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Hayakawa T, Kawaguchi Y, Ito K, Campisi A, Ardito F, Abe S, Nishisoka Y, Miyata A, Ichida A, Akamatsu N, Kaneko J, Giuliante F, Hasegawa K. Integrating surgical complexity and nutritional parameters to enhance prediction of postoperative complications in liver resection. Surgery 2024:S0039-6060(24)00600-7. [PMID: 39304447 DOI: 10.1016/j.surg.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 08/17/2024] [Accepted: 08/20/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND In patients undergoing liver resection, postoperative complications remain high. We hypothesized that the incidence of postoperative complications after liver resection would be predicted well by liver resection complexity and nutritional status. METHODS We retrospectively assessed patients undergoing liver resection at The University of Tokyo Hospital from 2011 to 2021. Liver resection procedures were categorized by surgical complexity using a 3-level complexity classification. Nutritional parameters (including cholinesterase and albumin levels) were evaluated together with well-known nutritional indexes, including the modified Glasgow Prognostic Score, prognostic nutritional index, platelet-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, and controlling nutritional status. RESULTS Of 1,258 patients, 570 (44.5%) experienced postoperative complications, with 506 (39.9%) requiring treatment (Clavien-Dindo grade II or greater). Multivariate logistic regression model analyses showed that cholinesterase and albumin levels, complexity classification, and open approach were associated with postoperative complications. The cholinesterase-liver resection complexity/approach model (area under the curve, 0.634) performed significantly better in predicting complications than the prognostic nutritional index (area under the curve, 0.560; P < .001), modified Glasgow Prognostic Score (area under the curve, 0.557; P < .001), controlling nutritional status (area under the curve, 0.502; P < .001), platelet-to-lymphocyte ratio (area under the curve, 0.513; P < .001), and neutrophil-to-lymphocyte ratio scores (area under the curve, 0.515; P < .001). On the basis of the cholinesterase-liver resection complexity/approach model, estimated complications ranged from 9.6% to 53.4%, and patients with well-maintained cholinesterase levels were estimated to have a 5-15% lower probability of complications than patients with impaired cholinesterase levels. This finding was validated with an external Western cohort. CONCLUSION The cholinesterase-liver resection complexity/approach model better predicted postoperative complications than nutritional indicators alone and may be useful for selecting patients who may benefit from nutritional support.
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Affiliation(s)
- Tomoaki Hayakawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Andrea Campisi
- Hepatobiliary Surgery Unit, Foundation and Teaching HospiSacred Hearttal IRCCS A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Foundation and Teaching HospiSacred Hearttal IRCCS A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Satoru Abe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yujiro Nishisoka
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akinori Miyata
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation and Teaching HospiSacred Hearttal IRCCS A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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2
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Muaddi H, Gudmundsdottir H, Cleary S. Current Status of Laparoscopic Liver Resection. Adv Surg 2024; 58:311-327. [PMID: 39089784 DOI: 10.1016/j.yasu.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The evolution of laparoscopic liver surgery, originating in the 1990s, has been marked by significant advancements and milestones, overcoming initial technical hurdles and gaining widespread acceptance within the surgical community as a precise and safe alternative to open procedures. Along this journey, numerous challenges emerged, leading to the accumulation of evidence and the development of guidelines aimed at assisting surgeons in determining the safety, suitability, and complexity of laparoscopic liver resection. This chapter provides a thorough examination of key aspects of laparoscopic liver resection, including difficulty scoring systems, criteria for patient selection, technical considerations, outcomes across different types of liver lesions, and the innovative solutions developed to address challenges, thus offering a comprehensive overview of laparoscopic liver resection, and highlighting its evolving significance in modern hepatobiliary surgery.
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Affiliation(s)
- Hala Muaddi
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Sean Cleary
- Division of Hepatobiliary and Pancreas Surgery, University of Toronto, Toronto, Ontario, Canada.
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3
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Sindayigaya R, Tzedakis S, Tribillon E, Gavignet C, Mazzotta A, Nassar A, Marchese U, Soubrane O, Fuks D. Assessing textbook outcome after single large hepatocellular carcinoma resection. HPB (Oxford) 2023; 25:1093-1101. [PMID: 37208281 DOI: 10.1016/j.hpb.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/27/2023] [Accepted: 05/01/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND This study aimed to investigate the impact and predictors of an ideal surgical care following SLHCC resection. METHODS SLHCC patients who underwent LR in two tertiary hepatobiliary centers between 2000 and 2021 were retrieved from prospectively maintained databases. The quality of surgical care was measured by the textbook outcome (TO). Tumor burden was defined by the tumor burden score (TBS). Factors associated with TO were determined on multivariate analysis. The impact of TO on oncological outcomes was assessed using Cox regressions. RESULTS Overall, 103 SLHCC patients were included. Laparoscopic approach was considered in 65 (63.1%) patients and 79 (76.7%) patients presented with moderate TBS. TO was achieved in 54 (52.4%) patients. Laparoscopic approach was independently associated with TO (OR 2.57; 95% CI 1.03-6.64; p = 0.045). Within 19 (6-38) months of median follow up, patients who achieved TO had better OS compared to non-TO patients (1-year OS: 91.7% vs. 66.9%; 5-year OS: 83.4% vs. 37.0%, p < 0.0001). On multivariate analysis, TO was independently associated with improved OS, especially in non-cirrhotic patients (HR 0.11; 95% CI 0.02-0.52, p = 0.005). CONCLUSIONS TO achievement could be a relevant surrogate marker of improved oncological care following SLHCC resection in non-cirrhotic patients.
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Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006, Paris, France.
| | - Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006, Paris, France
| | - Ecoline Tribillon
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Chloé Gavignet
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), 75014, Paris, France
| | - Alessandro Mazzotta
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Alexandra Nassar
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), 75014, Paris, France
| | - Ugo Marchese
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), 75014, Paris, France
| | - Olivier Soubrane
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006, Paris, France
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4
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Sucandy I, Kang RD, Adorno J, Crespo K, Syblis C, Ross S, Rosemurgy A. Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection. HPB (Oxford) 2023; 25:1022-1029. [PMID: 37217370 DOI: 10.1016/j.hpb.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/29/2023] [Accepted: 05/07/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND The Institut Mutualiste Montsouris (IMM) classification system is one of several widely accepted difficulty scoring systems for laparoscopic liver resections. Nothing is yet known about the applicability of this system for robotic liver resections. METHODS We conducted a retrospective review of 359 patients undergoing robotic hepatectomies between 2016 and 2022. Resections were classified into low, intermediate, and high difficulty level. Data were analyzed utilizing ANOVA of repeated measures, 3 x 2 contingency tables, and area under the receiving operating characteristic (AUROC) curves. Data are presented as median (mean ± SD). RESULTS Of the 359 patients, 117 were classified as low-difficulty level, 92 as intermediate, and 150 as high. The IMM system correlates well with tumor size (p = 0.002). The IMM system was a strong predictor of intraoperative outcomes including operative duration (p<0.001) and estimated blood loss (EBL) (p<0.001). The IMM system also showed a strong calibration for predicting an open conversion (AUC=0.705) and intraoperative complications (AUC=0.79). In contrast, the IMM system was a poor predictor of postoperative complications, mortality, and readmission. CONCLUSION The IMM system provides a strong correlation with intraoperative, but not postoperative outcomes. A dedicated difficulty scoring system should be developed for robotic hepatectomy.
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Affiliation(s)
- Iswanto Sucandy
- AdventHealth Tampa, Digestive Health Institute, Tampa, FL, USA.
| | - Richard D Kang
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | | | - Kaitlyn Crespo
- AdventHealth Tampa, Digestive Health Institute, Tampa, FL, USA
| | - Cameron Syblis
- AdventHealth Tampa, Digestive Health Institute, Tampa, FL, USA
| | - Sharona Ross
- AdventHealth Tampa, Digestive Health Institute, Tampa, FL, USA
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5
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Mazzotta AD, Yoshikuni K, Gayet B, Soubrane O. Response to the commentary for the article "Conditional cumulative incidence of postoperative complications stratified by complexity classification for laparoscopic liver resection: Optimization of in-hospital observation". Surgery 2023:S0039-6060(23)00162-9. [PMID: 37120381 DOI: 10.1016/j.surg.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/21/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Alessandro D Mazzotta
- Department of Digestive, Oncological, and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France.
| | - Kawaguchi Yoshikuni
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Brice Gayet
- Department of Digestive, Oncological, and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Soubrane
- Department of Digestive, Oncological, and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
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6
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Liu T, Ou Y, Huang T, Xue Z, Yao M, Li J, Huang Y, Cai X, Yan Y. Delimiting Low Level of Difficulty Scoring System Based on the Extent of Resection Difficulty Scoring System for Laparoscopic Liver Resection. J Laparoendosc Adv Surg Tech A 2023. [PMID: 36862541 DOI: 10.1089/lap.2022.0591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Background: The difficulty scoring system based on the extent of resection (DSS-ER) is a common tool for assessing the difficulty and risk of laparoscopic liver resection (LLR), but DSS-ER fails to comprehensively and accurately assess low level for beginners. Methods: The 93 cases of LLRs for primary liver cancer in the general surgery department of the Second Affiliated Hospital of Guangxi Medical University from 2017 to 2021 were retrospectively analyzed. The low level of DSS-ER difficulty scoring system was reclassified into three grades. The intraoperative and postoperative complications were compared among different groups. Results: There were significant differences in the operative time, blood loss, intraoperative allogeneic blood transfusion, conversion to laparotomy, and allogeneic blood transfusion among the different groups. Meanwhile, the postoperative complications were mainly pleural effusion and pneumonia, and the incidence of grade III was higher compared with other two grades. No significant difference existed in the postoperative biliary leakage and liver failure among three grades. Conclusions: This reclassified low level of DSS-ER difficulty scoring system has certain clinical value for LLR beginners to complete the corresponding learning curve.
