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Wang X, Lin J, Chen Y, Ye X. Surgical site wound infection and pain after laparoscopic repeat hepatectomy for recurrent hepatocellular carcinoma. Int Wound J 2023; 20:3262-3270. [PMID: 37086085 PMCID: PMC10502282 DOI: 10.1111/iwj.14206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023] Open
Abstract
This study aimed to compare the effects of laparoscopic repeat liver resection (LRLR) and open repeat liver resection (ORLR) on surgical site wound infection and pain in recurrent hepatocellular carcinoma. PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were systematically searched for studies comparing LRLR with ORLR for the treatment of recurrent hepatocellular carcinoma, with a search timeframe from their inception to December 2022. Two investigators independently screened the literature, extracted information, and evaluated the quality of the studies according to the inclusion and exclusion criteria. This study was performed using RevMan 5.4 software. A total of 20 publications with 4380 patients were included, with 1108 and 3289 patients in the LRLR and ORLR groups, respectively. The results showed that LRLR significantly reduced surgical site wound infection rate (1.71% vs. 5.16%, odds ratio [OR]:0.32, 95% confidence interval [CI]: 0.18-0.56, P < .001), superficial wound infection rate (1.29% vs. 4.92%, OR: 0.29, 95% CI: 0.14-0.58, P < .001), bile leakage (3.34% vs. 6.05%, OR: 0.59, 95% CI: 0.39-0.90, P = .01), organ/space wound infection rate (0.4% vs. 5.11%, OR: 0.23, 95% CI: 0.07-0.81, P = .02), and surgical site wound pain (mean difference: -2.00, 95% CI: -2.99 to -1.02, P < .001). Thus, the findings of this study showed that LRLR for recurrent hepatocellular carcinoma significantly reduced wound infection rates and improved postoperative wound pain.
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Affiliation(s)
- Xiao‐Bo Wang
- The Fourth School of Clinical MedicineZhejiang Chinese Medical UniversityHangzhouChina
| | - Jun‐Mei Lin
- Department of Traditional Chinese MedicineJinhua Municipal Central HospitalJinhuaChina
| | - Yan‐Ping Chen
- Department of GastroenterologyJinhua Municipal Central HospitalJinhuaChina
| | - Xu‐Xing Ye
- Department of Traditional Chinese MedicineJinhua Municipal Central HospitalJinhuaChina
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Shirai D, Shinkawa H, Kabata D, Takemura S, Tanaka S, Amano R, Kimura K, Ohira G, Nishio K, Tauchi J, Kinoshita M, Kubo S. Laparoscopic liver resection reduces postoperative infection in patients with hepatocellular carcinoma: a propensity score-based analysis. Surg Endosc 2022; 36:9194-9203. [PMID: 35838833 DOI: 10.1007/s00464-022-09403-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/19/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study is aimed to compare the occurrence of postoperative infections between patients with hepatocellular carcinoma (HCC) undergoing laparoscopic liver resection (LLR) and those undergoing open liver resection (OLR). METHODS This study included 446 patients who underwent initial curative liver resection for HCC 5 cm or less in size without macroscopic vascular invasion. To adjust for confounding factors between the LLR and OLR groups, propensity score matching and inverse probability weighting (IPW) analysis were performed. The incidence rates of postoperative infection, including incisional surgical site infection (SSI), organ/space SSI, and remote infection (RI), were compared between the two groups. RESULTS An imbalance in several confounding variables, including period of surgery, extent of liver resection, difficult location, proximity to a major vessel, tumor size ≥ 3 cm, and multiple tumors, was observed between the two groups in the original cohort. After matching and weighting, the imbalance between the two groups significantly decreased. Compared with OLR, LLR was associated with a lower volume of intraoperative blood loss (140 vs. 350 mL, P < 0.001 in the matched cohort; 120 vs. 320 mL, P < 0.001 in the weighted cohort) and reduced risk of postoperative infection (2.0% vs. 12%, P = 0.015 in the matched cohort; 2.9% vs. 14%, P = 0.005 in the weighted cohort). Of the types of postoperative infections, organ/space SSI and RI were less frequently observed in the LLR group than in the OLR group in the matched cohort (1.0% vs. 6.0%, P = 0.091 for organ/space SSI; 0% vs. 6.0%, P < 0.001 for RI) and in the weighted cohort (1.2% vs. 7.8%, P < 0.001 for organ/space SSI; 0.3% vs. 5.1%, P = 0.009 for RI). CONCLUSIONS Compared with OLR, LLR for HCC might reduce postoperative infections, including organ/space SSI and RI.
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Affiliation(s)
- Daisuke Shirai
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hiroji Shinkawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shigekazu Takemura
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kohei Nishio
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Jun Tauchi
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masahiko Kinoshita
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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Murtha-Lemekhova A, Fuchs J, Teroerde M, Chiriac U, Klotz R, Hornuss D, Larmann J, Weigand MA, Hoffmann K. Routine Postoperative Antibiotic Prophylaxis Offers No Benefit after Hepatectomy-A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:649. [PMID: 35625294 PMCID: PMC9138010 DOI: 10.3390/antibiotics11050649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/09/2022] [Accepted: 05/10/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Prophylactic antibiotics are frequently administered after major abdominal surgery including hepatectomies aiming to prevent infective complications. Yet, excessive use of antibiotics increases resistance in bacteria. The aim of this systematic review and meta-analysis is to assess the efficacy of prophylactic antibiotics after hepatectomy (postoperative antibiotic prophylaxis, POA). METHOD This systematic review and meta-analysis were completed according to the current PRISMA guidelines. The protocol has been registered prior to data extraction (PROSPERO registration Nr: CRD42021288510). MEDLINE, Web of Science and CENTRAL were searched for clinical reports on POA in hepatectomy restrictions. A random-effects model was used for synthesis. Methodological quality was assessed with RoB2 and ROBINS-I. GRADE was used for the quality of evidence assessment. RESULTS Nine comparative studies comprising 2987 patients were identified: six randomized controlled trials (RCTs) and three retrospectives. POA did not lead to a reduction in postoperative infective complications or have an effect on liver-specific complications-post-hepatectomy liver failure and biliary leaks. POA over four or more days was associated with increased rates of deep surgical site infections compared to short-term administration for up to two days (OR 1.54; 95% CI [1.17;2.03]; p = 0.03). Routine POA led to significantly higher MRSA incidence as a pathogen (p = 0.0073). Overall, the risk of bias in the studies was low and the quality of evidence moderate. CONCLUSION Routine POA cannot be recommended after hepatectomy since it does not reduce postoperative infection or liver-specific complications but contributes to resistance in bacteria. Studies into individualized risk-adapted antibiotic prophylaxis strategies are needed to further optimize perioperative treatment in liver surgery.
