Impact of COVID-19 pandemic on surgical outcomes after hepatopancreatobiliary (HPB) surgery

COVID-19 pandemic has disrupted healthcare systems worldwide, causing the postponement or cancellation of millions of elective surgeries. It is essential for hepatopancreatobiliary (HPB) surgeons to well understand the perioperative risk and management of HPB surgery during the COVID-19 pandemic, including the impact of preoperative COVID-19 infection and timing of surgery, the impact of COVID-19 infection on postoperative mortality, the postoperative pulmonary complications in patients with perioperative COVID-19 infection, and the postoperative complications without pulmonary involvement. Perioperative COVID-19 infection increases the risk of postoperative mortality and pulmonary complications in patients undergoing abdominal surgery. Furthermore, in some regions, the COVID-19 vaccine's availability is still limited, leading to an increase in the number of cases and potential medical collapse, which could hinder the improvement of HPB postoperative mortality rates. The timing of surgery for COVID-19 positive patients should be carefully considered, balancing the potential risks of delay with the risks of surgery during the infection.

[ERAS: perioperative care for the benefit of the patient]

During surgical procedures, surgery, and anesthesia lead to pathophysiological stress on the human body. The goal of perioperative medicine is to prepare patients and take all possible measures to reduce this pathophysiological stress. The emergence of ERAS over the past 15 years has made it possible to set up a multimodal program based on scientific evidence, showing that the adequate application of an improved rehabilitation program after surgery, ERAS-type, is possible in all surgical specialties, including gynecology, cardiac surgery, and neurosurgery. ERAS improves the quality of life of patients, reduces postoperative complications and lengths of stay, and finally, reduces costs. The purpose of this article is to show the most important elements of such an ERAS program by taking the example of digestive surgery.

Long-term outcomes of ruptured hepatocellular carcinoma: An international multicentric propensity score-matched study

Objective

Long-term outcomes of patients with ruptured hepatocellular carcinoma (rHCC) remain scant. This study aimed to assess disease-free survival (DFS) and overall survival (OS) after surgical resection of rHCC compared to non-ruptured HCC (nrHCC).

Methods

Patients with rHCC and nrHCC were collected from 8 centers in Europe, Asia, and North America. Resected rHCC patients were matched 1:1 to patients undergoing surgery for nrHCC using propensity score and nearest-neighbor method (matching criteria: age, tumor size, cirrhosis, Child-Pugh score, Barcelona Clinic Liver Cancer stage, resection status, grade, and microvascular invasion). Survival rates were calculated using Kaplan-Meier method.

Results

A total of 2033 patients were included: 226 rHCC patients (172 operated: 68 with upfront surgery and 104 after embolization) and 1807 nrHCC patients. Median DFS and OS of rHCC patients (all treatments confounded) were 10 months (95% CI 7–13) and 22 months (95% CI 13–31). Prognostic factors for worse OS among rHCC patients were absence of preoperative arterial embolization (HR 2.3, 95% CI 1.2–4.6, p=0.016), cirrhosis Child B/C (HR 2.4, 95% CI 1.1–5.4, p=0.040), and R1/R2 margins (HR 2, 95% CI 1–5, p=0.049). Survivals were similar between Western and Eastern rHCC patients.

After propensity score matching, 106 rHCC patients and 106 nrHCC patients displayed similar characteristics. Patients with rHCC had shorter median DFS (12 months, 95% CI 7–17 vs. 22 months, 95% CI 12–32, p=0.011), but similar median OS compared to nrHCC patients (43 months, 95% CI 21–65 vs. 63 months, 95% CI 21–105, p=0.060).

Conclusion

In this large dataset including Eastern and Western patients, rHCC was associated with shorter DFS compared to nrHCC, while OS was similar.

The Tokyo 2020 terminology of liver anatomy and resections: Updates of the Brisbane 2000 system

BACKGROUND

The Brisbane 2000 Terminology for Liver Anatomy and Resections, based on Couinaud's segments, did not address how to identify segmental borders and anatomic territories of less than one segment. Smaller anatomic resections including segmentectomies and subsegmentectomies, have not been well defined. The advent of minimally invasive liver resection has enhanced the possibilities of more precise resection due to a magnified view and reduced bleeding, and minimally invasive anatomic liver resection (MIALR) is becoming popular gradually. Therefore, there is a need for updating the Brisbane 2000 system, including anatomic segmentectomy or less. An online "Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" was hosted on February 23, 2021.

