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Yilmaz E, Torsello GF, Hosseini ASA, Zygmunt AC, Lorf T, Keck J, Schild-Suhren S, Wellge B, Oberhuber R, Kollmar O, Ghadimi M, Bösch F. Role of liver augmentation prior to hepatic resection - a survey on standards, procedures, and indications in Germany, Switzerland, and Austria. Langenbecks Arch Surg 2024; 409:228. [PMID: 39066906 PMCID: PMC11283428 DOI: 10.1007/s00423-024-03418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 07/13/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE For primary and secondary liver tumors oncological resection remains a chance of cure. Augmentation of functional liver tissue may be necessary to preserve sufficient future liver remnant (FLR). Clinical decision-making on liver augmentation techniques and indications may differ internationally. Thus, this study aims to identify standards of liver augmentation in hepato-pancreatico-biliary (HPB) centers in Germany, Switzerland, and Austria. METHODS Using a web-based survey, 48 hospitals in Germany, Switzerland, and Austria were invited to report their surgical indication, standard procedures, and results of liver augmentation. RESULTS Forty (83.3%) of the hospitals invited participated. Most of the hospitals were certified liver centers (55%), performing complex surgeries such as liver transplantation (57.5%) and ALPPS (80%). The standard liver augmentation technique in all countries was portal vein embolization (PVE; 56%), followed by ALPPS (32.1%) in Germany or PVE with hepatic vein embolization (33.3%) in Switzerland and Austria. Standard procedure for liver augmentation did not correlate with certification as liver center, performance of liver transplantation or ALPPS. Surgical indication for PVE varied depending on tumor entity. Most hospitals rated the importance of PVE before resection of cholangiocarcinoma or colorectal metastases as high, while PVE for hepatocellular carcinoma was rated as low. CONCLUSION The survey gives an overview of the clinical routine in HPB centers in Germany, Austria, and Switzerland. PVE seems to dominate as standard technique to increase the FLR. However, there is a variety in the main indication for liver augmentation. Further studies are necessary evaluating the differing PVE techniques for liver augmentation.
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Affiliation(s)
- Elif Yilmaz
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Giovanni F Torsello
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Anne-Christine Zygmunt
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Thomas Lorf
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Jan Keck
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Stina Schild-Suhren
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Björn Wellge
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Otto Kollmar
- Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, Basel, Switzerland
| | - Michael Ghadimi
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Florian Bösch
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen (UMG), Robert-Koch-Straße 40, 37075, Göttingen, Germany.
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Okada T, Shinkawa H, Taniuchi S, Kinoshita M, Nishio K, Ohira G, Kimura K, Tanaka S, Shintani A, Kubo S, Ishizawa T. Significance of Prediction Models for Post-Hepatectomy Liver Failure Based on Type IV Collagen 7s Domain in Patients with Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:1938. [PMID: 38792016 PMCID: PMC11120429 DOI: 10.3390/cancers16101938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/15/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Previous studies have attempted to establish predictive models for post-hepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) undergoing liver resection. However, a versatile and useful predictive model for PHLF remains to be developed. Therefore, we aimed to develop predictive models for PHLF based on type IV collagen 7s domain (7s collagen) in patients with HCC. Methods: We retrospectively collected data from 972 patients with HCC who had undergone initial curative liver resection between February 2000 and December 2020 at our hospital. Multivariate logistic regression analysis using a restricted cubic spline was performed to evaluate the effect of 7s collagen on the incidence of PHLF. A nomogram was developed based on 7s collagen. Results: PHLF grades B or C were identified in 104 patients (11%): 98 (10%) and 6 (1%) PHLF grades B and C, respectively. Multivariate logistic regression analysis revealed that the preoperative serum level of 7s collagen was significantly associated with a proportional increase in the risk of PHLF, which was confirmed in both laparoscopic and open liver resections. A nomogram was developed based on 7s collagen, with a concordance index of 0.768. The inclusion of 7s collagen values in the predictive model increased the predictive accuracy. Conclusion: The findings highlight the efficacy of the serum level of 7s collagen as a predictive factor for PHLF. Our novel nomogram using 7s collagen may be useful for predicting the risk of PHLF.
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Affiliation(s)
- Takuma Okada
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Hiroji Shinkawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Satsuki Taniuchi
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (S.T.); (A.S.)
| | - Masahiko Kinoshita
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Kohei Nishio
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (S.T.); (A.S.)
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka 545-8595, Japan; (T.O.); (M.K.); (K.N.); (G.O.); (K.K.); (S.T.); (S.K.); (T.I.)
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3
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Koh YX, Tan IEH, Zhao Y, Chong HM, Ang BH, Tan HL, Chua DW, Loh WL, Tan EK, Teo JY, Au MKH, Goh BKP. Evaluation of the American College of Surgeons risk calculator in hepatectomy for metastatic colorectal cancer in a Southeast Asian population. Langenbecks Arch Surg 2024; 409:152. [PMID: 38703240 DOI: 10.1007/s00423-024-03331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/20/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE This study evaluated the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculator in predicting outcomes after hepatectomy for colorectal cancer (CRC) liver metastasis in a Southeast Asian population. METHODS Predicted and actual outcomes were compared for 166 patients undergoing hepatectomy for CRC liver metastasis identified between 2017 and 2022, using receiver operating characteristic curves with area under the curve (AUC) and Brier score. RESULTS The ACS-NSQIP calculator accurately predicted most postoperative complications (AUC > 0.70), except for surgical site infection (AUC = 0.678, Brier score = 0.045). It also exhibited satisfactory performance for readmission (AUC = 0.818, Brier score = 0.011), reoperation (AUC = 0.945, Brier score = 0.002), and length of stay (LOS, AUC = 0.909). The predicted LOS was close to the actual LOS (5.9 vs. 5.0 days, P = 0.985). CONCLUSION The ACS-NSQIP calculator demonstrated generally accurate predictions for 30-day postoperative outcomes after hepatectomy for CRC liver metastasis in our patient population.
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Affiliation(s)
- Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore.
- Duke-National University of Singapore Medical School, Singapore, Singapore.
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore.
| | - Ivan En-Howe Tan
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Hui Min Chong
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Boon Hwee Ang
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
| | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Darren Weiquan Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| | - Wei-Liang Loh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore, 168582, Singapore
- Finance, SingHealth Community Hospitals, Singapore, 168582, Singapore
- Finance, Regional Health System & Strategic Finance, Singapore Health Services, Singapore, 168582, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Academia, 20 College Road, Singapore, 169856, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore, Singapore
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Azoulay D, Desterke C, Bhangui P, Serrablo A, De Martin E, Cauchy F, Salloum C, Allard MA, Golse N, Vibert E, Sa Cunha A, Cherqui D, Adam R, Saliba F, Ichai P, Feray C, Scatton O, Lim C. Rescue Liver Transplantation for Posthepatectomy Liver Failure: A Systematic Review and Survey of an International Experience. Transplantation 2024; 108:947-957. [PMID: 37749790 DOI: 10.1097/tp.0000000000004813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Rescue liver transplantation (LT) is the only life-saving option for posthepatectomy liver failure (PHLF) whenever it is deemed as irreversible and likely to be fatal. The goals were to perform a qualitative systematic review of rescue LT for PHLF and a survey among various international LT experts. METHODS A literature search was performed from 2000 to 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Population, Intervention, Comparison, Outcome framework, and to this, the authors' experience was added. The international online open survey included 6 cases of PHLF extracted from the literature and submitted to 976 LT experts. The primary outcome was whether experts would consider rescue LT for each case. Interrater agreement among experts was calculated using the free-marginal multirater kappa methodology. RESULTS The review included 40 patients. Post-LT mortality occurred in 8 (20%) cases (7/28 with proven cancer and 1/12 with benign disease). In the long term, 6 of 21 (28.6%) survivors with cancer died of recurrence (median = 38 mo) and 15 (71.4%) were alive with no recurrence (median = 111 mo). All 11 survivors with benign disease were alive and well (median = 39 mo). In the international survey among experts in LT, the percentage agreement to consider rescue LT was 28%-98%, higher for benign than for malignant disease ( P = 0.011). Interrater agreement for the primary endpoint was low, expected 5-y survival >50% being the strongest independent predictor to consider LT. CONCLUSIONS Rescue LT for PHLF may achieve good results in selected patients. Considerable inconsistencies of decision-making exist among LT experts when considering LT for PHLF.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Christophe Desterke
- University of Medicine Paris Saclay, Le Kremlin-Bicêtre, France
- INSERM Unit UMR1310, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Eleonora De Martin
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - François Cauchy
- Department of Hepato-biliary and Pancreatic Surgery and Liver Transplantation, University of Geneva, Geneva, Switzerland
| | - Chady Salloum
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Marc Antoine Allard
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Hôpital Universitaire Paul Brousse, Université Paris-Saclay, Villejuif, France
| | - Olivier Scatton
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
- Centre de Recherche de Saint-Antoine (CRSA), INSERM, UMRS-938, Paris, France
| | - Chetana Lim
- Département de Chirurgie et Transplantation Hépatique, Hôpital Universitaire Pitié-Salpêtrière, Sorbonne Université, Paris, France
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Vitello DJ, Shah D, Ko B, Brajcich BC, Peters XD, Merkow RP, Pitt HA, Bentrem DJ. Establishing the clinical relevance of grade A post-hepatectomy liver failure. J Surg Oncol 2024; 129:745-753. [PMID: 38225867 PMCID: PMC10922784 DOI: 10.1002/jso.27570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/09/2023] [Indexed: 01/17/2024]
Abstract
INTRODUCTION The International Study Group of Liver Surgery's criteria stratifies post-hepatectomy liver failure (PHLF) into grades A, B, and C. The clinical significance of these grades has not been fully established. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hepatectomy-targeted database was analyzed. Outcomes between patients without PHLF, with grade A PHLF, and grade B or C PHLF were compared. Univariate and multivariable logistic regression were performed. RESULTS Six thousand two hundred seventy-four adults undergoing elective major hepatectomy were included in the analysis. The incidence of grade A PHLF was 4.3% and grade B or C was 5.3%. Mortality was similar between patients without PHLF (1.2%) and with grade A PHLF (1.1%), but higher in those with grades B or C PHLF (25.4%). Overall morbidities rates were 19.3%, 41.7%, and 72.8% in patients without PHLF, with grade A PHLF, and with grade B or C PHLF, respectively (p < 0.001). Grade A PHLF was associated with increased morbidity (grade A: odds ratios [OR] 2.7 [95% CI: 2.0-3.5]), unplanned reoperation (grade A: OR 3.4 [95% CI: 2.2-5.1]), nonoperative intervention (grade A: OR 2.6 [95% CI: 1.9-3.6]), length of stay (grade A: OR 3.1 [95% CI: 2.3-4.1]), and readmission (grade A: OR 1.8 [95% CI: 1.3-2.5]) compared to patients without PHLF. CONCLUSIONS Although mortality was similar between patients without PHLF and with grade A PHLF, other postoperative outcomes were notably inferior. Grade A PHLF is a clinically distinct entity with relevant associated postoperative morbidity.
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Affiliation(s)
- Dominic J Vitello
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dhavan Shah
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bona Ko
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian C Brajcich
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xane D Peters
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago Prizker School of Medicine, Chicago, Illinois, USA
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Jesse Brown Veterans Administration Medical Center, Chicago, Illinois, USA
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Sofue K, Shimada R, Ueshima E, Komatsu S, Yamaguchi T, Yabe S, Ueno Y, Hori M, Murakami T. Evaluation and Prediction of Post-Hepatectomy Liver Failure Using Imaging Techniques: Value of Gadoxetic Acid-Enhanced Magnetic Resonance Imaging. Korean J Radiol 2024; 25:24-32. [PMID: 38184766 PMCID: PMC10788604 DOI: 10.3348/kjr.2023.0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/13/2023] [Accepted: 10/07/2023] [Indexed: 01/08/2024] Open
Abstract
Despite improvements in operative techniques and perioperative care, post-hepatectomy liver failure (PHLF) remains the most serious cause of morbidity and mortality after surgery, and several risk factors have been identified to predict PHLF. Although volumetric assessment using imaging contributes to surgical simulation by estimating the function of future liver remnants in predicting PHLF, liver function is assumed to be homogeneous throughout the liver. The combination of volumetric and functional analyses may be more useful for an accurate evaluation of liver function and prediction of PHLF than only volumetric analysis. Gadoxetic acid is a hepatocyte-specific magnetic resonance (MR) contrast agent that is taken up by hepatocytes via the OATP1 transporter after intravenous administration. Gadoxetic acid-enhanced MR imaging (MRI) offers information regarding both global and regional functions, leading to a more precise evaluation even in cases with heterogeneous liver function. Various indices, including signal intensity-based methods and MR relaxometry, have been proposed for the estimation of liver function and prediction of PHLF using gadoxetic acid-enhanced MRI. Recent developments in MR techniques, including high-resolution hepatobiliary phase images using deep learning image reconstruction and whole-liver T1 map acquisition, have enabled a more detailed and accurate estimation of liver function in gadoxetic acid-enhanced MRI.