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Affiliation(s)
- Anastasia Murtha-Lemekhova
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.F.); (M.T.); (R.K.); (K.H.)
| | - Juri Fuchs
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.F.); (M.T.); (R.K.); (K.H.)
| | - Miriam Teroerde
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.F.); (M.T.); (R.K.); (K.H.)
| | - Ute Chiriac
- Department of Pharmacy, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.F.); (M.T.); (R.K.); (K.H.)
- Study Center of the German Surgical Society (SDGC), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Daniel Hornuss
- Division of Infectious Diseases, Department of Medicine II, Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Jan Larmann
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.L.); (M.A.W.)
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.L.); (M.A.W.)
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany; (J.F.); (M.T.); (R.K.); (K.H.)
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Antibiotic Prophylaxis for Hepato-Biliopancreatic Surgery—A Systematic Review. Antibiotics (Basel) 2022; 11:antibiotics11020194. [PMID: 35203797 PMCID: PMC8868388 DOI: 10.3390/antibiotics11020194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/01/2022] [Accepted: 01/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Surgical site infections (SSIs) are among the most important determinants of morbidity after HBP surgery. Their frequency after HPB surgery is variable, from 1–2% after elective cholecystectomy to 25% after PD. Methods: A systematic review was performed to assess the role of antimicrobial prophylaxis (AP) in HPB elective surgery. Articles published between 2015 and 2021 were obtained; those before 2015 were not included because they antedate the WHO guidelines on SSI prevention. We conducted three different research methods for liver resection, elective cholecystectomy and pancreatic and biliary surgery regarding patients requiring preoperative biliary drainage. Results: Hepatic surgery, improvement in surgical technique and perioperative management lead to a very low SSI. One preoperative 2 g cefazolin dose may be adequate for surgical prophylaxis. From preoperative biliary drainage, we can derive that patients’ homeostasis rather than AP plays a paramount role in reducing postoperative morbidity. The time from biliary drainage could be an essential element in decision making for surgical prophylaxis. In the case of low-risk cholecystectomy, it is not easy to draw definitive conclusions about the effect of AP. Data from the literature are inconsistent, and some risk factors cannot be predicted before surgery. Conclusion: in our opinion, a strict preoperative cefazolin dose strategy can be reasonable in HBP surgery until a large-scale, multicentric RCT brings definitive conclusions.
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Niederwieser T, Braunwarth E, Dasari BVM, Pufal K, Szatmary P, Hackl H, Haselmann C, Connolly CE, Cardini B, Öfner D, Roberts K, Malik H, Stättner S, Primavesi F. Early postoperative arterial lactate concentrations to stratify risk of post-hepatectomy liver failure. Br J Surg 2021; 108:1360-1370. [PMID: 34694377 DOI: 10.1093/bjs/znab338] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 09/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) represents the major determinant for death after liver resection. Early recognition is essential. Perioperative lactate dynamics for risk assessment of PHLF and associated morbidity were evaluated. METHODS This was a multicentre observational study of patients undergoing hepatectomy with validation in international high-volume units. Receiver operating characteristics analysis and cut-off calculation for the predictive value of lactate for clinically relevant International Study Group of Liver Surgery grade B/C PHLF (clinically relevant PHLF (CR-PHLF)) were performed. Lactate and other perioperative factors were assessed in a multivariable CR-PHLF regression model. RESULTS The exploratory cohort comprised 509 patients. CR-PHLF, death, overall morbidity and severe morbidity occurred in 7.7, 3.3, 40.9 and 29.3 per cent of patients respectively. The areas under the curve (AUCs) regarding CR-PHLF were 0.829 (95 per cent c.i. 0.770 to 0.888) for maximum lactate within 24 h (Lactate_Max) and 0.870 (95 per cent c.i. 0.818 to 0.922) for postoperative day 1 levels (Lactate_POD1). The respective AUCs in the validation cohort (482 patients) were 0.812 and 0.751 and optimal Lactate_Max cut-offs were identical in both cohorts. Exploration cohort patients with Lactate_Max 50 mg/dl or greater more often developed CR-PHLF (50.0 per cent) than those with Lactate_Max between 20 and 49.9 mg/dl (7.4 per cent) or less than 20 mg/dl (0.5 per cent; P < 0.001). This also applied to death (18.4, 2.7 and 1.4 per cent), severe morbidity (71.1, 35.7 and 14.1 per cent) and associated complications such as acute kidney injury (26.3, 3.1 and 2.3 per cent) and haemorrhage (15.8, 3.1 and 1.4 per cent). These results were confirmed in the validation group. Combining Lactate_Max with Lactate_POD1 further increased AUC (ΔAUC = 0.053) utilizing lactate dynamics for risk assessment. Lactate_Max, major resections, age, cirrhosis and chronic kidney disease were independent risk factors for CR-PHLF. A freely available calculator facilitates clinical risk stratification (www.liver-calculator.com). CONCLUSION Early postoperative lactate values are powerful, readily available markers for CR-PHLF and associated complications after hepatectomy with potential for guiding postoperative care.Presented in part as an oral video abstract at the 2020 online Congress of the European Society for Surgical Research and the 2021 Congress of the Austrian Surgical Society.
