Patterns of care among patients undergoing hepatic resection: a query of the National Surgical Quality Improvement Program-targeted hepatectomy database

Transfusions of packed red blood cells in surgery for liver cancer: predictor of impaired overall survival but not recurrence-free survival - impact of blood transfusions in liver surgery

BACKGROUND

Liver surgery remains a cornerstone of potentially curative multimodal treatments for primary malignancies of the liver and hepatic metastases. Improving perioperative safety is a prerequisite in this context. Perioperative blood transfusions negatively influence postoperative recovery. This study aimed to identify risk factors for perioperative packed red blood cell (PRBC) transfusion and to elucidate its effect on postoperative outcomes.

METHODS

This was an observational study of a prospective data collection. A monocentric, retrospective analysis of 1118 hepatectomies at the University Hospital Carl Gustav Carus between 2013 and 2020 was conducted to compare postoperative short- and long-term outcomes in patients undergoing curative intended liver resection of hepatic primary or secondary malignancies. The outcomes were compared between 356 patients (31.8%) who received PRBC transfusions during surgery or within 7 days after surgery and 762 patients (68.2%) who did not receive PRBC transfusions.

RESULTS

Preoperative anemia could be observed in 45.0% of the whole cohort: 65.7% in the PRBC transfusion group and 35.3% in the nontransfused group. Postoperative complications were significantly more common in the PRBC transfusion group in association with prolonged lengths of hospital stay and increased 30-day mortality than in the nontransfused group. After adjustment for possible confounders, preexisting kidney failure, preoperative hemoglobin and albumin levels outside of the reference range, intraoperative plasma transfusions, and overall surgery time were recognized as negative predictors for perioperative PRBC transfusions. PRBC transfusion increased the risk of death by approximately 38.8% (hazard ratio, 1.388; 95% CI, 1.027-1.876; P = .033), whereas no influence on recurrence-free survival (RFS) was observed.

CONCLUSION

PRBC transfusions were associated with postoperative morbidity and mortality after curative-intended surgery for liver cancers and represented an independent poor prognostic indicator for overall survival but not for RFS.

Trends and predictions of perioperative transfusion and venous thromboembolism in hepatectomy using a North American Registry

BACKGROUND

Studies indicate a link between allogeneic blood transfusion and venous thromboembolism (VTE) post-major surgery. Analyzing trends and predictors of these outcomes after hepatectomy can inform risk management.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used for a retrospective analysis. Primary outcomes were perioperative red blood cell (RBC) transfusion and VTE events within 30 days of hepatectomy. Seven-year trends and predictors were evaluated.

RESULTS

Among 29,131 hepatectomy patients, transfusion rates showed no statistically significant decreasing trends (p = .122) from 2014 to 2020 (18.13%-16.71%), while VTE rates showed a downward trend over the 7 years (p = .021); 17.2% received RBC transfusion, with higher rates in surgeries lasting ≥282 min (median: 220 min). Calculated RBC mass [hematocrit (%) × body weight (kg) × 10-5  × 70/ √ (body mass index/22)] at or below 1.5 L substantially increased transfusion odds. VTE was reported postoperatively in 2.6% of cases more frequently in longer cases involving transfusions. The adjusted odds ratio (aOR) of VTE escalated from the shortest operative time to the longest (3.17; 95% confidence interval [CI], 2.37-4.22). The adjusted odds of VTE doubled for transfused patients compared to non-transfused patients (aOR, 2.19; 95% CI, 1.86-2.57).

CONCLUSIONS

Rates of RBC transfusion and VTE rates hepatectomy have minimally changed in the recent years. VTE prevention is challenging in extended surgeries at increased risk of bleeding and RBC transfusions. Patient-level data on coagulation and thromboprophylaxis can potentially refine risk assessment for postoperative VTE.

Association of Viral Hepatitis Status and Post-hepatectomy Outcomes in the Era of Direct-Acting Antivirals

BACKGROUND

The role of viral hepatitis status in post-hepatectomy outcomes has yet to be delineated. This large, multicentred contemporary study aimed to evaluate the effect of viral hepatitis status on 30-day post-hepatectomy complications in patients treated for hepatocellular carcinoma (HCC).

METHODS

Patients from the National Surgical Quality Improvement Program (NSQIP) database with known viral hepatitis status, who underwent hepatectomy for HCC between 2014 and 2018, were included. Patients were classified as HBV-only, HCV-only, HBV and HCV co-infection (HBV/HCV), or no viral hepatitis (NV). Multivariable models were used to assess outcomes of interest. The primary outcome was any 30-day post-hepatectomy complication. The secondary outcomes were major complications and post-hepatectomy liver failure (PHLF). Subgroup analyses were performed for cirrhotic and noncirrhotic patients.

RESULTS

A total of 3234 patients were included. The 30-day complication rate was 207/663 (31.2%) HBV, 356/1077 (33.1%) HCV, 29/81 (35.8%) HBV/HCV, and 534/1413 (37.8%) NV (p = 0.01). On adjusted analysis, viral hepatitis status was not associated with occurrence of any 30-day post-hepatectomy complications (ref: NV, HBV odds ratio (OR) 0.89 [95% confidence interval (CI): 0.71-1.12]; HCV OR 0.91 [95% CI: 0.75-1.10]; HBV/HCV OR 1.17 [95% CI: 0.71-1.93]). Similar results were found in cirrhotic and noncirrhotic subgroups, and for secondary outcomes: occurrence of any major complications and PHLF.

