacterial infection, toll-like receptor agonists polyinosinic:polycytidylic acid or lipopolysaccharide were added. Exposure to PRBC upregulated expression of CD83 and downregulated CD40 and CD80 on both DC subsets, and it suppressed production of interleukin (IL)-6, IL-8, IL-12, tumor necrosis factor-α, and interferon-gamma-inducible protein-10 by these cells. Similar effects were observed when modeling processes activated by concurrent infection. Furthermore, exposure to PRBC at date of expiry was associated with more pronounced effects in all assays. Our study suggests PRBC have an impact on recipient DC function, which may result in failure to establish an appropriate immune response, particularly in patients with underlying infection.

Preoperative Immune Response is Associated with Perioperative Transfusion Requirements in Glioma Surgery

Immunosuppression induced by transfusion causes postoperative adverse events including poor prognosis in cancer, but data on influence of the immune response on blood transfusion requirements during perioperative period are limited. The aim of this study was to investigate whether the preoperative immune response is associated with perioperative blood cell transfusion in a glioma surgical patient population. The authors identified 321 cases of surgery for treatment of glioma. Patient variables, preoperative laboratory variables (hemoglobin, platelet count, activated partial thromboplastin time, prothrombin time, hematocrit, red and white blood cell count), and transfusions were registered. Plasma concentration of Th-associated cytokines was measured by flow cytometry. Multivariable regression analysis and receiver operating characteristic curve were undertaken to identify predictors of transfusion. Of 321 patients, 157 (48.90%) received red blood cells transfusion. The mean age is significantly higher in transfusion group compared to no transfusion group, while postoperative hospital stay, preoperative hemoglobin, prothrombin time, activated partial thromboplastin time, platelet count, red and white blood cell count and hematocrit of patients did not differ significantly between the two groups. No significant differences of IL-2, -4, -6, -10 and INF-γ concentration were observed between transfusion and no transfusion group. The concentration of TNF and IL-17A was significantly lower in transfusion patients than in the no transfusion subjects. Low plasma TNF and IL-17A levels predicted high perioperative transfusion rate, the combination of them enlarged the prognostic accuracy of testing. Our study demonstrates that the preoperative immune response influences transfusion requirements, and TNF and IL-17 are important predictive risk factors for perioperative use of blood components in glioma patients.

Extracellular Ubiquitin is the Causal Link between Stored Blood Transfusion Therapy and Tumor Progression in a Melanoma Mouse Model

Background: The transfusion of blood that has been stored for some time was found to be associated with transfusion-related immune modulation (TRIM) responses in cancer patients, which could result in poor clinical outcomes, such as tumor recurrence, metastasis and reduced survival rate. Given the prior observation of the positive correlation between ubiquitin content in whole blood and storage duration by the investigators of the present study, it was hypothesized that this could be the causal link behind the association between the transfusion of stored blood and poor cancer prognosis.

Methods: In the present study, a melanoma mouse model was used to study the potential clinical impact of ubiquitin present in stored blood on cancer prognosis through a variety of cell biology methods, such as flow cytometry and immunohistochemistry.

Results: Both extracellular ubiquitin and the infusion of stored mice blood that comprised of ubiquitin reduced the apoptotic rate of melanoma cells, promoted lung tumor metastasis and tumor progression, and reduced the long-term survival rate of melanoma mice. In addition, the upregulation of tumor markers and tumorigenic TH2 cytokine generation, as well as reduced immune cell numbers, were observed in the presence of ubiquitin.

Conclusions: The present findings provide novel insights into the role of ubiquitin in immune regulation in a melanoma mouse model, and suggest ubiquitin as the causal link between allogeneic blood transfusion therapy and poor cancer prognosis.

