Postoperative Complications Affect Long-Term Survival Outcomes Following Hepatic Resection for Colorectal Liver Metastasis

Postoperative Complications Result in Poor Oncological Outcomes: What Is the Evidence?

The majority of patients with solid tumors undergo a curative resection of their tumor burden. However, the reported rate of postoperative complications varies widely, ranging from 10% to 70%. This narrative review aims to determine the impact of postoperative complications on recurrence and overall survival rates following elective cancer surgeries, thereby providing valuable insights into perioperative cancer care. A systematic electronic search of published studies and meta-analyses from January 2000 to August 2023 was conducted to examine the effect of postoperative complications on long-term survival after cancer surgeries. This comprehensive search identified fifty-one eligible studies and nine meta-analyses for review. Recurrence-free survival (RFS) and overall survival (OS) rates were extracted from the selected studies. Additionally, other oncological outcomes, such as recurrence and cancer-specific survival rates, were noted when RFS and OS were not reported as primary outcomes. Pooled hazard ratios and 95% confidence intervals were recorded from the meta-analyses, ensuring the robustness of the data. The analysis revealed that long-term cancer outcomes progressively worsen, from patients with no postoperative complications to those with minor postoperative complications (Clavien-Dindo grade ≤ II) and further to those with major postoperative complications (Clavien-Dindo grade III-IV), irrespective of cancer type. This study underscores the detrimental effect of postoperative complications on long-term oncological outcomes, particularly after thoracoabdominal surgeries. Importantly, we found a significant gap in the data regarding postoperative complications in surface and soft tissue surgical procedures, highlighting the need for further research in this area.

RAS mutation status in combination with the JSHBPS nomogram may be useful for preoperative identification of colorectal liver metastases with high risk of recurrence and mortality after hepatectomy

PURPOSE

To investigate the prognostic impact of RAS mutations on the Japanese Society of Hepatobiliary and Pancreatic Surgeons (JSHBPS) nomogram score in patients with colorectal cancer liver metastasis (CRLM) following hepatectomy.

METHODS

We included 218 consecutive patients undergoing hepatectomy for CRLM between 2004 and 2020. The JSHBPS nomogram score was calculated using six preoperative clinical factors. The score ranged from 0 to 25, and higher scores indicated greater tumor burden. Associations of RAS mutations with disease-free survival (DFS) and overall survival (OS) by the JSHBPS nomogram score were examined. Multivariable Cox proportional hazard regression models were used to estimate adjusted hazard ratios (HRs) and confidence intervals (CIs).

RESULTS

RAS mutations were detected in 72 (33%) of the 218 patients. Multivariate analyses revealed that RAS mutations were independently associated with poor DFS (HR, 1.93; 95% CI: 1.20-3.10; p = .007) and OS (HR, 2.65; 95% CI: 1.59-4.71; p = .001) compared with wild-type RAS with JSHBPS nomogram scores ≤ 10. However, in patients with scores ≥ 11, the association of RAS mutations with DFS or OS was not statistically significant (p > .08).

CONCLUSION

RAS mutation status in combination with the JSHBPS nomogram may be useful for preoperatively identifying CRLM with high risk of recurrence and mortality after hepatectomy.

Postoperative infectious complications are associated with diminished overall survival of patients undergoing resection for colorectal liver metastases

INTRODUCTION

Postoperative infectious complications (PIC) remain one of the most common complications after surgery. The influence of PIC on long-term survival for patients after liver surgery for colorectal liver metastases (CRLM) needs further investigation.

METHODS

Data of patients who underwent liver resection for CRLM between 2012 and 2017 at the Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin were evaluated. Overall survival (OS) was stratified according to the development of PIC. Independent predictors of PIC and diminished survival were identified using regression models.

