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Di Martino M, Nicolazzi M, Baroffio P, Polidoro MA, Colombo Mainini C, Pocorobba A, Bottini E, Donadon M. A critical analysis of surgical outcomes indicators in hepato-pancreato-biliary surgery: From crude mortality to composite outcomes. World J Surg 2024. [PMID: 39129054 DOI: 10.1002/wjs.12277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/24/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Indicators of surgical outcomes are designed to objectively evaluate surgical performance, enabling comparisons among surgeons and institutions. In recent years, there has been a surge in complex indicators of perioperative short-term and long-term outcomes. The aim of this narrative review is to provide an overview and a critical analysis of surgical outcomes indicators, with a special emphasis on hepato-pancreato-biliary (HPB) surgery. METHODS A narrative review of outcome measures was conducted using a combined text and MeSH search strategy to identify relevant articles focused on perioperative outcomes, specifically within HPB surgery. RESULTS The literature search yielded 624 records, and 94 studies were included in the analysis. Included papers were classified depending on whether they assessed intraoperative or postoperative specific or composite outcomes, and whether they assessed purely clinical or combined clinical and socio-economic indicators. Specific indicators included in composite outcomes were categorized into three main domains: intraoperative metrics, postoperative outcomes, and oncological outcomes. While postoperative mortality, complications, hospital stay and readmission were the indicators most frequently included in composite outcomes, oncological outcomes were rarely considered. CONCLUSIONS The evolution of surgical outcomes has shifted from the simplistic assessment of crude mortality rates to complex composite outcomes. Whether the recent explosion of publications on these topics has a clinical impact in real life is questionable. Outcomes from the patient perspective, integrating social and financial indicators, are not yet integrated into most of these composite analytical tools but should not be underestimated.
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Affiliation(s)
- Marcello Di Martino
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
- Department of Surgery, University Maggiore Hospital della Carità, Novara, Italy
| | - Marco Nicolazzi
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
- Department of Surgery, University Maggiore Hospital della Carità, Novara, Italy
| | - Paolo Baroffio
- Department of Surgery, University Maggiore Hospital della Carità, Novara, Italy
| | - Michela Anna Polidoro
- Hepatobiliary Immunopathology Laboratory, IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Amanda Pocorobba
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Eleonora Bottini
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Matteo Donadon
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
- Department of Surgery, University Maggiore Hospital della Carità, Novara, Italy
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2
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Nicolazzi M, Di Martino M, Baroffio P, Donadon M. 6,126 hepatectomies in 2022: current trend of outcome in Italy. Langenbecks Arch Surg 2024; 409:211. [PMID: 38985363 PMCID: PMC11236879 DOI: 10.1007/s00423-024-03398-6] [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: 01/19/2024] [Accepted: 06/26/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE Whether hospital volume affects outcome of patients undergoing hepatobiliary surgery, and whether the centralization of such procedures is justified remains to be investigated. The aim of this study was to analyze the outcome of liver surgery in Italy in relationship of hospital volume. METHODS This is a nationwide retrospective observational study conducted on data collected by the National Italian Registry "Piano Nazionale Esiti" (PNE) 2023 that included all liver procedures performed in 2022. Outcome measure were case volume and 30-day mortality. Hospitals were classified as very high-volume (H-Vol), intermediate-volume (I-Vol), low-volume (L-Vol) and very low-volume (VL-VoL). A review on centralization process and outcome measures was added. RESULTS 6,126 liver resections for liver tumors were performed in 327 hospitals in 2022. The 30-day mortality was 2.2%. There were 14 H-Vol, 19 I-Vol, 31 L-Vol and 263 VL-Vol hospitals with 30-day mortality of 1.7%, 2.2%, 2.6% and 3.6% respectively (P < 0.001); 220 centers (83%) performed less than 10 resections, and 78 (29%) centers only 1 resection in 2022. By considering the geographical macro-areas, the median count of liver resection performed in northern Italy exceeded those in central and southern Italy (57% vs. 23% vs. 20%, respectively). CONCLUSIONS High-volume has been confirmed to be associated to better outcome after hepatobiliary surgical procedures. Further studies are required to detail the factors associated with mortality. The centralization process should be redesigned and oversight.
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Affiliation(s)
- Marco Nicolazzi
- Department of Health Sciences, University of Piemonte Orientale, Novara, 28100, Italy
- Department of Surgery, University Maggiore Hospital della Carità, Corso Mazzini 18, Novara, 28100, Italy
| | - Marcello Di Martino
- Department of Health Sciences, University of Piemonte Orientale, Novara, 28100, Italy
- Department of Surgery, University Maggiore Hospital della Carità, Corso Mazzini 18, Novara, 28100, Italy
| | - Paolo Baroffio
- Department of Surgery, University Maggiore Hospital della Carità, Corso Mazzini 18, Novara, 28100, Italy
| | - Matteo Donadon
- Department of Health Sciences, University of Piemonte Orientale, Novara, 28100, Italy.
- Department of Surgery, University Maggiore Hospital della Carità, Corso Mazzini 18, Novara, 28100, Italy.
