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Thobani H, Durrani R, Raymond SL, Shah AA, Islam S, Khan FA. Hepatic resections for pediatric hepatoblastoma: analysis of 30-day outcomes using the National Surgical Quality Improvement Program-Pediatric database. Pediatr Surg Int 2024; 40:230. [PMID: 39154089 DOI: 10.1007/s00383-024-05820-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Surgical resection remains the cornerstone of treatment for hepatoblastoma in children and offers the best chance of disease-free survival. We aimed to analyze the 30 day outcomes of hepatic resection for hepatoblastoma stratified by extent using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P). METHODS We queried NSQIP-P for children undergoing resection of Hepatoblastoma from 2012 to 2021. Relevant clinical characteristics and outcomes were extracted for multivariate logistic regression to identify predictors of common adverse outcomes. RESULTS We included 458 children with a median age of 1.90 years. Overall complications were rare, and perioperative blood transfusion (64.2%) and postoperative ventilation > 48 h (10.0%) were the only adverse events prevalent in more than 5% of patients. Median transfusion volume was 15.7 ml/kg. On multivariate regression, only patients undergoing Trisectionectomy (aOR = 3.387, 95% C.I. = 1.348-8.510) had higher odds of receiving > 75th percentile blood transfusion. Furthermore, only perioperative transfusion and postoperative ventilation > 48 h were statistically more common in patients undergoing extended versus standard resections. CONCLUSIONS Outcomes following resection of hepatoblastoma are excellent, with low rates of postoperative adverse events. Although children undergoing trisectionectomy likely require greater transfusion volume, extended hepatic resections do not appear to have worse 30 day outcomes despite greater operative complexity and duration.
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Affiliation(s)
- Humza Thobani
- Section of Pediatric Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
- Division of Pediatric Surgery, Department of Surgery, Stanford Center for Academic Medicine, Lucile Packard Children's Hospital, 453 Quarry Rd, Palo Alto, Stanford, CA, 94304, USA
| | - Rafia Durrani
- Section of Pediatric Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Steven L Raymond
- Division of Pediatric Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Adil A Shah
- Department of Pediatric Surgery, Children's Hospital and Medical Center, University of Nebraska, Omaha, NE, USA
| | - Saleem Islam
- Section of Pediatric Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Faraz A Khan
- Division of Pediatric Surgery, Department of Surgery, Stanford Center for Academic Medicine, Lucile Packard Children's Hospital, 453 Quarry Rd, Palo Alto, Stanford, CA, 94304, USA.
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Liu WJ, Cheng WC, Chen YY, Kang CM, Chen JW, Ho MC, Lo SC. Detrimental effects of fresh frozen plasma transfusions on postoperative outcomes in patients undergoing liver resection for hepatocellular carcinoma. J Formos Med Assoc 2023; 122:1189-1198. [PMID: 37286421 DOI: 10.1016/j.jfma.2023.05.026] [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: 08/18/2022] [Revised: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Perioperative fresh frozen plasma (FFP) is commonly transfused to patients undergoing liver resection for hepatocellular carcinoma (HCC), but its impacts in this population remain unknown. This study aimed to investigate the association of perioperative FFP transfusion with short-term and long-term outcomes in these patients. METHODS We retrospectively identified and retrieved clinical data for HCC patients undergoing liver resection between March, 2007 and December, 2016. Study outcomes included postoperative bacterial infection, extended length of stay (LOS) and survival. Propensity score (PS) matching was used to determine the association of FFP transfusion with each outcome. RESULTS A total of 1427 patients were included, and 245 of them received perioperative FFP transfusions (17.2%). Patients received perioperative FFP transfusions were older, underwent liver resection in the earlier time period, and had more extensive resection, poorer clinical conditions, and higher proportions of receiving other blood components. Perioperative FFP transfusion was associated with higher odds of both postoperative bacterial infection (OR = 1.77, p = 0.020) and extended LOS (OR = 1.93, p=<0.001), and the results remained similar after PS-matching. However, perioperative FFP transfusion did not significantly affect survival in these patients (HR = 1.17, p = 0.185). A potential association of postoperative FFP transfusions and poorer 5-year but not overall survival was observed in a subgroup of patients with low postoperative albumin levels after PS-matching. CONCLUSION Perioperative FFP transfusions were associated with poorer short-term postoperative outcomes in HCC patients undergoing liver resection, including postoperative bacterial infection and extended LOS. Reducing perioperative FFP transfusions has the potential to improve their postoperative outcomes.