RESULTS

Of 270 patients, eighty-four (31%) patients developed PIC including intraabdominal infections (n = 51, 61%), cholangitis (n = 5, 6%), pneumonia (n = 12, 14%), wound infections (n = 28, 33%), urinary tract infections (n = 5, 6%), or central line-associated bloodstream infections (n = 4, 5%). PIC were associated with a significantly diminished five-year OS (30% vs. 43%, p = 0.008). Age >65 years (p = 0.016, hazard ratio [HR] = 2.2, 95% confidence interval [CI] = 1.2-4.0), comorbidity (p = 0.019, HR [95% CI] = 2.4 [1.2-4.9]), simultaneous resection of primary tumor (p = 0.005, HR [95% CI] = 4.3 [1.6-11.9]), biliary drainage (p < 0.001, HR [95% CI] = 4.1 [2.0-8.5]), and length of procedure ≥272 min (p = 0.012, HR [95% CI] = 2.2 [1.2-4.1]) were independent predictors for the development of PIC. Body-mass index (BMI) > 30 kg/m2 (p = 0.002, HR [95% CI] = 2.4 [1.4-4.0]), postoperative major complications (p = 0.003, HR [95% CI] = 2.2 [1.3-3.8]), and 3- or 4-MRGN bacteria (p = 0.001, HR [95% CI] = 7.7 [2.2-27.3]) were independently associated with diminished OS.

CONCLUSIONS

PIC are associated with diminished OS after resection for CRLM. Age >65 years, comorbidities, simultaneous resection of the primary tumor, and biliary drainages were identified as independent risk factors for the development of PIC. High BMI, postoperative major morbidity and 3-/4-MRGN bacteria were independently predictive of worse OS. These factors need to be considered in perioperative management for patients with CRLM.

Minimally Invasive Anatomic Liver Resection for Hepatocellular Carcinoma Using the Extrahepatic Glissonian Approach: Surgical Techniques and Comparison of Outcomes with the Open Approach and between the Laparoscopic and Robotic Approaches

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial

OBJECTIVE

To compare the early results of mass and layered closure of upper abdominal transverse incisions.

SUMMARY OF BACKGROUND DATA

Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking.

METHODS

This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727).

RESULTS

A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively.

CONCLUSIONS

Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

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.

Postoperative Infectious Complications Worsen Long-Term Survival After Curative-Intent Resection for Hepatocellular Carcinoma

BACKGROUND

Postoperative infectious complications may be associated with a worse long-term prognosis for patients undergoing surgery for a malignant indication. The current study aimed to characterize the impact of postoperative infectious complications on long-term oncologic outcomes among patients undergoing resection for hepatocellular carcinoma (HCC).

METHODS

Patients who underwent curative-intent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. The relationship between postoperative infectious complications, overall survival (OS), and recurrence-free survival (RFS) was analyzed.

RESULTS

Among 734 patients who underwent HCC resection, 269 (36.6%) experienced a postoperative complication (Clavien-Dindo grade 1 or 2 [n = 197, 73.2%] vs grade 3 and 4 [n = 69, 25.7%]). An infectious complication was noted in 81 patients (11.0%) and 188 patients (25.6%) had non-infectious complications. The patients with infectious complications had worse OS (median: infectious complications [46.5 months] vs no complications [106.4 months] [p < 0.001] and non-infectious complications [85.7 months] [p < 0.05]) and RFS (median: infectious complications [22.1 months] vs no complications [45.5 months] [p < 0.05] and non-infectious complications [38.3 months] [p = 0.139]) than the patients who had no complication or non-infectious complications. In the multivariable analysis, infectious complications remained an independent risk factor for OS (hazard ratio [HR], 1.7; p = 0.016) and RFS (HR, 1.6; p = 0.013). Among the patients with infectious complications, patients with non-surgical-site infection (SSI) had even worse OS and RFS than patients with SSI (median OS: 19.5 vs 70.9 months [p = 0.010]; median RFS: 12.8 vs 33.9 months [p = 0.033]).

CONCLUSION

Infectious complications were independently associated with an increased long-term risk of tumor recurrence and death. Patients with non-SSI versus SSI had a particularly worse oncologic outcome.

Synchronous resection of colorectal cancer primary and liver metastases: an outcomes analysis

BACKGROUND

Concurrent resection of the primary cancer and synchronous colorectal cancer liver metastases (CRCLM) was evaluated for differences in outcomes following stratification of both the liver and colorectal resection.

METHODS

Consecutive cases of synchronous resection of both the CRC primary and CRCLM were reviewed retrospectively at a single, high-volume institution over a 17-year period (2000-2017).