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Koh YX, Zhao Y, Tan IEH, Tan HL, Chua DW, Loh WL, Tan EK, Teo JY, Au MKH, Goh BKP. Comparative cost-effectiveness of open, laparoscopic, and robotic liver resection: A systematic review and network meta-analysis. Surgery 2024; 176:11-23. [PMID: 38782702 DOI: 10.1016/j.surg.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/25/2024] [Accepted: 04/11/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND This study evaluated the cost-effectiveness of open, laparoscopic, and robotic liver resection. METHODS A comprehensive literature review and Bayesian network meta-analysis were conducted. Surface under cumulative ranking area values, mean difference, odds ratio, and 95% credible intervals were calculated for all outcomes. Cluster analysis was performed to determine the most cost-effective clustering approach. Costs-morbidity, costs-mortality, and costs-efficacy were the primary outcomes assessed, with postoperative overall morbidity, mortality, and length of stay associated with total costs for open, laparoscopic, and robotic liver resection. RESULTS Laparoscopic liver resection incurred the lowest total costs (laparoscopic liver resection versus open liver resection: mean difference -2,529.84, 95% credible intervals -4,192.69 to -884.83; laparoscopic liver resection versus robotic liver resection: mean difference -3,363.37, 95% credible intervals -5,629.24 to -1,119.38). Open liver resection had the lowest procedural costs but incurred the highest hospitalization costs compared to laparoscopic liver resection and robotic liver resection. Conversely, robotic liver resection had the highest total and procedural costs but the lowest hospitalization costs. Robotic liver resection and laparoscopic liver resection had a significantly reduced length of stay than open liver resection and showed less postoperative morbidity. Laparoscopic liver resection resulted in the lowest readmission and liver-specific complication rates. Laparoscopic liver resection and robotic liver resection demonstrated advantages in costs-morbidity efficiency. While robotic liver resection offered notable benefits in mortality and length of stay, these were balanced against its highest total costs, presenting a nuanced trade-off in the costs-mortality and costs-efficacy analyses. CONCLUSION Laparoscopic liver resection represents a more cost-effective option for hepatectomy with superior postoperative outcomes and shorter length of stay than open liver resection. Robotic liver resection, though costlier than laparoscopic liver resection, along with laparoscopic liver resection, consistently exceeds open liver resection in surgical performance.
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Affiliation(s)
- Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore.
| | - Yun Zhao
- Group Finance Analytics, Singapore Health Services, Singapore
| | | | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Darren Weiquan Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Wei-Liang Loh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Marianne Kit Har Au
- Group Finance Analytics, Singapore Health Services, Singapore; Finance, SingHealth Community Hospitals, Singapore; Finance, Regional Health System & Strategic Finance, Singapore Health Services, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, SingHealth Duke-National University of Singapore Transplant Centre, Singapore
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4
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Alaimo L, Endo Y, Catalano G, Ruzzenente A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Cauchy F, Koerkamp BG, Endo I, Kitago M, Pawlik TM. Benchmarks in Liver Resection for Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2024; 31:3043-3052. [PMID: 38214817 PMCID: PMC10997542 DOI: 10.1245/s10434-023-14880-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/21/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Benchmarking in surgery has been proposed as a means to compare results across institutions to establish best practices. We sought to define benchmark values for hepatectomy for intrahepatic cholangiocarcinoma (ICC) across an international population. METHODS Patients who underwent liver resection for ICC between 1990 and 2020 were identified from an international database, including 14 Eastern and Western institutions. Patients operated on at high-volume centers who had no preoperative jaundice, ASA class <3, body mass index <35 km/m2, without need for bile duct or vascular resection were chosen as the benchmark group. RESULTS Among 1193 patients who underwent curative-intent hepatectomy for ICC, 600 (50.3%) were included in the benchmark group. Among benchmark patients, median age was 58.0 years (interquartile range [IQR] 49.0-67.0), only 28 (4.7%) patients received neoadjuvant therapy, and most patients had a minor resection (n = 499, 83.2%). Benchmark values included ≥3 lymph nodes retrieved when lymphadenectomy was performed, blood loss ≤600 mL, perioperative blood transfusion rate ≤42.9%, and operative time ≤339 min. The postoperative benchmark values included TOO achievement ≥59.3%, positive resection margin ≤27.5%, 30-day readmission ≤3.6%, Clavien-Dindo III or more complications ≤14.3%, and 90-day mortality ≤4.8%, as well as hospital stay ≤14 days. CONCLUSIONS Benchmark cutoffs targeting short-term perioperative outcomes can help to facilitate comparisons across hospitals performing liver resection for ICC, assess inter-institutional variation, and identify the highest-performing centers to improve surgical and oncologic outcomes.