CONCLUSIONS

In patients with HCC managed with resection, viral hepatitis status is not associated with 30-day post-hepatectomy complications, major complications, or PHLF compared with NV. This suggests that clinical decisions and prognostication of 30-day outcomes in this population likely should not be made based on viral hepatitis status.

Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial

INTRODUCTION

Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection.

METHODS

This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment.

DISCUSSION

The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.

Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND AND AIM

For those with a centrally located HCC, the two types of liver sectionectomy that can be performed are extended hepatectomy (EH) and central hepatectomy (CH). This meta-analysis aimed to compare the short- and long-term outcomes between patients treated with CH and patients treated with EH for those with centrally located HCC.

METHOD

We searched PubMed, Scopus, Web of Science, and Cochrane library for eligible studies from inception to 1 April 2022 and a systematic review and meta-analysis were done to compare the outcomes between the two groups.

RESULTS

we included 9 studies with a total of 1674 patients in this study. The pooled results in this meta-analysis showed equal long-term overall survival, Disease-free survival, recurrence and mortality between the two groups (5-year OS, RR = 1.14, 95% CI = 0.96-1.35, P = 0.12; I² = 56%), (5-year DFS, RR = 0.81, 95% CI = 0.61-1.08, P = 0.15; I² = 60%), (Recurrence, RR = 1.04, 95% CI = 0.94-1.15, P = 0.45; I² = 27%), and (Mortality, RR = 0.55, 95% CI = 0.26-1.15, P = 0.11; I² = 0%). In addition to that, no significant difference could be detected in the overall incidence of complications between the two groups (Complications, RR = 0.94, 95% CI = 0.76-1.16, P = 0.57; I² = 0%). However, CH is associated with a remarkable increase in the rate of biliary fistula (Biliary fistula, RR = 1.90, 95% CI = 1.07-3.40, P = 0.03; I² = 0%). And Liver cell failure was higher in the case of EH (LCF, RR = 0.47, 95% CI = 0.30-0.76, P = 0.002; I² = 0%). Regarding the operative details, CH is associated with longer operative time (Time of the operation, Mean difference = 0.82, 95% CI = 0.36, 1.27, P = 0.0004; I² = 57%).

CONCLUSION

No significant difference in the short and long-term survival and recurrence between CH and MH for CL-HCC. However, CH is associated with greater future remnant liver volume that decreases the incidence of LCF and provides more opportunities for a repeat hepatectomy after tumour recurrence.

Performance of risk prediction models for post-operative mortality in patients undergoing liver resection

BACKGROUND

Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis.

METHODS

This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality.

RESULTS

A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis.

CONCLUSION

The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.

Early postoperative ERAS compliance predicts decreased length of stay and complications following liver resection

BACKGROUND

Enhanced recovery after surgery (ERAS) components for liver resection lack standardization and compliance. We evaluated our ERAS protocol and describe the association of postoperative ERAS compliance with length of stay (LOS) and complications.

METHODS

We retrospectively reviewed patients undergoing liver resection at our institution from 2016 to 2020. Pre- and post-ERAS outcomes and compliance at 72 h were compared with LOS and complications. LOS beyond 72 h was defined as LOS72.

RESULTS

210 patients were included. Post-ERAS patients had significantly shorter LOS (5.1 vs. 7.3 days, p = 0.0014) with no difference in 30-day mortality, morbidity, or readmissions. ERAS components associated with shorter LOS72 were regular diet (HR 1.73), fluid discontinuation (HR 1.63), drain removal (HR 1.94), multimodal and oral analgesia (HR 1.51), and ambulation >100 ft (HR 2.23). LOS72 was 1-day for ≥9 ERAS component compliance, 4-days for 6-8 components, and 6-days for <6 components. 30-day complication rates for patients with ≥9 components by postoperative day 3 (POD3) were significantly lower than those with 6-8 (12 vs 32%).

CONCLUSION

ERAS decreases LOS after liver resection. Nutritional advancement, drain discontinuation, multimodal and oral analgesia, and ambulation >100 ft by POD3 are associated with decreased LOS72. Achieving ≥6 components by POD3 predicts decreased LOS72 and complications.

Application of albumin-bilirubin grade and platelet count to indocyanine green-based criteria for hepatectomy: Predicting impaired liver function and postoperative outcomes of hepatocellular carcinoma

BACKGROUND

Applicability of the albumin-bilirubin (ALBI) grade in preoperative decision-making criteria based on the indocyanine green retention (ICG) test remains unclear. This study aimed to predict abnormal ICG values using standard blood tests and evaluate the impact on postoperative outcomes among patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Data on 949 consecutive HCC patients undergoing curative-intent hepatectomy between 1996 and 2014 were retrospectively assessed. A nomogram using preoperative standard blood tests was created to predict abnormal ICGR15 (>15%).