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Affiliation(s)
- Tao Liu
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yangyang Ou
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Taiyun Huang
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhaosong Xue
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ming Yao
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianjun Li
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yubin Huang
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiaoyong Cai
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yihe Yan
- Department of General Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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7
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Martin AN, Tzeng CWD, Arvide EM, Skibber JM, Chang GJ, Nancy You YQ, Bednarski BK, Uppal A, Dewhurst WL, Cristo JV, Chun YS, Tran Cao HS, Vauthey JN, Newhook TE. Impact of cumulative operative time on postoperative complication risk in simultaneous resections of colorectal liver metastases and primary tumors. HPB (Oxford) 2023; 25:347-352. [PMID: 36697350 DOI: 10.1016/j.hpb.2022.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/14/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Simultaneous resection of colorectal liver metastases (CLM) and primary colorectal cancers (CRC) is nuanced without firm rules for selection. This study aimed to identify factors associated with morbidity after simultaneous resection. METHODS Using a prospective database, patients undergoing simultaneous CLM-CRC resection from 1/1/2017-7/1/2020 were analyzed. Regression modeling estimated impact of colorectal resection type, Kawaguchi-Gayet (KG) hepatectomy complexity, and perioperative factors on 90-day complications. RESULTS Overall, 120 patients underwent simultaneous CLM-CRC resection. Grade≥2 complications occurred in 38.3% (n = 46); these patients experienced longer length of stay (median LOS 7.5 vs. 4, p < 0.001) and increased readmission (39% vs. 1.4%, p < 0.001) compared to patients with zero or Grade 1 complications. Median OR time was 298 min. Patients within highest operative time quartile (>506 min) had higher grade≥2 complications (57%vs. 23%, p = 0.04) and greater than 4-fold increased odds of grade≥2 morbidity (OR 4.3, 95% CI (Confidence Interval) 1.41-13.1, p = 0.01). After adjusting for Pringle time, KG complexity and colorectal resection type, increasing operative time was associated with grade≥2 complications, especially for resections in highest quartile of operative time (OR 7.28, 95% CI 1.73-30.6, p = 0.007). CONCLUSION In patients undergoing simultaneous CLM-CRC resection, prolonged operative time is independently associated with grade≥2 complications. Awareness of cumulative operative time may inform intraoperative decision-making by surgical teams.
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Affiliation(s)
- Allison N Martin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John M Skibber
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George J Chang
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Qian Nancy You
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian K Bednarski
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abhineet Uppal
- Department of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jenilette V Cristo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun S Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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8
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Giuliante F, Ratti F, Panettieri E, Mazzaferro V, Guglielmi A, Ettorre GM, Gruttadauria S, Di Benedetto F, Cillo U, De Carlis L, Dalla Valle R, Ferrero A, Santambrogio R, Ardito F, Aldrighetti L. Short and long-term outcomes after minimally invasive liver resection for single small hepatocellular carcinoma: An analysis of 714 patients from the IGoMILS (Italian group of minimally invasive liver surgery) registry. HPB (Oxford) 2023:S1365-182X(23)00046-1. [PMID: 36922259 DOI: 10.1016/j.hpb.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/01/2023] [Accepted: 02/10/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Widespread use of minimally invasive liver surgery (MILS) contributed to the reduction of surgical risk of liver resection for hepatocellular carcinoma (HCC). Aim of this study was to analyze outcomes of MILS for single ≤3 cm HCC. METHODS Patients who underwent MILS for single ≤3 cm HCC (November 2014 - December 2019) were identified from the Italian Group of Minimally Invasive Liver Surgery (IGoMILS) Registry. RESULTS Of 714 patients included, 641 (93.0%) were Child-Pugh A; 65.7% were limited resections and 2.2% major resections, with a conversion rate of 5.2%. Ninety-day mortality rate was 0.3%. Overall morbidity rate was 22.4% (3.8% major complications). Mean postoperative stay was 5 days. Robotic resection showed longer operative time (p = 0.004) and a higher overall morbidity rate (p < 0.001), with similar major complications (p = 0.431). Child-Pugh B patients showed worse mortality (p = 0.017) and overall morbidity (p = 0.021), and longer postoperative stay (p = 0.005). Five-year overall survival was 79.5%; cirrhosis, satellite micronodules, and microvascular invasion were independently associated with survival. CONCLUSIONS MILS for ≤3 cm HCC was associated with low morbidity and mortality rates, showing high safety, and supporting the increasing indications for surgical resection in these patients.
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Affiliation(s)
- Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Elena Panettieri
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Mazzaferro
- Department of Surgery, Division of HPB, General Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Alfredo Guglielmi
- Department of Surgery, General and Hepatobiliary Surgery, University of Verona, University Hospital G.B. Rossi, Verona, Italy
| | - Giuseppe M Ettorre
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Transplant, Modena University Hospital, Modena, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Raffaele Dalla Valle
- Hepatobiliary Surgery Unit Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | - Roberto Santambrogio
- ASST Fatebenefratelli Sacco, Chirurgia Generale Ospedale Fatebenefratelli, Milan, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCSS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
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9
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Mazzotta AD, Kawaguchi Y, Pantel L, Tribillon E, Bonnet S, Gayet B, Soubrane O. Conditional cumulative incidence of postoperative complications stratified by complexity classification for laparoscopic liver resection: Optimization of in-hospital observation. Surgery 2023; 173:422-427. [PMID: 36041926 DOI: 10.1016/j.surg.2022.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/26/2022] [Accepted: 07/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal in-hospital observation periods associated with minimal risks of complications and unplanned readmission after laparoscopic liver resection are unknown. The purpose of this study was to assess changes in the risks of postoperative complications over time. METHODS Surgical complexity of laparoscopic liver resection was stratified into grades I (low complexity), II (intermediate), and III (high) using our 3-level complexity classification. The cumulative incidence rate and conditional probability of postoperative complication and risk factors for complication Clavien-Dindo grade ≥II (defined as treatment-requiring complications) were assessed. RESULTS The cumulative incidence of treatment-requiring complications was higher in patients undergoing grade III resection than in patients undergoing grade I resection (32.3% vs 10.4%, P < .001) and grade II resection (32.3% vs 20.7%, P = .019). The conditional probability of postoperative complication stratified by our complexity classification decreased over time and was <10% for patients undergoing grade I resection on postoperative day 1, grade II resection on postoperative day 4, and grade III resection on postoperative day 10. CONCLUSION The conditional cumulative incidence of treatment-requiring complications for patients undergoing laparoscopic liver resection is well stratified based on the 3-level complexity classification. Conditional complication risk analysis stratified by the 3 complexity grades may be useful for optimizing in-hospital observation after laparoscopic liver resection.
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Affiliation(s)
- Alessandro D Mazzotta
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France.