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Affiliation(s)
- Keitaro Sofue
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Ryuji Shimada
- Center for Radiology and Radiation Oncology, Kobe University Hospital, Kobe, Japan
| | - Eisuke Ueshima
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeru Yamaguchi
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinji Yabe
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiko Ueno
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masatoshi Hori
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takamichi Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
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Christopher CN, Kang DW, Wilson RL, Gonzalo-Encabo P, Ficarra S, Heislein D, Dieli-Conwright CM. Exercise and Nutrition Interventions for Prehabilitation in Hepato-Pancreato-Biliary Cancers: A Narrative Review. Nutrients 2023; 15:5044. [PMID: 38140303 PMCID: PMC10745391 DOI: 10.3390/nu15245044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Gastrointestinal (GI) cancers constitute over 25% of global cancer cases annually, with hepato-pancreato-biliary (HPB) cancers presenting particularly poor prognosis and challenging surgical treatments. While advancements in clinical care have improved post-operative outcomes over time, surgery for HPB cancers remains associated with high morbidity and mortality rates. Patients with HPB cancer are often older, diagnosed at later stages, and have a higher prevalence of co-morbid conditions, leading to reduced life expectancy, suboptimal post-operative recovery, and increased recurrence risk. Exercise and nutrition interventions have emerged as safe non-pharmacological strategies to enhance clinical outcomes among cancer survivors, but their potential in the pre-operative period for patients with HPB cancer remains underexplored. This narrative review evaluates existing evidence on exercise and nutritional interventions during pre-operative prehabilitation for HPB cancer populations, focusing on clinically relevant post-operative outcomes related to frailty and malnutrition. We conducted a literature search in PubMed and Google Scholar databases to identify studies utilizing a prehabilitation intervention in HPB cancer populations with exercise and nutritional components. The currently available evidence suggests that incorporating exercise and nutrition into prehabilitation programs offers a critical opportunity to enhance post-operative outcomes, mitigate the risk of comorbidities, and support overall survivorship among HPB cancer populations. This review underscores the need for further research to optimize the timing, duration, and components of pre-operative prehabilitation programs, emphasizing patient-centered, multidisciplinary approaches in this evolving field.
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Affiliation(s)
- Cami N. Christopher
- Department of Medical Oncology, Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (C.N.C.); (D.-W.K.); (R.L.W.); (P.G.-E.); (S.F.)
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Dong-Woo Kang
- Department of Medical Oncology, Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (C.N.C.); (D.-W.K.); (R.L.W.); (P.G.-E.); (S.F.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Rebekah L. Wilson
- Department of Medical Oncology, Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (C.N.C.); (D.-W.K.); (R.L.W.); (P.G.-E.); (S.F.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Paola Gonzalo-Encabo
- Department of Medical Oncology, Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (C.N.C.); (D.-W.K.); (R.L.W.); (P.G.-E.); (S.F.)
- Harvard Medical School, Boston, MA 02115, USA
- Departamento de Ciencias Biomédicas, Área de Educación Física y Deportiva, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, 28801 Madrid, Spain
| | - Salvatore Ficarra
- Department of Medical Oncology, Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (C.N.C.); (D.-W.K.); (R.L.W.); (P.G.-E.); (S.F.)
- Sport and Exercise Sciences Research Unit, Department of Psychology, Educational Science and Human Movement, University of Palermo, 90133 Palermo, Italy
| | - Diane Heislein
- Department of Physical Therapy, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, MA 02215, USA
| | - Christina M. Dieli-Conwright
- Department of Medical Oncology, Division of Population Health Sciences, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (C.N.C.); (D.-W.K.); (R.L.W.); (P.G.-E.); (S.F.)
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
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Gerwing M, Schindler P, Katou S, Köhler M, Stamm AC, Schmidt VF, Heindel W, Struecker B, Morgul H, Pascher A, Wildgruber M, Masthoff M. Multi-organ Radiomics-Based Prediction of Future Remnant Liver Hypertrophy Following Portal Vein Embolization. Ann Surg Oncol 2023; 30:7976-7985. [PMID: 37670120 PMCID: PMC10625940 DOI: 10.1245/s10434-023-14241-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/24/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Portal vein embolization (PVE) is used to induce remnant liver hypertrophy prior to major hepatectomy. The purpose of this study was to evaluate the predictive value of baseline computed tomography (CT) data for future remnant liver (FRL) hypertrophy after PVE. METHODS In this retrospective study, all consecutive patients undergoing right-sided PVE with or without hepatic vein embolization between 2018 and 2021 were included. CT volumetry was performed before and after PVE to assess standardized FRL volume (sFRLV). Radiomic features were extracted from baseline CT after segmenting liver (without tumor), spleen and bone marrow. For selecting features that allow classification of response (hypertrophy ≥ 1.33), a stepwise dimension reduction was performed. Logistic regression models were fitted and selected features were tested for their predictive value. Decision curve analysis was performed on the test dataset. RESULTS A total of 53 patients with liver tumor were included in this study. sFRLV increased significantly after PVE, with a mean hypertrophy of FRL of 1.5 ± 0.3-fold. sFRLV hypertrophy ≥ 1.33 was reached in 35 (66%) patients. Three independent radiomic features, i.e. liver-, spleen- and bone marrow-associated, differentiated well between responders and non-responders. A logistic regression model revealed the highest accuracy (area under the curve 0.875) for the prediction of response, with sensitivity of 1.0 and specificity of 0.5. Decision curve analysis revealed a positive net benefit when applying the model. CONCLUSIONS This proof-of-concept study provides first evidence of a potential predictive value of baseline multi-organ radiomics CT data for FRL hypertrophy after PVE.
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Affiliation(s)
- Mirjam Gerwing
- Clinic for Radiology, University Hospital Münster, Münster, Germany.
| | | | - Shadi Katou
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Münster, Münster, Germany
| | | | | | - Walter Heindel
- Clinic for Radiology, University Hospital Münster, Münster, Germany
| | - Benjamin Struecker
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Haluk Morgul
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Andreas Pascher
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, Münster, Germany
| | - Moritz Wildgruber
- Clinic for Radiology, University Hospital Münster, Münster, Germany
- Department for Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Münster, Münster, Germany
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9
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Chouari T, Merali N, La Costa F, Santol J, Chapman S, Horton A, Aroori S, Connell J, Rockall TA, Mole D, Starlinger P, Welsh F, Rees M, Frampton AE. The Role of the Multiparametric MRI LiverMultiScan TM in the Quantitative Assessment of the Liver and Its Predicted Clinical Applications in Patients Undergoing Major Hepatic Resection for Colorectal Liver Metastasis. Cancers (Basel) 2023; 15:4863. [PMID: 37835557 PMCID: PMC10571783 DOI: 10.3390/cancers15194863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/05/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
Liver biopsy remains the gold standard for the histological assessment of the liver. With clear disadvantages and the rise in the incidences of liver disease, the role of neoadjuvant chemotherapy in colorectal liver metastasis (CRLM) and an explosion of surgical management options available, non-invasive serological and imaging markers of liver histopathology have never been more pertinent in order to assess liver health and stratify patients considered for surgical intervention. Liver MRI is a leading modality in the assessment of hepatic malignancy. Recent technological advancements in multiparametric MRI software such as the LiverMultiScanTM offers an attractive non-invasive assay of anatomy and histopathology in the pre-operative setting, especially in the context of CRLM. This narrative review examines the evidence for the LiverMultiScanTM in the assessment of hepatic fibrosis, steatosis/steatohepatitis, and potential applications for chemotherapy-associated hepatic changes. We postulate its future role and the hurdles it must surpass in order to be implemented in the pre-operative management of patients undergoing hepatic resection for colorectal liver metastasis. Such a role likely extends to other hepatic malignancies planned for resection.
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Affiliation(s)
- Tarak Chouari
- MATTU, The Leggett Building, Daphne Jackson Road, Guildford GU2 7WG, UK; (T.C.)
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
- Oncology Section, Department of Clinical and Experimental Medicine, Faculty of Health and Medical Science, University of Surrey, Guildford GU2 7WG, UK
| | - Nabeel Merali
- MATTU, The Leggett Building, Daphne Jackson Road, Guildford GU2 7WG, UK; (T.C.)
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
- Oncology Section, Department of Clinical and Experimental Medicine, Faculty of Health and Medical Science, University of Surrey, Guildford GU2 7WG, UK
| | - Francesca La Costa
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Jonas Santol
- Department of Surgery, HPB Center, Vienna Health Network, Clinic Favoriten and Sigmund Freud Private University, 1090 Vienna, Austria
- Institute of Vascular Biology and Thrombosis Research, Center of Physiology and Pharmacology, Medical University of Vienna, 1090 Vienna, Austria
| | - Shelley Chapman
- Department of Radiology, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Alex Horton
- Department of Radiology, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
| | - Somaiah Aroori
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery and Transplant Surgery, Derriford Hospital, Plymouth PL6 8DH, UK
| | | | - Timothy A. Rockall
- MATTU, The Leggett Building, Daphne Jackson Road, Guildford GU2 7WG, UK; (T.C.)
- Oncology Section, Department of Clinical and Experimental Medicine, Faculty of Health and Medical Science, University of Surrey, Guildford GU2 7WG, UK
| | - Damian Mole
- Clinical Surgery, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh EH10 5HF, UK
- Centre for Inflammation Research, University of Edinburgh, Queen’s Medical Research Institute, Edinburgh EH105HF, UK
| | - Patrick Starlinger
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN 55902, USA
- Center of Physiology and Pharmacology, Medical University of Vienna, 1090 Vienna, Austria
- Department of Surgery, Medical University of Vienna, General Hospital, 1090 Vienna, Austria
| | - Fenella Welsh
- Hepato-Biliary Unit, Hampshire Hospitals Foundation Trust, Basingstoke, Hampshire RG24 9NA, UK
| | - Myrddin Rees
- Hepato-Biliary Unit, Hampshire Hospitals Foundation Trust, Basingstoke, Hampshire RG24 9NA, UK
| | - Adam E. Frampton
- MATTU, The Leggett Building, Daphne Jackson Road, Guildford GU2 7WG, UK; (T.C.)
- Department of Hepato-Pancreato-Biliary (HPB) Surgery, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK
- Oncology Section, Department of Clinical and Experimental Medicine, Faculty of Health and Medical Science, University of Surrey, Guildford GU2 7WG, UK
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10
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Lund A, Andersen KJ, Meier M, Pedersen MI, Knudsen AR, Kirkegård J, Mortensen FV, Nyengaard JR. Biochemical and morphological responses to post-hepatectomy liver failure in rats. Sci Rep 2023; 13:13544. [PMID: 37598250 PMCID: PMC10439910 DOI: 10.1038/s41598-023-40736-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/16/2023] [Indexed: 08/21/2023] Open
Abstract
The upper limit for partial hepatectomy (PH) in rats is 90%, which is associated with an increased risk of post-hepatectomy liver failure (PHLF), correlating with high mortality. Sixty-eight rats were randomized to 90% PH, sham operation, or no surgery. Further block randomization was performed to determine the time of euthanasia, whether 12, 24, or 48 h after surgery. A general distress score (GDS) was calculated to distinguish between rats with reversible (GDS < 10) and irreversible PHLF (GDS ≥ 10). At euthanasia, the liver remnant and blood were collected. Liver-specific biochemistry and regeneration ratio were measured. Hepatocyte proliferation and volume were estimated using stereological methods. All rats subjected to 90% experienced biochemical PHLF. The biochemical and morphological liver responses did not differ between the groups until 48 h after surgery. At 48 h, liver regeneration and function were significantly improved in survivors. The peak mean regeneration ratio was 15% for rats with irreversible PHLF compared to 26% for rats with reversible PHLF. The 90% PH rat model was associated with PHLF and high mortality. Irreversible PHLF was characterized by impaired liver regeneration capacity and an insufficient ability to metabolize ammonia.
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Affiliation(s)
- Andrea Lund
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Kasper Jarlhelt Andersen
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michelle Meier
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marie Ingemann Pedersen
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Riegels Knudsen
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jakob Kirkegård
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Frank Viborg Mortensen
- Department of Surgery, Section for Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Randel Nyengaard
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
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11
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Ito T, Tanemura A, Kuramitsu T, Murase T, Kaluba B, Noguchi D, Fujii T, Yuge T, Maeda K, Hayasaki A, Gyoten K, Iizawa Y, Murata Y, Kuriyama N, Kishiwada M, Mizuno S. Spleen volume is a predictor of posthepatectomy liver failure and short-term mortality for hepatocellular carcinoma. Langenbecks Arch Surg 2023; 408:297. [PMID: 37548783 DOI: 10.1007/s00423-023-03025-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/20/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND The study aimed at retrospectively assessing the impact of spleen volume (SpV) on the development of posthepatectomy liver failure (PHLF) in patients who underwent hepatectomy for hepatocellular carcinoma (HCC). METHODS 152 patients with primary HCC who underwent hepatectomy (sectionectomy or more) were classified into PHLF and non-PHLF groups, and then the relationship between PHLF and SpV was assessed. SpV (cm3) was obtained from preoperative CT and standardized based on the patient's body surface area (BSA, m2). RESULTS PHLF was observed in 39 (26%) of the 152 cases. SpV/BSA was significantly higher in the PHLF group, and the postoperative 1-year survival rate was significantly worse in the PHLF group than that in the non-PHLF group (p = 0.044). Multivariable analysis revealed SpV/BSA as a significant independent risk factor for PHLF. Using the cut-off value (160 cm3/m2), the 152 cases were divided into small SpV and large SpV groups. The incidence of PHLF was significantly higher in the large SpV group (p = 0.002), the liver failure-related mortality rate was also significantly higher in the large SpV group (p = 0.007), and the 1-year survival rate was significantly worse in the large SpV group (p = 0.035). CONCLUSION These results suggest SpV as a predictor of PHLF and short-term mortality in patients who underwent hepatectomy for HCC. Moreover, SpV measurement is a simple and potentially useful method for predicting PHLF in patients with HCC.
