Perioperative blood transfusion does not influence recurrence-free and overall survivals after curative resection for hepatocellular carcinoma: A Propensity Score Matching Analysis

Major Hepatectomy in Elderly Patients with Large Hepatocellular Carcinoma: A Multicenter Retrospective Observational Study

BACKGROUND

With an increase in life expectancy and improvement of surgical safety, more elderly patients with hepatocellular carcinoma (HCC), even with large tumors, are now considered for hepatectomy. This study aimed to clarify the impact of age on short- and long-term outcomes after major hepatectomy (≥3 segments) for large HCC (≥5 cm).

PATIENTS AND METHODS

Using a multicenter database, patients who underwent curative-intent major hepatectomy for large HCC between 2006 and 2016 were identified. Postoperative morbidity and mortality, overall survival (OS) and recurrence-free survival (RFS) were compared between the elderly (≥65 years) and younger (<65 years) patients. Univariable and multivariable Cox-regression analyses were performed to identify the risk factors of OS and RFS in the entire and elderly cohorts, respectively.

RESULTS

Of 830 patients, 92 (11.1%) and 738 (88.9%) were elderly and younger patients, respectively. There were no significant differences in postoperative 30-day mortality and morbidity between the two groups (5.4% vs 2.6% and 43.5% vs 38.3%, both P>0.05). The 5-year OS and RFS rates in elderly patients were also comparable to younger patients (35.0% vs 33.2% and 20.0% vs 20.8%, both P>0.05). In the entire cohort, multivariable Cox-regression analyses identified that old age was not independently associated with OS and RFS. However, in the elderly cohort, preoperative alpha-fetoprotein level >400 μg/L, multiple tumors, macrovascular invasion and microvascular invasion were independently associated with decreased OS and RFS.

CONCLUSION

Carefully selected elderly patients benefited from major hepatectomy for large HCC as much as younger patients, and their long-term prognosis was determined by preoperative alpha-fetoprotein level, tumor number and presence of macro- or micro-vascular invasion.

Perioperative Allogeneic Blood Transfusion Does not Influence Patient Survival After Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis

BACKGROUND

Whether perioperative allogeneic blood transfusion (PABT) negatively influences patient survival after hepatectomy (HR) for hepatocellular carcinoma (HCC) remains controversial.

METHODS

Five hundred two patients who underwent HR for initial HCC between 1994 and 2015 were enrolled in this study. All patients were divided into two groups: the PABT group and the non-PABT group. Differences of clinicopathological factors, overall survival (OS), recurrence-free survival (RFS), and the recurrence pattern between the two groups were evaluated. Using propensity score matching for tumor-related factors, liver functions, and surgical factors (total 11 factors), the survival impact of PABT was also analyzed.

RESULTS

In the entire cohort, 78 patients (15.5%) received PABT such as red cell concentrate, fresh-frozen plasma, or platelets. OS (5-year OS: 55% vs. 76%; p = 0.0005) and RFS (2-year RFS: 47% vs. 56%; p = 0.0131) were significantly worse in the PABT group. The extrahepatic recurrence happened more frequently in the PABT group (15% vs. 5.4%; p = 0.0039). There were many significant clinicopathological differences between the two groups: more advanced tumor stage (tumor diameter, stage III or IV, microvascular invasion), worse liver functions (albumin, indocyanine green retention rate at 15 min), and more surgical stress (blood loss, operation time) in the PABT group. After propensity score matching, 43 pairs of patients were extracted. In this matched cohort, the survival curves of the PABT and non-PABT groups almost completely overlapped both in OS (5-year OS: 62% vs. 62%; p = 0.4384) and in RFS (2-year RFS: 49% vs. 47%; p = 0.8195). The significant difference of the extrahepatic recurrence rate disappeared in the matched cohort (p = 0.5789).

CONCLUSION

Using propensity score matching, we found that PABT does not influence patient survival after HR for HCC.

Perioperative blood transfusion has distinct postsurgical oncologic impact on patients with different stage of hepatocellular carcinoma

Background

The influence of perioperative blood transfusion (PBT) on postsurgical survival of patients with different stage of hepatocellular carcinoma (HCC) is not well clarified. This study aimed to evaluate the impact of PBT on survival outcomes of different stage of HCC patients.

Methods

Consecutive patients who underwent liver resection for HCC between January 2009 and November 2015 were identified from an HCC prospective database in authors’ center. The survival outcomes were compared between patients receiving PBT and those without PBT before and after propensity score matching (PSM) in different stage subsets. Cox regression analysis was performed to verify the impact of PBT on outcomes of HCC.

Results

Among 1255 patients included, 804 (64.1%) were Barcelona Clinic Liver Cancer (BCLC) stage 0-A, and 347 (27.6%) received PBT. Before PSM, patients with PBT had worse disease free survival (DFS) and overall survival (OS) compared with those without PBT in both BCLC 0-A subset and BCLC B-C subset (all P < 0.05). After PSM, 288 pairs of patients (with and without PBT) were created. In the subset of BCLC 0-A, the median DFS of patients with PBT was shorter than those without PBT (12.0 months vs. 36.0 months, P = 0.001) Similar result was observed for OS (36.0 months vs. 96.0 months, P = 0.001). In the subset of BCLC B-C, both DFS and OS were comparable between patients with PBT and those without PBT. Cox regression analysis showed that PBT involved an increasing risk of DFS (HR = 1.607; P < 0.001) and OS (HR = 1.756; P < 0.001) for this subset. However, PBT had no impact on DFS (P = 0.126) or OS (P = 0.139) for those with stage B-C HCC.

Conclusions

PBT negatively influenced oncologic outcomes of patient with BCLC stage 0-A HCC, but not those with stage B-C after curative resection.

Recipient Age for Liver Transplantation: Should It Be Limited? A Propensity Score Matching Analysis of a Large European Series

BACKGROUND AND AIMS

The demand for older patients not to be denied access to liver transplantation (LT) has intensified as the European population continues to live longer and maintains better health.

AIM

This study aims to ascertain the impact of recipient age on the post-LT survival in 2 well-balanced populations at Vall d'Hebron University Hospital.

METHODS

From January 1990 to December 2016, LT recipients (young group: 50-65 years of age; elderly group: >65 years of age) were compared by means of a propensity score matching (PSM) method.

RESULTS

Prior to PSM, graft survival and patient survival were worse for the elderly group (P < .001). In 1126 LT recipients, a caliper width of 0.01 was used based on the donor (age, sex, cause of donor death, and donor intensive care unit stay) and recipient covariates (sex, body mass index, indication for LT, intraoperative blood transfusion, cardiovascular risk factors, and Model for End-Stage Liver Disease [MELD]-Era). After PSM, 206 patients were matched; 1-, 5-, and 10-year patient survival rates were 77%, 63%, and 52% vs 80%, 64%, and 45% (P = .50) for young vs elderly recipients, respectively. Similar graft survival rates were observed in both groups (P = .42).

CONCLUSIONS

Advanced age alone should not exclude patients from LT.

Effects of general anesthesia versus local anesthesia in primary hepatocellular carcinoma patients presenting for thermal ablation surgery: a multiple center retrospective cohort study with propensity score matching

Background

Whether anesthesia methods affect the prognosis of tumor patients is controversial. With the aim of comparing the effects of general anesthesia (GA) and local anesthesia (LA) in primary hepatocellular carcinoma (HCC) patients presenting for elective thermal ablation (TA) surgeries, a multiple center retrospective cohort study was designed and implemented.

Methods

Patients who received elective TA surgery under GA or LA from Jan. 2014 to Dec. 2016 and met the eligibility criteria were included. Survival analysis was used to identify the influence of anesthesia methods on recurrence-free survival (RFS) and overall survival (OS). Propensity score matching (PSM) was used to minimize the bias between the GA group and the LA group.

Results

A total of 244 patients with GA and 245 with LA were eligible for analysis. After PSM, 178 patients remained in each group. In the matched groups, GA showed a significantly higher recurrence rate compared with LA by both the Kaplan-Meier survival analyses (P=0.011) and multivariable Cox regression analyses (P=0.002). The multivariable Cox regression model also revealed that GA had a hazard ratio (HR) of 1.746 (P=0.036) for death compared with the LA group.

