Multi-Enzyme Activity of MIL-101 (Fe)-Derived Cascade Nano-Enzymes for Antitumor and Antimicrobial Therapy

The clinical application of oncology therapy is hampered by high glutathione concentrations, hypoxia, and inefficient activation of cell death mechanisms in cancer cells. In this study, Fe and Mo bimetallic sulfide nanomaterial (FeS2@MoS2) based on metal-organic framework structure is rationally prepared with peroxidase (POD)-, catalase (CAT)-, superoxide dismutase (SOD)-like activities and glutathione depletion ability, which can confer versatility for treating tumors and mending wounds. In the lesion area, FeS2@MoS2 with SOD-like activity can facilitate the transformation of superoxide anions (O2 -) to hydrogen peroxide (H2O2), and then the resulting H2O2 serves as a substrate for the Fenton reaction with FMS to produce highly toxic hydroxyl radicals (∙OH). Simultaneously, FeS2@MoS2 has an ability to deplete glutathione (GSH) and catalyze the decomposition of nicotinamide adenine dinucleotide phosphate (NADPH) to curb the regeneration of GSH from the source. Thus it can realize effective tumor elimination through synergistic apoptosis-ferroptosis strategy. Based on the alteration of the H2O2 system, free radical production, glutathione depletion and the alleviation of hypoxia in the tumor microenvironment, FeS2@MoS2 NPS can not only significantly inhibit tumors in vivo and in vitro, but also inhibit multidrug-resistant bacteria and hasten wound healing. It may open the door to the development of cascade nanoplatforms for effective tumor treatment and overcoming wound infection.

Effects of evidence-based nursing on surgical site wound infections in patients undergoing surgery for liver cancer: A meta-analysis

This study aimed to systematically evaluate the impact of evidence-based nursing (EBN) on perioperative wound infections and postoperative complications in patients undergoing surgery for liver hepatocellular carcinoma (LIHC). Randomised controlled trials (RCTs) on the application of EBN on patients receiving LIHC surgery were searched in PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database and China National Knowledge Infrastructure from the inception of each database to September 2023. Studies were screened and evaluated by two investigators based on inclusion and exclusion criteria, and data were extracted from the final included literature. RevMan 4.0 was used for data analysis. Overall, 15 RCTs involving 1374 patients with LIHC were included, with 687 in the EBN group and 687 in the conventional care group. The analysis revealed that the incidence of wound infections (odds ratio [OR] = 0.32, 95% confidence interval [CI]: 0.18-0.56, p < 0.001) and postoperative complications (OR = 0.22, 95% CI: 0.15-0.31, p < 0.001) was significantly lower in the EBN group than in the conventional care group. The available evidence suggests that nursing strategies for EBN applied in the perioperative period in patients with LIHC receiving surgery can effectively reduce the incidence of wound infections and postoperative complications and promote postoperative recovery.

Safety and Survival Outcomes of Liver Resection following Triple Combination Conversion Therapy for Initially Unresectable Hepatocellular Carcinoma

Triple combination conversion therapy, involving transcatheter arterial chemoembolization (TACE) or hepatic arterial infusion chemotherapy (HAIC) combined with tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs), has shown an encouraging objective response rate (ORR) and successful conversion surgery rate in initially unresectable hepatocellular carcinoma (HCC). However, the safety and long-term survival outcomes of subsequent liver resection after successful conversion still remain to be validated. From February 2019 to February 2023, 726 patients were enrolled in this retrospective study (75 patients received hepatectomy after conversion therapy [CLR group], and 651 patients underwent pure hepatectomy [LR group]). Propensity score matching (PSM) was used to balance the preoperative baseline characteristics. After PSM, 68 patients in the CLR group and 124 patients in the LR group were analyzed, and all the matching variables were well-balanced. Compared with the LR group, the CLR group experienced longer Pringle maneuver time, longer operation time, and longer hospital stays. In addition, the CLR group had significantly higher incidence rates of intra-abdominal bleeding, biliary leakage, post-hepatectomy liver failure (PHLF), and Clavien-Dindo grade IIIa complications than the LR group. There were no significant statistical differences in overall survival (OS) (hazard ratio [HR] 0.724; 95% confidence interval [CI] 0.356-1.474; p = 0.374) and recurrence-free survival (RFS) (HR 1.249; 95% CI 0.807-1.934; p = 0.374) between the two groups. Liver resection following triple combination conversion therapy in initially unresectable HCC may achieve favorable survival outcomes with manageable safety profiles; presenting as a promising treatment option for initially unresectable HCC.

Impact of sarcopenic obesity on post-hepatectomy bile leakage for hepatocellular carcinoma

BACKGROUND

Post-hepatectomy bile leakage (PHBL) is a potentially fatal complication that can arise after hepatectomy. Previous studies have identified obesity as a risk factor for PHBL. In this study, we investigated the impact of sarcopenic obesity on PHBL in hepatocellular carcinoma (HCC) patients.

METHODS

In total, we enrolled 409 patients who underwent hepatectomy without bilioenteric anastomosis for HCC between January 2010 and August 2021. Patients were grouped according to the presence or absence of PHBL. Patient characteristics, including body mass index and sarcopenic obesity, were then analyzed for predictive factors for PHBL.

RESULTS

Among the 409 HCC patients included in the study, 39 developed PHBL. Male sex, hypertension, cardiac disease, white blood cell counts, the psoas muscle area, and visceral fat area, and intraoperative blood loss were significantly increased in the PHBL (+) group compared with the PHBL (-) group. Multivariate analysis showed that the independent risk factors for the occurrence of PHBL were intraoperative blood loss ≥370 mL and sarcopenic obesity.

CONCLUSIONS

Our results show that it is important to understand whether a patient is at high risk for PHBL prior to surgery and to focus on reducing intraoperative blood loss during surgery for patients with risk factors for PHBL.

Surgical site wound infection and pain after laparoscopic repeat hepatectomy for recurrent hepatocellular carcinoma

This study aimed to compare the effects of laparoscopic repeat liver resection (LRLR) and open repeat liver resection (ORLR) on surgical site wound infection and pain in recurrent hepatocellular carcinoma. PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were systematically searched for studies comparing LRLR with ORLR for the treatment of recurrent hepatocellular carcinoma, with a search timeframe from their inception to December 2022. Two investigators independently screened the literature, extracted information, and evaluated the quality of the studies according to the inclusion and exclusion criteria. This study was performed using RevMan 5.4 software. A total of 20 publications with 4380 patients were included, with 1108 and 3289 patients in the LRLR and ORLR groups, respectively. The results showed that LRLR significantly reduced surgical site wound infection rate (1.71% vs. 5.16%, odds ratio [OR]:0.32, 95% confidence interval [CI]: 0.18-0.56, P < .001), superficial wound infection rate (1.29% vs. 4.92%, OR: 0.29, 95% CI: 0.14-0.58, P < .001), bile leakage (3.34% vs. 6.05%, OR: 0.59, 95% CI: 0.39-0.90, P = .01), organ/space wound infection rate (0.4% vs. 5.11%, OR: 0.23, 95% CI: 0.07-0.81, P = .02), and surgical site wound pain (mean difference: -2.00, 95% CI: -2.99 to -1.02, P < .001). Thus, the findings of this study showed that LRLR for recurrent hepatocellular carcinoma significantly reduced wound infection rates and improved postoperative wound pain.

Association of primary tumor location with long-term oncological prognosis following hepatectomy for hepatocellular carcinoma:A multicenter propensity score matching analysis

PURPOSE

There is a striking laterality in the site of hepatocellular carcinoma (HCC), with a strong predominance for the right side; however, the impact of primary tumor location on long-term prognosis after hepatectomy of HCC remains unclear. This study aimed to investigate the effect of primary tumor location on long-term oncological prognosis after hepatectomy for HCC.

PATIENTS AND METHODS

Data of consecutive patients undergoing curative hepatectomy for HCC between 2008 and 2017 were analyzed. Overall survival (OS) and recurrence-free survival (RFS) of left-sided HCC (LS group) and right-sided HCC (RS group) were compared by using propensity score matching (PSM) analysis. COX regression analysis was performed to assess the adjusted effect of tumor location on long-term oncological prognosis.