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Louis Pantel
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Ecoline Tribillon
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Stephane Bonnet
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Oliver Soubrane
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
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10
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Gau RY, Tsai HI, Yu MC, Chan KM, Lee WC, Wang HE, Wang SF, Cheng ML, Chiu CC, Chen HY, Lee CW. Laparoscopic liver resection is associated with less significant muscle loss than the conventional open approach. World J Surg Oncol 2022; 20:385. [PMID: 36464698 PMCID: PMC9721003 DOI: 10.1186/s12957-022-02854-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/24/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Laparoscopic liver resections (LLR) have been shown a treatment approach comparable to open liver resections (OLR) in hepatocellular carcinoma (HCC). However, the influence of procedural type on body composition has not been investigated. The aim of the current study was to compare the degree of skeletal muscle loss between LLR and OLR for HCC. METHODS By using propensity score matching (PSM) analysis, 64 pairs of patients were enrolled. The change of psoas muscle index (PMI) after the operation was compared between the matched patients in the LLR and OLR. Risk factors for significant muscle loss (defined as change in PMI > mean change minus one standard deviation) were further investigated by multivariate analysis. RESULTS Among patients enrolled, there was no significant difference in baseline characteristics between the two groups. The PMI was significantly decreased in the OLR group (P = 0.003). There were also more patients in the OLR group who developed significant muscle loss after the operations (P = 0.008). Multivariate analysis revealed OLR (P = 0.023), type 2 diabetes mellitus, indocyanine green retention rate at 15 min (ICG-15) > 10%, and cancer stage ≧ 3 were independent risk factors for significant muscle loss. In addition, significant muscle loss was associated with early HCC recurrence (P = 0.006). Metabolomic analysis demonstrated that the urea cycle may be decreased in patients with significant muscle loss. CONCLUSION LLR for HCC was associated with less significant muscle loss than OLR. Since significant muscle loss was a predictive factor for early tumor recurrence and associated with impaired liver metabolism, LLR may subsequently result in a more favorable outcome.
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Affiliation(s)
- Ruoh-Yun Gau
- grid.454211.70000 0004 1756 999XDivision of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, 33305 Taiwan
| | - Hsin-I Tsai
- grid.145695.a0000 0004 1798 0922Graduate Institute of Clinical Medical Sciences, Chang Gung University, Guishan, Taoyuan, Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan ,grid.454211.70000 0004 1756 999XDepartment of Anesthesiology, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan
| | - Ming-Chin Yu
- grid.454211.70000 0004 1756 999XDepartment of Anesthesiology, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan ,grid.413801.f0000 0001 0711 0593Division of General Surgery, Department of Surgery, New Taipei Municipal Tu-Cheng Hospital (built and operated by Chang Gung Medical Foundation), Tu-Cheng, New Taipei City, Taiwan
| | - Kun-Ming Chan
- grid.454211.70000 0004 1756 999XDivision of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, 33305 Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Wei-Chen Lee
- grid.454211.70000 0004 1756 999XDivision of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, 33305 Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Haw-En Wang
- grid.454211.70000 0004 1756 999XDepartment of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan
| | - Sheng-Fu Wang
- grid.454211.70000 0004 1756 999XDepartment of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan
| | - Mei-Ling Cheng
- grid.145695.a0000 0004 1798 0922Metabolomics Core Laboratory, Healthy Aging Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan ,grid.145695.a0000 0004 1798 0922Department of Biomedical Sciences, Chang Gung University, Guishan, Taoyuan, Taiwan ,grid.454211.70000 0004 1756 999XClinical Metabolomics Core Laboratory, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan
| | - Chien-Chih Chiu
- grid.454211.70000 0004 1756 999XDepartment of Nursing, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan
| | - Hsin-Yi Chen
- grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan ,grid.454211.70000 0004 1756 999XDepartment of Nursing, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan ,grid.454211.70000 0004 1756 999XDepartment of Cancer Center, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, Taiwan
| | - Chao-Wei Lee
- grid.454211.70000 0004 1756 999XDivision of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Guishan, Taoyuan, 33305 Taiwan ,grid.145695.a0000 0004 1798 0922Graduate Institute of Clinical Medical Sciences, Chang Gung University, Guishan, Taoyuan, Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
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Choi SH, Chen KH, Syn NL, Cipriani F, Cheung TT, Chiow AKH, Choi GH, Siow TF, Sucandy I, Marino MV, Gastaca M, Chong CC, Lee JH, Ivanecz A, Mazzaferro V, Lopez-Ben S, Fondevila C, Rotellar F, Campos RR, Efanov M, Kingham TP, Sutcliffe RP, Troisi RI, Pratschke J, Wang X, D'Hondt M, Yong CC, Levi Sandri GB, Tang CN, Ruzzenente A, Cherqui D, Ferrero A, Wakabayashi G, Scatton O, Aghayan D, Edwin B, Coelho FF, Giuliante F, Liu R, Sijberden J, Abu Hilal M, Sugioka A, Long TCD, Fuks D, Aldrighetti L, Han HS, Goh BKP. Utility of the Iwate difficulty scoring system for laparoscopic right posterior sectionectomy: do surgical outcomes differ for tumors in segments VI and VII? Surg Endosc 2022; 36:9204-9214. [PMID: 35851819 DOI: 10.1007/s00464-022-09404-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/19/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated. METHODS Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes. RESULTS The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle's maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality. CONCLUSION Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes.
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Affiliation(s)
- Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kuo-Hsin Chen
- Division of General Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Nicholas L Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital & National Cancer Centre Singapore, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore
- Ministry of Health Holdings, Singapore, Singapore
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China
| | - Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore, Singapore
| | - Gi-Hong Choi
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Tiing-Foong Siow
- Division of General Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, Tampa, FL, USA
| | - Marco V Marino
- General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
- Oncologic Surgery Department, P. Giaccone University Hospital, Palermo, Italy
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | - Charing C Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China
| | - Jae Hoon Lee
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Arpad Ivanecz
- Department of Abdominal and General Surgery, University Medical Center Maribor, Maribor, Slovenia
| | - Vincenzo Mazzaferro
- HPB Surgery, Hepatology and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Santiago Lopez-Ben
- Hepatobiliary and Pancreatic Surgery Unit, Department of Surgery, Dr. Josep Trueta Hospital, IdIBGi, Girona, Spain
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
- Digestive Surgery, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
- General and Digestive Surgery, IdiPAZ, CIBERehd, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Rotellar
- HPB and Liver Transplant, Department of General Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Ricardo Robles Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert P Sutcliffe
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Freie Universität Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Xiaoying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Chee Chien Yong
- Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
| | | | - Chung Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong SAR, China
| | - Andrea Ruzzenente
- General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics, GB Rossi Hospital, University of Verona, Verona, Italy
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Olivier Scatton
- Department of Digestive, HBP and Liver Transplantation, Hopital Pitie-Salpetriere, APHP, Sorbonne Université, Paris, France
| | - Davit Aghayan
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Fabricio Ferreira Coelho
- Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jasper Sijberden
- Department of Surgery, University Hospital Southampton, Southampton, UK
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton, Southampton, UK
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Tran Cong Duy Long
- HPB Surgery Department, University Medical Center, HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital and Vita Salute San Raffaele University, Milan, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital & National Cancer Centre Singapore, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.
- Duke-National University Singapore Medical School, Singapore, Singapore.
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Ruzzenente A, Bagante F, Poletto E, Campagnaro T, Conci S, De Bellis M, Pedrazzani C, Guglielmi A. A machine learning analysis of difficulty scoring systems for laparoscopic liver surgery. Surg Endosc 2022; 36:8869-8880. [PMID: 35604481 PMCID: PMC9652257 DOI: 10.1007/s00464-022-09322-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/27/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION In the last decade, several difficulty scoring systems (DSS) have been proposed to predict technical difficulty in laparoscopic liver resections (LLR). The present study aimed to investigate the ability of four DSS for LLR to predict operative, short-term, and textbook outcomes. METHODS Patients who underwent LLR at a single tertiary referral center from January 2014 to June 2020 were included in the present study. Four DSS for LLR (Halls, Hasegawa, Kawaguchi, and Iwate) were investigated to test their ability to predict operative and postoperative complications. Machine learning algorithms were used to identify the most important DSS associated with operative and short-term outcomes. RESULTS A total of 346 patients were included in the analysis, 28 (8.1%) patients were converted to open surgery. A total of 13 patients (3.7%) had severe (Clavien-Dindo ≥ 3) complications; the incidence of prolonged length of stay (> 5 days) was 39.3% (n = 136). No patients died within 90 days after the surgery. According to Halls, Hasegawa, Kawaguchi, and Iwate scores, 65 (18.8%), 59 (17.1%), 57 (16.5%), and 112 (32.4%) patients underwent high difficulty LLR, respectively. In accordance with a random forest algorithm, the Kawaguchi DSS predicted prolonged length of stay, high blood loss, and conversions and was the best performing DSS in predicting postoperative outcomes. Iwate DSS was the most important variable associated with operative time, while Halls score was the most important DSS predicting textbook outcomes. No one of the DSS investigated was associated with the occurrence of complication. CONCLUSIONS According to our results DDS are significantly related to surgical complexity and short-term outcomes, Kawaguchi and Iwate DSS showed the best performance in predicting operative outcomes, while Halls score was the most important variable in predicting textbook outcome. Interestingly, none of the DSS showed any correlation with or importance in predicting overall and severe postoperative complications.
