Greater complexity of liver surgery is not associated with an increased incidence of liver-related complications except for bile leak: an experience with 2,628 consecutive resections

Intention-to-Treat Analysis of Hepatic Resection for Liver Metastases from Uveal Melanoma: A Single-Center Experience

BACKGROUND

Uveal melanoma metastasizes to the liver in almost 50% of patients. The prognosis of liver metastases from uveal melanoma (LMUM) is dismal; however, results from retrospective monocentric series suggest that surgery may improve survival in selected patients. We report our results of surgical explorations and hepatic resections for LMUM.

METHODS

We retrospectively analyzed our prospectively collected institutional database of hepatic resections for LMUM between 2013 and 2023.

RESULTS

In total, 22 patients underwent surgical exploration (median age 61 years, 41% female patients): 15 (68%) underwent curative-intent surgery (surgery group) while 7 (32%) had their resection aborted owing to intraoperatively unresectable disease (staging alone group). Patients in the surgery group had a longer interval between diagnosis of the primary tumor and LMUM (> 36 months in 64%, versus 29% in the staging alone group, p = 0.18). Preoperative imaging and intraoperative staging were concordant in ten (45%) cases, while five (23%) had more lesions, six (27%) had miliary disease, and one (4.5%) had peritoneal carcinomatosis. Minor postoperative complications occurred in 3 (14%) patients. All patients in the staging alone group underwent subsequent systemic or locoregional treatment. Median overall survival was 27 (15-47) months after surgery and 15 (8-21) months after staging alone. Recurrence after surgery occurred in 7/15 patients, with a median disease-free survival of 28 (4-38) months.

CONCLUSIONS

More than 30% of patients with LMUM with preoperatively resectable disease are unresectable at explorative surgery. Acceptable recurrence rates and good survival outcomes are observed when radical surgery can be performed.

Machine learning based prediction model for bile leak following hepatectomy for liver cancer

OBJECTIVE

We sought to develop a machine learning (ML) preoperative model to predict bile leak following hepatectomy for primary and secondary liver cancer.

METHODS

An eXtreme Gradient Boosting (XGBoost) model was developed to predict post-hepatectomy bile leak using data from the ACS-NSQIP database. The model was externally validated using data from hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) multi-institutional databases.

RESULTS

Overall, 20,570 and 2253 patients were identified from the ACS-NSQIP and multi-institutional databases, respectively. The incidence rates of bile leak were 7.0 %, 6.3 % and 10.2 % in the ACS-NSQIP, HCC and ICC databases, respectively. The XGBoost model achieved areas under receiver operating characteristic curves (AUROC) of 0.748, 0.719 and 0.711 in the training, testing and external validation cohorts, respectively. The SHAP algorithm demonstrated that the factors most strongly predictive of postoperative bile leak were serum alkaline phosphatase, surgical approach and cancer diagnosis. An online tool was developed for ease-of-use and clinical applicability (https://altaf-pawlik-bileleak-calculator.streamlit.app/).

CONCLUSION

A novel ML model demonstrated strong discrimination power to preoperatively identify patients at high risk of developing bile leak post-hepatectomy. The online calculator may be used as a clinical tool to inform preoperative surgical planning, intraoperative decision-making, and postoperative recovery protocols for patients undergoing hepatectomy.

Liver surgery in the 2020s: ante-situm and in-situ resection are still indicated - A single-center study

BACKGROUND

Tumor infiltration of the hepatic outflow comprising all three hepatic veins and the inferior vena cava remains a surgical challenge. Liver resection under total vascular exclusion with or without extracorporeal bypass has been described as a therapeutic option for these tumors. Here, we present our experience with these complex surgical methods.

METHODS

We searched our database for patients treated with an in-situ or ante-situm liver resection (ISR and ASR, respectively) with extracorporeal bypass. We collected demographic and perioperative data.

RESULTS

From January 2010 to December 2021, we performed 2122 liver resections. Nine patients were treated with ASR and five were treated with ISR. Out of these 14 patients, six had colorectal liver metastases, six had cholangiocarcinoma, and two had non-colorectal liver metastases. The median operative time and bypass time in all patients were 536.5 and 150 min, respectively. Compared with ISR, ASR required a longer operative time (ASR 586 min and ISR 495 min) and a longer bypass time (ASR 155 min and ISR 122 min). Morbidity (Clavien-Dindo grade > 3A adverse events) occurred in 78.5% of patients. 90-day postoperative mortality was 7%. Median overall survival was 33 months. Seven patients experienced recurrence. In these patients, median disease-free survival was 9 months.