RESULTS

Of the 2799 included patients, 707 (25.3%) and 2092 (74.7%) were in the LS and RS groups, respectively. Using PSM analysis, 650 matched pairs of patients were created. In the PSM cohort, median OS (66.0 vs. 72.0 months, P = 0.001) and RFS (28.0 vs. 51.0 months, P < 0.001) were worse among patients in the LS group compared to individuals in the RS group. After further adjustment for other confounders using multivariable COX regression analyses, HCC located on the left side remained independently associated with worse OS and RFS.

CONCLUSION

Tumors located on the left side are associated with poorer OS and RFS after hepatectomy for HCC. Careful surgical options selection and frequent follow-up to improve long-term survival may be justified for HCC patients with left-sided primary tumors.

Post-hepatectomy biliary leaks: analysis of risk factors and development of a simplified predictive scoring system

PURPOSE

Most studies identifying risk factors for post-hepatectomy biliary leaks (PHBLs) have relatively small proportions of major hepatectomies. A simplified predictive score to identify high risk patients is necessary in order to investigate the efficacy of mitigation strategies.

METHODS

A retrospective analysis of a prospectively maintained database of liver resections from a high-volume cancer center was performed. Multivariate regression was utilized for identification of risk factors and development of the predictive score.

RESULTS

A total of 862 patients underwent a curative hepatic resection over 10 years, of whom 146 (16.9%) developed a biliary leak; 85 (9.86%), 52 (6.03%), and 9 (1.04%) patients had a grade A, B, and C leak respectively. A biliary-enteric anastomosis [OR 5.1 (95% CI 2.45-10.58); p < 0.001], a central [OR 4.33 (95% CI 1.25-14.95); p = 0.021] or an extended hepatectomy [OR 4.29 (95% CI 1.52-12.12); p = 0.006], liver steatosis [OR 2.28 (95% CI 1.09-4.77); p = 0.027], and blood loss of ≥ 2000 mL [OR 2.219 (95% CI 1.15-4.27); p = 0.017] were identified as independent predictors of a clinically significant biliary leak and were assigned 1 point each to develop the biliary leak score. Clinically significant biliary leaks were seen in 11 (2.79%), 20 (6.38%), 19 (15.4%), 9 (56.3%), and 1 (100%) patients with scores of 0, 1, 2, 3, and 4 respectively (p < 0.001).

CONCLUSION

A biliary-enteric anastomosis, a central or extended hepatectomy, liver steatosis, and blood loss ≥ 2L combined result in a simple predictive score for clinically significant biliary leaks.

The usefulness of preoperative bile cultures for hepatectomy with biliary reconstruction

Background

Infectious complications can cause lethal liver failure after hepatectomy with biliary reconstruction. This study assessed the increased risk for postoperative infectious complications in patients who underwent hepatectomy with biliary reconstruction and explored the possibility of predicting pathogenic microorganisms causing postoperative infectious complications based on preoperative monitoring of bile cultures.

Methods

This study involved 310 patients who received major hepatectomy with or without biliary reconstruction at our institution between January 2010 and December 2019. The relationship between the microorganisms detected through perioperative monitoring of bile culture and those in the postoperative infectious foci was examined.

Results

Forty-nine patients underwent major hepatectomy with biliary reconstruction, and 261 received hepatectomy without biliary reconstruction. The multivariate analysis revealed hepatectomy with biliary reconstruction to be associated with an increased risk of postoperative infectious complications (odds ratio: 22.9, 95% confidence interval: 5.2-164.3) compared to hepatectomy without biliary reconstruction. In the patients with biliary reconstruction, the concordance rates between the microorganisms detected in the postoperative infectious foci and those in preoperative bile cultures were as follows: incisional surgical site infection (44.4%), organ/space surgical site infection (52.9%), bacteremia (47.1%), and pneumonia (16.7%); the concordance rates were high, and the risk of infection increased over time.

Conclusions

Biliary reconstruction is a significant risk factor for postoperative infectious complications, and preoperative bile cultures may aid in prophylactic and therapeutic antimicrobial agent selection.

Minor hepatectomy for hepatocellular carcinoma in a patient with portal hypertension: A case report and review of the literature

INTRODUCTION

Curative modalities for early hepatocellular carcinoma (HCC) include liver resection (LR) and transplantation. For patients with portal hypertension (PH), liver transplantation (LT) is the preferred treatment but is oftentimes limited by organ shortage and can lead candidates to drop off due to disease progression, while hepatectomy has a higher risk of complications. This would pose a dilemma as to whether wait for donor organs or prioritize hepatectomy.

PATIENT CONCERNS

The patient was a 56-year-old male, a case of liver cirrhosis due to hepatitis C with sustained virological response following direct-acting antiviral agents. He was a liver transplant candidate, presented to the gastroenterology outpatient department for a recently-diagnosed liver tumor during a regular follow-up session. Pre-operative survey revealed PH manifested by thrombocytopenia, splenomegaly, huge splenorenal shunt and varices. The patient's Child-Pugh score was 7.

INTERVENTIONS AND DIAGNOSIS

Considering the patient's overall condition, tumor size and location, and a shortage of grafts, he underwent segment 5 and 6 partial hepatectomy. The pathological diagnosis was moderately differentiated HCC.

OUTCOMES

His postoperative course was complicated by refractory intraabdominal infection (IAI) and recovered under aggressive antibiotics treatment. He remained recurrence-free for over a year.

CONCLUSION

For patients with early resectable HCC, the approach of having a minor hepatectomy followed by salvage transplantation should serve as a compromising strategy. Tumor resection retards the progression of the disease. Comprehensive healthcare can expectantly improve clinical outcomes.

A Web-Based Prediction Model for Estimating the Probability of Post-hepatectomy Major Complications in Patients with Hepatocellular Carcinoma: A Multicenter Study from a Hepatitis B Virus-Endemic Area

BACKGROUND

The identification of patients at high risk of developing postoperative complications is important to improve surgical safety. We sought to develop an individualized tool to predict post-hepatectomy major complications in hepatitis B virus (HBV)-infected patients with hepatocellular carcinoma (HCC).

METHODS

A multicenter database of patients undergoing hepatectomy for HCC were analyzed; 2/3 and 1/3 of patients were assigned to the training and validation cohorts, respectively. Independent risks of postoperative 30-day major complications (Clavien-Dindo grades III-V) were identified and used to construct a web-based prediction model, which predictive accuracy was assessed using C-index and calibration curves, which was further validated by the validation cohort and compared with conventional scores.

RESULTS

Among 2762 patients, 391 (14.2%) developed major complications after hepatectomy. Diabetes mellitus, concurrent hepatitis C virus infection, HCC beyond the Milan criteria, cirrhosis, preoperative HBV-DNA level, albumin-bilirubin (ALBI), and aspartate transaminase to platelet ratio index (APRI) were identified as independent predictors of developing major complications, which were used to construct the online calculator ( http://www.asapcalculate.top/Cal11_en.html ). This model demonstrated good calibration and discrimination, with the C-indexes of 0.752 and 0.743 in the training and validation cohorts, respectively, which were significantly higher than those conventional scores (the training and validation cohorts: 0.565 ~ 0.650 and 0.568 ~ 0.614, all P < 0.001).

CONCLUSIONS

A web-based prediction model was developed to predict the probability of post-hepatectomy major complications in an individual HBV-infected patient with HCC. It can be used easily in the real-world clinical setting to help management-related decision-making and early warning, especially in areas with endemic HBV infection.

Phase 0 Study of Vandetanib-Eluting Radiopaque Embolics as a Preoperative Embolization Treatment in Patients with Resectable Liver Malignancies

PURPOSE

To assess the safety and tolerability of a vandetanib-eluting radiopaque embolic (BTG-002814) for transarterial chemoembolization (TACE) in patients with resectable liver malignancies.