Intrathecal Morphine Administration Does Not Affect Survival After Liver Resection for Hepatocellular Carcinoma

Introduction. Opioids may influence tumor recurrence and cancer-free survival in hepatocellular carcinoma (HCC). The relationship between intrathecal morphine administration, tumor recurrence, and patient survival after hepatectomy for HCC is unknown. Patients and Methods. This single-center, retrospective study included 1837 liver resections between July 2002 and December 2012; 410 cases were incorporated in the final univariate and multivariate analysis. Confirmatory propensity matching yielded 65 matched pairs (intrathecal morphine vs none). Primary outcomes were recurrence of HCC and survival. Secondary outcomes included characterization of factors associated with recurrence and survival. Results. Groups were similar except for increased coronary artery disease in the no intrathecal morphine group. All patients received volatile anesthesia. Compared with no intrathecal morphine (N = 307), intrathecal morphine (N = 103) was associated with decreased intraoperative intravenous morphine administration (median difference = 12.5 mg; 95% confidence interval [CI] = 5-20 mg). There was no difference in blood loss, transfusion, 3- or 5-year survival, or recurrence in the univariate analysis. Multivariate analysis identified covariates that significantly correlated with 5-year survival: intrathecal morphine (hazard ratio [HR] = 0.527, 95% CI = 0.296-0.939), lesion diameter (HR = 1.099, 95% CI = 1.060-1.141), vascular invasion (HR = 1.658, 95% CI = 1.178-2.334), and satellite lesions (HR = 2.238, 95% CI = 1.447-3.463). Survival analysis on the propensity-matched pairs did not demonstrate a difference in 5-year recurrence or survival. Discussion and Conclusion. Multivariate analysis revealed a significant association between intrathecal morphine and 5-year survival. This association did not persist after propensity matching. The association between intrathecal morphine and HCC recurrence and survival remains unclear and prospective work is necessary to determine whether an association exists.

A novel very simple laparoscopic hepatic inflow occlusion apparatus for laparoscopic liver surgery

BACKGROUND

Control of bleeding is extremely important for laparoscopic liver resection. We introduce a new and operationally simple laparoscopic hepatic inflow occlusion apparatus (LHIOA) and its successful application in laparoscopic surgery for patients with cirrhosis.

METHODS

The self-designed LHIOA was constructed using a tracheal catheter (7.5#) and infusion set. The tracheal catheter and infusion set were trimmed to 30 and 70 cm, to serve as an occlusion tube and occlusion tape, respectively. After establishment of pneumoperitoneum, the occlusion tape was inserted to encircle the hepatoduodenal ligament. The occlusion tube was then introduced and the ends of the occlusion tape were pulled out of it to occlude the hepatic inflow. Under intermittent vascular occlusion with the LHIOA, the liver parenchyma was transected using an ultrasonic scalpel and monopolar electrocoagulation. Outcomes of the application of the LHIOA in hepatocellular carcinoma patients with cirrhosis (LHIOA group, n = 46) were compared with patients undergoing laparoscopic hepatectomy without LHIOA (non-LHIOA group, n = 46), using one-to-one propensity case-matched analysis.

RESULTS

The LHIOA effectively occluded the hepatic inflow while showing no damage to the hepatoduodenal ligament. The time required for presetting the LHIOA is 6.8 ± 0.6 min. The conversion rate in the non-LHIOA group was 13.0% while there was no conversion in the occlusion group (P < 0.001). The median blood loss of patients in the LHIOA group (60 ml, range 50-200 ml) was significantly less than that of patients in the non-LHIOA group (250 ml, range 100-800) (P < 0.001). Transfusion was required in 8 patients in the non-LHIOA group while no transfusion was required in the LHIOA group. The median operative time in the LHIOA group (157 min, range 80-217 min) was significantly shorter than that in the non-LHIOA group (204 min, range 105-278 min) (P < 0.001).

CONCLUSIONS

The new LHIOA is effective, safe, and simple. It can significantly reduce conversion rate, blood loss, and operative time. It facilitates laparoscopic liver resection and is recommended for use.