Conclusions

GA is associated with decreased RFS and OS after surgery compared with LA in HCC patients undergoing TA surgery. Prospective trials exploring the effects of different anesthetic methods on cancer outcome in these patients are warranted.

Association between body mass index and postoperative morbidity after liver resection of hepatocellular carcinoma: A multicenter study of 1,324 patients

BACKGROUND

Morbidity remains a common problem following hepatic resection. The aim of this study was to investigate the association between preoperative body mass index (BMI) and morbidity in patients undergoing liver resection for hepatocellular carcinoma (HCC).

METHODS

Patients were divided into three groups according to preoperative BMI: low-BMI (≤18.4 kg/m2), normal-BMI (18.5-24.9 kg/m2) and high-BMI (≥25.0 kg/m2). Baseline characteristics, operative variables, postoperative 30-day mortality and morbidity were compared. Univariable and multivariable analyses were performed to identify independent risk factors associated with postoperative morbidity.

RESULTS

Among 1324 patients, 108 (8.2%), 733 (55.4%), and 483 (36.5%) were low-BMI, normal-BMI, and high-BMI, respectively. There were no differences in postoperative 30-day mortality among patients based on BMI (P = 0.199). Postoperative 30-day morbidity was, however, higher in low-BMI and high-BMI patients versus patients with a normal-BMI (33.3% and 32.1% vs. 22.9%, P = 0.018 and P < 0.001, respectively). Following multivariable analysis low-BMI and high-BMI remained independently associated with an increased risk of postoperative morbidity (OR: 1.701, 95%CI: 1.060-2.729, P = 0.028, and OR: 1.491, 95%CI: 1.131-1.966, P = 0.005, respectively). Similar results were noted in the incidence of postoperative 30-day surgical site infection (SSI).

CONCLUSION

Compared with normal-BMI patients, low-BMI and high-BMI patients had higher postoperative morbidity, including a higher incidence of SSI after liver resection for HCC.

Long-term Effects of Repeat Hepatectomy vs Percutaneous Radiofrequency Ablation Among Patients With Recurrent Hepatocellular Carcinoma: A Randomized Clinical Trial

IMPORTANCE

Repeat hepatectomy and percutaneous radiofrequency ablation (PRFA) are most commonly used to treat early-stage recurrent hepatocellular carcinoma (RHCC) after initial resection, but previous studies comparing the effectiveness of the 2 treatments have reported conflicting results.

OBJECTIVE

To compare the long-term survival outcomes after repeat hepatectomy with those after PRFA among patients with early-stage RHCC.

DESIGN, SETTING, AND PARTICIPANTS

This open-label randomized clinical trial was conducted at the Eastern Hepatobiliary Surgery Hospital and the National Center for Liver Cancer of China. A total of 240 patients with RHCC (with a solitary nodule diameter of ≤5 cm; 3 or fewer nodules, each ≤3 cm in diameter; and no macroscopic vascular invasion or distant metastasis) were randomized 1:1 to receive repeat hepatectomy or PRFA between June 3, 2010, and January 15, 2013. The median (range) follow-up time was 44.3 (4.3-90.6) months (last follow-up, January 15, 2018). Data analysis was conducted from June 15, 2018, to September 28, 2018.

INTERVENTIONS

Repeat hepatectomy (n = 120) or PRFA (n = 120).

MAIN OUTCOMES AND MEASURES

The primary outcome was overall survival (OS). Secondary outcomes included repeat recurrence-free survival (rRFS), patterns of repeat recurrence, and therapeutic safety.

RESULTS

Among the 240 randomized patients (216 men [90.0%]; median [range] age, 53.0 [24.0-59.0] years), 217 completed the trial. In the intention-to-treat (ITT) population, the 1-year, 3-year, and 5-year OS rates were 92.5% (95% CI, 87.9%-97.3%), 65.8% (95% CI, 57.8%-74.8%), and 43.6% (95% CI, 35.5%-53.5%), respectively, for the repeat hepatectomy group and 87.5% (95% CI, 81.8%-93.6%), 52.5% (95% CI, 44.2%-62.2%), and 38.5% (95% CI, 30.6%-48.4%), respectively, for the PRFA group (P = .17). The corresponding 1-year, 3-year, and 5-year rRFS rates were 85.0% (95% CI, 78.8%-91.6%), 52.4% (95% CI, 44.2%-62.2%), and 36.2% (95% CI, 28.5%-46.0%), respectively, for the repeat hepatectomy group and 74.2% (95% CI, 66.7%-82.4%), 41.7% (95% CI, 33.7%-51.5%), and 30.2% (95% CI, 22.9%-39.8%), respectively, for the PRFA group (P = .09). Percutaneous radiofrequency ablation was associated with a higher incidence of local repeat recurrence (37.8% vs 21.7%, P = .04) and early repeat recurrence than repeat hepatectomy (40.3% vs 23.3%, P = .04). In subgroup analyses, PRFA was associated with worse OS vs repeat hepatectomy among patients with an RHCC nodule diameter greater than 3 cm (hazard ratio, 1.72; 95% CI, 1.05-2.84) or an α fetoprotein level greater than 200 ng/mL (hazard ratio, 1.85; 95% CI, 1.15-2.96). Surgery had a higher complication rate than did ablation (22.4% vs 7.3%, P = .001).

CONCLUSIONS AND RELEVANCE

No statistically significant difference was observed in survival outcomes after repeat hepatectomy vs PRFA for patients with early-stage RHCC. Repeat hepatectomy may be associated with better local disease control and long-term survival in patients with an RHCC diameter greater than 3 cm or an AFP level greater than 200 ng/mL.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00822562.

Comparisons of recurrence-free survival and overall survival between microwave versus radiofrequency ablation treatment for hepatocellular carcinoma: A multiple centers retrospective cohort study with propensity score matching

Both microwave (MW) ablation and radiofrequency (RF) ablation are widely used for hepatocellular carcinoma (HCC) treatments in clinic. However, it is still unclear if ablative methods could influence the recurrence-free survival (RFS) and overall survival (OS) of HCC patients. Therefore, we carried out this multi-center retrospective cohort study to investigate the differences of recurrence-free survival (RFS) and overall survival (OS) between MW ablation and RF ablation by survival analysis. From January 2014 to December 2016, patients who received thermal ablation surgery for HCC treatment were screened. Finally, 452 patients met the eligibility criteria and finished the follow-up. Univariable and multivariable regression analyses were used to identify independent predictive factors of the RFS and OS. Also, propensity score matching (PSM) was used to balance the bias between two groups. Finally, we found that before the PSM, the univariable and multivariable regression analyses revealed that there were no significant differences on the RFS between two groups. Same results were obtained for the OS. After PSM, 115 pairs of patients were created, and both the univariable and multivariable regression analyses suggested that there were still no significant differences on the RFS between two groups. Same results were obtained for the OS. In conclusion, our present study showed that there were no significant differences between MW ablation and RF ablation for HCC patients on the RFS or OS.

Long-term outcomes after hepatectomy of huge hepatocellular carcinoma: A single-center experience in China

BACKGROUND

Currently, hepatectomy remains the first-line therapy for hepatocellular carcinoma (HCC). However, surgery for patients with huge (>10 cm) HCCs is controversial. This retrospective study aimed to explore long-term survival after hepatectomy for patients with huge HCC.

METHODS

The records of 188 patients with pathologically confirmed HCC who underwent curative hepatectomy between 2007 and 2017 were reviewed; patients were divided into three groups according to tumor size: huge (>10 cm; n = 84), large (5-10 cm; n = 51) and small (<5 cm; n = 53) HCC. Kaplan-Meier analysis was used to assess overall survival (OS) and disease-free survival (DFS), and log-rank analysis was performed for pairwise comparisons among the three groups. Risk factors for survival and recurrence were analyzed using the Cox proportional hazard model.

RESULTS

The median follow-up period was 20 months. Although the prognosis of small HCC was better than that of huge and large HCC, OS and DFS were not significantly different between huge and large HCC (P = 0.099 and P = 0.831, respectively). A family history of HCC, poor Child-Pugh class, vascular invasion, diolame, pathologically positive margins, and operative time ≥240 min were identified as independent risk factors for OS and DFS in a multivariate model. Tumor size (>10 cm) had significant effect on OS, and postoperative antiviral therapy and postoperative complications also had significant effects on DFS.

