A review of factors predicting perioperative death and early outcome in hepatopancreaticobiliary cancer surgery

Risk factors for major complications after liver resection: A large liver resection study from Morocco and audit of a non-Eastern/non-Western experience

BACKGROUND AND STUDY AIMS

In developing countries, endemic indications, blood shortages, and the scarcity of liver surgeons and intensive care providers can affect liver resection (LR) outcomes, but these have been rarely addressed in the literature. Therefore, in this study we determined risk factors for major complications after LR in a North African general surgery and teaching department.

PATIENTS AND METHODS

From January 2010 to December 2015, 213 consecutive LRs were performed on 203 patients. All patients underwent a postoperative follow-up of >90 days. Postoperative complications were assessed according to the Clavien-Dindo (CD) classification of surgical complications. A score of CD ≥III is considered as major postoperative complications. In this study, we analyzed the variables assumed to affect these complications.

RESULTS

The overall 90-day complication rate was 35.7% (n = 76), including a CD ≥III of 14% (n = 30) and a mortality rate of 6.1% (n = 14). According to the multivariate analysis, a preoperative performance status (PS) of ≥2 (P = 0.011; odds ratios [OR], 6.8; 95% confidence intervals [CI], 1.55-29.8), an estimated intraoperative blood loss of >500 ml (P = 0.002; OR, 3.71; 95% CI, 1.23-11.20), and bilioenteric anastomosis (P < 0.004; OR, 7.76; 95% CI, 1.5-3.89) were independent risk factors for major complications after LR.

CONCLUSION

We recommend that, in the setting of a non-Eastern/non-Western general surgery and teaching department, patients with a PS of ≥2 should undergo a specific selection and preoperative optimization protocol; intermittent clamping indications should be extended; and special attention should paid to patients undergoing LR associated with biliary reconstruction, such as for perihilar cholangiocarcinoma.

Skilled nursing facility (SNF) utilization and impact of SNF star-quality ratings on outcomes following hepatectomy among Medicare beneficiaries

BACKGROUND

An increasing number of patients require admission to a skilled nursing facility (SNF) following surgery. However, the impact of SNF quality on post-operative outcomes is unknown.

METHODS

The Medicare Standard Analytic Files and Nursing Home Compare Dataset were used to define SNF utilization and determine the influence of SNF star quality ratings on outcomes following hepatectomy.

RESULTS

Among 7256 Medicare beneficiaries, 918 (12.7%) required. Compared to patients discharged home, individuals discharged to SNF were older (median age: 75 [IQR 71-80] vs. 71 [IQR 68-76] years), and had a higher incidence of complications such as pulmonary failure, pneumonia, and acute renal failure during index hospitalization (all p < 0.05). Patients sent to a SNF were more likely to be readmitted within 30-days (30.1% vs. 13.4%, p < 0.001). The incidence of new complications within 30- and 90-days of discharge was similar regardless of star quality ratings (all p > 0.05). On multivariable analysis, Charlson comorbidity score ≥3 was the factor most strongly associated with 30-day readmission (OR 1.32-15.29, p = 0.016).

CONCLUSION

While post-discharge outcomes were similar across SNF quality ratings, roughly one in three Medicare patients discharged to a SNF were readmitted within 30-days.

Complications after liver surgery: a benchmark analysis

BACKGROUND

The best achievable short-term outcomes after liver surgery have not been identified. Several factors may influence the post-operative course of patients undergoing hepatectomy increasing the risk of post-operative complications. We sought to identify risk-adjusted benchmark values [BMV] for liver surgery.

METHODS

The National Surgery Quality Improvement Program (NSQIP) database was used to develop Bayesian models to estimate risk-adjusted BMVs for overall and liver related (post-hepatectomy liver failure [PHLF], biliary leakage [BL]) complications. A separate international multi-institutional database was used to validate the risk-adjusted BMVs.