Usefulness of aspartate aminotransferase to platelet ratio index as a prognostic factor following hepatic resection for hepatocellular carcinoma

Liver function is a major prognostic factor following hepatic resection for hepatocellular carcinoma (HCC), which is well correlated with the degree of fibrosis. On the other hand, the presence of liver cirrhosis itself leads to a higher incidence of HCC than chronic hepatitis. Therefore, preoperative noninvasive markers of fibrosis are important for the assessment of prognosis for treatment of HCC. The present study aimed to analyze whether aspartate aminotransferase to platelet ratio index (APRI) could predict prognosis following hepatic resection for HCC. The subjects were 162 patients who underwent hepatic resection for HCC between January 2000 and December 2011. The relationship between APRI and disease-free and overall survival were retrospectively investigated. In multivariate analysis, indocyanine green at 15 min (ICG-R15) ≥15% (P=0.0306), APRI ≥0.45 (P=0.0184), perioperative blood transfusion of red cell concentrates (RCC; P=0.0034) and TNM stage II, III or IV (P=0.0184) were significant predictors in disease-free survival. For overall survival, ICG-R15 ≥15% (P=0.0454), APRI ≥0.45 (P=0.0417), perioperative blood transfusion of RCC (P=0.0036) and TNM stage II, III or IV (P=0.0033) were significant predictors. In addition, higher APRI values were positively correlated with hepatitis C virus infection and preoperative liver function. In conclusion, APRI is an independent risk factor for disease-free and overall survival following hepatic resection for HCC.

The Effect of Anesthesia on the Immune System in Colorectal Cancer Patients

Colorectal cancer (CRC) is the key leading cause of high morbidity and mortality worldwide. Surgical excision is the most effective treatment for CRC. However, stress caused by surgery response can destroy the body's immunity and increase the likelihood of cancer dissemination and metastasis. Anesthesia is an effective way to control the stress response, and recent basic and clinical research has shown that anesthesia and related drugs can directly or indirectly affect the immune system of colorectal cancer patients during the perioperative period. Thus, these drugs may affect the prognosis of CRC surgery patients. This review is intended to summarize currently available data regarding the effects of anesthetics and related drugs on perioperative immune function and postoperative recurrence and metastasis in CRC patients. Determining the most suitable anesthesia for patients with CRC is of utmost importance.

Totally intra-corporeal Pringle maneuver during laparoscopic liver resection

INTRODUCTION

Laparoscopic resection has gained a significant place in liver surgery. As in open liver resection, bleeding control during hepatic transection remains a major issue and it represents the main reason for conversion to laparotomy. Pringle maneuver (PM) remains the standard inflow occlusion technique and a specific step-by-step description of totally intracorporeal laparoscopic PM is described.

METHODS

The technique includes placement of a tape around the hepatoduodenal which is then passed through a plastic drain. This creates a tourniquet that is locked with a heavy duty clip to allow intermittent use.

RESULTS

This technique has been used in over 400 cases over the past 15 years and has proved safe and efficient with no specific complications encountered. It has been used in in 97 of 170 cases (57%) in the past 4 years and its feasibility has been 97%. Its intracorporeal position does not require an additional trocar and does not interfere with the surgeons' view and operating technique. Cycles of clamping and unclamping can be performed in few seconds including in the emergency setting.

CONCLUSIONS

Totally laparoscopic PM is a simple, reproducible and inexpensive method of inflow occlusion during laparoscopic liver resection.

Anterior approach for right hepatectomy with hanging maneuver for hepatocellular carcinoma: a multi-institutional propensity score-matching study

BACKGROUND

This multi-institutional study aimed to assess the benefits of anterior approach for right hepatectomy with hanging maneuver (ARH-HM) for hepatocellular carcinoma (HCC) compared with conventional right hepatectomy (CRH).

METHODS

From January 2000 to December 2012, 306 patients with HCC ≥5 cm were divided into two groups: ARH-HM (n = 104) and CRH (n = 202).

RESULTS

After one-to-one propensity score-matched analysis, 72 ARH-HM and 72 CRH patients presented comparable background factors. Patients in the ARH-HM group demonstrated significantly less intraoperative blood loss (480 vs. 1,242 g, P < 0.001) and a lower frequency of red cell concentrate transfusion (21.1% vs. 50.7%, P < 0.001) compared with patients in the CRH group. The 5-year overall survival rate was significantly better in the ARH-HM group compared with the CRH group (50.2% vs. 31.4%, P = 0.021). Limited to patients with HCC ≥10 cm, recurrence-free and overall survival of the ARH-HM group was significantly greater than those of the CRH group.

CONCLUSION

In comparison with CRH, ARH-HM for large HCC can provide better overall survival rates with a decrease in intraoperative blood loss and transfusion rates. Survival impact was evident especially in patients with HCC ≥10 cm.