CONCLUSIONS

Huge HCC is not a contraindication of hepatectomy. Although most of these patients experienced recurrence after surgery, OS and DFS were not significantly different from those of patients with large HCC after resection.

Preoperative transcatheter arterial chemoembolization for surgical resection of huge hepatocellular carcinoma (≥ 10 cm): a multicenter propensity matching analysis

BACKGROUND AND AIMS

Surgical resection for hepatocellular carcinoma (HCC) is potentially curative, but long-term survival remains unsatisfactory. There is currently no effective neoadjuvant or adjuvant therapy for HCC. We sought to evaluate the impact of preoperative transcatheter arterial chemoembolization (TACE) on long-term prognosis after surgical resection of huge HCCs (≥ 10 cm).

METHODS

Using a multicenter database, consecutive patients who underwent curative-intent resection for huge HCC without macrovascular invasion between 2004 and 2014 were identified. The association between preoperative TACE with perioperative outcomes, long-term overall survival (OS), and recurrence-free survival (RFS) was assessed before and after propensity score matching (PSM).

RESULTS

Among the 377 enrolled patients, 88 patients (23.3%) received preoperative TACE. The incidence of perioperative mortality and morbidity was comparable among patients who did and did not undergo preoperative TACE (3.4% vs. 2.4%, p= 0.704, and 33.0% vs. 31.1%, p= 0.749, respectively). PSM analysis created 84 matched pairs of patients. In examining the entire cohort as well as the PSM cohort, median OS (overall cohort: 32.8 vs. 22.3 months, p= 0.035, and PSM only: 32.8 vs. 18.1 months, p= 0.023, respectively) and RFS (12.9 vs. 6.4 months, p= 0.016, and 12.9 vs. 4.1 months, p= 0.009, respectively) were better among patients who underwent preoperative TACE vs. patients who did not. After adjustment for other confounding factors on multivariable analyses, preoperative TACE remained independently associated with a favorable OS and RFS after the resection of huge HCC.

CONCLUSION

Preoperative TACE did not increase perioperative morbidity or mortality, yet was associated with an improved OS and RFS after liver resection of huge HCC (≥ 10 cm).

Transfusion of red blood cells does not impact progression-free and overall survival after surgery for ovarian cancer

BACKGROUND

Allogeneic red blood cells (RBCs) have the potential to impact the immunosurveillance of the recipient and may therefore increase the risk of recurrence after cancer surgery. In this article the relationship between perioperative RBC transfusion and the risk of recurrence after ovarian cancer surgery is examined.

STUDY DESIGN AND METHODS

This is a retrospective cohort analysis of a prospective database of patients who underwent surgery due to primary ovarian cancer between 2006 and 2014 and who had no residual disease after surgery. Patients who did and did not receive perioperative RBC transfusion were compared. The primary endpoint was progression-free survival (PFS). Propensity score matching (PSM) and Cox proportional hazards regression (CPH) was used to control for between-group differences of prognostic determinants.

RESULTS

A total of 529 patients with a median follow-up of 51.4 months (95% CI, 46.1-56.5) were eligible for analysis. Of those, 408 patients (77.1%) received allogeneic, leukoreduced RBCs with a median of 4 units (IQR, 2-6) per patient. There was a strong selection bias of prognostic determinants between patients with and without transfusion. In unadjusted analysis, transfusion of RBCs was associated with an increased risk of cancer recurrence (hazard ratio [HR] of PFS 2.71 [95% CI, 1.94-3.77], p < 0.001). After bias reduction, transfusion of RBCs was no longer associated with an increased risk of cancer recurrence, neither in PSM-adjusted (HR 1.03 [95% CI, 0.59-1.80], p = 0.91), nor in multivariable CPH-adjusted analysis (HR 1.26 [95% CI, 0.85-1.86], p = 0.23).

CONCLUSION

Perioperative transfusion of RBCs did not increase the risk of recurrence after ovarian cancer surgery.

Anatomic resection and wide resection margin play an important role in hepatectomy for hepatocellular carcinoma with peritumoural micrometastasis

BACKGROUND

Anatomic hepatectomy and wide resection margin may improve surgical outcome of patients with hepatocellular carcinoma (HCC), but not everyone gain survival benefit. It remains unclear what kind of patients would benefit from those surgical methods. We investigated the factors affecting survival of patients with HCC, with special attention paid to the surgical methods and pathological factors.

METHODS

A retrospective analysis was conducted on 231 patients with hepatitis B-related HCC who underwent surgery from August 2011 to November 2013 in authors' institute. The survival analysis included the following variables: gender, age, viral load, alpha-fetoprotein, des-γ-carboxy prothrombin, tumour size, cirrhosis, blood transfusion, complications, resection method, resection margin, microvascular invasion (mVI), peritumoural satellite nodule, recurrence time and recurrent burden.

RESULTS

The median follow-up time was 59 months. A total of 196 patients (84.9%) recurred and 151 patients (65.4%) deceased due to the disease. Multivariate analysis showed that cirrhosis, mVI and periturmoral satellite nodules were independent risk factors affecting overall survival after operation. The comparison between anatomic resection and local resection, and wide resection margin and narrow resection margin showed no significant differences for recurrence-free survival and overall survival, respectively (P = 0.089 and 0.068, 0.108 and 0.122). Stratified analysis revealed that anatomic resection and wide resection margin surgery improved survival when mVI or peritumoural satellite existed.

CONCLUSION

Anatomic resection and wide resection margin are effective methods to improve the surgical outcome of HCC with periturmoral micrometastasis, although tumour characteristics affect patients' survival more than surgical techniques.

Long-Term Survival Outcomes After Liver Resection for Binodular Hepatocellular Carcinoma: A Multicenter Cohort Study

BACKGROUND

The long-term prognosis after liver resection for multinodular (≥3 nodules) hepatocellular carcinoma (HCC) is generally considered to be unfavorable. However, the role of liver resection for binodular HCC is less investigated.

SUBJECTS, MATERIALS, AND METHODS

From a multicenter database, consecutive patients who underwent curative-intent liver resection for binodular HCC and without macrovascular invasion between 2003 and 2015 were retrospectively reviewed. Patients' clinical variables as well as perioperative and long-term survival outcomes were analyzed. Univariable and multivariable analyses were performed to identify the risk factors associated with overall survival (OS) and recurrence-free survival (RFS) after curative resection.

RESULTS

Of 263 enrolled patients, the perioperative 30-day mortality and morbidity rates were 1.5% and 28.5%. The 1-, 3-, and 5-year OS and RFS rates were 81.5%, 52.4%, and 39.1% and 57.1%, 35.8%, and 26.6%, respectively. Multivariable Cox-regression analyses identified preoperative alpha-fetoprotein level >400 μg/L, tumor size with a sum of two nodules >8 cm, tumor size ratio of large/small nodule >1.5 (asymmetrical proportion), unilateral hemiliver distribution of two nodules, distance of ≤3 cm between two nodules, and microvascular invasion in any nodule as independent risk factors associated with decreased OS and RFS.

CONCLUSION

Liver resection was safe and feasible in patients with binodular HCC, with acceptable perioperative and long-term outcomes. Sum of two tumor sizes, size ratio and distribution, and distance between two nodules were independent risk factors associated with long-term survival outcomes after surgery. These results may guide clinicians to make individualized surgical decisions and estimate long-term prognosis for these patients.

IMPLICATIONS FOR PRACTICE

Liver resection was safe and feasible in patients with binodular hepatocellular carcinoma, with acceptable perioperative and long-term outcomes. The sum of two tumor sizes, the size ratio and distribution of the two nodules, and the distance between two nodules were independent risk factors associated with long-term overall survival and recurrence-free survival after liver resection. The results of this study may guide clinicians to make individualized surgical decisions, estimate long-term prognosis, and plan recurrence surveillance and adjuvant therapy for these patients.

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial

BACKGROUND

It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation.

OBJECTIVE

The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients.

DESIGN

Prospective observational study.

SETTING

Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand.

PATIENTS

Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy.

INTERVENTIONS

Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5).

MAIN OUTCOME MEASURES

Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA.

RESULTS

From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically.

CONCLUSION

Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass.

TRIAL REGISTRATION

The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216.

