The impact of bile leakage on long-term prognosis in primary liver cancers after hepatectomy: A propensity-score-matched study

Impact of post-hepatectomy biliary leaks on long-term survival in different liver tumors: A single institute experience

Backgrounds/Aims

A postoperative biliary leak is one of the most morbid complications occurring after a liver resection, the long-term impact of which remains unknown.

Methods

Retrospective analysis of consecutive liver resections performed from 1 January 2011 to 31 December 2021. Primary endpoint of disease-free survival (DFS) was compared between patients with and without a bile leak, stratifying for tumor type. Survival curves were plotted using Kaplan-Meier estimates, and differences between them were analyzed using the log-rank test.

Results

In toto, 862 patients were analyzed, and included 306 (35.5%) hepatocellular carcinomas, 212 (24.6%) metastatic colorectal cancers, and 111 (12.9%) cholangiocarcinomas (69 intrahepatic cholangiocarcinomas, 42 hilar cholangiocarcinomas). Occurrence of a bile leak was associated with significantly poorer DFS only in patients with cholangiocarcinoma (median DFS 9.9 months vs. 24.9 months, p = 0.013), and further analysis was restricted to this cohort. A Cox regression performed for factors associated with DFS detriment in patients with cholangiocarcinoma showed that apart from node positivity (hazard ratio [HR]: 2.482, p = 0.033) and margin positivity (HR: 2.65, p = 0.021), development of a bile leak was independently associated with worsening DFS on both univariate and multiple regression analyses (HR: 1.896, p = 0.033).

Conclusions

Post-hepatectomy biliary leaks are associated with significantly poorer DFS only in patients with cholangiocarcinoma, but not in patients with hepatocellular carcinoma or metastatic colorectal cancer. Methods to mitigate this survival detriment need to be explored.

Deep learning-based automatic bleeding recognition during liver resection in laparoscopic hepatectomy

BACKGROUND

Intraoperative hemorrhage during laparoscopic hepatectomy (LH) is a risk factor for negative postoperative outcomes. Ensuring appropriate hemostasis enhances the safety of surgical procedures. An automatic bleeding recognition system based on deep learning can lead to safer surgeries; however, deep learning models that are useful for detecting and stopping bleeding in LH have not yet been reported. In this study, we aimed to develop a deep learning model to automatically recognize bleeding regions during liver transection in LH.

METHODS

In this retrospective feasibility study, bleeding scenes were randomly selected from LH videos, and the videos were divided into frames at 30 frames per second. Bleeding regions within the images were annotated by pixels, and subsequently, all images were assigned to the training, validation, and test datasets to develop the deep learning model. A convolutional neural network algorithm was used to perform semantic segmentation. After training and validation, the model was evaluated using images from the test dataset. Precision, recall, and Dice coefficients served as the evaluation metrics for the model.

RESULTS

In total, 2203 annotated images from 44 LH videos were utilized and divided into 1500, 400, and 303 frames for the training, validation, and test datasets, respectively. The precision, recall, and Dice coefficient values of the model were 0.76, 0.79, and 0.77, respectively.

CONCLUSIONS

We developed an automatic bleeding recognition model based on semantic segmentation and verified its performance. The proposed model is potentially useful for intraoperative alerting or evaluating surgical skills in the future.

Impact of bile leak on the prognosis of patients with hepatocellular carcinoma who have undergone liver resection

PURPOSE

The impact of postoperative bile leak on the prognosis of patients with hepatocellular carcinoma who underwent liver resection is controversial. This study aimed to investigate the prognostic impact of bile leak for patients with hepatocellular carcinoma who underwent liver resection.

METHODS

Patients with hepatocellular carcinoma who underwent liver resection between 2009 and 2019 at Kobe University Hospital and Hyogo Cancer Center were included. After propensity score matching between the bile leak and no bile leak groups, differences in 5-year recurrence-free and overall survival rates were evaluated using the Kaplan-Meier method.