METHODS

The Steering Committee invited 34 international experts from around the world. The Expert Committee (EC) selected 12 questions and two future research topics in the terminology session. The EC created seven tentative definitions and five recommendations based on the experts' opinions and the literature review performed by the Research Committee. Two Delphi Rounds finalized those definitions and recommendations.

RESULTS

This paper presents seven definitions and five recommendations regarding anatomic segmentectomy or less. In addition, two future research topics are discussed.

CONCLUSIONS

The PAM-HBP Surgery Consensus has presented the Tokyo 2020 Terminology for Liver Anatomy and Resections. The terminology has added definitions of liver anatomy and resections that were not defined in the Brisbane 2000 system.

Minimally invasive anatomic liver resection: Results of a survey of world experts

BACKGROUND

Although the number of minimally invasive liver resections (MILRs) has been steadily increasing in many institutions, minimally invasive anatomic liver resection (MIALR) remains a complicated procedure that has not been standardized. We present the results of a survey among expert liver surgeons as a benchmark for standardizing MIALR.

METHOD

We administered this survey to 34 expert liver surgeons who routinely perform MIALR. The survey contained questions on personal experience with liver resection, inflow/outflow control methods, and identification techniques of intersegmental/sectional planes (IPs).

RESULTS

All 34 participants completed the survey; 24 experts (70%) had more than 11 years of experience with MILR, and over 80% of experts had performed over 100 open resections and MILRs each. Regarding the methods used for laparoscopic or robotic anatomic resection, the Glissonean approach (GA) was a more frequent procedure than the hilar approach (HA). Although hepatic veins were considered essential landmarks, the exposure methods varied. The top three techniques that the experts recommended for identifying IPs were creating a demarcation line, indocyanine green negative staining method, and intraoperative ultrasound.

CONCLUSION

Minimally invasive anatomic liver resection remains a challenging procedure; however, a certain degree of consensus exists among expert liver surgeons.

Expert Consensus Guidelines: How to safely perform minimally invasive anatomic liver resection

BACKGROUND

The concept of minimally invasive anatomic liver resection (MIALR) is gaining popularity. However, specific technical skills need to be acquired to safely perform MIALR. The "Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" was developed as a special program during the 32nd meeting of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS).

METHODS

Thirty-four international experts gathered online for the consensus. A Research Committee performed a comprehensive literature review, classifying studies according to the Scottish Intercollegiate Guidelines Network method. Based on the literature review and experts' opinions, tentative recommendations were drafted and circulated among experts using online Delphi Rounds. Finally, formulated recommendations were presented online in the Expert Consensus Meeting of the JSHBPS on February 23rd, 2021. The final recommendations were validated and finalized by the 2nd Delphi Round in May 2021.

RESULTS

Seven clinical questions were selected, and 22 recommendations were formulated. All recommendations reached more than 85% consensus among experts at the final Delphi Round.

CONCLUSIONS

The Expert Consensus Meeting for safely performing MIALR has presented a set of clinical guidelines based on available literature and experts' opinions. We expect these guidelines to have a favorable effect on the safe implementation and development of MIALR.

Correlation Between Portal Pressure and Indocyanine Green Retention Rate is Unaffected by the Cause of Cirrhosis: A Prospective Study

Background

Accurate estimation of the hepatic functional reserve before liver resection is important to avoid post-hepatectomy liver failure (PHLF). The aim of the present study was to evaluate the association of indocyanine green retention test with portal pressure by the cause of cirrhosis (non-viral vs. viral) and assessed postoperative outcomes including incidence of PHLF in patients with viral and non-viral cirrhosis.

Methods

The cohort includes 50 consecutive patients with liver cirrhosis scheduled for liver resection for primary liver tumors at the Lausanne University Hospital between 2009 and 2018.

Results

There were 31 patients with non-viral liver cirrhosis (Non-virus group) and 19 with viral liver cirrhosis (virus group). The indocyanine green retention rate at 15 min (ICG-R15) (p = 0.276), Hepatic Venous Portal Gradient (HVPG; p = 0.301), and postoperative outcomes did not differ between the non-virus group and viral group. ICG-R15 and HVPG showed a significant linear correlation in all patients (Spearman’s rank correlation coefficient, ρ = 0.599, p < 0.001), the non-virus group (ρ = 0.555, p = 0.026), and the virus group (ρ = 0.534, p = 0.007). A receiver operating characteristic curve analysis showed that ICG-R15 was a predictor for presence of portal hypertension (PH; HVPG ≥ 12 mmHg) (area under the curve [AUC] = 0.780). The cut-off value of ICG-R15 for predicting the presence of PH was 16.0% with 72.3% of sensitivity and 79.0% of specificity.