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Affiliation(s)
- Wen-Jie Liu
- Taiwan Blood Services Foundation, Taipei, Taiwan
| | - Wern-Cherng Cheng
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | | | - Chun-Min Kang
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen-Wei Chen
- Taiwan Blood Services Foundation, Taipei, Taiwan
| | - Ming-Chih Ho
- Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan; Department of Surgery, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shyh-Chyi Lo
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan College of Medicine, Taipei, Taiwan.
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Otto CC, Czigany Z, Heise D, Bruners P, Kotelis D, Lang SA, Ulmer TF, Neumann UP, Klink C, Bednarsch J. Prognostic Factors for Mortality in Acute Mesenteric Ischemia. J Clin Med 2022; 11:jcm11133619. [PMID: 35806904 PMCID: PMC9267588 DOI: 10.3390/jcm11133619] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/07/2022] [Accepted: 06/20/2022] [Indexed: 12/23/2022] Open
Abstract
Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values.
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Affiliation(s)
- Carlos Constantin Otto
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany;
| | - Drosos Kotelis
- Department of Vascular Surgery, University Hospital RWTH Aachen, 52074 Aachen, Germany;
- Department of Vascular Surgery, University Hospital Bern, 3010 Bern, Switzerland
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Department of Surgery, Maastricht University Medical Center (MUMC), 6229 HX Maastricht, The Netherlands
| | - Christian Klink
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Department of Surgery, Diakonissen-Stiftungs-Krankenhaus Speyer, 67346 Speyer, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (C.C.O.); (Z.C.); (D.H.); (S.A.L.); (T.F.U.); (U.P.N.); (C.K.)
- Correspondence: ; Tel.: +49-241-80-89501
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Bednarsch J, Czigany Z, Heij LR, Amygdalos I, Heise D, Bruners P, Ulmer TF, Neumann UP, Lang SA. The role of re-resection in recurrent hepatocellular carcinoma. Langenbecks Arch Surg 2022; 407:2381-2391. [PMID: 35599252 PMCID: PMC9468093 DOI: 10.1007/s00423-022-02545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/04/2022] [Indexed: 01/27/2023]
Abstract
Abstract
Purpose
While liver resection is a well-established treatment for primary HCC, surgical treatment for recurrent HCC (rHCC) remains the topic of an ongoing debate. Thus, we investigated perioperative and long-term outcome in patients undergoing re-resection for rHCC in comparative analysis to patients with primary HCC treated by resection.
Methods
A monocentric cohort of 212 patients undergoing curative-intent liver resection for HCC between 2010 and 2020 in a large German hepatobiliary center were eligible for analysis. Patients with primary HCC (n = 189) were compared to individuals with rHCC (n = 23) regarding perioperative results by statistical group comparisons and oncological outcome using Kaplan–Meier analysis.
Results
Comparative analysis showed no statistical difference between the resection and re-resection group in terms of age (p = 0.204), gender (p = 0.180), ASA category (p = 0.346) as well as main preoperative tumor characteristics, liver function parameters, operative variables, and postoperative complications (p = 0.851). The perioperative morbidity (Clavien-Dindo ≥ 3a) and mortality were 21.7% (5/23) and 8.7% (2/23) in rHCC, while 25.4% (48/189) and 5.8% (11/189) in primary HCC, respectively (p = 0.851). The median overall survival (OS) and recurrence-free survival (RFS) in the resection group were 40 months and 26 months, while median OS and RFS were 41 months and 29 months in the re-resection group, respectively (p = 0.933; p = 0.607; log rank).