CONCLUSION

Resection of tumors infiltrating the hepatic outflow poses a high risk for patients. However, with rigorous selection and an experienced perioperative team, these patients can be treated surgically with reasonable oncological outcomes.

Combined High-Volume Common Complex Cancer Operations Safeguard Long-Term Survival in a Low-Volume Individual Cancer Operation Setting

BACKGROUND

We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes.

PATIENTS AND METHODS

A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease.

RESULTS

The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival.

CONCLUSIONS

MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.

Failure of enhanced recovery after surgery in liver surgery: a systematic review and meta analysis

Purpose

This study aimed to conduct a systematic review of the literature to identify and summarize the existing evidence regarding ERAS failure and related risk factors after hepatic surgery. The objective was to provide physicians with a better understanding of these factors so that they can take appropriate action to minimize ERAS failure and improve patient outcomes.

Method

A literature search of the PubMed MEDLINE, OVID, EMBASE, Cochrane Library, and Web of Science was performed. The search strategy involved terms related to ERAS, failure, and hepatectomy.

Result

A meta-analysis was conducted on four studies encompassing a total of 1,535 patients, resulting in the identification of 20 risk factors associated with ERAS failure after hepatic surgery. Four of these risk factors were selected for pooling, including major resection, ASA classification of ≥3, advanced age, and male gender. Major resection and ASA ≥ 3 were identified as statistically significant factors of ERAS failure.

Conclusion

The comprehensive literature review results indicated that the frequently identified risk factors for ERAS failure after hepatic surgery are linked to operative and anesthesia factors, including substantial resection and an American Society of Anesthesiologists score of 3 or higher. These insights will assist healthcare practitioners in taking prompt remedial measures. Nevertheless, there is a requirement for future high-quality randomized controlled trials with standardized evaluation frameworks for ERAS programs.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tumors located in the central column of the liver are associated with increased surgical difficulty and postoperative complications following open liver resection for colorectal metastases

BACKGROUND

To assess the impact of difficult location (based on preoperative computed tomography) of liver metastases from colorectal cancer (LMCRC) on surgical difficulty, and occurrence of severe postoperative complications (POCs).

METHODS

A retrospective single-centre study of 911 consecutive patients with LMCRC who underwent hepatectomy by the open approach between 1998 and 2011, before implementation of laparoscopic surgery to obviate approach selection bias. LMCRC with at least one of the following four features on preoperative imaging: tumor invading the hepatocaval confluence or retro-hepatic inferior vena cava, centrally located (Segments 4,5,8) and >10 cm in diameter, abutting the supra-hilar area, or involving the paracaval portion or caudate process of Segment 1; were considered as topographically difficult (top-diff). Independent predictors of surgical difficulty assessed by number of blood units transfused, duration of ischemia, and number of sessions of pedicle clamping during surgery and of severe POCs were identified by multivariate analysis before, and after propensity score matching.

RESULTS

Top-diff tumor location independently predicted surgical difficulty. Severe POCs were associated with the tumor location [top-diff vs. topographically non difficult (non top-diff)], preoperative portal vein embolization, and variables related to surgical difficulty.

CONCLUSION

LMCRC in difficult location independently predicts surgical difficulty and severe POCs.

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

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

Outcomes of simultaneous laparoscopic, hybrid, and open resection in colorectal cancer with synchronous liver metastases: a propensity score-matched study

We aimed to compare the short- and long-term outcomes of simultaneous laparoscopic, hybrid, and open resection for colorectal cancer and synchronous liver metastases. We retrospectively analyzed the data of 647 patients with simultaneous resection of colorectal cancer and liver metastases between January 2006 and December 2018 at three tertiary referral hospitals. Patient’s baseline characteristics, perioperative outcomes, pathological examination results, liver-specific recurrence rate and survivals were compared between the propensity score-matched groups. Forty-two and 81 patients were selected for the laparoscopic vs. hybrid groups, and 48 and 136 patients for laparoscopic vs. open groups, respectively. The laparoscopic group had fewer wound complications (2.1 vs. 13.2%; p = 0.028) than the open group, and a shorter postoperative hospital stay than the hybrid and open groups (8 vs. 11 days, p < 0.001 for both). The 5-year liver-specific recurrence rates were 38.7% and 46.0% in the laparoscopic and hybrid groups, respectively (p = 0.270), and 34.0% and 37.0% in the laparoscopic and open groups, respectively (p = 0.391). Simultaneous laparoscopic resection for colorectal cancer and liver metastases can be performed safely with significantly enhanced postoperative recovery and comparable long-term outcomes compared to hybrid and open resection.

