Effect of surgeon's experience on complications from laparoscopic hysterectomy

Ergonomic learning curves on gynecological laparoendoscopic single-site (LESS) surgery

BACKGROUND

Few previous studies have introduced general techniques to overcome the "chopstick effect" in laparoendoscopic single-site surgery (LESS). We aim to investigate and highlight the key ergonomic methodologies for gynaecologic LESS based on the surgeon's hands-on performance.

METHODS

The first author surgeon A reviewed and analyzed the LESS procedures performed by herself and how she taught surgeon B from January 2021 to April 2022. The procedures were classified based on technical difficulty and learning periods, and the hands-on technical skills of LESS module were evaluated.

RESULTS

Surgeon A conducted 580 LESS procedures, which were divided into the novice (n = 48) and intermediate (n = 33) periods, and the remaining cases were included in the routine period. We formed a special ergonomic LESS operating methodology: Maintain good LESS laparoscopic spatial sensation, keep hand-eye coordination, well cooperation between the main surgeon and the assistant; Experienced multiport laparoscopy surgery (MPS) skills, improve basic LESS technique: grasp, lift, transfer, place, blunt separating, coagulation and cutting. Coordination location, orientation, movements, and flexion or extension of shoulders, arms, elbow, wrist and finger joints; Maintain strength, tension and ambidexterity postures with joint and muscular efforts to control instruments. Surgeon B learned the above experiences by performing 39 LESS procedures under the guidance of surgeon A.

CONCLUSION

This educational research sheds light on the common challenges faced in LESS and presents the importance of ergonomic hands-on performance skills in improving surgical outcomes, which could serve as a guide for future training and education in LESS.

Technical, ergonomic and cognitive learning methodology in transumbilical single-port laparoscopic hysterectomy

OBJECTIVE

We introduced learning curves on a detailed step protocol and ergonomic aspect to determine key surgical points in transumbilical single-port laparoscopic hysterectomy (TSPLH) and to popularize both technical and cognitive methodology on laparoendoscopic single-site surgery (LESS).

MATERIALS AND METHODS

A retrospective analysis of 87 TSPLH procedures was conducted by a single surgeon in three learning stages. Technical, ergonomic, and cognitive steps were introduced, and surgical outcomes were analyzed.

RESULTS

Key production points in TSPLH include developing a clear retroperitoneal space, maintaining appropriate strength and direction with a vaginal manipulator, coagulating the uterine artery, and applying an improved vaginal stump suturing method. Technical factors included instrument domination, hand-eye coordination, and alternating hand functions. Ergonomic techniques focused on shoulder, elbow, arm, wrist, and finger movements, range of motion, muscle power, continuous forces, and flexibility. Improved cognitive factors such as confidence, decision-making, and communication were also observed.

CONCLUSIONS

The study aimed to form methodological education on TSPLH and LESS and benefit more surgeons. The detailed production and key ergonomic points will help guide self-learning and education.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy

INTRODUCTION

Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows.

MATERIEL AND METHODS

We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021.

RESULTS

Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p = 0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094).

CONCLUSION

The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".

Risk Assessment Model for Complications in Minimally Invasive Hysterectomy: A Pilot Study

Objective: To estimate the rate of intra-operative and postoperative complications, and to define the risk of 30-day major postoperative complications (Clavien-Dindo > 2) according to the presence of one of 10 different variables of minimally invasive (MI) hysterectomy; and then to create a risk assessment model easily applicable in clinical practice. Methods: A single center single arm retrolective study. Data of consecutive patients who have undergone MI hysterectomy for gynaecologic disorders between May 2018 and April 2021 were analyzed. Perioperative surgical outcomes, occurrence of intra- and postoperative complications, and readmissions within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major postoperative complications. Results: Over the study period, 445 patients were included in the study. The majority of patients developed a minor event, while major complications (grade III) were required in 14 patients. None of the patients showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or postoperative complications from those who did not experience complications. Body mass index (BMI) (p-value 0.045) and surgeon’s experience (p-value 0.015) were found to be associated with a different surgery time. Regarding major postoperative complications, a statistically significant association was found for the variables: BMI (p-value 0.006), previous abdominal surgery (p-value 0.015), and surgeon’s experience (p-value 0.035) in the univariate analysis. Also in the multivariate analysis, the risk of major postoperative complications was higher in these three different variables. BMI, previous surgery, and surgeon’s experience were inserted in a reproducible risk assessment model in order to stratify the risk of major postoperative complications. Conclusions: We proposed a risk assessment model including factors not previously considered in the literature: the standardization of the surgical technique, the surgeon’s experience, the best MI approach (laparoscopy or robot-assisted), and previous abdominal surgery are crucial tools to consider. Further prospective studies with a larger population sample are needed to validate these preliminary evaluations for patients undergoing MI hysterectomy.