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Affiliation(s)
- Andrea Ruzzenente
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy.
| | - Fabio Bagante
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
| | - Edoardo Poletto
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
| | - Simone Conci
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
| | - Mario De Bellis
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
| | - Corrado Pedrazzani
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
| | - Alfredo Guglielmi
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepato-Biliary Surgery, University of Verona, P. le L.A. Scuro, 37134, Verona, Italy
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DiPeri TP, Newhook TE, Arvide EM, Dewhurst WL, Bruno ML, Chun YS, Tran Cao HS, Lee JE, Vauthey JN, Tzeng CWD. Prospective Implementation of Standardized Post-Hepatectomy Care Pathways to Reduce Opioid Prescription Volume after Inpatient Surgery. J Am Coll Surg 2022; 235:41-48. [PMID: 35703961 PMCID: PMC9205619 DOI: 10.1097/xcs.0000000000000231] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Among the goals of prospectively implemented post-hepatectomy care pathways was a focus on patient-centric opioid reduction. We sought to evaluate the impact of pathway implementation on opioid volumes in the last 24-hour period and discharge prescriptions. STUDY DESIGN This is a retrospective cohort study comparing a prospective cohort ("POST," September 2019 through February 2020) treated after pathway implementation to a historical cohort of hepatectomy patients ("PRE," March 2016 through December 2017) before our 2018 departmental opioid reduction efforts. Opioid volumes in the last 24 hours and prescribed at discharge were converted to oral morphine equivalents (OME) and compared between cohorts. RESULTS There were 276 PRE and 100 POST patients. There was a similar proportion of major (PRE-34.1% vs POST-40%) and minimally invasive hepatectomies (PRE-19.9% vs POST-11%, p = 0.122). Implementation was associated with a shorter length of stay (median 5 d PRE vs 4 d POST, p < 0.001). Standardized opioid weaning was associated with a lower median last 24-hour OME (20 mg PRE vs 10 mg POST, p = 0.001). Using a standardized discharge calculation, median discharge OME were lower (200 mg PRE vs 50 mg POST, p < 0.001). More POST patients were discharged opioid-free (6.9% PRE vs 21% POST, p < 0.001). CONCLUSIONS Implementation of post-hepatectomy care pathways was associated with a 50% reduction in last 24-hour OME, which, combined with a standardized discharge calculation, was associated with an overall 75% reduction in discharge opioid volumes and tripled opioid-free discharges. These data suggest that no-cost, reproducible pathways can be considered in abdominal operations with similar incisions/length of stay to decrease variation in opioid dosing while prioritizing patient-centric opioid needs.
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Affiliation(s)
- Timothy P DiPeri
- From the Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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External validation of different difficulty scoring systems of laparoscopic liver resection for hepatocellular carcinoma. Surg Endosc 2022; 36:3732-3749. [PMID: 34406470 DOI: 10.1007/s00464-021-08687-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/07/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Several difficulty scoring systems (DSSs) have been proposed for evaluating difficulty of laparoscopic liver resection (LLR) and no study has validated their performance in a hepatocellular carcinoma (HCC)-only cohort at the same time. METHODS All cases with HCC that underwent LLR from January 2015 to December 2020 in our center were retrospectively collected. Performance of the IWATE-DSS, Halls-DSS, Hasegawa-DSS, and Kawaguchi-DSS in predicting perioperative outcomes was evaluated. Subgroup analyses were conducted to compare perioperative outcomes between surgeons on the learning curve and surgeons that have gone through the learning curve. RESULTS For all four DSSs, there were significant distributions of applying bleeding control, surgical time, estimated blood loss, postoperative major complications, and postoperative hospital stay among different groups of each DSS (P all < 0.05). Conversion to laparotomy or not was significantly distributed in different groups of the IWATE-DSS (P = 0.006) and Halls-DSS (P = 0.022), while it was not in the Hasegawa-DSS (P = 0.056) and Kawaguchi-DSS (P = 0.183). Trend tests showed that the conversion rates increased with higher DSS points in the IWATE-DSS (P < 0.001) and the Kawaguchi-DSS (P = 0.021), while not in the Halls-DSS (P = 0.064) and the Hasegawa-DSS (P = 0.068). In the medium and advanced/expert difficulty-level subgroups defined by the IWATE-DSS, there were larger estimated blood loss (P in medium-difficulty group = 0.009; P in the advanced/expert difficulty group = 0.004) and longer postoperative hospital stay (P in the medium-difficulty group = 0.012; P in the advanced/expert group = 0.035) in the learner-performed cases. CONCLUSIONS All DSSs performed well in predicting applying bleeding control, surgical time, estimated blood loss, postoperative major complications, and postoperative hospital stay, while only the IWATE-DSS was able to predict whether conversion to laparotomy or not for HCC patients underwent LLR. The IWATE-DSS was also able to help surgeons on the LLR learning curve choose cases and guide clinical practices.
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Sindayigaya R, Tribillon E, Ghedira A, Beaussier M, Sarran A, Tubbax C, Bonnet S, Gayet B, Soubrane O, Fuks D. Predictors of discharge timing and unplanned readmission after laparoscopic liver resection. HPB (Oxford) 2022; 24:708-716. [PMID: 34674952 DOI: 10.1016/j.hpb.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR). METHODS Consecutive LLR performed at the "Institut Mutualiste Montsouris" between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission. RESULTS Early discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75-125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98-12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60-11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12-15.8, p = 0.045). CONCLUSION Concomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.
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Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France.
| | - Ecoline Tribillon
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Abdessalem Ghedira
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Marc Beaussier
- Department of Anesthesiology, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Anthony Sarran
- Department of Radiology, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Candice Tubbax
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Stéphane Bonnet
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Olivier Soubrane
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014, Paris, France
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Kim BJ, Arvide EM, Gaskill C, Martin AN, Kawaguchi Y, Chiang YJ, Dewhurst WL, Lee T, Tran Cao HS, Chun YS, Katz MH, Vauthey JN, Tzeng CWD, Newhook TE. Risk-Stratified Post-Hepatectomy Pathways Based Upon the Kawaguchi-Gayet Complexity Classification and Impact on Length of Stay. Surg Open Sci 2022; 9:109-116. [PMID: 35747509 PMCID: PMC9209704 DOI: 10.1016/j.sopen.2022.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/25/2022] Open
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Cucchetti A, Aldrighetti L, Ratti F, Ferrero A, Guglielmi A, Giuliante F, Cillo U, Mazzaferro V, De Carlis L, Ercolani G. Variations in risk-adjusted outcomes following 4318 laparoscopic liver resections. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:521-530. [PMID: 35305075 PMCID: PMC9324820 DOI: 10.1002/jhbp.1141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/23/2022] [Accepted: 01/26/2022] [Indexed: 02/05/2023]
Abstract
Background/Purpose Quality measures in surgery are important to establish appropriate levels of care and to develop improvement strategies. The purpose of this study was to provide risk‐adjusted outcome measures after laparoscopic liver resection (LLR). Methods Data from a prospective, multicenter database involving 4318 patients submitted to LLRs in 41 hospitals from an intention‐to‐treat approach (2014–2020) were used to analyze heterogeneity (I2) among centers and to develop a risk‐adjustment model on outcome measures through multivariable mixed‐effect models to account for confounding due to case‐mix. Results Involved hospitals operated on very different patients: the largest heterogeneity was observed for operating in the presence of previous abdominal surgery (I2:79.1%), in cirrhotic patients (I2:89.3%) suffering from hepatocellular carcinoma (I2:88.6%) or requiring associated intestinal resections (I2:82.8%) and in regard to technical complexity (I2 for the most complex LLRs: 84.1%). These aspects determined substantial or large heterogeneity in overall morbidity (I2:84.9%), in prolonged in‐hospital stay (I2:86.9%) and in conversion rate (I2:73.4%). Major complication had medium heterogeneity (I2:46.5%). The heterogeneity of mortality was null. Risk‐adjustment accounted for all of this variability and the final risk‐standardized conversion rate was 8.9%, overall morbidity was 22.1%, major morbidity was 5.1% and prolonged in‐hospital stay was 26.0%. There were no outliers among the 41 participating centers. An online tool was provided. Conclusions A benchmark for LLRs including all eligible patients was provided, suggesting that surgeons can act accordingly in the interest of the patient, modifying their approach in relation to different indications and different experience, but finally providing the same quality of care.
