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Díaz Vico T, Granero Castro P, Alcover Navarro L, Suárez Sánchez A, Mihic Góngora L, Montalvá Orón EM, Maupoey Ibáñez J, Truán Alonso N, González-Pinto Arrillaga I, Granero Trancón JE. Two stage hepatectomy (TSH) versus ALPPS for initially unresectable colorectal liver metastases: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:550-559. [PMID: 36424260 DOI: 10.1016/j.ejso.2022.11.010] [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: 04/28/2022] [Revised: 10/03/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although numerous comparisons between conventional Two Stage Hepatectomy (TSH) and Associating Liver Partition and Portal Vein Ligation for staged hepatectomy (ALPPS) have been reported, the heterogeneity of malignancies previously compared represents an important source of selection bias. This systematic review and meta-analysis aimed to compare perioperative and oncological outcomes between TSH and ALPPS to treat patients with initially unresectable colorectal liver metastases (CRLM). METHODS Main electronic databases were searched using medical subject headings for CRLM surgically treated with TSH or ALPPS. Patients treated for primary or secondary liver malignancies other than CRLM were excluded. RESULTS A total of 335 patients from 5 studies were included. Postoperative major complications were higher in the ALPPS group (relative risk [RR] 1.46, 95% confidence interval [CI] 1.04-2.06, I2 = 0%), while no differences were observed in terms of perioperative mortality (RR 1.53, 95% CI 0.64-3.62, I2 = 0%). ALPPS was associated with higher completion of hepatectomy rates (RR 1.32, 95% CI 1.09-1.61, I2 = 85%), as well as R0 resection rates (RR 1.61, 95% CI 1.13-2.30, I2 = 40%). Nevertheless, no significant differences were achieved between groups in terms of overall survival (OS) (RR 0.93, 95% CI 0.68-1.27, I2 = 52%) and disease-free survival (DFS) (RR 1.08, 95% CI 0.47-2.49, I2 = 54%), respectively. CONCLUSION ALPPS and TSH to treat CRLM seem to have comparable operative risks in terms of mortality rates. No definitive conclusions regarding OS and DFS can be drawn from the results.
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Affiliation(s)
- Tamara Díaz Vico
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain; Health Research Institute of the Principality of Asturias (ISPA), Spain.
| | - Pablo Granero Castro
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain; Department of Surgery, University of Oviedo, Spain
| | - Laura Alcover Navarro
- Department of Anaesthesiology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Aida Suárez Sánchez
- Department of General Surgery, Hospital Universitario San Agustín (HUSA), Avilés, Spain
| | - Luka Mihic Góngora
- Department of Medical Oncology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Eva María Montalvá Orón
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital La Fe, Valencia, Spain
| | - Javier Maupoey Ibáñez
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital La Fe, Valencia, Spain
| | - Nuria Truán Alonso
- Department of Colorectal Surgery, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Ignacio González-Pinto Arrillaga
- Department of HPB Surgery and Transplantation Unit, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain; Department of Surgery, University of Oviedo, Spain
| | - José Electo Granero Trancón
- Department of Surgery, University of Oviedo, Spain; Department of Colorectal Surgery, Division of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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Early postoperative serum aspartate aminotransferase for prediction of post-hepatectomy liver failure. Perioper Med (Lond) 2022; 11:51. [PMID: 36203213 PMCID: PMC9540737 DOI: 10.1186/s13741-022-00283-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 09/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background Post-hepatectomy liver failure (PHLF) is a serious complication of hepatectomy. The current criteria for PHLF diagnosis (ISGLS consensus) require laboratory data on or after postoperative day (POD) 5, which may delay treatment for patients at risk. The present study aimed to determine the associations between early postoperative (POD1) serum aminotransferase levels and PHLF. Methods The medical records of patients who underwent hepatectomy at Ramathibodi Hospital from January 2008 to December 2019 were retrospectively examined. Patients were classified into PHLF and non-PHLF groups. Preoperative characteristics, intraoperative findings, and early postoperative laboratory data (serum AST, ALT, bilirubin, and international normalized ratio (INR) on POD0 to POD5) were analyzed. Results A total of 890 patients were included, of whom 31 (3.4%) had PHLF. Cut-off points for AST of 260 U/L and ALT of 270 U/L on POD1 were predictive of PHLF. In multivariate analysis, AST > 260 U/L on POD1, ICG-R15, major hepatectomy, blood loss, and INR were independently associated with PHLF. Conclusions Early warning from elevated serum AST on POD1, before a definitive diagnosis of PHLF is made on POD5, can help alert physicians that a patient is at risk, meaning that active management and vigilant monitoring can be initiated as soon as possible.
