Hepatic resection in the United States: indications, outcomes, and hospital procedural volumes from a nationally representative database

Trends in incidence, treatment and survival of patients with stage IV colorectal cancer: a population-based series

AIM

The incidence, patterns of care and survival were determined in patients with stage IV colorectal cancer (CRC) in a population-based series.

METHOD

Computer records for patients diagnosed with stage IV CRC diagnosed from 1 January 1995 to 31 December 2007 were retrieved from the Rotterdam Cancer Registry. Surgical resection of the primary tumour, chemotherapy use, hepatic surgery and survival were evaluated according to year of diagnosis, age, gender and primary tumour site.

RESULTS

In the southwestern part of the Netherlands, 19 014 new patients with CRC were diagnosed and synchronous metastatic disease was found in 3482 (18%). This proportion increased during the study period, from 16% to 21%. Surgical resection of the primary tumour was performed in approximately 50% of the patients and did not change over time. Postoperative 30-day mortality was 8%. Chemotherapy use increased from 18% in the first period to 56% in the latest period. Liver surgery increased from 4% in the first period to 10% in the latest period. Median survival increased from 7 months to 12 months and 2-year survival increased from 14% to 28%. Two-year survival declined with increasing age and was significantly worse for right-sided tumours (14%).

CONCLUSION

Survival of patients with stage IV CRC has improved over time and this is probably a result of the increased use of chemotherapy and the increased numbers of patients who underwent hepatic surgery.

Current state of surgical treatment of liver metastases from colorectal cancer

Hepatic resection is the procedure of choice for curative treatment of colorectal liver metastases (CLM). Objectives of surgical strategy are low intraoperative blood loss, short liver ischemic times and minor postoperative morbidity and mortality. Blood loss is an independent predictor of mortality and compromises, in common with postoperative complications, long-term outcome after hepatectomy for CLM. The type of liver resection has no impact on the outcome of patients with CLM; wedge resections are not inferior to anatomical resections in terms of tumor clearance, pattern of recurrence or survival. Despite the lack of proof of survival benefit, routine lymphadenectomy has been advocated, allowing the detection of microscopic lymph node metastases and with prognostic value. In experienced hands, minimally invasive liver surgery is safe with acceptable morbidity and mortality and oncological results comparable to open hepatic surgery, but with reduced blood loss and earlier recovery. The European Colorectal Metastases Treatment Group recommended treating up front with chemotherapy for patients with both resectable and unresectable CLM. However, neoadjuvant chemotherapy can induce damage to the remnant liver, dependent on the number of chemotherapy cycles. Therefore, in our opinion, preoperative chemotherapy should be reserved for patients whose CLM are marginally resectable or unresectable. A meta analysis of randomized trials dealing with perioperative chemotherapy for the treatment of resectable CLM demonstrated a benefit of systemic chemotherapy but did not answer the question of whether a neoadjuvant or adjuvant approach should be preferred. Analysis of the literature demonstrates that the results of specialized centers cannot be attained in the reality of comprehensive patient care. Reasons behind the commonly poorer results seen in cancer networks as compared with literature-based data are, on the one hand, geographical disparities in access to specialized surgical and medical care. On the other hand, a selection bias in the reports of the literature may be assumed. Studies of surgical resection for CLM derive almost exclusively from case series generally drawn from large academic centers where patient selection or surgical expertise is superior to what is found in many communities. Therefore, we may conclude that the comprehensive propagation of the standards outlined in this paper constitutes a major task in the near future to reduce the variations in survival of patients with CLM.

Comparative analysis of outcome in patients with hepatocellular carcinoma exceeding the milan criteria treated with liver transplantation versus partial hepatectomy

INTRODUCTION

Proponents of orthotopic liver transplantation (TXP) for the treatment of hepatocellular carcinoma (HCC) advocate expanding the Milan criteria. We performed a matched analysis comparing patients treated with TXP to patients treated with partial hepatectomy (PHX) for HCC exceeding the Milan criteria.

METHODS

From the United Network for Organ Sharing registry, we identified 92 US patients with HCC exceeding the Milan criteria who underwent TXP between 2002 and 2005. During the same period, 94 patients with similar tumor size criteria underwent PHX at a single center. Data were analyzed using χ(2), parametric, nonparametric, and Kaplan-Meier methods.

RESULTS

TXP patients were more commonly male (82% vs. 65%, P=0.01) and had a higher Model for End Stage Liver Disease score (median 11 vs. 7, P<0.001). Pathologic cirrhosis (79% TXP vs. 38% PHX, P<0.001), particularly secondary to hepatitis C virus (29% TXP vs. 5% PHX, P<0.001), was more common among TXP patients. Mean cumulative tumor size was 10.0 cm (63% exceeding University of California at San Francisco criteria) among PHX patients compared with 6.4 cm (20% exceeding University of California at San Francisco criteria) for TXP patients (P<0.001). With a median follow-up of 34 months (range, 1-86), 3-year survival was similar between the cohorts (66%±10% for TXP vs. 66%±10% for PHX, P=0.97). Cancer deaths (26/37, 70%) were more prevalent among PHX patients, whereas noncancer deaths (25/37, 68%) were common in TXP patients (P<0.001).

CONCLUSIONS

Among heterogeneous patients with HCC who exceed the Milan criteria, TXP and PHX achieve similar overall survival. Further study is needed to ensure appropriate patient selection for these disparate therapies.

Comparative assessment of the safety and effectiveness of radiofrequency ablation among elderly medicare beneficiaries with hepatocellular carcinoma

BACKGROUND

Radiofrequency ablation (RFA) use among patients with hepatocellular carcinoma (HCC) has increased dramatically over the last decade, but assessments outside specialized centers are lacking. This population-based study was intended to evaluate the safety and effectiveness of RFA when used to treat HCC.

METHODS

A cohort study of HCC patients (diagnosed 2002-2005) was performed using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Early (≤90-day) mortality and readmission as well as survival among patients undergoing RFA, resection, or no treatment were compared using multivariate and propensity score adjusted Poisson and Cox regression models.

RESULTS

Of 2631 patients (mean age 76.1±6.1 years, 65.9% male), 16% underwent RFA (49.6%) or resection (50.4%). Early mortality (13.6 vs. 18.7%, P=.16) and readmission (34.5 vs. 32.1%, P=.60) rates were similar among RFA and resection patients. The 1-year survival after RFA and resection was similar (72.2 vs. 79.7%, P=.18), but beyond 3 years there was a survival benefit among patients undergoing resection (39.2 vs. 58.0%, P<.001). Patients treated with RFA as a sole therapeutic intervention in the 1st year had a similar hazard of death compared with untreated patients (hazard ratio [HR] 0.84, 95% confidence interval [95% CI] 0.54-1.33).

CONCLUSIONS

In the general community, patients treated with RFA have a similar risk of early adverse events compared with those treated with resection with no clear survival benefit when used as a sole intervention. Although RFA has been described as a safe and effective treatment for HCC at specialized centers, this experience may not extrapolate to the general community and requires further evaluation.

Use of administrative data to identify colorectal liver metastasis

BACKGROUND

The ability to identify patients with colorectal cancer (CRC) liver metastasis (LM) using administrative data is unknown. The goals of this study were to evaluate whether administrative data can accurately identify patients with CRCLM and to develop a diagnostic algorithm capable of identifying such patients.