RESULTS

A total of 781 patients, including 43 with postoperative bile leak, were analyzed. In the matched cohort, 40 patients were included in each group. The 5-year recurrence-free survival rates after liver resection were 35% and 32% for the bile leak and no bile leak groups, respectively (P = 0.857). The 5-year overall survival rates were 44% and 54% for the bile leak and no bile leak groups, respectively (P = 0.216).

CONCLUSION

Overall, bile leak may not have a profound negative impact on the prognosis of patients with hepatocellular carcinoma who have undergone liver resection.

Impact of sarcopenic obesity on post-hepatectomy bile leakage for hepatocellular carcinoma

BACKGROUND

Post-hepatectomy bile leakage (PHBL) is a potentially fatal complication that can arise after hepatectomy. Previous studies have identified obesity as a risk factor for PHBL. In this study, we investigated the impact of sarcopenic obesity on PHBL in hepatocellular carcinoma (HCC) patients.

METHODS

In total, we enrolled 409 patients who underwent hepatectomy without bilioenteric anastomosis for HCC between January 2010 and August 2021. Patients were grouped according to the presence or absence of PHBL. Patient characteristics, including body mass index and sarcopenic obesity, were then analyzed for predictive factors for PHBL.

RESULTS

Among the 409 HCC patients included in the study, 39 developed PHBL. Male sex, hypertension, cardiac disease, white blood cell counts, the psoas muscle area, and visceral fat area, and intraoperative blood loss were significantly increased in the PHBL (+) group compared with the PHBL (-) group. Multivariate analysis showed that the independent risk factors for the occurrence of PHBL were intraoperative blood loss ≥370 mL and sarcopenic obesity.

CONCLUSIONS

Our results show that it is important to understand whether a patient is at high risk for PHBL prior to surgery and to focus on reducing intraoperative blood loss during surgery for patients with risk factors for PHBL.

Risk factors of postoperative bile leakage after liver resection: A systematic review and meta-analysis

OBJECTIVE

Postoperative bile leakage (POBL) is one of the most common complications after liver resection. However, current studies on the risk factors for POBL and their impacts on surgical outcomes need to be more consistent. This study aims to conduct a meta-analysis to analyze the risk factors for POBL after hepatectomy.

METHODS

We incorporated all eligible studies from Embase, PubMed, and the Web of Science database (until July 2022) into this study. RevMan and STATA software were used to analyze the extracted data.

RESULTS

A total of 39 studies, including 43,824 patients, were included in this meta-analysis. We found that gender, partial hepatectomy, repeat of hepatectomy, extended hepatectomy, abdominal drain, diabetes, Child≥B, solitary tumor, and chemotherapy are the factors of grade B and C POBL. Some recognized risk factors were considered potential risk factors for grade B and C bile leakage because no subgroup analysis was performed, like HCC, cholangiocarcinoma, major resection, posterior sectionectomy, bi-segmentectomy, S4 involved, S8 involved, central hepatectomy, and bile duct resection/reconstruction. Meanwhile, cirrhosis, benign diseases, left hepatectomy, and Segment 1 resection were not significant for grade B and C bile leakage. The influence of lateral sectionectomy, anterior sectionectomy, S1 involved, S3 involved, high-risk procedure, laparoscope, and blood loss>1000 mL on POBL of ISGLS needs further research. Meanwhile, POBL significantly influenced overall survival (OS) after liver resection.

CONCLUSIONS

We identified several risk factors for POBL after hepatectomy, which could prompt the clinician to decrease POBL rates and make more beneficial decisions for patients who underwent the hepatectomy.

Construction and Validation of a Nomogram for Predicting the Risk of Deep Vein Thrombosis in Hepatocellular Carcinoma Patients After Laparoscopic Hepatectomy: A Retrospective Study

Background

The incidence of deep vein thrombosis (DVT) in hepatocellular carcinoma (HCC) patients after laparoscopic hepatectomy (LH) is unclear, and there is no effective method for DVT risk assessment in these patients.

Methods

The data from the total of 355 consecutive HCC patients who underwent LH were included. A DVT risk algorithm was developed using a training set (TS) of 243 patients, and its predictive performance was evaluated in both the TS and a validation set (VS) of 112 patients. The model was then used to develop a DVT risk nomogram (TRN).