MATERIALS AND METHODS

The VEROnA clinical trial was a first-in-human, phase 0, single-arm, window-of-opportunity study. Eligible patients were aged ≥18 years and had resectable hepatocellular carcinoma (HCC) (Child-Pugh A) or metastatic colorectal cancer (mCRC). Patients received 1 mL of BTG-002814 transarterially (containing 100 mg of vandetanib) 7-21 days prior to surgery. The primary objectives were to establish the safety and tolerability of BTG-002814 and determine the concentrations of vandetanib and the N-desmethyl vandetanib metabolite in the plasma and resected liver after treatment. Biomarker studies included circulating proangiogenic factors, perfusion computed tomography, and dynamic contrast-enhanced magnetic resonance imaging.

RESULTS

Eight patients were enrolled: 2 with HCC and 6 with mCRC. There was 1 grade 3 adverse event (AE) before surgery and 18 after surgery; 6 AEs were deemed to be related to BTG-002814. Surgical resection was not delayed. Vandetanib was present in the plasma of all patients 12 days after treatment, with a mean maximum concentration of 24.3 ng/mL (standard deviation ± 13.94 ng/mL), and in resected liver tissue up to 32 days after treatment (441-404,000 ng/g). The median percentage of tumor necrosis was 92.5% (range, 5%-100%). There were no significant changes in perfusion imaging parameters after TACE.

CONCLUSIONS

BTG-002814 has an acceptable safety profile in patients before surgery. The presence of vandetanib in the tumor specimens up to 32 days after treatment suggests sustained anticancer activity, while the low vandetanib levels in the plasma suggest minimal release into the systemic circulation. Further evaluation of this TACE combination is warranted in dose-finding and efficacy studies.

Imaging Features of Main Posthepatectomy Complications: A Radiologist’s Challenge

In the recent years, the number of liver resections has seen an impressive growth. Usually, hepatic resections remain the treatment of various liver diseases, such as malignant tumors, benign tumors, hydatid disease, and abscesses. Despite technical advancements and tremendous experience in the field of liver resection of specialized centers, there are moderately high rates of postoperative morbidity and mortality, especially in high-risk and older patient populations. Although ultrasonography is usually the first-line imaging examination for postoperative complications, Computed Tomography (CT) is the imaging tool of choice in emergency settings due to its capability to assess the whole body in a few seconds and detect all possible complications. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for delineating early postoperative bile duct injuries and ischemic cholangitis that may arise in the late postoperative phase. Moreover, both MDCT and MRCP can precisely detect tumor recurrence. Consequently, radiologists should have knowledge of these surgical procedures for better comprehension of postoperative changes and recognition of the radiological features of various postoperative complications.

Complications Risk Assessment and Imaging Findings of Thermal Ablation Treatment in Liver Cancers: What the Radiologist Should Expect

One of the major fields of application of ablation treatment is liver tumors. With respect to HCC, ablation treatments are considered as upfront treatments in patients with early-stage disease, while in colorectal liver metastases (CLM), they can be employed as an upfront treatment or in association with surgical resection. The main prognostic feature of ablation is the tumor size, since the goal of the treatment is the necrosis of all viable tumor tissue with an adequate tumor-free margin. Radiofrequency ablation (RFA) and microwave ablation (MWA) are the most employed ablation techniques. Ablation therapies in HCC and liver metastases have presented a challenge to radiologists, who need to assess response to determine complication-related treatment. Complications, defined as any unexpected variation from a procedural course, and adverse events, defined as any actual or potential injury related to the treatment, could occur either during the procedure or afterwards. To date, RFA and MWA have shown no statistically significant differences in mortality rates or major or minor complications. To reduce the rate of major complications, patient selection and risk assessment are essential. To determine the right cost-benefit ratio for the ablation method to be used, it is necessary to identify patients at high risk of infections, coagulation disorders and previous abdominal surgery interventions. Based on risk assessment, during the procedure as part of surveillance, the radiologists should pay attention to several complications, such as vascular, biliary, mechanical and infectious. Multiphase CT is an imaging tool chosen in emergency settings. The radiologist should report technical success, treatment efficacy, and complications. The complications should be assessed according to well-defined classification systems, and these complications should be categorized consistently according to severity and time of occurrence.

Meta-Analysis of Risk Factors for Bile Leakage After Hepatectomy Without Biliary Reconstruction

Background and Aim: The risk factors for bile leakage after hepatectomy without biliary reconstruction are controversial. This study investigated the risk factors for bile leakage after hepatectomy without biliary reconstruction.

Methods: We searched databases (Embase (Ovid), Medline (Ovid), PubMed, Cochrane Library, and Web of Science) for articles published between January 1, 2000, and May 1, 2021, to evaluate the risk factors for bile leakage after hepatectomy without biliary reconstruction.

Results: A total of 16 articles were included in this study, and the overall results showed that sex (OR: 1.21, 95% CI: 1.04–1.42), diabetes (OR: 1.21, 95% CI: 1.05–1.38), left trisectionectomy (OR: 3.53, 95% CI: 2.32–5.36), central hepatectomy (OR: 3.28, 95% CI: 2.63–4.08), extended hemihepatectomy (OR: 2.56, 95% CI: 1.55–4.22), segment I hepatectomy (OR: 2.56, 95% CI: 1.50–4.40), intraoperative blood transfusion (OR:2.40 95%CI:1.79–3.22), anatomical hepatectomy (OR: 1.70, 95% CI: 1.19–2.44) and intraoperative bleeding ≥1,000 ml (OR: 2.46, 95% CI: 2.12–2.85) were risk factors for biliary leakage. Age >75 years, cirrhosis, underlying liver disease, left hepatectomy, right hepatectomy, benign disease, Child–Pugh class A/B, and pre-operative albumin <3.5 g/dL were not risk factors for bile leakage after hepatectomy without biliary reconstruction.

Conclusion: Comprehensive research in the literature revealed that sex, diabetes, left trisectionectomy, central hepatectomy, extended hemihepatectomy, segment I hepatectomy, intraoperative blood transfusion, anatomical hepatectomy and intraoperative bleeding ≥1,000 ml were risk factors for biliary leakage.

Anatomic Resection for Hepatocellular Carcinoma: Prognostic Impact Assessed from Recurrence Treatment

BACKGROUND

The oncologic advantage of anatomic resection (AR) for primary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the clinical advantages of AR for primary HCC by using propensity score-matching and by assessing treatment strategies for recurrence after surgery.

METHODS

The study reviewed data of patients who underwent AR or non-anatomic resection (NAR) for solitary HCC (≤ 5 cm) in two institutions between 2004 and 2017. Surgical outcomes were compared between the two groups in a propensity score-adjusted cohort. The time-to-interventional failure (TIF), defined as the elapsed time from resection to unresectable/unablatable recurrence, also was evaluated.

RESULTS

The inclusion criteria were met by 250 patients: 77 patients (31%) with AR and 173 patients (69%) with NAR. In the propensity score-matched populations (AR, 67; NAR, 67), the 5-year recurrence-free survival (RFS) for AR was better than for NAR (62% vs 35%; P = 0.005). No differences, however, were found in the 5-year overall survival between the two groups (72% vs 78%; P = 0.666). The 5-year TIF rates for the NAR group (60%) also were similar to those for the AR group (66%) (P = 0.413). In the cohort of 67 patients, curative repeat resection or ablation therapy was performed more frequently for the NAR patients (42%) than for the AR patients (10%) (P < 0.001).

CONCLUSION

For solitary HCC, AR decreases recurrence after the initial hepatectomy. However, aggressive curative-intent interventions for recurrence compensate for the impaired RFS, even for patients undergoing NAR.

Does intraoperative and postoperative analgesia cause bile leakage after hepatectomy?

PURPOSE

To evaluate the effect of morphine or morphine equivalents on the risk of bile leakage (BL) after hepatectomy.

METHODS

The subjects of this retrospective study were 379 patients who underwent hepatectomy without biliary reconstruction and biliary decompression tube insertion at Gunma University between 2016 and 2020. Clinical BL was defined as International Study Group of Liver Surgery post-hepatectomy bile leakage Grade B or C.