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Parwaiz I, Hakeem A, Nwogwugwu O, Prasad R, Hidalgo E, Lodge P, Toogood G, Pathak S. Does ALT Correlate with Survival After Liver Resection for Colorectal Liver Metastases? J Clin Exp Hepatol 2022; 12:1285-1292. [PMID: 36157153 PMCID: PMC9499836 DOI: 10.1016/j.jceh.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/24/2022] [Indexed: 12/12/2022] Open
Abstract
Background The pringle manoeuvre is commonly used during hepatectomy, which may cause ischaemia-reperfusion injury and transient liver dysfunction. Post-operative liver transaminases are often used to assess ischaemia-reperfusion injury, although there is conflicting evidence on survival outcomes. The primary aim was to assess post-operative alanine aminotransferase (ALT) with survival outcomes. Secondary aims were to assess ALT level with the length of stay and overall complications. Methods Post-operative day 2 ALT levels of five times the upper limit of normal (i.e. 280 U/L) were considered as clinically significant transaminitis. Kaplan-Meier survival curves were studied using log-rank analysis to identify the predictors of overall survival (OS) and recurrence-free survival (RFS). Results Out of 752 patients who underwent hepatectomy, 527 (70.1%) patients had low ALT (<280 U/L) and 225 (29.9%) patients had high ALT on day 2 post-op. Post-operative ALT did not affect OS (P = 0.883) or RFS (P = 0.063). Factors associated with a worse OS and RFS on multivariate analysis were pre-operative chemotherapy, number of tumours and largest tumour size (>4 cm). A high post-operative ALT was not associated with the increased length of stay or more complications. Conclusions Post-operative ALT does not affect survival outcomes post-hepatectomy for colorectal liver metastases.
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Affiliation(s)
- Iram Parwaiz
- Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Abdul Hakeem
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Obi Nwogwugwu
- Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Raj Prasad
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Ernest Hidalgo
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Peter Lodge
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Giles Toogood
- St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Samir Pathak
- Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK
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de Klein GW, Brohet RM, Liem MSL, Klaase JM. Post-operative Day 1 Serum Transaminase Levels in Relation to Morbidity After Liver Resection. World J Surg 2021; 46:433-440. [PMID: 34797398 DOI: 10.1007/s00268-021-06280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Post-operative serum transaminases have been proposed as possible early predictors of morbidity after liver resection. This study aimed to verify the clinical value of post-operative serum transaminases. METHODS Clinical data from 2001 to 2016 in a single non-academic referral HPB center were collected from a prospectively held database. Post-operative day 1 serum aspartate transaminase (AST) and alanine transaminase (ALT) were tested for their relationship with post-operative major morbidity, defined by a Clavien-Dindo score 3 or higher, and mortality. RESULTS For this analysis, 371 patients were included, including 149 (40%) undergoing major liver resections. In total, 17% of the patients developed major morbidity. Stepwise logistic regression demonstrated that AST, and not ALT, is an independent predictor for major morbidity (p = 0.017). The probability of major morbidity significantly increased with increasing AST values. A threshold value of 242 U/L was found to be predictive for one or more major complications. CONCLUSIONS In this study, post-operative serum AST on day 1 was a predictive factor for major morbidity after liver resection. For patients with low AST value, early discharge could be considered. However, because of the substantial inter-individual variability of AST values, more studies are needed to translate these results into clinical practice.