The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.

Predictive ability of preoperative CT scan for the intraoperative difficulty and postoperative outcomes of laparoscopic liver resection

BACKGROUND

The surgical difficulty and postoperative outcomes of laparoscopic liver resection (LLR) are related to the size of the cut liver surface. This study assessed whether the estimated parenchymal transection surface area could predict intraoperative difficulty and postoperative outcomes.

METHODS

LLRs performed between 2008 and 2018, for whom a preoperative CT scan was available for 3D review, were included in the study. The area of scheduled parenchymal transection was measured on the preoperative CT scan and cut-off values that could predict intraoperative difficulty were analyzed.

RESULTS

152 patients who underwent left lateral sectionectomy (n = 27, median estimated area 30.1 cm2 [range 16.6-65.9]), left/right hepatectomy (n = 17 and n = 70, 76.8 cm2 [range 43.9-150.9] and 72.2 cm2 [range 39.4-124.9], respectively), right posterior sectionectomy (n = 7, 113.3 cm2 [range 102.1-136.3]), central hepatectomy (n = 11, 109.1 cm2 [range 66.1-186.1]) and extended left/right hepatectomy (n = 6 and n = 14, 115.3 cm2 [range 92.9-128.9] and 50.7 cm2 [range 13.3-74.9], respectively) were included. An estimated parenchymal transection surface area ≥ 100 cm2 was associated with significant increase in operative time (AUC 0.81, 95% CI [0.70, 0.93], p < 0.001) and estimated blood loss (AUC 0.92, 95% CI [0.86, 0.97], p < 0.001), as well as a higher conversion rate (22.2% vs. 4.0%, p < 0.001). Overall (p = 0.017) and major morbidity (p = 0.003), biliary leakage (p < 0.001) and pulmonary complications (p < 0.001) were significantly higher in patients with an estimated parenchymal transection surface area ≥ 100 cm2.

CONCLUSIONS

An estimated parenchymal transection surface area ≥ 100 cm2 is a relevant indicator of surgical difficulty and postoperative complications in LLR.

The Impact of Establishing a Dedicated Liver Surgery Program at a University-affiliated Hospital on Workforce, Workload, Surgical Outcomes, and Trainee Surgical Autonomy and Academic Output

Objective

To detail the implementation of a dedicated liver surgery program at a university-affiliated hospital and to analyze its impact on the community, workforce, workload, complexity of cases, the short-term outcomes, and residents and young faculties progression toward technical autonomy and academic production.

Background

Due to the increased burden of liver tumors worldwide, there is an increased need for liver centers to better serve the community and facilitate the education of trainees in this field.

Methods

The implementation of the program is described. The 3 domains of workload, research, and teaching were compared between 2-year periods before and after the implementation of the new program. The severity of disease, complexity of procedures, and subsequent morbidity and mortality were compared.

Results

Compared with the 2-year period before the implementation of the new program, the number of liver resections increased by 36% within 2 years. The number of highly complex resections, the number of liver resections performed by residents and young faculties, and the number of publications increased 5.5-, 40-, and 6-fold, respectively. This was achieved by operating on more severe patients and performing more complex procedures, at the cost of a significant increase in morbidity but not mortality. Nevertheless, operations during the second period did not emerge as an independent predictor of severe morbidity.

Conclusions

A new liver surgery program can fill the gap between the demand for and supply of liver surgeries, benefiting the community and the development of the next generation of liver surgeons.

Risk Factors for Complications Requiring Interventional Radiological Treatment After Hepatectomy

PURPOSE

To identify perioperative factors that are significantly associated with complications requiring interventional radiology (IR) treatment after hepatectomy.