Conclusion
Re-resection is technically feasible and safe in patients with rHCC. Further, comparative analysis displayed similar oncological outcome in patients with primary and rHCC treated by liver resection. Re-resection should therefore be considered in European patients diagnosed with rHCC.
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Limitations of Nerve Fiber Density as a Prognostic Marker in Predicting Oncological Outcomes in Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:cancers14092237. [PMID: 35565366 PMCID: PMC9103173 DOI: 10.3390/cancers14092237] [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: 03/22/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 02/07/2023] Open
Abstract
It has been shown that the presence and density of nerve fibers (NFs; NFD) in the tumor microenvironment (TME) may play an important prognostic role in predicting long-term oncological outcomes in various malignancies. However, the role of NFD in the prognosis of hepatocellular carcinoma (HCC) is yet to be explored. To this end, we aimed to investigate the impact of NFs on oncological outcomes in a large European single-center cohort of HCC patients. In total, 153 HCC patients who underwent partial hepatectomy in a curative-intent setting between 2010 and 2021 at our university hospital were included in this study. Group comparisons between patients with and without NFs were conducted and the association of recurrence-free survival (RFS) and overall survival (OS) with the presence of NFs and other clinico-pathological variables were determined by univariate and multivariable Cox regression models. Patients with NFs in the TME presented with a median OS of 66 months (95% CI: 30−102) compared to 42 months (95% CI: 20−63) for patients without NFs (p = 0.804 log-rank). Further, RFS was 26 months (95% CI: 12−40) for patients with NFs compared to 18 months (95% CI: 9−27) for patients without NFs (p = 0.666 log-rank). In a subgroup analysis, patients with NFD ≤ 5 showed a median OS of 54 months (95% CI: 11−97) compared to 48 months (95% CI: 0−106) for the group of patients with NFD > 5 (p = 0.787 log-rank). Correspondingly, the RFS was 26 months (95% CI: 10−42) in patients with NFD ≤ 5 and 29 months (95% CI: 14−44) for the subcohort with NFD > 5 (p = 0.421 log-rank). Further, group comparisons showed no clinico-pathological differences between patients with NFs (n = 76) and without NFs (n = 77) and NFs were not associated with OS (p = 0.806) and RFS (p = 0.322) in our Cox regression models. In contrast to observations in various malignancies, NFs in the TME and NFD are not associated with long-term oncological outcomes in HCC patients undergoing surgery.
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Perioperative screening and management in elective complex hepatobiliary surgery. Curr Opin Crit Care 2022; 28:221-228. [PMID: 35131993 DOI: 10.1097/mcc.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Preoperative optimization and structured evidence-based perioperative care of a patient undergoing complex hepatobiliary (HPB) surgery are essential components in their management. Apart from advances in surgical technique, these perioperative measures have resulted in substantial reductions in morbidity and mortality. There hence, remains a continued need to have evidence-based updation in their management algorithm to ensure optimal outcomes. RECENT FINDINGS We present an evidence-based overview of the preoperative screening, optimization and perioperative management of patients undergoing complex HPB surgery. SUMMARY Perioperative care of these fragile patients is an evidence-based dynamic process. Optimal patient management undergoing HPB surgery requires risk assessment and stratification, and meticulous attention to the correction of underlying conditions. Despite this, postoperative morbidity remains relatively high and requires a cohesive multidisciplinary approach to minimize complications.