RESULTS

Three-hundred nine patients had abnormal ICGR15. Predictors of abnormal ICGR15 included in the nomogram were: ALBI grade >1 (hazard ratio [HR]: 2.16, 95% confidence interval [CI]: 1.59-2.94), platelet count <130 000/mm³ (HR: 2.27, 95% CI: 1.68-3.08), aspartate aminotransferase >50 (IU/L) (HR: 1.90, 95% CI: 1.29-2.81), and viral hepatitis infection (HR: 1.46, 95% CI: 1.03-2.07). The nomogram named the PLT-ALBI score was discriminative [C-statistics: 0.719 (0.684-0.754)], and reliable (Hosmer-Lemeshow Chi-Square: 9.05, p = 0.338). The higher PLT-ALBI score was associated with a more frequent incidence of clinically relevant posthepatectomy liver failure and poor overall survival.

CONCLUSIONS

The PLT-ALBI score is applicable in distinguishing HCC patients with abnormal ICGR15. Patients with higher PLT-ALBI score require more careful postoperative care, despite following the ICG criteria.

Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Hepatic Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Perioperative bleeding poses a major risk during liver surgery, which can result in increased transfusion requirements, morbidity, and mortality. Tranexamic acid (TXA) effectively reduces perioperative bleeding and transfusion requirements in trauma patients. However, there remains a lack of evidence of its use in liver surgery. This meta-analysis of randomised controlled trials evaluated the efficacy and safety of TXA in liver resection and transplantation.

METHOD

A comprehensive search of Medline, Embase, CENTRAL and Clinicaltrials.gov databases was undertaken to identify studies from January 1947 to September 2021. The outcomes of the need for blood transfusion, thromboembolic events and mortality were extracted from the included studies. Quantitative pooling of data was based on the random effects model.

RESULTS

Six studies reporting on 429 patients were included. TXA reduced the need for perioperative blood transfusion in liver resection and transplantation (OR 0.09; 95% CI 0.01 to 0.72). More importantly, TXA did not increase the incidence of thromboembolic events (OR 2.22; 95% CI 0.47 to 10.43) and mortality (OR 0.60; 95% CI 0.13 to 2.76).

CONCLUSION

TXA safely reduces the need for blood transfusion in patients undergoing liver resection and transplantation.

The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study

BACKGROUND

PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown.

METHODS

This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI.

RESULTS

The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004).

CONCLUSIONS

Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.

Effect of intraoperative hypovolemic phlebotomy on transfusion and clinical outcomes in patients undergoing hepatectomy: a retrospective cohort study

Background

There is no consensus on how to best achieve a low central venous pressure during hepatectomy for the purpose of reducing blood loss and red blood cell (RBC) transfusions. We analyzed the associations between intraoperative hypovolemic phlebotomy (IOHP), transfusions, and postoperative outcomes in cancer patients undergoing hepatectomy.

Methods

Using surgical and transfusion databases of patients who underwent hepatectomy for cancer at one institution (11 January 2011 to 22 June 2017), we retrospectively analyzed associations between IOHP and RBC transfusion on the day of surgery (primary outcome), and with total perioperative transfusions, intraoperative blood loss, and postoperative complications (secondary outcomes). We fitted logistic regression models by inverse probability of treatment weighting to adjust for confounders and reported adjusted odds ratio (aOR).

Results

There were 522 instances of IOHP performed during 683 hepatectomies, with a mean (standard deviation) volume of 396 (119) mL. The IOHP patients had a 6.9% transfusion risk on the day of surgery compared with 12.4% in non-IOHP patients (aOR, 0.53; 95% confidence interval [CI], 0.29 to 0.98; P = 0.04). Total perioperative RBC transfusion tended to be lower in IOHP patients compared with non-IOHP patients (14.9% vs 22.4%, respectively; aOR, 0.72; 95% CI, 0.44 to 1.16; P = 0.18). In patients with a predicted risk of ≥ 47.5% perioperative RBC transfusion, 24.6% were transfused when IOHP was used compared with 56.5% without IOHP. The incidence of severe postoperative complications (Clavien–Dindo scores ≥ 3) was similar in patients whether or not IOHP was performed (15% vs 16% respectively; aOR, 0.97; 95% CI, 0.53 to 1.54; P = 0.71).

Conclusions

The use of IOHP during hepatectomy was associated with less RBCs transfused on the same day of surgery. Trials comparing IOHP with other techniques to reduce blood loss and transfusion are needed in liver surgery.

Supplementary Information

The online version of this article (10.1007/s12630-021-01958-8) contains supplementary material, which is available to authorized users.

Risk Factors for Complications Requiring Interventional Radiological Treatment After Hepatectomy

PURPOSE

To identify perioperative factors that are significantly associated with complications requiring interventional radiology (IR) treatment after hepatectomy.

METHODS

We retrospectively reviewed data from 11,243 patients in the USA who underwent hepatectomy from 2014 to 2016 using the National Surgical Quality Improvement Program database. Data on the following IR procedures were extracted: abscess drain placement, endovascular treatment for bleeding, and postoperative percutaneous biliary drain (PBD) placement up to 30 days postoperatively. Patients' clinical and intraoperative factors were examined. Population, univariate, and multivariable analyses were performed. P < 0.05 was considered significant.

RESULTS

A total of 704 patients (6%) required IR treatment postoperatively, and 10,539 patients (94%) did not. On multivariable analysis, biliary reconstruction was a significant predictor of postoperative abscess drain placement (hazard ratio (HR), 3.5; 95% confidence interval (CI) 1.8, 6.5; P < .001), endovascular treatment for bleeding (HR, 3.3; 95% CI 1.4, 7.8 P = .006), and postoperative PBD placement (HR, 2.9; 95% CI 1.9, 4.2; P < .001). Compared with hepatectomy without biliary reconstruction, hepatectomy with biliary reconstruction was associated with significantly higher rates of complications treated with IR procedures (26% vs. 4.9%) and death within 30 days (6.0% vs. 1.2%) (both, P < .001).