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Affiliation(s)
- Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Toru Kuramitsu
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Taichi Murase
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Benson Kaluba
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Daisuke Noguchi
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tekehiro Fujii
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takuya Yuge
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Koki Maeda
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yusuke Iizawa
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Tsu, Japan
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12
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Impact of neoadjuvant chemotherapy on post-hepatectomy regeneration for patients with colorectal cancer liver metastasis - Systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:533-541. [PMID: 36631347 DOI: 10.1016/j.ejso.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/18/2022] [Accepted: 12/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Today, there is still debate on the impact of neoadjuvant chemotherapy (NeoChem) on liver regeneration (LivReg). The objectives of this study were to assess the impact of NeoChem and its characteristics (addition of bevacizumab, number of cycles and time from end of NeoChem) on post-hepatectomy LivReg. MATERIAL & METHODS Studies reporting LivReg in patients submitted to liver resection were included. Pubmed, Scopus, Web of Science, Embase, and Cochrane databases were searched. Only studies comparing NeoChem vs no chemotherapy or comparing chemotherapy characteristics from 1990 to present were included. Two researchers individually screened the identified records registered in a predesigned database. Primary outcome was future liver remnant regeneration rate (FLR3). Bias of the studies was evaluated with the ROBINS-I tool, and quality of evidence with the GRADE system. Data was presented as mean difference or standard mean difference. RESULTS Eight studies with a total of 681 patients were selected. Seven were retrospective and one prospective comparative cohort studies. In patients submitted to major hepatectomy, NeoChem did not have an impact on LivReg (MD 3.12, 95% CI -2,12-8.36, p 0,24). Adding bevacizumab to standard NeoChem was associated with better FLR3 (SMD 0.45, 95% CI 0.19-0.71, p 0.0006). DISCUSSION The main drawback of this review is the retrospective nature of the available studies. NeoChem does not have a negative impact on postoperative LivReg in patients submitted to liver resection. Regimens with bevacizumab seem to be associated with better postoperative LivReg rates when compared to standard NeoChem.
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13
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Keulen AMV, Gaspersz MP, van Vugt JLA, Roos E, Olthof PB, Coelen RJS, Bruno MJ, van Driel LMJW, Voermans RP, van Eijck CHJ, van Hooft JE, van Lienden KP, de Jonge J, Polak WG, Poley JW, Pek CJ, Moelker A, Willemssen FEJA, van Gulik TM, Erdmann JI, Hol L, IJzermans JNM, Büttner S, Koerkamp BG. Success, complication, and mortality rates of initial biliary drainage in patients with unresectable perihilar cholangiocarcinoma. Surgery 2022; 172:1606-1613. [PMID: 35989132 DOI: 10.1016/j.surg.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/09/2022] [Accepted: 06/20/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The patients with unresectable perihilar cholangiocarcinoma require biliary drainage to relieve symptoms and allow for palliative systemic chemotherapy. The aim of this study was to establish the success, complication, and mortality rates of the initial biliary drainage in patients with unresectable perihilar cholangiocarcinoma at presentation. METHODS In this retrospective multicenter study, patients with unresectable perihilar cholangiocarcinoma who underwent initial endoscopic or percutaneous transhepatic biliary drainage between 2002 and 2014 were included. The success of drainage was defined as a successful biliary stent or drain placement, no unscheduled reintervention within 14 days, and serum bilirubin levels <50 μmol/L (ie, 2.9 mg/dL) or a >50% decrease in serum bilirubin after 14 days. Severe complications, and 90-day mortality were recorded. RESULTS Included were 186 patients: 161 (87%) underwent initial endoscopic biliary drainage and 25 (13%) underwent initial percutaneous transhepatic biliary drainage. The success of initial drainage was observed in 73 patients (45%) after endoscopic biliary drainage and 6 (24%) after percutaneous transhepatic biliary drainage. The reasons for an unsuccessful initial drainage were: the failure to place a drain or stent in 39 patients (21%), an unplanned reintervention within 14 days in 52 patients (28%), and the bilirubin level >50 μmol/L (or not halved) after 14 days of initial drainage in 16 patients (9%). Severe drainage-related complications occurred in 19 patients (12%) after endoscopic biliary drainage and in 3 (12%) after percutaneous transhepatic biliary drainage. Overall, 66 patients (36%) died within 90 days after initial biliary drainage. CONCLUSION Initial biliary drainage in patients with unresectable perihilar cholangiocarcinoma had a success rate of 45% and a 90-day mortality rate of 36%. Future studies for patients with perihilar cholangiocarcinoma should focus on improving biliary drainage.
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Affiliation(s)
| | - Marcia P Gaspersz
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Roos
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, the Netherlands
| | - Pim B Olthof
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Robert J S Coelen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam Gastroenterology and Metabolism Institute, the Netherlands
| | | | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, the Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Amsterdam University Medical Center, the Netherlands
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Chulja J Pek
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - François E J A Willemssen
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, the Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam University Medical Centers, the Netherlands
| | - L Hol
- Department of Gastroenterology and Hepatology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Stefan Büttner
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
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14
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Predictors of Liver Failure in Non-Cirrhotic Patients Undergoing Hepatectomy. World J Surg 2022; 46:3081-3089. [PMID: 36209339 DOI: 10.1007/s00268-022-06742-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is associated with high mortality following liver resection. There have been limited studies evaluating predictors of PHLF and clinically significant PHLF in non-cirrhotic patients. METHODS This was a retrospective cohort study using the National Surgical Quality Improvement Program database (NSQIP) to evaluate 8,093 non-cirrhotic patients undergoing hepatectomy from 2014 to 2018. Primary endpoints were PHLF and clinically significant PHLF (PHLF grade B or C). RESULTS Among all patients, 4.74% (n = 383) developed PHLF and 2.5% clinically significant PHLF (n = 203). The overall 30-day mortality was 1.35% (n = 109), 11.5% (n = 44) in patients with PHLF, and 19.2% in those with clinically significant PHLF. Factors associated with PHLF were: metastatic liver disease (OR = 1.84, CI = 1.14-2.98), trisectionectomy (OR = 3.71, CI = 2.59-5.32), right total lobectomy (OR = 4.17, CI = 3.06-5.68), transfusions (OR = 1.99, CI = 1.52-2.62), organ/space SSI (OR = 2.84, CI = 2.02-3.98), post-operative pneumonia (OR = 2.43, CI = 1.57-3.76), sepsis (OR = 2.27, CI = 1.47-3.51), and septic shock (OR = 5.67, CI = 3.43-9.36). Patients who developed PHLF or clinically significant PHLF had 2-threefold increased risk of perioperative mortality. Post-hepatectomy renal failure (OR = 8.47, CI = 3.96-18.1), older age (OR = 1.04, CI = 1.014-1.063), male sex (OR = 1.83, CI = 1.07-3.14), sepsis (OR = 2.96, CI = 1.22-7.2), and septic shock (OR = 3.92, CI = 1.61-9.58) were independently associated with 30-mortality in patients with clinically significant PHLF. CONCLUSION PHLF in non-cirrhotic patients increased the risk of perioperative mortality and is associated with the extent of hepatectomy and infectious complications. Careful evaluation of the liver remnant, antibiotic prophylaxis, nutritional assessment, and timely management of post-operative infections could decrease major morbidity and mortality following hepatectomy.
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15
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Li YR, Chen JD, Huang J, Wu FX, Jin GZ. Post-hepatectomy liver failure prediction and prevention: Development of a nomogram containing postoperative anticoagulants as a risk factor. Ann Hepatol 2022; 27:100744. [PMID: 35964908 DOI: 10.1016/j.aohep.2022.100744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/15/2022] [Accepted: 07/19/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Posthepatectomy liver failure (PHLF) is a serious complication after hepatectomy, and its effective methods for preoperative prediction are lacking. Here, we aim to identify predictive factors and build a nomogram to evaluate patients' risk of developing PHLF. PATIENTS AND METHODS A retrospective review of a training cohort, including 199 patients who underwent hepatectomy at the Shanghai Eastern Hepatobiliary Surgery Hospital, was conducted. Independent risk variables for PHLF were identified using multivariate analysis of perioperative variables, and a nomogram was used to build a predictive model. To test the predictive power, a prospective study in which a validation cohort of 71 patients was evaluated using the nomogram. The prognostic value of this nomogram was evaluated by the C-index. RESULTS Independent risk variables for PHLF were identified from perioperative variables. In multivariate analysis of the training cohort, tumor number, Pringle maneuver, blood loss, preoperative platelet count, postoperative ascites and use of anticoagulant medications were determined to be key risk factors for the development of PHLF, and they were selected for inclusion in our nomogram. The nomogram showed a 0.911 C-index for the training cohort. In the validation cohort, the nomogram also showed good prognostic value for predicting PHLF. The validation cohort was used with similarly successful results to evaluate risk in two previously published study models with calculated C-indexes of 0.718 and 0.711. CONCLUSION Our study establishes for the first time a novel nomogram that can be used to identify patients at risk of developing PHLF.
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Affiliation(s)
- Yi-Ran Li
- Department of Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, The Third Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jin-Dong Chen
- School of Basic medical sciences, The Second Military Medical University, Shanghai, China
| | - Jian Huang
- Department of Third Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Fei-Xiang Wu
- Department of Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, The Third Affiliated Hospital of Naval Medical University, Shanghai, China.
| | - Guang-Zhi Jin
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
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Sparrelid E, Olthof PB, Dasari BVM, Erdmann JI, Santol J, Starlinger P, Gilg S. Current evidence on posthepatectomy liver failure: comprehensive review. BJS Open 2022; 6:6840812. [PMID: 36415029 PMCID: PMC9681670 DOI: 10.1093/bjsopen/zrac142] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Despite important advances in many areas of hepatobiliary surgical practice during the past decades, posthepatectomy liver failure (PHLF) still represents an important clinical challenge for the hepatobiliary surgeon. The aim of this review is to present the current body of evidence regarding different aspects of PHLF. METHODS A literature review was conducted to identify relevant articles for each topic of PHLF covered in this review. The literature search was performed using Medical Subject Heading terms on PubMed for articles on PHLF in English until May 2022. RESULTS Uniform reporting on PHLF is lacking due to the use of various definitions in the literature. There is no consensus on optimal preoperative assessment before major hepatectomy to avoid PHLF, although many try to estimate future liver remnant function. Once PHLF occurs, there is still no effective treatment, except liver transplantation, where the reported experience is limited. DISCUSSION Strict adherence to one definition is advised when reporting data on PHLF. The use of the International Study Group of Liver Surgery criteria of PHLF is recommended. There is still no widespread established method for future liver remnant function assessment. Liver transplantation is currently the only effective way to treat severe, intractable PHLF, but for many indications, this treatment is not available in most countries.
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Affiliation(s)
- Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pim B Olthof
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bobby V M Dasari
- Department of HPB Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Joris I Erdmann
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jonas Santol
- Department of Surgery, HPB Center, Viennese Health Network, Clinic Favoriten and Sigmund Freud Private University, Vienna, Austria.,Department of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Patrick Starlinger
- Division of General Surgery, Department of Surgery, Medical University of Vienna, General Hospital of Vienna, Vienna, Austria.,Department of Surgery, Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, New York, USA
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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17
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Gilg S, Sparrelid E, Engstrand J, Baumgartner R, Nowak G, Stål P, D'Souza M, Jansson A, Isaksson B, Jonas E, Stromberg C. Molecular adsorbent recirculating system treatment in patients with post-hepatectomy liver failure: Long-term results of a pilot study. Scand J Surg 2022; 111:48-55. [PMID: 36000747 DOI: 10.1177/14574969221112224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) is the leading cause of postoperative mortality following major liver resection. Between December 2012 and May 2015, 10 consecutive patients with PHLF (according to the Balzan criteria) following major/extended hepatectomy were included in a prospective treatment study with the molecular adsorbent recirculating system (MARS). Sixty- and 90-day mortality rates were 0% and 10%, respectively. Of the nine survivors, four still had liver dysfunction at 90 days postoperatively. One-year overall survival (OS) of the MARS-PHLF cohort was 50%. The present study aims to assess long-term outcome of this cohort compared to a historical control cohort. METHODS To compare long-term outcome of the MARS-PHLF treatment cohort with PHLF patients not treated with MARS, the present study includes all 655 patients who underwent major hepatectomy at Karolinska University Hospital between 2010 and 2018. Patients with PHLF were identified according to the Balzan criteria. RESULTS The cohort was split into three time periods: pre-MARS period (n = 192), MARS study period (n = 207), and post-MARS period (n = 256). The 90-day mortality of patients with PHLF was 55% (6/11) in the pre-MARS period, 14% during the MARS study period (2/14), and 50% (3/6) in the post-MARS period (p = 0.084). Median OS (95% confidence interval (CI)) was 37.8 months (29.3-51.7) in the pre-MARS cohort, 57 months (40.7-75.6) in the MARS cohort, and 38.8 months (31.4-51.2) in the post-MARS cohort. The 5-year OS of 10 patients included in the MARS study was 40% and the median survival 11.6 months (95% CI: 3 to not releasable). In contrast, for the remaining 21 patients fulfilling the Balzan criteria during the study period but not treated with MARS, the 5-year OS and median survival were 9.5% and 7.3 months (95% CI, 0.5-25.9), respectively (p = 0.138)). CONCLUSIONS MARS treatment may contribute to improved outcome of patients with PHLF. Further studies are needed.The initial pilot study was registered at ClinicalTrials.gov (NCT03011424).