Application value of thromboelastography in perioperative clinical blood transfusion and its effect on the outcome of patient

Application value of thromboelastography (TEG) in perioperative clinical blood transfusion and its effect on the outcome of patient were investigated. Seventy-four patients, admitted to The Surgical Department of the First Hospital of Zibo from March 2015 to March 2018, were selected for this study. Among them, 34 patients took only the traditional coagulation function testing method as the blood transfusion guide during the perioperative period and they were regarded as the control group. The other 40 patients used TEG as the blood transfusion guide during the perioperative period, and they were regarded as the TEG group. The coagulation function indicators in 2 h before the operation and in 24 h after the operation, the transfusion amount and blood loss during the operation, the condition of the blood transfusion during the perioperative period, the occurrence rate of the postoperative rebleeding, the length of hospital stay and mortality of the patients in the two groups were compared. The coagulation function indicators of the patients in the two groups in 2 h before the operation and in 24 h after the operation showed that there was no significant difference between the two groups (P>0.050). However, APTT and Pt of the patients in the two groups both increased when compared with those before the treatment (P<0.050) and Hb, Hct, Plt and Fib all decreased (P<0.050). The suspended erythrocytes, Plt, fibrinogen and plasma in the TEG group were both significantly lower than those in the control group (P<0.001). Compared with the traditional coagulation function test, TEG was more accurate for estimating the coagulation function of patient and was more suitable for estimating the condition of blood transfusion of patient in the perioperative period; also, it could shorten the recovery period of patient and it is worthwhile to promote it in the clinic.

Clinicopathological features and prognosis of young gastric cancer patients following radical gastrectomy: a propensity score matching analysis

The aim of the this retrospective study was to investigate the clinicopathological features of gastric cancer (GC) in young patients and the potential impact of age on the prognosis of patients undergoing radical gastrectomy for GC. From November 2010 to November 2016, 317 young (≤45 years) and 1344 older patients (>45 years) who underwent radical gastrectomy for stage I-III GC were enrolled. The association between age and prognosis was estimated by univariate and multivariate analyses after propensity score matching (PSM). Compared with older patients, the proportion of females, poorly differentiated tumors, good nutritional status, and who received neo-adjuvant and/or adjuvant chemotherapy was significant higher in younger patients, but were less likely to suffer from comorbidities or post-operative complications (all P < 0.05). PSM analysis created 310 pairs of patients. After matching, the long-term survival in younger patients was significantly longer than in older patients at stage I, but similar at stages II and III. However, a young age was not identified as a significant prognostic factor. In conclusion, the prognosis of young GC patients is comparable with and even better than that in older patients after radical gastrectomy when matched for baseline characteristics. Early detection could improve the prognosis of young GC patients.

Association of family history with long-term prognosis in patients undergoing liver resection of HBV-related hepatocellular carcinoma

Background

Family history is a risk factor for the development of hepatocellular carcinoma (HCC). The aim of the current study was to investigate the association between family history of HCC and long-term oncologic prognosis among patients undergoing curative liver resection for hepatitis B virus (HBV)-related HCC.

Methods

Patients who underwent curative liver resection of HBV-related HCC between 2003 and 2013 were consecutively enrolled. Family history was defined as a self-reported history of HCC in a first-degree relative. Propensity score matching (PSM) and multivariable Cox-regression analyses were performed to compare overall survival (OS) and recurrence-free survival (RFS) among patients with and without a family history.

Results

Among 1,112 patients, 183 (16.5%) patients had a family history of HCC. Using PSM, 179 pairs of patients with and without a family history were created that had no differences in the baseline characteristics and operative variables. On matched analysis, family history was associated with decreased OS and RFS after curative-intent resection of HBV-related HCC in the propensity matching cohort (P=0.042 and 0.006, respectively). On multivariable Cox-regression analyses, a family history of HCC was associated with decreased OS (HR: 1.574; 95% CI: 1.171-2.116; P=0.003) and RFS (HR: 1.534; 95% CI: 1.176-2.002; P=0.002) after adjusting for other prognostic risk factors.

Conclusions

Family history was associated with decreased OS and RFS rates among patients undergoing curative liver resection of HBV-related HCC.

Microvascular invasion predicts a poor prognosis of solitary hepatocellular carcinoma up to 2 cm based on propensity score matching analysis

AIM

Microvascular invasion (MVI) is not discussed for solitary hepatocellular carcinoma (HCC) up to 2 cm in the 8th Edition of the American Joint Committee on Cancer Staging Manual. The present study aimed to reappraise the influence of MVI on solitary HCC up to 2 cm in diameter.

METHODS

Between January 2010 and December 2012, a retrospective cohort of 496 HCC patients from the Eastern Hepatobiliary Surgery Hospital was analyzed. Propensity score matching was carried out to balance the baseline characteristics. Survival analysis was carried out using the Kaplan-Meier method. Risk factors were evaluated using the Cox proportional hazards model. Multivariate logistic regression was used to identify the risk factors associated with MVI.

RESULTS

All patients were classified into either an MVI-negative group (n = 332) or an MVI-positive group (n = 164). The MVI-positive group had poorer recurrence-free survival and overall survival before and after propensity score matching. The multivariate analysis showed that MVI; being male; increased total bilirubin levels, alanine transaminase levels and γ-glutamyl transpeptidase levels; decreased albumin levels; and HBV DNA load >10³  IU/mL were risk factors for recurrence-free survival. MVI, older age, lower albumin levels, and cirrhosis were risk factors for overall survival. Age <50 years, alpha-fetoprotein >20 ng/mL, and lack of or an incomplete capsule were significantly independent predictors for MVI.

CONCLUSIONS

MVI had a negative impact on the prognosis of solitary HCC up to 2 cm after curative hepatectomy. The 8th edition of the American Joint Committee on Cancer staging system could be improved by subdividing solitary HCC up to 2 cm according to MVI.

Intrathecal Morphine Administration Does Not Affect Survival After Liver Resection for Hepatocellular Carcinoma

Introduction. Opioids may influence tumor recurrence and cancer-free survival in hepatocellular carcinoma (HCC). The relationship between intrathecal morphine administration, tumor recurrence, and patient survival after hepatectomy for HCC is unknown. Patients and Methods. This single-center, retrospective study included 1837 liver resections between July 2002 and December 2012; 410 cases were incorporated in the final univariate and multivariate analysis. Confirmatory propensity matching yielded 65 matched pairs (intrathecal morphine vs none). Primary outcomes were recurrence of HCC and survival. Secondary outcomes included characterization of factors associated with recurrence and survival. Results. Groups were similar except for increased coronary artery disease in the no intrathecal morphine group. All patients received volatile anesthesia. Compared with no intrathecal morphine (N = 307), intrathecal morphine (N = 103) was associated with decreased intraoperative intravenous morphine administration (median difference = 12.5 mg; 95% confidence interval [CI] = 5-20 mg). There was no difference in blood loss, transfusion, 3- or 5-year survival, or recurrence in the univariate analysis. Multivariate analysis identified covariates that significantly correlated with 5-year survival: intrathecal morphine (hazard ratio [HR] = 0.527, 95% CI = 0.296-0.939), lesion diameter (HR = 1.099, 95% CI = 1.060-1.141), vascular invasion (HR = 1.658, 95% CI = 1.178-2.334), and satellite lesions (HR = 2.238, 95% CI = 1.447-3.463). Survival analysis on the propensity-matched pairs did not demonstrate a difference in 5-year recurrence or survival. Discussion and Conclusion. Multivariate analysis revealed a significant association between intrathecal morphine and 5-year survival. This association did not persist after propensity matching. The association between intrathecal morphine and HCC recurrence and survival remains unclear and prospective work is necessary to determine whether an association exists.

Identification of Actual 10-Year Survival After Hepatectomy of HBV-Related Hepatocellular Carcinoma: a Multicenter Study

BACKGROUND

Hepatitis B virus (HBV) infection is the leading cause of hepatocellular carcinoma (HCC) worldwide. The aim of the study was to identify the incidence and predictive factors of actual 10-year survival following liver resection of HBV-related HCC.

METHODS

A Chinese multicenter database of patients undergoing curative hepatectomy of HBV-related HCC was reviewed. Patients who survived ≥ 10 years and patients who died < 10 years after surgery were compared and analyzed. Univariable and multivariable regression analyses were performed to identify predictive factors associated with 10-year survival.