CONCLUSION

Biliary reconstruction is a strong predictor of the need for postoperative IR treatment after hepatectomy. One in four patients who underwent biliary reconstruction required IR treatment of a complication during the first 30 days after hepatectomy.

Intravenous iron supplementation after liver surgery: Impact on anemia, iron, and hepcidin levels-a randomized controlled trial

BACKGROUND

Anemia is a recognized risk factor for perioperative related morbidity and mortality and is frequently reported in liver surgeries with an estimated incidence of 32%. We aim to assess the impact of intravenous iron administration in the immediate postoperative period on anemia and iron status as well as to determine the kinetics of hepcidin after liver surgery.

METHODS

The HepciFer trial, a randomized controlled trial, included 50 patients undergoing liver surgery. In accordance with the randomization process, patients received either ferric carboxymaltose (15 mg/kg, maximum 1 g) or placebo 4 hours after surgery.

RESULTS

The mean hemoglobin level, 7 days after surgery, did not differ significantly between the intervention and control group (11.1 ± 1.8 g/dL and 10.4 ± 1.6 g/dL, respectively) with a mean difference of +0.7 g/dL ([95% confidence interval, -0.3 to +1.7], P = .173). Within patients receiving intravenous iron supplementation, none presented biological signs of functional iron deficiency. Hepcidin levels remained significantly higher during the observation period in the intervention group. Inflammatory biomarkers, red blood cells transfusion rate and hospital duration of stay were similar between groups.

CONCLUSION

Intravenous ferric carboxymaltose administration did not result in a significant increase of hemoglobin levels 7 days after surgery. However, this study suggests that intravenous iron supplementation in the immediate postoperative settings prevents functional iron deficiency. Intravenous iron supplementation overcame the hepcidin-mediated blockade of iron absorption and should be considered as the preferred route of administration in the postoperative period.

Hospital variation in use of prophylactic drains following hepatectomy

BACKGROUND

Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use.

METHODS

Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed.

RESULTS

Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level.

CONCLUSION

Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.

Clinical impact of intraoperative bile leakage during laparoscopic liver resection

BACKGROUND

Despite the increasing number of laparoscopic liver resection (LLR) procedures, postoperative bile leakage (POBL) remains a major complication. We occasionally experienced intraoperative bile leakage (IOBL) during LLR and managed it within the restrictions of laparoscopic surgery. However, there have been no reports about IOBL in LLR. We therefore investigated the impact of IOBL on postoperative outcomes and its predictive factors.

METHODS

We reviewed 137 patients who underwent LLR from April 2016 to March 2019 at our institute and assigned them to IOBL-positive or IOBL-negative groups. We compared clinicopathological characteristics and perioperative outcomes. Patients were further divided into four groups according to IOBL pattern, and the frequency of POBL in each was calculated. Predictors of IOBL were identified using multivariate logistic regression analysis.

RESULTS

There were 30 and 107 patients in the IOBL-positive and IOBL-negative groups, respectively. In the IOBL-positive group, operative time and postoperative hospital stays were significantly longer (P < 0.001). The frequency of POBL was significantly higher in the IOBL-positive group (P = 0.006). The IOBL-positive group was divided into two subgroups: IOBL from the transected parenchyma (IOBL-TP, n = 18) and from the main Glissonean pedicle (IOBL-mGP, n = 12). The IOBL-negative group was divided into two subgroups: bile staining in the mGP (BS-mGP, n = 9) and no change (NC, n = 98). POBL occurred in 11% (n = 2/18) of patients with IOBL-TP, 25% (n = 3/12) of those with IOBL-mGP, 11% (n = 1/9) of those with BS-mGP, and 1% (n = 1/98) of those with NC. Age, diabetes mellitus, indocyanine green retention rate, and Glissonean approach were predictors of IOBL (P < 0.05).

CONCLUSIONS

IOBL was relatively common during LLR and resulted in a higher incidence of POBL. Depending on the predictive factors, IOBL must be promptly identified and appropriately managed.

Intraoperative Hemorrhagic Shock in Cancer Surgical Patients: Short and Long-Term Mortality and Associated Factors

BACKGROUND

Management of hemorrhagic shock is well codified by international guidelines. These guidelines are predominantly based on trauma patients. We aimed to evaluate factors associated with 30-day mortality and long-term survival after intraoperative hemorrhagic shock during major oncological surgery.

METHODS

This retrospective study was conducted in a cancer referral center from January 2013 to February 2018. All adult cancer patients admitted in the operative room for scheduled or emergency oncological surgery associated with an intraoperative hemorrhagic shock were included.