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Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical sciences – DIMEC; Alma Mater StudiorumUniversity of BolognaBolognaItaly
- MorgagniPierantoni HospitalForlìItaly
| | - Luca Aldrighetti
- Hepatobiliary Surgery DivisionDepartment of Surgery, IRCCS San Raffaele Hospital, School of MedicineMilanItaly
| | - Francesca Ratti
- Hepatobiliary Surgery DivisionDepartment of Surgery, IRCCS San Raffaele Hospital, School of MedicineMilanItaly
| | - Alessandro Ferrero
- Department of General and Oncological SurgeryMauriziano HospitalTurinItaly
| | - Alfredo Guglielmi
- Department of Hepatobiliary SurgeryG. B. Rossi Hospital, University of VeronaVeronaItaly
| | - Felice Giuliante
- Unit of Hepato‐Biliary SurgeryFoundation 'Policlinico Universitario A. Gemelli', Università Cattolica del Sacro CuoreRomeItaly
| | - Umberto Cillo
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - Vincenzo Mazzaferro
- Department of Surgery, Hepatopancreatobiliary Surgery and Liver TransplantationUniversity of MilanMilanItaly
| | - Luciano De Carlis
- Department of General Surgery and TransplantationNiguarda Ca' Granda HospitalMilanItaly
| | - Giorgio Ercolani
- Department of Medical and Surgical sciences – DIMEC; Alma Mater StudiorumUniversity of BolognaBolognaItaly
- MorgagniPierantoni HospitalForlìItaly
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18
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Improved Survival over Time After Resection of Colorectal Liver Metastases and Clinical Impact of Multigene Alteration Testing in Patients with Metastatic Colorectal Cancer. J Gastrointest Surg 2022; 26:583-593. [PMID: 34506029 DOI: 10.1007/s11605-021-05110-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/20/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The past 20 years have seen advances in colorectal cancer management. We sought to determine whether survival in patients undergoing resection of colorectal liver metastases (CLM) has improved in association with three landmark advances: introduction of irinotecan- and/or oxaliplatin-containing regimens, molecular targeted therapy, and multigene alteration testing. METHODS Patients undergoing CLM resection during 1998-2014 were identified and grouped by resection year. The influence of alterations in RAS, TP53, and SMAD4 was evaluated and validated in an external cohort including patients with unresectable metastatic colorectal cancer. RESULTS Of 1961 patients, 1599 met the inclusion criteria. Irinotecan- and/or oxaliplatin-containing regimens and molecular targeted therapy were used for more than 50% of patients starting in 2001 and starting in 2006, respectively, so patients were grouped as undergoing resection during 1998-2000, 2001-2005, or 2006-2014. Liver resectability indications expanded over time. The 5-year overall survival (OS) rate was significantly better in 2006-2014, vs. 2001-2005 (56.5% vs. 44.1%, P < 0.001). RAS alteration was associated with worse 5-year OS than RAS wild-type (44.8% vs. 63.3%, P < 0.001). However, OS did not differ significantly between patients with RAS alteration and wild-type TP53 and SMAD4 and patients with RAS wild-type in our cohort (P = 0.899) or the external cohort (P = 0.932). Of 312 patients with genetic sequencing data, 178 (57.1%) had clinically actionable alterations. CONCLUSION OS after CLM resection has improved with advances in medical therapy and surgical technique. Multigene alteration testing is useful for prognostication and identification of potential therapeutic targets.
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Watanabe G, Kawaguchi Y, Ichida A, Ishizawa T, Akamatsu N, Kaneko J, Arita J, Hasegawa K. Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay. HPB (Oxford) 2022; 24:226-233. [PMID: 34312059 DOI: 10.1016/j.hpb.2021.06.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND After liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time. METHODS Surgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed. RESULTS Of 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection. CONCLUSION Conditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.
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Affiliation(s)
- Genki Watanabe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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20
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OUP accepted manuscript. Br J Surg 2022; 109:455-463. [DOI: 10.1093/bjs/znac017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 12/06/2021] [Accepted: 01/04/2022] [Indexed: 01/27/2023]
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21
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Kawaguchi Y, Fuks D, Vauthey JN, Kokudo N, Gayet B, Hasegawa K. A novel simple three-level liver resection classification without compromising the performance to predict surgical and postoperative outcomes. Eur J Surg Oncol 2021; 48:305-306. [PMID: 34862096 DOI: 10.1016/j.ejso.2021.11.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - David Fuks
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France; Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, Paris, France
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Norihiro Kokudo
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Brice Gayet
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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22
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Cheung TT, Wang X, Efanov M, Liu R, Fuks D, Choi GH, Syn NL, Chong CC, Sucandy I, Chiow AKH, Marino MV, Gastaca M, Lee JH, Kingham TP, D'Hondt M, Choi SH, Sutcliffe RP, Han HS, Tang CN, Pratschke J, Troisi RI, Goh BKP. Minimally invasive liver resection for huge (≥10 cm) tumors: an international multicenter matched cohort study with regression discontinuity analyses. Hepatobiliary Surg Nutr 2021; 10:587-597. [PMID: 34760963 DOI: 10.21037/hbsn-21-327] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/10/2021] [Indexed: 12/18/2022]
Abstract
Background The application and feasibility of minimally invasive liver resection (MILR) for huge liver tumours (≥10 cm) has not been well documented. Methods Retrospective analysis of data on 6,617 patients who had MILR for liver tumours were gathered from 21 international centers between 2009-2019. Huge tumors and large tumors were defined as tumors with a size ≥10.0 cm and 3.0-9.9 cm based on histology, respectively. 1:1 coarsened exact-matching (CEM) and 1:2 Mahalanobis distance-matching (MDM) was performed according to clinically-selected variables. Regression discontinuity analyses were performed as an additional line of sensitivity analysis to estimate local treatment effects at the 10-cm tumor size cutoff. Results Of 2,890 patients with tumours ≥3 cm, there were 205 huge tumors. After 1:1 CEM, 174 huge tumors were matched to 174 large tumors; and after 1:2 MDM, 190 huge tumours were matched to 380 large tumours. There was significantly and consistently increased intraoperative blood loss, frequency in the application of Pringle maneuver, major morbidity and postoperative stay in the huge tumour group compared to the large tumour group after both 1:1 CEM and 1:2 MDM. These findings were reinforced in RD analyses. Intraoperative blood transfusion rate and open conversion rate were significantly higher in the huge tumor group after only 1:2 MDM but not 1:1 CEM. Conclusions MILR for huge tumours can be safely performed in expert centers It is an operation with substantial complexity and high technical requirement, with worse perioperative outcomes compared to MILR for large tumors, therefore judicious patient selection is pivotal.
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Affiliation(s)
- Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Xiaoying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France
| | - Gi-Hong Choi
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nicholas L Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Charing C Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong, China
| | - Iswanto Sucandy
- AdventHealth Tampa, Digestive Health Institute, Tampa, FL, USA
| | - Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore, Singapore
| | - Marco V Marino
- General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.,Oncologic Surgery Department, P. Giaccone University Hospital, Palermo, Italy
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | - Jae Hoon Lee
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Robert P Sutcliffe
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chung Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and Duke-National University Singapore Medical School, Singapore, Singapore
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Efanov M, Kazakov I, Alikhanov R, Vankovich A, Koroleva A, Kovalenko D, Salimgereeva D, Tsvirkun V, Khatkov I. A randomized prospective study of the immediate outcomes of the use of a hydro-jet dissector and an ultrasonic surgical aspirator for laparoscopic liver resection. HPB (Oxford) 2021; 23:1332-1338. [PMID: 33618991 DOI: 10.1016/j.hpb.2021.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND No prospective randomized trials comparing transection techniques for the liver parenchyma transection during laparoscopic liver resection have been performed. The aim of the study was to compare the immediate outcomes of hydro-jet dissection with ultrasonic surgical aspirator in laparoscopic liver parenchyma transection in a prospective randomized single-center study. METHODS Consecutive patients with liver benign and malignant tumors presenting to a single center from May 2017 to May 2020 were enrolled in the study. The primary endpoint was the intraoperative estimated blood loss. The secondary endpoints included duration of parenchymal transection, morbidity, and overall hospital stay. RESULTS A total of 68 patients were enrolled in the study, with 34 patients in each group. There were no differences between groups in the difficulty of resection (according to IWATE criteria and IMM score) and other basic surgical parameters. No differences were found in all primary and secondary endpoints except the expenditure. The cost of equipment was significantly higher in the group of ultrasonic aspirator. CONCLUSION Despite the wider use of the ultrasonic aspirator in laparoscopic liver surgery, hydro-jet and ultrasonic surgical aspirators have shown similar efficacy and safety for transection of the liver parenchyma during laparoscopic resection.
