Prediction of perioperative outcome after hepatic resection for pediatric patients

Central Liver Segments Resections vs Extended Hepatectomies in Children: Single-Center Experience

BACKGROUND

Central liver segments resection (CLSR) still is not widely used in pediatric surgery due to its technical difficulty, whereas this procedure is widely spread as a parenchyma sparing approach of centrally located liver tumors in adults. The aim of this study is to analyze the outcomes of CLSR in comparison with extended hepatectomy (EH) in children with different liver tumors.

METHODS

A single-center retrospective analysis of patients who received CLSR (n = 14) and EH (n = 44) from June 2017 to December 2023 was applied. Patient's characteristics, preoperative, intra- and postoperative data were compared between 2 groups.

RESULTS

Preoperative CT-volumetry showed that future liver remnant volume was higher in CLSR group compared to EH (FLR-V; (54 ± 29 (40-91) % vs 40 ± 12 (17-73) %, p = 0.016). The intraoperative blood loss (200 [90-1150] (20-3000) ml vs 100 [30-275] (10-9000) ml, p = 0.088) and transfusion volume (310 [85-590] (0-1860) ml vs 150 [0-310] (0-4770) ml, p = 0.484) were similar in both groups, while operation time was longer in CLSR group (420 [320-595] (145-785) min vs 280 [203-390] (125-710) min), p = 0.011). There was no difference in biliary leakage (3 (21.4 %) vs 12 (27.3 %); p = 0.479), other complications (4 (28.6 %) vs 5 (11.4 %), p = 0.198) and complications ≥ IIIb by Clavien-Dindo (2 (14.3 %) vs 8 (18.2 %), p = 0.385) postoperatively.

CONCLUSION

CLSRs allow to preserve more healthy liver parenchyma compared to EH with similar intraoperative and postoperative outcomes. «Extended mesohepatectomy» allows to achieve R0 resection when central liver tumor extends on the left lateral and/or right posterior section.

TYPE OF STUDY

Retrospective Comparative Study (Level of Evidence III).

Parenchyma Sparing Anatomic Liver Resections (Bi- and Uni-Segmentectomies) for Liver Tumours in Children-A Single-Centre Experience

Purpose: To present a single-centre experience in bi- and uni-segmentectomies for primary liver tumours in children.

METHODS

This study included 23 patients that underwent (bi)segmentectomy. There were 15 malignant tumours (hepatoblastoma-13 patients), 7 benign tumours, and 1 calcifying nested stromal epithelial tumour.

RESULTS

The median tumour diameter was 52 mm (range 15-170 mm). Bisegmentectomy 2-3 was most frequently performed (seven patients), followed by bisegmentectomy 5-6 (four patients). The median operative time was 225 min (range 95-643 min). Intraoperative complications occurred in two patients-small bowel perforation in one and an injury of the small peripheral bile duct resulting in biloma in the other. The median resection margin in patients with hepatoblastoma was 3 mm (range 1-15 mm). Microscopically negative margin status was achieved in 12 out of 13 patients. There were two recurrences. After a median follow-up time of 38 months (range 12-144 months), all 13 patients with HB were alive with no evidence of disease. Two relapsed patients were alive with no evidence of disease.

CONCLUSIONS

From the available literature and data presented here, we propose that (bi)segmentectomy can become a viable surgical option in carefully selected paediatric patients and is sufficient to achieve a cure. Further studies evaluating the impact of parenchymal preservation surgery on surgical and oncological outcome should be conducted with a larger dataset.

Comparison of transection techniques in pediatric major hepatectomy: a matched pair analysis

BACKGROUND

Evidence on safety and efficacy of different liver transection techniques in pediatric major hepatectomy is completely lacking, as no study has been conducted so far. The use of stapler hepatectomy has never before been reported in children.

METHODS

Three liver transection techniques were compared: (1) ultrasonic dissector (CUSA), (2) tissue sealing device (LigaSure™), and (3) stapler hepatectomy. All pediatric hepatectomies performed at a referral center in a 12-year study period were analyzed, patients were pair-matched in a 1:1:1-fashion. Intraoperative weight-adjusted blood loss, operation time, use of inflow occlusion, liver injury (peak-transaminase levels), postoperative complications (CCI), and long-term outcome were compared.