RESULTS

Eighty-four patients were included in this study. The 30-day mortality rate was 26% (n = 22), the mean follow-up from the time of ICU admission was 20 months (95% CI, 15-25 months), 39 (46%) patients died during this period. Using logistic regression for multivariate analysis, factors independently associated with 30-day mortality were SAPS II score (odds ratio (OR) =1.056, 95% confident interval (CI) =1.010-1.1041), delta SOFA (SOFA score at day 3 - SOFA score at day 1) (OR= 1.780, 95% CI 1.184-2.677) and ISTH-DIC score (OR = 2.705, 95% CI 1.108-6.606). Using Cox multivariate analysis, factors associated with long-term mortality were delta SOFA (hazard ratio (HR) =1.558, 95% CI 1.298-1.870), ISTH-DIC score (HR = 1.381, 95% CI 1.049-1.817), hepatic dysfunction (HR = 7.653, 95% CI 2.031-28.842), and Charlson comorbidity index (HR = 1.330, 95% CI 1.041-1.699).

CONCLUSION

The worsening of organ dysfunctions during the first 3 days of ICU admission as well as intraoperative coagulation disturbances (increased ISTH-DIC score) are independently associated with short and long-term mortality. Comorbidities (Charlson comorbidity index) and postoperative hepatic dysfunction were independently associated with long-term mortality. Early perioperative bundle strategies should be evaluated in order to improve patient's survival in this specific situation.

Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility

BACKGROUND

Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial.

METHODS

Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL).

RESULTS

A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326).

CONCLUSION

Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).

Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients

BACKGROUND

The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear.

METHODS

Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model.

RESULTS

A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522).

CONCLUSION

While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.

Hypovolemic phlebotomy in liver surgery is associated with decreased red blood cell transfusion

BACKGROUND

Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis.

METHODS

Consecutive patients who underwent liver resection at one institution (2010-2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression.

RESULTS

A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H₂O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068-0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64-5.18, p = 0.0003), preoperative hemoglobin < 125 g/L (OR 6.02, 95% CI 3.44-10.56, p < 0.0001), and underlying liver disease (OR 2.24, 95% CI 1.27-3.95, p = 0.0051) were significantly associated with perioperative RBC transfusion.

CONCLUSION

Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.

Ottawa Criteria for Appropriate Transfusions in Hepatectomy: Using the RAND/UCLA Appropriateness Method

OBJECTIVE

Create practice guidelines for the appropriate use of red blood cell transfusions in hepatectomy.

BACKGROUND

Hepatectomy is associated with a high prevalence of transfusions. A transfusion can be life-saving, but can be associated with important adverse effects. Given the prevalence, the potential for benefit and harm, and the difficulty in conducting clinical trials, transfusion in hepatectomy is well-suited for a study of appropriateness.

METHODS

Using the RAND/UCLA appropriateness method, an international, multidisciplinary expert panel in hepatobiliary surgery, anesthesia, transfusion medicine, and critical care rated a series of 468 perioperative scenarios for transfusion appropriateness. Scenarios were rated individually, and again during an inperson group moderated session. Median scores and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or uncertain.

RESULTS

Approximately, 47.4% of scenarios were rated as appropriate for transfusion, 28.2% were inappropriate, and 24.4% were uncertain. The key recommendations for intraoperative transfusion were (i) it is never inappropriate to transfuse for significant bleeding or ST segment changes; (ii) it is never inappropriate to transfuse for an intraoperative hemoglobin ≤75 g/L; and (iii) in the absence of significant bleeding or ST changes, transfusion for hemoglobin of ≥95 g/L is inappropriate, and transfusion for hemoglobin of ≥85 g/L requires strong justification. The key recommendations for postoperative transfusions were: (i) in a stable, asymptomatic patient, an appropriate transfusion trigger is 70 g/L (without coronary artery disease) or 80 g/L (with coronary artery disease) and (ii) it is appropriate to transfuse any patient for a hemoglobin of ≤75 g/L either immediately post-operative, or with a significant decrease from the previous day (>15 g/L).

CONCLUSIONS

Based on best available evidence and expert opinion, criteria for appropriate perioperative red blood cell transfusions in hepatectomy were determined.

Current Pattern of Use and Impact of Pringle Maneuver in Liver Resections in the United States

BACKGROUND

Pringle maneuver (PM) is used for inflow vascular control during hepatectomy, but its use remains controversial. We aimed to report its pattern of use and association with postoperative outcomes.

METHODS

We identified hepatectomy patients using the liver-targeted National Surgical Quality Improvement Program database (2014-2016). Associations between PM and posthepatectomy liver failure (PHLF), receipt of blood transfusion, and total hospital length of stay (LOS) were evaluated.

RESULTS

We identified 7870 patients (74.9%) with no Pringle maneuver and 2632 (25.1%) with PM. PM patients were older (median age 61 versus 60 y, P = 0.002) and had higher ASA scores (76.1% versus 71.4% were ASA 3-4, P < 0.001). PM had more malignancy (83.0% versus 73.0%, P < 0.001), neoadjuvant therapy (37.7% versus 28.8%, P < 0.001), total lobectomy (30.6% versus 23.2%, P < 0.001), open resection (90.8% versus 74.9%, P < 0.001), and longer operations (246 min versus 212 min, P < 0.001). PM was associated with longer LOS (0.36 d, 95% confidence interval [CI] 0.11-0.60) and increased risk of PHLF (odds ratio [OR] 1.36, 95% CI 1.11-1.66), although not clinically significant grade B/C PHLF (OR 0.82, 95% CI 0.57-1.19), but was not associated with receipt of perioperative blood transfusions (OR 1.00, 95% CI 0.69-1.64).