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Affiliation(s)
- Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Department of Surgery, University of Verona, Verona, Italy
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - François Cauchy
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Lopez-Lopez V, Morise Z, Albaladejo-González M, Gavara CG, Goh BKP, Koh YX, Paul SJ, Hilal MA, Mishima K, Krürger JAP, Herman P, Cerezuela A, Brusadin R, Kaizu T, Lujan J, Rotellar F, Monden K, Dalmau M, Gotohda N, Kudo M, Kanazawa A, Kato Y, Nitta H, Amano S, Valle RD, Giuffrida M, Ueno M, Otsuka Y, Asano D, Tanabe M, Itano O, Minagawa T, Eshmuminov D, Herrero I, Ramírez P, Ruipérez-Valiente JA, Robles-Campos R, Wakabayashi G. Explainable artificial intelligence prediction-based model in laparoscopic liver surgery for segments 7 and 8: an international multicenter study. Surg Endosc 2024; 38:2411-2422. [PMID: 38315197 PMCID: PMC11078826 DOI: 10.1007/s00464-024-10681-6] [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: 08/07/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Artificial intelligence (AI) is becoming more useful as a decision-making and outcomes predictor tool. We have developed AI models to predict surgical complexity and the postoperative course in laparoscopic liver surgery for segments 7 and 8. METHODS We included patients with lesions located in segments 7 and 8 operated by minimally invasive liver surgery from an international multi-institutional database. We have employed AI models to predict surgical complexity and postoperative outcomes. Furthermore, we have applied SHapley Additive exPlanations (SHAP) to make the AI models interpretable. Finally, we analyzed the surgeries not converted to open versus those converted to open. RESULTS Overall, 585 patients and 22 variables were included. Multi-layer Perceptron (MLP) showed the highest performance for predicting surgery complexity and Random Forest (RF) for predicting postoperative outcomes. SHAP detected that MLP and RF gave the highest relevance to the variables "resection type" and "largest tumor size" for predicting surgery complexity and postoperative outcomes. In addition, we explored between surgeries converted to open and non-converted, finding statistically significant differences in the variables "tumor location," "blood loss," "complications," and "operation time." CONCLUSION We have observed how the application of SHAP allows us to understand the predictions of AI models in surgical complexity and the postoperative outcomes of laparoscopic liver surgery in segments 7 and 8.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Zeniche Morise
- Department of Surgery, Fujita Health University School of Medicine Okazaki Medical Center, Okazaki, Aichi, Japan
| | | | - Concepción Gomez Gavara
- Department of HPB Surgery and Transplants, Vall d'Hebron University Hospital, Barcelona Autonomic University, Barcelona, Spain
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore
- Surgery Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore
- Surgery Academic Clinical Programme, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Sijberden Jasper Paul
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kohei Mishima
- Department of Surgery, Ageo Central General Hospital, Ageo, Japan
| | - Jaime Arthur Pirola Krürger
- Serviço de Cirurgia do Fígado, Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Serviço de Cirurgia do Fígado, Divisão de Cirurgia do Aparelho Digestivo, Departamento de Gastroenterologia, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Alvaro Cerezuela
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Roberto Brusadin
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Takashi Kaizu
- Department of General, Pediatric and Hepatobiliary-Pancreatic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Juan Lujan
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
- Department of General Surgery, School of Medicine, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Fernando Rotellar
- Department of General Surgery, School of Medicine, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, Hiroshima, Japan
| | - Mar Dalmau
- Department of HPB Surgery and Transplants, Vall d'Hebron University Hospital, Barcelona Autonomic University, Barcelona, Spain
| | - Naoto Gotohda
- Department of Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masashi Kudo
- Department of Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Akishige Kanazawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Yutaro Kato
- Department of Surgery, Fujita Health University, Toyoake, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Iwate, Japan
| | - Satoshi Amano
- Department of Surgery, Iwate Medical University, Iwate, Japan
| | | | - Mario Giuffrida
- General Surgery Unit, Parma University Hospital, Parma, Italy
| | - Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, Japan
| | | | - Daisuke Asano
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Osamu Itano
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Takuya Minagawa
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Irene Herrero
- Department of Surgery, Getafe University Hospital, Madrid, Spain
| | - Pablo Ramírez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | | | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Ageo, Japan
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Laroche S, Lim C, Goumard C, Rayar M, Cherqui D, Chiche L, Barbier L, Salamé E, Mabrut JY, Lesurtel M, Truant S, Boleslawski E, Muscari F, Hobeika C, Chirica M, Buc E, Hardwigsen J, Herrero A, Navarro F, Faitot F, Bachellier P, Regimbeau JM, Laurent A, Fuks D, Soubrane O, Azoulay D, Vibert E, Scatton O. Comparing indications, complexity and outcomes of laparoscopic liver resection between centers with and without a liver transplant program: a French nationwide study. HPB (Oxford) 2024; 26:586-593. [PMID: 38341287 DOI: 10.1016/j.hpb.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND There are no data to evaluate the difference in populations and impact of centers with liver transplant programs in performing laparoscopic liver resection (LLR). METHODS This was a multicenter study including patients undergoing LLR for benign and malignant tumors at 27 French centers from 1996 to 2018. The main outcomes were postoperative severe morbidity and mortality. RESULTS A total of 3154 patients were included, and 14 centers were classified as transplant centers (N = 2167 patients, 68.7 %). The transplant centers performed more difficult LLRs and more resections for hepatocellular carcinoma (HCC) in patients who more frequently had cirrhosis. A higher rate of performing the Pringle maneuver, a lower rate of blood loss and a higher rate of open conversion (all p < 0.05) were observed in the transplant centers. There was no association between the presence of a liver transplant program and either postoperative severe morbidity (<10 % in each group; p = 0.228) or mortality (1 % in each group; p = 0.915). CONCLUSIONS Most HCCs, difficult LLRs, and cirrhotic patients are treated in transplant centers. We show that all centers can achieve comparable safety and quality of care in LLR independent of the presence of a liver transplant program.