RESULTS

Of 57 pediatric liver resections, 15 patients were matched as triples based on age, weight, tumor stage, and extent of resection. Intraoperative blood loss was not significantly different between the groups (p = 0.765). Stapler hepatectomy was associated with significantly shorter operation time (p = 0.028). Neither postoperative death nor bile leakage occurred, and no reoperation due to hemorrhage was needed in any patient.

CONCLUSION

This is the first comparison of transection techniques in pediatric liver resection and the first report on stapler hepatectomy in children. All three techniques can be safely applied and may harbor individual advantages in pediatric hepatectomy each.

Hemorrhage in pheochromocytoma surgery: evaluation of preoperative risk factors

OBJECTIVE

Pheochromocytoma surgery carries a higher risk of hemorrhage. Our objective was to identify preoperative risk factors for hemorrhage during pheochromocytoma surgery.

METHODS

Patients who underwent surgery and with postoperative pathological confirmation were enrolled. A total of 251 patients from our center were included in the investigation, and 120 patients from the First Affiliated Hospital, Sun Yat-sen University were included as an external validation dataset. Family and medical history, demographics, hemodynamics, biochemical parameters, image data, anesthesia and operation records, postoperative outcomes were collected. Postoperative complications were graded by the Clavien-Dindo classification. Correlation between intraoperative hemorrhage volume and postoperative outcomes was assessed. The features associated with intraoperative hemorrhage were identified by linear regression. All features that were statistically significant in the multiple linear regression were then used to construct models and nomograms for predicting intraoperative hemorrhage. The constructed models were evaluated by Akaike Information Criterion. Finally, internal and external validations were carried out by tenfold cross-validation.

RESULTS

Intraoperative hemorrhage volume was positively correlated with the postoperative hospitalization time (R = 0.454, P < 0.001) and the Clavien-Dindo grades (R = 0.664, P < 0.001). Features associated with intraoperative hemorrhage were male gender (β = 0.533, OR = 1.722, P = 0.002), tumor diameter (β = 0.027, OR = 1.027, P < 0.001), preoperative CCB use (β = 0.318, OR = 1.308, P = 0.123) and open surgery (β = 1.175, OR = 3.234, P < 0.001). Validations showed reliable results (internal (R = 0.612, RMSE = 1.355, MAE = 1.111); external (R = 0.585, RMSE = 1.398, MAE = 0.964)).

CONCLUSION

More intraoperative hemorrhage is correlated with longer postoperative hospitalization time and more severe postoperative complications. Male gender, larger tumor, preoperative CCB use and open surgery are preoperative risk factors for hemorrhage in PCC surgery.

Surgical Outcome of Children with a Malignant Liver Tumour in The Netherlands: A Retrospective Consecutive Cohort Study

Introduction: Six to eight children are diagnosed with a malignant liver tumour yearly in the Netherlands. The majority of these tumours are hepatoblastoma (HB) and hepatocellular carcinoma (HCC), for which radical resection, often in combination with chemotherapy, is the only curative treatment option. We investigated the surgical outcome of children with a malignant liver tumour in a consecutive cohort in the Netherlands. Methods: In this nationwide, retrospective observational study, all patients (age < 18 years) diagnosed with a malignant liver tumour, who underwent partial liver resection or orthotopic liver transplantation (OLT) between January 2014 and April 2021, were included. Children with a malignant liver tumour who were not eligible for surgery were excluded from the analysis. Data regarding tumour characteristics, diagnostics, treatment, complications and survival were collected. Outcomes included major complications (Clavien−Dindo ≥ 3a) within 90 days and disease-free survival. The results of the HB group were compared to those of a historical HB cohort. Results: Twenty-six children were analysed, of whom fourteen (54%) with HB (median age 21.5 months), ten (38%) with HCC (median age 140 months) and one with sarcoma and a CNSET. Thirteen children with HB (93%) and three children with HCC (30%) received neoadjuvant chemotherapy. Partial hepatic resection was possible in 19 patients (12 HB, 6 HCC, and 1 sarcoma), whilst 7 children required OLT (2 HB, 4 HCC, and 1 CNSET). Radical resection (R0, margin ≥ 1.0 mm) was obtained in 24 out of 26 patients, with recurrence only in the patient with CNSET. The mean follow-up was 39.7 months (HB 40 months, HCC 40 months). Major complications occurred in 9 out of 26 patients (35% in all, 4 of 14, 29% for HB). There was no 30- or 90-day mortality, with disease-free survival after surgery of 100% for HB and 80% for HCC, respectively. Results showed a tendency towards a better outcome compared to the historic cohort, but numbers were too small to reach significance. Conclusion: Survival after surgical treatment for malignant liver tumours in the Netherlands is excellent. Severe surgical complications arise in one-third of patients, but most resolve without long-term sequelae and have no impact on long-term survival.

