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Vaghiri S, Lehwald-Tywuschik N, Prassas D, Safi SA, Kalmuk S, Knoefel WT, Dizdar L, Alexander A. Predictive factors of 90-day mortality after curative hepatic resection for hepatocellular carcinoma: a western single-center observational study. Langenbecks Arch Surg 2024; 409:149. [PMID: 38698255 PMCID: PMC11065924 DOI: 10.1007/s00423-024-03337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE The aim of this study was to identify predictive risk factors associated with 90-day mortality after hepatic resection (HR) in hepatocellular carcinoma (HCC). METHODS All patients undergoing elective resection for HCC from a single- institutional and prospectively maintained database were included. Multivariate regression analysis was conducted to identify pre- and intraoperative as well as histopathological predictive factors of 90-day mortality after elective HR. RESULTS Between August 2004 and October 2021, 196 patients were enrolled (148 male /48 female). The median age of the study cohort was 68.5 years (range19-84 years). The rate of major hepatectomy (≥ 3 segments) was 43.88%. Multivariate analysis revealed patient age ≥ 70 years [HR 2.798; (95% CI 1.263-6.198); p = 0.011], preoperative chronic renal insufficiency [HR 3.673; (95% CI 1.598-8.443); p = 0.002], Child-Pugh Score [HR 2.240; (95% CI 1.188-4.224); p = 0.013], V-Stage [HR 2.420; (95% CI 1.187-4.936); p = 0.015], and resected segments ≥ 3 [HR 4.700; (95% 1.926-11.467); p = 0.001] as the major significant determinants of the 90-day mortality. CONCLUSION Advanced patient age, pre-existing chronic renal insufficiency, Child-Pugh Score, extended hepatic resection, and vascular tumor involvement were identified as significant predictive factors of 90-day mortality. Proper patient selection and adjustment of treatment strategies could potentially reduce short-term mortality.
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Affiliation(s)
- Sascha Vaghiri
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Nadja Lehwald-Tywuschik
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
- Department of Surgery, Katholisches Klinikum Essen, Philippusstift, Teaching Hospital of Duisburg-Essen University, Huelsmannstrasse 17, 45355, Essen, Germany
| | - Sami Alexander Safi
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Sinan Kalmuk
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany.
| | - Levent Dizdar
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
| | - Andrea Alexander
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Duesseldorf, Duesseldorf, Germany
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Terasaki F, Hirakawa S, Tachimori H, Sugiura T, Nanashima A, Komatsu S, Miyata H, Kakeji Y, Kitagawa Y, Nakamura M, Endo I. Morbidity after left trisectionectomy for hepato-biliary malignancies: An analysis of the National Clinical Database of Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1304-1315. [PMID: 37750342 DOI: 10.1002/jhbp.1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND The aim of this study was to analyze the nationwide surgical outcome of a left trisectionectomy (LT) and to identify the perioperative risk factors associated with its morbidity. METHODS Cases of LT for hepato-biliary malignancies registered at the Japanese National Clinical Database between 2013 and 2019 were retrospectively reviewed. Statistical analyses were performed to identify the perioperative risk factors associated with a morbidity of Clavien-Dindo classification (CD) ≥III. RESULTS Left trisectionectomy was performed on 473 and 238 cases of biliary and nonbiliary cancers, respectively. Morbidity of CD ≥III and V occurred in 45% and 5% of cases with biliary cancer, respectively, compared with 26% and 2% of cases with nonbiliary cancer, respectively. In multivariable analyses, biliary cancer was significantly associated with a morbidity of CD ≥III (odds ratio, 1.87; p = .018). In subgroup analyses for biliary cancer, classification of American Society of Anesthesiologists physical status (ASA-PS) 2, portal vein resection (PVR), and intraoperative blood loss ≥30 mL/kg were significantly associated with a morbidity of CD ≥III. CONCLUSIONS Biliary cancer induces severe morbidity after LT. The ASA-PS classification, PVR, and intraoperative blood loss indicate severe morbidity after LT for biliary cancer.