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Bednarsch J, Czigany Z, Heij LR, Luedde T, Loosen SH, Dulk MD, Bruners P, Lang SA, Ulmer TF, Neumann UP. The prognostic role of in-hospital transfusion of fresh frozen plasma in patients with cholangiocarcinoma undergoing curative-intent liver surgery. Eur J Surg Oncol 2021; 48:604-614. [PMID: 34565633 DOI: 10.1016/j.ejso.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Major hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies. MATERIAL AND METHODS Patients undergoing hepatectomy for CCA from 2010 to 2019 at a single institution were eligible for this study. Survival analysis was carried out according to Kaplan-Meier and the associations of cancer-specific (CSS) and recurrence-free survival (RFS) with in-hospital application of FFP and other clinico-pathological characteristics were assessed using Cox regression models. Perioperatively deceased patients were excluded from the analysis. RESULTS A total of 219 CCA patients were included in this survival analysis of which 53.0% (116/219) received FFP during hospitalization. Patients receiving in-hospital FFP showed a median CCS of 33 months (3-year-CSS = 46%, 5-year-CSS = 29%) compared to 83 months (3-year-CSS = 55%, 5-year-CSS = 53%) in patients who did not receive in-hospital FFP (p = 0.006 log rank). Further, in-hospital FFP was identified as an independent predictor of oncological outcome in multivariable analysis (CSS: HR = 1.71, p = 0.016; RFS: HR = 1.89, p = 0.003). CONCLUSION In a large European cohort of patients, in-hospital transfusion of FFP was identified as a novel independent prognostic marker in CCA patients undergoing curative-intent liver surgery. A restrictive transfusion policy is therefore recommended to improve long-term outcome in these patients.
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Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Lara R Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marcel den Dulk
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven A Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom F Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands.
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Bednarsch J, Czigany Z, Loosen SH, Heij L, Ruckgaber L, Maes H, Krause JP, Reen M, Toteva B, Vosdellen T, Bruners P, Lang SA, Ulmer TF, Roderburg C, Luedde T, Neumann UP. Perioperative rifaximin is not associated with enhanced functional and volumetric recovery after major liver resection. Sci Rep 2021; 11:17936. [PMID: 34504196 PMCID: PMC8429542 DOI: 10.1038/s41598-021-97442-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/18/2021] [Indexed: 02/07/2023] Open
Abstract
The objective of this randomized controlled trial (RCT) was to assess the impact of rifaximin on the course of liver function, liver regeneration and volumetric recovery in patients undergoing major hepatectomy. The ARROW trial was an investigator initiated, single-center, open-label, phase 3 RCT with two parallel treatment groups, conducted at our hepatobiliary center from 03/2016 to 07/2020. Patients undergoing major hepatectomy were eligible and randomly assigned 1:1 to receive oral rifaximin (550 mg twice daily for 7-10 or 14-21 days in case of portal vein embolization preoperatively and 7 days postoperatively) versus no intervention. Primary endpoint was the relative increase in postoperative liver function measured by LiMAx from postoperative day (POD) 4 to 7. Secondary endpoint were the course of liver function and liver volume during the study period as well as postoperative morbidity and mortality. Between 2016 and 2020, 45 patients were randomized and 35 patients (16 individuals in the rifaximin and 19 individuals in the control group) were eligible for per-protocol analysis. The study was prematurely terminated following interim analysis, due to the unlikelihood of reaching a significant primary endpoint. The median relative increase in liver function from POD 4 to POD 7 was 27% in the rifaximin group and 41% in the control group (p = 0.399). Further, no significant difference was found in terms of any other endpoints of functional liver- and volume regeneration or perioperative surgical complications following the application of rifaximin versus no intervention. Perioperative application of rifaximin has no effect on functional or volumetric regeneration after major hepatectomy (NCT02555293; EudraCT 2013-004644-28).
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Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Sven H Loosen
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University, Duesseldorf, Germany
| | - Lara Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Lorenz Ruckgaber
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Henning Maes
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Jan-Pit Krause
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Matthias Reen
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Beata Toteva
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Theresa Vosdellen
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Christoph Roderburg
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University, Duesseldorf, Germany
| | - Tom Luedde
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University, Duesseldorf, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.