MATERIALS AND METHODS

A retrospective cohort study was conducted to validate the diagnostic and procedural codes found in administrative databases of the Veterans Administration (VA) system. CRC patients evaluated at a major VA center were identified (1997-2008, n = 1671) and classified as having liver-specific ICD-9 and/or CPT codes. The presence of CRCLM was verified by primary chart abstraction in the study sample. Contingency tables were created and the positive predictive value (PPV) for CRCLM was calculated for each candidate administrative code. A multivariate logistic-regression model was used to identify independent predictors (codes) of CRCLM, which were used to develop a diagnostic algorithm. Validity of the algorithm was determined by discrimination (c-statistic) of the model and PPV of the algorithm.

RESULTS

Multivariate logistic regression identified ICD-9 diagnosis codes 155.2 (OR 9.7 [95% CI 2.5-38.4]) and 197.7 (84.6 [52.9-135.3]), and procedure code 50.22 (5.9 [1.3-25.5]) as independent predictors of CRCLM diagnosis. The model's discrimination was 0.89. The diagnostic algorithm, defined as the presence of any of these codes, had a PPV of 87%.

CONCLUSIONS

VA administrative databases reliably identify patients with CRCLM. This diagnostic algorithm is highly predictive of CRCLM diagnosis and can be used for research studies evaluating population-level features of this disease within the VA system.

Impact of expanding criteria for resectability of colorectal metastases on short- and long-term outcomes after hepatic resection

BACKGROUND

An expansion of resectability criteria of colorectal liver metastases (CLM) is justified provided "acceptable" short-term and long-term outcomes. The aim of the present study was to ascertain this paradigm in an era of modern liver surgery.

METHODS

All consecutive patients who underwent hepatic resection for CLM at our institute between 1990 and 2010 were included in the study. Ninety-day mortality and morbidity rates were determined in the total study population and in 2 separate time periods (group I: 1990-2000; group II: 2000-2010). Similarly, overall and progression-free survival rates were determined. Independent predictors of postoperative morbidity were identified at multivariate analysis.

RESULTS

Between 1990 and 2010, 1394 hepatectomies were performed in 1028 patients. Overall perioperative mortality and postoperative morbidity rates were 1.3% and 33%, respectively. Although patients in group II were older, had more often comorbid illnesses, and presented with more extensive liver disease, similar perioperative mortality rates were observed (1.1% in group I and 1.4% in group II; P = 0.53). A trend toward a higher morbidity rate was observed in group II (34% vs 31% in group I; P = 0.16). Independent predictors of postoperative morbidity were: treatment between 2000 and 2010, total hepatic ischemia time of 60 minutes or more, maximum size of CLM of 30 mm or more at histopathology, and presence of abnormalities in the nontumoral liver parenchyma. Although a trend toward lower overall survival was observed in patients with significant postoperative complications, no significant differences were observed in long-term outcomes between both treatment periods.

CONCLUSION

After an aggressive multidisciplinary treatment of CLM, acceptable overall mortality and morbidity rates were observed. Perioperative mortality rates did not differ according to treatment period; however, more recently operated patients experienced more postoperative complications. These favorable short-term outcomes, without worsening of long-term outcomes, justify an expansion of the criteria for resectability in this patient category.

Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis

BACKGROUND

As indications for liver resection expand, objective measures to assess the risk of peri-operative morbidity are needed. The impact of sarcopenia on patients undergoing liver resection for colorectal liver metastasis (CRLM) was investigated.

METHODS

Sarcopenia was assessed in 259 patients undergoing liver resection for CRLM by measuring total psoas area (TPA) on computed tomography (CT). The impact of sarcopenia was assessed after controlling for clinicopathological factors using multivariate modelling.

RESULTS

Median patient age was 58 years and most patients (60%) were male. Forty-one (16%) patients had sarcopenia (TPA ≤ 500 mm(2) /m(2) ). Post-operatively, 60 patients had a complication for an overall morbidity of 23%; 26 patients (10%) had a major complication (Clavien grade ≥3). The presence of sarcopenia was strongly associated with an increased risk of major post-operative complications [odds ratio (OR) 3.33; P= 0.008]. Patients with sarcopenia had longer hospital stays (6.6 vs. 5.4 days; P= 0.03) and a higher chance of an extended intensive care unit (ICU) stay (>2 days; P= 0.004). On multivariate analysis, sarcopenia remained independently associated with an increased risk of post-operative complications (OR 3.12; P= 0.02). Sarcopenia was not significantly associated with recurrence-free [hazard ratio (HR) = 1.07] or overall (HR = 1.05) survival (both P > 0.05).

CONCLUSIONS

Sarcopenia impacts short-, but not long-term outcomes after resection of CRLM. While patients with sarcopenia are at an increased risk of post-operative morbidity and longer hospital stay, long-term survival is not impacted by the presence of sarcopenia.

Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion

OBJECTIVES

Defining perioperative mortality as death that occurs within 30 days of surgery may underestimate 'true' mortality among patients undergoing hepatic resection. To better define perioperative mortality, trends in the risk for death during the first 90 days after hepatectomy were assessed.

METHODS

Surveillance, Epidemiology and End Results (SEER) Medicare data were used to identify 2597 patients who underwent hepatic resection during 1991-2006. Data on their clinicopathological characteristics, surgical management and perioperative mortality were collected and survival was assessed at 30, 60 and 90 days post-surgery.

RESULTS

Overall, 5.7% of patients died within the first 30 days. Postoperative mortality at 60 and 90 days were 8.3% and 10.1%. In-hospital mortality after hepatic resection was greater among patients with hepatocellular carcinoma (HCC) than among those with colorectal liver metastases (CRLM) (8.9% and 3.8%, respectively; P < 0.001). In CRLM patients, mortality increased from 4.3% at 30 days to 8.4% at 90 days, whereas mortality in HCC patients increased from 9.7% at 30 days to 15.0% at 90 days (both P < 0.05). Patients with HCC were twice as likely as CRLM patients to die within 30 days [odds ratio (OR) 2.03], 60 days (OR = 1.74) and 90 days (OR = 1.71) (all P < 0.001). Differences in 30- and 90-day mortality were greatest among HCC patients undergoing major hepatic resection (P < 0.05).

CONCLUSIONS

Reporting deaths that occur within a maximum of 30 days of surgery underestimates the mortality associated with hepatic resection. Traditional 30-day definitions of mortality are misleading and surgeons should report all perioperative outcomes that occur within 90 days of hepatic resection.

Morbidity and mortality after hepatic and pancreatic resections: results from one surgeon at a low-volume urban hospital over thirty years

BACKGROUND

Recent reviews of state and national databases suggest that hospital volume is inversely proportional to morbidity after hepatic and pancreatic resection. Volume may be a surrogate marker for factors such as coordination of care and surgeon training. The authors hypothesized that low-volume centers can obtain acceptable outcomes if these requirements are satisfied.

METHODS

A retrospective review was performed of all hepatic and pancreatic resections performed from 1978 to 2008 by 1 surgeon at 1 low-volume institution. The etiology of disease, type of resection, and 30-day morbidity and mortality were assessed.