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Affiliation(s)
- Thomas Niederwieser
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Kamil Pufal
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Peter Szatmary
- Department of Hepato-Biliary Surgery, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Hubert Hackl
- Institute of Bioinformatics, Biocentre, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Haselmann
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Catherine E Connolly
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Keith Roberts
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hassan Malik
- Department of Hepato-Biliary Surgery, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of General, Visceral and Vascular Surgery, Salzkammergut Klinikum, Vöcklabruck, Austria
| | - Florian Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Department of Hepato-Biliary Surgery, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of General, Visceral and Vascular Surgery, Salzkammergut Klinikum, Vöcklabruck, Austria
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Gupta S, Sinha PK, Patil NS, Mohapatra N, Sindwani G, Garg N, Khillan V, Pamecha V. Randomized control trial on perioperative antibiotic prophylaxis in live liver donors: Are three doses enough? JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:1124-1132. [PMID: 34623761 DOI: 10.1002/jhbp.1053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/08/2021] [Accepted: 09/13/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The duration of perioperative antibiotic prophylaxis following live liver donor hepatectomy (LDH) is not known. METHODS This is a double-blind equivalence trial. All consecutive LDH were randomized into: group A (three doses) and group B (nine doses) of perioperative antibiotics (piperacillin + tazobactam - 4.5 g intravenous) at fixed 8 hourly intervals. Primary end point was incidence of infective complications as per CDC (Centers for Disease Control and Prevention) criteria. Secondary end points were liver function tests, total leukocyte count, international normalized ratio, hospital stay, morbidity, and cost analysis. RESULTS One hundred and twenty-six LDHs were enrolled. A total of 19.8% (n = 25) experienced postoperative complications, 11 (17.7%) in group A and 14 (21.9%) in group B (P = .561). Infective complications were seen in 11 donors (8.1%), five in group A and six in group B (P = .79). A total of 8.1% of donors required continuation/up-gradation of antibiotics in group A and 9.4% in group B. Return to soft diet was delayed in group B (P = .039). Median hospital stay and cost were similar. CONCLUSION Three doses of perioperative antibiotic are equally effective in preventing infective complications.
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Affiliation(s)
- Sahil Gupta
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Kumar Sinha
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nilesh Sadashiv Patil
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nihar Mohapatra
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gaurav Sindwani
- Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Neha Garg
- Department of Anaesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikas Khillan
- Department of Clinical Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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Chen Z, Jiang H, Wang Y, Liang R, Xu L, Lai J, Shen J, Li J, Li D, Li S, Lei K, Zhou Q, Peng B, Peng H, Peng S, Kuang M. Three-day postoperative antibiotics reduces post-hepatectomy infection rate in hepatitis B virus-related hepatocellular carcinoma. J Gastroenterol Hepatol 2021; 36:2531-2539. [PMID: 33948991 DOI: 10.1111/jgh.15528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM The evidences for use of postoperative antibiotics (POA) in hepatocellular carcinoma (HCC) patients who underwent hepatectomy are controversial. We aimed to explore the relationship between POA and hepatectomy-related infection in a hepatitis B virus (HBV)-related HCC population. METHODS We retrospectively collected 934 HCC patients who underwent hepatectomy for curative intent from three tertiary hospitals in China. The incidences of postoperative infection including surgical site infection and remote site infection were recorded and calculated. Univariable and multivariable logistic regression analyses were performed to explore related factors of postoperative infection and POA. And the relationship between infection rates with different durations of POA was investigated. RESULTS The overall infection rate was 8.2% (77/934), including 6.5% (61/934) of surgical site infection and 2.0% (19/934) of remote site infection. Multivariable analysis revealed that the administration of POA was negatively related with the incidence of postoperative infection significantly (odds ratio = 0.50, 95% confidence interval = 0.30 to 0.83; P = 0.008). Albumin-bilirubin score, Barcelona Clinic Liver Cancer (BCLC) stage and extent of hepatectomy were independently related to the POA. And 3-day regimen seemed to be the shortest duration of POA to gain the lowest incidence of postoperative infection. CONCLUSIONS Postoperative antibiotic is necessary for HBV-related HCC patients to prevent postoperative infection, especially for those with higher albumin-bilirubin score, at BCLC stage B-C, or who underwent major hepatectomy. For HBV-related HCC patients, postoperative second-generation cephalosporins, or ceftriaxone for 3 days after surgery might be proper.
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Affiliation(s)
- Zebin Chen
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Jiang
- Department of Pediatric Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuanqi Wang
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruiming Liang
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lixia Xu
- Department of Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiaming Lai
- Department of Pancreato-biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingxian Shen
- Department of Medical Imaging, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jiali Li
- Department of Hepatobiliary Surgery, Dongguan People's Hospital, Dongguan, China
| | - Dongming Li
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoqiang Li
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Kai Lei
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Zhou
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baogang Peng
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Peng
- Department of Pancreato-biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sui Peng
- Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ming Kuang
- Department of Liver Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Abstract
Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.
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9
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Shinkawa H, Tanaka S, Takemura S, Amano R, Kimura K, Nishioka T, Ito T, Miyazaki T, Ishihara A, Kubo S. Giving short-term prophylactic antibiotics in patients undergoing open and laparoscopic hepatic resection. Ann Gastroenterol Surg 2019; 3:506-514. [PMID: 31549010 PMCID: PMC6750139 DOI: 10.1002/ags3.12267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/29/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
AIM The 2016 guidelines of the Japan Society for Surgical Infection and the Japan Society of Chemotherapy advocate giving prophylactic antibiotics 1 hour before surgery and until 24 hours after surgery in patients undergoing elective hepatic resection. However, the efficacy of short-term antimicrobial prophylaxis has not been evaluated according to surgical approach. We evaluated the efficacy of giving prophylactic antibiotics in patients undergoing open or laparoscopic hepatic resection. METHODS The study comprised 218 and 185 patients undergoing open and pure laparoscopic hepatic resection, respectively. Incidence rates of postoperative infectious complications were compared between patients who received flomoxef sodium as the prophylactic antibiotic before and until 24 hours after surgery (short-term group) and those who received flomoxef sodium until 72 hours after surgery (long-term group) among patients undergoing open or laparoscopic hepatic resection. Propensity score matching analysis was carried out to adjust for confounding factors between the short- and long-term groups. RESULTS There was no significant difference in the postoperative infectious complication incidence between the short- and long-term groups among patients undergoing open (18.9% vs 12.2%; P = 0.36) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection after propensity score matching. Incidence rate of surgical site infections was comparable between the short- and long-term groups among patients undergoing open (13.5% vs 10.8%; P = 0.80) or laparoscopic (3.3% vs 1.7%; P > 0.99) hepatic resection. CONCLUSION Giving short-term prophylactic antibiotics might be sufficient in preventing postoperative infectious complications in patients undergoing open and laparoscopic hepatic resection.