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Affiliation(s)
- Fumihiro Terasaki
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shinya Hirakawa
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
| | - Hisateru Tachimori
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Atsushi Nanashima
- Project Management Subcommittee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Shohei Komatsu
- Project Management Subcommittee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yuko Kitagawa
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Masafumi Nakamura
- Project Committee, Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
| | - Itaru Endo
- Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
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Zhang H, Zhang L, Wang Y, Zou J, Zhang T. Sarcopenia Predicts Prognosis of Patients Undergoing Liver Resection for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis. Nutr Cancer 2023; 75:776-784. [PMID: 36537813 DOI: 10.1080/01635581.2022.2159046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recently, several studies have investigated the impact of preoperative sarcopenia on the prognosis of patients with hepatocellular carcinoma (HCC) after liver resection, but their conclusions are controversial. Therefore, we performed a meta-analysis to evaluate the prognostic role of sarcopenia in HCC patients undergoing liver resection. PubMed, SinoMed, Embase, Cochrane Library, Medline, and Web of Science databases were systematically searched for all published literature on the prognostic value of preoperative sarcopenia in HCC patients undergoing liver resection. Pooled hazard ratios (HR), odds ratios (OR) and weighted mean differences (WMD) of the 95% confidence intervals (95% CI) were estimated using a fixed-effects or random-effects model. A total of 12 articles with 1,774 patients were included. The results of meta-analysis showed that sarcopenia would increase postoperative complications (OR = 1.30, 95%CI 1.03 ∼ 1.65, P = 0.03), prolong hospital stay (SMD = 0.22, 95%CI 0.05 ∼ 0.39, P = 0.01), and also be associated with shorter overall survival (OS) (HR = 1.69, 95%CI 1.09 ∼ 2.62, P = 0.02) and worse disease free survival (DFS) (HR = 1.54, 95%CI 1.23 ∼ 1.93, P < 0.01). Sarcopenia has an adverse effect on the prognosis of HCC patients undergoing liver resection.
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Affiliation(s)
- Hao Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Meishan People's Hospital, Meishan, Sichuan, China
| | - Li Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Meishan People's Hospital, Meishan, Sichuan, China
| | - Yi Wang
- Department of Hepatobiliary and Pancreatic Surgery, Meishan People's Hospital, Meishan, Sichuan, China
| | - Ji Zou
- Department of Hepatobiliary and Pancreatic Surgery, Meishan People's Hospital, Meishan, Sichuan, China
| | - Ting Zhang
- Department of Gastroenterology, Meishan People's Hospital, Meishan, Sichuan, China
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Okada M, Ihara K, Miyoshi K, Nakao S, Tanabe M, Tokumitsu Y, Harada E, Sakamoto K, Nagano H, Ito K. Portal vein embolization via the ipsilateral percutaneous transhepatic approach versus laparotomic transileocecal approach: complications, profile and changes in future liver remnant volume. Br J Radiol 2022; 95:20210854. [PMID: 35348358 PMCID: PMC10996331 DOI: 10.1259/bjr.20210854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Major liver resection is an effective treatment option for patients with liver malignancy. The future liver remnant (FLR) volume and complications after portal vein embolization (PVE) were compared between the ipsilateral right portal vein (PTPE) and transileocolic (TIPE) approaches. METHODS A total of 42 patients (TIPE, n = 22; PTPE, n = 20) underwent right lobectomy after PVE. CT and hepatobiliary scintigraphy were repeated before and after PVE. The blood examination findings and the FLR values (FLRCT: calculated from CT, %FLRCT: FLRCT ratio, %FLRSPECT: FLR ratio using single photon emission CT, FLRCT/BS: FLRCT to body surface ratio) were compared between two approach sites. The complications and mortality were also analyzed after PVE and major right hepatectomy. RESULTS There were no significant differences in the patient characteristics, blood examination findings or FLR values between two groups. Adequate liver regeneration was observed without significant differences between PTPE and TIPE (increased ratio of FLRCT: 8.7% vs 19.2%, p = 0.15 [25-75 percentile: 17.1-60.4], %FLRCT: 11.2% vs 8.3%, p = 0.25 [6.3-13.3], %FLRSPECT: 15.4% vs 19.2%, p = 0.09 [16.0-22.4], FLRCT/BS: 33.6% vs 47.1%, p = 0.19 [17.2-60.4], respectively), but TIPE required a significantly longer procedure time than PTPE [181.4 min vs 108.7 min, p < 0.01 (103.3-193.5)]. However, one patient was converted to TIPE due to bleeding during PTPE. After right lobectomy, portal vein stenosis or thrombosis was noted in three patients [two with TIPE (9.1%) and one with PTPE (5%)] and three TIPE patients died within 90 days (13.6%) after right hepatectomy. CONCLUSION FLR volume significantly increased after PVE, regardless of the approach sites; however, PTPE is a useful technique with a shorter procedure time.