RESULTS

Intra- and post-operative analgesia comprised intravenous patient-controlled analgesia (IV-PCA) with fentanyl (n = 58), epidural analgesia with fentanyl (n = 157), epidural analgesia with morphine (n = 151), and epidural analgesia with ropivacaine or levobupivacaine (n = 13). Clinical BL was diagnosed in 14 of the 379 (3.7%) patients. The significant risk factors for clinical BL were hepatocellular carcinoma (HCC), elevated serum total bilirubin, high indocyanine green retention at 15 min, elevated Mac-2-binding protein glycosylated isomer, prolonged duration of surgery, and a large volume of blood loss. There was no significant correlation of clinical BL with intra- and post-operative analgesia and total oral morphine equivalents.

CONCLUSION

Intra- and post-operative IV-PCA and epidural analgesia were not related to clinical BL after hepatectomy. Based on our data, fentanyl and morphine can be administered safely as epidural or intravenous analgesic agents.

Direct Bilirubin in Drainage Fluid 3 days after Hepatectomy Is Useful for Detecting Severe Bile Leakage

INTRODUCTION

The International Study Group of Liver Surgery (ISGLS) definition of bile leakage is an elevated total bilirubin concentration in the drainage fluid after post-operative day (POD) 3, which has been widely accepted. However, there were no reports about direct bilirubin in drainage fluid to predict bile leakage.

METHODS

Data from 257 patients who underwent hepatectomy were retrospectively reviewed. The optimal cut-off value was investigated using receiver-operating characteristic curves. The predictive power of drainage fluid total bilirubin (dTB) and drainage fluid direct bilirubin (dDB) to predict bile leakage, which was defined using ISGLS grade B or grade C, were compared.

RESULTS

ISGLS grade B bile leakage occurred in 16 patients (6.2%). Area under the curve (AUC) of dDB was always higher than that of dTB on each POD. The AUC of dDB was >0.75 on PODs 2, 3, and 5, and then it increased with the increasing POD. The dDB on POD 5 showed the highest accuracy (0.91) and positive predictive value (PPV) (0.67), which was followed by dTB/serum total bilirubin (sTB) on POD 3 (accuracy, 0.91; PPV, 0.33). Because the PPV of dDB increased as the POD increased, dDB was better than dTB for predicting clinically significant bile leakage. dDB on POD 3 showed the highest negative predictive value (0.97). The positive likelihood of dDB increased and the negative likelihood of dDB decreased on the basis of the POD. Among patients with dTB/sTB ≤3 on POD 3, 19.1% of these patients had bile leakage when dDB was >0.44 on POD 3.

CONCLUSIONS

Measurement of both dDB and dTB, which are easy to perform, can be used to effectively predict clinically significant bile leakage.

The Impact of Time Interval between Hepatic Resection and Liver Transplantation on Clinical Outcome in Patients with Hepatocellular Carcinoma

Simple Summary

Recurrence of disease or worsening of liver function after hepatic resection (HR) for hepatocellular carcinoma (HCC) may require secondary liver transplantation (SLT). However, a history of HR is supposed to increase the surgical complexity of LT. This is one of the largest series of SLT and it demonstrates that among all the features analyzed regarding the prior HR, only time interval between HR and SLT was an independent predictor of severe complications after SLT. In particular, an increasing probability of severe complications was observed in those patients who were transplanted close (<15 months) to the HR. There was no significant association between HCC-related death and the time between HR and SLT at the multivariable competing risks regression model. Furthermore, these results remained inside the benchmark values recently reported for LT, confirming that tertiary referral centers with consistent experience in HPB surgery and LT may have benefits in both fields.

Abstract

Hepatic resection (HR) for hepatocellular carcinoma (HCC) may require secondary liver transplantation (SLT). However, a previous HR is supposed to worsen post-SLT outcomes. Data of patients treated by SLT between 2000 and 2018 at two tertiary referral centers were analyzed. The primary outcome of the study was to analyze the impact of HR on post-LT complications. A Comprehensive Complication Index ≥ 29.6 was chosen as cutoff. The secondary outcome was HCC-related death by means of competing-risk regression analysis. In the study period, 140 patients were included. Patients were transplanted in a median of 23 months after HR (IQR 14–41). Among all the features analyzed regarding the prior HR, only time interval between HR and SLT (time HR-SLT) was an independent predictor of severe complications after LT (OR = 0.98, p < 0.001). According to fractional polynomial regression, the probability of severe complications increased up to 15 months after HR (43%), then slowly decreased over time (OR = 0.88, p < 0.001). There was no significant association between HCC-related death and time HR-SLT at the multivariable competing risks regression model (SHR, 1.06; 95% CI: 0.69–1.62, p = 0.796). This study showed that time HR-SLT was key in predicting complications after LT, without affecting HCC-related death.

Postoperative morbidity adversely impacts long-term oncologic prognosis following hepatectomy for hepatocellular carcinoma: A multicenter observational study

BACKGROUND & AIMS

Postoperative morbidity following hepatectomy for hepatocellular carcinoma (HCC) is common and its impact on long-term oncological outcome remains unclear. This study aimed to investigate if postoperative morbidity impacts long-term survival and recurrence following hepatectomy for HCC.

METHODS

The data from a multicenter Chinese database of curative-intent hepatectomy for HCC were analyzed, and independent risks of postoperative 30-day morbidity were identified. After excluding patients with postoperative early deaths (≤90 days), early (≤2 years) and late (>2 years) recurrence rates, overall survival (OS), and time-to-recurrence (TTR) were compared between patients with and without postoperative morbidity.

RESULTS

Among 2,161 patients eligible for the study, 758 (35.1%) had postoperative 30-day morbidity. Multivariable logistic regression analysis showed that diabetes mellitus, obesity, Child-Pugh grade B, cirrhosis, and intraoperative blood transfusion were independent risks of postoperative morbidity. The rates of early and late recurrence among patients with postoperative morbidity were higher than those without (50.7% vs. 38.8%, P < 0.001; and 41.7% vs. 34.1%, P = 0.017). Postoperative morbidity was associated with decreased OS (median: 48.1 vs. 91.6 months, P < 0.001) and TTR (median: 19.8 vs. 46.1 months; P < 0.001). After adjustment of confounding factors, multivariable Cox-regression analyses revealed that postoperative morbidity was associated with a 27.8% and 18.7% greater likelihood of mortality (hazard ratio 1.278; 95% confidence interval: 1.126-1.451; P < 0.001) and recurrence (1.187; 1.058-1.331; P = 0.004).

CONCLUSION

This large multicenter study provides strong evidence that postoperative morbidity adversely impacts long-term oncologic prognosis after hepatectomy for HCC. The prevention and management of postoperative morbidity may be oncologically important.

Laparoscopic resection reduces superficial surgical site infection in liver surgery

BACKGROUND

Laparoscopic liver resection is beneficial compared to open liver resection. This study aimed to evaluate whether laparoscopic liver resection could reduce postoperative infections.

METHODS

This study included 125 and 115 patients with liver tumors who underwent open and pure laparoscopic partial resections or left lateral sectionectomies, respectively. Propensity score matching and stabilized inverse probability of treatment weighting were carried out to compare the postoperative infectious complication rates between the two groups.

RESULTS

Patients with tumors located in Couinaud segment 1, 7, or 8; with tumors adjacent to major vessels; or who underwent repeated resections were more likely to receive open resection. After propensity score matching, the superficial incisional surgical site infection rate tended to be lower in the laparoscopic liver resection group than in the open liver resection group. Moreover, overall infectious complication rate and superficial incisional surgical site infection rate were lower in the laparoscopic group (the cohort formed by the stabilized inverse probability of treatment weighting).

CONCLUSIONS

Using the laparoscopic approach for partial resections and left lateral sectionectomies for liver tumors, the superficial incisional surgical site infection rate could be reduced.

Prognostic Nutritional Index Considering Resection Range Is Useful for Predicting Postoperative Morbidity of Hepatectomy

BACKGROUND

Poor preoperative nutritional and immunological status are major risk factors for postoperative complications in patients with various malignancies. Lower preoperative prognostic nutrition index (PNI) is associated with higher rates of postoperative complications and poorer prognosis in those patients. The aim of this study was to analyze the predictive value of the PNI for post-hepatectomy complications in patients with hepatocellular carcinoma (HCC), and evaluate its utility in the surgical procedure.