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Affiliation(s)
- Hiroji Shinkawa
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Shogo Tanaka
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Shigekazu Takemura
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Ryosuke Amano
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Kenjiro Kimura
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Takayoshi Nishioka
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Tokuji Ito
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Toru Miyazaki
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Atsushi Ishihara
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
| | - Shoji Kubo
- Department of Hepato‐Biliary‐Pancreatic SurgeryOsaka City University Graduate School of MedicineOsakaJapan
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Berry PS, Rosenberger LH, Guidry CA, Agarwal A, Pelletier S, Sawyer RG. Intraoperative Versus Extended Antibiotic Prophylaxis in Liver Transplant Surgery: A Randomized Controlled Pilot Trial. Liver Transpl 2019; 25:1043-1053. [PMID: 31063679 DOI: 10.1002/lt.25486] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/11/2019] [Indexed: 02/07/2023]
Abstract
The appropriate duration of surgical antibiotic prophylaxis in orthotopic liver transplantation (OLT) in the presence of significant iatrogenic immunosuppression is unclear. We hypothesized that 72 hours of perioperative antibiotic prophylaxis would decrease rates of surgical site infection (SSI) in OLT patients when compared with intraoperative antibiotic prophylaxis alone. OLT recipients were randomized to receive either intraoperative antibiotics only (short antibiotics [SAs]) or 72 hours of perioperative antibiotics (extended antibiotics [EAs]). A total of 102 patients were randomized: 51 to the EA group and 51 to the SA group. Rates of SSI and nosocomial infection (NI) in the SA group were 19% and 17%, respectively, compared with 27% (SSI; P = 0.36) and 22% (NI; P = 0.47) in the EA group, although these differences were not statistically significant. Intensive care unit (ICU) length of stay (LOS), hospital LOS, 30-day mortality, and time to infection were also similar between the 2 groups. Patients developing infections had longer ICU LOS and hospital LOS and a higher association with reoperation, endoscopic retrograde cholangiopancreatography, and 30-day readmission. In conclusion, extending perioperative antibiotics to 72 hours from intraoperative dosing alone in OLT patients does not appear to decrease the incidence of SSI or NI. The results from this pilot trial with 60% power suggest that it is acceptable for OLT recipients to receive intraoperative antibiotic prophylaxis alone.
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Affiliation(s)
- Puja S Berry
- Department of Surgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Christopher A Guidry
- School of Medicine, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Avinash Agarwal
- Department of Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Shawn Pelletier
- Department of Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University, Kalamazoo, MI
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11
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Guo T, Ding R, Yang J, Wu P, Liu P, Liu Z, Li Z. Evaluation of different antibiotic prophylaxis strategies for hepatectomy: A network meta-analysis. Medicine (Baltimore) 2019; 98:e16241. [PMID: 31261586 PMCID: PMC6617204 DOI: 10.1097/md.0000000000016241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The application of antibiotic prophylaxis for hepatectomy remains uncertain. This research aims to evaluate different antibiotic prophylaxis strategies for hepatectomy based on network meta-analysis. METHODS Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating antibiotic prophylaxis strategies for hepatectomy. Relative parametric data, including surgical site infection (SSI), remote site infection (RSI) and total infection (TI), were quantitatively pooled and estimated based on the Bayesian theorem. The values of surface under the cumulative ranking curve (SUCRA) probabilities regarding each parameter were calculated and ranked. Node-splitting analysis was performed to test the inconsistency of the main results, and publication bias was assessed by examining the funnel plot symmetry. Additional pairwise meta-analyses were performed to validate the differences between respective strategies at the statistical level. RESULTS After a detailed review, a total of 5 RCTs containing 4 different strategies were included for the network meta-analysis. The results indicated that the application of no antibiotics possessed the highest possibility of having the best clinical effects on SSI (SUCRA, 0.56), RSI (SUCRA, 0.46) and TI (SUCRA, 0.61). Moreover, node-splitting analysis and funnel plot symmetries illustrated no inconsistencies in the current study. Additional pairwise meta-analyses determined that additional and long-duration applications had no clinical benefit. CONCLUSION Based on current evidence, we concluded that antibiotic prophylaxis did not reveal clinical benefit in hepatectomy. However, more relative trials and statistical evidence are still needed.