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Affiliation(s)
- Munemasa Okada
- Department of Radiology, National Hospital Organization, Kanmon
Medical Center, Shimonoseki,
Japan
| | - Kenichiro Ihara
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
| | - Keisuke Miyoshi
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
| | - Sei Nakao
- Department of Surgery and Clinical Science, Yamaguchi
University Graduate School of Medicine,
Ube, Japan
| | - Masahiro Tanabe
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
| | - Yukio Tokumitsu
- Department of Gastroenterological, Breast and Endocrine
Surgery, Yamaguchi University Graduate School of Medicine,
Ube, Japan
| | - Eijiro Harada
- Department of Surgery and Clinical Science, Yamaguchi
University Graduate School of Medicine,
Ube, Japan
| | - Kazuhiko Sakamoto
- Department of Surgery, National Hospital Organization, Kanmon
Medical Center, Shimonoseki,
Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine
Surgery, Yamaguchi University Graduate School of Medicine,
Ube, Japan
| | - Katsuyoshi Ito
- Department of Radiology, Yamaguchi University Graduate School
of Medicine, Ube,
Japan
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Thormann M, Omari J, Pech M, Damm R, Croner R, Perrakis A, Strobel A, Wienke A, Surov A. Low skeletal muscle mass and post-operative complications after surgery for liver malignancies: a meta-analysis. Langenbecks Arch Surg 2022; 407:1369-1379. [PMID: 35583832 PMCID: PMC9283156 DOI: 10.1007/s00423-022-02541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/29/2022] [Indexed: 12/03/2022]
Abstract
Purpose To assess the influence of low skeletal muscle mass (LSMM) on post-operative complications in patients with hepatic malignancies grade (Clavien Dindo ≥ 3) undergoing resection. Methods MEDLINE, Cochrane, and SCOPUS databases were screened for associations between sarcopenia and major post-operative complications (≥ grade 3 according to Clavien-Dindo classification) after resection of different malignant liver tumors. RevMan 5.3 software was used to perform the meta-analysis. The methodological quality of the included studies was assessed according to the QUIPS instrument. Results The analysis included 17 studies comprising 3157 patients. Subgroup analyses were performed for cholangiocarcinoma (CCC), colorectal cancer (CRC) liver metastases, and hepatocellular carcinoma (HCC). LSMM as identified on CT was present in 1260 patients (39.9%). Analysis of the overall sample showed that LSMM was associated with higher post-operative complications grade Clavien Dindo ≥ 3 (OR 1.56, 95% CI 1.25–1.95, p < 0.001). In the subgroup analysis, LSMM was associated with post-operative complications in CRC metastases (OR 1.60, 95% CI 1.11–2.32, p = 0.01). In HCC and CCC sub-analyses, LSMM was not associated with post-operative complications in simple regression analysis. Conclusion LSMM is associated with major post-operative complications in patients undergoing surgery for hepatic metastases and it does not influence major post-operative complications in patients with HCC and CCC.