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Affiliation(s)
- Sophie Laroche
- Sorbonne University, Paris, France; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Chetana Lim
- Sorbonne University, Paris, France; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Research Unit, Université de Picardie-Jules Verne, UR UPJV 7518 SSPC, Amiens, France
| | - Claire Goumard
- Sorbonne University, Paris, France; Centre de Recherche de Saint-Antoine (CRSA), INSERM, UMRS-938, Paris, France
| | - Michel Rayar
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Claude Huriez Hospital, Rennes, France
| | - Daniel Cherqui
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France
| | - Laurence Chiche
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Bordeaux University Hospital-Magellan Centre, Bordeaux, France
| | - Louise Barbier
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Bordeaux University Hospital-Magellan Centre, Bordeaux, France
| | - Ephrem Salamé
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Trousseau Hospital, Tours Regional University Hospital, Tours, France
| | - Jean-Yves Mabrut
- Department of Hepatopancreato-Biliary Surgery and Liver Transplantation, La Croix Rousse Hospital, Lyon, France
| | - Mickael Lesurtel
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Beaujon Hospital, Clichy, France
| | - Stéphanie Truant
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Beaujon Hospital, Clichy, France
| | - Emmanuel Boleslawski
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Claude Huriez Hospital, Lille, France
| | - Fabrice Muscari
- Department of Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Rangueil Hospital, Toulouse, France
| | - Christian Hobeika
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Beaujon Hospital, Clichy, France
| | - Mircea Chirica
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Grenoble Alpes Hospital, Grenoble, France
| | - Emmanuel Buc
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Estaing Hospital, Clermont-Ferrand, France
| | - Jean Hardwigsen
- Department of Hepatopancreato-Biliary Surgery and Liver Transplantation, La Timone Hospital, Marseille, France
| | - Astrid Herrero
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Saint-Eloi Hospital, Montpellier, France
| | - Francis Navarro
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Saint-Eloi Hospital, Montpellier, France
| | - François Faitot
- Department of Hepatopancreato-Biliary Surgery and Liver Transplantation, Hautepierre Hospital, Strasbourg, France
| | - Philippe Bachellier
- Department of Hepatopancreato-Biliary Surgery and Liver Transplantation, Hautepierre Hospital, Strasbourg, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Amiens, France; Research Unit, Université de Picardie-Jules Verne, UR UPJV 7518 SSPC, Amiens, France
| | - Alexis Laurent
- Department of Hepato-Pancreato-Biliary Surgery, APHP Henri Mondor Hospital, Creteil, France
| | - David Fuks
- Department of Hepato-Pancreato-Biliary Surgery, APHP Cochin Hospital, Paris, France
| | - Olivier Soubrane
- Sorbonne University, Paris, France; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris France
| | - Daniel Azoulay
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France
| | - Eric Vibert
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Paul Brousse Hospital, Villejuif, France
| | - Olivier Scatton
- Sorbonne University, Paris, France; Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Centre de Recherche de Saint-Antoine (CRSA), INSERM, UMRS-938, Paris, France.
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7
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Linn YL, Chong Y, Tan EK, Koh YX, Cheow PC, Chung AYF, Chan CY, Jeyaraj PR, Goh BKP. Early experience with pure laparoscopic donor hepatectomy: comparison with open donor hepatectomy and non-donor laparoscopic hepatectomy. ANZ J Surg 2024; 94:515-521. [PMID: 37069484 DOI: 10.1111/ans.18464] [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: 12/03/2022] [Revised: 03/18/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Pure laparoscopic donor hepatectomy (L-DH) has seen a rise in uptake in recent years following the popularization of minimally invasive modality for major hepatobiliary surgery. Our study aimed to determine the safety and compare the perioperative outcomes of L-DH with open donor hepatectomy (O-DH) and laparoscopic non donor hepatectomy (L-NDH) based on our single institution experience. METHODS Eighty of 113 laparoscopic hemi-hepatectomies performed between 2015 and 2022 met study inclusion criteria. Of these, 11 were L-DH. PSM in a 1:2 ratio of L-DH versus L-NDH and 1:1 ratio of L-DH versus O-DH were performed, identifying patients with similar baseline clinicopathological characteristics. RESULTS After 2:1 matching, the L-DH cohort were significantly younger (P < 0.001) and had lower ASA scores (P < 0.001) than the L-NDH cohort. L-DH was associated with a longer median operating time (P < 0.001) and shorter median postoperative stay (P < 0.001) than L-NDH. After 1:1 matching, there were no significant differences in baseline demographic between the L-DH and O-DH cohorts. L-DH was associated with lower median blood loss (P = 0.040) and shorter length of stay compared to O-DH (P = 0.004). There were no significant differences in recipient outcomes for both cohorts. CONCLUSION L-DH can be adopted safely by surgeons experienced in L-NDH and ODH. It is associated with decreased blood loss and shorter length of stay compared to O-DH.