METHODS

This retrospective study included 510 patients who underwent open hepatectomies for HCC. The predictive value of the preoperative nutritional and immunological status for postoperative complications was assessed using the PNI. Postoperative complications were defined as grade II or higher per the Clavien-Dindo classification. Postoperative complication rates were compared according to surgical procedure (major hepatectomy vs minor hepatectomy).

RESULTS

Patients with postoperative complications had significantly lower PNIs than those without (43.1 ± 5.5 vs 47.0 ± 5.7, P < 0.001). In the multivariate analysis, low preoperative PNI (< 45) was an independent risk factor for postoperative complications after hepatectomy (hazard ratio, 3.85). When patients were classified per their PNI (high vs low) and extent of surgical procedures (major vs minor), there were more complications among patients with low PNI than those with high PNI, regardless of the extent of surgical procedures. Specifically, the group of patients with low PNI who underwent major hepatectomy had significantly higher rates of postoperative complications than the other groups.

CONCLUSIONS

Adding the resection range to the PNI is useful for predicting the postoperative morbidities of hepatectomy patients.

A novel online calculator based on albumin-bilirubin and aspartate transaminase-to-platelet ratio index for predicting postoperative morbidity following hepatectomy for hepatocellular carcinoma

Email

zhangchengwuzr@hotmail.com; Prof. Tian Yang, MD. Department of Hepatobiliary Surgery, Eastern Hepatobiliary Surgery Hospital, Navy Medical University, Shanghai 200438, China. Email: yangtiandfgd@hotmail.com.

Background

Identifying patients at high risks of developing postoperative morbidity is important to improve perioperative outcomes. We sought to define the accuracy of two objective and non-invasive serological-based scores, i.e., albumin-bilirubin (ALBI) and aspartate transaminase-to-platelet ratio index (APRI), to predict postoperative morbidity among patients undergoing hepatectomy for hepatocellular carcinoma (HCC), and build up a personalized predictive tool for clinical practice.

Methods

Clinical data of patients who underwent hepatectomy for HCC at 8 hospitals from a multicenter database were retrospectively analyzed. The predictive accuracy of ALBI and APRI relative to 30-day overall and major morbidity were evaluated using area under the receiver operating characteristic curves (AUC). Based on multivariable logistic regression analyses, preoperative and postoperative nomogram models and consequent online calculators were constructed to predict overall and major morbidity, respectively.

Results

Among 2,301 patients, 725 (31.5%) experienced postoperative complications (major morbidity, 35.9%, 260/725). Multivariable analyses identified high ALBI grade (>−2.6) and APRI grade (>1.5) as independent risk factors associated with overall and major morbidity in both preoperative and postoperative prediction models. Two nomogram predictive models and corresponding online calculators that combined ALBI and APRI were subsequently constructed. The AUCs of the preoperative and postoperative models were 0.728 and 0.742 to predict overall morbidity, and 0.739 and 0.713 to predict major morbidity, respectively, which were much higher than those of Child-Pugh score and the model for end-stage liver disease (MELD). Using the bootstrap validation method, the resulting models were internally validated well.

Conclusions

Preoperative ALBI and APRI scores can predict postoperative morbidity following hepatectomy for HCC. An easy-to-use online calculator that combined ALBI and APRI was proposed for individually predicting the probabilities of postoperative overall and major morbidity before and immediately after surgery, so as to provide useful information to inform conversations about surgical risks.

Subcuticular Sutures Versus Staples for Wound Closure in Open Liver Resection: A Randomised Clinical Trial

BACKGROUND

Subcuticular sutures reduce wound complication rates only in clean surgeries. Repeat resection is frequently required in liver surgery, due to the high recurrence rate (30-50%) of liver cancers. The aim of this study is to assess that subcuticular sutures is superior to staples in liver surgery.

METHODS

This single-centre, single-blinded, randomised controlled trial was conducted at a university hospital between January 2015 and October 2018. Patients were randomly assigned (1:1) to receive either subcuticular sutures or staples for skin closure. Three risk factors (repeat resection, diabetes mellitus and liver function) were matched preoperatively for equal allocation. The primary endpoint was the wound complication rate, while secondary endpoints were surgical site infection (SSI), duration of postoperative hospitalisation and total medical cost. Subset analyses were performed only for the 3 factors allocated as secondary endpoints.

RESULTS

Of the 581 enrolled patients, 281 patients with subcuticular sutures and 283 patients with staples were analysed. As the primary outcome, the wound complication rate with subcuticular sutures (12.5%) did not differ from that with staples [15.9%; odds ratio (OR), 1.33; 95% confidence interval (CI), 0.83-2.15; p = 0.241]. As secondary outcomes, no significant differences were identified between the two procedures in the overall cohort while overall wound complications [7 patients (8.5%) vs. 17 patients (20.0%); OR, 2.68; 95% CI, 1.08-7.29; p = 0.035] with repeat incision were significantly less frequent with subcuticular sutures.

CONCLUSION

Subcuticular sutures were not shown to reduce wound complications compared to staples in open liver resection, but appear beneficial for repeat incisions.

Association between preoperative prealbumin level and postoperative mortality and morbidity after hepatic resection for hepatocellular carcinoma: A multicenter study from a HBV-endemic area

BACKGROUND

Prealbumin is a more sensitive serum biomarker in reflecting liver function and nutritional status than albumin, because of its shorter half-life and its characteristics that could hardly be affected by supplemental venous infusion of albumin or blood transfusion. This study aimed to identify whether preoperative prealbumin level was associated with postoperative mortality and morbidity after hepatic resection for patients with hepatocellular carcinoma (HCC).

METHODS

From a Chinese multicenter database, patients who underwent hepatic resection for HCC were divided into the low and normal prealbumin groups by using 17 mg/dL as the cut-off level for serum prealbumin taken within a week before surgery. Using univariable and multivariable logistic regression analyses, independent predictors associated with postoperative 30-day and 90-day mortality, 30-day overall and major morbidity, and postoperative hepatic insufficiency were identified.

RESULTS

Among 1356 patients, 409 (30.2%) had a low preoperative prealbumin level. Postoperative 30-day and 90-day mortality, and 30-day overall and major morbidity in the low prealbumin group were significantly higher than the normal prealbumin group (2.9% vs. 0.5%, 5.1% vs. 1.5%, 35.7% vs. 18.4%, and 14.4% vs. 6.5%, respectively, all P < 0.001). Multivariable analyses identified that preoperative prealbumin level, but not albumin level, was independently associated with postoperative 30-day mortality (OR: 3.486, 95% CI: 1.184-10.265), 90-day mortality (2.504, 1.219-5.145), 30-day overall morbidity (1.727, 1.302-2.292), 30-day major morbidity (1.770, 1.155-2.711) and postoperative hepatic insufficiency (1.967, 1.119-3.427).

CONCLUSIONS

Preoperative prealbumin level could be used to predict postoperative morbidity and mortality for patients treated with hepatic resection for HCC.

The impact of metabolic syndrome (MetS) on surgical outcome for patients with mostly HBV-related hepatocellular carcinoma (HCC) underwent hepatectomy

BACKGROUND AND OBJECTIVES

The impact of metabolic syndrome (MetS) on surgical outcome, mostly in patients with HBV-related hepatocellular carcinoma (HCC) who underwent hepatectomy.

METHODS

A propensity score matching analysis was conducted. Patients were categorized into two groups MetS-related hepatocellular carcinoma (MetS-HCC) and 1:1 matched non-MetS-related HCC (non-MetS-HCC). Surgical outcomes were compared between the two groups.

RESULTS

Seventy-four MetS-HCC patients and 74 propensity score-matched non-MetS-HCC patients were selected for analysis. The incidence of surgical site infection was higher in the MetS-HCC group than in the non-MetS-HCC group (12.16% vs 0%, P < .005). There was no difference in the recurrence-free survival and overall survival between patients in the MetS-HCC group and in non-MetS-HCC group (P > .05). Microvascular invasion and severe postoperative complications were independent risk factors for recurrence-free survival and overall survival.

CONCLUSIONS

Hepatectomy for patients with mostly HBV-related HCC in the presence of MetS can result in a higher rate of postoperative surgical site infection compared with those in the absence of MetS, but long-term survival rates are comparable.