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Affiliation(s)
- Stefan Gilg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jennie Engstrand
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ruth Baumgartner
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Greg Nowak
- Department for Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Per Stål
- Department of Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | - Melroy D'Souza
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Jansson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Isaksson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Eduard Jonas
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Cecilia Stromberg
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Yugawa K, Maeda T, Nagata S, Shiraishi J, Sakai A, Yamaguchi S, Konishi K, Hashimoto K. Impact of aspartate aminotransferase-to-platelet ratio index based score to assess posthepatectomy liver failure in patients with hepatocellular carcninoma. World J Surg Oncol 2022; 20:248. [PMID: 35918753 PMCID: PMC9344632 DOI: 10.1186/s12957-022-02714-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Posthepatectomy liver failure (PHLF) is a life-threatening complication following hepatic resection. The aspartate aminotransferase-to-platelet ratio index (APRI) is a non-invasive model for assessing the liver functional reserve in patients with hepatocellular carcinoma (HCC). This study aimed to establish a scoring model to stratify patients with HCC at risk for PHLF. METHODS This single-center retrospective study included 451 patients who underwent hepatic resection for HCC between 2004 and 2017. Preoperative factors, including non-invasive liver fibrosis markers and intraoperative factors, were evaluated. The predictive impact for PHLF was evaluated using receiver operating characteristic (ROC) curves of these factors. RESULTS Of 451 patients, 30 (6.7%) developed severe PHLF (grade B/C). Multivariate logistic analysis indicated that APRI, model for end-stage liver disease (MELD) score, operating time, and intraoperative blood loss were significantly associated with severe PHLF. A scoring model (over 0-4 points) was calculated using these optimal cutoff values. The area under the ROC curve of the established score for severe PHLF was 0.88, which greatly improved the predictive accuracy compared with these factors alone (p < 0.05 for all). CONCLUSIONS The scoring model-based APRI, MELD score, operating time, and intraoperative blood loss can predict severe PHLF in patients with HCC.
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Affiliation(s)
- Kyohei Yugawa
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Takashi Maeda
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan.
| | - Shigeyuki Nagata
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Jin Shiraishi
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Akihiro Sakai
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Shohei Yamaguchi
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Kozo Konishi
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Kenkichi Hashimoto
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
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Preoperative Osteopenia Is Associated with Significantly Shorter Survival in Patients with Perihilar Cholangiocarcinoma. Cancers (Basel) 2022; 14:cancers14092213. [PMID: 35565342 PMCID: PMC9103099 DOI: 10.3390/cancers14092213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/06/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Osteopenia is defined as low bone mineral density (BMD) and has been shown to be associated with outcomes of patients with various cancers. The association between osteopenia and perihilar cholangiocarcinoma is unknown. The aim of this study was to evaluate osteopenia as a prognostic factor in patients with perihilar cholangiocarcinoma. Methods: A total of 58 patients who underwent surgery for perihilar cholangiocarcinoma were retrospectively analyzed. The BMD at the 11th thoracic vertebra was measured using computed tomography scan within one month of surgery. Patients with a BMD < 160 HU were considered to have osteopenia and b BMD ≥ 160 did not have osteopenia. The log-rank test was performed for survival using the Kaplan−Meier method. After adjusting for confounding factors, overall survival was assessed by Cox′s proportional-hazards model. Results: The osteopenia group had 27 (47%) more females than the non-osteopenia group (p = 0.036). Median survival in the osteopenia group was 37 months and in the non-osteopenia group was 61 months (p = 0.034). In multivariable analysis, osteopenia was a significant independent risk factor associated with overall survival in patients with perihilar cholangiocarcinoma (hazard ratio 3.54, 95% confidence interval 1.09−11.54, p = 0.036), along with primary tumor stage. Conclusions: Osteopenia is associated with significantly shorter survival in patients with perihilar cholangiocarcinoma.
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Burlaka AA, Makhmudov DE, Lisnyi II, Paliichuk AV, Zvirych VV, Lukashenko AV. Parenchyma-sparing strategy and oncological prognosis in patients with colorectal cancer liver metastases. World J Surg Oncol 2022; 20:122. [PMID: 35430799 PMCID: PMC9013456 DOI: 10.1186/s12957-022-02579-1] [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: 01/29/2022] [Accepted: 03/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Preliminary study results demonstrated parenchyma-sparing surgery (PSS) as an effective approach which allowed to remove colorectal cancer (CRC) metastatic lesions within the central liver cites and increased the probability of the liver re-resections. Methods The prospective analysis re-evaluation of the 185 CRC patients surgical treatment has been performed. Results An overall 5-year survival (OS) of the 185 enrolled patients was 43 ± 7%, and the mean and median value for OS was 48.7 ± 1.9% and 55.2 ± 5 (95% CI: 44.4–66.1) months. The 5-year OS for CRC patients whose metastatic lesions were predominantly located within peripheral and central liver segments was 56 ± 8% and 27 ± 9%, respectively (p = 0.08). A 5-year disease-free survival (DFS) rates of patients with peripheral and central liver cites metastatic lesions were 31 ± 7 % and 15 ± 7%, p = 0,12. And the DFS median was 34.2 and 46.5 months for R1v and R0 cohorts, respectively, p = 0.62. Conclusions Parenchyma-sparing surgery should be a priority pathway for complex treatment of patients with deeply located lesions of the right liver lobe. Trial registration The study is registered in https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5ed9f60863e9bf0016624456/, no. 5679.
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21
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Papamichail M, Pizanias M, Heaton ND, M P, M P, Nd H. Minimizing the risk of small-for-size syndrome after liver surgery. Hepatobiliary Pancreat Dis Int 2022; 21:113-133. [PMID: 34961675 DOI: 10.1016/j.hbpd.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Primary and secondary liver tumors are not always amenable to resection due to location and size. Inadequate future liver remnant (FLR) may prevent patients from having a curative resection or may result in increased postoperative morbidity and mortality from complications related to small-for-size syndrome (SFSS). DATA SOURCES This comprehensive review analyzed the principles, mechanism and risk factors associated with SFSS and presented current available options in the evaluation of FLR when planning liver surgery. In addition, it provided a detailed description of specific modalities that can be used before, during or after surgery, in order to optimize the conditions for a safe resection and minimize the risk of SFSS. RESULTS Several methods which aim to reduce tumor burden, preserve healthy liver parenchyma, induce hypertrophy of FLR or prevent postoperative complications help minimize the risk of SFSS. CONCLUSIONS With those techniques the indications of radical treatment for patients with liver tumors have significantly expanded. The successful outcome depends on appropriate patient selection, the individualization and modification of interventions and the right timing of surgery.
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Affiliation(s)
- Michail Papamichail
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK.
| | - Michail Pizanias
- Department of General Surgery, Whittington Hospital, London N19 5NF, UK
| | - Nigel D Heaton
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Papamichail M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Pizanias M
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
| | - Heaton Nd
- Department of Hepato-Pancreato-Biliary Surgery, Royal Blackburn Hospital, Blackburn BB2 3HH, UK; Department of General Surgery, Whittington Hospital, London N19 5NF, UK; Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver Studies, Kings Health Partners at King's College Hospital NHS Trust, London SE5 9RS, UK
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22
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Prediction of Posthepatectomy Liver Failure with a Combination of Albumin-Bilirubin Score and Liver Resection Percentage. J Am Coll Surg 2022; 234:155-165. [PMID: 35213436 DOI: 10.1097/xcs.0000000000000027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Posthepatectomy liver failure (PHLF) is a main cause of death after partial hepatectomy. The aim of this study was to develop a practical stratification system using the albumin-bilirubin (ALBI) score and liver resection percentage to predict severe PHLF and conduct safe hepatectomy. METHODS Between January 2002 and March 2021, 361 hepatocellular carcinoma (HCC) patients who underwent partial hepatectomy were enrolled. Medical image analysis software was applied postoperatively to accurately simulate hepatectomy. The liver resection percentage was calculated as follows: (postoperatively reconstructed resected specimen volume [ml] - tumor volume [ml])/total functional liver volume (ml) × 100. Multivariate analysis was performed to identify risk factors for PHLF grade B/C. A heatmap for predicting grade B/C PHLF was generated by combining the ALBI score and liver resection percentage. RESULTS Thirty-nine patients developed grade B/C PHLF; 2 of these patients (5.1%) died. Multivariate analysis demonstrated that a high ALBI score and high liver resection percentage were independent predictors of severe PHLF (odds ratio [OR], 8.68, p < 0.001; OR, 1.10, p < 0.001). With a threshold PHLF probability of 50% for the heatmap, hepatectomy was performed for 346 patients meeting our criteria (95.8%) and 325 patients meeting the Makuuchi criteria (90.0%). The positive predictive value and negative predictive value for severe PHLF were 91.6% and 66.7% for our system and 91.7% and 33.3% for the Makuuchi criteria. CONCLUSION Our stratification system could increase the number of hepatectomy candidates and is practical for deciding the surgical indications and determining the upper limit of the liver resection percentage corresponding to each patient's liver function reserve, which could prevent PHLF and yield better postoperative outcomes.
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Xiang F, Liang X, Yang L, Liu X, Yan S. CT radiomics nomogram for the preoperative prediction of severe post-hepatectomy liver failure in patients with huge (≥ 10 cm) hepatocellular carcinoma. World J Surg Oncol 2021; 19:344. [PMID: 34895260 PMCID: PMC8667454 DOI: 10.1186/s12957-021-02459-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/27/2021] [Indexed: 02/07/2023] Open
Abstract
Background This study aimed to establish a radiomics-based nomogram for predicting severe (grade B or C) post-hepatectomy liver failure (PHLF) in patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC). Methods One hundred eighty-six patients with huge HCC (training dataset, n = 131 and test dataset, n = 55) that underwent curative hepatic resection were included in this study. The least absolute shrinkage and selection operator (LASSO) approach was applied to develop a radiomics signature for grade B or C PHLF prediction using the training dataset. A multivariable logistic regression model was used by incorporating radiomics signature and other clinical predictors to establish a radiomics nomogram. Decision tree analysis was performed to stratify the risk for severe PHLF. Results The radiomics signature consisting of nine features predicted severe PHLF with AUCs of 0.766 and 0.745 for the training and test datasets. The radiomics nomogram was generated by integrating the radiomics signature, the extent of resection and the model for end-stage liver disease (MELD) score. The nomogram exhibited satisfactory discrimination ability, with AUCs of 0.842 and 0.863 for the training and test datasets, respectively. Based on decision tree analysis, patients were divided into three risk classes: low-risk patients with radiomics score < -0.247 and MELD score < 10 or radiomics score ≥ − 0.247 but underwent partial resections; intermediate-risk patients with radiomics score < − 0.247 but MELD score ≥10; high-risk patients with radiomics score ≥ − 0.247 and underwent extended resections. Conclusions The radiomics nomogram could predict severe PHLF in huge HCC patients. A decision tree may be useful in surgical decision-making for huge HCC hepatectomy. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02459-0.
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Affiliation(s)
- Fei Xiang
- Department of Hepatobiliary Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Xiaoyuan Liang
- Department of Hepatobiliary Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Lili Yang
- Department of Radiology, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Xingyu Liu
- Department of Hepatobiliary Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Sheng Yan
- Department of Hepatobiliary Pancreatic Surgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
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Mesenchymal stromal cells mitigate liver damage after extended resection in the pig by modulating thrombospondin-1/TGF-β. NPJ Regen Med 2021; 6:84. [PMID: 34862411 PMCID: PMC8642541 DOI: 10.1038/s41536-021-00194-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022] Open
Abstract
Post-surgery liver failure is a serious complication for patients after extended partial hepatectomies (ePHx). Previously, we demonstrated in the pig model that transplantation of mesenchymal stromal cells (MSC) improved circulatory maintenance and supported multi-organ functions after 70% liver resection. Mechanisms behind the beneficial MSC effects remained unknown. Here we performed 70% liver resection in pigs with and without MSC treatment, and animals were monitored for 24 h post surgery. Gene expression profiles were determined in the lung and liver. Bioinformatics analysis predicted organ-independent MSC targets, importantly a role for thrombospondin-1 linked to transforming growth factor-β (TGF-β) and downstream signaling towards providing epithelial plasticity and epithelial-mesenchymal transition (EMT). This prediction was supported histologically and mechanistically, the latter with primary hepatocyte cell cultures. MSC attenuated the surgery-induced increase of tissue damage, of thrombospondin-1 and TGF-β, as well as of epithelial plasticity in both the liver and lung. This suggests that MSC ameliorated surgery-induced hepatocellular stress and EMT, thus supporting epithelial integrity and facilitating regeneration. MSC-derived soluble factor(s) did not directly interfere with intracellular TGF-β signaling, but inhibited thrombospondin-1 secretion from thrombocytes and non-parenchymal liver cells, therewith obviously reducing the availability of active TGF-β.