Conclusions

The ICG-R15 level was associated with portal pressure in both patients with non-virus cirrhosis and patients with virus cirrhosis and predicts the incidence of PH with relatively good discriminatory ability.

Clinical trial number

https://clinicalTrials.gov(ID:NCT00827723)

Local ethics committee number

CER-VD 251.08

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review

BACKGROUND

The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR.

METHODS

A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript.

RESULTS

The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes.

CONCLUSIONS

Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.

Therapeutic effect of portal vein stenting for portal vein stenosis after upper-abdominal surgery

BACKGROUND

The therapeutic effect of portal vein (PV) stenting for PV stenosis following nontransplant hepato-pancreato-biliary (HPB) surgery has not been fully investigated.

METHODS

Changes in portal venous pressure (PVP) gradient before and after stenting, complications, symptomatic improvement, and stent patency were evaluated.

RESULTS

We identified 14 consecutive patients undergoing PV stenting for malignant (n = 8) and benign (n = 6) PV stenosis. Signs of PV stenosis were composed of refractory ascites in 6 patients, varices with hemorrhagic tendencies in 5, and abnormal liver function in 5. The median PVP gradient after PV stenting was 3.0 cm H₂O (range, 1.5-3.0), which was significantly smaller than that before PV stenting (median, 15 cm H₂O [range, 2.5-25]; P < 0.01). Thirteen out of 14 (93%) achieved clinical success with symptomatic improvement, except one patient with sustained refractory ascites because of peritoneal seeding. During the median follow-up time of 7.3 months (range, 1.0-87), stent occlusion occurred in two patients (14%) because of intrastent tumor growth. The 1-year cumulative stent patency rate was 76% in the entire cohort.

CONCLUSIONS

Based on durable effect on patency, we deemed PV stenting for PV stenosis after HPB surgery to be safe and beneficial for improving symptoms.

Assessment of Preoperative Liver Function for Surgical Decision Making in Patients with Hepatocellular Carcinoma

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) have underlying liver disease and a preoperative liver function evaluation is important to avoid postoperative liver failure and death. In Western guidelines, portal hypertension (PH) is listed as a contraindication for liver resection. On the other hand, the indocyanine green retention rate at 15 min (ICG R15) has been widely used in Asian countries for surgical decision making. However, these criteria are based on reports published in the 20th century that included only a small number of patients and were developed empirically.

SUMMARY

The number of published case series concerning liver resection in HCC patients with PH has been rapidly increasing since 2011, indicating that liver resection in HCC patients with PH is now routinely performed in specialized centers worldwide. Although PH certainly has an impact and should be considered as a contraindication for major liver resection, it is no longer considered to be a contraindication for minor liver resection, especially laparoscopic liver resection. In addition, new biomarkers and imaging tools to assess preoperative liver function have been extensively reported. The combination of these new factors to well-known risk factors, such as PH and ICG R15, might strengthen the ability to stratify the risk of postoperative liver failure.

KEY MESSAGES

The present review covers recent topics regarding the assessment of preoperative liver function for surgical decision making in patients with HCC.

Quantitative Assessment of the Accuracy of Real-Time Virtual Sonography for Liver Surgery

Background. Real-time virtual sonography (RVS) is a navigation system for liver surgery. In this study, the degree of misalignment of intraoperative RVS images with computed tomographic (CT) images was measured. Methods. Between December 2014 and July 2015, intraoperative RVS was performed in a total of 33 patients undergoing liver surgery. Reconstructed CT images, rendered like intraoperative ultrasonographic (IOUS) images, were adjusted with the IOUS images and visualized side by side. The degree of misalignment between the reconstructed CT images and IOUS images was measured at anterior section, posterior section, and left liver in each patient. Furthermore, the time required for the adjustment was measured as the "adjustment time." Results. The degree of misalignment between the images could potentially be measured for a total of 96 points in the 33 patients. Of these, the actual measurement could not be conducted for 35 points due to poor visualization of the intrahepatic vasculature (n = 20) or to a large misalignment that hampered continuation of further adjustment (n = 15). The median degree of misalignment was 9.8 mm (range = 2.4-37.6 mm) in the right anterior section, 9.8 mm (range = 2.7-71.5 mm) in the right posterior section, and 9.5 mm (range = 0.9-37.6 mm) in the left liver. The median adjustment time was 105 seconds (range = 51-245 seconds). Conclusions. Although some misalignment occurred, it might be acceptable for selected situations. Further investigation is needed to reduce the frequency of adjustment failure.