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Affiliation(s)
- Maximilian Thormann
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Jazan Omari
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Maciej Pech
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Robert Damm
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Roland Croner
- Department of General-, Visceral-, Vascular- and Transplantation Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Aristotelis Perrakis
- Department of General-, Visceral-, Vascular- and Transplantation Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - Alexandra Strobel
- Institute of Medical Epidemiology, Biometry, and Informatics, Martin Luther University, Halle-Wittenberg, Germany
- Profile Area Clinical Studies & Biostatistics, Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University, Halle-Wittenberg, Halle, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biometry, and Informatics, Martin Luther University, Halle-Wittenberg, Germany
- Profile Area Clinical Studies & Biostatistics, Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University, Halle-Wittenberg, Halle, Germany
| | - Alexey Surov
- Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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Vasavada B, Patel H. Postoperative mortality after liver resection for hepatocellular carcinoma‐ A systematic review. metanalysis and metaregression of studies published in last 5 years. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Bhavin Vasavada
- Department of hepatobiliary and liver transplant surgery Shalby Hospitals Ahmedabad
| | - Hardik Patel
- Department of hepatobiliary and liver transplant surgery Shalby Hospitals Ahmedabad
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Percutaneous Ablation for Colorectal Metastases in Australia: Are Patients Missing Out? Cardiovasc Intervent Radiol 2022; 45:712-714. [PMID: 35166882 DOI: 10.1007/s00270-022-03078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/17/2022] [Indexed: 11/02/2022]
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Lei GY, Shen L, Junnarkar SP, Huey CT, Low J, Shelat VG. Predictors of 90-Day Mortality following Hepatic Resection for Hepatocellular Carcinoma. Visc Med 2021; 37:102-109. [PMID: 33981750 PMCID: PMC8077452 DOI: 10.1159/000510811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/10/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND/PURPOSE 90-day mortality is a key performance indicator for short-term perioperative outcome of hepatic resection (HR). Although many preoperative, intraoperative, and postoperative variables predict 90-day mortality following elective HR, only few are specific to hepatocellular carcinoma (HCC). This study aims to determine the predictors of 90-day mortality following elective HR for HCC. METHODS We report a retrospective analysis of patients who underwent elective HR between January 1, 2007, and December 31, 2017. Health status, perioperative variables, and the presence of post-hepatectomy liver failure (PHLF) were studied. Cox's regression evaluated factors predicting 90-day mortality. RESULTS Two hundred and forty-four patients diagnosed with HCC underwent HR; 102 (41.8%) underwent a major HR. The postoperative 90-day mortality rate was 5.3%. Multivariate analysis demonstrated that Child-Pugh score (p < 0.001), intraoperative blood loss (p = 0.013), the 50-50 criteria for PHLF (p < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (p = 0.007) on postoperative day 3 predict 90-day mortality. CONCLUSION In patients with HCC undergoing HR, Child-Pugh score, intraoperative blood loss, the 50-50 criteria for PHLF on postoperative day 5, and peak serum bilirubin >119 µmol/L on postoperative day 3 predict 90-day mortality following elective HR for HCC.
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Affiliation(s)
- Geraldine Yanlei Lei
- Department of General Surgery, Ministry of Health Holdings, Singapore, Singapore
| | - Liang Shen
- Department of Biostatistics Unit, National University Health System, Singapore, Singapore
| | - Sameer P. Junnarkar
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - CheongWei Terence Huey
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - JeeKeem Low
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G. Shelat
- Hepato-Pancreatico-Biliary Surgery, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Qi Y, LeVan TD, Haynatzki G, Are C, Farazi PA. Development of an Integer-based Risk Score to Predict 90-Day Mortality After Hepatectomy in Patients With Hepatocellular Carcinoma. Am J Clin Oncol 2020; 43:640-647. [PMID: 32889834 DOI: 10.1097/coc.0000000000000724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of liver cancer has more than tripled since 1980. Hepatectomy represents the major curative treatment for liver cancer. The risk factors associated with 90-day mortality after hepatectomy are not well understood and there are currently no good prediction models for this outcome. The objectives of the current study were to identify risk factors of 90-day mortality after hepatectomy in patients with hepatocellular carcinoma and to develop an integer-based risk score using the National Cancer Database. METHODS Hepatectomies recorded in the National Cancer Database during 2004-2012 were reviewed for 90-day mortality. Risk factors were identified by multivariate logistic regression models. An integer-based risk score was developed using the β coefficients derived from the logistic regression model and tested for discriminatory ability. According to the total risk score, patients were grouped into 4 risk groups. RESULTS The overall 90-day mortality was 10.2%. Ten risk factors were identified, which included sex, age, race/ethnicity, insurance status, education, annual hospital volume, stage, tumor grade, Charlson-Deyo Score, and surgical procedure. The risk of 90-day mortality was stratified into 4 groups. The calculated 90-day mortality rates were 2.47%, 5.88%, 12.58%, and 24.67% for low-risk, medium-risk, high-risk, and excessive-risk groups, respectively. An area under the receiver operating characteristic curve of 0.69 was obtained for model discrimination. CONCLUSIONS The integer-based risk score we developed could easily quantify each patient's risk level and predict 90-day mortality after hepatectomy. The stratified risk score could be a useful addition to perioperative risk management and a tool to improve 90-day mortality after hepatectomy.