Glasgow prognostic score predicts therapeutic outcome after hepatic resection for hepatocellular carcinoma

Systemic inflammation, as evidenced by the Glasgow prognostic score (GPS), predicts cancer-specific survival in various cancer types. The aim of this study was to evaluate the significance of the GPS in the therapeutic outcome of the patient following surgical resection for hepatocellular carcinoma. In total, 144 patients underwent surgical resection for hepatocellular carcinoma. For the assessment of systemic inflammatory response using the GPS, patients were classified into three groups: Patients with normal serum albumin (<3.5 g/dl) and normal serum C-reactive protein (CRP) (≤1.0 mg/dl) were classified as GPS 0 (n=76), those with low serum albumin (<3.5 g/dl) or elevated serum CRP (>1.0 mg/dl) were classified as GPS 1 (n=58), and those with low serum albumin (<3.5 g/dl) and elevated serum CRP (>1.0 mg/dl) were classified as GPS 2 (n=10). Retrospectively, the relationship between patient characteristics including GPS, disease-free as well as overall survival were investigated. In disease-free survival, GPS 2 (P=0.019), with a tumor number ≥3 (P=0.004), and positive portal or venous invasion (P=0.034) were independent predictors of cancer recurrence in multivariate analysis. In overall survival, GPS 1 (P=0.042), GPS 2 (P<0.001) and positive portal or venous invasion (P<0.001) were independent predictors of poor patient outcome according to multivariate analysis. To conclude, the GPS in patients with hepatocellular carcinoma is an independent prognostic predictor after hepatic resection.

The impact of perioperative red blood cell transfusions in patients undergoing liver resection: a systematic review

BACKGROUND

Liver resection is associated with a high proportion of red blood cell transfusions. There is a proposed association between perioperative transfusions and increased risk of complications and tumor recurrence. This study reviews the evidence of this association in the literature.

METHODS

The Medline, EMBASE, and Cochrane databases were searched for clinical trials or observational studies of patients undergoing liver resection that compared patients who did and did not receive a perioperative red blood cell transfusion. Outcomes were mortality, complications, and cancer survival.

RESULTS

Twenty-two studies involving 6832 patients were included. All studies were retrospective, with no clinical trials. No studies were scored as low risk of bias. The overall proportion of patients transfused was 38.3%. After multivariate analysis, 1 of 5 studies demonstrated an association between transfusion and increased mortality; 5 of 6 demonstrated an association between transfusion and increased complications; and 10 of 18 demonstrated an association between transfusion and decreased cancer survival.

CONCLUSION

This review supports the evidence linking perioperative blood transfusions to negative outcomes. The most convincing association was with post-operative complications, some association with long-term cancer outcomes, and no convincing association with mortality. These findings support the initiation, and further study, of restrictive transfusion protocols.

Three-point transfusion risk score in hepatectomy

BACKGROUND

Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score.

METHODS

A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated.

RESULTS

There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66.

CONCLUSION

The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.

Restrictive use of perioperative blood transfusion does not increase complication rates in microvascular breast reconstruction

INTRODUCTION

With increasing appreciation of the possible adverse effects of peri-operative blood transfusion, restrictive policies regarding use of blood products have been adopted in many surgical specialties. Although microvascular breast reconstruction has become a routine procedure, high peri-operative transfusion rates continue to be reported in the literature. In this study we examine the impact of our restrictive approach on blood transfusion rates and postoperative complications in patients undergoing microvascular blood transfusion.

METHODS

A retrospective review of patients undergoing microvascular breast reconstruction with abdominal flaps at a single institution was performed. Patient age and body mass index as well as type, timing and laterality of reconstruction was recorded. Pre-operative and post-operative hemoglobin and hematocrit were recorded. Peri-operative blood transfusion rates were calculated. Post-operative complication rates were compared between patients with higher and lower post-operative hemoglobin levels.

RESULTS

Five hundred and twelve patients were included in this study. The peri-operative transfusion rate was 0.98% in this series. There was no significant difference between transfusion rates in unilateral and bilateral reconstructions (0.68 vs 1.36% p = 0.08) or immediate and delayed reconstructions (1.02 vs 0.51% p = 0.72 and 1.01 vs 1.60% p = 0.09 for unilateral and bilateral respectively). Lower post-operative hemoglobin levels were not associated with increased flap related, surgical or medical complications rates.