CONCLUSIONS

PM is associated with similar clinically significant PHLF and transfusion requirements but longer LOS compared with no Pringle maneuver.

Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP)

BACKGROUND

Risk of red blood cell transfusion (RBCT) in partial hepatectomy is 17-27%; strategies to reduce transfusions can be targeted in patients at increased risk. A Three Point Transfusion Risk Score (TRS) was previously developed to predict patients' risk of transfusion during and following hepatectomy. Here, it was subject to external validation using the ACS-NSQIP database.

METHODS

TRIPOD guidelines were followed. A validation cohort was created with the ACS-NSQIP dataset. Risk groups for RBCT were created using the TRS: anemia (hematocrit ≤36%), major liver resection (≥4 segments) and primary liver malignancy. Concordance index was used to assess the discrimination. The Hosmer-Lemeshow test for goodness of fit and calibration curves were used to assess calibration.

RESULTS

Of 2854 hepatectomies, 18.9% received RBCT. The TRS stratified patients from low (8.5% risk of RBCT) to very high risk (40.6%) of RBCT. The concordance was 0.68 (95% CI 0.66-0.70). Hosmer-Lemeshow test and calibration curves supported good predictive performance of the model.

CONCLUSION

The TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify patients at high transfusion risk. It can be used to tailor patient blood management initiatives and reduce the use of RBCT.

Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection

BACKGROUND

Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.

METHODS

Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.

RESULTS

Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262).

CONCLUSION

Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.

Ablation approach for primary liver tumors: Peri-operative outcomes

BACKGROUND AND OBJECTIVES

Ablation is a common treatment modality for malignant primary liver tumors(PLTs), outcomes following laparoscopic (LA) versus open ablation (OA) are ill-defined. This project compares peri-procedural outcomes of LA versus OA for PLTs.

MATERIALS AND METHODS

Patients with PLTs undergoing radiofrequency ablation were queried from ACS NSQIP Database (2005-2013) using CPT codes. Patients undergoing percutaneous ablation or hepatic resection were excluded. Multivariable logistic regression analyses determined the association of ablation approach with 30-day morbidity and mortality.

RESULTS

Of 5747 with PLTs, 655 (11.4%) ablations were identified: 177 (27.0%) underwent OA, 478 (73.0%) underwent LA. Patients undergoing LA had lower mortality (1.9% vs 5.1%, P = 0.026), lower minor morbidity (2.3% vs 5.7%, P = 0.031), and lower major morbidity (4.2% vs 17.0%, P < 0.001). Adjusting for demographics, disease-specific variables (preoperative ascites, total bilirubin, platelet count, albumin, and INR), 30-day mortality (OR 3.85, 95%CI: 1.38-10.80, P = 0.010), minor morbidity (OR 2.98, 95%CI: 1.16-7.67, P = 0.024), and major morbidity (OR 4.59 95%CI: 2.41-8.76, P < 0.001) were statistically lower in LA. OA demonstrated increased length of stay(LOS) (5 vs 2 days, P < 0.001), and longer operative time (152 vs 112 min, P < 0.001).

CONCLUSION

LA offers decreased peri-procedural morbidity, mortality, and reduced LOS. LA should be the preferred method for hepatic ablation.

Current practices in perioperative blood management for patients undergoing liver resection: a survey of surgeons and anesthesiologists

BACKGROUND

Development of intraoperative techniques and blood management strategies in liver resection, and the multidisciplinary nature of perioperative transfusion decision making, creates an opportunity for practice variation. The aim of this study was to describe the current practices in perioperative blood management and explore differences between surgeons and anesthesiologists.

STUDY DESIGN AND METHODS

A Web-based survey was developed, piloted, and circulated to Canadian liver surgeons and anesthesiologists. The survey focused on management of preoperative anemia, blood conservation strategies, estimation of blood loss, and transfusion decision making in a multidisciplinary setting.

RESULTS

A total of 198 physicians received the survey, with 117 responding (59%). Most responding surgeons (67%) perform more than 20 liver resections per year, while most responding anesthesiologists (90%) take part in fewer than 20. Anesthesiologists most commonly stated that preoperative anemia is managed by someone else (38%), while surgeons most commonly reported "no specific treatment" (45%). The most common intraoperative blood conservation technique used is administration of antifibrinolytics (63% used them at least occasionally). The most important factor for anesthesiologists when deciding on an intraoperative transfusion was hemoglobin value (47%); for surgeons, it was patient hemodynamics (33%). Compared to when they started their career, 60% of respondents felt that they were less likely to transfuse a patient now.

CONCLUSION

The results of our survey provide insights into current transfusion practice and decision making in liver resection, including a comparison between anesthesiologist and surgeon transfusion behavior. Management of preoperative anemia, increased use of intraoperative blood conservation techniques, and improved communication between providers were identified as targets for quality improvement.

Role of Drain Placement in Major Hepatectomy: A NSQIP Analysis of Procedure-Targeted Hepatectomy Cases

BACKGROUND

The value of drain placement in hepatic surgery has not been conclusive. The aim of this study was to determine whether drain placement during major hepatectomy was associated with negative postoperative outcomes and whether its placement reduced the need for secondary procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Hepatectomy Database was used to identify patients who underwent major hepatectomy. Patients were divided into two groups based on the placement of a drain during the procedure. Propensity score-matched cohorts of patients who underwent major hepatic resection with or without drain placement were created accounting for patient characteristics. The primary outcomes were 30-day postoperative complications including bile leak, post-hepatectomy liver failure, and invasive intervention as well as mortality and readmission.