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Hoffmann K, Hinz U, Stravodimos C, Knoblich T, Schön MR, Büchler MW, Mehrabi A. Risk assessment for liver resection. Surgery 2018; 164:998-1005. [PMID: 30107885 DOI: 10.1016/j.surg.2018.06.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/11/2018] [Accepted: 06/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND In recent years, the profile for patients undergoing complex liver resections has changed, with mortality rates remaining generally stable. With these factors in mind, the objective of this study was to evaluate the variables associated with surgical outcomes after hepatectomy and identify groups at high risk for postoperative mortality. METHODS The records of 1,796 patients who underwent liver resection of more than one liver segment at the Department of General and Transplantation Surgery, University Hospital Heidelberg, Germany, were analyzed. The primary end point was a 90-day in-hospital mortality. Logistic regression analyses were performed to identify risk factors associated with mortality. A risk score was created in accordance with weighted points based on the odds ratios obtained from multivariate logistic regression analyses. External validation of the score was performed, using data derived from 281 patients at the board-certified center for liver surgery in Karlsruhe, Germany. RESULTS The overall patient morbidity rate (Clavien-Dindo Grade II or greater) was 32%. The 30- and 90-day mortality rates were 3.0% and 4.5%, respectively. In multivariate analysis, factors independently associated with risk for 90-day in-hospital mortality were age ≥60 years (OR 3.71), ASA classification III (OR 2.94), ASA IV (15.66), perihilar cholangiocarcinoma (OR 5.65), intrahepatic cholangiocarcinoma (OR 3.08), INR ≥ 1.1 (OR 2.43), g-GT ≥ 60 U/L (OR 2.86), platelet count ≤ 120/nL (OR 5.52), creatinine ≥ 2 mg/dL (OR 9.85), and right trisectionectomy (OR 2.88). The 90-day mortality-risk score that was created based on these factors effectively stratified patients into very low risk (0-1 points, 0.2% mortality rate in 662 patients), low risk (2-3 points, 2.9% mortality rate in 769 patients), medium risk (4-5 points, 14.7% mortality rate in 232 patients), and high risk (≥6 points, 33% mortality rate in 57 patients) groups (P < .0001). As a performance metric, the C-index for the proposed risk score for 90-day mortality was 0.86; whereas external validation revealed that this C-index was 0.89 (P = .0002). CONCLUSION Based on patient-related factors and procedure-specific variables, the proposed preoperative-risk score can be used to identify high-risk patients to determine 90-day mortality after liver resection.
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Affiliation(s)
- Katrin Hoffmann
- Department of General, Visceral and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Christos Stravodimos
- Department of General and Visceral Surgery, Städtisches Klinikum, Karlsruhe, Germany
| | - Tanja Knoblich
- Department of General, Visceral and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Michael R Schön
- Department of General and Visceral Surgery, Städtisches Klinikum, Karlsruhe, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany.