METHODS

We retrospectively reviewed data from 11,243 patients in the USA who underwent hepatectomy from 2014 to 2016 using the National Surgical Quality Improvement Program database. Data on the following IR procedures were extracted: abscess drain placement, endovascular treatment for bleeding, and postoperative percutaneous biliary drain (PBD) placement up to 30 days postoperatively. Patients' clinical and intraoperative factors were examined. Population, univariate, and multivariable analyses were performed. P < 0.05 was considered significant.

RESULTS

A total of 704 patients (6%) required IR treatment postoperatively, and 10,539 patients (94%) did not. On multivariable analysis, biliary reconstruction was a significant predictor of postoperative abscess drain placement (hazard ratio (HR), 3.5; 95% confidence interval (CI) 1.8, 6.5; P < .001), endovascular treatment for bleeding (HR, 3.3; 95% CI 1.4, 7.8 P = .006), and postoperative PBD placement (HR, 2.9; 95% CI 1.9, 4.2; P < .001). Compared with hepatectomy without biliary reconstruction, hepatectomy with biliary reconstruction was associated with significantly higher rates of complications treated with IR procedures (26% vs. 4.9%) and death within 30 days (6.0% vs. 1.2%) (both, P < .001).

CONCLUSION

Biliary reconstruction is a strong predictor of the need for postoperative IR treatment after hepatectomy. One in four patients who underwent biliary reconstruction required IR treatment of a complication during the first 30 days after hepatectomy.

CBCT-based navigation system for open liver surgery: Accurate guidance toward mobile and deformable targets with a semi-rigid organ approximation and electromagnetic tracking of the liver

Purpose

The surgical navigation system that provides guidance throughout the surgery can facilitate safer and more radical liver resections, but such a system should also be able to handle organ motion. This work investigates the accuracy of intraoperative surgical guidance during open liver resection, with a semi‐rigid organ approximation and electromagnetic tracking of the target area.

Methods

The suggested navigation technique incorporates a preoperative 3D liver model based on diagnostic 4D MRI scan, intraoperative contrast‐enhanced CBCT imaging and electromagnetic (EM) tracking of the liver surface, as well as surgical instruments, by means of six degrees‐of‐freedom micro‐EM sensors.

Results

The system was evaluated during surgeries with 35 patients and resulted in an accurate and intuitive real‐time visualization of liver anatomy and tumor's location, confirmed by intraoperative checks on visible anatomical landmarks. Based on accuracy measurements verified by intraoperative CBCT, the system’s average accuracy was 4.0 ± 3.0 mm, while the total surgical delay due to navigation stayed below 20 min.

Conclusions

The electromagnetic navigation system for open liver surgery developed in this work allows for accurate localization of liver lesions and critical anatomical structures surrounding the resection area, even when the liver was manipulated. However, further clinically integrating the method requires shortening the guidance‐related surgical delay, which can be achieved by shifting to faster intraoperative imaging like ultrasound. Our approach is adaptable to navigation on other mobile and deformable organs, and therefore may benefit various clinical applications.

Variation in Drain Management Among Patients Undergoing Major Hepatectomy

BACKGROUND

Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection.

METHODS

The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3.

RESULTS

Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection (n = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients (n = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal (R² = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p = 0.009) compared with delayed drain removal (> POD 3).

CONCLUSIONS

Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy.

Preoperative nomogram to predict posthepatectomy liver failure

BACKGROUND AND OBJECTIVES

Posthepatectomy liver failure (PHLF) is associated with significant morbidity and mortality. However, it is often difficult to predict the risk of PHLF in an individual patient. We aimed to develop a preoperative nomogram to predict PHLF and allow better risk stratification before surgery.

METHODS

Data for patients undergoing a partial or major hepatectomy were extracted from the hepatectomy-specific NSQIP database for years 2014-2016. Data set from 2017 was used for validation. Patients with Grade B/C liver failure were compared with patients with no liver failure.

RESULTS

A total of 10 808 patients from 2014-2016 data set were included. Of these, 316 patients (2.9%) developed Grade B/C PHLF. In the multivariable model consisting of preoperative variables, the following were predictive of Grade B/C PHLF (all p < 0.05): male gender, biliary stent, neoadjuvant therapy, viral hepatitis B or C, concurrent resections, biliary reconstruction, low sodium, and low albumin (model c statistic-0.78). This model was used to construct a nomogram. In the 2017 validation cohort of 4367 patients the nomogram again demonstrated good c-statistic (0.78).