RESULTS

Among all enrolled 1016 patients, the actuarial 10-year survival rate was 24.1%, while the actual 10-year survival rate was 16.6%. There were 169 patients who survived at least 10 years after surgery and 688 who died within 10 years from surgery. These patients constituted the study population of this study. Multivariable regression analysis revealed that cirrhosis, preoperative HBV viral load > 104 copies/mL, maximum tumor size > 5 cm, multiple tumors, macroscopic and microscopic vascular invasion, postoperative HBV reactivation, and early recurrence (< 2 years after surgery) were independent risk factors associated with actual 10-year survival, while postoperative antiviral therapy, regular recurrence surveillance, and curative treatments for initial recurrence were independent protective factors.

CONCLUSIONS

The actual 10-year survival after curative resection of HBV-related HCC was calculated to be 16.6%. Postoperative antiviral therapy and regular recurrence surveillance were independent protective factors associated with actual 10-year survival after liver resection of HBV-related HCC.

Multicentre study of the prognostic impact of preoperative bodyweight on long-term prognosis of hepatocellular carcinoma

BACKGROUND

Whether preoperative bodyweight is associated with long-term prognosis in patients after liver resection for hepatocellular carcinoma (HCC) is controversial. This study aimed to investigate the relationship of patient weight with long-term recurrence and overall survival (OS) after curative liver resection for HCC.

METHODS

Data for patients with HCC who underwent curative liver resection between 2000 and 2015 in five centres in China were analysed retrospectively in three groups according to their preoperative BMI: underweight (BMI 18·4 kg/m2 or less), normal weight (BMI 18·5-24·9 kg/m2 ) and overweight (BMI 25·0 kg/m2 or above). Patients' baseline characteristics, operative variables and long-term survival outcomes were compared. Univariable and multivariable Cox regression analyses were performed to identify risk factors for OS and recurrence-free survival (RFS) after resection.

RESULTS

Of 1524 patients, 107 (7·0 per cent) were underweight, 891 (58·5 per cent) were of normal weight and 526 (34·5 per cent) were overweight. Univariable analyses showed that underweight and overweight patients had poorer OS (both P < 0·001) and RFS (both P < 0·001) than patients of normal weight. Multivariable Cox regression analysis also identified both underweight and overweight to be independent risk factors for OS (hazard ratio (HR) 1·22, 95 per cent c.i. 1·19 to 1·56, P = 0·019; and HR 1·57, 1·36 to 1·81, P < 0·001, respectively) and RFS (HR 1·28, 1·16 to 1·53, P = 0·028; and HR 1·34, 1·17 to 1·54, P < 0·001).

CONCLUSION

Underweight and overweight patients appear to have a worse prognosis than those of normal weight following liver resection for HCC.

Preoperative prealbumin level as an independent predictor of long-term prognosis after liver resection for hepatocellular carcinoma: a multi-institutional study

BACKGROUND

Serum prealbumin is a sensitive and stable marker for nutritional status and liver function. Whether preoperative prealbumin level is associated with long-term prognosis in patients undergoing liver resection for hepatocellular carcinoma (HCC) is unclear.

METHODS

Patients who underwent liver resection for HCC between 2001 and 2014 at six institutions were enrolled. These patients were divided into the low and normal prealbumin groups using a cut-off value of 170 mg/L for preoperative prealbumin level. The overall survival (OS) and recurrence-free survival (RFS) were compared between them.

RESULTS

In 1483 patients, 437 (29%) had a low prealbumin level. The 3- and 5-year OS and RFS rates of patients in the low-prealbumin group were 57 and 31%, and 40 and 20%, respectively, which were significantly poorer than those in the normal-prealbumin group (76 and 43%, and 56 and 28%, respectively, both p < 0.001). Multivariable Cox-regression analyses revealed that preoperative prealbumin level was an independent predictor of OS (HR, 1.45, 95% CI: 1.24-1.70, p <0.001) and RFS (HR, 1.28, 95% CI: 1.10-1.48, p <0.001).

CONCLUSIONS

Preoperative prealbumin level could be used in predicting long-term prognosis for patients undergoing liver resection for HCC.

Perioperative and long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with well-preserved liver function and cirrhotic background: a propensity score matching study

BACKGROUND

Although laparoscopic liver resection (LLR) has advanced into a safe and effective alternative to conventional open liver resection (OLR), it has not been widely accepted by surgeons. This article aimed to investigate the perioperative and long-term benefits of LLR versus OLR for hepatocellular carcinoma (HCC) in selected patients with well-preserved liver function and cirrhotic background.

METHODS

A retrospective study was conducted on 1085 patients with HCC who underwent liver resection at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from July 2010 to July 2015, and 346 patients with well-preserved liver function and cirrhotic background were selected. A 1:1 propensity score matching (PSM), which is the best option to overcome selection bias, was conducted to compare the surgical outcomes and long-term prognosis between LLR and OLR. After PSM, a logistic regression analysis was used to identify the predictive risk factors of posthepatectomy liver failure (PHLF).

RESULTS

By using PSM, the two groups were well balanced with 86 patients in each group. In the LLR group, only the median operation time was significantly longer than the OLR group, but the hospital stay, overall morbidity, and the incidence of PHLF were significantly decreased compared to OLR. There were no significant differences in the overall survival and disease-free survival rates between the two groups. On multivariate analysis, OLR was identified to be the only independent risk factor for PHLF.

CONCLUSIONS

In selected HCC patients with well-preserved liver function and cirrhotic background, LLR could be a better option compared to OLR.

A wide-margin liver resection improves long-term outcomes for patients with HBV-related hepatocellular carcinoma with microvascular invasion

BACKGROUND

The impact of the resection margin on survival outcomes in patients with hepatocellular carcinoma remains to be determined. This study aimed to examine the association between the width of resection margin and the presence of microvascular invasion in hepatitis B virus-related hepatocellular carcinoma.

METHODS

We reviewed data on 2,508 consecutive patients who underwent liver resection for a solitary, hepatitis B virus-related hepatocellular carcinoma for operative morbidity, tumor recurrence, and overall survival.

RESULTS

Microvascular invasion was identified histologically in 929 patients (37.0%). A wide margin of resection (≥1 cm, n = 384) resulted in better 5-year recurrence and overall survival versus a narrow margin of resection (<1 cm, n = 545) among patients with microvascular invasion (71.1% versus 85.9%; 44.9% versus 25.0%; both P < .001), but not in patients without microvascular invasion (P = .131, .182). Similar results were identified after propensity-score matching. A wide margin resection also had a lesser incidence of early recurrence developed within the first postoperative 24 months (58.1% versus 72.7%; P < .001). Compared with a wide resection margin, a narrow margin was associated with worse recurrence and overall survival in patients with microvascular invasion (hazard ratio: 1.50 and 1.75). In addition, a wide or a narrow resection margin had differences in the rate of grade I-III, but not grade IV complications (31.0% versus 21.7%; P = .017; 3.5% versus 1.6%; P = .147) among cirrhotic patients with microvascular invasion.

CONCLUSION

The presence of microvascular invasion was associated with a worse prognosis after resection. A wide resection margin resulted in better long-term prognoses versus a narrow resection margin among patients with hepatitis B virus-related hepatocellular carcinoma with microvascular invasion.

Association of Preoperative Antiviral Treatment With Incidences of Microvascular Invasion and Early Tumor Recurrence in Hepatitis B Virus-Related Hepatocellular Carcinoma

IMPORTANCE

A reduced incidence of microvascular invasion (MVI) in hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) may be associated with a decreased risk of early tumor recurrence and better survival after partial hepatectomy.

OBJECTIVE

To examine the association of preoperative antiviral treatment (AVT) with the incidences of MVI and posthepatectomy early tumor recurrence in HBV-related HCC.

DESIGN, SETTING, AND PARTICIPANTS

Data on a cohort of 2362 patients who underwent R0 resection for HBV-related HCC between January 2008 and April 2010 at the Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China, were reviewed. The median (interquartile range) postoperative follow-up was 44.8 (22.8-59.3) months. Data were analyzed from June 2016 to October 2017.

INTERVENTIONS

Preoperative AVT and partial hepatectomy.

MAIN OUTCOMES AND MEASURES

Overall survival and time to recurrence after surgery were calculated and compared using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Independent risk factors of MVI presence were assessed by logistic regression analysis.