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Giustiniano E, Nisi F, Rocchi L, Zito PC, Ruggieri N, Cimino MM, Torzilli G, Cecconi M. Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist. Cancers (Basel) 2021; 13:cancers13092203. [PMID: 34063684 PMCID: PMC8125060 DOI: 10.3390/cancers13092203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Major high-risk surgery (HRS) exposes patients to potential perioperative adverse events. Hepatic resection of colorectal metastases can surely be included into the HRS class of operations. Limiting such risks is the main target of the perioperative medicine. In this context the collaboration between the anesthetist and the surgeon and the sharing of management protocols is of utmost importance and represents the key issue for a successful outcome. In our institution, we have been adopting consolidated protocols for patients undergoing this type of surgery for decades; this made our mixed team (surgeons and anesthetists) capable of achieving a safe outcome for the majority of our surgical population. In this narrative review, we report the most recent state of the art of perioperative management of hepatic resection of colorectal metastases along with our experience in this field, trying to point out the main issues. Abstract Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients’ management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist’s point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Correspondence: (E.G.); (F.N.); Tel.: +39-02-8224-7459 (E.G.); +39-02-8224-4115 (F.N.); Fax: +39-02-8224-4190 (E.G. & F.N.)
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Correspondence: (E.G.); (F.N.); Tel.: +39-02-8224-7459 (E.G.); +39-02-8224-4115 (F.N.); Fax: +39-02-8224-4190 (E.G. & F.N.)
| | - Laura Rocchi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Paola C. Zito
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
| | - Matteo M. Cimino
- Hepato-Biliary & Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (M.M.C.); (G.T.)
| | - Guido Torzilli
- Hepato-Biliary & Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (M.M.C.); (G.T.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, 20089 Milan, Italy; (L.R.); (P.C.Z.); (N.R.); (M.C.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
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Miller H, Czigany Z, Lurje I, Reichelt S, Bednarsch J, Strnad P, Trautwein C, Roderburg C, Tacke F, Gaisa NT, Knüchel-Clarke R, Neumann UP, Lurje G. Impact of Angiogenesis- and Hypoxia-Associated Polymorphisms on Tumor Recurrence in Patients with Hepatocellular Carcinoma Undergoing Surgical Resection. Cancers (Basel) 2020; 12:cancers12123826. [PMID: 33352897 PMCID: PMC7767259 DOI: 10.3390/cancers12123826] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Hepatocellular carcinoma remains a leading cause of cancer-related death and the most common primary hepatic malignancy in the Western hemisphere. Previous research found that angiogenesis-related cytokines and elevated levels of interleukin 8 and vascular endothelial growth factor (VEGF) shorten the expected time of survival. Moreover, factors of tumor angiogenesis- and hypoxia-driven signaling pathways are already associated with worse outcome in disease-free survival in several tumor entities. Our study investigates the prognosis of hepatocellular carcinoma patients based on a selection of ten different single-nucleotide polymorphisms from angiogenesis, carcinogenesis, and hypoxia pathways. Our study with 127 patients found supporting evidence that polymorphisms in angiogenesis-associated pathways corelate with disease-free survival and clinical outcome in patients with hepatocellular carcinoma. Abstract Tumor angiogenesis plays a pivotal role in hepatocellular carcinoma (HCC) biology. Identifying molecular prognostic markers is critical to further improve treatment selection in these patients. The present study analyzed a subset of 10 germline polymorphisms involved in tumor angiogenesis pathways and their impact on prognosis in HCC patients undergoing partial hepatectomy in a curative intent. Formalin-fixed paraffin-embedded (FFPE) tissues were obtained from 127 HCC patients at a German primary care hospital. Genomic DNA was extracted, and genotyping was carried out using polymerase chain reaction (PCR)–restriction fragment length polymorphism-based protocols. Polymorphisms in interleukin-8 (IL-8) (rs4073; p = 0.047, log-rank test) and vascular endothelial growth factor (VEGF C + 936T) (rs3025039; p = 0.045, log-rank test) were significantly associated with disease-free survival (DFS). After adjusting for covariates in the multivariable model, IL-8 T-251A (rs4073) (adjusted p = 0.010) and a combination of “high-expression” variants of rs4073 and rs3025039 (adjusted p = 0.034) remained significantly associated with DFS. High-expression variants of IL-8 T-251A may serve as an independent molecular marker of prognosis in patients undergoing surgical resection for HCC. Assessment of the patients’ individual genetic risks may help to identify patient subgroups at high risk for recurrence following curative-intent surgery.