CONCLUSIONS

Our nomogram provides patient-specific probabilities for PHLF, and is easy to use. This is a valuable tool that can be utilized for preoperative patient counseling and selection.

Treating Porcine Abscesses with Histotripsy: A Pilot Study

Infected abscesses are walled-off collections of pus and bacteria. They are a common sequela of complications in the setting of surgery, trauma, systemic infections and other disease states. Current treatment is typically limited to antibiotics with long-term catheter drainage, or surgical washout when inaccessible to percutaneous drainage or unresponsive to initial care efforts. Antibiotic resistance is also a growing concern. Although bacteria can develop drug resistance, they remain susceptible to thermal and mechanical damage. In particular, short pulses of focused ultrasound (i.e., histotripsy) generate mechanical damage through localized cavitation, representing a potential new paradigm for treating abscesses non-invasively, without the need for long-term catheterization and antibiotics. In this pilot study, boiling and cavitation histotripsy treatments were applied to subcutaneous and intramuscular abscesses developed in a novel porcine model. Ultrasound imaging was used to evaluate abscess maturity for treatment monitoring and assessment of post-treatment outcomes. Disinfection was quantified by counting bacteria colonies from samples aspirated before and after treatment. Histopathological evaluation of the abscesses was performed to identify changes resulting from histotripsy treatment and potential collateral damage. Cavitation histotripsy was more successful in reducing the bacterial load while having a smaller treatment volume compared with boiling histotripsy. The results of this pilot study suggest focused ultrasound may lead to a technology for in situ treatment of acoustically accessible abscesses.

Clinical Implementation of In-House Developed MR-Based Patient-Specific 3D Models of Liver Anatomy

Knowledge of patient-specific liver anatomy is key to patient safety during major hepatobiliary surgery. Three-dimensional (3D) models of patient-specific liver anatomy based on diagnostic MRI images can provide essential vascular and biliary anatomical insight during surgery. However, a method for generating these is not yet publicly available. This paper describes how these 3D models of the liver can be generated using open source software, and then subsequently integrated into a sterile surgical environment. The most common image quality aspects that degrade the quality of the 3D models as well possible ways of eliminating these are also discussed. Per patient, a single diagnostic multiphase MRI scan with hepatospecific contrast agent was used for automated segmentation of liver contour, arterial, portal, and venous anatomy, and the biliary tree. Subsequently, lesions were delineated manually. The resulting interactive 3D model could be accessed during surgery on a sterile covered tablet. Up to now, such models have been used in 335 surgical procedures. Their use simplified the surgical treatment of patients with a high number of liver metastases and contributed to the localization of vanished lesions in cases of a radiological complete response to neoadjuvant treatment. They facilitated perioperative verification of the relationship of tumors and the surrounding vascular and biliary anatomy, and eased decision-making before and during surgery.

National survey of Korean hepatobiliary-pancreatic surgeons on attitudes about the enhanced recovery after surgery protocol

Backgrounds/Aims

The purpose of this study was to investigate attitudes regarding the Enhanced Recovery After Surgery (ERAS) protocol of hepato-biliary-pancreatic (HBP) surgeons in Korea and the extent to which they use the protocol for perioperative management.

Methods

An online survey was conducted among members of the Korean Association of Hepato-Biliary-Pancreatic Surgery (KAHBPS) for eight weeks beginning on August 2019. The questionnaire, which was written in Korean, was based on the latest ERAS guidelines. Total responses were collected from 127 surgeons.

Results

Of the 127 total respondents, the largest proportion (44.9%) were working in Seoul. In terms of established in-hospital clinical pathways (CP), 19.7% of the participating surgeons had and followed a CP in pancreaticoduodenectomy (PD) and 21.3% in hepatectomy. Regarding the ERAS protocol for each surgery, four items (18.2%) regarding PD and seven items (35.0%) related to hepatectomy were followed by more than 50% of respondents.

Conclusions

ERAS guidelines are one of the consensuses for better recovery in perioperative management of patients undergoing major surgeries and encompass the overall process of patient recovery including patient education, pain control, physiologic balance, and perioperative nutrition. A novel project is needed to successfully implement an evidence-based enhanced recovery strategy.