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Affiliation(s)
- Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia.
| | - Ivan Kazakov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Andrey Vankovich
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Anna Koroleva
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Dmitry Kovalenko
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Diana Salimgereeva
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Victor Tsvirkun
- Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
| | - Igor Khatkov
- Moscow Clinical Scientific Center, 11123, Shosse Entuziastov, 86, Moscow, Russia
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24
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Hobeika C, Tribillon E, Marchese U, Faermark N, Ghedira A, Bonnet S, Nassar A, Gayet B, Fuks D. Validation of the IMM classification in laparoscopic repeat liver resections for colorectal liver metastases. Surgery 2021; 170:1448-1456. [PMID: 34176600 DOI: 10.1016/j.surg.2021.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/05/2021] [Accepted: 05/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND To validate the Institut Mutualiste Montsouris classification as a difficulty scoring system applicable to laparoscopic repeat liver resections and identify risk-factors of unexpected difficulty. METHODS From a prospectively collected database between 2000 and 2019, patients undergoing laparoscopic repeat liver resections were classified according to the Institut Mutualiste Montsouris classification. Doubly robust estimators (weighted regressions) were used to assess the effect of factors on intra- and postoperative outcomes and allowed for strong adjustment on age, body mass index, American Society of Anesthesiologists, carcinoembryonic antigen, number, and size of lesions. Unexpected difficulty was defined as a composite indicator which included substantial blood loss and/or substantial operative time and/or conversion. RESULTS Of 205 laparoscopic repeat liver resections patients, 87, 25, and 93 procedures were classified as grade 1, 2, and 3 laparoscopic repeat liver resections, respectively. After doubly robust adjustment, the IMM classification was associated with blood loss (Cohen f2 0.12; P = 0.001), operative time (Cohen f2 0.07; P = .001), and length of stay (Cohen f2 0.13; P = .001), as well as with the risk of both minor and severe complications (odd ratio = 2.94; 95% confidence interval: 2.06-4.20) and the chances of achieving textbook outcome (relative risk = 0.57; 95% confidence interval: 0.41-0.81). Independently from the Institut Mutualiste Montsouris classification, a first major hepatectomy (relative risk = 1.15, 95% confidence interval: 1.03-1.29) as well as sinusoidal obstruction syndrome (relative risk = 1.24, 95% confidence interval: 1.09-1.41) were independent risk factors of unexpected difficulty. A first major resection was associated with decreased chances of textbook outcome (relative risk = 0.53; 95% confidence interval: 0.33-0.85). CONCLUSION The Institut Mutualiste Montsouris classification is a valuable difficulty scoring system for laparoscopic repeat liver resections procedures, while previous major resection and presence of sinusoidal obstruction syndrome are likely to jeopardize the outcomes.
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Affiliation(s)
- Christian Hobeika
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France.
| | - Ecoline Tribillon
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - Ugo Marchese
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - Nicole Faermark
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - Abdessalem Ghedira
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - Stéphane Bonnet
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - Alexandra Nassar
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
| | - David Fuks
- Department of Digestive, Oncologic, and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, Paris, France
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25
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Probability of Postoperative Complication after Liver Resection: Stratification of Patient Factors,Operative Complexity, and Use of Enhanced Recovery after Surgery. J Am Coll Surg 2021; 233:357-368.e2. [PMID: 34111534 DOI: 10.1016/j.jamcollsurg.2021.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current study aimed to assess the performance of the 3-level complexity classification that stratified liver resection procedures into 3 complexity grades (grade I, low; grade II, intermediate; and grade III, high complexity) and to evaluate whether the Enhanced Recovery after Surgery (ERAS) protocol improves postoperative outcomes for each complexity grade. STUDY DESIGN Consecutive patients undergoing open liver resection and laparoscopic liver resection at Lausanne University Hospital during 2010 to 2020 were assessed. RESULTS A total of 437 patients were included. Operative time, estimated blood loss, and length of hospital stay increased significantly, with a stepwise increase of the grades from I to III in open liver resection and laparoscopic liver resection (all, p < 0.05). The same trend for Comprehensive Complication Index was found in open liver resection (p < 0.005). Age (p = 0.004), 3-level complexity classification (grade II vs I; p = 0.001; grade III vs I; p < 0.001), no use of the ERAS protocol (p = 0.016), and biliary reconstruction (p < 0.001) were significant predictors for postoperative complication, defined as Comprehensive Complication Index ≥ 26.2 in a multivariable logistic regression analysis. The prediction model incorporating the 4 factors had a calculated Concordance Index of 0.735 and 0.742 based on the bootstrapping method. The use of ERAS protocol was associated with lower probability of postoperative complication for each complexity grade and age. CONCLUSIONS The use of ERAS protocol can decrease the probability of postoperative complication for each surgical complexity of liver resection and patient age. This finding emphasized the importance of tailoring perioperative management according to surgical complexity and patient age to improve outcomes after liver resection.
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Barron JO, Orabi D, Moro A, Quintini C, Berber E, Aucejo FN, Sasaki K, Kwon CHD. Validation of the IWATE criteria as a laparoscopic liver resection difficulty score in a single North American cohort. Surg Endosc 2021; 36:3601-3609. [PMID: 34031739 DOI: 10.1007/s00464-021-08561-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 05/11/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) involves a difficult learning curve, for which multiple difficulty scores have been proposed to assist with safe adaptation. The IWATE Criteria is a 4-level difficulty score shown to correlate with conversion to open surgery, estimated blood loss (EBL), and operative time in Japanese and French cohorts. We set out to validate the IWATE Criteria in a North American cohort, describe the evolution of our LLR program, and analyze the IWATE Criteria's ability to predict conversion to open surgery. METHODS Patients that underwent LLR between January 2006 and December 2019 were selected from a prospectively maintained database. Difficulty outcomes, including conversion to open surgery, EBL, operative time, and post-operative complications were analyzed according to IWATE difficulty level, both overall and between chronological eras. The IWATE Criteria's ability to predict conversion to open surgery was assessed with a receiver operating characteristic (ROC) analysis. RESULTS A total of 426 patients met inclusion criteria. Operative time, EBL, and conversion to open surgery increased in concordance with low to advanced IWATE difficulty. ROC analysis for conversion to open surgery demonstrated an overall area under the curve (AUC) of 0.694. Predictive performance was superior during the first two eras, with AUCs of 0.771 and 0.775; predictive value decreased as the LLR program gained experience, with AUCs of 0.708 and 0.551 for eras three and four. CONCLUSIONS This study validated the IWATE Criteria in a North American population distinct from previous Japanese and French cohorts, based on its correlation with operative time, EBL, and conversion to open surgery. The IWATE Criteria may be of utility for identification of LLR cases appropriate for surgeon experience, as well as determination of laparoscopic feasibility. Interval difficulty score recalibration may be warranted as surgeon perception of difficulty evolves.
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Affiliation(s)
- John O Barron
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Danny Orabi
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Amika Moro
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Eren Berber
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Federico N Aucejo
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Kazunari Sasaki
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA. .,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
| | - Choon-Hyuck D Kwon
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, 44195, USA.,Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
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Nassar A, Tribillon E, Marchese U, Faermark N, Bonnet S, Beaussier M, Gayet B, Fuks D. Feasibility and outcomes of multiple simultaneous laparoscopic liver resections. Surg Endosc 2021; 36:2466-2472. [PMID: 33966122 DOI: 10.1007/s00464-021-08531-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Surgeons often remain reluctant to consider laparoscopic approach in multiple liver tumors. This study assessed feasibility and short-term results of patients who had more than 3 simultaneous laparoscopic liver resections (LLR). METHODS All consecutive patients who underwent LLR for primary or secondary malignancies between 2009 and 2019 were analyzed. After exclusion of major LLR, patients were divided into three groups: less than three (Group A), between three and five (Group B), and more than five resections (Group C) in the same procedure. Intraoperative details, postoperative outcomes, and textbook outcome (TO) were compared in the 3 groups. RESULTS During study period, 463 patients underwent minor LLR. Among them, 412 (88.9%) had less than 3 resections, 38 (8.2%) between 3 and 5 resections, and 13 (2.8%) more than 5 resections. Despite a difficulty score according to IMM classification comparable in the 3 groups (with high difficulty grade 3 procedures of 16.5% vs. 15.7% vs. 23.1% in Group A, B, and C, respectively, p = 0.124), mean operative time was significantly longer in Group C (p = 0.039). Blood loss amount (p = 0.396) and conversion rate (p = 0.888) were similar in the 3 groups. Rate of R1 margins was not significantly different between groups (p = 0.078). Achievement of TO was not different between groups (p = 0.741). In multivariate analysis, non-achievement of TO was associated with difficulty according to IMM classification (OR = 2.29 (1.33-3.98)). CONCLUSION Since intra- and post-operative outcomes and quality of resection are comparable, multiple liver resections should not preclude the laparoscopic approach.