Albumin-Indocyanine Green Evaluation (ALICE) grade combined with portal hypertension to predict post-hepatectomy liver failure

AIM

The aim of this study was to evaluate the role of liver function factors in predicting a postoperative large-volume ascites (LA) and post-hepatectomy liver failure (PHLF).

METHODS

We included 1025 consecutive patients undergoing hepatectomy for hepatocellular carcinoma between 2002 and 2014. Univariate and multivariate analyses were carried out to evaluate the role of each factor of liver function in predicting LA and PHLF. Factors included the presence of portal hypertension (PH), extent of resection, Model for End-stage Liver Disease (MELD) score, and Albumin-Indocyanine Green Evaluation (ALICE) grade.

RESULTS

The ALICE score was the strongest predictor for LA (odds ratio [OR], 5.02) and PHLF (OR, 10.94). Conversely, MELD score was not a significant predictive factor for LA or PHLF based on the multivariate analysis. In the ALICE grade 2 group, patients with PH showed a significantly high incidence of developing LA and experiencing PHLF compared with those without PH (LA, 22.4% vs. 10.3%, P < 0.001; PHLF, 8.6% vs. 1.3%, P < 0.001, respectively). Of patients in the ALICE 2 group, those undergoing sectoriectomy or more extensive resection were associated with extremely poor outcomes (LA, 54.2%; PHLF, 29.2%).

CONCLUSIONS

A combination of ALICE grade and presence of PH is a useful predictor of LA and PHLF.

Liver Resection for Hepatocellular Carcinoma in Patients with Renal Dysfunction

BACKGROUND

The aim of this study was to evaluate the feasibility of liver resection in hepatocellular carcinoma (HCC) patients with preoperative renal dysfunction (RD).

METHODS

Data from 735 patients undergoing primary liver resection for HCC between 2002 and 2014 were analyzed. Short- and long-term outcomes were compared between the RD group, defined by a preoperative estimated glomerular filtration rate of <45 mL/min/1.73 m², and the non-RD group.

RESULTS

Sixty-two patients had RD. The incidence of postoperative pleural effusion (24 vs. 11%; P = 0.007) and major complications (Clavien-Dindo III-V; 31 vs. 15%; P = 0.003) were significantly higher in RD patients. In RD patients with Child-Pugh A, 90-day mortality rate (1.9%) and median survival time (6.11 years) were comparable to that of non-RD patients. In contrast, RD patients with Child-Pugh B had a very high 90-day mortality rate (22.2%), and a significant shorter median survival time compared to non-RD patients (1.19 vs. 4.84 years; P = 0.001).

CONCLUSIONS

Liver resection for Child-Pugh A patients with RD is safe and has comparable oncological outcomes compared to non-RD patients. However, selection of liver resection candidates from Child-Pugh B patients with RD should be stricter.

Surgical Site Infection after Hepatectomy for Hepatocellular Carcinoma

AIMS

To clarify the clinical impact, risk factors, and preventive methods for surgical site infection (SSI) after hepatectomy for hepatocellular carcinoma (HCC).

METHODS

We included 879 consecutive patients who underwent hepatectomy for HCC between 2002 and 2011. Univariate and multivariate analyses were conducted to identify the risk factors for incisional and organ/space SSIs. ORs and 95% CIs are reported.

RESULTS

The incidences of incisional and organ/space SSIs were 24 (2.7%) and 73 (8.3%), respectively. High body mass index, multiple resections, and organ/space SSI were associated with incisional SSIs, while repeat hepatectomy (OR 2.14, 95% CI 1.27-3.60), ascites (OR 2.97, 95% CI 1.55-5.48), and bile leakage (OR 4.77, 95% CI 2.77-8.11) were independent risk factors for organ/space SSI. Among the cases with bile leakage, lower rates of organ/space SSIs tended to be observed in patients with cystic duct tubes than in patients without such tubes (13.2 vs. 26.5%, p = 0.157). Retrograde drain infections increased when drain placement was prolonged for more than 4 postoperative days.

CONCLUSION

Bile leakage was associated with the greatest risk of organ/space SSI after hepatectomy for HCC. Cystic duct tubes might be useful for preventing bile leakage and subsequent organ/space SSI after procedures that extensively expose Glissonean pedicles.