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Fromer MW, Gaughan JP, Atabek UM, Spitz FR. Primary Malignancy is an Independent Determinant of Morbidity and Mortality after Liver Resection. Am Surg 2017. [DOI: 10.1177/000313481708300515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although outcomes after liver resection have improved, there remains considerable perioperative morbidity and mortality with these procedures. Studies suggest a primary liver cancer diagnosis is associated with poorer outcomes, but the extent to which this is attributable to a higher degree of hepatic dysfunction is unclear. To better delineate this, we performed a matched pair analysis of primary versus metastatic malignancies using a national database. The American College of Surgeons National Surgical Quality Improvement Program (2005–2013) was analyzed to select elective liver resections. Diagnoses were sorted as follows: 1) primary liver cancers and 2) metastatic neoplasms. A literature review identified factors known to impact hepatectomy outcomes; these variables were evaluated by a univariate analysis. The most predictive factors were used to create similar groups from each diagnosis category via propensity matching. Multivariate regression was used to validate results in the wider study population. Outcomes were compared using chi-squared test and Fisher exact test. Matched groups of 4838 patients were similar by all variables, including indicators of liver function. A number of major complications were significantly more prevalent with a primary diagnosis; overall major morbidity rates in the metastatic and primary groups were 29.3 versus 41.6 per cent, respectively. The mortality rate for primary neoplasms was 4.6 per cent (vs 1.6%); this represents a risk of death nearly three-times greater (95% confidence interval = 2.20–3.81, P < 0.0001) in cancers of hepatic origin. Hepatectomy carries substantially higher perioperative risk when performed for primary liver cancers, independent of hepatic function and resection extent. This knowledge will help to improve treatment planning, patient education, and resource allocation in oncologic liver resection.
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Affiliation(s)
- Marc W. Fromer
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - John P. Gaughan
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - Umur M. Atabek
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
| | - Francis R. Spitz
- Department of Surgery, Cooper University Hospital, Camden, New Jersey
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Ma KW, Cheung TT. Surgical resection of localized hepatocellular carcinoma: patient selection and special consideration. J Hepatocell Carcinoma 2016; 4:1-9. [PMID: 28097107 PMCID: PMC5207474 DOI: 10.2147/jhc.s96085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Localized hepatocellular carcinoma (HCC) refers to a solitary or few tumors located within either the left or right hemiliver without evidence of bilobar or extrahepatic spread. This term encompasses a heterogeneous morphology with no regard to stage of prognosis of the disease. Surgical resection remains the mainstay of curative treatment for the localized HCC. Various biochemical and radiological tests constitute an indispensible part of preoperative assessment. Emergence of laparoscopic hepatectomy has brought liver resection into a new era. Improved understanding of the pathophysiology of HCC allows more aggressive surgical resection without compromising outcomes. New insights into the management of special situations, such as ruptured HCC, pyogenic transformation of HCC, and HCC with portal vein tumor thrombus, rekindle the hopes of curative resection in these terminal events. Amalgamating salvage liver transplantation into the surgical management of resectable HCC has revolutionized the treatment paradigm of this deadly disease.
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Affiliation(s)
- Ka Wing Ma
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Fromer MW, Aloia TA, Gaughan JP, Atabek UM, Spitz FR. The utility of the MELD score in predicting mortality following liver resection for metastasis. Eur J Surg Oncol 2016; 42:1568-75. [PMID: 27365199 DOI: 10.1016/j.ejso.2016.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The MELD score has been demonstrated to be predictive of hepatectomy outcomes in mixed patient samples of primary and secondary liver cancers. Because MELD is a measure of hepatic dysfunction, prior conclusions may rely on the high prevalence of cirrhosis observed with primary lesions. This study aims to evaluate MELD score as a predictor of mortality and develop a risk prediction model for patients specifically undergoing hepatic metastasectomy. METHODS ACS-NSQIP 2005-2013 was analyzed to select patients who had undergone liver resections for metastases. A receiver operating characteristic (ROC) analysis determined the MELD score most associated with 30-day mortality. A literature review identified variables that impact hepatectomy outcomes. Significant factors were included in a multivariable analysis (MVA). A risk calculator was derived from the final multivariable model. RESULTS Among the 14,919 patients assessed, the mortality rate was 2.7%, and the median MELD was 7.3 (range = 34.4). A MELD of 7.24 was identified by ROC (sensitivity = 81%, specificity = 51%, c-statistic = 0.71). Of all patients above this threshold, 4.4% died at 30 days vs. 1.1% in the group ≤7.24. This faction represented 50.1% of the population but accounted for 80.3% of all deaths (p < 0.001). The MVA revealed mortality to be increased 2.6-times (OR = 2.55, 95%CI 1.69-3.84, p < 0.001). A risk calculator was successfully developed and validated. CONCLUSIONS MELD>7.24 is an important predictor of death following hepatectomy for metastasis and may prompt a detailed assessment with the provided risk calculator. Attention to MELD in the preoperative setting will improve treatment planning and patient education prior to oncologic liver resection.