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Affiliation(s)
- Alexandra Nassar
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France.
| | - Ecoline Tribillon
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Ugo Marchese
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Nicole Faermark
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Stéphane Bonnet
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Marc Beaussier
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
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Validation and comparison of the Iwate, IMM, Southampton and Hasegawa difficulty scoring systems for primary laparoscopic hepatectomies. HPB (Oxford) 2021; 23:770-776. [PMID: 33023824 DOI: 10.1016/j.hpb.2020.09.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/20/2020] [Accepted: 09/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Various difficulty scoring systems (DSS) have been formulated to grade the complexity of laparoscopic hepatectomies (LH). This study aims to externally validate and compare 4 contemporary DSS including the Iwate, Institut Mutualiste Montsouris (IMM), Southampton and Hasegawa DSS in predicting the intraoperative technical difficulty and postoperative outcomes after LH. METHODS Retrospective review of 548 consecutive patients who underwent LH of which 455 met the study inclusion criteria. Outcomes measures of technical difficulty included operation time, Pringles maneuver, blood loss and blood transfusion rate. Postoperative outcomes measured included morbidity, major morbidity and postoperative hospital stay. RESULTS There was a statistically significant progressive increase in blood loss, blood transfusion rate, operation time and postoperative stay associated with all 4 DSS. There was also good calibration with respect to blood loss, operation time, Pringles maneuver, open conversion rate, postoperative morbidity, postoperative major morbidity and postoperative stay for all 4 DSS. The Southampton score demonstrated the poorest calibration in terms of operation time and discrimination in terms of application of Pringles maneuver and major morbidity amongst all 4 systems. CONCLUSION All 4 DSS significantly correlated with outcome measures associated with intraoperative technical difficulty and postoperative outcomes. The Southampton DSS was the poorest system in our cohort of patients.
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Kobayashi K, Uldry E, Kokudo T, Cristaudi A, Kawaguchi Y, Shirata C, Yamaguchi T, Dormond O, Duran R, Hasegawa K, Demartines N, Halkic N. Correlation Between Portal Pressure and Indocyanine Green Retention Rate is Unaffected by the Cause of Cirrhosis: A Prospective Study. World J Surg 2021; 45:2546-2555. [PMID: 33891139 PMCID: PMC8236033 DOI: 10.1007/s00268-021-06111-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
Background Accurate estimation of the hepatic functional reserve before liver resection is important to avoid post-hepatectomy liver failure (PHLF). The aim of the present study was to evaluate the association of indocyanine green retention test with portal pressure by the cause of cirrhosis (non-viral vs. viral) and assessed postoperative outcomes including incidence of PHLF in patients with viral and non-viral cirrhosis. Methods The cohort includes 50 consecutive patients with liver cirrhosis scheduled for liver resection for primary liver tumors at the Lausanne University Hospital between 2009 and 2018. Results There were 31 patients with non-viral liver cirrhosis (Non-virus group) and 19 with viral liver cirrhosis (virus group). The indocyanine green retention rate at 15 min (ICG-R15) (p = 0.276), Hepatic Venous Portal Gradient (HVPG; p = 0.301), and postoperative outcomes did not differ between the non-virus group and viral group. ICG-R15 and HVPG showed a significant linear correlation in all patients (Spearman’s rank correlation coefficient, ρ = 0.599, p < 0.001), the non-virus group (ρ = 0.555, p = 0.026), and the virus group (ρ = 0.534, p = 0.007). A receiver operating characteristic curve analysis showed that ICG-R15 was a predictor for presence of portal hypertension (PH; HVPG ≥ 12 mmHg) (area under the curve [AUC] = 0.780). The cut-off value of ICG-R15 for predicting the presence of PH was 16.0% with 72.3% of sensitivity and 79.0% of specificity. Conclusions The ICG-R15 level was associated with portal pressure in both patients with non-virus cirrhosis and patients with virus cirrhosis and predicts the incidence of PH with relatively good discriminatory ability. Clinical trial number https://clinicalTrials.gov(ID:NCT00827723) Local ethics committee number CER-VD 251.08
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Affiliation(s)
- Kosuke Kobayashi
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland. .,Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Emilie Uldry
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Takashi Kokudo
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Alessandra Cristaudi
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Yoshikuni Kawaguchi
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Chikara Shirata
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takamune Yamaguchi
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Olivier Dormond
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Rafael Duran
- Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kiyoshi Hasegawa
- Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Laparoscopic Liver Resection Should Be a Standard Procedure for Hepatocellular Carcinoma with Low or Intermediate Difficulty. J Pers Med 2021; 11:jpm11040266. [PMID: 33918197 PMCID: PMC8067022 DOI: 10.3390/jpm11040266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To investigate the feasibility of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC), we compared the outcome between LLR and conventional open liver resection (OLR) in patient groups with different IWATE criteria difficulty scores (DS). METHODS We retrospectively reviewed 607 primary HCC patients (LLR: 81, OLR: 526) who underwent liver resection in Linkou Chang Gung Memorial hospital from 2012 to 2019. By using 1:1 propensity score-matched (PSM) analysis, their baseline characteristics and the DS stratified by the IWATE criteria were matched between the LLR and OLR. Their perioperative and oncologic outcomes were compared. RESULTS After 1:1 PSM, 146 patients (73 in LLR, 73 in OLR) were analyzed. Among them, 13, 41, 13 and 6 patients were classified as low, intermediate, advanced and expert DS group, respectively. Compared to OLR, the LLR had shorter hospital stay (9.4 vs. 11.5 days, p = 0.071), less occurrence of surgical complications (16.4% vs. 30.1%, p = 0.049), lower rate of hepatic inflow control (42.5% vs. 65.8%, p = 0.005), and longer time of inflow control (70 vs. 51 min, p = 0.022). The disease-free survival (DFS) and overall survivals were comparable between the two groups. While stratified by the DS groups, the LLR tended to have lower complication rate and shorter hospital stay than OLR. The DFS of LLR in the intermediate DS group was superior to that of the OLR (p = 0.020). In the advanced and expert DS groups, there were no significant differences regarding outcomes between the two groups. CONCLUSION We have demonstrated that with sufficient experience and technique, LLR for HCC is feasible and the perioperative outcome is favorable. Based on the current study, we suggest LLR should be a standard procedure for HCC with low or intermediate difficulty. It can provide satisfactory postoperative recovery and comparable oncological outcomes. Further larger scale prospective studies are warranted to validate our findings.
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Comment on "Stratification of Major Hepatectomies According to Their Outcome Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis". Ann Surg 2021; 276:e134-e135. [PMID: 33914451 DOI: 10.1097/sla.0000000000004878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Efanov M, Azizzoda Z, Elizarova N, Alikhanov R, Karimkhon K, Melekhina O, Kulezneva Y, Kazakov I, Vankovich A, Chitadze A, Salimgereeva D, Tsvirkun V. Laparoscopic radical and conservative surgery for hydatid liver echinococcosis: PSM based comparative analysis of immediate and long-term outcomes. Surg Endosc 2021; 36:1224-1233. [PMID: 33650004 DOI: 10.1007/s00464-021-08391-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diffusion of laparoscopic radical surgery for hydatid liver echinococcosis remains limited. There are no published data on a comparative analysis of the immediate and long-term results of radical and conservative laparoscopic surgery for liver hydatid cysts. Comparison of the immediate and long-term outcomes after laparoscopic radical and conservative cystectomies was aimed. METHODS HPB center (Center 1) and general surgery hospital in an endemic area (Center 2) participated in a retrospective study. Radical surgery included total, subtotal pericystectomy, and liver resection. Conservative surgery comprised cystectomy without/with partial pericystectomy. RESULTS The total number of patients who underwent surgery for liver hydatid cysts was 213. Laparoscopic cystectomy was performed in 106 (50%) patients. This number included 47 radical laparoscopic cystectomy (Center 1). Conservative laparoscopic procedures were used in 59 patients (Center 2). Finally, twenty-seven pairs of patients were matched. Immediate outcomes were better for radical treatment in terms of severe morbidity, length of hospital stay, and time of abdominal drainage before and after PSM. The mean follow-up length was 23 (4-66) and 29 (6-66) months and the recurrence rate was 2% and 5% in groups of radical and conservative treatment respectively. No differences were found in 1-, 3-, and 5-year disease free survival. After second PSM for recurrence, 20 pairs were matched with no relapse of disease. CONCLUSION Laparoscopic radical surgery leads to the better immediate outcomes and can be recommended as the preferred treatment option in a specialized HPB center. Conservative option is justified in general hospitals in endemic area for selected uncomplicated cysts.