Preclinical study of c-Met inhibitor as an adjuvant treatment for hepatocellular carcinoma with macroscopic portal vein invasion

301

Background: Patients with advanced hepatocellular carcinoma (HCC) demonstrating a macroscopic portal vein tumor thrombus (PVTT) have been reported to have an extremely poor prognosis. Palliative sorafenib is the only recommended treatment option. Methods: We statistically compared the patient characteristics and surgical outcomes in HCC patients with PVTT. Among 1,611 hepatic resections, 105 cases of PVTT were identified. Microarray analysis was performed in three patients to identify gene expression changes in PVTT compared with those in the principal tumor, and the changes were validated in 20 human HCC tissues with PVTT. The human HCC cell lines HuH-7 and SKHep-1 were used for this experimental study. A subcutaneously transplanted xenograft model was employed for the in vivo study. The c-Met inhibitor SU11274 was used in both in vitro and in vivoanalyses. Results: The median survival time in patients with PVTT was 2.01 years, while that in patients without PVTT was 6.43 years; the median time to recurrence was 0.31 and 1.61 years, respectively. Microarray analysis revealed 36 genes related to PVTT. Immunohistochemistry analysis revealed that compared with the principal tumor, E-cadherin (a key regulator of cancer metastatic potential) significantly decreased in PVTT in all 20 patients. The c-Met inhibitor elevated the E-cadherin expression level in HCC cells both in vitro and in vivo. This inhibitor induced sheet formation and attenuated the migration of HCC cells. Conclusions: Although liver resection provides acceptable overall survival for patients with PVTT, the recurrence rate remains high. The c-Met inhibitor exhibits an anti-metastatic effect in vitro and in vivo and may be useful as an adjuvant treatment for PVTT.

Ectopic Jejunal Variceal Rupture in a Liver Transplant Recipient Successfully Treated With Percutaneous Transhepatic Coil Embolization: A Case Report

Here we present the rupture of ectopic jejunal varices developing in a liver transplant recipient without portal hypertension, which was successfully treated with percutaneous transhepatic coil embolization.A 48-year-old man with massive melena was admitted to our department. He had undergone liver transplantation for hepatitis B virus-related liver cirrhosis 8 months before, and his postoperative course was satisfactory except for an acute cellular rejection. No evidence of bleeding was detected by upper endoscopy or colonoscopy, but dynamic multidetector computed tomography of the whole abdomen revealed an intestinal varix protruding into the lumen of the jejunum with suspected extravasation. There was no evidence of portal venous stenosis or thrombosis. Immediately upon diagnosis of the ruptured ectopic jejunal varix, percutaneous transhepatic coil embolization was performed, achieving complete hemostasis. The portal venous pressure measured during the procedure was within normal limits. He was discharged from the hospital 11 days after embolization and remained in stable condition without re-bleeding 6 months after discharge.This is the first report of an ectopic intestinal variceal rupture in an uneventful liver transplant recipient that was successfully treated with interventional percutaneous transhepatic coil embolization. Clinicians encountering liver transplant recipients with melena should be aware of the possibility of late-onset rupture of ectopic varices, even in those having an uneventful post-transplant course without portal hypertension.

Isolation of novel mycobacteria contaminating an aquarium fish tank in a Japanese university hospital

AIMS

To better understand nontuberculous mycobacteria (NTM) contamination in a hospital setting, six freshwater fish gut homogenates and water in an aquarium fish tank placed on the reception counter of a nursing station were cultured for mycobacteria.

METHODS AND RESULTS

By direct sequencing of 16s rRNA, rpoB and hsp65, scotochromogenic and nonchromogenic Mycobacterium szulgai isolates containing hsp65 type II (GenBank accession nos. FJ384762 and FJ384764, respectively), Mycobacterium gordonae isolates containing rpoB clusters B and E (GenBank accession no. FJ384766), and Mycobacterium kansasii isolates containing hsp65 type VI were collected from the gut homogenates and water from the fish tank. However, no isolates were obtained from the tap water used to refill the fish tank. A randomly amplified polymorphic DNA (RAPD) analysis using a 10-mer primer (5'-TGGTCGCGGC) showed that some NTM from the fish tank water were identical to those obtained from the gut homogenates.

CONCLUSIONS

Fish and water in the tank were contaminated by the novel NTM.

SIGNIFICANCE AND IMPACT OF THE STUDY

These findings could help to elucidate infection routes and contamination sources of novel NTM from water sources.