CONCLUSION

A restrictive approach to peri-operative blood transfusion can be safely adopted in microvascular breast reconstruction without compromising flap viability or overall complication rates.

Perioperative Blood Transfusion as a Significant Predictor of Biochemical Recurrence and Survival after Radical Prostatectomy in Patients with Prostate Cancer

Purpose

There have been conflicting reports regarding the association of perioperative blood transfusion (PBT) with oncologic outcomes including recurrence rates and survival outcomes in prostate cancer. We aimed to evaluate whether perioperative blood transfusion (PBT) affects biochemical recurrence-free survival (BRFS), cancer-specific survival (CSS), and overall survival (OS) following radical prostatectomy (RP) for patients with prostate cancer.

Materials and Methods

A total of 2,713 patients who underwent RP for clinically localized prostate cancer between 1993 and 2014 were retrospectively analyzed. We performed a comparative analysis based on receipt of transfusion (PBT group vs. no-PBT group) and transfusion type (autologous PBT vs. allogeneic PBT). Univariate and multivariate Cox-proportional hazard regression analysis were performed to evaluate variables associated with BRFS, CSS, and OS. The Kaplan-Meier method was used to calculate survival estimates for BRFS, CSS, and OS, and log-rank test was used to conduct comparisons between the groups.

Results

The number of patients who received PBT was 440 (16.5%). Among these patients, 350 (79.5%) received allogeneic transfusion and the other 90 (20.5%) received autologous transfusion. In a multivariate analysis, allogeneic PBT was found to be statistically significant predictors of BRFS, CSS, and OS; conversely, autologous PBT was not. The Kaplan-Meier survival analysis showed significantly decreased 5-year BRFS (79.2% vs. 70.1%, log-rank, p = 0.001), CSS (98.5% vs. 96.7%, log-rank, p = 0.012), and OS (95.5% vs. 90.6%, log-rank, p < 0.001) in the allogeneic PBT group compared to the no-allogeneic PBT group. In the autologous PBT group, however, none of these were statistically significant compared to the no-autologous PBT group.

Conclusions

We found that allogeneic PBT was significantly associated with decreased BRFS, CSS, and OS. This provides further support for the immunomodulation hypothesis for allogeneic PBT.

A Conceptual Technique for Laparoscopic Right Hepatectomy Based on Facts and Oncologic Principles: The Caudal Approach

OBJECTIVE

To evaluate a new conceptual technique of laparoscopic right hepatectomy.

BACKGROUND

Despite significant improvements in surgical care in the last decades, morbidity is still high after major hepatectomy. Blood loss and transfusions are known to significantly increase the risk of postoperative complications and cancer recurrence after liver resection. A laparoscopic approach may improve perioperative outcomes in these cases, but data in literature are limited and the surgical technique is not yet standardized.

METHODS

A new conceptual technique of right hepatectomy was designed using evidence-based facts and oncologic rules: laparoscopy with pneumoperitoneum, low central venous pressure, intermittent pedicle clamping, anterior approach without mobilization, and parenchymal section with ultrasonic dissector. Thirty patients were prospectively enrolled between October 2011 and September 2013. Primary endpoint was intraoperative blood loss.

RESULTS

Eighty percent of patients underwent surgery for malignant disease and cirrhosis was present in 11 patients. Benign lesions accounted for 13% of indications, whereas living liver donation was performed in 2 cases. Median blood loss was 100 mL (50-700) and transfusion rate was 7%. Five patients (16.6%) required conversion to laparotomy, including 2 using hybrid technique. The median operative time was 360 minutes (210-510). R0 resection rate was 87% (21/24). Postoperative morbidity rate was 23% (7/30) with 8 complications including 6 Clavien III-IV. No respiratory complication occurred. The median hospital stay was 8 days. No patient died.

CONCLUSIONS

This study showed that several evidence-based facts could be combined to define a new conceptual technique of laparoscopic right hepatectomy allowing for low blood loss and morbidity.