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Mir ZM, Golding H, McKeown S, Nanji S, Flemming JA, Groome PA. Appraisal of multivariable prognostic models for post-operative liver decompensation following partial hepatectomy: a systematic review. HPB (Oxford) 2021; 23:1773-1788. [PMID: 34332894 DOI: 10.1016/j.hpb.2021.06.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 06/20/2021] [Accepted: 06/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few reports have evaluated prognostic modelling studies of tools used for surgical decision-making. This systematic review aimed to describe and critically appraise studies that have developed or validated multivariable prognostic models for post-operative liver decompensation following partial hepatectomy. METHODS This study was designed using the CHARMS checklist. Following a comprehensive literature search, two reviewers independently screened candidate references for inclusion and abstracted relevant study details. Qualitative assessment was performed using the PROBAST tool. RESULTS We identified 36 prognostic modelling studies; 25 focused on development only, 3 developed and validated models, and 8 validated pre-existing models. None compared routine use of a prognostic model against standard clinical practice. Most studies used single-institution, retrospective cohort designs, conducted in Eastern populations. In total, 15 different outcome definitions for post-operative liver decompensation events were used. Statistical concerns surrounding model overfitting, performance assessment, and internal validation led to high risk of bias for all studies. CONCLUSIONS Current prognostic models for post-operative liver decompensation following partial hepatectomy may not be valid for routine clinical use due to design and methodologic concerns. Landmark resources and reporting guidelines such as the TRIPOD statement may assist researchers, and additionally, model impact assessment studies represent opportunities for future research.
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Affiliation(s)
- Zuhaib M Mir
- Department of Surgery, Division of General Surgery, Queen's University, Kingston, ON, Canada; Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | - Haley Golding
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Sandra McKeown
- Bracken Health Sciences Library, Queen's University, Kingston, ON, Canada
| | - Sulaiman Nanji
- Department of Surgery, Division of General Surgery, Queen's University, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada; Department of Medicine, Division of Gastroenterology, Queen's University, Kingston, ON, Canada; Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada; Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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Mir ZM, Djerboua M, Nanji S, Flemming JA, Groome PA. Predictors of Postoperative Liver Decompensation Events After Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-Based Study. Ann Surg Oncol 2021; 29:288-299. [PMID: 34549362 DOI: 10.1245/s10434-021-10801-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. METHODS This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. RESULTS Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. CONCLUSIONS Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.
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Affiliation(s)
- Zuhaib M Mir
- Division of General Surgery, Department of Surgery, Victory 3, Kingston General Hospital, Queen's University, Kingston, ON, Canada. .,Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | | | - Sulaiman Nanji
- Division of General Surgery, Department of Surgery, Victory 3, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's University, Kingston, ON, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,ICES Queen's University, Kingston, ON, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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Ryu LN, Hwang S, Ha S. Therapeutic plasma exchange as an effective salvage measure for post-hepatectomy hepatic failure: A case report. Ann Hepatobiliary Pancreat Surg 2021; 25:270-275. [PMID: 34053931 PMCID: PMC8180401 DOI: 10.14701/ahbps.2021.25.2.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/17/2022] Open
Abstract
Major hepatectomy can result in post-hepatectomy hepatic failure (PHHF) and therapeutic plasma exchange (TPE) can be used as a salvage procedure for liver support. We herein present a case of 69-year-old male patient with perihilar cholangiocarcinoma who was successfully managed with salvage TPE. Preoperative portal embolization was performed to reduce the parenchymal resection rate. The extent of surgery was right hepatectomy with partial excision of the ventral portion of the segment IV, caudate lobectomy, bile duct resection and extensive lymph node dissection. No noticeable surgical complications occurred after the operation, but serum total bilirubin level increased gradually and reached 10 mg/dl at 1 month after the operation. At postoperative day 38, total bilirubin level raised to 19.8 mg/dl and prothrombin time deteriorated significantly, thus salvage TPE was started. TPE was performed three times per week for 2 weeks; consequently, the total bilirubin level was maintained below 10 mg/dl. A few days later, a rebound of total bilirubin occurred; accordingly, 2 sessions of TPE were performed additionally. Overall, a total of 8 sessions of TPE were performed. The patient was discharged at 84 days after operation. The total bilirubin level returned to normal at 5 months after operation. This patient is doing well for past 9 months. In Korea, TPE for liver support has been approved by the social health insurance since August 2020. In conclusion, salvage TPE is an effective liver support measure for PHHF, thus we suggest starting TPE if serum total bilirubin level reaches 10 mg/dl after hepatectomy.
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Affiliation(s)
- Lee Na Ryu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suhyeon Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Timing of Complication and Failure to Rescue after Hepatectomy: Single-Institution Analysis of 28 Years of Hepatic Surgery. J Am Coll Surg 2021; 233:415-425. [PMID: 34029677 DOI: 10.1016/j.jamcollsurg.2021.04.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Morbidity after hepatectomy remains a significant, potentially preventable, outcome. Understanding the pattern of complications and rescue pathways is critical for the development of targeted initiatives intended to salvage patients after operative morbidity. STUDY DESIGN Patients undergoing liver resection from 1991 to 2018 at a single institution were analyzed. Failure to rescue (FTR) was defined as percentage of deaths in patients with a complication within 30 days. Generalized estimating equations with log-link function assessed associations between clinical characteristics and major complications and between complications at fewer than 30 days and 30 to 90 days. Logistic regression assessed associations between complications and FTR. RESULTS A total of 6,191 patients and 6,668 operations were identified, of which 55.6% were performed for management of metastatic colorectal cancer. Major complications (grade ≥3) occurred in 20.2% of operations (1,346 of 6,668). Ninety-day mortality was 2.2%. The most common complication was intra-abdominal abscess at 9.0% (95% CI, 8.3% to 9.7%). Ten percent of patients with a complication at 30 days had another complication between 30 and 90 days compared with 2% without an early complication (odds ratio [OR] 5.09; 95% CI, 3.97 to 6.54; p < 0.001). FTR for liver failure, cardiac arrest, abscess, and hemorrhage was 36%, 56%, 3%, and 6%, respectively. Risk of 90-day mortality was higher in patients with liver failure (53% vs 2%; OR 61.42; 95% CI, 37.47 to 100.67; p < 0.001), cardiac arrest (69% vs 2%; OR 96.95; 95% CI, 33.23 to 283.80; p < 0.001), hemorrhage (11% vs 2%; OR 5.51; 95% CI, 2.59 to 11.73; p < 0.001), and abscess (7% vs 2%; OR 4.05; 95% CI, 2.76 to 5.94; p < 0.001) compared with those without these complications. CONCLUSIONS Morbidity after hepatectomy is frequent despite low mortality. This study identifies targets for improvement in morbidity and failure to rescue after hepatectomy. Efforts to improve recognition and intervention for infections and early complications are needed to improve outcomes.
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Dondorf F, Deeb AA, Bauschke A, Felgendreff P, Tautenhahn HM, Ardelt M, Settmacher U, Rauchfuss F. Ligation of the middle hepatic vein to increase hypertrophy induction during the ALPPS procedure. Langenbecks Arch Surg 2021; 406:1111-1118. [PMID: 33970336 PMCID: PMC8208903 DOI: 10.1007/s00423-021-02181-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Here, we analyse the technical modification of the ALPPS procedure, ligating the middle hepatic vein during the first step of the operation to enhance remnant liver hypertrophy. METHODS In 20 of 37 ALPPS procedures, the middle hepatic vein was ligated during the first step. Hypertrophy of the functional remnant liver volume was assessed in addition to postoperative courses. RESULTS Volumetric analysis showed a significant volume increase, especially for patients with colorectal metastases. Pre-existing liver parenchyma damage (odds ratio = 0.717, p = 0.017) and preoperative chemotherapy were found to be significant predictors (odds ratio = 0.803, p = 0.045) of higher morbidity and mortality. In addition, a survival benefit for maintenance of middle hepatic vein was shown. CONCLUSION This technical modification of the ALPPS procedure can accentuate future liver remnant volume hypertrophy. The higher morbidity and mortality observed are most likely associated with pre-existing parenchymal damage within this group.
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Affiliation(s)
- F Dondorf
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - A Ali Deeb
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - A Bauschke
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - P Felgendreff
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | - H M Tautenhahn
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | - M Ardelt
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - U Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - F Rauchfuss
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
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30
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Saadat LV, Brajcich BC, Liu Y, Ko C, D'Angelica MI. Defining the risk of liver failure after minor hepatectomy: a NSQIP analysis of 7029 patients. HPB (Oxford) 2021; 23:551-559. [PMID: 32952033 PMCID: PMC8422033 DOI: 10.1016/j.hpb.2020.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) remains a significant complication after hepatic resection. This study aims to determine the rate of PHLF in patients undergoing resection of 3 or fewer segments and analyze the association of PHLF with perioperative characteristics and postoperative complications. METHODS The American College of Surgeons hepatectomy-targeted National Surgical Quality Improvement Program database was queried for patients undergoing left hemi-hepatectomy or partial resection from 2014 to 2018. The primary outcome was PHLF, defined by ISGLS. Multivariable logistic regression models assessed the association between PHLF, preoperative and operative variables and postoperative complications. RESULTS Among 7029 patients, 187 (2.7%) experienced PHLF, with clinically significant (grade B/C) PHLF in 1.4%. PHLF was associated with older age, male gender, higher ASA classification, ascites, and elevated SGOT. Preoperative ascites (OR 4.94, 95%CI: 2.45-9.94, p < 0.001) had the strongest association with PHLF. There was no association between PHLF and concurrent colorectal resection, neoadjuvant therapy, or concurrent ablation. Surgical site infection (OR 3.64, 95%CI: 2.40-5.54, p < 0.001), sepsis (OR 3.78, 95%CI: 2.16-6.61, p < 0.001), postoperative invasive procedure (OR 6.92, 95%CI: 4.91-9.76, p < 0.001), and bile leak (OR 4.65, 95%CI: 3.04-7.12, p < 0.001) were associated with PHLF. CONCLUSION PHLF after minor hepatectomy is rare and associated with signs of preoperative liver dysfunction. The association with infectious complications suggests a multifactorial etiology and provides targets for quality improvement.
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Affiliation(s)
- Lily V Saadat
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Brian C Brajcich
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Yaoming Liu
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA
| | - Clifford Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL, USA; Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael I D'Angelica
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Li B, Qin Y, Qiu Z, Ji J, Jiang X. A cohort study of hepatectomy-related complications and prediction model for postoperative liver failure after major liver resection in 1,441 patients without obstructive jaundice. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:305. [PMID: 33708932 PMCID: PMC7944277 DOI: 10.21037/atm-20-5472] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background This cohort study, based on a large sample of extensive hepatectomy cases, aimed to analyze the distribution of hepatectomy-related complications and to develop a predictive model of posthepatectomy liver failure (PHLF). Methods Data of patients who underwent hepatectomy of ≥3 liver segments at the Eastern Hepatobiliary Surgery Hospital from 2000 to 2016 were collected and analyzed. Information on hepatectomy-related complications was collected and risk factors were analyzed. A total of 1,441 eligible patients were randomly assigned at 3:1 ratio into the derivation (n=1,080) and validation (n=361) cohorts. The multivariable logistic regression model was used to establish the prediction model of PHLF in the derivation cohort. Results The incidence rates of PHLF, ascites, bile leakage, intra-abdominal bleeding, and abscesses were 58.22%, 10.76%, 11.17%, 9.71%, and 4.16%, respectively. The 90-day perioperative mortality rate was 1.32%. Multivariate analyses found that age, gender, platelet, creatinine, gamma-glutamyltransferase, thrombin time, fibrinogen, hepatitis B e (HBe) antigen positive, and number of resected liver segments were independent prognostic factors of PHLF in the derivation cohort and included in the nomogram. The prediction model demonstrated good discrimination [area under the curve =0.726, 95% confidence interval (CI), 0.696–0.760, P<0.0001] and calibration. Conclusions Our study showed a high perioperative safety and a low risk of serious complications in patients who underwent major liver resection (MLR) at a large hepatobiliary surgery center. Routine preoperative clinical information can be used to develop a postoperative liver failure risk prediction model for rational planning of surgery.
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Affiliation(s)
- Bin Li
- Biliary Tract Surgery Department I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Zhiquan Qiu
- Biliary Tract Surgery Department I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, Shanghai, China
| | - Jun Ji
- Laboratory diagnosis Department, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, Shanghai, China
| | - Xiaoqing Jiang
- Biliary Tract Surgery Department I, Eastern Hepatobiliary Surgery Hospital, Secondary Military Medical University, Shanghai, China
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Lee DH, Lee ES, Bae JS, Lee JY, Han JK, Yi NJ, Lee KW, Suh KS, Kim H, Lee KB, Choi BI. 2D shear wave elastography is better than transient elastography in predicting post-hepatectomy complication after resection. Eur Radiol 2021; 31:5802-5811. [PMID: 33459859 DOI: 10.1007/s00330-020-07662-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Both transient elastography (TE) and 2D shear wave elastography (SWE) are accurate methods to evaluate liver fibrosis. We aimed to evaluate the diagnostic performance of 2D-SWE in predicting post-hepatectomy complication and to compare it with TE. METHODS We prospectively enrolled 125 patients with liver tumors. Liver stiffness (LS) (kilopascal [kPa]) was measured using both TE and 2D-SWE before surgery. All post-operative complication was evaluated using the comprehensive complication index (CCI), and CCI ≥ 26.2 was defined as severe complication. Logistic regression analysis was performed to identify predictive factors for severe complication. Receiver operating characteristic analysis was used to evaluate the diagnostic performance of TE/2D-SWE in detecting liver fibrosis and severe complication. RESULTS Severe complication developed in 18 patients. The median LS in patients with severe complication was significantly higher for both 2D-SWE (11.4 kPa vs. 7.0 kPa, p < 0.001) and TE (8.9 kPa vs. 6.2 kPa, p = 0.009). LS obtained from 2D-SWE was a significant factor correlated with severe complication (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥F3 (p = 0.024) and F4 (p = 0.048). The area under the curve of 2D-SWE to predict severe complication was 0.854, significantly higher than 0.692 of TE (p = 0.004). The optimal cut-off LS from 2D-SWE to predict severe complication was 8.6 kPa, with sensitivity of 88.9% (16/18) and specificity of 73.8% (79/107). CONCLUSION LS obtained from 2D-SWE was a significant predictive factor for severe complication, and 2D-SWE showed significantly a better diagnostic performance than TE in detecting liver fibrosis and severe complication. KEY POINTS • The diagnostic performance of 2D-SWE was significantly higher than that of TE in detecting both ≥ F3 (AUC: 0.853 vs. 0.779, p = 0.024) and F4 (AUC: 0.929 vs. 0.872, p = 0.048). • Liver stiffness value obtained from 2D-SWE was a significant factor correlated with the development of severe complication defined as CCI ≥ 26.2 after hepatic resection for liver tumors (odds ratio: 1.27 per kPa [1.10-1.46], p = 0.001). • 2D-SWE provided significantly a better diagnostic performance in predicting severe complication after hepatic resection than TE (AUC for 2D-SWE: 0.853 vs. AUC for TE: 0.692, p = 0.004).