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Affiliation(s)
- Tao Guo
- Department of Hepatobiliary and Pancreatic Surgery
| | - Ruiwen Ding
- Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan
| | - Jian Yang
- School of Nursing, Huanggang Polytechnic College, Huanggang, PR China
| | - Ping Wu
- Department of Hepatobiliary and Pancreatic Surgery
| | - Pengpeng Liu
- Department of Hepatobiliary and Pancreatic Surgery
| | - Zhisu Liu
- Department of Hepatobiliary and Pancreatic Surgery
| | - Zhen Li
- Department of Hepatobiliary and Pancreatic Surgery
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12
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Antimicrobial prophylaxis for 1 day versus 3 days in liver cancer surgery: a randomized controlled non-inferiority trial. Surg Today 2019; 49:859-869. [DOI: 10.1007/s00595-019-01813-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/08/2019] [Indexed: 12/27/2022]
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13
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Gyoeri GP, Pereyra D, Braunwarth E, Ammann M, Jonas P, Offensperger F, Klinglmueller F, Baumgartner R, Holzer S, Gnant M, Laengle F, Staettner S, Gruenberger T, Starlinger P. The 3-60 criteria challenge established predictors of postoperative mortality and enable timely therapeutic intervention after liver resection. Hepatobiliary Surg Nutr 2019; 8:111-124. [PMID: 31098358 DOI: 10.21037/hbsn.2019.02.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background To date, definitions of liver dysfunction (LD) after hepatic resection rely on late postoperative time points. Further, the used parameters are markedly influenced by perioperative management. Thus, we aimed to establish a very early postoperative score to predict postoperative mortality. Methods Liver related parameters were evaluated after liver resection in a retrospective evaluation cohort of 228 colorectal cancer patients with liver metastasis (mCRC) and subsequent validation in a prospective set of 482 consecutive patients from 4 independent institutions undergoing hepatic resection was performed. Results C-reactive protein (CRP, AUC =0.739, P<0.001) and antithrombinIII-activity (ATIII, AUC =0.844, P<0.001) on the first postoperative day (POD) were found to be elevated in patients with LD. Cut-off values for CRP at 3 mg/dL and for ATIII at 60% significantly identified high-risk patients for postoperative LD and mortality (P<0.001) and thus defined the 3-60 criteria on POD1. The 3-60 criteria showed superior sensitivity and specificity compared to established criteria for LD [3-60 criteria: total positive patients: 26 patients (70% mortality detected), odds ratio (OR): 48.8; International Study Group for Liver Surgery: total positive patients: 43 (70% mortality detected), OR: 23.3; Peak7: total positive patients: 9 (30% mortality detected), OR: 27.8; 50-50: total positive patients: 9 (30% mortality detected), OR: 27.8]. These results could be validated in a multi-center analysis and ultimately the 3-60 criteria remained an independent predictor of postoperative mortality upon multivariable analysis. Conclusions The 3-60 criteria on POD1 predict postoperative LD and mortality early after liver resection with a comparable or better accuracy than established criteria, allowing for immediate identification of high-risk patients.
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Affiliation(s)
- Georg P Gyoeri
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - David Pereyra
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - Eva Braunwarth
- Department of Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Ammann
- Department of Surgery, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Philipp Jonas
- Department of Surgery, Kaiser Franz Josef Hospital, Vienna, Austria
| | - Florian Offensperger
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - Florian Klinglmueller
- Core Unit for Medical Statistics and Informatics, Medical University of Vienna, Vienna, Austria
| | - Ruth Baumgartner
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - Sandra Holzer
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael Gnant
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - Friedrich Laengle
- Department of Surgery, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Stefan Staettner
- Department of Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Patrick Starlinger
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
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14
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Day RW, Aloia TA. Enhanced recovery in liver surgery. J Surg Oncol 2019; 119:660-666. [PMID: 30802314 DOI: 10.1002/jso.25420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/06/2019] [Accepted: 02/09/2019] [Indexed: 12/11/2022]
Abstract
Enhanced recovery in liver surgery has been shown to improve outcomes including patient-reported outcomes, length of stay, return to intended oncology therapy, and cost. The goal of this chapter will be to review the elements of a modern enhanced recovery pathway that is utilized across the entire episode of care in liver surgery.
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Affiliation(s)
- Ryan W Day
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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15
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Single Dose Based Ertapenem Prophylaxis Reduces Surgical Site Infection after Selective Hepatectomy of Hepatocellular Carcinoma: A Propensity Score Matching Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2520191. [PMID: 30246017 PMCID: PMC6136539 DOI: 10.1155/2018/2520191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/16/2018] [Accepted: 08/26/2018] [Indexed: 01/29/2023]
Abstract
Objective This study aimed to assess whether a single dose of ertapenem prophylaxis was more effective than other antibiotics to prevent surgical site infection (SSI) after selective hepatectomy for hepatocellular carcinoma (HCC). Methods The data from HCC patients with open hepatectomy between January 2012 and June 2017 in Shengjing Hospital were retrospectively analyzed. These patients were divided into two groups: ertapenem (ER) group, where a single dose of ER was administered; non-ertapenem (NER) group, where NER antibiotics were administered. The SSI rates were compared between two groups before and after matching the propensity scores. Results The enrolled patients consisted of 78 in the ER group and 197 in the NER group. After matching the propensity scores, each group was down-selected to 65 patients. The SSI rate among the matched 130 patients was 14.6%, 7.7% occurred in the ER group and 21.5% in the NER group (P<0.05). The SSI rates in organ/space of the ER and NER groups were 3.1% and 13.8%, respectively (P<0.05). Conclusions A single dose of ER before surgery was more effective in mitigating SSI after selective hepatectomy compared with other antibiotics use. The results imply that the selection of both antibiotics and administration timing is important for the efficacy in preventing SSI.
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16
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Duration of Antimicrobial Prophylaxis in Patients Undergoing Major Hepatectomy With Extrahepatic Bile Duct Resection: A Randomized Controlled Trial. Ann Surg 2017; 267:142-148. [PMID: 27759623 DOI: 10.1097/sla.0000000000002049] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the optimal duration of antimicrobial prophylaxis in patients undergoing "complicated"' major hepatectomy with extrahepatic bile duct resection. BACKGROUND To date, 4 randomized controlled trials (RCTs) have assessed the duration of antimicrobial prophylaxis after hepatectomy. However, all of these previous studies involved only "simple" hepatectomy without extrahepatic bile duct resection. METHODS Patients with suspected hilar obstruction scheduled to undergo complicated hepatectomy after biliary drainage were randomized to 2-day (antibiotic treatment on days 1 and 2) or 4-day (on days 1 to 4) groups. Antibiotics were selected based on preoperative bile culture. The primary endpoint was the incidence of postoperative infectious complications. RESULTS In total, 86 patients were included (43 patients in each arm) without between-group differences in baseline characteristics. Bile culture positivity was similar between the 2 groups. No significant between-group differences were observed in surgical variables. The incidence of any infectious complications was similar between the 2 groups (30.2% in the 2-day group and 32.6% in the 4-day group). The positive rate of systemic inflammatory response syndrome and the incidence of additional antibiotic use were almost identical between the 2 groups. According to Clavien-Dindo classification, grade 3a or higher complications occurred in 23 patients (53.5%) in the 2-day group and 29 patients (67.4%) in the 4-day group (P = 0.186). Postoperative hospital stay was not different between the 2 groups. CONCLUSIONS Two-day administration of antimicrobial prophylaxis is sufficient for patients undergoing hepatectomy with extrahepatic bile duct resection [Registration number: ID 000009800 (University Hospital Medical Information Network, http://www.umin.ac.jp)].