RESULTS

Among 2362 included patients, 1999 (84.6%) were men, and the median (interquartile range) age was 50.6 (43.1-57.3) years. A total of 2036 patients (86.2%) did not receive any preoperative AVT, while 326 (13.8%) received ongoing AVT more than 90 days before surgery. In the non-AVT group, compared with a preoperative HBV DNA level of less than 2000 IU/mL, a preoperative HBV DNA level of 2000 IU/mL or greater was associated with an increased risk of MVI (odds ratio [OR], 1.399; 95% CI, 1.151-1.701). Compared with the non-AVT group, patients receiving AVT had a lower incidence of MVI (38.7% [126 of 326] vs 48.6% [989 of 2036]; P = .001) and reduced risk of MVI (OR, 0.758; 95% CI, 0.575-0.998). A complete response to AVT was an independent protective factor of MVI (OR, 0.690; 95% CI, 0.500-0.952). Accordingly, preoperative AVT was associated with decreased 6-month, 1-year, and 2-year recurrences vs non-AVT (14.2%, 24.6%, and 38.5%, respectively, vs 23.4%, 37.1%, and 52.3%; P < .001); AVT was protective of early tumor recurrence (hazard ratio, 0.732; 95% CI, 0.605-0.886). In addition, patients in the non-AVT group were more likely to have multiple intrahepatic recurrences (49.1% [549 of 1119] vs 36.2% [54 of 149]; P = .003) and recurrences involving multiple hepatic segments compared with patients receiving AVT.

CONCLUSIONS AND RELEVANCE

A high preoperative HBV DNA level was an independent risk factor of MVI. Antiviral treatment administered more than 90 days before surgery was associated with reduced incidences of MVI and early tumor recurrence after partial hepatectomy for HBV-related HCC.

The impact of perioperative allogeneic blood transfusion on prognosis of hepatocellular carcinoma after radical hepatectomy: A systematic review and meta-analysis of cohort studies

This meta-analysis aims to clarify the clinical impacts of allogeneic blood transfusion (ABT) on hepatectomy outcome in hepatocellular carcinoma (HCC) patients. A systematic literature search was performed for relevant articles in international and Chinese databases up to May 2018. Random- or fixed-effect meta-analysis was used to pool the effect estimates. Publication bias was assessed by Egger's and Peters's test. Heterogeneity was assessed using the I statistic. The strength of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation system. A total of 29 studies met the eligibility criteria. Meta-analysis showed HCC patients in ABT group had lower survival rate at 1, 3, 5, and 10 years after radical hepatectomy than those in no blood transfusion (NBT) group (RR = 0.9, 95%CI: 0.87-0.93, P < .05; RR = 0.83, 95%CI: 0.77-0.89, P < .05; RR = 0.7, 95%CI: 0.65-0.74, P < .05; RR = 0.64, 95%CI: 0.54-0.75, P < .05). Similar results were observed in disease-free survival (DFS) (respectively: RR = 0.86, 95%CI: 0.82-0.91, P < .05; RR = 0.77, 95%CI: 0.67-0.79, P < .05; RR = 0.71, 95%CI: 0.64-0.79, P < .05; RR = 0.62, 95%CI: 0.48-0.8, P < .05). Cancer recurrence rate was higher for the patients in ABT group at 1 and 3 years (RR = 1.5, 95%CI: 1-2.24, P < .05; RR = 1.27, 95%CI: 1.09-1.49, P < .05, respectively), but not statistically significant at 5years (RR = 1.08, 95%CI: 0.98-1.19, P = .512). The HCC patients in ABT group increased postoperative complications occurrence compared with those in NBT group (RR = 1.87, 95%CI: 1.42-2.45, P < .05). This meta-analysis demonstrated that ABT was associated with adverse clinical outcomes for HCC patients undergoing radical hepatectomy, including poor survival, DFS, and complications. Surgeons should reduce blood loss during hepatectomy and avoid perioperative allogenic blood transfusion.

Preoperative survival calculator for resectable hepatocellular carcinoma

Background

Estimation of preoperative overall survival (OS) of hepatocellular carcinoma (HCC) may guide surgical decision-making.

Methods

OS was analyzed using the National Cancer Data Base from 1998-2012. Patients with HCC who underwent wedge resection, lobectomy or extended lobectomy were selected. Patients who had metastatic disease or previous treatment prior to surgery were excluded. Data was randomly allocated to model building (n_b =4,364) and validation cohorts (n_v =1,091). Multivariable regression analyses of the n_b were used to construct prediction models and optimized using n_v.

Results

HCC patients (n=5,455) who underwent curative resection had a median OS of 36 months (95% CI, 34-38 months) with 1- and 3-year OS of 73% (95% CI, 72-74%) and 50% (95% CI, 49-51%), respectively. The patient median age was 65, 66% of patients were male, median tumor size was 60 mm; clinical stage 1 =25%, stage 2 =30% and stage 3 =45%. Alpha fetoprotein (AFP) was elevated in 63% of patients. Factors significant in the prediction model included degree of resection, age, race, tumor size, grade, and histologic subtype.

Conclusions

A preoperative OS calculator was developed to assist in the treatment evaluation and OS prediction of HCC patients.

Impact of peri-operative blood transfusion on post-operative infections after radical gastrectomy for gastric cancer: a propensity score matching analysis focusing on the timing, amount of transfusion and role of leukocyte depletion

Purpose

Allogeneic blood transfusions (BTF) are sometimes inevitable during radical gastrectomy with lymphadenectomy for advanced gastric cancer. The aim of this retrospective study was to investigate the association between BTF and post-operative infections, focusing on the impact of timing, amount of transfusion and the role of leukocyte depletion.

Methods

The study cohort was 2064 patients who underwent gastrectomy for gastric cancer from November 2010 to August 2017. The association between BTF and post-operative infections was estimated by univariate and multivariate analyses after propensity score matching. Subgroup analysis was performed according to the timing and amount of transfusion, and leukocyte depletion or not.

Results

Out of a total 2064 patients, 426 (20.6%) received peri-operative BTF. After one-to-one matching, 361 pairs of patients were included for further analysis, of who 68 (9.4%) developed infections. Multivariate analysis identified that an operation time ≥ 240 min, combined multi-organ resection, BTF and BMI ≥ 25 kg/m² were independent risk factors for post-operative infection. Patients given a high-volume (> 7.5 U), intra-operatively of leukocyte-non-depleted BTF had the highest risk of developing infections clarified by subgroup analysis.

Conclusion

Infection was the most common complication following gastrectomy for gastric cancer and BTF was identified as an independent risk factor by propensity score matching and multivariate analyses. The timing, amount of transfusion and leukocyte depletion had an impact on the incidence of infection. To decrease infection, BTF should be avoided where possible, particularly during operation, with a large amount and leukocyte-not-depleted blood.

Perioperative blood transfusion has no effect on overall survival after esophageal resection for esophageal squamous cell carcinoma: A retrospective cohort study

BACKGROUND

The impact of perioperative blood transfusion (PBT) on the prognosis of esophageal cancer patients remains inconclusive. The purpose of this study was to assess the association between PBT and survival in esophageal squamous cell carcinoma (ESCC) patients.

MATERIALS AND METHODS

In this retrospective study, patients with ESCC who underwent esophageal resection from January 2008 to December 2011 were analyzed. The overall survival and postoperative outcomes between PBT and non-PBT patients were compared using Cox regression and propensity score matching (PSM) analysis.

RESULTS

A total of 935 patients were enrolled in this study. Before PSM, the 5-year overall survival rates in PBT and non-PBT patients were 48.4% and 56.3% (P = 0.001), respectively. The postoperative infection rate in PBT patients was 32.32%, which exceeded the rate of 24.22% in non-PBT patients (P = 0.008). PSM created 306 pairs of patients. After PSM, the 5-year overall survival rates in PBT and non-PBT patients were 49.4% and 51.0% (P = 0.334), respectively. The postoperative infection rate in PBT patients was 31.04%, which was higher than the rate of 26.47% in non-PBT patients (P = 0.105). Multivariable Cox regression analyses showed that PBT was not an independent risk factor for overall survival (HR: 0.792, 95% CI: 0.615-1.021, P = 0.072).

CONCLUSION

Perioperative blood transfusion has no effect on the overall survival of ESCC patients.