Stratification of Major Hepatectomies According to Their Outcome: Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis

OBJECTIVE

To stratify major hepatectomies (MajHs) according to their outcomes.

SUMMARY OF BACKGROUND DATA

MajHs are associated with non-negligible operative risks, but they include a wide range of procedures. Detailed depiction of the outcomes of different MajHs is the basis for a new classification of liver resections.

METHODS

We retrospectively considered patients that underwent hepatectomy in 17 high-volume centers. Patients with an associated digestive/biliary resection were excluded. We analyzed open MajHs in non-cirrhotic patients. MajHs were classified according to the Brisbane nomenclature. Right hepatectomies (RHs) were reference standards. Outcomes were adjusted for potential confounders, including indication, liver function, preoperative portal vein embolization, and enrolling center.

RESULTS

We analyzed a series of 2212 patients. In comparison with RH, left hepatectomy had lower mortality [0.6% vs 2.2%, odds ratio (OR) = 0.25], severe morbidity (11.7% vs 14.4%, OR = 0.62), and liver failure rates (2.1% vs 11.6%, OR = 0.16). Left hepatectomy+Sg1 and mesohepatectomy+/-Sg1 had outcomes similar to RH, except for higher bile leak rate (31.3% and 13.5% vs 6.7%, OR = 4.36 and OR = 2.29). RH + Sg1 had slightly worse outcomes than RH. Right and left trisectionectomies had higher mortality (5.0% and 7.3% vs 2.2%, OR = 2.07 and OR = 2.71) and liver failure rates than RH (19.0% and 22.0% vs 11.6%, OR = 2.03 and OR = 2.21). Left trisectionectomy had even higher severe morbidity (25.6% vs 14.4%, OR = 2.07) and bile leak rates (14.6% vs 6.7%, OR = 2.31).

CONCLUSIONS

The term "major hepatectomy" includes resections having heterogeneous outcome. Different MajHs can be stratified according to their mortality, severe morbidity, liver failure, and bile leak rates.

Multidisciplinary treatment for colorectal liver metastases in elderly patients

BACKGROUND

Limited data describe the therapeutic practice and outcomes of colorectal liver metastases (CRLMs) in elderly patients. We aimed to evaluate the impact of age on multidisciplinary treatment for CRLMs.

METHODS

We reviewed treatment and outcomes for patients in different age groups who underwent initial hepatectomy for CRLMs from 2004 through 2012.

RESULTS

We studied 462 patients who were divided into three groups by age: ≤ 64 years (n = 265), 65-74 years (n = 151), and ≥ 75 years (n = 46). The rate of major hepatectomy and incidence of postoperative complications did not differ between groups. Adjuvant chemotherapy was used less in the ≥ 75-year group (19.6%) than that in the ≤ 64 (54.3%) or 65-74 age group (43.5%). Repeat hepatectomy for liver recurrence was performed less in the ≥ 75-year group (35%) than in the ≤ 64 (57%) or 65-74 (66%) age group. The 5-year disease-specific survival (DSS) rate of 44.2% in the ≥ 75-year group was lower than in the ≤ 64 (59.0%) or 65-74 (64.7%) age group. Multivariate analysis revealed age ≥ 75 years was an independent predictor of poor DSS.

CONCLUSIONS

Liver resection for CRLMs can be performed safely in elderly patients. However, repeat resection for recurrence are performed less frequently in the elderly, which may lead to the poorer disease-specific prognosis.

Comprehensive Complication Index Validates Improved Outcomes Over Time Despite Increased Complexity in 3707 Consecutive Hepatectomies

OBJECTIVE

The aim of this study was to evaluate trends over time in perioperative outcomes for patients undergoing hepatectomy.

BACKGROUND

As perioperative care and surgical technique for hepatectomy have improved, the indications for and complexity of liver resections have evolved. However, the resulting effect on the short-term outcomes over time has not been well described.

METHODS

Consecutive patients undergoing hepatectomy during 1998 to 2015 at 1 institution were analyzed. Perioperative outcomes, including the comprehensive complication index (CCI), were compared between patients who underwent hepatectomy in the eras 1998 to 2003, 2004 to 2009, and 2010 to 2015.