RESULTS

One hundred sixty-eight hepatic resections were performed for malignant (76%) or benign (24%) etiologies. Major resections included extended lobectomy (n = 19), lobectomy (n = 58), and segmentectomy (n = 62); minor resections consisted of wedge resections (n = 29). Overall 30-day mortality was 1.8%, and major morbidity was 17.9%; for major hepatic resections, mortality and morbidity were 1.4% and 20.1%, respectively. One hundred fourteen pancreatic resections were performed for malignant (76.3%) or benign (23.7%) etiologies. Major resections included pancreaticoduodenectomy (n = 91), central pancreatectomy (n = 1), and total pancreatectomy (n = 4); minor resections consisted of distal pancreatectomy (n = 18). Overall 30-day mortality was 2.6%, and major morbidity was 27.2%; for major pancreatic resections, mortality and morbidity were 3.1% and 31.3%, respectively.

CONCLUSIONS

Hepatic and pancreatic resections can be performed safely at a low-volume hospital with adequate surgeon training and perioperative systems of care.

Radical surgery in the presence of biliary metallic stents: revising the palliative scenario

BACKGROUND

The application of endobiliary self-expandable metallic stents (SEMS) is considered the palliative treatment of choice in patients with biliary obstruction in the setting of inoperable malignancies. In the presence of SEMS, however, radical surgery is the only curative option when the resectability status is revised in case of malignancies or for overcoming complications arising from their application in benign conditions that masquerade as inoperable tumours. The aim of our study was to report our surgical experience with patients who underwent an operation due to revision of the initial palliative approach, whilst they had already been treated with biliary SEMS exceeding the hilar bifurcation.

METHODS

Three patients with hilar cholangiocarcinoma that was considered inoperable and one patient with IgG4 autoimmune cholangio-pancreatopathy mimicking pancreatic cancer underwent radical resections in the presence of biliary SEMS.

RESULTS

After a detailed preoperative workup, two right trisectionectomies, one left extended hepatectomy and a radical extrahepatic biliary resection were performed. All cases demanded resection and reconstruction of the portal vein. R0 resection was achieved in all the malignant cases. Two patients required multiple biliodigestive anastomoses entailing three and seven bile ducts respectively. There was one perioperative death due to postoperative portal vein and hepatic artery thrombosis, whilst two patients developed grade III complications. At follow-up, one patient died at 13 months due to disease recurrence, whilst the remaining two are free of disease or symptoms at 21 and 12 months, respectively.

CONCLUSIONS

Revising the initial palliative approach and operating in the setting of biliary metallic stents is extremely demanding and carries significant mortality and morbidity. Radical resection is the only option for offering cure in such complex cases, and this should only be attempted in advanced hepatopancreaticobiliary centres with active involvement in liver transplantation.

National trends in discharge disposition after hepatic resection for malignancy

BACKGROUND

There is a paucity of data on the trends in discharge disposition for patients undergoing hepatic resection for malignancy.

AIM

To analyse the national trends in discharge disposition after hepatic resection for malignancy.

METHODS

The National Inpatient Sample (NIS) database was queried (1993 to 2005) to identify patients that underwent hepatic resection for malignancy and analyse the discharge status (home, home health or rehabilitation/skilled facility).

RESULTS

A weighted total of 74,520 patients underwent hepatic resection of whom, 53,770 patients had a principal diagnosis of malignancy. The overall mortality improved from 6.3% to 3.4%. After excluding patients that died in the post-operative period and those with incomplete discharge status, 45,583 patients were included. The proportion of patients that had acute care needs preventing them from being discharged home without assistance increased from 10.9% in 1993 to 19.5% in 2005. While there was an increase in the number of patients discharged to home health care during this time (8.9% to 13.8%), there was a larger increase in the proportion of patients that were discharged to a rehabilitation or skilled nursing facility (2% to 5.7%). Despite a decrease in the mortality rates, there was no improvement in rate of patients discharged home without assistance over the period of the study.

CONCLUSIONS

The results of the present study demonstrate that after hepatic resection, a significant proportion of patients will need assistance upon discharge. This information needs to be included in patient counselling during pre-operative risk and benefit assessment.

Milestones in the evolution of hepatic surgery

This paper describes the rapid evolution of modern liver surgery, starting in the middle of the twentieth century. Claude Couinaud studied and described the segmental anatomy of the liver, Thomas Starzl performed the first liver transplantations, and Henri Bismuth introduced the concept of anatomical resections. Hepatic surgery has developed significantly since those early days. To date, innovative techniques are applied, using cutting-edge technologies: Intraoperative ultrasound, techniques of vascular exclusion of the liver, new devices for performing homeostasis and dissection, laparoscopy for resections, and new drugs that allow the resection of previously unresectable tumors. The next stage in liver surgery will probably be the implementation of a multidisciplinary holistic approach to the liver-diseased patient that will ensure the best and most efficient treatments in the future.

Liver tissue sparing resection using a novel planning tool

PURPOSE

Accurate preoperative prediction of liver function, volume, and vessel anatomy is essential in preventing postoperative liver failure, optimizing safety, and ensuring optimal outcome in patients undergoing hepatic surgery. We propose that preoperative resection planning provides useful anatomical and volumetric data, allowing for sparing of liver tissue in surgical resections. The purpose of the present study was to evaluate the use of a novel resection planning tool.

METHODS

Thirteen patients undergoing hemihepatectomy were included. Preoperative resection planning was performed using the commercially available software Mint Liver. During resection planning, virtual resections were calculated based on Couinaud classification, Cantlie's line (standard), and individually by the operating surgeon (individual). Intraoperatively, volume and weight of the resected specimen were measured. A 14-day follow-up was conducted, and laboratory parameters were collected. Statistical analysis was performed, comparing virtual resection volumes (i.e., standard vs. individual) and secondarily virtual vs. actual resection volume.

RESULTS

We found a significant difference (p = 0.001) in the comparison of standard vs. individual in all 13 cases, with an average 92.8 mL smaller resected volume, sparing 11.3% of liver parenchyma with virtual resection. No patients suffered from acute liver failure. Perioperative mortality was 0%.

CONCLUSION

Mint Liver is capable of acquiring exact anatomical and volumetric knowledge prior to hepatic resections. Liver parenchyma can be spared by preoperative assessment of the resection plan. We propose that this tool could be an important addition to preoperative patient evaluation, especially in complex liver surgery and living donor liver transplantation where precise volumetry is the decisive factor.

Liver resection: a regional hospital experience

BACKGROUND

Liver resection is a significant operation usually limited to large metropolitan hospitals. Liver resections were first performed at the Launceston General Hospital (LGH), a regional centre (bed capacity 280), in May 2000. This is a summary of liver resection at LGH.

METHODS

Data of liver resections performed between May 2000 and March 2008 at LGH were collected retro-prospectively and reviewed with attention to patient survival, post-operative complications and mortality.

RESULTS

There were 102 consecutive liver resections during the study period. Metastatic colorectal adenocarcinoma was the most frequent pathology (n = 61). Six patients had metastases from primaries other than colorectal cancer. There were 13 resections for primary liver malignancy, 2 from invasion by gallbladder carcinoma, 1 for contiguous invasion by gastric cancer and 19 were for benign conditions. Thirteen patients had post-operative wound infections and six had significant bile leaks. There were five deaths in-hospital (surgical mortality 4.9%). At the end of the study period, 51 cancer patients were still alive (14 with disease recurrences) and 30 have died (23 from recurrent diseases). Patients operated for colorectal cancer metastases achieved a 44% 5-year survival rate (median survival = 46 months). Patients with hepatocellular carcinoma had 3-year survival rate of 15% (median survival = 24 months).