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Affiliation(s)
- Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia.
| | - Zubaydullo Azizzoda
- Department of Surgical Diseases No 1, Avicenna Tajik State Medical University, Kamongaron str., 3, Dushanbe, 734067, Tajikistan
| | - Natalia Elizarova
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Kurbonov Karimkhon
- Department of Surgical Diseases No 1, Avicenna Tajik State Medical University, Kamongaron str., 3, Dushanbe, 734067, Tajikistan
| | - Olga Melekhina
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Yulia Kulezneva
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Ivan Kazakov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Andrey Vankovich
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Alena Chitadze
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Diana Salimgereeva
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
| | - Victor Tsvirkun
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Center Named After Loginov A.S., shosse Entuziastov, 86, Moscow, 11123, Russia
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Hobeika C, Nault JC, Barbier L, Schwarz L, Lim C, Laurent A, Gay S, Salamé E, Scatton O, Soubrane O, Cauchy F. Influence of surgical approach and quality of resection on the probability of cure for early-stage HCC occurring in cirrhosis. JHEP Rep 2020; 2:100153. [PMID: 32995713 PMCID: PMC7502347 DOI: 10.1016/j.jhepr.2020.100153] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND & AIMS The quality of surgical care of patients with HCC is associated with improved long-term prognosis and may also be influenced by the type of surgical approach. The present study aimed at evaluating the role of the laparoscopic approach on quality of surgical care and long-term prognosis in optimal HCC surgical candidates. METHODS All consecutive patients undergoing open (OLR) or laparoscopic liver resection (LLR) for early-stage HCC in cirrhosis (METAVIR F4) at 5 French expert hepato-pancreatico-biliary centres between 2010 and 2018 were enrolled. Quality of surgical care was defined by textbook outcome (TO), a combination of 6 criteria representing ideal hospitalisation. Factors associated with TO were determined on multivariate analysis. Comparison between LLR and OLR was performed after propensity score matching (PSM). The primary endpoint was disease-free survival (DFS). Statistical cure was modelled using a non-mixture model. RESULTS Overall, 425 patients were included. Median follow-up was 42.0 months. LLR was performed in 267 (62.8%) patients. TO was achieved in 140 (32.9%) patients. LLR was independently associated with TO (odds ratio [OR] 2.81; 95% CI 1.29-6.12; p = 0.009). After PSM, LLR patients cumulated higher number of TO criteria than OLR patients (5 vs. 4; p = 0.012). The 1-, 3-, and 5-year DFS of LLR patients with and without TO were 82.3%, 64.4%, and 62.5%, and 76.9%, 51.4%, and 30.2%, respectively (p = 0.003). On multivariable Cox regression, TO was independently associated with improved DFS (hazard ratio 0.34; p = 0.001). The cure fraction of the whole population was 24.4%. Patients achieving TO had increased cure fraction than patients not achieving TO (32.6% vs. 18.1%). CONCLUSIONS Quality of surgical care improves the prognosis of patients with early-stage HCC and is promoted by the laparoscopic approach. LAY SUMMARY The overall quality of surgical care, as measured by TO, plays a pivotal role in the prognosis and, in particular, on the probability of statistical cure of patients with resectable early-stage HCC occurring in cirrhosis. By influencing TO, laparoscopy has an indirect impact on the probability of cure and long-term management of these patients. This study strongly supports the promising curative role of mini-invasive treatments for early-stage HCC, such as low-difficulty LLR.
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Key Words
- AFP, alpha-fetoprotein
- ALBI, albumin-bilirubin
- CCI, Comprehensive Complication Index
- CT, computed tomography
- DFS, disease-free survival
- HPB, hepato-pancreatico-biliary
- HR, hazard ratio
- Hepatocellular carcinoma
- IMM, Institut Mutualiste Montsouris
- ISGLS, International Study Group of Liver Surgery
- LLR, laparoscopic liver resection
- LOS, length of stay
- LR, liver resection
- Laparoscopic liver resection
- MELD, model for end-stage liver disease
- OLR, open liver resection
- OR, odds ratio
- OS, overall survival
- PHLF, post-hepatectomy liver failure
- Quality of care
- Statistical cure
- TO, textbook outcome
- Textbook outcome
- VIF, variance inflation factor
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Affiliation(s)
- Christian Hobeika
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
- Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Jean Charles Nault
- Liver Unit, Jean Verdier Hospital, Bondy, France
- Assistance Publique-Hôpitaux de Paris, Université Paris-XIII, Paris, France
- Unité de Formation et de Recherche Santé Médecine et Biologie Humaine, Université Paris-XIII, Paris, France
- Centre de Recherche des Cordeliers, Inserm, Sorbonne Université, Université Paris, INSERM UMR 1148 Functional Genomics of Solid Tumors laboratory, F-75006, Paris, France
| | - Louise Barbier
- Department of Digestive, Endocrine, HPB Surgery and Liver Transplantation, Trousseau University Hospital, Tours, France
- INSERM U1082, Poitiers, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Charles Nicolle University Hospital, Rouen, France
| | - Chetana Lim
- Department of HPB Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
- Assistance Publique-Hôpitaux de Paris, Université Paris Sorbonne, Paris, France
| | - Alexis Laurent
- Department of Digestive Surgery, Henri Mondor Hospital, Creteil, France
- Assistance Publique-Hôpitaux de Paris, Université Paris-Est Creteil, Paris, France
| | - Suzanne Gay
- Department of Digestive Surgery, Charles Nicolle University Hospital, Rouen, France
| | - Ephrem Salamé
- Department of Digestive, Endocrine, HPB Surgery and Liver Transplantation, Trousseau University Hospital, Tours, France
- INSERM U1082, Poitiers, France
| | - Olivier Scatton
- Department of HPB Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
- Centre de Recherche Sur l'Inflammation, Inserm, Université de Paris, INSERM UMR 1149 De l'Inflammation au Cancer Laboratory, Paris, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
- Centre de Recherche Sur l'Inflammation, Inserm, Université de Paris, INSERM UMR 1149 De l'Inflammation au Cancer Laboratory, Paris, France
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Abstract
Patients with hepatocellular carcinoma (HCC) have many treatment options. For patients with surgical indication, consideration of future liver remnant and the surgical complexity of the procedure is essential. A new 3-level complexity classification categorizing 11 liver resection procedures predicts surgical complexity and postoperative morbidity better than reported classifications. Preoperative portal vein embolization can mitigate the risk of hepatic insufficiency. For small HCCs, both liver resection and ablation are effective. New medical treatment options are promising and perioperative use of these drugs may further improve outcomes for patients undergoing liver resection and lead to changes in current treatment guidelines.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA; Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Heather A Lillemoe
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX 77030, USA.
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Hasegawa Y, Nitta H, Takahara T, Katagiri H, Kanno S, Umemura A, Akiyama Y, Iwaya T, Otsuka K, Sasaki A. Surgical outcomes of 118 complex laparoscopic liver resections: a single- center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:942-949. [PMID: 33058554 DOI: 10.1002/jhbp.848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 12/07/2022]
Abstract
BACKGROUND Indications for laparoscopic liver resection (LLR) are continuously expanding. The Japanese Society of Hepato-Biliary-Pancreatic Surgery defines highly difficult hepatectomy as a procedure involving one or more sections (except for left lateral sectionectomy) or anatomical segmentectomy. This study aimed to assess the outcomes of complex LLR procedures and compare their technical difficulties, about which only a little is known to date. METHODS We performed a retrospective review of the operative outcomes of 118 consecutive patients who underwent pure laparoscopic complex hepatectomy. The surgical outcomes, including operative times, blood loss amounts, and postoperative morbidity rates, were compared among complex LLR procedures. RESULTS The overall median operative time was 280 minutes, and the median intraoperative blood loss was 86 mL. Two patients required conversion to open laparotomy (1.7%). The postoperative major morbidity rate was 11.0% Posterosuperior segmentectomy, right hemihepatectomy, and anterior sectionectomy required the longest operative times. Anterior and posterior sectionectomy resulted in the highest blood loss, and right hemihepatectomy and anterior sectionectomy resulted in the most complications. CONCLUSIONS The surgical difficulties associated with complex LLR procedures vary. It is critical to recognize the specific risks and cautionary points to ensure patient safety and provide proper systemic training to surgeons.
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Affiliation(s)
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | | | | | - Shoji Kanno
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Akira Umemura
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Yuji Akiyama
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University, Yahaba, Japan
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Hołówko W, Triantafyllidis I, Neuberg M, Tabchouri N, Beaussier M, Bennamoun M, Sarran A, Lefevre M, Louvet C, Gayet B, Fuks D. Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes? Eur J Surg Oncol 2020; 46:1620-1627. [PMID: 32561203 DOI: 10.1016/j.ejso.2020.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Prognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM. METHODS All patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed. RESULTS A total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R1 resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022). CONCLUSION The higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence.
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Affiliation(s)
- Wacław Hołówko
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France; Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Ioannis Triantafyllidis
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France; Department of General Surgery, General Hospital of Veria, Greece
| | - Maud Neuberg
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - Nicolas Tabchouri
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - Marc Beaussier
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - Mostefa Bennamoun
- Department of Oncology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Anthony Sarran
- Department of Radiology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Marine Lefevre
- Department of Pathology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Christophe Louvet
- Department of Oncology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Brice Gayet
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - David Fuks
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France.
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