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17
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Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CHC, Garden OJ, Farges O, Kokudo N, Vauthey JN, Clavien PA, Demartines N. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2017; 40:2425-40. [PMID: 27549599 DOI: 10.1007/s00268-016-3700-1] [Citation(s) in RCA: 378] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. METHODS A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. RESULTS A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. CONCLUSIONS The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
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Affiliation(s)
- Emmanuel Melloul
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Scott
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Snowden
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, The Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - James Prentis
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center and NUTRIM School for Translational Research in Metabolism, Maastricht, The Netherlands
| | - O James Garden
- Department of Clinical Surgery, School of Clinical Sciences, The University of Edinburgh, Edinburgh, UK
| | - Olivier Farges
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, U.T. MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre-Alain Clavien
- Swiss Hepato-pancreato-biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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18
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Sakoda M, Iino S, Mataki Y, Kawasaki Y, Kurahara H, Maemura K, Ueno S, Natsugoe S. Influence of a Shorter Duration of Post-Operative Antibiotic Prophylaxis on Infectious Complications in Patients Undergoing Elective Liver Resection. Surg Infect (Larchmt) 2017; 18:149-156. [DOI: 10.1089/sur.2016.170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Masahiko Sakoda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Satoshi Iino
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Yuko Mataki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Kosei Maemura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Shinichi Ueno
- Department of Clinical Oncology, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
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19
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Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, Gomes SM, Gans S, Wallert ED, Wu X, Abbas M, Boermeester MA, Dellinger EP, Egger M, Gastmeier P, Guirao X, Ren J, Pittet D, Solomkin JS. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. THE LANCET. INFECTIOUS DISEASES 2016; 16:e288-e303. [PMID: 27816414 DOI: 10.1016/s1473-3099(16)30402-9] [Citation(s) in RCA: 476] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/28/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.
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Affiliation(s)
- Benedetta Allegranzi
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland.
| | - Bassim Zayed
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Peter Bischoff
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | - N Zeynep Kubilay
- Infection Prevention and Control Global Unit, Service Delivery and Safety, WHO, Geneva, Switzerland
| | - Stijn de Jonge
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Fleur de Vries
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Sarah Gans
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Elon D Wallert
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | - Xiuwen Wu
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Mohamed Abbas
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marja A Boermeester
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine, Berlin, Germany
| | | | - Jianan Ren
- Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Didier Pittet
- Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; WHO Collaborating Centre on Patient Safety (Infection Control and Improving Practices), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Joseph S Solomkin
- OASIS Global, Cincinnati, OH, USA; University of Cincinnati College of Medicine, Cincinnati, OH, USA
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20
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Kikuchi Y, Hiroshima Y, Matsuo K, Kawaguchi D, Murakami T, Yabushita Y, Endo I, Taguri M, Koda K, Tanaka K. A Randomized Clinical Trial of Preoperative Administration of Branched-Chain Amino Acids to Prevent Postoperative Ascites in Patients with Liver Resection for Hepatocellular Carcinoma. Ann Surg Oncol 2016; 23:3727-3735. [PMID: 27338747 DOI: 10.1245/s10434-016-5348-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Massive postoperative ascites remains a major threat that can lead to liver failure and other fatal complications, especially in patients with poor liver function. Branched-chain amino acid (BCAA) administration increases biosynthesis and secretion of albumin by hepatocytes and increases oncotic pressure by elevating blood albumin concentration, thereby decreasing peripheral edema, ascites, and pleural effusion. METHOD We randomly allocated consecutive patients undergoing major liver resection for hepatocellular carcinoma to either a group where oral BCAA administration was initiated 3 weeks before liver resection, or a non-BCAA group. The primary study endpoint was development of postoperative ascites. RESULTS Overall, 39 patients were allocated to the BCAA group, while 38 were assigned to the non-BCAA group. No significant difference in the rate of refractory ascites, considered alone, was evident between the BCAA (5.1 %) and non-BCAA groups (13.2 %; p = 0.263). However, the occurrence of refractory ascites and/or pleural effusion was significantly less frequent in the BCAA group (5.1 %) than in the non-BCAA group (21.1 %; p = 0.047). Furthermore, the postoperative serum concentration of reduced-state albumin was greater immediately after liver resection in the BCAA group than in the non-BCAA group. CONCLUSION Preoperative administration of BCAA did not significantly improve prevention of refractory ascites, but significant effectiveness in preventing ascites, pleural effusion, or both, as well as improving metabolism of albumin, was demonstrated [University Hospital Medical Information Network (UMIN) reference number 000004244].