CONCLUSION

Resection provides the best hope of cure for patients with primary or secondary hepatic malignancy. With adequate expertise, liver resections can be performed safely in a regional hospital.

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

OBJECTIVES

In the context of comparisons of surgical outcomes, risk adjustment is the retrospective adjustment of a provider's or a surgeon's results for case mix and/or hospital volume. It allows accurate, meaningful inter-provider comparison. It is therefore an essential component of any audit and quality improvement process. The aim of this study was to review the literature to identify those factors known to affect prognosis in hepatobiliary and pancreatic cancer surgery.

METHODS

PubMed was used to identify studies assessing risk in patients undergoing resection surgery, rather than bypass surgery, for hepatobiliary and pancreatic cancer.

RESULTS

In total, 63 and 68 papers, pertaining to 24 609 and 63 654 patients who underwent hepatic or pancreatic resection for malignancy, respectively, were identified. Overall, 22 generic preoperative factors predicting outcome on multivariate analysis, including demographics, blood results, preoperative biliary drainage and co-morbidities, were identified, with tumour characteristics proving disease-specific factors. Operative duration, transfusion, operative extent, vascular resection and additional intra-abdominal procedures were also found to be predictive of early outcome.

CONCLUSIONS

The development of a risk adjustment model will allow for the identification of those factors with most influence on early outcome and will thus identify potential targets for preoperative optimization and allow for the development of a multicentre risk prediction model.

Body mass index and adverse perioperative outcomes following hepatic resection

BACKGROUND

The effect of obesity on perioperative outcomes following hepatic resection is not clearly defined. We sought to understand the implications of obesity on post-hepatectomy outcomes in a nationally represented cohort of patients.

METHODS

Using a retrospective cohort design, we studied the effect of obesity on complications and 30-day mortality using multivariable logistic regression using comprehensive clinical data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2008).

RESULTS

During our study period, 3,960 patients underwent hepatic resection; 32.4% had a normal body mass index (BMI; 18.5-24.9 kg/m(2)), 2.5% were underweight (<18.5 kg/m(2)), 33.4% were overweight (25.0-29.9 kg/m(2)), and 31.7% were obese (>30.0 kg/m(2)). 23.3% had at least one post-operative complication and the overall mortality rate was 2.5%. Compared to normal patients, obese patients had significantly higher unadjusted odds of having a complication (26.5% vs. 21.3%, OR 1.34, 95% CI 1.12-1.61) and dying (3.0% vs. 1.7%, OR 1.79, 95% CI 1.05-3.05). The obese were also more likely to have multiple complications compared to normal BMI patients (6.1% vs. 3.7%, OR 1.70, 95% CI 1.17-2.46). After risk adjustment, obesity was associated with attenuated but significantly higher odds of having any perioperative complication (OR 1.24, 95% CI 1.01-1.55), but was not a significant predictor of mortality.

CONCLUSIONS

After adjusting for other clinical factors, the degree of obesity is independently associated with an increasing complication rate but not mortality. Risk adjustment may not capture the total clinical risk of patients at the extremes of BMI.

Utility or futility of prognostic scoring systems for colorectal liver metastases in an era of advanced multimodal therapy

OBJECTIVES

To assess the general applicability of prognostic scores for colorectal liver metastases (CRLM).

METHODS

Review of English language studies from 1980 to 2008 (Medline and Embase). Search keywords included "Colorectal neoplasms", "liver metastases", "liver resection", "prognostic scoring system".

RESULTS

Six scoring systems and fourteen prognostic factors within these studies were identified. No prognostic factor was common in all scoring methods. Five scores retained the number of metastases as a prognostic factor. Size of metastases and time between the onset of the primary tumor and the discovery of metastases were present in four scores. Three scores predicted 5-year survival using carcinoembryonic antigen (CEA) and R1 resection. Only two scores were assessed preoperatively. Successive scoring methods had improved predictive accuracy compared to earlier systems. However, their applicability in general populations remains debatable. An evaluation of the scores applicability to different patient populations demonstrated that the models were minimally effective in predicting disease-specific survival and recurrence, suggesting that stratification of patients by clinical and pathologic factors alone, may be clinically unreliable and not applicable for selection of patients for surgery.

CONCLUSION

The utility of prognostic models on general populations is inconsistent. Current clinicopathologic factors may be inadequate to determine disease prognosis in CRLM. Future attempts to develop prognostic scores should include additional biologic and clinical variables, and be validated in larger populations.

Consensus on the current use of sorafenib for the treatment of hepatocellular carcinoma

An expert panel was convened to reach a consensus on the current use of sorafenib in the treatment of hepatocellular carcinoma (HCC). A multinational, multidisciplinary group of experts objectively reviewed clinical data of sorafenib and considered clinical experience to develop statements summarizing our consensus on the current use of sorafenib. Sorafenib is the standard of care for Child-Pugh (CP) A patients with advanced HCC (i.e. not amenable to surgery or locoregional treatment). There is currently insufficient evidence to support the routine clinical use of sorafenib in CP B patients, but sorafenib can be offered as an option for those with compensated liver cirrhosis. Patients with stable performance status who have progressive disease during sorafenib treatment can be maintained on sorafenib, although there are no clear data supporting the continuation of sorafenib in these patients. The effectiveness of the adjuvant use of sorafenib in preventing recurrence after resection or local ablation, or in combination with transarterial chemoembolization, are being evaluated in clinical studies. In conclusion, sorafenib has extended treatment options for patients with HCC, and is now established as the standard of care for CP A patients with HCC not amenable to surgery or locoregional treatment. Based on its multikinase-inhibitor activity and proven efficacy in prolonging survival in HCC, broader use - including a subgroup of patients with CP B (clinically compensated cirrhosis) and earlier disease stages - might be expected dependent on the results of ongoing studies of safety and clinically relevant benefit in these patients.

Quality of care in advanced ovarian cancer: the importance of provider specialty

BACKGROUND

One of the cornerstones of ovarian cancer therapy is cytoreductive surgery, which can be performed by surgeons with different specialty training. We examined whether surgeon specialty impacts quality of life (as proxied by presence of ostomy) and overall survival for women with advanced ovarian cancer.

METHODS

Stage IIIC/IV ovarian cancer patients were identified using 4 state cancer registries: California, Washington, New York, and Florida and linked records to the corresponding inpatient-hospital discharge file, AMA Masterfile, and 2000 U.S. Census SF4 File. Predictors of receipt of care by a general surgeon and creation of fecal ostomy were analyzed. Multivariate modeling was performed to assess the association of hospital volume (low volume (LV) [0-4 cases], middle volume (MV) [5-9], high volume (HV) [10-19], and very high volume (VHV) [20+]) and surgeon specialty training (gynecologic oncologists/gynecologists, general surgeons, and other specialty) on survival.