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Affiliation(s)
- G W de Klein
- Department of Surgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - R M Brohet
- Department of Research and Innovation, Isala, Zwolle, Netherlands
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - J M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, Netherlands.
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Li K, Jiang F, Aizpuru M, Larson EL, Xie X, Zhou R, Xiang B. Successful management and technical aspects of major liver resection in children: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e24420. [PMID: 33578534 PMCID: PMC7886405 DOI: 10.1097/md.0000000000024420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 01/03/2021] [Indexed: 02/05/2023] Open
Abstract
Optimal treatment of patients with various types of liver tumors or certain liver diseases frequently demands major liver resection, which remains a clinical challenge especially in children.Eighty seven consecutive pediatric liver resections including 51 (59%) major resections (resection of 3 or more hepatic segments) and 36 (41%) minor resections (resection of 1 or 2 segments) were analyzed. All patients were treated between January 2010 and March 2018. Perioperative outcomes were compared between major and minor hepatic resections.The male to female ratio was 1.72:1. The median age at operation was 20 months (range, 0.33-150 months). There was no significant difference in demographics including age, weight, ASA class, and underlying pathology. The surgical management included functional assessment of the future liver remnant, critical perioperative management, enhanced understanding of hepatic segmental anatomy, and bleeding control, as well as refined surgical techniques. The median estimated blood loss was 40 ml in the minor liver resection group, and 90 ml in major liver resection group (P < .001). Children undergoing major liver resection had a significantly longer median operative time (80 vs 140 minutes), anesthesia time (140 vs 205 minutes), as well as higher median intraoperative total fluid input (255 vs 450 ml) (P < .001 for all). Fourteen (16.1%) patients had postoperative complications. By Clavien-Dindo classification, there were 8 grade I, 4 grade II, and 2 grade III-a complications. There were no significant differences in complication rates between groups (P = .902). Time to clear liquid diet (P = .381) and general diet (P = .473) was not significantly different. There was no difference in hospital length of stay (7 vs 7 days, P = .450). There were no 90-day readmissions or mortalities.Major liver resection in children is not associated with an increased incidence of postoperative complications or prolonged postoperative hospital stay compared to minor liver resection. Techniques employed in this study offered good perioperative outcomes for children undergoing major liver resections.
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Affiliation(s)
- Kewei Li
- Department of Pediatric Surgery, West China Hospital of Sichuan University
| | - Fanwen Jiang
- West China School of Medicine of Sichuan University, Chengdu, China
| | | | | | - Xiaolong Xie
- Department of Pediatric Surgery, West China Hospital of Sichuan University
| | - Rongxing Zhou
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Xiang
- Department of Pediatric Surgery, West China Hospital of Sichuan University
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Prasanna T, Wong R, Price T, Shapiro J, Tie J, Wong HL, Nott L, Roder D, Lee M, Kosmider S, Jalali A, Burge M, Padbury R, Maddern G, Carruthers S, Moore J, Sorich M, Karapetis CS, Gibbs P, Yip D. Metastasectomy and BRAF mutation; an analysis of survival outcome in metastatic colorectal cancer. Curr Probl Cancer 2020; 45:100637. [PMID: 32826083 DOI: 10.1016/j.currproblcancer.2020.100637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Resection of oligometastases improves survival in metastatic colorectal cancer (mCRC). It is unclear whether the benefit is consistent for BRAF V600E mutant (MT) and wild type (WT) mCRC. This retrospective analysis explores the influence of BRAF MT on survival after metastasectomy. METHODS Overall survival (OS) and recurrence-free survival (RFS) for BRAF MT and WT mCRC were evaluated. Survival was also analyzed in the cohort of BRAF MT with or without metastasectomy. RESULTS Five hundred and thirteen patients who had undergone metastasectomy were identified, 6% were BRAF-MT. Median age 63. Median OS in BRAF MT vs WT: 25.7 vs 48.5 months (hazard ratio [HR] 1.95; 1.18-3.22). However, difference was not significant in a multivariate model. Right primary tumor, intact primary, >1 metastatic site, non-R0 resection, peritoneal metastasis, and synchronous metastasis were independent predictors of worse OS. Among 364 patients with RFS data there was no difference between BRAF MT and WT (16 vs 19 months, p=0.09). In another cohort of 158 BRAF-MT patients, OS was significantly better after metastasectomy compared to "no metastasectomy" (HR 0.34; 0.18-0.65, P= 0.001). Proficient mismatch repair status showed a trend toward worse survival after metastasectomy in BRAF MT (HR 1.71, P = 0.08). CONCLUSION OS did not differ after metastasectomy between BRAF MT and WT in a multivariate model. Median OS was >2 years in this study after metastasectomy among BRAFV600E MT patients suggesting a survival benefit of metastasectomy in this group where systemic therapeutic options are limited. Metastasectomy may be considered in carefully selected BRAF-MT patients.