Safety of Use of a Sheet-Type Adhesion Barrier (Interceed®) During Liver Surgery

BACKGROUND

Adhesion barriers are increasingly used in hepatobiliary surgery. However, there has been no solid evidence yet in support of their safety.

METHODS

Incidences of global postoperative morbidities and major abdominal morbidities were compared between 101 consecutive patients who received a sheet-type adhesion barrier (Interceed^®) and 134 patients who did not receive any adhesion barriers during hepatectomy. Propensity score (PS) adjustment was used to account for potential bias to receive Interceed.

RESULTS

In the PS-adjusted population, the incidences of both global postoperative morbidities and major abdominal morbidities showed no significant difference between the Interceed group and the control group (17.9% vs. 17.6%; P = 0.948 and 7.8% vs. 9.1%; P = 0.813, respectively). Multivariate analysis showed that age + 10 years (odds ratio [OR], 1.70; 95% CI, 1.15-2.50; P = 0.007), estimated blood loss + 100 mL (OR, 1.05; 95% CI, 1.01-1.09, P = 0.009), and laparoscopic approach (OR, 0.10; 95% CI, 0.01-0.75; P = 0.026) were independent predictors for global postoperative morbidities and operation time + 1 h (OR, 1.56; 95% CI, 1.23-1.96; P < 0.001) was a risk factor for major abdominal morbidity, while no specific association between the use of Interceed and the risk of postoperative morbidity was observed.

CONCLUSIONS

Use of Interceed does not increase the risk of postoperative morbidities after hepatectomy.

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.

Albumin-Indocyanine Green Evaluation (ALICE) grade predicts bile leakage after hepatic resection

PURPOSE

We investigated the predictors of bile leakage after hepatic resection.

METHODS

The data of 270 consecutive patients who underwent curative hepatic resection in our institute between January, 2016 and April, 2019 were reviewed retrospectively. The patients were assigned to one of two groups according to the presence of bile leakage and the clinicopathological and surgical outcomes were analyzed. Bile leakage was defined by the International Study Group of Liver Surgery (ISGLS) grade.

RESULTS

There were no hospital deaths. The median intraoperative blood loss volume was 167 ml. Bile leakage occurred in 12 patients (4.4%), as ISGLS grade A leakage in 1 and as ISGLS grade B leakage in 11. The mean hospital stay was significantly longer for patients with bile leakage. High-risk procedures, hepatocellular carcinoma, and Albumin-Indocyanine Green Evaluation (ALICE) grade 3 were independent predictors of ISGLS grade B or C postoperative bile leakage. In patients with three high-risk factors, the incidence of bile leakage was 53.9%.

CONCLUSIONS

Based on this retrospective analysis, high-risk procedures, hepatocellular carcinoma, and ALICE grade 3 were independent predictors of bile leakage in patients undergoing hepatic resection. Thus, special care must be taken during surgery to prevent bile leakage in patients with these risk factors.

Postoperative collections after liver surgery: Risk factors and impact on long-term outcomes

INTRODUCTION

Postoperative collection (PC) can occur after liver surgery, but little is known on their impact on short and long-term outcomes. The aim of this study was to analyse factors predicting the occurrence of PC, the need of drainage and their impact on oncologic outcomes.

METHODS

This single-center, cohort-study included adult patients undergoing liver surgery between 2008 and 2017. The primary objective was to determine variables associated with PC occurrence defined by fluid collection on postoperative day-7 CT scan. Secondary objectives were factors predicting drainage requirement, and predictors of overall survival.

RESULTS

During the study period 395 patients were included: 53.6% of them (n=210) developed a PC with 12% (n=49) requiring drainage. Variables associated to the occurrence of PC were body mass index>35kg/m² (OR 8.09, 95%CI (1.50,43.60) P=0.015) and extension of liver surgery (major vs. minor, OR 1.96, 95% CI (1.05,3.64) P<0.034) while laparoscopic approach was associated to a protective role (OR 0.35, 95%CI (0.18,0.67) P=0.001) in the multivariate analysis. The presence of a PC requiring treatment was associated to long-term mortality (OR:1.85, 95% CI (1.15, 2.97) P<0.01) in patients with malignant disease.

CONCLUSIONS

Patients undergoing to major open liver surgery with BMI>35kg/m² have an increased risk to develop a PC: this target population need a systematic imaging in the postoperative period, even if the indication for drainage should be guided by clinical symptoms. Last, the presence of PC requiring treatment has a negative impact on overall survival among patients treated for malignant disease.

Predicting surgical site infections using a novel nomogram in patients with hepatocelluar carcinoma undergoing hepatectomy

BACKGROUND

Surgical site infections (SSI) remain a major cause of morbidity after hepatectomy for hepatocellular carcinoma (HCC).

AIM

To identify the risk factors associated with SSI, and develop a nomogram to predict SSI among patients undergoing hepatectomy.

METHODS

We retrospectively reviewed the data of patients diagnosed with HCC undergoing hepatectomy at two academic institutions in China, and evaluated the occurrence of SSI. Independent risk factors for SSI were identified using univariate and multivariate analyses. Based on these independent risk factors, a nomogram was established using the data of patients in the first institution, and was validated using data from an external independent cohort from the second institution.

RESULTS

The nomogram was established using data from 309 patients, whereas the validation cohort used data from 331 patients. The operation duration, serum albumin level, repeat hepatectomy, and ASA score were identified as independent risk factors. The concordance index (C-index) of the nomogram for SSI prediction in the training cohort was 0.86; this nomogram also performed well in the external validation cohort, with a C-index of 0.84. Accordingly, we stratified patients into three groups, with a distinct risk range based on the nomogram prediction, to guide clinical practice.

CONCLUSION

Our novel nomogram offers good preoperative prediction for SSIs in patients undergoing hepatectomy.

Impact of postoperative infective complications on long-term survival after liver resection for hepatocellular carcinoma

Background

Postoperative complications have a great impact on the postoperative course and oncological outcomes following major cancer surgery. Among them, infective complications play an important role. The aim of this study was to evaluate whether postoperative infective complications influence long-term survival after liver resection for hepatocellular carcinoma (HCC).

Methods

Patients who underwent resection with curative intent for HCC between July 2003 and June 2016 were identified from a multicentre database (8 institutions) and analysed retrospectively. Independent risk factors for postoperative infective complications were identified. After excluding patients who died 90 days or less after surgery, overall survival (OS) and recurrence-free survival (RFS) were compared between patients with and without postoperative infective complications within 30 days after resection.

Results

Among 2442 patients identified, 332 (13·6 per cent) had postoperative infective complications. Age over 60 years, diabetes mellitus, obesity, cirrhosis, intraoperative blood transfusion, duration of surgery exceeding 180 min and major hepatectomy were identified as independent risk factors for postoperative infective complications. Univariable analysis revealed that median OS and RFS were poorer among patients with postoperative infective complications than among patients without (54·3 versus 86·8 months, and 22·6 versus 43·2 months, respectively; both P &lt; 0·001). After adjustment for other prognostic factors, multivariable Cox regression analyses identified postoperative infective complications as independently associated with decreased OS (hazard ratio (HR) 1·20, 95 per cent c.i. 1·02 to 1·41; P = 0·027) and RFS (HR 1·19, 1·03 to 1·37; P = 0·021).

Conclusion

Postoperative infective complications decreased long-term OS and RFS in patients treated with liver resection for HCC.

Analysis of risk factors for portal vein thrombosis after liver resection

Purpose

We evaluated the risk factors for posthepatectomy thrombosis including portal vein thrombosis (PVT) and clinical outcomes.

Methods

We retrospectively analyzed 563 patients who had undergone hepatectomy from February 2009 to December 2014. Twenty-nine patients with preoperatively confirmed thrombosis and tumor recurrence-related thrombosis were excluded. We identified the location of the thrombosis as main portal vein (MPV), peripheral portal vein (PPV) and other site such as hepatic vein or inferior vena cava. Patients with MPV thrombosis and PPV thrombosis with main portal flow disturbance were treated with anticoagulation therapy. We performed operative thrombectomy before anticoagulation therapy who did combined portal vein (PV) segmental resection.