RESULTS

We identified 31,897 Stage IIIC/IV patients; mean age was 64 years. Treatment of patients by a general surgeon was predicted by LV, rural patient residence, poverty, and high level of comorbidity. Patients had lower hazard of death when treated in higher volume hospitals as compared to LV [VHV hazard ratio (HR)=0.79, P<.0001; HV HR=0.89, P<0.001]. Patients treated by a general surgeon had higher likelihood of an ostomy (OR=4.46, P<.0001) and hazard of death (HR=1.63, P<.0001) compared to gynecologic oncologist/gynecologist.

CONCLUSIONS

Advanced stage ovarian cancer patients have better survival when treated by gynecologic oncology/gynecology trained surgeons. Data suggest that referral to these specialists may optimize surgical debulking and minimize the creation of a fecal ostomy.

Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis

BACKGROUND

The impact of postoperative morbidity, and in particular infective complications on long-term outcomes, following hepatic resection for colorectal liver metastasis (CRLM) is not widely published.

OBJECTIVE

To evaluate the effect of postoperative complications on disease recurrence and overall survival in patients undergoing hepatic resection for CRLM.

METHODS

All patients undergoing hepatic resection for CRLM from January 1993 and March 2007 were identified, and postoperative complications analyzed. Patients who died of postoperative complications within 30 days of surgery were excluded form the study. Postoperative complications were graded using a validated system of classification. Complications were further classified into infective and noninfective complication groups and the primary end points of the study were disease free survival (DFS) and overall survival (OS) at 5 years.

RESULT

A total of 705 patients underwent hepatic resection in the study period. Median follow-up was 38 months. Operative morbidity and mortality were 28% and 3.6%, respectively. The total number of patients was 197 (28%) with complications, and 508 (72%) without complications. The 5 year DFS and OS for those with and without complications were: 13% versus 26% (P < 0.001) and 24% versus 37% (P < 0.001), respectively. Multivariate analysis showed inflammatory response to tumor score, blood transfusion, tumor number >8, and postoperative sepsis to be independent factors associated with DFS, and inflammatory response to tumor, tumor number >8, and postoperative sepsis to be independent predictors for OS. Intra-abdominal and respiratory infection but not wound infections were associated with poorer long-term outcomes.

CONCLUSIONS

Postoperative complications influence long-term outcomes in hepatic resection for CRLM. Specifically, postoperative sepsis is an independent predictor of disease free and overall survival. Thorough preoperative optimization, meticulous surgical technique and careful management in the postoperative period may reduce the incidence of these complications and influence long-term outcomes.

Perioperative mortality for management of hepatic neoplasm: a simple risk score

OBJECTIVES

To develop a population-based risk score for stratifying patients by risk of in-hospital mortality following procedural intervention for hepatic neoplasm.

BACKGROUND

There has been growing support for the value of surgical management of hepatic neoplastic disease, both primary and metastatic. Advances in surgical and ablative technologies have contributed to a decrease in the mortality associated with these procedures. However, multiple patient-, disease- and treatment-related factors can contribute to perioperative morbidity and mortality.

METHODS

Using the Nationwide Inpatient Sample from 1998 to 2005, a retrospective cohort of patient-discharges for hepatic procedures with a concurrent diagnosis of hepatic primary or metastatic neoplasm to the liver was assembled. Procedures were categorized as lobectomy, wedge resection, or enucleation/ablation. Logistic regression and bootstrap methods were used to create an integer score for estimating the risk of in-hospital mortality using patient demographics, comorbidities, procedure type, tumor type, and hospital characteristics. A randomly selected sample of 80% of the cohort was used to create the risk score. Testing was conducted in the remaining 20% validation-set.

RESULTS

In total, 12,969 patient-discharges were identified. Overall in-hospital mortality was 3.45%. Predictive characteristics incorporated into the model included: age, sex, Charlson comorbidity score, procedure type, hospital type, and type of neoplasm. Integer values were assigned to these, and used to calculate an additive score. Five clinically relevant groups were assembled to stratify risk, with a 36-fold gradient in mortality. Rates in the groups were as follows: 0.9%, 2.5%, 6.8%, 17.6%, and 35.9%. In the derivation set, as well as in the validation set, the simple score discriminated well, with c-statistics of 0.76 and 0.70, respectively.

CONCLUSIONS

An integer-based risk score can be used to predict in-hospital mortality after hepatic procedure for neoplasm, and may be useful for preoperative risk stratification and patient counseling.

Endoscopic and percutaneous preoperative biliary drainage in patients with suspected hilar cholangiocarcinoma

INTRODUCTION

Controversy exists over the preferred technique of preoperative biliary drainage (PBD) in patients with hilar cholangiocarcinoma (HCCA) requiring major liver resection. The current study compared outcomes of endoscopic biliary drainage (EBD) and percutaneous transhepatic biliary drainage (PTBD) in patients with resectable HCCA.

METHODS

One hundred fifteen consecutive patients were explored for HCCA between 2001 and July 2008 and assigned by initial PBD procedure to either EBD or PTBD.

RESULTS

Of these patients, 101 (88%) underwent PBD; 90 patients underwent EBD as primary procedure, and 11 PTBD. The technical success rate of initial drainage was 81% in the EBD versus 100% in the PTBD group (P = 0.20). Stent dislocation was similar in the EBD and PTBD groups (23% vs. 20%, P = 0.70). Infectious complications were significantly more common in the endoscopic group (48% vs. 9%, P < 0.05). Patients in the EBD group underwent more drainage procedures (2.8 vs. 1.4, P < 0.01) and had a significantly longer drainage period until laparotomy (mean 15 weeks vs. 11 weeks in the PTBD group; P < 0.05). In 30 patients, EBD was converted to PTBD due to failure of the endoscopic approach.

CONCLUSIONS

Preoperative percutaneous drainage could outperform endoscopic stent placement in patients with resectable HCCA, showing fewer infectious complications, using less procedures.

Surgeon volume is predictive of 5-year survival in patients with hepatocellular carcinoma after resection: a population-based study

BACKGROUND AND AIM

No study has examined associations between physician volume or hospital volume and survival in patients with liver malignancies in the hepatitis B virus-endemic areas such as Taiwan. This study was to examine the effect of hospital and surgeon volume on 5-year survival and to determine whether hospital or surgeon volume is the stronger predictor in patients with hepatocellular carcinoma after hepatic resection in Taiwan.

METHODS

Using the 1997-1999 Taiwan National Health Insurance Research Database and the 1997-2004 Cause of Death Data File, we identified 2,799 patients who underwent hepatic resection and 1,836 deaths during the 5-year follow-up period. The Cox proportional hazard regressions were performed to adjust for patient demographics, comorbidity, physician, and hospital characteristics when assessing the association of hospital and surgeon volume with 5-year survival.

RESULTS

When we examined the effect of physician and hospital volumes separately, both physician and hospital volumes significantly predicted 5-year survival after adjusting for characteristics of patient, surgeon, and hospital. However, after we adjusted for characteristics of physician and hospital, only physician volume remained a significant predictor of the 5-year survival.

CONCLUSIONS

Physician volume is a stronger predictor of 5-year survival in hepatocellular carcinoma patients receiving hepatic resection.