Portal Vein Embolization Followed by Right-Side Hemihepatectomy for Hepatocellular Carcinoma Patients: A Japanese Multi-Institutional Study

BACKGROUND

Portal vein embolization (PVE) is useful to expand the indications of major hepatectomy; however, its oncologic effects are not fully understood. This study aimed to confirm the efficacy of preoperative PVE for hepatocellular carcinoma patients.

STUDY DESIGN

Between 2000 and 2012, five hundred and ten patients with hepatocellular carcinoma undergoing right-side hemihepatectomy were enrolled (PVE group, n = 162 and non-PVE group, n = 348). To equalize background factors, one-to-one propensity case-matched analysis and multivariate analysis were performed. Short- and long-term outcomes were evaluated.

RESULTS

Propensity score-matched patients, 148 in each group, were selected. The percentage of resected liver volume on admission was significantly greater in the PVE group (60.5% vs 48.3%; p < 0.001), but decreased considerably after PVE, from 60.5% to 50.3% (p < 0.001). The 5-year cumulative recurrence-free survival (36.4% vs 35.3%) and overall survival (58.6% vs 52.8%) rates were comparable. Extrahepatic recurrences were less common in the PVE group (18.1% vs 38.8%; p = 0.004). Independent prognostic factors for recurrence-free survival were morbidity (hazard ratio [HR] = 1.56), multiple tumors (HR = 1.97), red cell concentrate administration (HR = 1.57), older age (HR = 2.09), and massive portal invasion (HR = 2.33); and those for overall survival were morbidity (HR = 2.37), multiple tumors (HR = 1.71), and massive hepatic venous invasion (HR = 3.49).

CONCLUSIONS

Even though hepatocellular carcinoma patients who underwent preoperative PVE and right-side hemihepatectomy had a significantly larger resected liver volume on admission, they have a comparable long-term prognosis as patients with up front hepatectomy. In addition, PVE might decrease extrahepatic recurrences.

Does tranexamic acid reduce blood loss during head and neck cancer surgery?

Background and Aims:

Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery.

Methods:

After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications.

Results:

Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600–1000] ml vs. P - 780 [150–2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120–250] ml vs. TA - 250 [50–1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar.

Conclusion:

In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.

The impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels: A systematic review and meta-analysis

BACKGROUND AND AIMS

Intraoperative vascular occlusion techniques during liver surgeries have been performed and refined for decades. However, the impact of these techniques on postoperative peak ALT levels remains uncertain. Thus, we performed a literature review and meta-analysis to determine the impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels.

METHODS

A systematic literature search of the PubMed database was conducted to discover relevant controlled clinical trials. Studies that reported postoperative peak ALT values for both an observation group and a control group were included. The Q statistic and the I(2) index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test and Orwin's fail-safe N test.

RESULTS

Of the 281 retrieved articles, 10 articles fulfilled the inclusion criteria. These 10 articles involved 12 randomized controlled trials with a total of 1443 records. The pooled estimation results indicated that intraoperative vascular occlusion significantly elevated postoperative peak ALT levels (test for SMD: Z = 4.09, P < 0.001; 95% CI: 0.59-1.68), with high heterogeneity (I(2) = 93.8%). Subgroup analysis revealed that intermittent inflow occlusion and Pringle's maneuver vascular occlusions may be the potential crucial factors. No obvious publication bias was detected by Egger's test (P = 0.541) or Orwin's fail-safe N test (Nfs0.05 = 2059.19).

CONCLUSIONS

Intraoperative vascular occlusion, especially intermittent inflow occlusion and Pringle's maneuver vascular occlusions, may be a potential risk factor that could lead higher postoperative peak ALT values than non-occlusion procedures for liver surgeries.

Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy

Background

Left hepatic trisectionectomy (LHT) is a challenging major anatomical hepatectomy with a high complication rate and a worldwide experience that remains limited. The aim of this study was to describe changes in surgical practice over time, to analyse the outcomes of patients undergoing LHT for hepatobiliary malignancy, and to identify factors associated with morbidity and mortality.

Methods

A cohort study was undertaken of patients who underwent LHT at a single tertiary hepatobiliary referral centre between January 1993 and March 2013. Univariable and multivariable analysis was used to identify factors associated with short- and long-term outcomes following LHT.