HabibTM 4X-assisted resection versus clamp-crush resection for hepatocellular carcinoma: a propensity-matching study

Long term outcome of ablation-assisted hepatic resection is unclear for hepatocellular carcinoma (HCC) patients. This study was scheduled to compare the outcome of Habib 4X ablation assisted resection (Habib group) with clamp-crush resection (CC group) for HCC. In this study, we retrospectively enrolled 81 patients from the Habib group and 103 patients from the CC group. Oncologic outcomes were analyzed using a propensity score matching (PSM) method. Compared with the CC group, the Habib group had higher levels of γ-glutamyltransferase (P=0.044) and albumin (P=0.001), larger tumor sizes (P=0.007), shorter operation times (P=0.001), less blood loss (P=0.005), and less blood transfusions (P=0.038). There were no significant differences in complications (P=0.310), recurrence-free survival rates (RFS, P=0.112), or overall survival rates (OS, P=0.203) between the two groups. For the 67 patient pairs selected from the PSM analysis, the Habib group had better RFS and OS (P=0.033 and P=0.014, respectively). A Cox proportional hazards analysis revealed that Habib-assisted resection was an independent factor for RFS and OS (P=0.008 and P=0.016, respectively). Furthermore, for the 42 patients with central and large tumors, the Habib group had better RFS and OS than the CC group (P=0.035 and P=0.038, respectively). However, the differences of RFS and OS (P=0.117 and P=0.126, respectively) were not significant among 92 patients with peripheral or small tumors. Hence, Habib^TM 4X-assisted resection is safe and provides better survival for HCC patients, particularly those with central and large tumors.

The prognostic role of perioperative allogeneic blood transfusions in gastric cancer patients undergoing curative resection: A systematic review and meta-analysis of non-randomized, adjusted studies

The impact of allogeneic perioperative blood transfusions (APTs) on the prognosis of gastric cancer patients undergoing curative-intent gastrectomy is still a highly debated topic. Two meta-analyses were published in 2015, and new studies report conflicting results. A literature review was conducted using PubMed, Scopus, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews, updated to March 1, 2016. Thirty-eight non-randomized studies reporting data on overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS) and postoperative complications (PCs) were included. An inverse variance random-effects meta-analysis was conducted. APTs showed an association with worse OS, DFS, DSS and an increased number of PCs. The hazard ratio (HR) for OS was 1.49, with a 95% confidence interval (95% CI) of 1.32-1.69 (p < .00001; Q-test p = .001, I-squared = 56%). After outlier exclusion, the HR for OS was 1.34 (95% CI = 1.23-1.45, p < .00001; Q-test p = .64, I-squared = 0%). The HR for DFS was 1.48 (95% CI = 1.18-1.86, p = .0007; Q-test p = .31, I-squared = 16%), and the HR for DSS was 1.66 (95% CI = 1.5-2.19, p = .0004; Q-test p = .96, I-squared = 0%). The odds ratio for PCs was 3.33 (95% CI = 2.10-5.29, p < .00001; Q-test p = .14, I-squared = 42%). This meta-analysis showed a significant association between transfusions and OS, DFS, DSS and PCs. The quality of the evidence was low. Aggregation, selection and selective reporting bias were detected. The biases shifted the results towards significance. Further studies using accurate adjustment methods are needed. Until such additional studies are performed, caution in administering transfusions and optimization of cancer patient blood management are warranted.

Peri-Operative Blood Transfusion Does Not Influence Overall and Disease-Free Survival After Radical Gastrectomy for Stage II/III Gastric Cancer: a Propensity Score Matching Analysis

OBJECTIVE

Whether peri-operative blood transfusions (BTF) negatively impact long-term survival after gastrectomy for gastric cancer (GC) remains controversial. The aim of this retrospective study was to investigate independent predictive factors of BTF and the potential impact of BTF on overall survival (OS) and disease-free survival (DFS) in patients who underwent radical gastrectomy for stage II/III GC.

METHODS

Of 1020 patients who underwent gastrectomy for stage II/III GC from November 2010 to December 2015, 231 (22.6%) patients received BTF. The independent predictive factors of BTF were identified using univariate and multivariate analyses. Cox regression and propensity score matching (PSM) analyses of OS and DFS in patients who received BTF or not were compared.

RESULTS

Multivariate analysis revealed that age, pre-operative hemoglobin levels, tumor size, operation time, combined multi-organ resection, and intra-operative blood loss were independent predictive factors for BTF. PSM analysis created 205 pairs of patients. BTF was significantly associated with decreased OS (P = 0.025) and DFS (P = 0.034) in the entire cohort before PSM. After PSM, there was no longer a significant association between BTF and OS (P = 0.850) or DFS (P = 0.880). BTF was not identified as an independent risk factor for OS or DFS by multivariate Cox regression analysis.

CONCLUSIONS

The present study revealed that BTF did not influence OS and DFS after radical gastrectomy for stage II/III GC. Worse oncological outcomes were caused by clinical circumstances requiring blood transfusions, including longer operation time and advanced tumor stage, not due to BTF itself.

Perioperative blood transfusion does not affect recurrence-free and overall survivals after curative resection for intrahepatic cholangiocarcinoma: a propensity score matching analysis

Background

Whether perioperative blood transfusions (PBTs) adversely influence oncological outcomes for intrahepatic cholangiocarcinoma (ICC) patients after curative resection remains undetermined.

Methods

Of the 605 patients who underwent curative liver resection for ICC between 2000 and 2012, 93 received PBT. We conducted Cox regression and variable selection logistic regression analyses to identify confounding factors of PBT. Propensity score matching (PSM) and Cox regression analyses were used to compare the overall survival (OS) and disease-free survival (DFS) between the patients with or without PBT.

Results

After exclusion, 93 eligible patients (15.4%) received PBT, compared with 512 (84.6%) who did not receive PBT; the groups were highly biased in terms of the propensity score (PS) analysis (0.096 ± 0.104 vs. 0.479 ± 0.372, p < 0.001). PBT was associated with an increased risk of OS (HR: 1.889, 95% CI: 1.446–2.468, p < 0.001) and DFS (HR: 1.589, 95% CI: 1.221–2.067, p < 0.001) in the entire cohort. After propensity score matching (PSM), no bias was observed between the groups (PS,0.136 ± 0.117 VS. 0.193 ± 0.167, p = 0.785). In the multivariate Cox analysis, PBT was not associated with increased risks of OS (HR: 1.172, 95% CI: 0.756–1.816, p = 0.479) and DFS (HR: 0.944, 95% CI: 0.608–1.466, p = 0.799). After propensity score adjustment, PBT was still not associated with OS or DFS after ICC curative resection.

Conclusions

The present study found that PBT did not affect DFS and OS after curative resection of ICC.

Perioperative entecavir for patients with HBV-related hepatocellular carcinoma and low levels of viral DNA: analysis using propensity score matching

The safety and efficacy of perioperative antiviral therapy for patients with hepatitis B virus related hepatocellular carcinoma and low serum levels of hepatitis B virus DNA are unknown. This retrospective study compared serum levels of hepatitis B virus DNA, liver function, morbidity, and length of hospital stay between patients who underwent hepatic resection alone and patients who received entecavir therapy before and after resection (n = 44 in each group). Propensity score matching was used to reduce confounding due to baseline differences between the groups. Hepatitis B virus reactivation during follow-up, which lasted a median of 6.1 months, occurred in one patient in the entecavir group (2.3%) and 11 patients in the resection-only group (25%; P = 0.02). Liver function, especially alanine aminotransferase levels, recovered much faster in the entecavir group. This group also showed a slightly lower rate of morbidity (P = 0.081) as well as significantly shorter overall hospital stay (20.1 ± 4.9 vs 24.9 ± 13.2 days; P = 0.028) and postoperative hospital stay (11.4 ± 1.9 vs 16.8 ± 13.1 days; P = 0.008). These results from this pilot study suggest that patients with hepatitis B virus related hepatocellular carcinoma and low levels of hepatitis B virus DNA are at risk of hepatitis B virus reactivation following resection, and that perioperative entecavir therapy can safely and effectively reduce this risk. Such therapy also appears to improve liver function and shorten hospitalization.

The impact of expanded indications on short-term outcomes for resection of malignant tumours of the liver over a 30 year period

BACKGROUND

There are two philosophical approaches to planning liver resection for malignancy: one strives towards zero postoperative mortality by stringent selection of candidates, thus inherently limiting patients selected; the other, accepts a low yet definite postoperative mortality rate, and offers surgery to all those with potential gain in survival. The aim of this study was to retrospectively analyse an alternative and evolving strategy, and its impact on short-term outcomes.