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Affiliation(s)
- Thiru Prasanna
- Department of Medical Oncology, The Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Australia; University of Canberra, ACT, Australia.
| | - Rachel Wong
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; Department of Medical Oncology, Eastern Health, Melbourne, Australia; Monash University, Faculty of Medicine, Nursing and Health Sciences, Melbourne, Australia
| | - Timothy Price
- The Queen Elizabeth Hospital and University of Adelaide, Adelaide, Australia
| | - Jeremy Shapiro
- Cabrini Haematology and Oncology Centre, Melbourne, Australia
| | - Jeanne Tie
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; Department of Medical Oncology, Western Hospital, Melbourne, Australia; Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Hui-Li Wong
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Louise Nott
- Department of Medical Oncology, Royal Hobart Hospital, Hobart, Tasmania, Australia; Menzies Research institute, Hobart, Australia
| | - David Roder
- South Australian Health & Medical Research Institute (SAHMRI), Australia; University of South Australia, Adelaide, Australia
| | - Margaret Lee
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; Department of Medical Oncology, Eastern Health, Melbourne, Australia
| | - Suzanne Kosmider
- Department of Medical Oncology, Western Hospital, Melbourne, Australia
| | - Azim Jalali
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; Department of Medical Oncology, Western Hospital, Melbourne, Australia
| | - Matthew Burge
- Department of Medical Oncology, Royal Brisbane Hospital, Brisbane, Australia
| | - Robert Padbury
- Flinders University, Bedford Park, Australia; Department of Surgery, Flinders Medical Centre, Australia
| | - Guy Maddern
- University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Scott Carruthers
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - James Moore
- Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Christos S Karapetis
- Flinders University, Bedford Park, Australia; Department of Medical Oncology, Flinders Medical Centre, Australia
| | - Peter Gibbs
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; Department of Medical Oncology, Western Hospital, Melbourne, Australia
| | - Desmond Yip
- Department of Medical Oncology, The Canberra Hospital, Garran, ACT, Australia; ANU Medical School, Australian National University, Australia
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Bellver Oliver M, Escrig-Sos J, Rotellar Sastre F, Moya-Herráiz Á, Sabater-Ortí L. Outcome quality standards for surgery of colorectal liver metastasis. Langenbecks Arch Surg 2020; 405:745-756. [PMID: 32577822 DOI: 10.1007/s00423-020-01908-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Liver metastases are the most common malignant solid liver lesions, approximately 40% of which stem from colorectal tumors. Liver resection is currently the only curative treatment for colorectal cancer liver metastases (CRLM). However, there is a lack of consensus criteria to assess the results of this treatment. In order to evaluate the quality of surgical outcomes, it is necessary to identify quality indicators (QIs) and their corresponding quality standards (QS). We propose a simple method to determine QI and QS in CRLM surgery (CRLMS) and establish acceptable quality limits (AQL) for each QI. MATERIAL AND METHODS A systematic review of CRLMS results published from 2006 to 2016. Clinical guidelines, consensus conferences, and publications related to the CRLMS were reviewed to identify and select QIs. Once selected, a new review of the papers including the results of at least one of the QIs was performed. Statistical process control (SPC) method was applied to calculate the QS and AQL of each QI. The limits of variability were established from mean and confidence intervals at 95% and 99.8%. RESULTS The most relevant QIs and its AQLs were postoperative mortality (2%, < 4.5%), overall postoperative morbidity (33%, < 41%), liver failure (5%, < 8%), postoperative hemorrhage (1%, < 3%), biliary fistula (6%, < 10%), reoperation (3%, < 6%), R1 resection margins (18%, < 25%), and overall survival at 12 and 60 months (84%, > 77%; and 34%, > 25%, respectively). CONCLUSIONS Despite its limitations, the present study constitutes the most extensive scientific evidence to date on QI and AQL in CRLMS and may constitute a reference in future studies.