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Affiliation(s)
- Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea.,Department of Radiology, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Jae Young Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea. .,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Joon Koo Han
- Department of Radiology, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, South Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Bun Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, South Korea
| | - Byung Ihn Choi
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea
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Masthoff M, Katou S, Köhler M, Schindler P, Heindel W, Wilms C, Schmidt HH, Pascher A, Struecker B, Wildgruber M, Morgul H. Portal and hepatic vein embolization prior to major hepatectomy. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:35-42. [PMID: 33429448 DOI: 10.1055/a-1330-9450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To analyze safety and effectiveness of simultaneous portal and hepatic vein embolization (PHVE) or sequential hepatic vein embolization (HVE) compared to portal vein embolization (PVE) for future remnant liver (FRL) hypertrophy prior to major hepatic surgery. METHODS Patients undergoing PVE, PHVE or HVE at our tertiary care center between 2018 and 2020 were retrospectively included. FRLV, standardized FRLV (sFRLV) and sFRLV growth rate per day were assessed via volumetry, as well as laboratory parameters. RESULTS 36 patients (f = 15, m = 21; median 64.5 y) were included, 16 patients received PHVE and 20 patients PVE, of which 4 received sequential HVE. Significant increase of FRLV was achieved with both PVE and PHVE compared to baseline (p < 0.0001). sFRLV growth rate did not significantly differ following PHVE (2.2 ± 1.2 %/d) or PVE (2.2 ± 1.7 %/d, p = 0.94). Left portal vein thrombosis (LPVT) was observed after PHVE in 6 patients and in 1 patient after PVE. Sequential HVE showed a considerably high growth rate of 1.42 ± 0.45 %/d after PVE. CONCLUSION PHVE effectively induces FRL hypertrophy but yields comparable sFRLV to PVE. Sequential HVE further induces hypertrophy after insufficient growth due to PVE. Considering a potentially higher rate of LPVT after PHVE, PVE might be preferred in patients with moderate baseline sFRLV, with optional sequential HVE in non-sufficient responders.
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Affiliation(s)
- Max Masthoff
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany
| | - Shadi Katou
- Department for General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
| | - Michael Köhler
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany
| | - Philipp Schindler
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany
| | - Walter Heindel
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany
| | - Christian Wilms
- Department of Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Hartmut H Schmidt
- Department of Gastroenterology and Hepatology, University Hospital Muenster, Muenster, Germany
| | - Andreas Pascher
- Department for General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
| | - Benjamin Struecker
- Department for General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
| | - Moritz Wildgruber
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany.,Department of Radiology, University Hospital Ludwig-Maximilians-Universität, Munich, Germany
| | - Haluk Morgul
- Department for General, Visceral and Transplantation Surgery, University Hospital Muenster, Muenster, Germany
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Honmyo N, Kobayashi T, Kuroda S, Oshita A, Onoe T, Kohashi T, Fukuda S, Ohmori I, Abe T, Imaoka Y, Akita T, Tanaka J, Ohdan H. A novel model for predicting posthepatectomy liver failure based on liver function and degree of liver resection in patients with hepatocellular carcinoma. HPB (Oxford) 2021; 23:134-143. [PMID: 32563594 DOI: 10.1016/j.hpb.2020.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/23/2020] [Accepted: 05/13/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The permissible liver resection rate for preventing posthepatectomy liver failure (PHLF) remains unclear. We aimed to develop a novel PHLF-predicting model and to strategize hepatectomy for hepatocellular carcinoma (HCC). METHODS This retrospective study included 335 HCC patients who underwent anatomical hepatectomy at eight institutions between 2013 and 2017. Risk factors, including volume-associated liver-estimating parameters, for PHLF grade B-C were analyzed in a training set (n = 122) via multivariate analysis, and a PHLF prediction model was developed. The utility of the model was evaluated in a validation set (n = 213). RESULTS Our model was based on the three independent risk factors for PHLF identified in the training set: volume-associated indocyanine green retention rate at 15 min, platelet count, and prothrombin time index (the VIPP score). The areas under the receiver operating characteristic curve of the VIPP scores for severe PHLF in the training and validation sets were 0.864 and 0.794, respectively. In both sets, the VIPP score stratified patients at risk for severe PHLF, with a score of 3 (specificity, 0.92) indicating higher risk. CONCLUSION Our model facilitates the selection of the appropriate hepatectomy procedure by providing permissible liver resection rates based on VIPP scores.
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Affiliation(s)
- Naruhiko Honmyo
- Department of Gastroenterological and Transplant Surgery, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan.
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Akihiko Oshita
- Department of Gastroenterological, Breast, and Transplant Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujinakanda, Minami-ku, Hiroshima, Japan
| | - Takashi Onoe
- Department of Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, 3-1 Aoyamacho, Kure, Japan
| | - Toshihiko Kohashi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakita-ku, Hiroshima, Japan
| | - Saburo Fukuda
- Department of Surgery, Chugoku Rosai Hospital, 1-5-1 Hirotagaya, Kure, Japan
| | - Ichiro Ohmori
- Department of Surgery, National Hospital Organization Higashihiroshima Medical Center, 513 Saijochojike, Higashihiroshima, Japan
| | - Tomoyuki Abe
- Department of Surgery, Onomichi General Hospital, 1-10-23 Hirahara, Onomichi, Japan
| | - Yasuhiro Imaoka
- Department of Surgery, National Hospital Organization Hiroshima-nishi Medical Center, 4-4-1 Kuba, Otake, Japan
| | - Tomoyuki Akita
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
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Pavel MC, Casanova R, Estalella L, Memba R, Llàcer-Millán E, Achalandabaso M, Julià E, Geoghegan J, Jorba R. The effect of preoperative chemotherapy on liver regeneration after portal vein embolization/ligation or liver resection in patients with colorectal liver metastasis: a systematic review protocol. Syst Rev 2020; 9:279. [PMID: 33276812 PMCID: PMC7718667 DOI: 10.1186/s13643-020-01545-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver resection (LR) in patients with liver metastasis from colorectal cancer remains the only curative treatment. Perioperative chemotherapy improves prognosis of these patients. However, there are concerns regarding the effect of preoperative chemotherapy on liver regeneration, which is a key event in avoiding liver failure after LR. The primary objective of this systematic review is to assess the effect of neoadjuvant chemotherapy on liver regeneration after (LR) or portal vein embolization (PVE) in patients with liver metastasis from colorectal cancer. The secondary objectives are to evaluate the impact of the type of chemotherapy, number of cycles, and time between end of treatment and procedure (LR or PVE) and to investigate whether there is an association between degree of hypertrophy and postoperative liver failure. METHODS This meta-analysis will include studies reporting liver regeneration rates in patients submitted to LR or PVE. Pubmed, Scopus, Web of Science, Embase, and Cochrane databases will be searched. Only studies comparing neoadjuvant vs no chemotherapy, or comparing chemotherapy characteristics (bevacizumab administration, number of cycles, and time from finishing chemotherapy until intervention), will be included. We will select studies from 1990 to present. Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Primary outcome will be future liver remnant regeneration rate. Bias of the studies will be evaluated with the ROBINS-I tool, and quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a qualitative systematic review will be performed. DISCUSSION The results of this systematic review may help to better identify the patients affected by liver metastasis that could present low regeneration rates after neoadjuvant chemotherapy. These patients are at risk to develop liver failure after extended hepatectomies and therefore are not good candidates for such aggressive procedures. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42020178481 (July 5, 2020).
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Affiliation(s)
- Mihai-Calin Pavel
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain. .,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain.
| | - Raquel Casanova
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Laia Estalella
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Robert Memba
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Erik Llàcer-Millán
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
| | - Mar Achalandabaso
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Elisabet Julià
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain
| | - Justin Geoghegan
- HPB and Liver Transplant Surgery Department, St. Vincent's University Hospital, Dublin, Ireland
| | - Rosa Jorba
- HPB Unit, Department of General Surgery, Hospital Universitari de Tarragona Joan XXIII, C/ Dr. Mallafrè Guasch, 4, 43005, Tarragona, Spain.,Departament de Medicina i Cirugia, Universitat Rovira i Virgili, Reus, Spain
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Jo HS, Kim HA, Lee JC, Yoon KC, Yoon YI, Choi YY, Seok JI, Moon MH, Kim DS. Lipidomic signatures of post-hepatectomy liver failure using porcine hepatectomy models. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1363. [PMID: 33313108 PMCID: PMC7723583 DOI: 10.21037/atm-20-3596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Clinical diagnosis of post-hepatectomy liver failure (PHLF) can only be made on or after the 5th postoperative day. Biomarker for early diagnosis is considered as a critical unmet need. Methods Twenty domestic female crossbreed (Yorkshire-landrace and duroc) pigs underwent sham operation (n=6), 70% (n=7) and 90% (n=7) partial hepatectomy (PH). A comprehensive lipidomic analysis was conducted using sera collected at pre-operation (PO), 14, 30, and 48 h after PH using nanoflow ultrahigh performance liquid chromatography-electrospray ionization-tandem mass spectrometry. Results Of the 184 quantified lipids, 14 lipids showed significant differences between the two resection groups starting at 30 h after surgery. Four phosphatidylcholine (PC) plasmalogen species (P-16:0/16:0, P-18:0/18:2, P-18:0/20:4, and P-18:0/22:6) and PC 32:2 significantly increased in the 90% PH group while these returned to PO level after 30 h in the 70% PH group, presumably implying the failure markers. In contrast, eight triacylglycerol (TG) species (40:0, 42:1, 42:0, 44:1, 44:2, 46:1, 46:2, and 48:3) and sphingomyelin d18:1/20:0 showed an opposite trend, wherein they significantly decreased in the 90% PH group while these in the 70% PH group were abruptly increased until 30 h but returned to near PO levels at 48 h, implying the recovery markers. Same trends could also be observed in the level of whole lipid classes of PC plasmalogens and TGs, in addition to selected individual lipid species. Conclusions Characteristic lipidomic signatures of PHLF could be identified using large animal models. These candidates have a potential to serve as a tool for early diagnosis and may open new paths to the study to overcome PHLF.
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Affiliation(s)
- Hye-Sung Jo
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hae A Kim
- Department of Chemistry, Yonsei University, Seoul, Korea
| | - Jong Cheol Lee
- Department of Chemistry, Yonsei University, Seoul, Korea
| | - Kyung Chul Yoon
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon Young Choi
- Department of Biomedical Science, Korea University College of Medicine Graduate School, Seoul, Korea
| | - Jin-I Seok
- Department of Biomedical Science, Korea University College of Medicine Graduate School, Seoul, Korea
| | | | - Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Bae JS, Lee DH, Yoo J, Yi NJ, Lee KW, Suh KS, Kim H, Lee KB. Association between spleen volume and the post-hepatectomy liver failure and overall survival of patients with hepatocellular carcinoma after resection. Eur Radiol 2020; 31:2461-2471. [PMID: 33026503 DOI: 10.1007/s00330-020-07313-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/05/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Post-hepatectomy liver failure (PHLF) can occur as a major complication after hepatic resection (HR) in patients with hepatocellular carcinoma (HCC) and negatively affects the prognosis. We aimed to retrospectively assess whether the spleen volume (SV) measured from preoperative CT images would be associated with the development of PHLF and overall survival (OS) after HR in patients with HCC. METHODS We enrolled 317 consecutive patients with very early/early stage HCC who underwent a preoperative CT and HR between January 2010 and December 2016. The SV was obtained from preoperative CT images using semi-automated volumetric software and was divided by body surface area to yield SVBSA. Receiver operating characteristic (ROC) curves and logistic regression analyses were performed to identify factors affecting the development of PHLF. The Cox proportional hazard model was used to identify prognostic factors for OS. RESULTS PHLF was observed in 72 patients (22.7% [72/317]). SVBSA was associated with the development of PHLF (odds ratio, 2.321; 95% CI, 1.347-4.001; p = 0.002) with the area under the ROC curve of 0.663 using the cutoff value of 107.5 cm3 (p < 0.001). SVBSA was also an influencing factor for OS (hazard ratio, 3.935; 95% CI 1.520-10.184; p = 0.005), with the optimal cutoff of 146 cm3. The 5-year OS rate was higher in 245 patients with a SVBSA ≤ 146 cm3 than in 72 patients with a SVBSA > 146 cm3 (95.0% vs. 78.7%, p < 0.001). CONCLUSIONS In patients with HCC, a larger SVBSA was associated with a higher rate of PHLF and worse OS after HR. The SVBSA may be useful in selecting good surgical candidates. KEY POINTS • A significantly higher spleen volume divided by body surface area was observed in patients who experienced post-hepatectomy liver failure than in patients who did not (148 cm3 vs. 112 cm3, p < 0.001). • The area under the receiver operating characteristic curve of spleen volume divided by body surface area to predict the development of post-hepatectomy liver failure was 0.663 (p < 0.001). • Spleen volume divided by body surface area was a significant influencing factor for overall survival (hazard ratio, 3.935; 95% CI, 1.520-10.184; p < 0.001), with the optimal cutoff of 146 cm3.