RESULTS

273 patients underwent simultaneous resection of CRCLM. The distribution of the primary lesion was similar between the colon (52.4%) and rectum (47.6%), while 46.9% of patients had bilobar liver disease. Major liver/major colorectal resection (n = 24) were significantly more likely to experience colorectal specific morbidity (OR 3.98, 95% CI 1.56-10.15, p = 0.004), liver specific morbidity (OR 7.4, 95% CI 2.22-24.71, p = 0.001), total morbidity (OR 2.91, 95% CI 1.18-7.18, p = 0.020) and 90-day mortality (OR 5.50, 95% CI 1.27-23.81, p = 0.023). Failure to receive adjuvant chemotherapy secondary to postoperative morbidity was associated with significantly worsened survival (HR for death 5.91, 95% CI 1.59-22.01, p = 0.008).

CONCLUSIONS

Postoperative morbidity precluding the administration of adjuvant chemotherapy is associated with an increase in mortality. Combining a major liver with major colorectal resection is associated with a significant increase in major morbidity and 90-day mortality, and should be avoided.

Morbidity and mortality after liver surgery for colorectal liver metastases: a cohort study in a high-volume fast-track programme

BACKGROUND

For colorectal liver metastases, surgery is a high-risk procedure due to perioperative morbidity. The objective was to assess severity of complications after fast-track liver surgery for colorectal liver metastases and their impact on morbidity and mortality.

METHODS

All patients were treated according to the same fast-track programme. Complications were graded according to the Clavien-Dindo classification for patients undergoing surgery from 2013 to 2015. Correlation between complications and length of stay was analysed by multivariate linear regression.

RESULTS

564 patient cases were included of which three patients died within 3 months (0.53%, 95% CI: 0.17-1.64%). Complications were common with Grade ≤ 2 in 167 patients (30%) and ≥ Grade 3a in 93 (16%). Patients without complications had a mean length of stay of 4.1 days, which increased with complications: 1.4 days (95% CI: 1.3-1.5) for Grade 2, 1.7 days (1.5-2.0) for Grade 3a, 2.3 days (1.7-3.0) for Grade 3b, 2.6 days (1.6-4.2) for Grade 4a, and 2.9 days (2.8-3.1) for Grade 4b. Following were associated with increased length of stay: complication severity grade, liver insufficiency, ascites, biliary, cardiopulmonary, and infectious complications.

CONCLUSIONS

Complications after liver surgery for colorectal liver metastases, in a fast track setting, were associated with low mortality, and even severe complications only prolonged length of stay to a minor degree.

Impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer: A multicenter retrospective cohort study

AIMS

Primary tumor resection for patients with incurable stage IV colorectal cancer can prevent tumor-related complications but may cause postoperative complications. Postoperative complications delay the administration of chemotherapy and can lead to the spread of malignancy. However, the impact of postoperative complications after primary tumor resection on survival in patients with incurable stage IV colorectal cancer remains unclear. Therefore, this study aimed to investigate how postoperative complications after primary tumor resection affect survival in this patient group.

METHODS

We reviewed data on 966 patients with stage IV colorectal cancer who underwent palliative primary tumor resection between January 2006 and December 2007. We examined the association between major complications (National Cancer Institute Common Terminology Criteria for Adverse Events v3.0 grade 3 or more) and overall survival using Cox proportional hazard model and explored risk factors associated with major complications using multivariable logistic regression analysis.

RESULTS

Ninety-three patients (9.6%) had major complications. The 2-year overall survival rate was 32.7% in the group with major complications and 50.3% in the group with no major complications. Patients with major complications had a significantly poorer prognosis than those without major complications (hazard ratio: 1.62; 95% confidence interval: 1.21-2.18; P < .01). Male, rectal tumor, and open surgery were identified to be risk factors for major complications.

CONCLUSIONS

Postoperative complications after primary tumor resection was associated with decreased long-term survival in patients with incurable stage IV colorectal cancer.

Improved Mortality, Morbidity and Long-term Outcome after Anatomical Hepatectomy with the Glissonean Pedicle Approach in Patients with Hepatocellular Carcinoma: 30 years' Experience at a Single Institute

OBJECTIVE

We evaluated the morbidity and mortality after anatomical hepatectomy with the Glissonean pedicle approach, and long-term outcomes in relation to the morbidity in patients with hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

The mortality, morbidity, and long-term outcomes were evaluated retrospectively.