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Affiliation(s)
- Yun Le Linn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
| | - Yvette Chong
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
| | - Ek-Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
- Academic Clinical Program of Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
- Liver Transplant Service, Singhealth Duke-National University of Singapore Transplant Center, Singapore
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8
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Kitano Y, Inoue Y, Sato Y, Oba A, Ono Y, Sato T, Ito H, Matsueda K, Baba H, Takahashi Y. Management of potential portal vein thrombus during laparoscopic right hemihepatectomy following portal vein embolization. Langenbecks Arch Surg 2024; 409:56. [PMID: 38332380 DOI: 10.1007/s00423-024-03250-x] [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: 06/23/2023] [Accepted: 02/01/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Portal vein embolization (PVE) is often performed prior to right hemihepatectomy (RH) to increase the future liver remnants. However, intraoperative removal of portal vein thrombus (PVT) is occasionally required. An algorithm for treating the right branch of the PV using laparoscopic RH (LRH) after PVE is lacking and requires further investigation. METHODS In our department, after the confirmation of a lack of extension of PVT to the main portal trunk or left branch on preoperative examination (ultrasound and contrast-enhanced computed tomography), a final evaluation was performed using intraoperative ultrasonography (IOUS). Here we present the cases of eight patients who underwent LRH after PVE and examine the safety of our treatment strategies. RESULTS IOUS revealed PVT extension into the main portal trunk in two cases. For the other six patients without PVT extension, we continued the laparoscopic procedure. In contrast, in the two cases with PVT extension, we converted to laparotomy after hepatic transection and removed the PVT. The median operation time for hepatectomy was 562 min (421-659 min), the median blood loss was 293 mL (85-1010 mL), no liver-related postoperative complications were observed, and the median length of stay was 10 days (6-34 days). CONCLUSIONS PVT evaluation and removal are important in cases of LRH after PVE. Our strategy is safe and IOUS is particularly useful for laparoscopically evaluating PVT extension.
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Affiliation(s)
- Yuki Kitano
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Yozo Sato
- Department of Diagnostic Imaging, Japanese Foundation for Cancer Research, Cancer Institute Hospital, Ariake, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Japanese Foundation for Cancer Research, Cancer Institute Hospital, Ariake, Tokyo, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Japanese Foundation for Cancer Research, Cancer Institute Hospital, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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9
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Fermi F, Ratti F, Stepanyan P, Corallino D, Ingallinella S, Reineke R, Beretta L, Aldrighetti L. Navigator nurse implementation within a fast track program of liver resections: How to improve the healthcare service and perioperative results. World J Surg 2024; 48:193-202. [PMID: 38526497 DOI: 10.1002/wjs.12026] [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: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 03/26/2024]
Abstract
BACKGROUND The introduction into the clinical practice of the navigator nurse (NaNu) to address the task of counseling and short term follow-up help the effective implementation of the fast track protocol. The aim of the present study was to investigate the impact of the standardization of the NaNu's role in patients undergoing liver surgery. METHODS Patients undergoing elective liver surgery for all diagnosis and approach, from 2015, received counseling and postoperative follow-up by NaNu and constituted the study group (n = 890). This group was compared with the control group (n = 712) including patients treated in the era before the implementation of the NaNu role (2011-2014). Outcome was evaluated in terms of discrepancy between functional recovery and discharge, number of ER accesses, number of readmissions. RESULTS Preoperative characteristics of patients and disease, as well as type of resection and postoperative outcomes were similar between the two groups. The proportion of laparoscopic cases was higher in the study group (51.2% vs. 32% in the control). Time for discharge, interval between functional recovery and discharge, number of ER accesses and number of readmissions were reduced in the study group. Benign diagnosis, absence of complications, laparoscopic approach and presence of NaNu were independent predictors of shorter length of stay. The positive effect of NaNu's activation was recorded in patients with complications and undergoing open surgery. CONCLUSION The implementation of NaNu's role has allowed to us optimize the level of healthcare service offered to patients. The wider benefit was offered in the setting of complex patients.