Results

Of the 534 patients, 22 (4.1%) developed posthepatectomy thrombosis after hepatectomy. Among them, 19 (86.4%) had PVT. The mean duration of Pringle's maneuver was significant longer in the PVT group than the no-thrombosis group (P = 0.020). Patients who underwent combined PV segmental resection during hepatectomy were more likely to develop posthepatectomy PVT (P = 0.001). Thirteen patients who had MPV thrombosis and PPV thrombosis with main portal flow disturbance received anticoagulation therapy immediately after diagnosis and all of them were improved. Among them, 2 patients who developed PVT at the PV anastomosis site after PV segmental resection, underwent operative thrombectomy before anticoagulation therapy and both were improved. There were no patients who developed complications related to anticoagulation therapy.

Conclusion

Long duration of Pringle's maneuver and PV segmental resection were risk factors. Anticoagulation therapy or operative thrombectomy should be considered for PVT without contraindications.

Single Dose Based Ertapenem Prophylaxis Reduces Surgical Site Infection after Selective Hepatectomy of Hepatocellular Carcinoma: A Propensity Score Matching Study

Objective

This study aimed to assess whether a single dose of ertapenem prophylaxis was more effective than other antibiotics to prevent surgical site infection (SSI) after selective hepatectomy for hepatocellular carcinoma (HCC).

Methods

The data from HCC patients with open hepatectomy between January 2012 and June 2017 in Shengjing Hospital were retrospectively analyzed. These patients were divided into two groups: ertapenem (ER) group, where a single dose of ER was administered; non-ertapenem (NER) group, where NER antibiotics were administered. The SSI rates were compared between two groups before and after matching the propensity scores.

Results

The enrolled patients consisted of 78 in the ER group and 197 in the NER group. After matching the propensity scores, each group was down-selected to 65 patients. The SSI rate among the matched 130 patients was 14.6%, 7.7% occurred in the ER group and 21.5% in the NER group (P<0.05). The SSI rates in organ/space of the ER and NER groups were 3.1% and 13.8%, respectively (P<0.05).

Conclusions

A single dose of ER before surgery was more effective in mitigating SSI after selective hepatectomy compared with other antibiotics use. The results imply that the selection of both antibiotics and administration timing is important for the efficacy in preventing SSI.

Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection

BACKGROUND

Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.

METHODS

Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.

RESULTS

Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262).

CONCLUSION

Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.

A nomogram prediction of postoperative surgical site infections in patients with perihilar cholangiocarcinoma

Surgical site infection (SSI) is one of the major morbidities after radical resection for perihilar cholangiocarcinoma (PHCC). This study aimed to clarify the risk factors and construct a nomogram to predict SSIs in patients with PHCC.A total of 335 consecutive patients who underwent hepatectomy combined with hepaticojejunostomy between January 2013 and December 2015 were analyzed retrospectively. SSIs, including incisional (superficial and deep) and space/organ infection, were defined according to the Centers for Disease Control and Prevention (CDC)'s National Nosocomial Infection Surveillance (NNIS) system. Risk factors associated with postoperative SSIs were analyzed by univariate and multivariate analyses. A nomogram was developed on the basis of results from the multivariate logistic model and the discriminatory ability of the model was analyzed.PHCC patients had higher organ/space SSI rate than incisional SSI rate after radical resection. Multivariate analysis showed that risk factors indicating postoperative overall SSIs (incisional and organ/space) included coexisting cholangiolithiasis [odds ratio (OR): 6.77; 95% confidence interval (95% CI): 2.40-19.11; P < .001], blood loss >1500 mL (OR: 4.77; 95% CI: 1.45-15.65; P  =  .010), having abdominal surgical history (OR: 5.85; 95% CI: 1.91-17.97; P  =  .002), and bile leakage (OR: 15.28; 95% CI: 5.90-39.62; P < .001). The β coefficients from the multivariate logistic model were used to construct the model for estimation of SSI risk. The scoring model was as follows: -4.12 +1.91 × (coexisting cholangiolithiasis  =  1) + 1.77 × (having previous abdominal surgical history  =  1) +1.56 × (blood loss >1500 mL  =  1) + 2.73 × (bile leakage  =  1). The discriminatory ability of the model was good and the area under the receiver operating characteristic (ROC) curve (AUC) was 0.851.In PHCC patients, there may be a relationship between postoperative SSIs and abdominal surgical history, coexisting cholangiolithiasis, bile leakage, and blood loss. The nomogram can be used to estimate the risk of postoperative SSIs in patients with PHCC.

Incidence and Risk Factors for Organ/Space Infection after Radiofrequency-Assisted Hepatectomy or Ablation of Liver Tumors in a Single Center: More than Meets the Eye

Introduction

Surgical site infections (SSIs) and especially organ/space infection (O/SI) after resection or ablation of liver tumors are associated with increased morbidity and mortality. A secondary blood stream infection (BSI) is considered an O/SI but the exact prevalence is unknown. We aimed to investigate the incidence of O/SI and BSIs in a cohort of consecutive patients after liver resection or ablation, to seek for a possible connection between them and to search for potential risk factors.

Materials and methods

We reviewed all patients who underwent hepatic resection or intraoperative liver ablation between January 2012 and December 2016 in our department. We focused on age, gender, Child–Pugh score, preoperative biliary drainage, indication for surgery, type of resection, resection or ablation of tumor, need for bilioenteric reconstruction, additional procedure to hepatectomy, blood transfusion, operative time, postoperative admission to ICU, and antibiotic chemoprophylaxis. All positive cultures from intra-abdominal fluids and blood were recorded. O/SI and BSIs were diagnosed by the criteria set by Centers for Disease Control. All variables were compared between the group with O/SI and the group without infection. BSIs were associated with these infections also.

Results

Eighty-one consecutive patients with a mean age of 64 years were enrolled. Fifteen patients presented a positive culture postoperatively: intra-abdominal fluid in eight, blood cultures in six, and both blood and intra-abdominal fluid in one patient. The directly estimated incidence of O/SI amounted to 11.1%. Four blood cultures were secondary to O/SI, and the remaining two secondary to central line catheter. O/SI was diagnosed indirectly, through the BSI in an additional 4.9% of the patients, raising the incidence of SSI to 16%. Among the factors studied, only admission to the ICU was found to be statistically significant as a risk factor for the development of O/SI (p = 0.026).

Conclusion

O/SI should be actively seeked for after liver surgery including blood cultures. Patients with affected physical status, comorbidities are in greater risk of developing O/SI.

Evolution and revolution of laparoscopic liver resection in Japan

Due to important technological developments and improved endoscopic techniques, laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide. Recent systematic reviews and meta‐analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient's quality of life. LLR will not totally supplant open liver surgery, and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high‐volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery conducted emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi‐hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015 to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

Risk factors and long-term outcome for postoperative intra-abdominal infection after hepatectomy for hepatocellular carcinoma

Intra-abdominal infection (IAI) after hepatectomy is an important morbidity. Identification of risk factors that could be avoided in the perioperative period may reduce the prevalence of IAI after hepatectomy for hepatocelluar carcinoma (HCC).Between January 1995 and December 2009, all patients with HCC who underwent curative liver resection were evaluated retrospectively. Long-term outcomes were compared in IAI patients and non-IAI patients after hepatectomy. Preoperative, intraoperative, and tumor-related factors that could be independent factors for postoperative IAI were identified.Of 622 patients with HCC, 24 patients (3.9%) had IAI after hepatectomy. Both median survival and survival of patients with postoperative IAI were shorter than those for non-IAI patients (P < .05). Upon univariate analysis followed by multivariate analyses, three independent predictors for IAI were identified: weight loss (odds ratio [OR], 3.27; 95% confidence interval [CI], 1.17-9.11; P = .024), liver cirrhosis (0.28, 0.12-0.67, .004), and operative time >300 minutes (3.44, 1.46-8.12, .005).IAI after hepatectomy affects outcome adversely. Preoperative weight loss, liver cirrhosis, and operative time >300 minutes are independent predictors of postoperative IAI.

Rate of Organ Space Infection Is Reduced with the Use of an Air Leak Test During Major Hepatectomies

BACKGROUND

Organ/space surgical site infections (OSIs) constitute an important postoperative metric. We sought to assess the impact of a previously described air leak test (ALT) on the incidence of OSI following major hepatectomies.