METHODS

1953 patients with HCC underwent various anatomical hepatectomies with the Glissonean pedicle approach between 1985 and 2014. The mortality (30-day and 90-day) and morbidity (Clavien-Dindo class IIIa or higher) were evaluated among six 5-year eras (1985-1989, 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014).

RESULTS

460 patients (24%) showed morbidity, and the overall 30-day and 90-day mortality rates were 1.8% and 3.3%, respectively. The 30-day (3.9%, 3.0%, 1.8%, 1.3%, 0.3%, 0.5%: p = 0.0074) and 90-day mortality (6.0%, 4.3%, 3.8%, 2.8%, 2.2%, 1.4%: p = 0.0445) significantly improved over the eras. Blood loss >2 L (Odd ratio: 11.808, p = 0.0244) was an independent risk factor for 30-day mortality, and blood loss >2 L (Odd ratio: 4.046, p = 0.0271) and bile leakage (Odd ratio: 2.122, p = 0.0078) were independent risk factors for 90-day mortality on multivariate analysis. Morbidity was significant independent prognostic factors for overall survival (Relative Risk: 2.129, p < 0.0001) and recurrence-free survival (Relative Risk: 1.299, p < 0.0001) in patients with HCC.

CONCLUSIONS

Anatomical hepatectomy with the Glissonean pedicle approach was achieved safely in patients with HCC. For more safety and longer survival, blood loss, bile leakage, and morbidity should be reduced. Long-term outcomes after anatomical hepatectomy with the Glissonean pedicle approach in patients with HCC have been improved over 30 years with gradually less mortality and morbidity due to decreases in blood loss>2L and bile leakage.

Relevance of blood loss as key indicator of the quality of surgical care in laparoscopic liver resection for colorectal liver metastases

BACKGROUND

The development of laparoscopic liver resection has led to the hypothesis that intraoperative blood loss may be a key indicator of surgical care quality. This study assessed short- and long-term results of patients according to three levels of intraoperative blood loss during laparoscopic liver resection for colorectal liver metastasis.

METHODS

All patients who underwent laparoscopic liver resection for colorectal liver metastasis between 2000 and 2018 were included. Difficulty of laparoscopic liver resection was defined according to the Institut Mutualiste Montsouris classification. Three levels of the extent of intraoperative blood loss were defined: massive (≥1,000 mL), substantial (≥75th percentile of intraoperative blood loss within each grade of difficulty), and normal intraoperative blood loss.

RESULTS

During study period, 317 patients underwent laparoscopic liver resection for colorectal liver metastasis. Among them, 213 (67.2%), 80 (25.2%), and 24 (7.6%) patients had normal, substantial, and massive intraoperative blood loss, respectively. Twenty-six patients (8.2%) required transfusion. Massive intraoperative blood loss came from a major hepatic vein in 54% of cases and were managed by laparoscopy in 83% of the cases. Laparoscopic liver resection difficulty grade (odds ratio = 3.15; P = .053) and number of colorectal liver metastasis (odds ratio = 1.24; P = .020) were independently associated with massive intraoperative blood loss. Risks factors for substantial intraoperative blood loss were bi-lobar colorectal liver metastasis (odds ratio = 3.12; P = .033) and sinusoidal obstruction syndrome (odds ratio = 3.27; P = .004). The level of intraoperative blood loss was not associated with severe complications nor overall and disease-free survival. Requirement of transfusion was associated with severe complications (odds ratio = 7.27; P = .002) and decreased 1-, 3-, and 5-year overall survival (87%, 68%, and 61% vs 95%, 88%, and 79%; P = .042).

CONCLUSION

The extent of intraoperative blood loss did not affect short- and long-term results of laparoscopic liver resection for colorectal liver metastasis. Massive intraoperative blood loss was often incidental and, 83% of the time, manageable by laparoscopy. Rather than intraoperative blood loss, transfusion is a better relevant indicator of laparoscopic liver resection surgical quality.

Predictors of long-term survival in patients with hepatic resection of colorectal metastases: Analysis of a Brazilian Cancer Center Cohort

BACKGROUND

Hepatic metastases are a major cause of death in patients with colorectal cancer. A comprehensive assessment of the prognostic factors associated with long-term survival could improve patient selection for surgical approaches and decrease morbidity and futile locoregional treatments.

METHODS

We performed a retrospective analysis of patients who underwent hepatectomy for colorectal liver metastases at a single center from 2000 to 2012.