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Affiliation(s)
- Francesca Fermi
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | | | - Diletta Corallino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Sara Ingallinella
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Raffaella Reineke
- Anaesthesiology and Intensive Care Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luigi Beretta
- Anaesthesiology and Intensive Care Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
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10
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Hołówko W, Serednicki W, Bartkowiak M, Wysocki M, Domurat M, Mielko J, Pierściński S, Hogendorf P, Masior Ł, Kalinowski P, Wierdak M, Frączek M, Tarasik A, Wróblewski T, Budzyński A, Pędziwiatr M, Grąt M. Early adoption of laparoscopic liver surgery in Poland: a national retrospective cohort study. Int J Surg 2024; 110:361-371. [PMID: 37816169 PMCID: PMC10793755 DOI: 10.1097/js9.0000000000000840] [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: 07/26/2023] [Accepted: 09/29/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND The need for safe and efficient dissemination of minimally invasive approach in liver surgery is among the current challenges for hepatobiliary surgeons. After the stage of innovators and pioneers, the following countries should adopt a laparoscopic approach. The aim of this study was to assess the national experience and trend in implementing laparoscopic liver resection (LLR) in Poland. MATERIALS AND METHODS A national registry of LLR performed in Poland was established in June 2020. All LLR cases performed before were included retrospectively, followed by prospectively collected new cases. Baseline characteristics, preoperative and intraoperative data, short-term results and long-term follow-up were recorded. RESULTS Since 2010 up to the end of 2022 there were 718 LLRs performed in Poland. The national rate of laparoscopic approach has gradually increased since 2017 ( P <0.001), reaching the rate of 11.7% in 2022. There were 443 (61.7%), 107 (14.9%), and 168 (23.4%) LLRs performed in accordance to increasing grades of difficulty. The move towards more demanding cases had an increasing trend over the years ( P <0.001). Total intraoperative adverse event and postoperative severe complications rates were estimated for 13.5% ( n =97) and 6.7% ( n =48), respectively. 30-day reoperation, readmission and postoperative mortality rates were 3.6% ( n =26), 2.8% ( n =20), and 0.8% ( n =6), respectively. While the R0 resection margin was assessed in 643 (89.6%) cases, the total textbook outcomes (TO) were achieved in 525 (74.5%) cases. Overcoming the learning curve of 60 LLRs, resulted in an increasing TO rate from 72.3 to 80.6% ( P =0.024). CONCLUSIONS It is the first national analysis of a laparoscopic approach in liver surgery in Poland. An increasing trend of minimizing invasiveness in liver resection has been observed. Responsible selection of cases in accordance with difficulty may provide results within global benchmark values and textbook outcomes already during the learning curve.
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Affiliation(s)
| | - Wojciech Serednicki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow
| | | | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital
| | - Marian Domurat
- Department of Oncological Surgery, Regional Oncological Center, Białystok, Poland
| | - Jerzy Mielko
- Department of Surgical Oncology, Medical University of Lublin, Lublin
| | - Stanisław Pierściński
- Department of General and Endocrine Surgery, Nicolaus Copernicus University Collegium Medicum, Bydgoszcz
| | - Piotr Hogendorf
- Department of General and Transplant Surgery, Medical University of Łódź, Barlicki Teaching Hospital, Łódź
| | - Łukasz Masior
- Department of General Transplant and Liver Surgery
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw
| | | | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow
| | - Mariusz Frączek
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw
| | - Aleksander Tarasik
- Department of Oncological Surgery, Regional Oncological Center, Białystok, Poland
| | | | - Andrzej Budzyński
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow
| | - Michał Grąt
- Department of General Transplant and Liver Surgery
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11
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Alaimo L, Moazzam Z, Lima HA, Endo Y, Ruzzenente A, Guglielmi A, Ratti F, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Popescu I, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Cauchy F, Koerkamp BG, Endo I, Kitago M, Aucejo F, Sasaki K, Fields RC, Hugh T, Lam V, Pawlik TM. An attempt to establish and apply global benchmarks for liver resection of malignant hepatic tumors. Surgery 2023; 174:1384-1392. [PMID: 37741777 DOI: 10.1016/j.surg.2023.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/02/2023] [Accepted: 08/16/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Benchmarking is a process of continuous self-evaluation and comparison with best-in-class hospitals to guide quality improvement initiatives. We sought to define global benchmarks relative to liver resection for malignancy and to assess their achievement in hospitals in the United States. METHODS Patients who underwent curative-intent liver resection for hepatocellular carcinoma, intrahepatic cholangiocarcinoma, or colorectal or neuroendocrine liver metastases between 2000 and 2019 were identified from an international multi-institutional database. Propensity score matching was conducted to balance baseline characteristics between open and minimally invasive approaches. Best-in-class hospitals were defined relative to the achievement rate of textbook oncologic outcomes and case volume. Benchmark values were established relative to best-in-class institutions. The achievement of benchmark values among hospitals in the National Cancer Database was then assessed. RESULTS Among 2,624 patients treated at 20 centers, a majority underwent liver resection for hepatocellular carcinoma (n = 1,609, 61.3%), followed by colorectal liver metastases (n = 650, 24.8%), intrahepatic cholangiocarcinoma (n = 299, 11.4%), and neuroendocrine liver metastases (n = 66, 2.5%). Notably, 1,947 (74.2%) patients achieved a textbook oncologic outcome. After propensity score matching, 6 best-in-class hospitals with the highest textbook oncologic outcome rates (≥75.0%) were identified. Benchmark values were calculated for margin positivity (≤11.7%), 30-day readmission (≤4.1%), 30-day mortality (≤1.6%), minor postoperative complications (≤24.7%), severe complications (≤12.4%), and failure to achieve the textbook oncologic outcome (≤22.8%). Among the National Cancer Database hospitals, global benchmarks for margin positivity, 30-day readmission, 30-day mortality, severe complications, and textbook oncologic outcome failure were achieved in 62.9%, 27.1%, 12.1%, 7.1%, and 29.3% of centers, respectively. CONCLUSION These global benchmarks may help identify hospitals that may benefit from quality improvement initiatives, aiming to improve patient safety and surgical oncologic outcomes.