RESULTS

Among the 11,243 patients included in the NSQIP database, the incidence of complications, PHLF, and BL was 36%, 5%, and 8%, respectively. The risk-adjusted BMVs for complication (range, 16-72%), PHLF (range, 1%-20%), and BL (range, 4%-22%) demonstrated a high variability based on patients characteristics. When tested using an international database including nine institutes, the risk-adjusted BMVs for complications ranged from 26% (Institute-4) to 43% (Institute-1), BMVs for PHLF between 3% (Institute-3) and 12% (Institute-5), while BMVs for BL ranged between 5% (Institute-4) and 9% (Institute-7).

CONCLUSIONS

Multiple factors influence the risk of complications following hepatectomy. Risk-adjusted BMVs are likely much more applicable and appropriate in assessing "acceptable" benchmark outcomes following liver surgery.

The Outcome of Complex Hepato-Pancreato-Biliary Surgery for Elderly Patients: A Propensity Score Matching Analysis

BACKGROUND/AIMS

Postoperative mortality and morbidity rates after hepato-pancreato-biliary (HPB) surgery remain high, and the number of elderly patients requiring such surgery has been increasing. This study aimed to investigate postoperative outcomes of complex HPB surgery for elderly patients.

METHODS

We retrospectively reviewed perioperative data of 721 patients who underwent complex HPB surgery between 2010 and 2015. The patients were divided into 2 groups: elderly (≥75 years) and non-elderly (< 75 years). Surgical outcomes of both groups were compared after propensity score-matching analysis. Subsequently, risk factors for serious postoperative morbidity were identified by multivariate analysis.

RESULTS

Before matching, the elderly group (n = 170) had more comorbidities, such as cardiovascular and renal disease, than the non-elderly group (n = 551). Matching yielded elderly (n = 170) and non-elderly groups (n = 170) with similar preoperative backgrounds. The mortality and morbidity rates did not differ significantly between the groups. In multivariate analyses, operative time (OR 1.79; p = 0.005) and blood loss (OR 1.66; p = 0.03) were identified as independent risk factors for serious postoperative morbidity, whereas older age did not have a predictive impact (OR 1.16; p = 0.52).

CONCLUSIONS

Although elderly -patients had more comorbidities and higher incidences of postoperative mortality and several complications before matching, their postoperative outcomes were equivalent to those of non-elderly patients after matching.

ERAS: Improving outcome in the cachectic HPB patient

The enhanced recovery after surgery (ERAS) program has reduced postoperative morbidity and duration of hospital stay but not mortality in patients undergoing hepatopancreatobiliary (HPB) surgery. Many HPB patients suffer from cancer cachexia, a syndrome of severe weight and muscle loss. This may affect outcomes of HPB surgery even within an ERAS program. A tailored ERAS approach may be essential in further improving outcome in this vulnerable patient category.

Is signet-ring cell carcinoma a specific entity among gastric cancers?

BACKGROUND

The prognosis and chemoresistance of signet-ring cell (SRC) gastric adenocarcinoma have been reported and debated, and the utility of perioperative chemotherapy for such a tumor has been questioned . This study was performed to assess the impact of the SRC type on survival following resection of gastric adenocarcinoma, and to assess whether the prognostic factors (including perioperative chemotherapy) for non-SRC adenocarcinoma differed from those for SRC adenocarcinoma.

METHODS

1799 cases of adenocarcinoma that were consecutively treated from 1997 to 2010 in 19 French centers by subtotal or total gastrectomy were included in a retrospective study. A D2 lymphadenectomy was performed for antropyloric tumors, and a modified D2 for upper tumors. SRC adenocarcinoma was diagnosed based on the presence of isolated carcinoma cells containing mucin.

RESULTS

A total gastrectomy was performed in 979 (54.4 %) patients. SRC adenocarcinoma was diagnosed in 899 (50 %) patients. Patients with an SRC tumor were more frequently female, younger, and malnourished, had lower ASA scores, and had larger tumors than non-SRC patients. Median survival in patients with non-SRC carcinoma was 51 months, as compared to 26 months in patients with SRC carcinoma (p < 0.001). At multivariate analysis, SRC type remained an independent adverse prognostic factor (HR = 1.182). Factors that were prognostic in the SRC subgroup but not in the non-SRC subgroup were age >60 years, linitis, and involvement of adjacent organs. In contrast to non-SRC tumors, pre- and postoperative chemotherapy did not significantly impact on survival following resection of SRC adenocarcinoma.