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Affiliation(s)
- Manuel Bellver Oliver
- Department of Surgery, HPB Unit, Hospital General Universitario Castellón, Jaume I University, Castellón de la Plana, Spain.
| | - Javier Escrig-Sos
- Department of Surgery, HPB Unit, Hospital General Universitario Castellón, Jaume I University, Castellón de la Plana, Spain
| | - Fernando Rotellar Sastre
- HPB and Liver Transplant Unit, General and Digestive Surgery, University Clinic of Navarra, University of Navarra, Pamplona, Spain
| | - Ángel Moya-Herráiz
- Department of Surgery, HPB Unit, Hospital General Universitario Castellón, Jaume I University, Castellón de la Plana, Spain
| | - Luis Sabater-Ortí
- Department of Surgery, Biomedical Research Institute INCLIVA, Hospital Clínico, University of Valencia, Valencia, Spain
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Abstract
OBJECTIVE The aim of this study was to use the concept of benchmarking to establish robust and standardized outcome references after the procedure ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy). BACKGROUND AND AIMS The recently developed ALPPS procedure, aiming at removing primarily unresectable liver tumors, has been criticized for safety issues with high variations in the reported morbidity/mortality rates depending on patient, disease, technical characteristics, and center experience. No reference values for relevant outcome parameters are available. METHODS Among 1036 patients registered in the international ALPPS registry, 120 (12%) were benchmark cases fulfilling 4 criteria: patients ≤67 years of age, with colorectal metastases, without simultaneous abdominal procedures, and centers having performed ≥30 cases. Benchmark values, defined as the 75th percentile of the median outcome parameters of the centers, were established for 10 clinically relevant domains. RESULTS The benchmark values were completion of stage 2: ≥96%, postoperative liver failure (ISGLS-criteria) after stage 2: ≤5%, ICU stay after ALPPS stages 1 and 2: ≤1 and ≤2 days, respectively, interstage interval: ≤16 days, hospital stay after ALPPS stage 2: ≤10 days, rates of overall morbidity in combining both stage 1 and 2: ≤65% and for major complications (grade ≥3a): ≤38%, 90-day comprehensive complication index was ≤22, the 30-, 90-day, and 6-month mortality was ≤4%, ≤5%, and 6%, respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic disease-free survival was ≥86%, ≥50%, ≥57%, and ≥65%, respectively. CONCLUSIONS This benchmark analysis sets key reference values for ALPPS, indicating similar outcome as other types of major hepatectomies. Benchmark cutoffs offer valid tools not only for comparisons with other procedures, but also to assess higher risk groups of patients or different indications than colorectal metastases.