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Affiliation(s)
- Yutaro Kikuchi
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Yukihiko Hiroshima
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Kenichi Matsuo
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Daisuke Kawaguchi
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Takashi Murakami
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masataka Taguri
- Department of Biostatistics and Epidemiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Kuniya Tanaka
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan. .,Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
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21
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A Randomized Clinical Trial of Early Enteral Nutrition to Prevent Infectious Complications in Patients With Extensive Liver Resection. Int Surg 2015. [DOI: 10.9738/intsurg-d-15-00060.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
After major liver resections, infections and liver insufficiency are the most common complications; these may coincide. We performed a randomized clinical trial to clarify ability of early enteral nutrition to prevent infectious complications and liver failure following major hepatectomy. We prospectively allocated consecutive patients who underwent major liver resection into either an early enteral nutrition group in which such nutrition was initiated on the first postoperative day or a nonenteral nutrition group. The primary study endpoint was rate of infectious complications. Thirty-two patients were randomly allocated to the enteral nutrition group, while 31 were assigned to the nonenteral nutrition group. No significant difference in rate of infection complications was evident between enteral (9.4%) and nonenteral group (22.6%, P = 0.184). However, complications of grade III severity or worse were significantly less frequent in the enteral (9.4%) than in the nonenteral group (32.3%, P = 0.031). Further, postoperative serum concentrations of pre-albumin and reduced-state albumin were greater in the enteral than in the nonenteral group. Early enteral nutrition did not significantly improve prevention of infectious complications, but some effectiveness in preventing severe complications and improving nutritional status was demonstrated.
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22
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Tanaka K, Matsuo K, Kawaguchi D, Murakami T, Hiroshima Y, Hirano A, Sato S, Endo I, Taguri M, Koda K. Randomized clinical trial of peritoneal lavage for preventing surgical site infection in elective liver surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:446-53. [DOI: 10.1002/jhbp.222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/05/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Kuniya Tanaka
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
- Department of Gastroenterological Surgery; Yokohama City University Graduate School of Medicine; Yokohama Kanagawa Japan
| | - Kenichi Matsuo
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
| | - Daisuke Kawaguchi
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
| | - Takashi Murakami
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
| | - Yukihiko Hiroshima
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
| | - Atsushi Hirano
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
| | - Sho Sato
- Department of Gastroenterological Surgery; Yokohama City University Graduate School of Medicine; Yokohama Kanagawa Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery; Yokohama City University Graduate School of Medicine; Yokohama Kanagawa Japan
| | - Masataka Taguri
- Department of Biostatistics and Epidemiology; Yokohama City University Graduate School of Medicine; Yokohama Kanagawa Japan
| | - Keiji Koda
- Department of Surgery; Teikyo University Chiba Medical Center; Ichihara Chiba Japan
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Ciacio O, Voron T, Pittau G, Lewin M, Vibert E, Adam R, Sa Cunha A, Cherqui D, Schielke A, Soubrane O, Scatton O, Salloum C, Azoulay D, Benoist S, Goyer P, Vaillant JC, Hannoun L, Boleslawski E, Agostini H, Samuel D, Castaing D. Interest of preoperative immunonutrition in liver resection for cancer: study protocol of the PROPILS trial, a multicenter randomized controlled phase IV trial. BMC Cancer 2014; 14:980. [PMID: 25523036 PMCID: PMC4302113 DOI: 10.1186/1471-2407-14-980] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Malnutrition is an independent risk factor of postoperative morbidity and mortality and it's observed in 20 to 50% of surgical patients. Preoperative interventions to optimize the nutritional status, reduce postoperative complications and enteral nutrition has proven to be superior to the parenteral one. Moreover, regardless of the nutritional status of the patient, surgery impairs the immunological response, thus increasing the risk of postoperative sepsis. Immunonutrition has been developed to improve the immunometabolic host response in perioperative period and it has been proven to reduce significantly postoperative infectious complications and length of hospital stay in patients undergoing elective gastrointestinal surgery for tumors. We hypothesize that a preoperative oral immunonutrition (ORAL IMPACT®) can reduce postoperative morbidity in liver resection for cancer. METHODS/DESIGN Prospective multicenter randomized placebo-controlled double-blind phase IV trial with two parallel treatment groups receiving either study product (ORAL IMPACT®) or control supplement (isocaloric isonitrogenous supplement--IMPACT CONTROL®) for 7 days before liver resection for cancer. A total of 400 patients will be enrolled. Patients will be stratified according to the type of hepatectomy, the presence of chronic liver disease and the investigator center. The main end-point is to evaluate in intention-to-treat analysis the overall 30-day morbidity. Secondary end-points are to assess the 30-day infectious and non-infectious morbidity, length of antibiotic treatment and hospital stay, modifications on total food intake, compliance to treatment, side-effects of immunonutrition, impact on liver regeneration and sarcopenia, and to perform a medico-economic analysis. DISCUSSION The overall morbidity rate after liver resection is 22% to 42%. Infectious post-operative complications (12% to 23%) increase the length of hospital stay and costs and are responsible for a quarter of 30-day mortality. Various methods have been advocated to decrease the rate of postoperative complications but there is no evidence to support or refute the use of any treatment and further trials are required. The effects of preoperative oral immunonutrition in non-cirrhotic patients undergoing liver resection for cancer are unknown. The present trial is designed to evaluate whether the administration of a short-term preoperative oral immunonutrition can reduce postoperative morbidity in non-cirrhotic patients undergoing liver resection for cancer. TRIAL REGISTRATION Clinicaltrial.gov: NCT02041871.
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Affiliation(s)
- Oriana Ciacio
- Centre Hépato-biliaire, Paul Brousse Hospital - APHP, 12-14 Avenue Paul Vaillant Couturier, 94800 Villejuif, France.