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Affiliation(s)
- Hannah Miller
- Charité–Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte|Campus Virchow-Klinikum, 13353 Berlin, Germany; (H.M.); (S.R.)
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
| | - Isabella Lurje
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
- Charité–Universitätsmedizin Berlin, Department of Gastroenterology and Hepatology, Campus Charité Mitte|Campus Virchow-Klinikum, 13353 Berlin, Germany; (C.R.); (F.T.)
| | - Sophie Reichelt
- Charité–Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte|Campus Virchow-Klinikum, 13353 Berlin, Germany; (H.M.); (S.R.)
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
| | - Pavel Strnad
- Department of Internal Medicine III, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Christoph Roderburg
- Charité–Universitätsmedizin Berlin, Department of Gastroenterology and Hepatology, Campus Charité Mitte|Campus Virchow-Klinikum, 13353 Berlin, Germany; (C.R.); (F.T.)
- Department of Internal Medicine III, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Frank Tacke
- Charité–Universitätsmedizin Berlin, Department of Gastroenterology and Hepatology, Campus Charité Mitte|Campus Virchow-Klinikum, 13353 Berlin, Germany; (C.R.); (F.T.)
- Department of Internal Medicine III, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Nadine Therese Gaisa
- Institute of Pathology, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (N.T.G.); (R.K.-C.)
| | - Ruth Knüchel-Clarke
- Institute of Pathology, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (N.T.G.); (R.K.-C.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
| | - Georg Lurje
- Charité–Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte|Campus Virchow-Klinikum, 13353 Berlin, Germany; (H.M.); (S.R.)
- Department of Surgery and Transplantation, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, 52074 Aachen, Germany; (Z.C.); (I.L.); (J.B.); (U.P.N.)
- Correspondence: ; Tel.: +49-30-450-652339
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11
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Bednarsch J, Czigany Z, Heise D, Joechle K, Luedde T, Heij L, Bruners P, Ulmer TF, Neumann UP, Lang SA. Prognostic evaluation of HCC patients undergoing surgical resection: an analysis of 8 different staging systems. Langenbecks Arch Surg 2020; 406:75-86. [PMID: 33294952 PMCID: PMC7870608 DOI: 10.1007/s00423-020-02052-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023]
Abstract
Purpose No consensus exists regarding the most appropriate staging system to predict overall survival (OS) for hepatocellular carcinoma (HCC) in surgical candidates. Thus, we aimed to determine the prognostic ability of eight different staging systems in a European cohort of patients undergoing liver resection for HCC. Methods Patients resected for HCC between 2010 and 2019 at our institution were analyzed with Kaplan-Meier and Cox regression analyses. Likelihood ratio (LR) χ2 (homogeneity), linear trend (LT) χ2 (discriminatory ability), and Akaike Information Criterion (AIC, explanatory ability) were used to determine the staging system with the best overall prognostic performance. Results Liver resection for HCC was performed in 160 patients. Median OS was 39 months (95% confidence interval (CI): 32–46 months) and median RFS was 26 months (95% CI: 16–34 months). All staging systems (BCLC, HKLC, Okuda, CLIP, ITA.LI.CA staging and score, MESH, and GRETCH) showed significant discriminatory ability regarding OS, with ITA.LI.CA score (LR χ2 30.08, LT χ2 13.90, AIC 455.27) and CLIP (LR χ2 28.65, LT χ2 18.95, AIC 460.07) being the best performing staging systems. Conclusions ITA.LI.CA and CLIP are the most suitable staging system to predict OS in European HCC patients scheduled for curative-intent surgery.
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Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Katharina Joechle
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tom Luedde
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Lara Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, Netherlands
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
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