CONCLUSION

In comparison to non-SRC adenocarcinoma, the SRC type has a worse prognosis, different prognostic factors, and is only poorly sensitive to perioperative chemotherapy. Non-SRC and SRC adenocarcinomas should be considered different entities in future therapeutic trials.

Liver resection morbidity, mortality, and risk factors at the departments of hepatobiliary surgery in Veracruz, Mexico

INTRODUCTION

Liver resection has been associated with high morbidity and mortality, and the most serious complication is liver failure. Patient evaluation is limited to risk scales. The 50-50 criteria and bilirubin peak>7mg/dl have been used as mortality predictors.

AIM

The aim of this study was to determine the risk factors associated with morbidity and mortality for liver resection in our population.

MATERIAL AND METHODS

A retrospective study was carried out on 51 patients that underwent liver resection. Sociodemographic variables, pathology, and the surgical act were analyzed, together with morbidity and mortality and their associated factors.

RESULTS

Fifty-one patients, 23 men and 28 women, were analyzed. They had a mean age of 51.4±19.13 years, 64.7% had concomitant disease, and their mean MELD score was 7.49±1.79. The mean size of the resected lesions was 7.34±3.47cm, 51% were malignant, and 34 minor resections were performed. The Pringle maneuver was used in 64.7% of the cases and the mean blood loss was 1,090±121.76ml. Morbidity of 25.5% was associated with viral hepatitis infection, greater blood loss, transfusion requirement, the Pringle maneuver, lower hemoglobin and PTT values, and higher MELD, INR, bilirubin, and glucose values. A total 3.9% mortality was associated with hyperbilirubinemia, hyperglycemia, and greater blood loss and transfusions.

CONCLUSIONS

The main risk factors associated with the morbidity and mortality of liver resection in our population were those related to the preoperative biochemical parameters of the patient and the factors that occurred during the surgical act.

Sarcopenia Impacts on Short- and Long-term Results of Hepatectomy for Hepatocellular Carcinoma

OBJECTIVE

To evaluate the prevalence of sarcopenia among European patients with resectable hepatocellular carcinoma (HCC) and to assess its prognostic impact on overall and disease-free survival.

BACKGROUND

Identification of preoperative prognostic factors in liver surgery for HCC is required to better select patients and improve survival. Recent studies have shown that preoperative discrimination of patients with low skeletal muscle mass (sarcopenic patients) using computed tomography was associated with morbidity and mortality after liver and colorectal surgery. Assessment of sarcopenia could be used to evaluate patients before hepatectomy for HCC.

METHODS

All consecutive patients who underwent hepatectomy for HCC in our institution, between February 2006 and September 2012, were included. Univariate and multivariate analyses evaluating prognostic factors of postoperative mortality and cancer recurrence were performed, including preoperative, surgical, and histopathological factors.

RESULTS

Among 198 patients who underwent hepatectomy for HCC, 109 patients had an available computed tomographic scan and represent the study cohort. After a median follow-up of 21.23 months, 27 patients (24.8%) died. There were 20 deaths among the 59 patients who had sarcopenia and only 7 deaths in the nonsarcopenic group. Sarcopenic patients had significantly shorter median overall survival than nonsarcopenic patients (52.3 months vs 70.3 months; P = 0.015). On multivariate analysis, sarcopenia was found to be an independent predictor of poor overall survival (hazard ratio = 3.19; P = 0.013) and disease-free survival (hazard ratio = 2.60; P = 0.001).

CONCLUSIONS

Sarcopenia was found to be a strong and independent prognostic factor for mortality after hepatectomy for HCC in European patients and could be used to evaluate eligibility of patients with HCC before surgery.