Urologic Complication after Laparoscopic Hysterectomy in Gynecology Oncology: A Single-Center Analysis and Narrative Review of the Literature

Background and Objectives: Minimally invasive surgery (MIS) has recently increased its application in the treatment of gynecological malignancies. Despite technological and surgical advances, urologic complications (UC) are still the main concern in gynecology surgery. Current literature reports a wide range of urinary tract injuries, and consistent scientific evidence is still lacking or dated. This study aims to report a large single-center experience of urinary complications during laparoscopic hysterectomy for gynecologic oncologic disease. Materials and Methods: All patients who underwent laparoscopic hysterectomy for gynecologic malignancy at the Department of Medicine and Surgery of the University Hospital of Parma from 2017 to 2021 were retrospectively included. Women with endometrial cancer, cervical cancer, ovarian cancer, uterine sarcoma, or borderline ovarian tumors were included. Patients undergoing robotic surgery with incomplete anatomopathological data or patients lost during follow-up were excluded from the analysis. Intraoperative and postoperative UC were analyzed and ranked according to the Clavien-Dindo classification. Results: Two hundred-sixty patients were included in the study: 180 endometrial cancer, 18 cervical cancer, nine ovarian cancer, two uterine sarcomas, and 60 borderline ovarian tumors. Nine (3.5%) UCs were reported (five intraoperative and four postoperative complications). No anamnestic variables showed a statistical correlation with the surgical complication in the univariable analyses. C1 radical hysterectomy, a higher FIGO stage, and postoperative adjuvant treatment (p-value = 0.001, p-value = 0.046, and p-value = 0.046, respectively) were independent risk factors associated with the occurrence of UC. Conclusions: The urological complication rates in patients with oncological disease are relatively rare events in the expert hands of dedicated surgeons. Radical hysterectomy, FIGO stage, and adjuvant treatment are independent factors associated with urinary complications.

Systematic review and meta-analysis of all randomized controlled trials comparing gynecologic laparoscopic procedures with and without robotic assistance

OBJECTIVE

Following the publication of several high quality randomized controlled trials regarding the comparison of similar laparoscopic gynecologic procedures being performed with or without robotic assistance, we aimed to perform a systematic review to identify any differences in patient safety and expected incidence of complications in these procedures.

DATA SOURCES

Articles on ClinicalTrials.Gov, Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were retrieved and screened for eligibility up to April 1st 2021.

METHODS OF STUDY SELECTION

In addition to meeting our screening algorithm, we included studies that met all the following: randomized control trials (RCT), enrolling patients for indicated laparoscopic gynecologic procedures, and comparing Robotic Surgery (RS) with Laparoscopic Surgery (LS) in terms of safety or complications.

TABULATION, INTEGRATION, AND RESULTS

Data was pooled as mean difference (MD) or risk ratio (RR) with a 95% confidence interval (CI). Ultimately, six studies were included in this meta-analysis. Pooled data revealed that RS and LS have similar risk for intraoperative complications (RR = 0.87; 95% CI [0.23, 3.36], P = 0.84), postoperative complications (RR = 1.07; 95% CI [0.57, 2.01], P = 0.83), significant intraoperative hemorrhage (RR = 1.40; 95% CI [0.59, 3.34], P = 0.44), postoperative hemorrhage (RR = 0.43; 95% CI [0.15, 1.22], P = 0.11), vaginal cuff dehiscence (RR = 1.13; 95% CI [0.24, 5.41], P = 0.88), postoperative wound infection, urinary tract infection, and urinary bladder or ureteral injury. RS had "surgeon declared" lower estimated blood loss (MD = 85.27; 95% CI [46.45, 124.09], P < 0.00001) and shorter postoperative hospital stay (MD = 1.20; 95% CI [0.38, 2.01], P = 0.004).

CONCLUSION

There was a statistically significant decrease in hospital stay and "surgeon declared" blood loss seen in the RS group. There was no statistically significant increase in risk of developing other postoperative complications between the LS and R groups.

Uterine artery closure at the origin versus at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial

INTRODUCTION

The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other.

MATERIAL AND METHODS

We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, versus closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up.

RESULTS

Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] versus 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ.

CONCLUSIONS

Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.