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Affiliation(s)
- M W Fromer
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - T A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler, Unit 1484, Houston, TX, 77030, USA.
| | - J P Gaughan
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - U M Atabek
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
| | - F R Spitz
- Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ, 08103, USA.
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Patrizi A, Jezequel C, Sulpice L, Meunier B, Rayar M, Boudjema K. Disposable bipolar irrigated sealer (Aquamantys(®)) for liver resection: use with caution. Updates Surg 2016; 68:171-7. [PMID: 27193968 DOI: 10.1007/s13304-016-0367-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/14/2016] [Indexed: 01/15/2023]
Abstract
The disposable bipolar irrigated sealer has been demonstrated to reduce perioperative bleeding, but its role in preventing postoperative cut-surface complications has not been evaluated to date. A prospective observational study was performed between January and September 2013 to evaluate a disposable bipolar irrigated sealed (Aquamantys(®)) on a continuous series of 51 first liver resections without biliary reconstruction. Primary end-point was the occurrence of cut-surface complications during the postoperative period. Secondary endpoints were postoperative complications and the 1-year overall survival rate. The results were compared to a propensity score matched group of 153 liver resections performed with conventional monopolar cautery. A cut-surface complication occurred in 13/51 (25.5 %) resected patients. Bleeding, bile leakage and subphrenic abscess occurred in 7.8, 11.8 and 11.8 % patients, respectively. Compared to the matched group, the resected group had a higher rate of cut-surface complications (25.5 vs. 14.7 %, p < 0.01) and a higher rate of Clavien-Dindo type ≥3 postoperative complications (29.5 vs. 17.2 %, p < 0.01). In the multivariate analysis, preoperative chemotherapy (p = 0.03, 95 % CI 1.09-5.9, OR 2.53), blood transfusion (p = 0.02, 95 % CI 1.78-6.55, OR 2.78) and Aquamantys(®) use (p = 0.02, 95 % CI 1.21-6.7, OR 2.85) were independent of cut-surface complications within the first 90 postoperative days. The overall 1-year survival rates were not different between the two groups (p = 0.078). Aquamantys(®) use is associated with an increased rate of postoperative complications compared to classical monopolar cautery, and we recommend that it should be used with caution in this type of surgery.
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Affiliation(s)
- Andrea Patrizi
- Service de chirurgie hépatobiliaire et digestive, Hôpital Pontchaillou, Université de Rennes 1, Rennes, France.