Result

Some 113 patients underwent LHT for colorectal liver metastasis (57), hilar cholangiocarcinoma (22), intrahepatic cholangiocarcinoma (12) and hepatocellular carcinoma (11); 11 patients had various other indications. Overall morbidity and 90-day mortality rates were 46·0 and 9·7 per cent respectively. Overall 1- and 3-year survival rates were 71·3 and 44·4 per cent respectively. Total hepatic vascular exclusion and intraoperative blood transfusion were independent predictors of postoperative morbidity, whereas blood transfusion was the only factor predictive of in-hospital mortality. Time period analysis revealed a decreasing trend in blood transfusion, duration of hospital stay, and postoperative morbidity and mortality in the last 5 years.

Conclusion

Morbidity, mortality and long-term survival after LHT support its use in selected patients with a significant tumour burden.

Selective Inflow Occlusion Technique Versus Intermittent Pringle Maneuver in Hepatectomy for Large Hepatocellular Carcinoma: A Retrospective Study

Selective inflow occlusion (SIO) maneuver preserved inflow of nontumorous liver and was supposed to protect liver function. This study aims to evaluate whether SIO maneuver is superior to Pringle maneuver in patients undergoing partial hepatectomy with large hepatocellular carcinomas (HCCs). Between January 2008 and May 2012, 656 patients underwent large HCC resections and were divided into 2 groups: intermittent Pringle maneuver (IP) group (n = 336) and SIO group (n = 320). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed. In comparison to the IP maneuver, the SIO maneuver significantly decreased intraoperative blood loss (473 vs 691  mL, P = 0.001) and transfusion rates (11.3% vs 28.6%, P = 0.006). The rate of major complication between the 2 groups was comparable (22.6% vs 18.8%, P = 0.541). Patients with moderate/severe cirrhosis, total bilirubin > 17  μmol/L, or HBV DNA> = 104  copy/mL in SIO group resulted in lower major complication rates. The SIO maneuver is a safe and effective technique for large HCC resections. In patients with moderate/severe cirrhosis, total bilirubin > 17  μmol/L, or HBV DNA> = 104  copy/mL, the SIO technique is preferentially recommended.

Laparoscopic Major Hepatectomy-Technique and Outcomes

BACKGROUND

With technological innovations especially newer parenchymal transection devices, improved understanding of hepatic anatomy facilitated by better imaging, and reconstructions along with experiences gained from advanced minimal invasive procedures, laparoscopic liver surgery is gaining momentum with more than 5300 reported cases worldwide. Most of the published literature comprises nonanatomical and segmental resections with only few case series having major hepatic resections performed by minimally invasive approach. Aim of this article is to share our technique and experience of total laparoscopic major hepatectomy.

METHODS

It is a retrospective analysis of prospectively maintained database of 56 patients, who underwent laparoscopic major hepatectomy for various indications during 2001 to 2013.

RESULTS

Of 56 patients operated, 37 had malignant disease and 19 had benign lesions with mean size of 6.0 ± 2.8 cm. Thirty-four patients underwent right hepatectomy and 22 left with mean age of 54.8 ± 15.3 years. Mean operating time was 227.4 ± 51.8 min with mean blood loss 265.5 ± 143.4 ml and transfusion needed in 10.7 %. Pringle's maneuver was used in 19.6 % with mean occlusion time of 34.0 ± 11.4 min. Liver-specific complications were observed in 12.5 % and overall complications in 19.6 %. Mean resection margin length in malignant lesions was 2.1 ± 0.9 cm, with <1 cm margin noted in 5.4 %. Median hospital stay was 8 days (6-29) with readmission rate of 8.9 %, re-intervention rate of 5.3 % and 90 days mortality of 1.7 %.

CONCLUSION

Laparoscopic major liver resection is a formidable task. It requires considerable expertise in both, advanced laparoscopy, and liver surgery. It can be feasible, safe, and oncologically adequate in well-selected cases in experience hands.

The superficial precoagulation, sealing, and transection method: a "bloodless" and "ecofriendly" laparoscopic liver transection technique

Supplemental Digital Content is available in the text.