Timing of multimodality therapy for resectable synchronous colorectal liver metastases: a retrospective multi-institutional analysis

The optimal timing of chemotherapy relative to resection of synchronous colorectal liver metastases (SCRLM) is not known. The objective of this retrospective multi-institutional study was to assess the influence of chemotherapy administered before and after hepatic resection on long-term outcomes among patients with initially resectable SCRLM treated from 1995 to 2005. Clinicopathologic data, treatments, and long-term outcomes from patients with initially resectable SCRLM who underwent partial hepatectomy at three hepatobiliary centers were reviewed. Four hundred ninety-nine consecutive patients underwent resection; 297 (59.5%) and 264 (52.9%) were treated with chemotherapy before and after resection. Chemotherapy strategies included pre-hepatectomy alone (n = 148, 24.7%), post-hepatectomy alone (n = 115, 23.0%), perioperative (n = 149, 29.0%), and no chemotherapy (n = 87, 17.4%). Male gender (p = 0.0029, HR = 1.41 [1.12-1.77]), node-positive primary tumor (p = 0.0046, HR = 1.40 [1.11-1.77]), four or more SCRLM (p = 0.0005, HR = 1.65 [1.24-2.18]), and post-hepatectomy chemotherapy treatment for 6 months or longer (p = 0.039, HR = 0.75 [0.57-0.99]) were associated with recurrence-free survival after discovery of SCRLM. Carcinoembryonic antigen >200 ng/ml (p = 0.0003, HR = 2.33 [1.48-3.69]), extrahepatic metastatic disease (p = 0.0025, HR = 2.34 [1.35-4.05]), four or more SCRLM (p = 0.033, HR = 1.43 [1.03-2.00]), and post-hepatectomy chemotherapy treatment for 2 months or longer (p < 0.0001, HR = 0.59 [0.45-0.76]) were associated with overall survival. Pre-hepatectomy chemotherapy was not associated with recurrence-free or overall survival. Patients treated with perioperative chemotherapy had similar outcomes as patients treated with post-hepatectomy chemotherapy only. We conclude that chemotherapy administered after but not before resection of SCRLM was associated with improved recurrence-free and overall survival. However, prospective randomized trials are needed to determine the optimal timing of chemotherapy.

Volumes of liver transplant and partial hepatectomy procedures are independently associated with lower postoperative mortality following resection for hepatocellular carcinoma

Partial hepatectomy for hepatocellular carcinoma (HCC) is a high-risk procedure, especially in the presence of portal hypertension. We assessed whether the volume of hospital liver transplant procedures was associated with lower in-hospital mortality independently of the volume of partial hepatectomy procedures. We queried the Nationwide Inpatient Sample (1998-2005) to identify patients who had undergone partial hepatectomy for HCC and used logistic regression to assess the independent effect of volumes of hospital liver transplant and partial hepatectomy procedures on mortality while adjusting for demographic, clinical, and hospital factors. Overall in-hospital mortality was 7.7%. Patients with portal hypertension experienced higher mortality than those who did not (24.5% versus 5.8%, P < 0.0001). Postoperative mortality benefited from a higher volume of hospital liver transplants (>12 per year) and partial hepatectomy procedures (>5 resections per year). Undergoing partial hepatectomy at a center that performed an effective liver transplant volume (eLTV; >12 transplants per year) was associated with lower mortality in both the portal hypertensive group (16.4% versus 33.7%, P = 0.004) and non-portal hypertensive group (4% versus 8%, P = 0.0002). After multivariate adjustment, the odds ratio (OR) of in-hospital death for those with portal hypertension was 4.5 [95% confidence interval (CI), 2.98-6.81]. The lower mortality observed with eLTV (OR, 0.59; 95% CI, 0.37-0.93) was independent of the mortality benefit from an effective partial hepatectomy volume (>5 hepatectomies per year; OR, 0.54; 95% CI, 0.31-0.94). Postoperative complications were also fewer at centers with eLTV compared to those without eLTV (39.2% versus 29.3%, P < 0.0001). In conclusion, given the postoperative mortality benefit independent of the volume of partial hepatectomy procedures, referral to a center with eLTV should be considered for HCC resection, especially in the presence of portal hypertension.

The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship

BACKGROUND

Although the relationship between hepato-pancreato-biliary (HPB) procedure volume and outcomes is established, the relative importance of hospital and surgeon effects and the specificity of the volume-outcomes effect remain ill-defined. We sought to comprehensively characterize the hospital and surgeon volume-outcomes relationships in high-risk HPB surgery.

STUDY DESIGN

The 1998 to 2005 State Inpatient Databases for Florida, Maryland, and New York were used to identify patients undergoing complex HPB surgery and to quantify hospital and surgeon procedure volumes. The effects of hospital and surgeon procedure volumes on casemix-adjusted inpatient mortality were analyzed using multilevel logistic regression models.

RESULTS

For hepatic resection, hospital procedure volume predicted mortality (high versus low volume, odds ratio [OR] 0.48, p=0.04), but surgeon volume did not (p=0.42). For pancreatic resection, in contrast, both hospital (OR 0.32, p < 0.001) and surgeon (OR 0.30, p < 0.001) procedure volume predicted mortality. The hospital volume effect for pancreatic resection was largely explained by surgeon volume. In both procedure groups, volume-outcomes effects were very specific. Only volumes of the primary procedure were predictive of mortality; volumes of related HPB procedures and overall HPB volume demonstrated no independent effect on mortality.

CONCLUSIONS

In HPB surgery, the relative contributions of hospital versus surgeon volume vary according to the specific procedure in question. In addition, the association between hospital or surgeon volume and in-hospital mortality is very specific to the procedure in question. High-volume expertise in one area of HPB surgery does not translate into improved outcomes for related procedures. These data may have implications for quality assessment and improvement, patient referral, and HPB surgical training.

Hepatectomy for liver metastasis of colorectal cancer

OBJECTIVE

The objective of this study was to investigate whether hepatic resection (HR) can increase the survival of liver metastasis of colorectal cancer (CRC).

MATERIALS AND METHODS

CRC patients (n=669) with liver metastasis treated at the Zhongshan Hospital, Fudan University from 1/2000 to 7/2007 were included in the study to investigate the relationship between HR and cancer survival.

RESULTS

CRC patients (n=669) with liver metastases who had primary tumor resection were grouped in synchronous liver metastasis (SLM; 56.7%, n=379) and metachronous liver metastasis (MLM) groups (43.3%, n=290). Hepatic resection rates were lower (32.5%, n=123) in the SLM than the MLM group (44.8%, n=130, P<0.05). The 30-day mortality rate in the MLM (2.3%) was significantly lower than SLM (2.4%) groups. The 5-year survival rates (36.6%) was same compared to SLM group (33.1%, P>0.05). One-, 2-, and 3-year survival of stages I and II operation cases were 92.5% vs 86.5%, 0.7% vs 58.0%, and 42.1% vs 44.9% (P>0.05) in the SLM group, respectively. Recurrence after first hepatic resection associated with a 2.23-fold increased risk of death (P<0.01). Incision margins larger than 1 cm and HR for recurrence associated with 34% and 27% (P<0.05) decreased death risk.

CONCLUSIONS

Hepatic resection could help the survival of liver metastasis of colorectal cancer, and stage I surgery is safe for this disease.