| | - Caroline Jezequel
- Service des maladies du foie. Hôpital Pontchaillou, Université de Rennes 1, Rennes, France
| | - Laurent Sulpice
- Service de chirurgie hépatobiliaire et digestive, Hôpital Pontchaillou, Université de Rennes 1, Rennes, France
| | - Bernard Meunier
- Service de chirurgie hépatobiliaire et digestive, Hôpital Pontchaillou, Université de Rennes 1, Rennes, France.,Service des maladies du foie. Hôpital Pontchaillou, Université de Rennes 1, Rennes, France
| | - Michel Rayar
- Service de chirurgie hépatobiliaire et digestive, Hôpital Pontchaillou, Université de Rennes 1, Rennes, France
| | - Karim Boudjema
- Service de chirurgie hépatobiliaire et digestive, Hôpital Pontchaillou, Université de Rennes 1, Rennes, France
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Thirty-day mortality leads to underestimation of postoperative death after liver resection: A novel method to define the acute postoperative period. Surgery 2015; 158:1530-7. [PMID: 26298028 DOI: 10.1016/j.surg.2015.07.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/18/2015] [Accepted: 07/04/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative mortality commonly is defined as death occurring within 30 days of surgery or during hospitalization. After resection for liver malignancies, this definition may result in underreporting, because mortality caused by postoperative complications can be delayed as the result of improved critical care. The aim of this study was to estimate statistically the acute postoperative period (APP) after partial hepatectomy and to compare mortality within this phase to standard timestamps. METHODS From a prospective database, 784 patients undergoing resection for primary and secondary hepatic malignancies between 2003 and 2013 were reviewed. For estimation of APP, a novel statistical method applying tests for a constant postoperative hazard was implemented. Multivariable mortality analysis was performed. RESULTS The APP was determined to last for 80 postoperative days (95% confidence interval 40-100 days). Within this period, 55 patients died (7.0%; 80-day mortality). In comparison, 30-day mortality (N = 32, 4.0%) and in-hospital death (N = 39, 5.0%) were relevantly less. No patient died between postoperative days 80 and 90. The causes of mortality within 30 days and from days 30-80 did not greatly differ, especially regarding posthepatectomy liver failure (44% vs 39%, P = .787). Septic complications, however, tended to cause late deaths more frequently (43% vs 25%, P = .255). Comorbidities (Charlson comorbidity index ≥ 3; P = .046), increased preoperative alanine aminotransferase activity (P = .030), and major liver resection (P = .035) were independent risk factors of 80-day mortality. CONCLUSION After liver resection for primary and secondary malignancies, 90-day rather than 30-day or in-hospital mortality should be used to avoid underreporting of deaths.
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Ulyett S, Wiggans MG, Bowles MJ, Aroori S, Briggs CD, Erasmus P, Minto G, Stell DA. Clinical assessment before hepatectomy identifies high-risk patients. J Surg Res 2015; 198:87-92. [PMID: 26095422 DOI: 10.1016/j.jss.2015.05.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/14/2015] [Accepted: 05/22/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Liver resection is associated with significant morbidity, and assessment of risk is an important part of preoperative consultations. Objective methods exist to assess operative risk, including cardiopulmonary exercise testing (CPX). Subjective assessment is also made in clinic, and patients perceived to be high-risk are referred for CPX at our institution. This article addresses clinicians' ability to identify patients with a higher risk of surgical complications after hepatectomy, using selection for CPX as a surrogate marker for increased operative risk. MATERIALS AND METHODS Prospectively collected data on patients undergoing hepatectomy between February 2008 and November 2013 were retrieved and the cohort divided according to CPX referral. Complications were classified using the Clavien-Dindo system. RESULTS CPX testing was carried out before 101 of 405 liver resections during the study period. The median age was 72 and 64 in CPX and non-CPX groups, respectively (P < 0.001). The resection size was similar between the groups. No difference was noted for grade III complications between CPX and non-CPX tested-groups; however, 19 (18.8%) and 28 (9.2%) patients suffered grade IV-V complications, respectively (P = 0.009). There was no difference in long-term survival between groups (P = 0.63). CONCLUSIONS This study attempts to assess clinicians' ability to identify patients at greater risk of complications after hepatectomy. The confirmation that patients identified in this way are at greater risk of grade IV-V complications demonstrates the value of preoperative counseling. High-risk patients do not have worse long-term outcomes suggesting survival is determined by other factors, particularly disease recurrence.
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Affiliation(s)
- Simon Ulyett
- South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom; Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom.
| | | | - Matthew J Bowles
- South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom
| | - Somaiah Aroori
- South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom
| | | | - Paul Erasmus
- South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom
| | - Gary Minto
- South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom
| | - David A Stell
- South-West Liver Unit, Derriford Hospital, Plymouth, United Kingdom; Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom
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