RESULTS

The study included 3707 hepatic resections. The number of hepatectomies increased in each era (794 in 1998 to 2003, 1402 in 2004 to 2009, and 1511 in 2010 to 2015). Technical complexity increased over time as evidenced by increases in the rates of major hepatectomy (20%, 23%, 30%, P < 0.0001), 2-stage hepatectomy (0%, 3%, 4%, P < 0.001), need for portal vein embolization (5%, 9%, 9%, P = 0.001), preoperative chemotherapy for colorectal liver metastases (70%, 82%, 89%, P < 0.001) and median operative time (180, 175, 225 minutes, P < 0.001). Significant decreases over time were observed in median blood loss (300, 250, 200 mL, P < 0.001), transfusion rate (19%, 15%, 5%, P < 0.001), median length of hospitalization (7, 7, 6 days, P < 0.001), rates of CCI ≥26.2 (20%, 22%, 16%, P < 0.001) and 90-day mortality (3.1%, 2.6%, 1.3%, P < 0.01). On multivariable analysis, hepatectomy in the most recent era 2010 to 2015 was associated with a lower incidence of CCI ≥26.2 (odds ratio 0.7, 95% confidence interval 0.6-0.8, P < 0.0001).

CONCLUSION

Despite increases in complexity over an 18-year period, continued improvements in surgical technique and perioperative outcomes yielded a resultant decrease in CCI in the most current era.

Haemostatic Efficacy of Topical Agents During Liver Resection: A Network Meta-Analysis of Randomised Trials

BACKGROUND

Hepatic resection carries a high risk of parenchymal bleeding both intra- and post-operatively. Topical haemostatic agents are frequently used to control bleeding during hepatectomy, with multiple products currently available. However, it remains unknown which of these is most effective for achieving haemostasis and improving peri-operative outcomes.

METHODS

A systematic review and random-effects Bayesian network meta-analysis of randomised trials investigating topical haemostatic agents in hepatic resection was performed. Interventions were analysed by grouping into similar products; fibrin patch, fibrin glue, collagen products, and control. Primary outcomes were the rate of haemostasis at 4 and 10 min.

RESULTS

Twenty randomized controlled trials were included in the network meta-analysis, including a total of 3267 patients and 7 different interventions. Fibrin glue and fibrin patch were the most effective interventions for achieving haemostasis at both 4 and 10 min. There were no significant differences between haemostatic agents with respect to blood loss, transfusion requirements, bile leak, post-operative complications, reoperation, or mortality.

CONCLUSIONS

Amongst the haemostatic agents currently available, fibrin patch and fibrin glue are the most effective methods for reducing time to haemostasis during liver resection, but have no effect on other peri-operative outcomes. Topical haemostatic agents should not be used routinely, but may be a useful adjunct to achieve haemostasis when needed.

ERAS in minimally invasive hepatectomy

Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.

The impact of bile leakage on long-term prognosis in primary liver cancers after hepatectomy: A propensity-score-matched study

BACKGROUND

The impact of bile leakage (BL) on the long-term prognosis in patients with primary liver cancers after hepatectomy remains unclear.

METHODS

One thousand nine hundred and seventy-one consecutive patients with primary liver cancers who underwent curative hepatectomy were enrolled. 75 patients encountered BL, including 34 long-time BL (LTBL) and 41 short-time BL (STBL) according to 4-weeks demarcation. Variables associated with BL were identified using multiple logistic regression analysis. 75 patients without BL were enrolled into the Non-BL group using a one-to-one propensity score matched analysis before assessing the impact of BL on the long-term prognosis. The levels of interleukin-6 (IL-6) and C-reactive protein (CRP) in the serum and drain fluid were detected and compared.

RESULTS

The tumor size, type of liver cancer, operation time, blood loss and blood transfusion were independent risk factors for BL. The long-term survival showed no difference between the patients with and without BL (p > 0.05), while the LTBL was a significant predictor of poor long-term prognosis (p < 0.001). Compared with the patients without BL, the patients with BL had a higher level of IL-6 from postoperative day (POD) 1 to POD 60, and a higher level of CRP from POD 7 to POD 60. By POD 60, the levels of IL-6 and CRP hadn't restored to the normal level in the LTBL group.

CONCLUSIONS

The LTBL has a negative impact on the long-term prognosis of patients with primary liver cancers after hepatectomy, in which the inflammatory responses may play a pivotal role.