Background:

Minimizing blood loss is an important aspect of laparoscopic liver resection. Liver transection is the most challenging part of liver resection, but no standard method is available for this step at present. Herein, we have introduced the superficial precoagulation, sealing, and transection (SPST) method, a potentially “bloodless” and “ecofriendly” laparoscopic liver transection technique involving reusable devices: the VIO soft-coagulation system; VIO BiClamp (bipolar electrosurgical coagulation); Olympus SonoSurg (ultrasonic surgical system); and CUSA (ultrasonic aspirator). Furthermore, we have reported the short-term outcomes of laparoscopic liver transection with the SPST method.

Methods:

The study included 14 consecutive patients who underwent laparoscopic partial liver resection with the SPST method at a single institution between August 2008 and June 2010.

Results:

The median operative time was 201 minutes (range, 97 to 332 min) and the median blood loss was 5 mL (range, 5 to 250 mL). There was no requirement for blood transfusion, no intraoperative complications, and no cases of conversion to open laparotomy. There were no liver transection-related complications such as postoperative bile leakage, bleeding, or infection. All surgical margins were negative, with a mean margin of 4.6 mm, and no local recurrence was observed at an average follow-up of 37.6 months.

Conclusions:

The SPST method is a simple, efficient, and cost-effective surgical technique for laparoscopic liver resection. It is associated with low intraoperative blood loss and good short-term outcomes. We recommend that the SPST method should be used as a standard technique for laparoscopic liver transection (Supplemental Digital Content 1, http://links.lww.com/SLE/A103).

Preoperative Serum Bilirubin and Lactate Levels Predict Postoperative Morbidity and Mortality in Liver Surgery: A Single-Center Evaluation

Background and Aims:

In spite of huge developments in liver surgery during the last decades, morbidity and mortality continue to pose problems in this field. The aim of this study was to identify preoperative predictors for postoperative mortality and morbidity in liver surgery.

Material and Methods:

In a single-center study, an extensive analysis of a prospective database, including clinical criteria and laboratory tests of patients undergoing liver surgery between July 2007 and July 2012 was performed. Cutoff values of selected laboratory tests were calculated.

Results:

In all, 337 patients were included in the study. Univariate analysis showed a statistically significant association of preoperative bilirubin, lactate, hemoglobin levels, platelet count, and prothrombin time with postoperative morbidity and mortality. Multivariate analysis revealed preoperatively elevated serum bilirubin and lactate levels as independent predictors for increased postoperative morbidity and mortality after liver surgery.

Conclusions:

The identified laboratory values showed a statistically significant association with postoperative morbidity and mortality in liver surgery and might be helpful in preoperative patient selection.

Prognostic Factors of Cholangiocarcinoma After Surgical Resection: A Retrospective Study of 293 Patients

Background

Cholangiocarcinoma is one of the most common malignancies in China. Surgical resection is the only treatment option; however, diagnosis at advanced stage precludes surgery. Comprehensive knowledge of prognostic markers is missing. Hence, the aim of this study was to determine clinicopathological indexes that would be indicative of prognosis in post-operative cases of cholangiocarcinoma.

Material/Methods

A retrospective analysis of 293 cases of cholangiocarcinoma patients attending the 301 Military Hospital in Beijing, China between January 2004 and December 2010 were included in the study. The patients had follow-up history until August 2012. Cox proportional hazards model analysis was performed to identify indexes of prognosis. All indicators were analyzed by univariate and multivariate analysis.

Results

The median follow-up time was 55.90 months, with recurrence and metastasis in 162 cases (55.3%) and death in 223 cases (76.1%). The 1-year, 3-year, and 5-year survival rates were 71.7%, 38.2%, and 10.6%, respectively. The independent risk factors of overall survival were degree of tumor differentiation, TNM stage, surgical margin, intraoperative blood transfusion, tumor location, alkaline phosphatase levels in blood, and relapse.

Conclusions

Good prognosis in cholangiocarcinoma patients is indicated by highly differentiated tumor, early stages of TNM staging, no resection margin invaded, no intraoperative blood transfusion, intrahepatic tumor, normal alkaline phosphatase levels, and no relapse.