The role of liver resection in metastatic nephroblastoma: a systematic review and Meta-regression analysis

BACKGROUND

The impact of hepatic resection for liver metastases (LM) on the survival of pediatric patients with Wilms' tumor (WT) is unclear. So far, there is a lack of studies investigating the best suited treatment for patients with WTLM, and the role of liver resection has rarely been investigated. Thus, the development of evidence-based guidelines concerning indications of liver resection for WTLM remains difficult.

AIM

To investigate the role of surgery in the therapy of WTLM. All available data on liver resections and subgroup outcomes of patients with WTLM are analyzed. Main research question is whether liver resection improves survival rates of patients with WTLM compared to non-surgical treatment.

METHODS

A systematic literature search of MEDLINE, Web of Science, and Central provided the basis for this PRISMA-compliant systematic review. For the main analysis (I), all studies reporting on surgical treatment of pediatric WTLM were included. To provide a representative overview of the general outcome of WTLM patients, in analysis II all studies with cohorts of at least five WTLM patients, regardless of the kind of treatment, were reviewed and analyzed. A Multiple meta-regression model was applied to investigate the impact liver resection on overall survival.

RESULTS

14 studies with reports of liver resection for WTLM were found (Analysis I). They included a total of 212 patients with WTLM, of which 93 underwent a liver resection. Most studies had a high risk of bias, and the quality was heterogenous. For the analysis II, eight studies with subgroups of at least five WTLM patients were found. The weighted mean overall survival (OS) of WTLM patients across the studies was 55% (SD 29). A higher rate of liver resection was a significant predictor of better OS in a multiple meta-regression model with 4 covariates (I2 29.43, coefficient 0.819, p = 0.038).

CONCLUSIONS

This is the first systematic review on WTLM. Given a lack of suited studies that specifically investigated WTLM, ecological bias was high in our analyses. Generating evidence is complicated in rare pediatric conditions and this study must be viewed in this context. Meta-regression analyses suggest that liver resection may improve survival of patients with WTLM compared to non-surgical treatment. Especially patients with persisting disease after neoadjuvant chemotherapy but also patients with metachronous LM seem to benefit from resection. Complete resection of LM is vital to achieve higher OS. Studies that prospectively investigate the impact of surgery on survival compared to non-surgical treatment for WTLM are highly needed to further close the current evidence gap.

STUDY REGISTRATION

PROSPERO 2021 CRD42021249763  https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249763 .

A novel strategy to promote liver regeneration: utilization of secretome obtained from survivin-overexpressing adipose-derived stem cells

Purpose

Survivin is a typical antiapoptotic protein. It is copiously expressed during human fetal development but is infrequently present in adult tissues. In this experiment, we researched the treatment effect of the secretome that adipose-derived stem cells (ASCs) transfected with survivin.

Methods

First of all, we generated survivin-overexpressing ASCs transfected with a plasmid comprising a gene encoding survivin. The secreted substances released from survivin-overexpressing ASCs (survivin-secretome) were collected, and were determined their in vitro and in vivo therapeutic potential, especially in the model of liver impairment.