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Nikfarjam M, Weinberg L, Fink MA, Muralidharan V, Starkey G, Jones R, Staveley-O'Carroll K, Christophi C. Pressurized pulse irrigation with saline reduces surgical-site infections following major hepatobiliary and pancreatic surgery: randomized controlled trial. World J Surg 2014; 38:447-55. [PMID: 24170152 DOI: 10.1007/s00268-013-2309-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infections (SSI) are a significant cause of postoperative morbidity. Pressurized pulse irrigation of subcutaneous tissues may lower infection rates by aiding in the debridement of necrotic tissue and reducing bacterial counts compared to simply pouring saline into the wound. METHODS A total of 128 patients undergoing laparotomy extending beyond 2 h were randomized to treatment of wounds by pressurized pulse lavage irrigation (<15 psi) with 2 L normal saline (pulse irrigation group), or to standard irrigation with 2 L normal saline poured into the wound, immediately prior to skin closure (standard group). Only elective cases were included, and all cases were performed within a specialized hepatobiliary and pancreatic surgery unit. RESULTS There were 62 patients managed by standard irrigation and 68 were managed by pulse irrigation. The groups were comparable in most aspects. Overall there were 16 (13 %) SSI. Significantly fewer SSI occurred in the pulse irrigation group [4 (6 %) vs. 12 (19 %); p = 0.032]. On multivariate analysis, the use of pulse irrigation was the only factor associated with a reduction in SSI with an odds ratio (OR) of 0.3 [95 % confidence interval (95 % CI) 0.1-0.8; p = 0.031]. In contrast, hospital length of stay of greater than 14 days was associated with increased infections with an OR of 7.6 (95 % CI 2.4-24.9; p = 0.001). CONCLUSIONS Pulse irrigation of laparotomy wounds in operations exceeding 2 h duration reduced SSI after major hepatobiliary pancreatic surgery. (Australian New Zealand Clinical Trials Registry, ACTRN12612000170820).
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Affiliation(s)
- Mehrdad Nikfarjam
- University of Melbourne Department of Surgery, Austin Health, LTB 8, Studley Rd, Heidelberg, VIC, 3084, Australia,
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Siu J, McCall J, Connor S. Systematic review of pathophysiological changes following hepatic resection. HPB (Oxford) 2014; 16:407-21. [PMID: 23991862 PMCID: PMC4008159 DOI: 10.1111/hpb.12164] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection. METHODS The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were 'hepatectomy/', 'liver function/', 'liver failure/' and 'physiology/'. RESULTS Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure. CONCLUSIONS The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.
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Affiliation(s)
- Joey Siu
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - John McCall
- Department of Surgery, Dunedin HospitalDunedin, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand,Correspondence Saxon Connor, Department of Surgery, Christchurch Hospital, Christchurch 8011, New Zealand. Tel: + 64 3 364 0640. Fax: + 64 3 364 0352. E-mail:
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Hirokawa F, Hayashi M, Miyamoto Y, Asakuma M, Shimizu T, Komeda K, Inoue Y, Uchiyama K, Nishimura Y. Evaluation of postoperative antibiotic prophylaxis after liver resection: a randomized controlled trial. Am J Surg 2013; 206:8-15. [DOI: 10.1016/j.amjsurg.2012.08.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 08/09/2012] [Accepted: 08/19/2012] [Indexed: 10/26/2022]
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Gurusamy KS, Naik P, Davidson BR. Methods of decreasing infection to improve outcomes after liver resections. Cochrane Database Syst Rev 2011:CD006933. [PMID: 22071832 DOI: 10.1002/14651858.cd006933.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Infections cause both morbidity and mortality in patients undergoing liver resection. Various methods have been advocated to decrease the infectious complications after liver resection. We do not know if they are of any benefit to the patient or the health-care funder. OBJECTIVES To determine the benefits and harms of different interventions in decreasing the infectious complications and improving the outcomes after liver resection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2011. SELECTION CRITERIA We included all randomised clinical trials that were performed to compare interventions aimed at decreasing the infectious complications after liver resection. DATA COLLECTION AND ANALYSIS Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we calculated the risk ratio (RR), rate ratio, or mean difference (MD) with 95% confidence intervals (CI) based on available patient data analysis. MAIN RESULTS We included seven trials including 521 patients for this review. The sample size in the trials varied from 12 to 180 patients. All the trials were of high risks of systematic errors and of random errors. Four trials included patients who underwent liver resection only. In the remaining three trials, patients underwent combined liver resection with extrahepatic biliary resection resulting in a biliary enteric anastomosis. Four trials included only major liver resection. The remaining three trials included a mixture of major and minor liver resections. It appears that the proportion of cirrhotic patients in the trials was very low. The comparisons performed included whether antibiotics are necessary routinely during the peri-operative period of liver resection, the duration of antibiotics, the use of prebiotics and probiotics in the perioperative period, use of recombinant bactericidal-permeability increasing protein 21 (rBPI21), and the use of topical povidone iodine gel at the time of wound closure. Only one or two trials were included under each comparison. There was no significant differences in mortality or severe morbidity in any of the comparisons. Quality of life was not reported in any of the trials. AUTHORS' CONCLUSIONS There is currently no evidence to support or refute the use of any treatment to reduce infectious complications after liver resections. Further well designed trials with low risk of systematic error and low risk of random errors are necessary.
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Outcome of and risk factors for incisional hernia after partial hepatectomy. J Gastrointest Surg 2008; 12:1115-20. [PMID: 18213504 DOI: 10.1007/s11605-008-0469-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 01/07/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION This study was conducted to analyze differences among abdominal incisions, and risk factors for incisional hernia after partial hepatectomy. MATERIALS AND METHODS In 626 posthepatectomy cases, we analyzed retrospectively the distribution regarding the type of incision and assessed risk factors for incisional hernia. RESULTS Of the patients, 95 (15.2%) had median incisions, 233 (37.2%) had J-shaped incisions, 206 (32.9%) had right transverse incisions with vertical extensions in the midline from the subumbilical region to the xiphoid process (RTVE), and 92 (14.7%) had bilateral transverse incision with a vertical extension to the xiphoid process (a reversed T incision). The respective frequencies of incisional hernia after median, J-shaped, RTVE, and reversed T incisions were 6.3, 4.7, 5.4, and 21.7%, so that the difference between reversed T and other incisions was significant. A diagnosis of "no hernia" required a minimum follow-up of 12 months. The risk factors for incisional hernia were incision type, postoperative ascites, body mass index, repeat hepatectomy, and steroid use in multivariate analysis. CONCLUSION The incidence of incisional hernia after reversed T incision was significantly higher than after other incisions. If incision extension is necessary, the midline incision should be extended from the subumbilical region.
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