Towards development of a tele-mentoring framework for minimally invasive surgeries

BACKGROUND

Tele-mentoring facilitates the transfer of surgical knowledge. The objective of this work is to develop a tele-mentoring framework that enables a specialist surgeon to mentor an operating surgeon by transferring information in a form of surgical instruments' motion required during a minimally invasive surgery.

METHOD

A tele-mentoring framework is developed to transfer video stream of the surgical field, poses of the scope and port placement from the operating room to a remote location. From the remote location, the motion of virtual surgical instruments augmented onto the surgical field is sent to the operating room.

RESULTS

The proposed framework is suitable to be integrated with laparoscopic as well as robotic surgeries. It takes on average 1.56 s to send information from the operating room to the remote location and 0.089 s for vice versa over a local area network.

CONCLUSIONS

The work demonstrates a tele-mentoring framework that enables a specialist surgeon to mentor an operating surgeon during a minimally invasive surgery.

The Large Uterus Classification System: a prospective observational study

Objective

To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri.

Design

Prospective observational study.

Setting

Two referral centres.

Population or sample

Three hundred and ninety‐two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line).

Methods

Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3.

Main outcome measures

Patients’ characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri.

Results

Two hundred and fifty‐one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32–3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14–0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13–1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2–3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09–3.68; P = 0.02).

Conclusions

The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri.

Tweetable abstract

The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.

The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.

Palmer's test usefulness in the correct positioning of the Veress needle and the reduction of complications during laparoscopic access maneuvers

AIM

Abdominal cavity access accounts for 50% of complications during laparoscopic surgery. Different safety maneuvers have been used to try to diminish these. Our study aims to establish the usefulness of Palmer's test in the correct positioning of the Veress needle and the reduction of complications during laparoscopic access maneuvers, when used in addition to the determination of intraabdominal pressure.

METHODS

Prospective observational analytic multi-centered cohort study with 370 patients undergoing gynecologic laparoscopy between July 2014 and November 2019, comparing the additional use of Palmer's test in 185 patients (Palmer-Test-Yes, PTY), with intraabdominal pressure determination alone in 185 patients (Palmer-Test-No, PTN).

RESULTS

Intergroup homogeneity was described for the basic characteristics of both population samples, except for mean age and percentage of previous laparotomy. A total of 19 complications were recorded, 10 in PTY and 9 in PTN, with no significant differences (P = 0.814). No differences were found in the analysis of these complications, except for the rate of conversion to laparotomy, which occurred four times in the PTY group and none in PTN (P = 0.044). Furthermore, no differences were found once fixed for the history of previous laparotomy (P = 514.), nor for the percentage of successful access after the first attempt between both groups (P = 0.753).

CONCLUSION

Palmer's test, when used in addition to intraabdominal pressure determination, has not shown to be effective in preventing failed access to abdominal cavity or reducing complications associated with access maneuvers with the Veress needle. Hence, its systematic use is not justified, since it could generate a sense of false security.

Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes

Introduction

There has been an exponential increase in referrals for transmasculine patients seeking genital affirmation surgery. Despite transgender men’s equal interest in metoidioplasty and phalloplasty, research has primarily focused on phalloplasty.

Aim

To summarize and investigate the relationship between surgical technique, complications, and patient-satisfaction.

Methods

We performed a systematic review and meta-analysis of surgical techniques and physician- and patient-reported outcomes of gender-affirming clitoral release and metoidioplasty (PROSPERO# 158722) with literature from PubMed, Google Scholar, and ScienceDirect. Data were extracted using PRISMA guidelines. All searches, extractions, and grading were independently completed by 2 authors.

Main Outcome Measures

Main measures were surgical technique, patient satisfaction, voiding, urethral stricture, and urethral fistula.

Results and Conclusion

A total of 7 non-overlapping articles on metoidioplasty were identified, with a total of 403 patients. We identified 4 metoidioplasty techniques: Hage, Belgrade, labial ring flap, and extensive metoidioplasty. All techniques included urethral lengthening. The reported neophallus length ranged from 2 cm to 12 cm, with the smallest neophallus occurring with the labial ring flap technique and extensive metoidioplasty the largest. Across techniques, voiding while standing was reported in most patients, with the lowest rate reported with the labial ring flap (67%). Complications were impacted by surgical technique, with the lowest rates of fistula and stricture occurring with the Belgrade technique. Fistula rates ranged from 5% to 37%, while stricture ranged from 2% to 35% of patients. The Belgrade technique reported significantly lower rates of fistula and stricture (P = .000). The patient-reported outcomes were described for the Belgrade technique and extensive metoidioplasty. Both techniques showed high aesthetic and sexual satisfaction. Transgender individuals can achieve an aesthetically and sexually satisfactory neophallus using a variety of metoidioplasty techniques; however, urethral outcomes vary significantly by technique. The Belgrade technique reported the best outcomes, although data remains limited. Patient priorities should be used to determine surgical technique.