Recent trends of hepatic resection in Canada: 1995-2004

INTRODUCTION

Recently, many surgical procedures have become regionalized in the United States, likely owing to research demonstrating a relationship between volume and outcome. We sought to describe patient characteristics and outcomes according to hospital volume along with patterns of regionalization for hepatic resection in Canada from 1995 to 2004.

METHODS

Discharge data from all hospitals across Canada except Quebec were obtained from the Canadian Institute for Health Information for 1995-2004. All patients undergoing a hepatic resection were identified using ICD-9 and ICD-10 codes. High-volume hospitals were defined as those performing ten or more procedures per year.

RESULTS

A total of 9,912 patients (mean age 59 years) underwent hepatic resection. The proportion of procedures performed at high-volume hospitals increased from 42% in 1995 to 84% in 2004. Overall mortality rate for the study period was 5.0% which decreased over time. Mortality rates were higher at low-volume (6.1%) compared to high-volume centers (4.6%), but this finding was not statistically significant (p = 0.7451). Those factors predictive of mortality in a multivariate analysis included age, gender, year of operation, operative indication, comorbidity score, and admission status.

DISCUSSION

Mortality rates have significantly improved. Hospital volume is not a significant predictor of mortality following liver resection in Canada.

Focal Nodular Hyperplasia: Report of an Unusual Case and Review of the Literature

Focal nodular hyperplasia (FNH) is the second most common benign lesion of the liver and a common differential in the workup of solid liver lesions. With increasing use of modern imaging modalities FNH is becoming clinically more relevant. We present a case of pedunculated FNH presenting as a pericholecystic mass. This was resected laparoscopically due to persistent symptoms and uncertainty in diagnosis. We summarize the current literature with regard to the diagnosis, etiology, and management of FNH lesions.

The Mount Sinai experience with orthotopic liver transplantation for benign tumors: brief report and literature review: case reports

Orthotopic liver transplantation (OLT) is performed for benign hepatic lesions that are symptomatic, too large to be resected, have a malignant transformation potential, cause debilitating/life-threatening manifestations, or in patients experiencing posthepatectomy acute liver failure. Among benign tumors, polycystic liver disease (PLD) is the most common indication for OLT alone, or combined liver-kidney transplantation. Our 10-year experience with OLT for benign tumors includes two patients with PLD and one with a benign giant fibrous tumor. In this report, we present our experience with OLT for benign liver tumors, commenting on relevant published studies.

Surgical specialization and operative mortality in hepato-pancreatico-biliary (HPB) surgery

INTRODUCTION

Surgeon specialization has been shown to result in improved outcomes but may not be the sole measure of surgical quality in hepato-pancreatico-biliary (HPB) surgery. We attempted to determine which factors predominate in optimal patient outcomes between volume, surgeon, and hospital resources.

METHODS

All non-transplant pancreatic (n = 7195) and liver operations (n = 4809) from the Nationwide Inpatient Sample (NIS) were examined from 1998-2005. Surgeons and hospitals were divided into two groups, transplant (TX) or non-transplant (non-TX), using the unique surgeon and hospital identifier of NIS. A logistic regression model examined the relationship between factors while accounting for patient and hospital factors.

RESULTS

We identified 4,355 primary surgeons (165 TX, 4,190 non-TX) who performed HPB surgery in 675 hospitals across 12 different states. Non-TX surgeons performed the majority of pancreatic (97%) and liver procedures (81%). There was no difference in mortality after HPB surgery depending on surgeon specialty (p = 0.59). Factors for inpatient death after HPB surgery included increasing age, male gender, and public insurance (p < 0.05). In addition, surgery performed at a TX center had a 21% lower odds of perioperative mortality.

DISCUSSION

Non-TX surgeons performed the majority of pancreatic and liver surgery in the US. Hospital factors like support of transplantation but not surgical specialty, appeared to impact operative mortality. Future regulatory benchmarks should consider these types of center-based facilities and resources to assess patient outcomes.

Racial disparity in surgical mortality after major hepatectomy

BACKGROUND

The relationship between surgical mortality and race has not been studied for major hepatectomy. We sought to quantify and explore the nature of racial disparities in surgical mortality after major hepatectomy in a nationally representative cohort of patients.

STUDY DESIGN

We conducted a retrospective cohort study using data from the Nationwide Inpatient Sample (1998 to 2005). Adult patients undergoing major hepatectomy within 1 day of nontrauma admission were included. Logistic regression models were used to assess the variation of in-hospital mortality by race after adjustment for other risk factors.

RESULTS

The study cohort consisted of 3,552 observations representing 17,794 patients undergoing major hepatectomy. Unadjusted analyses revealed that African-American patients had a two-fold increased odds of surgical mortality (odds ratio 2.22, 95% CI 1.38 to 3.57) relative to Caucasians. Even after adjustment for other risk factors, African Americans had a two-fold increased odds of surgical mortality (odds ratio 2.15, 95% CI 1.28 to 3.61) relative to Caucasians. Stratified analyses restricting the cohort to patients without comorbidities, those with neoplasms, those with private insurance, or those treated at high-volume hospitals all demonstrated racial disparities in surgical mortality.

CONCLUSIONS

In-hospital mortality after major hepatectomy varies substantially by race. After adjustment for potential confounders, African-American patients have two-fold higher population-level odds of surgical mortality than Caucasian patients do. Our analyses suggest that clinical factors, insurance status, and hospital factors do not account for these differences. Additional studies to clarify the nature of this disparity and identify targets for intervention are warranted.

Hepatocellular carcinoma: Defining the place of surgery in an era of organ shortage

Liver resection (LR) and transplantation offer the only potential chance of cure for patients with hepatocellular carcinoma (HCC). Historically, all patients were treated by hepatic resection. With the advent of liver transplantation (LT) patients with HCC were preferentially placed on the waiting list for LT. However, early experience with LT was associated with a high rate of tumour recurrence and poor long-term survival. The increasing scarcity of donor livers resulted in restrictions being placed on tumour size, and an improvement in patient survival. To date there have been no randomised clinical trials comparing LR to LT. We review the evidence supporting LR and/or LT for HCC and discuss the role of neoadjuvant therapy. The decision of whether to resect or transplant remains debatable and is often determined by centre experience, availability of LT and donor organs.

Effect of postoperative morbidity on long-term survival after hepatic resection for metastatic colorectal cancer

PURPOSE

Resection is the most effective treatment for metastatic colorectal cancer (MCRC) to the liver. However, postoperative morbidity is common and its impact on long-term oncological outcome is unclear. The objective of this study was to evaluate the impact of postoperative morbidity on the long-term outcome after liver resection for MCRC.

METHODS

Medical records of patients who underwent liver resection for MCRC with curative intent between 1991 and 2002 were reviewed. Patients who died of postoperative complications were excluded; operative and perioperative data, including morbidity and clinicopathological variables, were analyzed. Patients were stratified by disease extent and risk of recurrence using a clinical risk scoring system.

RESULTS

A total of 1067 patients were included in the study and the median follow-up period was 41 months. The overall morbidity rate was 42%; the 5-year disease-specific survival (DSS) and overall disease-free survival (DFS) rates of patients who had complications were 41% and 25%, respectively, compared with 48% and 33%, respectively, for patients who did not have complications (P = 0.0059 for DSS, P = 0.0053 for DFS). On multivariate analysis, morbidity was not an independent predictor of either DSS or DFS; however, in a subgroup of patients with low clinical risk scores, morbidity was associated with a significant reduction in both DSS and DFS.