RESULTS

To identify factors associated with 5- and 10-year overall (OS) and disease-free survival (DFS), we analyzed 280 patients and 150 patients in the 5- and 10-year cohorts, respectively. Only seven relapses occurred after 5 years of follow-up, and no relapses occurred after 10 years. Multivariable analysis indicated that bilobar disease and extra-hepatic disease before hepatectomy were independent 5- and 10-year predictors of OS, and major postoperative complications predicted OS in the 5-year survival cohort only. Our analysis indicated that prognostic factors associated with DFS included some confounders and was therefore inconclusive.

CONCLUSIONS

Taken together, our results suggest that the predictors of 5- and 10-year OS rates of colorectal cancer patients with hepatic metastases are similar, differing only by postoperative complications that influenced exclusively 5-year survival. Since no relapse occurred 10 years after hepatic resection, oncological remission is likely.

Impact of the strategy for curative treatment of synchronous colorectal cancer liver metastases

AIM OF THE STUDY

Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: "classic", "combined", and "liver-first". The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival.

PATIENTS AND METHODS

Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) "classic": surgery of primary tumor and then surgery of sCRLM; (2) "combined": combined surgery of primary tumor and sCRLM: and (3) "liver-first": surgery of sCRLM and then surgery of primary tumor.

RESULTS

During this period, 170 patients who underwent 209 hepatectomies were included ("classic": 149, "combined": 34, "liver-first": 26). The rate of severe complications was higher in the "combined" group compared to the "classic" group (35% vs. 12%, P=0.03), and the "liver-first" group (35% vs. 19%, P=0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups.

CONCLUSION

All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The "combined" strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

Can We Improve Prediction of Adverse Surgical Outcomes? Development of a Surgical Complexity Score Using a Novel Machine Learning Technique

BACKGROUND

An optimal method to quantify surgical complexity using patient comorbidities derived from administrative billing data is lacking. We sought to develop a novel, easy-to-use surgical Complexity Score to accurately predict adverse outcomes among patients undergoing elective surgery.

STUDY DESIGN

A novel surgical Complexity Score was developed using 100% Medicare Inpatient and Outpatient Standard Analytic Files (SAFs) from years 2012 to 2016 (n = 1,049,160). Comorbid conditions were entered into a machine learning algorithm to assign weights to maximize the correlation with multiple postoperative outcomes including morbidity, readmission, mortality, and postoperative super-use. Predictive ability was compared against 3 of the most commonly used risk adjustment indices: the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), and the Centers for Medicare and Medicaid Service's Hierarchical Condition Category (CMS-HCC).

RESULTS

Patients underwent colectomy (12.6%), abdominal aortic aneurysm repair (4.4%), coronary artery bypass grafting (13.0%), total hip replacement (22.0%), total knee replacement (43.0%), or lung resection (5.0%). The Complexity Score had a good to very good predictive ability for all adverse outcomes. The Complexity Score had the highest accuracy in predicting perioperative morbidity (area under the curve [AUC]: 0.868, 95% CI 0.866 to 0.869); this performed better than the CCI (AUC: 0.717, 95% CI 0.715 to 0.719), ECI (AUC: 0.799, 95% CI 0.797 to 0.800), and similar to the CMS-HCC (AUC: 0.862, 95% CI 0.861 to 0.863). Similarly, the Complexity Score outperformed each of the 3 other comorbidity indices in predicting 90-day readmission (AUC: 0.707, 95% CI 0.705 to 0.709), 30-day readmission (AUC: 0.717, 95% CI 0.715 to 0.720), and postoperative super-use (AUC: 0.817, 95% CI 0.814 to 0.820).

CONCLUSIONS

Compared with the most commonly used comorbidity and surgical risk scores, the novel surgical Complexity Score outperformed the CCI, ECI, and CMS-HCC in predicting postoperative morbidity, 30-day readmission, 90-day readmission, and postoperative super-use.

The impact of posthepatectomy liver failure on long-term survival after hepatectomy for colorectal liver metastasis

BACKGROUND

Postoperative complications affect both the short-term and long-term outcomes. The aim of this study was to identify specific prognostic factors among complications after hepatectomy for colorectal liver metastasis (CRLM).