Results

In vitro, the survivin-secretome significantly increased cell viability and promoted the expression of proliferation-related markers (proliferating cell nuclear antigen [PCNA], phospho-signal transducer and activator of transcription 3 (p-STAT3), hepatocyte growth factor [HGF], vascular endothelial growth factor [VEGF]) and anti-apoptosis-related markers (myeloid cell leukemia-1 [Mcl-1] and survivin) (P < 0.05). In vivo using 70% hepatectomy mice, the survivin-secretome group exhibited the lowest serum levels of interleukin-6, tumor necrosis factor-α (P < 0.05). The serum levels of liver transaminases (alanine aminotransferase and aspartate aminotransferase) were also the lowest in the survivin-secretome group (P < 0.05). The survivin-secretome group also exhibited the highest liver regeneration on the 7th day after 70% partial hepatectomy (P < 0.05). In the subsequent liver specimen analysis, the specimens of survivin-secretome exhibited the highest expression of p-STAT3, HGF, VEGF, PCNA, and Mcl-1 and the lowest expression of bcl-2-like protein 4 (P < 0.05).

Conclusion

Taken together, secretome secreted by survivin-overexpressing ASCs could be an effective way to improve liver regeneration and repair for liver injury treatment.

Establishing a Standardized Measure of Quality in Pediatric Liver Surgery: Definition and Validation of Textbook Outcome With Associated Predictors

Purpose: To establish comparable reporting of surgical results in pediatric liver surgery, the recently introduced composite outcome measures Textbook Outcome (TO) and Comprehensive Complication Index (CCI) are applied and validated in a pediatric surgery context for the first time. In a representative cohort of pediatric patients undergoing liver resection, predictive factors for TO and CCI are investigated, and outcomes are compared to available literature on surgical outcomes of pediatric liver resection.

Methods: All liver resections for patients under 21 years of age performed at the Department of General, Visceral, Transplantation and Pediatric Surgery of the University of Heidelberg between 2009 and 2020 were included in the analysis. Criteria for TO were defined prior to the analysis. Univariate and Multivariate regression was applied to identify factors associated with TO and CCI.

Results: Fifty-three pediatric patients underwent liver resections during the observation period. No 30- or 90-day mortality occurred. Twenty-three patients (43.4%) had a TO. CCI and TO showed highly significant correlation (b = −30.33, 95% CI [−37.44; −23.22], p < 0.001). Multivariate analyses revealed significant association between intraoperative blood loss (adjusted for circulating blood volume) and CCI (b = 0.70, 95%CI [0.22; 1.32], p = 0.008) and failure to achieve TO (OR = 0.85, 95%CI [0.69; 0.97], p = 0.048).

Conclusion: TO and CCI are suited outcome measures in pediatric surgical studies and offer objective comparability of results. Their application in clinical studies will be a major step forward to establish evidence-based therapies in pediatric surgery. Systematic utilization of TO and CCI can aid in generating comparable studies on surgical techniques and outcomes in pediatric liver resection.

When does a Pringle Maneuver cause harm?

BACKGROUND

The Pringle Maneuver (PM) is considered to be safe and effective. However, data regarding perioperative outcomes after a PM are conflicting. Therefore, the aim of this analysis is to compare the outcomes of patients who have and have not undergone a PM in North America.

METHODS

Patients undergoing major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-17 ACS-NSQIP hepatectomy database. Patients with and without a PM were compared. Propensity matching was utilized, and subgroup analyses by liver texture, hepatectomy extent and pathology were performed.

RESULTS

Prior to matching, 3706 (24%) of 15,748 hepatectomy patients underwent a PM. The PM was utilized in 1445 (27%) of major and 2261 (22%) of partial hepatectomies. After matching, 3295 patients with and 3295 without a PM were compared. Operative time was significantly increased for patients undergoing a PM (246 vs. 225 min, p < 0.001). Subgroup analyses revealed post-hepatectomy liver failure and septic shock to be significantly increased (both p < 0.05) for patients undergoing a PM during a partial hepatectomy or in patients with metastatic disease.

CONCLUSION

Patients undergoing a partial hepatectomy and those with metastatic disease have worse outcomes when a Pringle Maneuver is performed.