METHOD

3118 consecutive hepatectomies performed in 2627 patients over 3 decades (1980-2011) were analysed. Patient demographics, tumour characteristics, operative details, and postoperative outcomes were analysed.

RESULTS

1528 patients (58%) were male. Colorectal liver metastases (1221 patients, 47%) and hepatocellular carcinoma (584 patients, 22%) were the most common diagnoses. Anatomical resections were performed in 2045 (66%), some form of vascular clamping was used in 2385 (72%), and blood transfusion was required in 1130 (36%) patients. Use of preoperative techniques to increase feasibility and safety of complex liver resections allowed expansion of indications to include sicker patients with larger tumours in the later period of the study. Overall morbidity and mortality rates were 31% and 3% respectively. During the first vs. second half of the study period the postoperative morbidity and mortality were 19% vs. 36% (p < 0.001) and 2% vs. 4% (p = 0.006) respectively.

CONCLUSION

With increasing experience, more patients were accepted for complex hepatectomies. However, there was a definite yet contained increase in postoperative morbidity and mortality.

Do packed red blood cell transfusions really worsen oncologic outcomes in colon cancer?

BACKGROUND

Data from small retrospective studies have argued that perioperative packed red blood cell transfusions may increase the risk of developing metastatic recurrence in cancer patients. This study tests this assumption in a large cohort spanning a decade of operatively treated colon cancer patients.

METHODS

All patients undergoing primary resection of a colon cancer at a tertiary care center between 2004-2014 (n = 1,423) were included in a retrospective review of a prospectively maintained data repository. Survival and disease-free survival were compared and also adjusted in multivariable Cox regression standardized for follow-up, American Society of Anesthesiologists score, age, sex, postoperative chemotherapy, baseline staging, and tumor grade.

RESULTS

Of the 1,423 patients, 305 (21.4%) received a perioperative packed red blood cell transfusion during their index admission. During follow-up, overall mortality was greater in patients who received perioperative packed red blood cell (53.1% vs 30.9%; P < .001); however, there were no appreciable differences in rates of long-term distant recurrence (in patients without baseline metastasis 11.1% vs 13.9%; P = .25), or disease-specific mortality (21.3% vs 17.3%; P = .104; without baseline metastasis: 8.6% vs 8.9%; P = .89). Similarly, multivariable Cox regression showed no statistical difference in recurrence (hazard ratio: 0.83, 95% confidence interval, 0.83-1.26; P = .38) or disease-specific mortality (hazard ratio: 1.12, 95% confidence interval, 0.83-1.51; P = .47).

CONCLUSION

Mortality rates were significantly greater in patients with perioperative packed red blood cell transfusions, a finding that is backed by a body of evidence that associates perioperative packed red blood cell transfusion with comorbidity and serious illness, but contrary to earlier evidence, findings in our cohort do not support a hypothesis that perioperative perioperative packed red blood cell transfusions have a detrimental effect on recurrence rates of operatively treated colon cancer patients.

Impact of intraoperative blood transfusion on short and long term outcomes after curative hepatectomy for intrahepatic cholangiocarcinoma: a propensity score matching analysis by the AFC-IHCC study group

BACKGROUND

The impact of intraoperative blood transfusion (IBT) on outcomes following intrahepatic cholangiocarcinoma (IHCC) resection remains to be ascertained.

METHODS

All consecutive IHCC resected were analyzed. A first cohort (n = 569) was used for investigating short-term outcomes (morbidity and mortality). A second cohort (n = 522) excluding patients dead within 90 days of surgery was analyzed for exploring overall survival (OS) and disease free survival (DFS). Patients who received IBT were compared to those who did not, after using a propensity score matching (PSM) method.

RESULTS

Among 569 patients, 90-day morbidity and mortality rates were 47% (n = 269) and 8% (n = 47). After PSM, 208 patients were matched. There was an association between IBT and increased overall morbidity and severe morbidity (p = 0.010). However, IBT did not impact 90-day mortality rate (p > 0.999). Regarding long-term outcomes analysis in the second cohort (n = 522), 5-year OS and DFS rates were 39% and 25%. Using PSM, 196 patients were matched and no association between IBT and OS or DFS was found (p = 0.333 and p = 0.491).

CONCLUSIONS

IBT is associated with an increased risk of morbidity but does not impact on long-term outcomes. Need for IBT should be considered as a surrogate of advanced disease requiring complex resection. Still, restricted transfusion policy should remain advocated for IHCC resection.

Identification of the resection severity index as a significant independent prognostic factor for early mortality and observed survival >5 and >10 years after liver resection for hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

This study evaluates predictive factors for observed long-term survival of more than 5 and 10 years for patients after liver resection for hepatocellular carcinoma and compares their life expectancy to the normal national population matched for sex, year of birth and age at resection.

METHODS

230 patients after primary liver resection for HCC (01.01.1995-31.12.2004) were analyzed. Multivariable logistic regression models were determined based on Cox regression results and their prognostic capability evaluated with areas under the receiver operating characteristic curve (AUROCs).

RESULTS

Life years after surgery in deceased patients compared to the normal national population matched for sex, year of birth and age at resection was reduced by median 21.7 years. Independent predictive factors for 10-year survival were age at resection (p < 0.001; OR = 0.898; 95%-CI: 0.846-0.954), UICC 7 tumor staging (p = 0.003; OR = 0.344; 95%-CI: 0.126-0.941) and ASAT (GOT) in U/l divided by Quick in percent multiplied by the extent of liver resection graded in points labelled as the resection severity index (p < 0.001; OR = 0.136; 95%-CI: 0.022-0.843) enabling prediction of 10-year survival with an AUROC of 0.884. The same factors plus revision surgery (yes/no) predict 5-year survival (AUROC 0.736).

CONCLUSIONS

Liver resection enables predictable long-term survival >5 and > 10 years. The proposed resection severity index quantifies the prognostic relevance of liver cellular damage, synthesis and loss of parenchyma for long-term survival.

Effects of antiviral therapy on post-hepatectomy HBV reactivation and liver function in HBV DNA-negative patients with HBV-related hepatocellular carcinoma

The ability of antiviral therapy to reduce risk of post-hepatectomy hepatitis B virus (HBV) reactivation in patients negative for viral DNA is unclear. This prospective study involved 174 consecutive patients with hepatitis B virus related hepatocellular carcinoma who were negative for hepatitis B virus DNA in serum and who underwent hepatic resection. Hepatitis B virus reactivation occurred in 30 patients in the non-antiviral group (27.8%) but in only 2 patients in the antiviral group (3.0%, P < 0.001). Based on multivariate analysis, risk of hepatitis B virus reactivation was associated with minor hepatectomy and absence of antiviral therapy. Liver function indicators at one week after resection did not differ significantly between the two groups, or between patients who experienced hepatitis B virus reactivation or not. Nevertheless, alanine aminotransferase and albumin at 1 month after resection were significantly higher in the antiviral group than in the non-antiviral group, and they were significantly higher in patients who did not experience hepatitis B virus reactivation than in those who did. Therefore, patients with hepatitis B virus related hepatocellular carcinoma face substantial risk of hepatitis B virus reactivation after hepatectomy, even if they are negative for viral DNA at baseline. Antiviral therapy can reduce the risk of reactivation, helping improve liver function after surgery.

Anatomical resection of hepatocellular carcinoma: A critical review of the procedure and its benefits on survival

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC (e.g., imaging studies and liver function tests), surgical techniques, and postoperative care have improved the surgical outcomes and survival of patients who undergo hepatic resection for HCC. However, in the last 20 years, the long-term survival after hepatectomy has remained unsatisfactory owing to the high rates of local recurrence and multicentric occurrence. Anatomical liver resection (AR) was introduced in the 1980s. Although several studies have revealed tangible benefits of AR for HCC, these benefits are still debated. Because most HCCs occur in patients with liver cirrhosis and poor hepatic function, there are many factors that affect survival, including the surgical method. Nevertheless, many studies have documented the perioperative and long-term benefits of AR in various conditions. In this article, we review the results of several recently published, well-designed comparative studies of AR, to investigate whether AR provides real benefits on survival outcomes. We also discuss the potential pitfalls associated with this approach.