RESULTS

A total of 1005 patients underwent major hepatectomy; 500 patients (49.8 %) had prophylactic drains placed at the conclusion of the procedure. Drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), renal insufficiency (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.02), length of stay (p = 0.001), and readmission (p < 0.001). In the matched cohort, drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), superficial surgical site infection (SSI) (p = 0.028), bile leak (p < 0.001), and longer length of stay (0.03). In addition, placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.21) (Table 2). In multivariate analysis, drain placement was independently associated with any complication (p < 0.001), blood transfusion (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.011), superficial surgical site infection (SSI) (p = 0.039), and hospital readmission (p = 0.005) (Table 3). Placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.15).

CONCLUSION

Drain placement after major hepatectomy may lead to increased postoperative complications including bile leak, superficial surgical site infection, and hospital length of stay and does not decrease the need for secondary procedures in patients with bile leaks.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intrahepatic cholangiocarcinoma: current perspectives

Intrahepatic cholangiocarcinoma (ICC) is the second most common malignancy arising from the liver. ICC makes up about 10% of all cholangiocarcinomas. It arises from the peripheral bile ducts within the liver parenchyma, proximal to the secondary biliary radicals. Histologically, the majority of ICCs are adenocarcinomas. Only a minority of patients (15%) present with resectable disease, with a median survival of less than 3 years. Multidisciplinary management of ICC is complicated by large differences in disease course for individual patients both across and within tumor stages. Risk models and nomograms have been developed to more accurately predict survival of individual patients based on clinical parameters. Predictive risk factors are necessary to improve patient selection for systemic treatments. Molecular differences between tumors, such as in the epidermal growth factor receptor status, are promising, but their clinical applicability should be validated. For patients with locally advanced disease, several treatment strategies are being evaluated. Both hepatic arterial infusion chemotherapy with floxuridine and yttrium-90 embolization aim to downstage locally advanced ICC. Selected patients have resectable disease after downstaging, and other patients might benefit because of postponing widespread dissemination and biliary obstruction.

Albumin-Bilirubin Score: Predicting Short-Term Outcomes Including Bile Leak and Post-hepatectomy Liver Failure Following Hepatic Resection

INTRODUCTION

Post-operative bile leak (BL) and post hepatectomy liver failure (PHLF) are the major potential sources of morbidity among patients undergoing liver resection. We sought to define the incidence of BL and PHLF among a large cohort of patients, as well as examine the prognostic impact of model for end-stage liver disease (MELD) and albumin-bilirubin (ALBI) scores to predict these short-term outcomes.

MATERIALS AND METHODS

Patients who underwent a hepatectomy between January 1, 2014 and December 31, 2014 were identified using the National Surgical Quality Improvement Program (NSQIP) liver-targeted database. Risk factors for BL and PHLF were identified using multivariable logistic regression.

RESULTS

Among the 3064 patients identified, median age was 60 years (IQR 50-68). Most patients underwent surgery (78.9 %) for malignant lesions. Post-operatively, 250 (8.5 %) patients experienced a BL while PHLF occurred in 149 cases (4.9 %). Both MELD (MELD <10 4.9 %; MELD ≥10, 10 %; P = 0.001) and ALBI (grade 1, 4.0 %; grade 2, 7.2 %; grade 3, 10.0 %; P = 0.001) were associated with PHLF occurrence, while only ALBI predicted PHLF severity (P = 0.008). Moreover, ALBI was associated with BL (grade 1, 7.1 %; grade 2, 11.5 %; grade 3, 14.0 %; P < 0.001), whereas MELD was not (MELD <10, 8.4 %; MELD ≥10, 11.2 %; P = 0.13). On multivariable analysis, ALBI grade 2/3 was associated with PHLF (OR 1.57, 95 % CI 1.08-2.27; P = 0.02), PHLF severity (OR 3.06, 95 % CI 1.50-6.23; P = 0.003), and the development of a BL (OR 1.35, 95 % CI 1.02-1.80; P = 0.04).

CONCLUSION

The ALBI score was associated with short-term post-operative outcomes following hepatic resection and represents a useful pre-operative risk-assessment tool to identify patients at risk for adverse post-operative outcomes.

Does neoadjuvant chemotherapy affect morbidity, mortality, reoperations, or readmissions in patients undergoing lumpectomy or mastectomy for breast cancer?

BACKGROUND

The influence of neoadjuvant chemotherapy (NAC) prior to breast cancer surgery on postoperative complications is unclear. Our objective was to determine whether NAC was associated with postoperative outcomes in patients undergoing lumpectomy or mastectomy without reconstruction.

METHODS

Patients meeting inclusion criteria were identified from the National Surgical Quality Improvement Program (NSQIP) database participant user files from 2005 through 2012, after which NSQIP discontinued the NAC variable. Primary outcome measures included a composite measure of morbidity and mortality (M&M) and reoperations and readmissions within 30 days of the index procedure. Rates of postoperative complications stratified by receipt of NAC were compared by χ2. A logistic regression model was then built that included confounding factors for M&M.