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Affiliation(s)
- Laura Alaimo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; Department of Surgery, University of Verona, Italy
| | - Zorays Moazzam
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Henrique A Lima
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | | | | | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, University of Sydney, NSW, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - François Cauchy
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Federico Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, OH
| | | | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tom Hugh
- Department of Surgery, School of Medicine, University of Sydney, NSW, Australia
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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12
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Choi WJ, Babakhani S, Claasen MPAW, Castelo M, Bucur R, Gaviria F, Jones O, Shwaartz C, McCluskey SA, McGilvray I, Gallinger S, Moulton CA, Reichman T, Cleary S, Sapisochin G. Performance evaluation of a North American center using the established global benchmark for laparoscopic liver resections: A retrospective study. Surgery 2023; 174:1393-1400. [PMID: 37863687 DOI: 10.1016/j.surg.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/07/2023] [Accepted: 09/05/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND The global benchmark cut-offs were set for laparoscopic liver resection procedures: left lateral sectionectomy, left hepatectomy, and right hepatectomy. We aimed to compare the performance of our North American center with the established global benchmarks. METHODS This is a single-center study of adults who underwent laparoscopic liver resection between 2010 to 2022 at the Toronto General Hospital. Fourteen benchmarking outcomes were assessed: operation time, intraoperative blood transfusion, estimated blood loss, blood loss ≥500 mL, blood loss ≥1000mL, open-conversion, postoperative length of stay, return to operation, postoperative morbidity, postoperative major-morbidity, 30-day mortality, 90-day mortality, R1 resection, and failure to rescue. Low-risk benchmark cases were defined as follows: patients aged 18 to 70 years, American Society of Anesthesiologist score ≤ 2, tumor size <10 cm, and Child-Pugh score ≤A. Cases involving bilio-enteric anastomosis, hilar dissection, or concomitant major procedures were excluded from the low-risk category. Cases that did not meet the criteria for low-risk selection were considered high-risk cases. RESULTS A total of 178 laparoscopic liver resection cases were analyzed (109 left lateral sectionectomies, 45 left hepatectomies, 24 right hepatectomies). Forty-four (25%) cases qualified as low-risk cases (23 left lateral sectionectomies, 16 left hepatectomies, 5 right hepatectomies). The postoperative major morbidity and 90-day mortality after left lateral sectionectomy, left hepatectomy, and right hepatectomy for the low-risk cases were 0%, 0%, and 0%, and 0%, 0%, and 0%, respectively. For the high-risk cases post-2017, the outcomes in the same order were 0%, 0%, and 12%; 0%, 0%, and 0%, respectively. For the high-risk cases operated pre2017, the outcomes in the same order were 9%∗, 16%∗, and 18%; 2%∗, 0%, and 9%∗ (asterisks indicate not meeting the global cut-off), respectively. CONCLUSION A North American center was able to achieve outcomes comparable to the established global benchmark for laparoscopic liver resection.
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Affiliation(s)
- Woo Jin Choi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/WJChoiMD
| | - Shiva Babakhani
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Marco P A W Claasen
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada; Department of Surgery, division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Matthew Castelo
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Roxana Bucur
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Felipe Gaviria
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Owen Jones
- University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Chaya Shwaartz
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Stuart A McCluskey
- Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian McGilvray
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Steven Gallinger
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Carol-Anne Moulton
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Trevor Reichman
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada
| | - Sean Cleary
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN
| | - Gonzalo Sapisochin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada.
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13
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Tripke V, Sommer N. An update on liver surgery - a new terminology and modern techniques. Innov Surg Sci 2023; 8:197-201. [PMID: 38510365 PMCID: PMC10949114 DOI: 10.1515/iss-2023-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 12/08/2023] [Indexed: 03/22/2024] Open
Abstract
Liver surgery is the cornerstone of the curative treatment of malignant liver tumors. However, the liver anatomy is very complex, and liver surgery is still associated with relevant morbidity despite many technical advances. The Brisbane nomenclature is used worldwide to classify liver resection. However, this nomenclature has several limitations as multiple terms are used for the same type of resection. Non-anatomical resections, multiple resections, and combined bilio-vascular resections were not mentioned. Therefore, new terminologies have been proposed for the precise and simple classification of liver resection. Furthermore, in recent years, many technical innovations have been introduced in liver surgery, such as 3D imaging systems and indocyanine green fluorescence, for better preoperative and intraoperative identification of tumor localization and critical vascular structures. Minimally invasive techniques are used more frequently in liver surgery. Potential benefits include less intraoperative blood loss, less pain, and a shorter hospital stay. The implementation of robotic systems also has an impact on liver surgery, and the number of cases reported in the literature is constantly increasing. The potential benefits of robotic liver resection over laparoscopic liver resection will be the subject of future studies.