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Hepatic steatosis in patients undergoing resection of colorectal liver metastases: A target for prehabilitation? A narrative review. Surg Oncol 2019; 30:147-158. [PMID: 31471139 DOI: 10.1016/j.suronc.2019.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 06/20/2019] [Accepted: 07/22/2019] [Indexed: 12/16/2022]
Abstract
The prevalence of elevated intra-hepatic fat (IHF) is increasing in the Western world, either alone as hepatic steatosis (HS) or in conjunction with inflammation (steatohepatitis). These changes to the hepatic parenchyma are an independent risk factor for post-operative morbidity following liver resection for colorectal liver metastases (CRLM). As elevated IHF and colorectal malignancy share similar risk factors for development it is unsurprisingly frequent in this cohort. In patients undergoing resection IHF may be elevated due to excess adiposity or its elevation may be induced by neoadjuvant chemotherapy, termed chemotherapy associated steatosis (CAS). Additionally, chemotherapy is implicated in the development of inflammation termed chemotherapy associated steatohepatitis (CASH). Following cessation of chemotherapy, patients awaiting resection have a 4-6 week washout period prior to resection that is a window for prehabilitation prior to surgery. In patients with NAFLD dietary and pharmacological interventions can reduce IHF within this timeframe but this approach to modifying IHF is untested in this population. In this review, the aetiology of CAS and CASH is reviewed with recommendations to identify those at risk. We also focus on the post-chemotherapy washout period, reviewing dietary interventions applied to the metabolic population and suggest this window may be used as an opportunity to optimise IHF with such a regime as part of a pre-operative prehabilitation programme to produce improved patient outcomes.
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10
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Joechle K, Goumard C, Vega EA, Okuno M, Chun YS, Tzeng CWD, Vauthey JN, Conrad C. Long-term survival after post-hepatectomy liver failure for colorectal liver metastases. HPB (Oxford) 2019; 21:361-369. [PMID: 30100391 DOI: 10.1016/j.hpb.2018.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/09/2018] [Accepted: 07/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND While post-hepatectomy liver failure (PHLF) accurately predicts short-term mortality, its role in prognosticating long-term overall survival (OS) remains unclear. METHODS Patients who underwent hepatectomy for colorectal liver metastases (CRLM) after portal vein embolization during 1999-2015 were evaluated retrospectively. PHLF was defined per International Study Group of Liver Surgery (ISGLS) criteria and as PeakBil >7 mg/dl. Survival was analyzed using log-rank statistic and Cox regression; patient mortality within 90 days was excluded. RESULTS Of 175 patients, 68 (39%) had PHLF according to ISGLS criteria, including 40 (23%) with ISGLS grade B/C, and 14 (8%) had PeakBil >7 mg/dl. Patients with PeakBil >7 mg/dl had significantly worse OS than patients without PHLF (median OS, 16 vs 58 months, p = 0.001). Patients with ISGLS defined PHLF (p = 0.251) and patients with ISGLS grade B/C PHLF (p = 0.220) did not have worse OS than patients without PHLF. CONCLUSION Peak bilirubin >7 mg/dl impacts on long-term survival after hepatectomy for CRLM and is a better predictor of long-term survival than ISGLS-defined PHLF.
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Affiliation(s)
- Katharina Joechle
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claire Goumard
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo A Vega
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Masayuki Okuno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun-Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Dasari BVM, Hodson J, Sutcliffe RP, Marudanayagam R, Roberts KJ, Abradelo M, Muiesan P, Mirza DF, Isaac J. Developing and validating a preoperative risk score to predict 90-day mortality after liver resection. J Surg Oncol 2019; 119:472-478. [PMID: 30637737 DOI: 10.1002/jso.25350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatobiliary surgeons continue to expand the pool of patients undergoing liver resection using combinations of surgical and interventional procedures with chemotherapy. Improved perioperative care allows for operation on higher risk surgical patients. Postoperative outcomes, including 90-day mortality that improved over the past decade but still varies across cohorts. This study developed a preoperative risk score, on the basis significant clinical and laboratory variables, to predict 90-day mortality after hepatectomy. METHODS All patients who underwent hepatectomy between 2011 and 2016 were included. Univariable and multivariable analyses were performed to identify the predictors of postoperative mortality and a risk score was derived and validated. RESULTS The overall 90-day mortality rate in the derivation cohort (n = 1269 patients) was 4.0% (N = 51). Increasing patient age (P < 0.001), extent of resection (P = 0.001), diabetes mellitus (P = 0.006), and low preoperative sodium (P = 0.012) were predictors of the increased 90-day mortality in the multivariable analysis. The risk model developed based on these factors had an AUROC of 0.778 (P < 0.001) and remained significant in a validation cohort of 788 patients (AUROC: 0.703, P < 0.001). CONCLUSION The proposed preoperative risk score to predict 90-day mortality after liver resection could be useful for appropriate counseling, optimization, and risk-adjusted assessment of surgical outcomes.