RESULTS

There were 30,309 patients meeting inclusion criteria. NAC was not associated with any postoperative outcomes from 2005 through 2012, but it was associated with higher M&M in lumpectomy patients during 2011 to 2012 [P=0.011, odds ratio (OR) 2.579; 95% confidence interval (CI), 1.239-5.368].

CONCLUSIONS

The finding that NAC was associated with higher M&M in lumpectomy patients during 2011 to 2012 warrants further investigation. Therefore, we recommend that the NSQIP database reinstitute the NAC variable to allow monitoring during anticipated changes in chemotherapy agents and protocols.

Rate of Organ Space Infection Is Reduced with the Use of an Air Leak Test During Major Hepatectomies

BACKGROUND

Organ/space surgical site infections (OSIs) constitute an important postoperative metric. We sought to assess the impact of a previously described air leak test (ALT) on the incidence of OSI following major hepatectomies.

METHODS

A single-institution hepatobiliary database was queried for patients who underwent a major hepatectomy without biliary-enteric anastomosis between January 2009 and June 2015. Demographic, clinicopathologic, and intraoperative data-including application of ALT-were analyzed for associations with postoperative outcomes, including OSI, hospital length of stay (LOS), morbidity and mortality rates, and readmission rates.

RESULTS

Three hundred eighteen patients were identified who met inclusion criteria, of whom 210 had an ALT. ALT and non-ALT patients did not differ in most disease and treatment characteristics, except for higher rates of trisegmentectomy among ALT patients (53 vs. 34 %, p = 0.002). ALT patients experienced lower rates of OSI and 90-day morbidity than non-ALT patients (5.2 vs. 13.0 %, p = 0.015 and 24.8 vs. 40.7 %, p = 0.003, respectively). In turn, OSI was the strongest independent predictor of longer LOS (OR = 4.89; 95 % CI, 2.80-6.97) and higher rates of 30- (OR = 32.0; 95 % CI, 10.9-93.8) and 45-day readmissions (OR = 29.4; 95 % CI, 10.2-84.6).

CONCLUSIONS

The use of an intraoperative ALT significantly reduces the rate of OSI following major hepatectomy and may contribute to lower post-discharge readmission rates.

Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections

BACKGROUND

Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations.

METHODS

Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H₂O). The target phlebotomy volume was 7-10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison.

RESULTS

A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3 cm H₂O (0-15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications.

CONCLUSION

Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.

Patterns of hepatic resections in North America: use of concurrent partial resections and ablations

BACKGROUND

National registries have not adequately captured concurrent partial hepatic resections or ablations. Therefore, the aim of this analysis was to describe the patterns of concurrent partial resections and ablations in North America.

METHODS

Patients undergoing a hepatic resection were identified using the American College of Surgeons-National Surgical Quality Improvement Program Targeted Hepatectomy database. Perioperative outcomes were compared for patients undergoing concurrent "wedge" resections and/or ablations and other subsets.

RESULTS

A total of 2714 patients were identified who met inclusion criteria. Major hepatectomy was performed in 1037 patients (38.2%) while partial lobectomy was performed in 1677 (61.8%) patients. Concurrent "wedge" hepatic resections and ablations were undertaken in 56.0% and 14.2% of patients, respectively, and were more frequently performed among patients undergoing a partial lobectomy and among patients undergoing surgery for colorectal liver metastasis (both p < 0.001). While associated with a decreased incidence of postoperative complications (p = 0.027) and liver failure (p = 0.031) among patients undergoing a major hepatectomy, concurrent therapies were associated with comparable 30-day outcomes for patients undergoing partial lobectomy.

CONCLUSION

Concurrent "wedge" hepatic resections and ablations are performed in 56.0% and 14.2%, respectively of patients undergoing hepatectomy. Concurrent procedures were not associated with worse clinical outcomes.

Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy

BACKGROUND

Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy.

MATERIALS AND METHODS

Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality.

RESULTS

Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870).

CONCLUSIONS

Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.

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

BACKGROUND

Liver resection is commonly performed for malignant and benign disease and is associated with frequent use of intraoperative and postoperative blood transfusions. Blood transfusions are potentially life-saving, but they have many adverse effects; some well understood, and others less so. Some of the poorly understood side effects include increased risk of postoperative complications and possibly worse oncologic outcomes. The objective of this systematic review is to provide estimates of transfusion prevalence and the effects of perioperative blood transfusion on postoperative mortality and morbidity and long-term cancer outcomes in patients undergoing liver resection.

METHODS/DESIGN

The Cochrane, Medline, and EMBASE databases will be searched for any randomized controlled trial or observational cohort study comparing liver resection patients that received intraoperative or postoperative allogeneic red blood cell transfusions to those who did not. Outcomes include postoperative mortality, postoperative morbidity (infectious, liver failure, renal failure, cardiovascular/cerebrovascular events, and thromboembolic events), and long-term disease-free and overall survival. Only studies with adult, human patients (>18 years old) undergoing liver resection, in which the primary intervention of interest is blood transfusion will be included. Data will be extracted by two reviewers in duplicate and synthesized into a narrative review. Risk of bias will be assessed. When clinically and methodologically appropriate, meta-analysis will be performed.

DISCUSSION

Our review will synthesize the literature pertaining to the potential beneficial and detrimental effects of red blood cell transfusion in patients undergoing liver resection. It will be an important step in the development of guidelines for the appropriate use of blood transfusions in patients undergoing liver resection.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015026132.