Results

The incidence of DVT in the present study was 18.6%. Age, sex, body mass index (BMI), comorbidities and operative position were independent risk factors for DVT in the TS. The model based on these factors had a good predictive ability. In the TS, it had an area under the receiver operating characteristic (AUC) curve of 0.861, Hosmer-Lemeshow (H-L) goodness of fit p value of 0.626, sensitivity of 44.4%, specificity of 96.5%, positive predictive value (PPV) of 74.1%, negative predictive value (NPV) of 88.4%, and accuracy of 86.8%. In the VS, it had an AUC of 0.818, H-L p value of 0.259, sensitivity of 38.1%, specificity of 98.9%, PPV of 88.9%, NPV of 87.4%, and accuracy of 87.5%. The TRN performed well in both the internal and the external validation, indicating a good clinical application value. The TRN had a better predictive value of DVT than the Caprini score (p < 0.001).

Conclusion

The incidence of DVT after LH was high, and should not be neglected in HCC patients. The TRN provides an efficacious method for DVT risk evaluation and individualized pharmacological thromboprophylaxis.

Application of Near-Infrared Fluorescence Imaging Technology in Liver Cancer Surgery

Background. Hepatocellular carcinoma, among the most common malignant digestive system tumorsworldwide, is most effectively treated with precise surgical resection. Near-infrared fluorescence imaging technology is being increasingly used clinically and has achieved great initial results in the navigation of liver cancer surgery. Methods. This review describes the application of indocyanine green fluorescence (ICG) imaging technology with near-infrared window I in the navigation of liver cancer surgery, explores novel fluorescent probes and near-infrared window II fluorescence imaging technology, and discusses the development status of the 2 emerging tools. Results. ICG fluorescence imaging technology can precisely localize the tumor, reveal the boundary of liver cancer or liver segment, and identify the bile leakage. The novel fluorescent probe is more targeted than ICG, which makes the detection of cancer more accurate. Near-infrared window II fluorescence imaging technology can lead to outstanding gains in deeper detection, higher resolution, and fidelity. But, due to the shortcomings of machine and probe, it is not widely used in clinical. Conclusion. Near-infrared fluorescence imaging has great development potential. With the advent of precision medicine and the progress of various biotechnology studies, fluorescence imaging technology will be better developed and applied in the diagnosis, surgical navigation, and treatment of liver cancer.

Long-term oncological outcomes of laparoscopic versus open transhiatal resection for patients with Siewert type II adenocarcinoma of the esophagogastric junction

BACKGROUND

Insufficient information is available about the long-term outcomes of patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) who undergo laparoscopic transhiatal approach (LTH). Here we evaluated the oncological safety of LTH for patients with Siewert type II AEG compared with the open transhiatal approach (OTH).

METHODS

Subjects included 79 patients with Siewert type II AEG who underwent gastrectomy combined with lower esophagectomy from 2008 to 2018 at our institution. Overall survival (OS), recurrence-free survival (RFS), status of adjuvant chemotherapy, late-phase complications, and recurrence patterns were compared between the OTH (n = 29) and LTH groups (n = 43).

RESULTS

The median observation periods were 60 months (6-120 months) and 36 months (1-88) for the OTH and LTH groups, respectively. The 5-year OS rates were significantly different: 74% (95% CI 71-77%) and 98% (95% CI 97-99) in the OTH and LTH groups (HR 0.10, 95% CI 0.01-0.83), respectively, though the OTH group included more patients with advanced disease. After stratification, according to pathological stage to adjust for selection bias, the 5-year OS and RFS rates were longer, but not significantly different among patients in the LTH group with pStage III (HR 0.42, 95% CI 0.05-3.47; HR 0.47, 95% CI 0.10-2.12, respectively). Recurrence patterns were similar in the both groups.

CONCLUSIONS

Long-term outcomes of the LTH group were not inferior to those of the OTH group, suggesting the possibility of LTH as a treatment option for selected patients with Siewert type II AEG.