METHODS

Between 2002 and 2014, 427 patients underwent initial hepatectomy for CRLM. The clinicopathological parameters including postoperative complications were evaluated to identify the prognostic factors for the overall (OS) and relapse-free survival (RFS).

RESULTS

One hundred and forty-nine patients (34%) developed postoperative complications, including surgical site infection (n = 49, 11.4%), bile leakage (n = 41, 9.6%), posthepatectomy liver failure (PHLF) (n = 26, 6.0%), and pulmonary complication (n = 20, 4.6%). The independent predictors of RFS included primary nodal metastasis, abnormal CA19-9 levels, extrahepatic metastasis, bilateral CRLMs, ≥5 CRLMs, preoperative chemotherapy, lack of adjuvant chemotherapy and PHLF. The 5-year RFS rates in patients with and without PHLF were 8% and 32%, respectively (P < 0.001). The independent prognostic factors for OS included primary nodal metastasis, abnormal CA19-9 levels, extrahepatic metastasis, positive surgical margins, preoperative chemotherapy, lack of adjuvant chemotherapy and PHLF. The 5-year OS rates in patients with and without PHLF were 31% and 63%, respectively (P = 0.004).

CONCLUSIONS

Among the complications, only PHLF was associated with decreased long-term survival after hepatectomy for CRLM as well as tumor-specific prognostic factors.

Impact of concomitant ablation on the perioperative outcomes of patients with colorectal liver metastases undergoing hepatectomy: a propensity score matched nationwide analysis

BACKGROUND

Intraoperative ablation (IA) is often performed at the time of liver resection (LR) for colorectal liver metastases (CRLMs) but its impact on postoperative outcomes remains poorly understood.

METHODS

The ACS-NSQIP targeted hepatectomy database was used to identify patients who underwent LR vs LR + IA for CRLMs during 2014-2016. Perioperative outcomes were compared following propensity score match based on age, receipt of neoadjuvant therapy, operative approach, liver resection type, tumor diameter and number of metastases.

RESULTS

Among 1,384 patients, 692 (50%) underwent LR alone and 692 (50%) underwent LR + IA. After propensity score matching, overall morbidity (22% vs 13%, P < 0.0001) was increased among patients undergoing LR alone compared to LR + IA, whereas mortality did not differ (1.1% vs 0.8%, P=0.5911). On multivariable analysis, ASA class ≥3 (OR: 1.5, 95% CI: 1.06-2.3), preoperative biliary stent (OR: 3.5, 95% CI: 0.9-13.01), biliary reconstruction (OR: 5.02, 95% CI: 1.3-18.6), operative time > 245 minutes (OR: 1.8, 95% CI:1.3-2.4) and IA (OR:0.5, 95% CI:0.3-0.7) were associated with overall morbidity.

CONCLUSIONS

In this propensity matched nationwide analysis of patients undergoing LR for CRLM, the use of concomitant IA was associated with decreased postoperative morbidity compared to LR alone. These findings suggest that IA combined with LR is a safe approach that may expand the number of patients who are candidates for curative-intent surgical strategies.

Prognostic Factors Affecting Long-Term Survival after Resection for Noncolorectal, Nonneuroendocrine, and Nonsarcoma Liver Metastases

AIM

To evaluate feasibility and long-term outcome after hepatic resection for noncolorectal, nonneuroendocrine, and nonsarcoma (NCNNNS) liver metastases in a single center.

METHODS

We retrospectively reviewed our experience on patients who underwent surgery for NCNNNS liver metastases from 1995 to 2015. Patient baseline characteristics, tumor features, treatment options, and postoperative outcome were retrieved.

RESULTS

We included 47 patients. The overall 5-year survival (OS) rate after hepatectomy was 27.6%, with a median survival of 21 months. Overall survival was significantly longer for patients operated for nongastrointestinal liver metastases when compared with gastrointestinal (41 versus 10 months; p = 0.027). OS was significantly worse in patients with synchronous metastases than in those with metachronous disease (10 versus 22 months; p = 0.021). The occurrence of major postoperative complication negatively affected long-term prognosis (OS 23.5 versus 9.0 months; p = 0.028). Preoperative tumor characteristics (number and size of the lesions), intraoperative features (extension of resection, need for transfusions, and Pringle's maneuver), and R0 at pathology were not associated with differences in overall survival.