CONCLUSIONS

Postoperative morbidity adversely affects long-term outcome after hepatic resection for MCRC in patients at lower risk for recurrence. Efforts aimed at reducing perioperative morbidity will not only reduce usage of resources but will likely further enhance the therapeutic benefit of resection for such patients.

Operative mortality after hepatic resection: are literature-based rates broadly applicable?

INTRODUCTION

Literature-based data on mortality after hepatectomy may be misleading, as poor outcomes are less likely to be published. The objective of the current study was to compare published vs public, nationally available mortality rates after hepatic resection.

MATERIALS AND METHODS

A systematic MEDLINE review was conducted to identify reports of hepatectomy outcome between January 1998-December 2004. Data were analyzed to calculate literature-based mortality rate and then compared with population-based mortality rate for hepatectomy using the Nationwide Inpatient Sample (NIS) dataset.

RESULTS

Twenty-three publications fulfilled screening criteria. The studies included 7,073 patients who had undergone hepatic resection (46.1% within USA vs 53.9% outside USA). Most patients were male (58.6%) with median age of 56 years. Indications for hepatic resection included hepatocellular carcinoma (47.7%), metastatic disease (34.3%), or other (18.1%). Cirrhosis was present in 23.2% of patients; 46.9% patients underwent either a hemi-hepatectomy or extended resection. The literature-based mortality rate was 3.6% (US centers only, 2.8%). Analysis of NIS revealed 11,429 hepatectomy cases. After controlling for gender, age, extent of hepatectomy, hepatocellular cancer diagnosis, and presence of cirrhosis, the adjusted NIS-based perioperative mortality rate for hepatectomy was 5.6% (95% CI, 5.0-6.2%). The relative mortality after hepatectomy was 1.6-fold higher based on population-based data compared with reports from the literature (P<0.05).

CONCLUSION

Actual population-based mortality rates for major liver resections may be higher than those reported in the literature. Informed consent should reflect actual local and national mortality rates rather than selective reports from the literature.

Sonographic preoperative assessment of liver volume before major liver resection

OBJECTIVE

The use of ultrasonography is widespread for both the diagnosis and treatment of liver tumors. However, the measurement of liver volume by ultrasonography is not commonly done. We report an original method of liver volumetry using ultrasonography and an investigation into the usefulness of ultrasonography in this context.

METHODS

The data for 50 patients undergoing various types of major hepatectomy were collected. We preoperatively measured liver volume using ultrasonography, dividing the liver into three main compartments according to precise anatomical landmarks, and then made comparisons with the volume of the actual specimen after hepatectomy, for all of the study participants.

RESULTS

Total volume correlation between the two groups was good (r = 0.916, P < 0.001). However, the correlation was weaker in cases of right hepatectomy compared with other types of hepatectomy.

CONCLUSION

This study demonstrates the possibility of doing liver volumetry using an ultrasound device. Further investigation to establish the reliability of this easily available and noninvasive approach is needed.

Impact of surgeon training on outcomes after resective hepatic surgery

BACKGROUND

Higher hospital and surgeon volumes have been associated with improved outcomes after hepatic resection. Subspecialty training has not previously been associated with improved outcomes after hepatic resection. The objective of this study was to determine what effects, if any, surgeon's volume and training had on the outcomes after hepatic resection.

METHODS

Administrative procedure codes were used to identify all adult patients from the fiscal year 1991-1992 to 2003-2004 who underwent a hepatic resection in two large urban health regions in Canada (Calgary and Capital health regions). The primary outcomes were operative mortality and postoperative complications.

RESULTS

There were 1107 hepatic resections in the stated time period performed by a total of 72 surgeons. There were 66 deaths, resulting in an in-hospital mortality rate of 6.0%, and an overall complication rate of 46%. Statistically significant predictors of operative mortality were: urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing burden of comorbid medical illness. Surgeon training along with patient's sex, the urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing comorbidity were predictive of postoperative complications.

CONCLUSIONS

This study found surgeon training to be highly predictive of postoperative complications after hepatic resection.

Liver volumetry plug and play: do it yourself with ImageJ

Background

A small remnant liver volume is an important risk factor for posthepatectomy liver failure and can be predicted accurately by computed tomography (CT) volumetry using radiologic image analysis software. Unfortunately, this software is expensive and usually requires support by a radiologist. ImageJ is a freely downloadable image analysis software package developed by the National Institute of Health (NIH) and brings liver volumetry to the surgeon’s desktop. We aimed to assess the accuracy of ImageJ for hepatic CT volumetry.

Methods

ImageJ was downloaded from http://www.rsb.info.nih.gov/ij/. Preoperative CT scans of 15 patients who underwent liver resection for colorectal cancer liver metastases were retrospectively analyzed. Scans were opened in ImageJ; and the liver, all metastases, and the intended parenchymal transection line were manually outlined on each slice. The area of each selected region, metastasis, resection specimen, and remnant liver was multiplied by the slice thickness to calculate volume. Volumes of virtual liver resection specimens measured with ImageJ were compared with specimen weights and calculated volumes obtained during pathology examination after resection.

Results

There was an excellent correlation between the volumes calculated with ImageJ and the actual measured weights of the resection specimens (r² = 0.98, p < 0.0001). The weight/volume ratio amounted to 0.88 ± 0.04 (standard error) and was in agreement with our earlier findings using CT-linked radiologic software.

Conclusion

ImageJ can be used for accurate hepatic CT volumetry on a personal computer. This application brings CT volumetry to the surgeon’s desktop at no expense and is particularly useful in cases of tertiary referred patients, who already have a proper CT scan on CD-ROM from the referring institution. Most likely the discrepancy between volume and weight results from exsanguination of the liver after resection.

Predictors of survival after hepatic resection among patients with colorectal liver metastasis

Studies suggest improved survival following resection of colorectal cancer liver metastases (CLMs). We investigated predictors of survival among patients with CLM who underwent hepatic resection using the SEER-Medicare database to identify patients >/=65 years diagnosed with CLM, 1991-2003, who underwent hepatectomy. Cox proportional hazards models were used to identify factors associated with survival after hepatectomy. Of 923 patients with CLM who underwent hepatectomy, 514 were stages I-III and developed CLM>6 months after diagnosis (metachronous), and 409 were stage IV with CLM at diagnosis (synchronous). From the date of hepatectomy, 5 year survival was 22%; younger age, being married, female gender, surgery in an NCI-designated cancer centre, fewer comorbidities, fewer positive lymph nodes, and lower grade were associated with improved survival. Both 5-fluorouracil (5FU)-based chemotherapy and hepatic arterial infusion (HAI) of floxuridine-based chemotherapy following hepatectomy improved survival (HR=0.62, 95% CI: 0.50-0.78; HR=0.51, 95% CI: 0.28-0.97, respectively) in the synchronous, but not metachronous, group. The HR for overall mortality was higher in hospitals with a high vs low procedure volume (0.75, 95% CI: 0.58-0.94). A substantial subgroup of patients with CLM who undergo hepatectomy experiences long-term survival. High hospital procedure volume and use of 5FU-based or HAI-based chemotherapy after resection were associated with improved prognosis.