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Affiliation(s)
- Bobby V M Dasari
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Robert P Sutcliffe
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Ravi Marudanayagam
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Keith J Roberts
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Manuel Abradelo
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - John Isaac
- Deptartment of HPB and Liver Transplantation surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Abnormal Liver Function Induced by Space-Occupying Lesions Is Associated with Unfavorable Oncologic Outcome in Patients with Colorectal Cancer Liver Metastases. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9321270. [PMID: 29862297 PMCID: PMC5976940 DOI: 10.1155/2018/9321270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/25/2018] [Accepted: 02/27/2018] [Indexed: 02/06/2023]
Abstract
An early prediction of prognosis for patients with colorectal liver metastasis (CRLM) may help us determine treatment strategies. Liver function reflects the effect of the overall metastatic burden. We investigated the prognostic value of liver function in CRLM patients. In our study, patients with abnormal LFTs (liver function tests) had a poorer prognosis than did those with normal LFTs (P < 0.05). A multivariate analysis revealed that LFTs was an independent prognostic factor for CRLM. For those patients with abnormal LFTs, novel prognostic contour maps were generated using LFTs, and no positive correlation exists between the values of survival duration and abnormal LFTs. Additionally, the MTVR (metastatic tumor volume ratio) was measured directly by magnetic resonance imaging and was shown to be highly correlated to LFTs by a Pearson correlation analysis. A multivariate logistic regression analysis also demonstrated that the MTVR and hepatectomy were independently predictive of abnormal LFTs. The space-occupying effect of metastatic lesions can cause abnormal LFTs, resulting in a poor prognosis. Biochemical analyses of LFTs at the initial diagnosis of CRLM enable the stratification of patients into low- and high-risk groups; it may help clinicians determine promising treatment strategies.
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Postoperative day one serum alanine aminotransferase does not predict patient morbidity and mortality after elective liver resection in non-cirrhotic patients. Hepatobiliary Pancreat Dis Int 2016; 15:655-659. [PMID: 27919856 DOI: 10.1016/s1499-3872(16)60090-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Serum aminotransferases have been used as surrogate markers for liver ischemia-reperfusion injury that follows liver surgery. Some studies have suggested that rises in serum alanine aminotransferase (ALT) correlate with patient outcome after liver resection. We assessed whether postoperative day 1 (POD 1) ALT could be used to predict patient morbidity and mortality following liver resection. We reviewed our prospectively held database and included consecutive adult patients undergoing elective liver resection in our institution between January 2013 and December 2014. Primary outcome assessed was correlation of POD 1 ALT with patient's morbidity and mortality. We also assessed whether concurrent radiofrequency ablation, neoadjuvant chemotherapy and use of the Pringle maneuver significantly affected the level of POD 1 ALT. A total of 110 liver resections were included in the study. The overall in-hospital patient morbidity and mortality were 31.8% and 0.9%, respectively. The median level of POD 1 ALT was 275 IU/L. No correlation was found between POD 1 serum ALT levels and patient morbidity after elective liver resection, whilst correlation with mortality was not possible because of the low number of mortalities. Patients undergoing concurrent radiofrequency ablation were noted to have an increased level of POD 1 serum ALT but not those given neoadjuvant chemotherapy and those in whom the Pringle maneuver was used. Our study demonstrates POD 1 serum ALT does not correlate with patient morbidity after elective liver resection.