CONCLUSION

Liver resection represents a possible curative option for patients with NCNNNS metastases. The origin of the primary tumor and the timing of metastases presentation may help clinicians to better select which patients could take advantages from surgical intervention.

Effect of insulin infusion line on glycaemic variability in a perioperative high dependency unit (HDU): a prospective randomised controlled trial

BACKGROUND

Glucose control is an important issue in post-operative patients. The objective here was to compare two insulin infusion lines by syringe pumps to assess the impact of medical devices on glycaemic variability in surgical patients under intensive insulin therapy. This open, prospective, single-centre randomised study was conducted in a fifteen-bed perioperative high dependency unit (HDU) in a university hospital. In total, 172 eligible patients receiving insulin therapy agreed to participate in the study. Subcutaneous continuous glucose monitoring was set up for all patients and an optimised system with a dedicated insulin infusion line for half of the patients.

RESULTS

Eighty-six patients were infused via the optimised infusion line and 86 patients via the standard infusion line. No significant difference was found according to the glycaemic lability index score [mean difference between groups (95% CI): -0.09 (-0.34; 0.16), p = 0.49 after multiple imputation]. A glucose control monitoring system indicated a trend towards differences in the duration of hypoglycaemia (blood glucose level below 70 mg dl^-1 (3.9 mmol l^-1) over 1000 h of insulin infusion (9.7 ± 25.0 h in the standard group versus 4.4 ± 14.8 h in the optimised group, p = 0.059) and in the number of patients experiencing at least one hypoglycaemia incident (25.7 vs. 12.9%, p = 0.052). Time in the target range was similar for both groups.

CONCLUSIONS

The use of optimised infusion line with a dedicated insulin infusion line did not reduce glycaemic variability but minimised the incidence of hypoglycaemia events. The choice of the medical devices used to infuse insulin seems important for improving the safety of insulin infusion in perioperative HDU.

Liver surgery for metastatic colorectal cancer: the surgical oncologist perspective

Neoadjuvant/conversion chemotherapy has emerged as an indispensable tool to achieve resectability of initially unresectable metastatic colorectal cancer and improves oncological outcomes. In parallel, surgical strategy has adopted a more aggressive treatment approach to achieve complete tumor clearance. However, chemotherapy affects liver function and combined with extensive liver resection, morbidity has increased, thereby compromising oncological outcome. There is an imperative need for careful patient selection to optimize patient management. In this review, we discuss available evidence and indications for neoadjuvant treatment in the management of colorectal cancer liver metastases, on preoperative patient selection and identification of high-risk patients, potential treatment strategies to promote postoperative liver regeneration to avoid postoperative morbidity and potentially deleterious side effects of these therapies on tumor growth.

Predictors of Severe Morbidity After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Patients With Colorectal Peritoneal Carcinomatosis

BACKGROUND

Severe morbidity after cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is, besides the obvious short-term consequences, associated with impaired long-term outcomes. The risk factors for severe morbidity in patients with peritoneal carcinomatosis (PC) of colorectal origin are poorly defined. This study aimed to identify risk factors for severe morbidity after CRS + HIPEC in patients with colorectal PC.

METHODS

Patients with colorectal PC who underwent CRS + HIPEC between 2007 and 2015 were categorized and compared between those with and those without severe morbidity. Risk factors were identified using logistic regression analysis. Morbidity was graded according to the Clavien-Dindo classification, with grade 3 or higher indicating severe morbidity.

RESULTS

This study included 211 patients, of whom 53 patients (25.1%) experienced morbidity of grade 3 or higher. The identified risk factors for severe morbidity were extensive prior surgery [odds ratio (OR) 4.3], a positive recent smoking history (OR 4.0), a poor physical performance status (OR 2.9), and extensive cytoreduction (OR 1.2 per additional resection). Patients with a greater number of risk factors more often had severe morbidity and higher reoperation, readmission, and mortality rates. Furthermore, an internally validated preoperative prediction model for severe morbidity with an area under the curve of 70% was constructed.

CONCLUSION

The current study identified risk factors for severe morbidity after CRS + HIPEC in patients with colorectal PC. Patients with a combination of risk factors have a substantial risk of severe morbidity and therefore should be carefully selected for CRS + HIPEC. The preoperative decision model can be a valuable additional tool in this process of patient selection.