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Affiliation(s)
- Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Jeongin Yoo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Kyung Bun Lee
- Department of Pathology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Short-Term Outcomes of Patients Undergoing Portal Vein Embolization: an ACS-NSQIP Procedure-Targeted Hepatectomy Analysis. J Gastrointest Surg 2020; 24:1571-1580. [PMID: 31346961 DOI: 10.1007/s11605-019-04312-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 06/13/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative portal vein embolization (PVE) is utilized to induce growth of the future liver remnant volume (FLRV) among patients at elevated risk of post-hepatectomy liver failure (PHLF). METHODS The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database was used to compare short-term outcomes of PVE versus non-PVE patients. A propensity score match (PSM) was used to compare short-term outcomes among PVE and non-PVE patients. RESULTS Among the 11,243 patients included in the study, 462 (4.1%) patients had a PVE. Postoperatively, patients who underwent PVE had a higher incidence of overall (PVE, 44% vs. non-PVE, 23%) and liver-specific complications (biliary leak PVE, 16% vs. non-PVE, 7%; post-hepatectomy liver failure [PHLF] PVE, 17% vs. non-PVE, 5%), as well as a longer length of stay (> 7 days PVE, 39% vs. non-PVE, 22%) compared with the non-PVE group (all p < 0.001). After PSM, no differences in mortality or LOS were observed among PVE and non-PVE patients. PVE patients remained more likely to have a bile leak, organ/surgical-site infection, and PHLF versus non-PVE patients (all p < 0.05). CONCLUSION Among patients who underwent PVE before hepatectomy, the risk of postoperative complications was 1.6-fold higher than non-PVE patients. After PSM, PVE patients still had an increased risk of complications.
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Systematic review of MARS treatment in post-hepatectomy liver failure. HPB (Oxford) 2020; 22:950-960. [PMID: 32249030 DOI: 10.1016/j.hpb.2020.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/26/2020] [Accepted: 03/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) remains a serious complication after major liver resection with severe 90-day mortality. Molecular adsorbent recirculating system (MARS) is a potential treatment option in PHLF. This systematic review sought to analyze the experiences and results of MARS in PHLF. METHODS Following the PRISMA guidelines, a systematic literature review using PubMed and Embase was performed. Non-randomized trials were assessed by the MINORS criteria. RESULTS 2884 records were screened and 22 studies were extracted (no RCT). They contained 809 patients including 82 patients with PHLF. Five studies (n = 34) specifically investigated the role of MARS in patients with PHLF. In these patients, overall 90-day survival was 47%. Patients with primary PHLF had significantly better 90-day survival compared to patients with secondary PHLF (60% vs 14%, p = 0.03) and treatment was started earlier (median POD 6 (range 2-21) vs median POD 30 (range 15-39); p < 0.001). Number of treatments differed non-significantly in these groups. Safety and feasibility of early MARS treatment following hepatectomy was demonstrated in one prospective study. No major adverse events have been reported. CONCLUSION Early MARS treatment is safe and feasible in patients with PHLF. Currently, MARS cannot be recommended as standard of care in these patients. Further prospective studies are warranted.
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Abstract
BACKGROUND The "Small-for-Size" syndrome is defined as a liver failure after a liver transplant with a reduced graft or after a major hepatectomy. The later coined "Small-for-Flow" syndrome describes the same situation in liver resections but based on hemodynamic intraoperative parameters (portal pressure > 20 mmHg and/or portal flow > 250 ml/min/100 g). This focuses on the damage caused by the portal hyperafflux related to the volume of the remnant. METHODS Relevant studies were reviewed using Medline, PubMed, and Springer databases. RESULTS Portal hypertension after partial hepatectomies also leads to a higher morbidity and mortality. There are plenty of experimental studies focusing on flow rather than size. Some of them also perform different techniques to modulate the portal inflow. The deleterious effect of high posthepatectomy portal venous pressure is known, and that is why the idea of portal flow modulation during major hepatectomies in humans is increasing in everyday clinical practice. CONCLUSIONS Considering the extensive knowledge obtained with the experimental models and good results in clinical studies that analyze the "Small-for-Flow" syndrome, we believe that measuring portal flow and portal pressure during major liver resections should be performed routinely in extended liver resections. Applying these techniques, the knowledge of hepatic hemodynamics would be improved in order to advance against posthepatectomy liver failure.
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Komatsu S, Kido M, Tanaka M, Kuramitsu K, Tsugawa D, Awazu M, Gon H, Yanagimoto H, Toyama H, Fukumoto T. Clinical Significance of Hepatectomy for Hepatocellular Carcinoma Associated with Extrahepatic Metastases. Dig Surg 2020; 37:411-419. [PMID: 32454487 DOI: 10.1159/000507436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/22/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND This study evaluated the prognosis of hepatocellular carcinoma (HCC) patients with extrahepatic metastases who can undergo hepatectomy. METHODS A total of 32 patients who underwent hepatectomy for HCC with extrahepatic metastases, including lymph node and/or distant metastases were recruited for this study. RESULTS Fourteen patients had lymph node metastasis only, 16 had distant metastasis only, and 2 had both metastasis types during preoperative diagnosis. The 3-year overall survival (OS) rate of all patients was 17.9%, and the median survival time (MST) was 11.8 months. Univariate analysis revealed that intrahepatic maximal tumor size, intrahepatic tumor number, and intrahepatic tumor control after hepatectomy were significant factors influencing OS (p < 0.05). Multivariate analysis revealed that independent risk factors for OS were intrahepatic maximal tumor size and intrahepatic tumor number (p < 0.05). The MST and 3-year OS rate of patients with maximal tumor size <100 mm and intrahepatic tumor number ≤2 were 39.0 months and 51.9%, respectively. CONCLUSIONS Hepatectomy is not recommended for HCC patients with extrahepatic metastasis with ≥3 intrahepatic tumors, even when all intrahepatic tumors can be eliminated via hepatectomy. Aggressive surgery may be justified for HCC patients with ≤2 intrahepatic tumors and maximal tumor size <100 mm, irrespective of vascular invasion.
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Affiliation(s)
- Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan,
| | - Masahiro Kido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Motofumi Tanaka
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kaori Kuramitsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Tsugawa
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahide Awazu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidetoshi Gon
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirochika Toyama
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Fernández-Placencia R, Golse N, Cano L, Allard MA, Pittau G, Ciacio O, Cunha AS, Castaing D, Salloum C, Azoulay D, Cherqui D, Samuel D, Adam R, Vibert E. Spleen volumetry and liver transient elastography: Predictors of persistent posthepatectomy decompensation in patients with hepatocellular carcinoma. Surgery 2020; 168:17-24. [PMID: 32204923 DOI: 10.1016/j.surg.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/27/2020] [Accepted: 02/05/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Posthepatectomy decompensation remains a frequent and poor outcome after hepatectomy, but its prediction is still inaccurate. Liver stiffness measurement can predict posthepatectomy decompensation, but there is a so-called "gray zone" that requires another predictor. Because splenomegaly is an objective sign of portal hypertension, we hypothesized that spleen volumetry could improve the identification of patients at risk. METHODS Patients with hepatocellular carcinoma who underwent hepatectomy in our tertiary center between August 2014 and December 2017 were reviewed. The primary endpoint was to determine if the spleen volumetry and liver stiffness measurement were independent predictors of posthepatectomy decompensation, and secondarily, to determine if they were synergistic through a theoretic predictive model. RESULTS One hundred and seven patients were included. The median follow-up time was 3 months (3-5). Postoperative 90-day mortality was 4.7%. By multivariate analysis, liver stiffness measurement and spleen volumetry predicted posthepatectomy decompensation. The liver stiffness measurement had a cutoff point of 11.6 kPa (area under receiver operating curve = 0.71 confidence interval 95% 0.71-0.88, sensitivity: 89%, specificity: 47%). The spleen volumetry cutoff point was 381.1 cm3 (area under receiver operating curve = 0.78, 95% confidence interval 0.77-0.93, sensitivity: 55%, specificity: 91%). The spleen volumetry improved prediction of posthepatectomy decompensation, because use of the spleen volumetry increased sensitivity (from 62% to 97%) and the negative predictive value (from 96% to 100%) along with a negligible decrease in specificity (from 96.7 to 93.4) and positive predictive value (from 64% to 59%) (P = .003). CONCLUSION Spleen volumetry (>380 cm3) and liver stiffness measurement (>12 kPa) are non-invasive, independent, and synergistic tools that appear to be able to predict posthepatectomy decompensation. The importance of this finding is that these measurements may help to anticipate posthepatectomy decompensation and may possibly be used to direct alternative treatments to resection.
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Affiliation(s)
- Ramiro Fernández-Placencia
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Department of Abdominal Surgery, Hepato-Pancreato-Biliary Section, Instituto Nacional de Enfermedades Neoplásicas (INEN) Lima, Peru
| | - Nicolas Golse
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France; Univ Paris-Sud, UMR-S 1193, Villejuif, France
| | - Luis Cano
- INSERM, Unit 991, Univ Rennes, Centre Hospitalier Universitaire Rennes, INRA, Univ Bretagne Loire, Nutrition Metabolism and Cancer, Rennes, France
| | - Marc-Antoine Allard
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France
| | - Gabriella Pittau
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France
| | - Oriana Ciacio
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France
| | - Antonio Sa Cunha
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France
| | - Denis Castaing
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France
| | - Chady Salloum
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France
| | - Daniel Azoulay
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Daniel Cherqui
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France
| | - Didier Samuel
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France; Univ Paris-Sud, UMR-S 1193, Villejuif, France
| | - René Adam
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 985, Villejuif, France; Univ Paris-Sud, UMR-S 985, Villejuif, France
| | - Eric Vibert
- Department of Surgery, Paul-Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), Centre Hépato-Biliaire, Villejuif, France; Département Hospitalo-Universitaire Hepatinov, Villejuif, France; INSERM, Unit 1193, Villejuif, France; Univ Paris-Sud, UMR-S 1193, Villejuif, France.
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Preoperative predictors of liver decompensation after mini-invasive liver resection. Surg Endosc 2020; 35:718-727. [PMID: 32124061 DOI: 10.1007/s00464-020-07438-2] [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: 10/01/2019] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) represents the most frequent complication after liver surgery, and the most common cause of morbidity and mortality. Aim of the study is to identify the predictors of PHLF after mini-invasive liver surgery in cirrhosis and chronic liver disease, and to develop a model for risk prediction. METHODS The present study is a multicentric prospective cohort study on 490 consecutive patients who underwent mini-invasive liver resection from the Italian Registry of Mini-invasive Liver Surgery (I go MILS). Retrospective additional biochemical and clinical data were collected. RESULTS On 490 patients (26.5% females), PHLF occurred in 89 patients (18.2%). The only independent predictors of PHLF were Albumin-Bilirubin (ALBI) score (OR 3.213; 95% CI 1.661-6.215; p < .0.0001) and presence of ascites (OR 3.320; 95% CI 1.468-7.508; p = 0.004). Classification and regression tree (CART) modeling led to the identification of three risk groups: PHLF occurred in 23/217 patients with ALBI grade 1 (10.6%, low risk group), in 54/254 patients with ALBI score 2 or 3 and absence of ascites (21.3%, intermediate risk group) and in 12/19 patients with ALBI score 2 or 3 and evidence of ascites (63.2%, high risk group), p < 0.0001. The three groups showed a corresponding increase in postoperative complications (20.0%, 27.5% and 66.7%), Comprehensive Complication Index (5.1 ± 11.1, 6.0 ± 10.9 and 18.8 ± 18.9) and hospital stay (6.0 ± 4.0, 6.0 ± 6.0 and 8.0 ± 5.0 days). CONCLUSION The risk of PHLF can be stratified by determining two easily available preoperative factors: ALBI and ascites. This model of risk prediction offers an objective instrument for a correct clinical decision-making.
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Sahara K, Paredes AZ, Merath K, Tsilimigras DI, Bagante F, Ratti F, Marques HP, Soubrane O, Beal EW, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Martel G, Aklile W, Guglielmi A, Hugh T, Aldrighetti L, Endo I, Pawlik TM. Evaluation of the ACS NSQIP Surgical Risk Calculator in Elderly Patients Undergoing Hepatectomy for Hepatocellular Carcinoma. J Gastrointest Surg 2020; 24:551-559. [PMID: 30937717 DOI: 10.1007/s11605-019-04174-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator (SRC) aims to help predict patient-specific risk for morbidity and mortality. The performance of the SRC among an elderly population undergoing curative-intent hepatectomy for hepatocellular carcinoma (HCC) remains unknown. METHODS Patients > 70 years of age who underwent hepatectomy for HCC between 1998 and 2017 were identified using a multi-institutional international database. To estimate the performance of SRC, 12 observed postoperative outcomes were compared with median SRC-predicted risk, and C-statistics and Brier scores were calculated. RESULTS Among 500 patients, median age was 75 years (IQR 72-78). Most patients (n = 324, 64.8%) underwent a minor hepatectomy, while 35.2% underwent a major hepatectomy. The observed incidence of venous thromboembolism (VTE) (3.2%) and renal failure (RF) (4.4%) exceeded the median predicted risk (VTE, 1.8%; IQR 1.5-3.1 and RF, 1.0%; IQR 0.5-2.0). In contrast, the observed incidence of 30-day readmission (7.0%) and non-home discharge (2.5%) was lower than median-predicted risk (30-day readmission, 9.4%; IQR 7.4-12.8 and non-home discharge, 5.7%; IQR 3.3-11.7). Only 57.8% and 71.2% of patients who experienced readmission (C-statistic, 0.578; 95%CI 0.468-0.688) or mortality (C-statistic, 0.712; 95%CI 0.508-0.917) were correctly identified by the model. CONCLUSION Among elderly patients undergoing hepatectomy for HCC, the SRC underestimated the risk of complications such as VTE and RF, while being no better than chance in estimating the risk of readmission. The ACS SRC has limited clinical applicability in estimating perioperative risk among elderly patients being considered for hepatic resection of HCC.