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Postoperative peak transaminases correlate with morbidity and mortality after liver resection. HPB (Oxford) 2016; 18:915-921. [PMID: 27600437 PMCID: PMC5094483 DOI: 10.1016/j.hpb.2016.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/25/2016] [Accepted: 07/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transaminase levels are usually measured as markers of hepatocellular injury following liver resection, but recent evidence was unclear on their clinical value. This study aimed to identify factors that determine peak postoperative transaminase levels and correlated transaminase levels to postoperative complications. STUDY DESIGN All liver resections performed at a single center between 2006 and 2015 were included in the analysis. Multivariate analysis was used to identify factors that determine peak ALT and AST levels and postoperative morbidity and mortality. An ALT and AST cutoff for the prediction of mortality was determined using receiver operating characteristic curves analysis. RESULTS A total of 539 resections were included. Clavien-Dindo grade III or higher complications, intraoperative transfusion, and operative duration were identified as determinants of peak transaminases. A peak AST cut-off value for predicting mortality was defined at 828 U/L, with an area under the curve of 0.81 (0.73-0.89). The cut-off was an independent predictor of mortality (P < 0.01) along with (intraoperative) transfusion (P < 0.01), fifty-fifty criteria (P < 0.01), and age (P < 0.01). CONCLUSION Postoperative transaminase levels are independent predictors of postoperative morbidity and mortality and therefore clinically relevant. Transaminase levels usually peak during the first 24 h after surgery and thus possess early prognostic power in terms of postoperative mortality.
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Ongoing Adjuvant/Neoadjuvant Trials in Resectable Metastatic Colorectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2016. [DOI: 10.1007/s11888-016-0342-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Ubink I, Jongen JMJ, Nijkamp MW, Meijer EFJ, Vellinga TT, van Hillegersberg R, Molenaar IQ, Borel Rinkes IHM, Hagendoorn J. Surgical and Oncologic Outcomes After Major Liver Surgery and Extended Hemihepatectomy for Colorectal Liver Metastases. Clin Colorectal Cancer 2016; 15:e193-e198. [PMID: 27297446 DOI: 10.1016/j.clcc.2016.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 03/23/2016] [Accepted: 04/27/2016] [Indexed: 02/09/2023]
Abstract
PURPOSE To determine the surgical and oncologic outcomes after major liver surgery for colorectal liver metastases (CRLM) at a Dutch University Hospital. PATIENTS AND METHODS Consecutive patients with CRLM who had undergone major liver resection, defined as ≥ 4 liver segments, between January 2000 and December 2015 were identified from a prospectively maintained database. RESULTS Major liver surgery was performed in 117 patients. Of these, 26 patients had undergone formal extended left or right hemihepatectomy. Ninety-day postoperative mortality was 8%. Major postoperative complications occurred in 27% of patients; these adverse events were more common in the extended hemihepatectomy group. Median disease-free survival was 11 months and median overall survival 44 months. CONCLUSION Major liver surgery, including formal extended hemihepatectomy, is associated with significant operative morbidity and mortality but can confer prolonged overall survival for patients with CRLM.
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Affiliation(s)
- Inge Ubink
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Maarten W Nijkamp
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eelco F J Meijer
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas T Vellinga
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - I Quintus Molenaar
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jeroen Hagendoorn
- Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands.
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Narita M, Oussoultzoglou E, Bachellier P, Jaeck D, Uemoto S. Post-hepatectomy liver failure in patients with colorectal liver metastases. Surg Today 2015; 45:1218-26. [DOI: 10.1007/s00595-015-1113-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 11/04/2014] [Indexed: 12/17/2022]
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