Anti-inflammatory liposomes have no impact on liver regeneration in rats

INTRODUCTION

Surgical resection is the gold standard in treatment of hepatic malignancies, giving the patient the best chance to be cured. The liver has a unique capacity to regenerate. However, an inflammatory response occurs during resection, in part mediated by Kupffer cells, that influences the speed of regeneration. The aim of this study was to investigate the effect of a Kupffer cell targeted anti-inflammatory treatment on liver regeneration in rats.

METHODS

Two sets of animals, each including four groups of eight rats, were included. Paired groups from each set received treatment with placebo, low dose dexamethasone, high dose dexamethasone or low dose anti-CD163 dexamethasone. Subsequently, the rats underwent 70% partial hepatectomy. The two sets were evaluated on postoperative day 2 or 5, respectively. Blood was drawn for circulating markers of inflammation and liver cell damage; liver tissue was sampled for analysis of regeneration rate and proliferation index.

RESULTS

The high dose dexamethasone group had significantly lower body and liver weight than the placebo and anti-CD163-dex groups. There were no differences in liver regeneration rates between groups. Hepatocyte proliferation was completed faster in the placebo group, although this was not significant. The anti-CD163-dex group showed increased blood levels of albumin and alanine aminotransferase and a diminished inflammatory response in terms of significantly reduced haptoglobin, α2-macroglobulin and Interleukine-6.

CONCLUSION

Low dose dexamethasone targeted to Kupffer cells does not affect histological liver cell regeneration after 70% hepatectomy in rats, but reduces the inflammatory response judged by circulating markers of inflammation.

[Arterial and portal venous complications after HPB surgical procedures: Interdisciplinary management]

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (<5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5-9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.

Research gaps in pancreatic cancer research and comparative effectiveness research methodologies

Despite advances in cancer care, pancreatic adenocarcinoma remains one of the most lethal tumors. Most patients with pancreatic cancer are diagnosed with late stage disease, and approximately 6 % of patients are alive 5 years after diagnosis. Of the 10-20 % of patients who are candidates for resection and multi-modality therapy, most will succumb to the disease with 5-year survival rates only reaching approximately 25 % (Lim et al. in Annals of surgery 237(1):74-85, 2003 [1]; Trede et al. in Annals of surgery 211(4):447-458, 1990 [2]; Crist et al. in Annals of surgery 206(3):358-365, 1987 [3]). Clearly, there is a need to improve the management of this disease. To identify gaps in research and formulate strategies to address these issues, we designed a framework to encompass the scope of research for pancreatic cancer. In this chapter, we will examine each topic heading within this framework for gaps in knowledge and present research strategies focusing on diverse comparative effectiveness research (CER) methodologies to address the identified gaps.

The Interaction between Diabetes, Body Mass Index, Hepatic Steatosis, and Risk of Liver Resection: Insulin Dependent Diabetes Is the Greatest Risk for Major Complications

Background. This study aimed to assess the relationship between diabetes, obesity, and hepatic steatosis in patients undergoing liver resection and to determine if these factors are independent predictors of major complications. Materials and Methods. Analysis of a prospectively maintained database of patients undergoing liver resection between 2005 and 2012 was undertaken. Background liver was assessed for steatosis and classified as <33% and ≥33%. Major complications were defined as Grade III-V complications using the Dindo-Clavien classification. Results. 504 patients underwent liver resection, of whom 56 had diabetes and 61 had steatosis ≥33%. Median BMI was 26 kg/m(2) (16-54 kg/m(2)). 94 patients developed a major complication (18.7%). BMI ≥ 25 kg/m(2) (P = 0.001) and diabetes (P = 0.018) were associated with steatosis ≥33%. Only insulin dependent diabetes was a risk factor for major complications (P = 0.028). Age, male gender, hypoalbuminaemia, synchronous bowel procedures, extent of resection, and blood transfusion were also independent risk factors. Conclusions. Liver surgery in the presence of steatosis, elevated BMI, and non-insulin dependent diabetes is not associated with major complications. Although diabetes requiring insulin therapy was a significant risk factor, the major risk factors relate to technical aspects of surgery, particularly synchronous bowel procedures.