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Affiliation(s)
- Kota Sahara
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Anghela Z Paredes
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, University of Verona, Verona, Italy
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Eliza W Beal
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Workneh Aklile
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | | | - Tom Hugh
- Department of Surgery, The University of Sydney, School of Medicine, Sydney, Australia
| | | | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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45
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Shen YN, Tang TY, Yao WY, Guo CX, Yi-Zong, Song W, Liang TB, Bai XL. A nomogram for prediction of posthepatectomy liver failure in patients with hepatocellular carcinoma: A retrospective study. Medicine (Baltimore) 2019; 98:e18490. [PMID: 31861033 PMCID: PMC6940184 DOI: 10.1097/md.0000000000018490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To generate a nomogram to predict posthepatectomy liver failure (PHLF), we attempted to elucidate salient risk factors in patients with hepatocellular carcinoma (HCC).We performed a retrospective review of 665 patients with HCC who received hepatectomy in 2 academic institutions in China. Independent risk factors for PHLF were identified from putative demographic, intrinsic, biochemical, surgery-related, and volumetric data. A predictive nomogram was formulated based on relevant risk factors, and we compared this with existing models.We identified clinical signs of portal hypertension (P = .023), serum total bilirubin (P = .001), serum creatinine (P = .039), and intraoperative hemorrhage (P = .015) as being important risk factors in predicting PHLF. The nomogram had a C-index of 0.906 for the externally validated data. The nomogram displayed better predictive value than 2 of the other most cited models (C-indices of 0.641 and 0.616, respectively) in the current cohort. Additionally, we were able to patients into low- (<10%), intermediate- (10-30%), and high-risk (≥30%) groups based on the nomogram. This allows us to facilitate person-specific management.Here, we constructed a simple nomogram for prediction of PHLF in patients with HCC weighted by independent risk factors. Further prospective studies are required to confirm the predictive ability of our nomogram.
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Affiliation(s)
- Yi-Nan Shen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Tian-Yu Tang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Wei-Yun Yao
- Department of General Surgery, The People's Hospital of Changxing County, Huzhou
| | - Cheng-Xiang Guo
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Yi-Zong
- The 5th Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, The Second Military Medical University, Shanghai, China
| | - Wei Song
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
| | - Xue-Li Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou
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46
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Meier M, Knudsen AR, Andersen KJ, Ludvigsen M, Eriksen PL, Pedersen AKN, Honoré B, Mortensen FV. Perturbations of urea cycle enzymes during posthepatectomy rat liver failure. Am J Physiol Gastrointest Liver Physiol 2019; 317:G429-G440. [PMID: 31373508 DOI: 10.1152/ajpgi.00293.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Posthepatectomy liver failure (PHLF) may occur after extended partial hepatectomy (PH). If malignancy is widespread in the liver, the size of PH and hence the size of the future liver remnant (FLR) may limit curability. We aimed to characterize differences in protein expression between different sizes of FLRs and identify proteins specific to the regenerative process of minimal-size FLR (MSFLR), with special focus on postoperative day (POD) 1 when PHLF is present. A total of 104 male Wistar rats were subjected to 30, 70, or 90% PH (MSFLR in rats), sham operation, or no operation. Blood and liver tissue were harvested at POD1, 3, and 5 (n = 8 per group). Protein expression was assessed by proteomic profiling by unsupervised two-dimensional polyacrylamide gel electrophoresis (2D-PAGE) liquid chromatography tandem mass spectrometry (LC-MS/MS), followed by supervised selected reaction monitoring (SRM)-MS/MS. In all, 1,035 protein spots were detected, 54 of which were significantly differentially expressed between groups and identifiable. During PHLF after PH(90%) at POD1, urea cycle and related proteins showed significant perturbations, including the urea cycle flux-regulating enzyme of carbamoyl phosphate synthase-1, ornithine transcarbamylase, and arginase-1, as well as the ornithine aminotransferase and propionyl-CoA carboxylase alpha chain. Plasma-ammonia increased significantly at POD1 after PH(90%), followed by a prompt decrease. At the protein level, we found perturbations of urea cycle and related enzymes in the MSFLR during PHLF. Our results suggest that these perturbations may augment urea cycle function, which may be pivotal for increased ammonia elimination after extensive PHs and potential PHLF.NEW & NOTEWORTHY Posthepatectomy liver failure (PHLF) is associated with high mortality. In a rat model of 90% hepatectomy, PHLF is present. Our results on liver tissue proteomics suggest that the ability of the liver remnant to sufficiently eliminate ammonia may be brought about by perturbation related to urea cycle proteins and that enhancing the urea cycle capacity may play a key role in surviving PHLF.
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Affiliation(s)
- Michelle Meier
- Department of Surgery, Section for Upper Gastrointestinal and Hepatico-Pancreatico-Biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Riegels Knudsen
- Department of Surgery, Section for Upper Gastrointestinal and Hepatico-Pancreatico-Biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Jarlhelt Andersen
- Department of Surgery, Section for Upper Gastrointestinal and Hepatico-Pancreatico-Biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Maja Ludvigsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Peter Lykke Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Bent Honoré
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Frank Viborg Mortensen
- Department of Surgery, Section for Upper Gastrointestinal and Hepatico-Pancreatico-Biliary Surgery, Aarhus University Hospital, Aarhus, Denmark
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47
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Manterola C, Grande L, Otzen T, Duque G. Surgical treatment results of hepatocellular carcinoma in non-cirrhotic liver in southern Chile: case series with follow-up. ANZ J Surg 2019; 90:92-96. [PMID: 31566295 DOI: 10.1111/ans.15455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatocellular carcinoma is the most frequent primary tumour of the liver. Although often associated with chronic liver disease, it can also occur in non-cirrhotic livers. The aim of this study was to describe post-operative morbidity (POM), and survival of patients with hepatocellular carcinoma in non-cirrhotic liver treated surgically, and to identify variables associated with prognosis. METHODS Case series of patients who underwent surgery for hepatocellular carcinoma in non-cirrhotic liver at Clínica RedSalud Mayor de Temuco, Chile (2001-2017), were studied. The minimum follow-up time considered was 12 months. Principal outcomes were development of POM and survival. Other variables of interest were age, sex, tumour diameter, surgical time, hospital stay, follow-up time, need for surgical re-intervention, mortality, vascular and lymph node invasion and staging. Descriptive and analytic statistics were calculated. RESULTS A total of 32 patients were studied. They were characterized by a mean age of 67.3 ± 7.2 years, 62.5% of whom were men. Averages of tumour diameter, surgical time and hospitalization were 12.0 ± 2.6 cm, 114.4 ± 32.3 min and 7.2 ± 2.9 days, respectively. POM was 31.3%. There was no mortality and there were no re-interventions. The overall actuarial survival at 1, 2 and 3 years was 96.8%, 73.4% and 17.3%, respectively. Lower survival was verified in patients with vascular invasion, lymph node infiltration and stages III and IVa. CONCLUSION Despite the tumour diameter and extent of the resections, POM in patients with hepatocellular carcinoma in non-cirrhotic liver is moderate. However, its prognosis is poor. Vascular invasion, lymph node invasion and advances stages were associated with worse survival.
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Affiliation(s)
- Carlos Manterola
- Department of Surgery, Universidad de La Frontera, Temuco, Chile.,Center for Excellence in Morphological and Surgical Studies, Universidad de La Frontera, Temuco, Chile.,PhD Program in Medical Sciences, Universidad de La Frontera, Temuco, Chile
| | - Luis Grande
- PhD Program in Medical Sciences, Universidad de La Frontera, Temuco, Chile.,Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tamara Otzen
- Center for Excellence in Morphological and Surgical Studies, Universidad de La Frontera, Temuco, Chile.,PhD Program in Medical Sciences, Universidad de La Frontera, Temuco, Chile
| | - Galo Duque
- PhD Program in Medical Sciences, Universidad de La Frontera, Temuco, Chile.,Faculty of Medicine, Universidad del Azuay, Cuenca, Ecuador
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48
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Yuan G, Li J, Yu S, Chen X, He S. Letter to the Editor: Predicting Postoperative Liver Dysfunction Based on Blood Derived MicroRNA Signatures. Hepatology 2019; 70:1080-1081. [PMID: 31034633 DOI: 10.1002/hep.30689] [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: 12/07/2022]
Affiliation(s)
- Guandou Yuan
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Jiangfa Li
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Shuiping Yu
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, University of Science and Technology, Hubei, China
| | - Songqing He
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
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49
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Bagante F, Ruzzenente A, Beal EW, Campagnaro T, Merath K, Conci S, Akgül O, Alexandrescu S, Marques HP, Lam V, Shen F, Poultsides GA, Soubrane O, Martel G, Iacono C, Guglielmi A, Pawlik TM. Complications after liver surgery: a benchmark analysis. HPB (Oxford) 2019; 21:1139-1149. [PMID: 30718185 DOI: 10.1016/j.hpb.2018.12.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/25/2018] [Accepted: 12/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The best achievable short-term outcomes after liver surgery have not been identified. Several factors may influence the post-operative course of patients undergoing hepatectomy increasing the risk of post-operative complications. We sought to identify risk-adjusted benchmark values [BMV] for liver surgery. METHODS The National Surgery Quality Improvement Program (NSQIP) database was used to develop Bayesian models to estimate risk-adjusted BMVs for overall and liver related (post-hepatectomy liver failure [PHLF], biliary leakage [BL]) complications. A separate international multi-institutional database was used to validate the risk-adjusted BMVs. RESULTS Among the 11,243 patients included in the NSQIP database, the incidence of complications, PHLF, and BL was 36%, 5%, and 8%, respectively. The risk-adjusted BMVs for complication (range, 16-72%), PHLF (range, 1%-20%), and BL (range, 4%-22%) demonstrated a high variability based on patients characteristics. When tested using an international database including nine institutes, the risk-adjusted BMVs for complications ranged from 26% (Institute-4) to 43% (Institute-1), BMVs for PHLF between 3% (Institute-3) and 12% (Institute-5), while BMVs for BL ranged between 5% (Institute-4) and 9% (Institute-7). CONCLUSIONS Multiple factors influence the risk of complications following hepatectomy. Risk-adjusted BMVs are likely much more applicable and appropriate in assessing "acceptable" benchmark outcomes following liver surgery.
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Affiliation(s)
- Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Surgery, University of Verona, Verona, Italy
| | | | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Simone Conci
- Department of Surgery, University of Verona, Verona, Italy
| | - Ozgür Akgül
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | | | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, AP-HP, Beaujon Hospital, Clichy, France
| | - Guillaume Martel
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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50
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Dasari BVM, Pathanki A, Hodson J, Roberts KJ, Marudanayagam R, Mirza DF, Isaac J, Sutcliffe RP, Muiesan P. Propensity-matched analysis of the influence of perioperative statin therapy on outcomes after liver resection. BJS Open 2019; 3:509-515. [PMID: 31388643 PMCID: PMC6677106 DOI: 10.1002/bjs5.50155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/18/2019] [Indexed: 11/11/2022] Open
Abstract
Background Perioperative use of statins is reported to improve postoperative outcomes after cardiac and non‐cardiovascular surgery. The aim of this study was to investigate the influence of statins on postoperative outcomes including complications of grade IIIa and above, posthepatectomy liver failure (PHLF), and 90‐day mortality rates after liver resection. Methods Patients who underwent hepatectomy between 2013 and 2017 were reviewed to identify statin users and non‐users (controls). Propensity matching was conducted for age, BMI, type of surgery and preoperative co‐morbidities to compare subgroups. Univariable and multivariable analyses were performed for the following outcomes: 90‐day mortality, significant postoperative complications and PHLF. Results Of 890 patients who had liver resection during the study period, 162 (18·2 per cent) were taking perioperative statins. Propensity analysis selected two matched groups, each comprising 154 patients. Overall, 81 patients (9·1 per cent) developed complications of grade IIIa or above, and the 90‐day mortality rate was 3·4 per cent (30 patients), with no statistically significant difference when the groups were compared before and after matching. The rate of PHLF was significantly lower in patients on perioperative statins than in those not taking statins (10·5 versus 17·3 per cent respectively; P = 0·033); similar results were found after propensity matching (10·4 versus 20·8 per cent respectively; P = 0·026). Conclusion The rate of PHLF was significantly lower in patients taking perioperative statins, but there was no statistically significant difference in severe complications and mortality rates.
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Affiliation(s)
- B V M Dasari
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - A Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - J Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - K J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - R Marudanayagam
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - D F Mirza
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - J Isaac
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - R P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - P Muiesan
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
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