Jolly D, Wu CA, Boskey ER, et al. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021;9:100294

Trends and Risk Factors for Vaginal Cuff Dehiscence after Laparoscopic Hysterectomy

STUDY OBJECTIVE

The primary objective was to assess the effect of the route of closure of the vaginal cuff on the incidence of vaginal cuff dehiscence (VCD) in laparoscopic hysterectomy (LH). The secondary objective was to assess patient- and surgical-risk factors associated with VCD, rate of perioperative complications by route of closure, and impact of surgeon volume on complications.

DESIGN

Retrospective chart review with case-control component.

SETTING

Tertiary care center (main hospital and regional hospitals).

PATIENTS

A total of 1278 women underwent LH or robot-assisted hysterectomy in 2016, and met the inclusion criteria. Independently, 26 cases of VCD were identified from 2009 through 2016.

INTERVENTIONS

A retrospective comparison of patients with vaginal cuff closure and laparoscopic cuff closure (LCC) undergoing LH or robot-assisted hysterectomy in 2016. Patients with VCD from 2009 through 2016 (n = 26) were matched by route of cuff closure to the next 7 patients who underwent hysterectomies (n = 182), who became controls.

MEASUREMENTS AND MAIN RESULTS

In 2016, there were 9 cases of VCD (0.70%). There was no significant difference in VCD between LCC (8/989; 0.81%) and vaginal cuff closure (1/289; 0.35%; p = .41). Seven VCD cases were performed by high-volume surgeons (>30 hysterectomies per year) who were more likely to perform LCC and use barbed suture. There were no significant differences in the rates of perioperative complications or surgeon volume between routes of cuff closure. The case-control patients differed in smoking status (p = .010) and history of prior laparotomy (p = .017). Logistic regression showed that increasing age (odds ratio 0.95; 95% confidence interval, 0.91-0.99) and increasing body mass index (odds ratio 0.98; 95% confidence interval, 0.83-0.97) were protective for VCD.

CONCLUSION

VCD is a rare but serious complication of LH. Despite previous studies, we did not find a significant difference in VCD or intra- and perioperative complications by route of cuff closure or surgeon volume. Given the lack of evidence favoring one route of cuff closure, we recommend that, to optimize patient outcomes, surgeons employ the closure technique that they are best accustomed to.

Perioperative Interventions to Minimize Blood Loss at the Time of Hysterectomy for Uterine Leiomyomas: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.

DATA SOURCES

Librarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.

METHODS OF STUDY SELECTION

Included studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.

TABULATION, INTEGRATION, AND RESULTS

Surgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; p < .01) and blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (-69.07 mL; 95% CI, -135.20 to -2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (-27.72 mL; 95% CI, -35.07 to -20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, -0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; p = .79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, -8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.

CONCLUSION

Perioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.

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

BACKGROUND

The impact of bile leakage (BL) on the long-term prognosis in patients with primary liver cancers after hepatectomy remains unclear.

METHODS

One thousand nine hundred and seventy-one consecutive patients with primary liver cancers who underwent curative hepatectomy were enrolled. 75 patients encountered BL, including 34 long-time BL (LTBL) and 41 short-time BL (STBL) according to 4-weeks demarcation. Variables associated with BL were identified using multiple logistic regression analysis. 75 patients without BL were enrolled into the Non-BL group using a one-to-one propensity score matched analysis before assessing the impact of BL on the long-term prognosis. The levels of interleukin-6 (IL-6) and C-reactive protein (CRP) in the serum and drain fluid were detected and compared.

RESULTS

The tumor size, type of liver cancer, operation time, blood loss and blood transfusion were independent risk factors for BL. The long-term survival showed no difference between the patients with and without BL (p > 0.05), while the LTBL was a significant predictor of poor long-term prognosis (p < 0.001). Compared with the patients without BL, the patients with BL had a higher level of IL-6 from postoperative day (POD) 1 to POD 60, and a higher level of CRP from POD 7 to POD 60. By POD 60, the levels of IL-6 and CRP hadn't restored to the normal level in the LTBL group.

CONCLUSIONS

The LTBL has a negative impact on the long-term prognosis of patients with primary liver cancers after hepatectomy, in which the inflammatory responses may play a pivotal role.