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Affiliation(s)
- Verena Tripke
- Department of General, Visceral and Transplantation Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Chirurgische Arbeitsgemeinschaft Junge Chirurgie CAJC, Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Berlin, Germany
| | - Nils Sommer
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
- Chirurgische Arbeitsgemeinschaft Junge Chirurgie CAJC, Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Berlin, Germany
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14
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Gudmundsdottir H, Fiorentini G, Essaji Y, D'Souza D, Torres-Ruiz T, Geller DA, Helton WS, Hogg ME, Iannitti DA, Kamath AS, Onkendi EO, Serrano PE, Simo KA, Sucandy I, Warner SG, Alseidi A, Cleary SP. Circumstances and implications of conversion from minimally invasive to open liver resection: a multi-center analysis from the AMILES registry. Surg Endosc 2023; 37:9201-9207. [PMID: 37845532 DOI: 10.1007/s00464-023-10431-0] [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: 05/04/2023] [Accepted: 08/31/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Minimally invasive approaches to liver resection (MILR) are associated with favorable outcomes. The aim of this study was to determine the implications of conversion to an open procedure on perioperative outcomes. METHODS Patients who underwent MILR at 10 North American institutions were identified from the Americas Minimally Invasive Liver Resection (AMILES) database. Outcomes of patients who required conversion were compared to those who did not. Additionally, outcomes after conversion due to unfavorable findings (poor visualization/access, lack of progress, disease extent) versus intraoperative events (bleeding, injury, cardiopulmonary instability) were compared. RESULTS Of 1675 patients who underwent MILR, 102 (6.1%) required conversion. Conversion rate ranged from 4.4% for left lateral sectionectomy to 10% for right hepatectomy. The primary reason for conversion was unfavorable findings in 67 patients (66%) and intraoperative adverse events in 35 patients (34%). By multivariable analysis, major resection, cirrhosis, prior liver surgery, and tumor proximity to major vessels were identified as risk factors for conversion (p < 0.05). Patients who required conversion had higher blood loss, transfusion requirements, operative time, and length of stay, (p < 0.05). They also had higher major complication rates (23% vs. 5.2%, p < 0.001) and 30-day mortality (8.8% vs. 1.3%, p < 0.001). When compared to those who required conversion due to unfavorable findings, patients who required conversion due to intraoperative adverse events had significantly higher major complication rates (43% vs. 14%, p = 0.012) and 30-day mortality (20% vs. 3.0%, p = 0.007). CONCLUSIONS Conversion from MILR to open surgery is associated with increased perioperative morbidity and mortality. Conversion due to intraoperative adverse events is rare but associated with significantly higher complication and mortality rates, while conversion due to unfavorable findings is associated with similar outcomes as planned open resection. High-risk patients may benefit from early conversion in a controlled fashion if difficulties are encountered or anticipated.
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Affiliation(s)
| | - Guido Fiorentini
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | | | | | | | - David A Geller
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | - Edwin O Onkendi
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | | | | | - Susanne G Warner
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Adnan Alseidi
- Virginia Mason Medical Center, Seattle, WA, USA
- University of California San Francisco, San Francisco, CA, USA
| | - Sean P Cleary
- Department of Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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Wu Y, Li S, Yuan J, Zhang H, Wang M, Zhang Z, Qin R. Benchmarking: a novel measuring tool for outcome comparisons in surgery. Int J Surg 2023; 109:419-428. [PMID: 37093075 PMCID: PMC10389472 DOI: 10.1097/js9.0000000000000212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/05/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Benchmarking, a novel measuring tool for outcome comparisons, is a recent concept in surgery. The objectives of this review are to examine the concept, definition, and evolution of benchmarking and its application in surgery. METHODS The literature about benchmarking was reviewed through an ever-narrowing search strategy, commencing from the concept, definition, and evolution of benchmarking to the application of benchmarking and experiences of benchmarking in surgery. PubMed, Web of Science, Embase, and Science Direct databases were searched until 20 September 2022, in the English language according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS In the first phase of the literature search, the development of benchmarking was identified. The definitions of benchmarking evolved from a surveying term to a novel quality-improvement tool to assess the best achievable results in surgery. In the second phase, a total of 23 studies were identified about benchmarking in surgery, including esophagectomy, hepatic surgery, pancreatic surgery, rectum resection, and bariatric surgery. All studies were multicenter analyses from national, international, or global expert centers. Most studies (87.0%) adopted the definition that benchmark was the 75th percentile of the median values of centers. Performance metrics to define benchmarks were clinically relevant intraoperative and postoperative outcome indicators. CONCLUSION Benchmarking in surgery is a novel quality-improvement tool to define and measure the best achievable results, establishing a meaningful reference to evaluate surgical performance.
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Affiliation(s)
- Yi Wu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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