Improving surgical outcomes in pancreatic surgery with preoperative nutrition

The purposes of this study were (1) to describe the relationship between preoperative physical status and postoperative outcomes in patients undergoing Whipple resection, and (2) to determine if the use of specialized immunonutrition with IMPACT Advanced Recovery supplementation improved postoperative outcomes (pancreatic leak rate, length of stay, and postoperative complications) in patients undergoing Whipple resection. The trial was a case-controlled prospective pilot study that took place in an outpatient gastrointestinal surgical oncology office in an urban community hospital in the northeast United States. The study population consisted of nine patients undergoing Whipple surgery. Patients were given IMPACT Advanced Recovery supplementation 4 days prior to Whipple surgery. Prospective data were collected on all patients and then compared to national averages in terms of outcomes. Study approval was obtained from the Fairfield University Institutional Review Board (IRB), though IRB approval was not required by the study facility due to the fact that this was a pilot study. Consent was also not required for retrospective chart review. Patients with lower scores according to the American Society of Anesthesiologists Physical Status Classification System have a shorter operating time in the setting of preoperative nutrition. Patients in this study who received preoperative nutrition with IMPACT Advanced Recovery supplementation had outcomes comparable to the national average. This pilot study suggests that there is a need for a multi-institutional randomized study powered to further evaluate the effectiveness of preoperative nutrition in pancreatic surgery. The literature supports the fact that preoperative nutritional supplementation should be offered to patients undergoing Whipple surgery. Optimization of nutritional status can translate to decreased length of stay and cost savings.

Renal dysfunction is an independent risk factor for mortality after liver resection and the main determinant of outcome in posthepatectomy liver failure

Introduction. The aim of this study was to assess the interaction of liver and renal dysfunction as risk factors for mortality after liver resection. Materials and Methods. A retrospective analysis of 501 patients undergoing liver resection in a single unit was undertaken. Posthepatectomy liver failure (PHLF) was defined according to the International Study Group of Liver Surgery (ISGLS) definition (assessed on day 5) and renal dysfunction according to RIFLE criteria. 90-day mortality was recorded. Results. Twenty-three patients died within 90 days of surgery (4.6%). The lowest mortality occurred in patients without evidence of PHLF or renal dysfunction (2.7%). The mortality rate in patients with isolated PHLF or renal dysfunction was 20% compared to 45% in patients with both. Diabetes (P = 0.028), renal dysfunction (P = 0.030), and PHLF on day 5 (P = 0.011) were independent predictors of 90-day mortality. Discussion. PHLF and postoperative renal dysfunction are independent predictors of 90-day mortality following liver resection but the predictive value for mortality is significantly higher when failure of both organ systems occurs simultaneously.

Pre-operative cardiopulmonary exercise testing predicts adverse post-operative events and non-progression to adjuvant therapy after major pancreatic surgery

BACKGROUND

Surgery followed by chemotherapy is the primary modality of cure for patients with resectable pancreatic cancer but is associated with significant morbidity. The aim of the present study was to evaluate the role of cardiopulmonary exercise testing (CPET) in predicting post-operative adverse events and fitness for chemotherapy after major pancreatic surgery.

METHODS

Patients who underwent a pancreaticoduodenectomy or total pancreatectomy for pancreatic head lesions and had undergone pre-operative CPET were included in this retrospective study. Data on patient demographics, comorbidity and results of pre-operative evaluation were collected. Post-operative adverse events, hospital stay and receipt of adjuvant therapy were outcome measures.