METHODS

A single-institution hepatobiliary database was queried for patients who underwent a major hepatectomy without biliary-enteric anastomosis between January 2009 and June 2015. Demographic, clinicopathologic, and intraoperative data-including application of ALT-were analyzed for associations with postoperative outcomes, including OSI, hospital length of stay (LOS), morbidity and mortality rates, and readmission rates.

RESULTS

Three hundred eighteen patients were identified who met inclusion criteria, of whom 210 had an ALT. ALT and non-ALT patients did not differ in most disease and treatment characteristics, except for higher rates of trisegmentectomy among ALT patients (53 vs. 34 %, p = 0.002). ALT patients experienced lower rates of OSI and 90-day morbidity than non-ALT patients (5.2 vs. 13.0 %, p = 0.015 and 24.8 vs. 40.7 %, p = 0.003, respectively). In turn, OSI was the strongest independent predictor of longer LOS (OR = 4.89; 95 % CI, 2.80-6.97) and higher rates of 30- (OR = 32.0; 95 % CI, 10.9-93.8) and 45-day readmissions (OR = 29.4; 95 % CI, 10.2-84.6).

CONCLUSIONS

The use of an intraoperative ALT significantly reduces the rate of OSI following major hepatectomy and may contribute to lower post-discharge readmission rates.

High Rate of Organ/Space Surgical Site Infection After Hepatectomy with Preexisting Bilioenteric Anastomosis

BACKGROUND

The clinical course of hepatectomy in patients with preexisting bilioenteric anastomosis (BEA) is poorly understood. The aim of this study was to evaluate the potential influence of preexisting BEA on organ/space surgical site infection (SSI) after hepatectomy.

METHODS

We analyzed consecutive hepatectomies performed between March 2005 and January 2015. Patients' background, operative results, and complications were compared between hepatectomies with and without preexisting BEA.

RESULTS

Twenty-two hepatectomies with preexisting BEA were identified among 1745 hepatectomies. The rate of organ/space SSI was much higher in hepatectomies with preexisting BEA than in those without preexisting BEA (40.9 vs. 6.4 %, P < 0.001). Multivariate analyses identified four variables as independent factors associated with organ/space SSI: liver-directed chemotherapy [odds ratio 5.06 (95 % confidence interval 2.29-10.54), P < 0.001], operative time ≥ 300 min [2.40 (1.30-4.54), P = 0.006], estimated blood loss ≥ 500 ml [2.34 (1.26-4.31), P < 0.001], and preexisting BEA [12.08 (4.54-31.32), P < 0.001]. A higher rate of organisms from intestinal flora was detected in organ/space SSI after hepatectomies with preexisting BEA (77.8 vs. 21.3 % without BEA, P = 0.002). Analysis of hepatectomies with preexisting BEA identified selection of antibiotics for prophylaxis as the sole risk factor for organ/space SSI (P = 0.049 for cefazolin versus other antibiotics targeting intestinal flora).

CONCLUSIONS

Preexisting BEA is an independent risk factor for the development of organ/space SSI after hepatectomy. Antibiotics targeting intestinal flora are strongly recommended for prophylaxis of infectious complications.

The utility of 5-aminolevulinic acid-mediated photodynamic diagnosis in the detection of intraoperative bile leakage

PURPOSE

The purpose of this retrospective study was to evaluate the utility of the new intraoperative bile leakage test as a preventive measure of postoperative bile leakage.

METHOD

737 patients were retrospectively analyzed with respect to the management of intra- and post-operative bile leakage.

RESULTS

Nine (8.3%) of 109 patients evaluated using conventional white light fluorescent imaging were recognized as having intra-operative bile leakage. However, performance of 5-aminolevulinic acid (5-ALA)-mediated PDD detected bile leakage intraoperatively not only in these 9 patients, but also in an additional 6 patients, such that 'red fluorescence' at the cut surface of the liver, was visualized in a total of 15 patients. The postoperative courses of most patients were uneventful, and postoperative bile leakages occurred in only one (0.9%) patient.

CONCLUSION

5-ALA fluorescence imaging may be needed to prevent postoperative bile leakage in patients at high risk for this surgical complication after hepatic resection.

Location of a biliary leak after liver resection determines success of endoscopic treatment

BACKGROUND

Bile leaks after hepatic resection are serious complications associated with substantial morbidity and mortality. The aim of this prospective observational study was to determine the therapeutic success of endoscopic treatment of biliary leakage after liver resection.

PATIENTS AND METHODS

Grade B biliary leaks were considered for endoscopic treatment in patients after liver resection between 1/09 and 4/12. Endoscopic treatment (sphincterotomy only, plastic stent distal to leak or bridging) was defined as successful when the patient remained without symptoms after drain removal and without extravasation follow-up ERC 8 weeks later.

RESULTS

Overall rate of biliary leak was 7.4 % (61/826). 35 patients with a grade B bile leak were considered for endoscopic treatment. 22 (63 %) had bile leaks that were peripherally located, and 13 (37 %) had bile leaks at central location. In 3 patients, sphincterotomy only was performed; in 19 patients, a stent distal to the leak and in 13 patients, a bridging stent was inserted. The overall success rate was 74 % (26/35 patients). Endoscopic treatment failed in 26 % (9/35), and mortality rate was 11 % (4/35). In all patients with leaks located at the right or left hepatic duct, treatment with the bridging stent was successful.

CONCLUSION

Endoscopic therapy for biliary leakage after liver resection is safe and effective and should be considered as a first-line therapy in patients who are suitable for an interventional, non-surgical approach. Patients with a centrally located leak who are treated with a bridging stent are more likely to benefit from endoscopic intervention.

Bile Leakage After Hepatectomy for Liver Tumors

This study aimed to clarify the predictive factors for bile leakage after hepatectomy for liver tumor in terms of the International Study Group of Liver Surgery (ISGLS) definition. Between August 2006 and July 2012, 242 patients with a diagnosis of liver tumor underwent hepatectomy in our department, and the total bilirubin level of peritoneal drainage fluid prior to removal of the abdominal drains was examined. The data on all of the patients were analyzed retrospectively to identify the factors that might significantly affect the postoperative bile leakage. There was no grade C bile leakage, and grade A was documented in 65 patients (26.9%) and grade B in 7 patients (2.9%) in terms of the ISGLS definition. Although there was no significant difference in postoperative hospital stay between grade A bile leakage only and those without bile leakage (P = 0.933), a significant difference was noted between grades A and B (median, 11.0 versus 21.0 days; P &lt; 0.001). Multivariate analysis revealed 4 independent significant predictive factors: prolonged operation time (P = 0.040), cholecystectomy (P = 0.048), non–portal vein embolization (P = 0.010), and preoperative chemotherapy (P = 0.021). The ISGLS definition of bile leakage is clinically useful. Prolonged operation time, cholecystectomy, non–portal vein embolization, and preoperative chemotherapy were significant independent risk factors of bile leakage in this study.

Liver resection for hepatocellular carcinoma using a microwave tissue coagulator: Experience of 1118 cases

AIM: To present our extensive experience of hepatectomy for hepatocellular carcinoma using a microwave tissue coagulator to demonstrate the effectiveness of this device.

METHODS: A total of 1118 cases (1990-2013) were reviewed, with an emphasis on intraoperative blood loss, postoperative bile leakage and fluid/abscess formation, and adaptability to anatomical resection and hepatectomy with hilar dissection.

RESULTS: The median intraoperative blood loss was 250 mL; postoperative bile leakage and fluid/abscess formation were seen in 3.0% and 3.3% of cases, respectively. Anatomical resection was performed in 275 cases, including 103 cases of hilar dissection that required application of microwave coagulation near the hepatic hilum. There was no clinically relevant biliary tract stricture or any vascular problems due to heat injury. Regarding the influence of cirrhosis on intraoperative blood loss, no significant difference was seen between cirrhotic and non-cirrhotic patients (P = 0.38), although cirrhotic patients tended to have smaller tumors and underwent less invasive operations.

CONCLUSION: This study demonstrated outcomes of an extensive experience of hepatectomy using heat coagulative necrosis by microwave tissue coagulator.