RESULTS

One hundred patients were included. Patients with an anaerobic threshold less than 10 ml/kg/min had a significantly greater incidence of a post-operative pancreatic fistula [International Study Group for Pancreatic Surgery (ISGPS) Grades A-C, 35.4% versus 16%, P = 0.028] and major intra-abdominal abscesses [Clavien-Dindo (CD) Grades III-V, 22.4% versus 7.8%, P = 0.042] and were less likely to receive adjuvant therapy [hazard ratio (HR) 6.30, 95% confidence interval (CI) 1.25-31.75, P = 0.026]. A low anaerobic threshold was also associated with a prolonged hospital stay (median 20 versus 14 days, P = 0.005) but not with other adverse events.

DISCUSSION

CPET predicts a post-operative pancreatic fistula, major intra-abdominal abscesses as well as length of hospital stay after major pancreatic surgery. Patients with a low anaerobic threshold are less likely to receive adjuvant therapy.

Serum arterial lactate concentration predicts mortality and organ dysfunction following liver resection

BACKGROUND

The aim of this study was to determine if the post-operative serum arterial lactate concentration is associated with mortality, length of hospital stay or complications following hepatic resection.

METHODS

Serum lactate concentration was recorded at the end of liver resection in a consecutive series of 488 patients over a seven-year period. Liver function, coagulation and electrolyte tests were performed post-operatively. Renal dysfunction was defined as a creatinine rise of >1.5x the pre-operative value.

RESULTS

The median lactate was 2.8 mmol/L (0.6 to 16 mmol/L) and was elevated (≥2 mmol/L) in 72% of patients. The lactate concentration was associated with peak post-operative bilirubin, prothrombin time, renal dysfunction, length of hospital stay and 90-day mortality (P < 0.001). The 90-day mortality in patients with a post-operative lactate ≥6 mmol/L was 28% compared to 0.7% in those with lactate ≤2 mmol/L. Pre-operative diabetes, number of segments resected, the surgeon's assessment of liver parenchyma, blood loss and transfusion were independently associated with lactate concentration.

CONCLUSIONS

Initial post-operative lactate concentration is a useful predictor of outcome following hepatic resection. Patients with normal post-operative lactate are unlikely to suffer significant hepatic or renal dysfunction and may not require intensive monitoring or critical care.

Risk of morbidity and mortality following hepato-pancreato-biliary surgery

INTRODUCTION

Hepatic, pancreatic, and complex biliary (HPB) surgery can be associated with major morbidity and significant mortality. For the past 5 years, the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has gathered robust data on patients undergoing HPB surgery. We sought to use the ACS-NSQIP data to determine which preoperative variables were predictive of adverse outcomes in patients undergoing HPB surgery.

METHODS

Data collected from ACS-NSQIP on patients undergoing hepatic, pancreatic, or complex biliary surgery between 2005 and 2009 were analyzed (n = 13,558). Diagnoses and surgical procedures were categorized into 10 and eight groups, respectively. Seventeen preoperative clinical variables were assessed for prediction of 30-day postoperative morbidity and mortality. Multivariate logistic regression was utilized to develop a risk model.

RESULTS

Of the 13,558 patients who underwent an HPB procedure, 7,321 (54%) had pancreatic, 4,881 (36%) hepatic, and 1,356 (10%) biliary surgery. Overall, 70.3% of patients had a cancer diagnosis. Post-operative complications occurred in 3,850 patients for an overall morbidity of 28.4%. Serious complications occurred in 2,522 (18.6%) patients; 366 patients died for an overall peri-operative mortality of 2.7%. Peri-operative outcome was associated with diagnosis and type of procedure. Hepatic trisectionectomy (5.8%) and total pancreatectomy (5.4%) had the highest 30-day mortality. Of the preoperative variables examined, age >74, dyspnea with moderate exertion, steroid use, prior cardiac procedure, ascites, and pre-operative sepsis were associated with morbidity and mortality (all P < 0.05).

CONCLUSIONS

While overall morbidity and mortality for HPB surgery are low, peri-operative outcomes are heterogeneous and depend on diagnosis, procedure type, and key clinical factors. By combining these factors, an ACS-NSQIP "HPB Risk Calculator" may be developed in the future to help better risk-stratify patients being considered for complex HPB surgery.