Type of response to conversion chemotherapy strongly impacts survival after hepatectomy for initially unresectable colorectal liver metastases

BACKGROUND

Hepatectomy for initially unresectable colorectal liver metastases (IU-CLM) is considered at high risk due to the extensive preoperative chemotherapy (CHT) and complex surgical procedures required, and its results are questioned due to frequent and early post-operative recurrence. We aim to compare patients with initially resectable CLM (IR-CLM) and IU-CLM and identify prognostic factors among IU-CLM patients.

METHODS

A total of 81 patients with IU-CLM, undergoing hepatectomy following conversion CHT, were compared to 526 IR-CLM patients. Predictors of overall (OS) and disease-free survival (DFS) were identified for IU-CLM patients.

RESULTS

Patients resected for IU-CLM, compared to IR-CLM, had more and larger CLM and more frequently underwent prolonged CHT and major/extended hepatectomy (P < 0.001 for all comparisons). Such characteristics paralleled higher rates of overall and major (Clavien-Dindo ≥3) complications, longer median post-operative length of stay and lower 5-year survival rates (P < 0.001 for all comparisons) among IU-CLM patients compared to IR-CLM, with similar mortality (1.2% and nil for IU-CLM and IR-CLM, respectively). Among IU-CLM patients, 62 with partial response to CHT (versus tumour stability according to the Response Evaluation Criteria in Solid Tumors criteria) had better DFS (hazard ratio 2.76, P = 0.001) and OS (hazard ratio 2.83, P =  0.002), and their 5-year survival rates (DFS 19.8%, OS 46.7%) approached those of IR-CLM patients (DFS 31%, OS 59%, P > 0.05 for both comparisons).

CONCLUSION

Resection of IU-CLM has acceptable perioperative results. Tumour responsiveness to conversion CHT improves IU-CLM patient selection for hepatectomy.

Minor Hepatectomies: Focusing a Blurred Picture: Analysis of the Outcome of 4471 Open Resections in Patients Without Cirrhosis

OBJECTIVE

To elucidate minor hepatectomy (MiH) outcomes.

SUMMARY BACKGROUND DATA

Liver surgery has moved toward a parenchyma-sparing approach, favoring MiHs over major resections. MiHs encompass a wide range of procedures.

METHODS

We retrospectively evaluated consecutive patients who underwent open liver resections in 17 high-volume centers.

EXCLUSION CRITERIA

cirrhosis and associated digestive/biliary resections. Resections were classified as (Brisbane nomenclature): limited resections (LR); (mono)segmentectomies/bisegmentectomies (Segm/Bisegm); right anterior and right posterior sectionectomies (RightAnteriorSect/RightPosteriorSect). Additionally, we defined: complex LRs (ComplexLR = LRs with exposed vessels); postero-superior segmentectomies (PosteroSuperiorSegm = segment (Sg)7, Sg8, and Sg7+Sg8 segmentectomies); and complex core hepatectomies (ComplexCoreHeps = Sg1 segmentectomies and combined resections of Sg4s+Sg8+Sg1). Left lateral sectionectomies (LLSs, n = 442) and right hepatectomies (RHs, n = 1042) were reference standards. Outcomes were adjusted for potential confounders.

RESULTS

Four thousand four hundred seventy-one MiHs were analyzed. Compared with RHs, MiHs had lower 90-day mortality (0.5%/2.2%), severe morbidity (8.6%/14.4%), and liver failure rates (2.4%/11.6%, P < 0.001), but similar bile leak rates. LR and LLS had similar outcomes. ComplexLR and Segm/Bisegm of anterolateral segments had higher bile leak rates than LLS rates (OR = 2.35 and OR = 3.24), but similar severe morbidity rates. ComplexCoreHeps had higher bile leak rates than RH rates (OR = 1.94); the severe morbidity rate approached that of RH. PosteroSuperiorSegm, RightAnteriorSect, and RightPosteriorSect had severe morbidity and bile leak rates similar to RH rates. MiHs had low liver failure rates, except RightAnteriorSect (vs LLS OR = 4.02).

CONCLUSIONS

MiHs had heterogeneous outcomes. Mortality was low, but MiHs could be stratified according to severe morbidity, bile leak, and liver failure rates. Some MiHs had postoperative outcomes similar to RH.

Prevention of biliary fistula after partial hepatectomy by transcystic biliary drainage: randomized clinical trial

Background

Biliary fistula is one of the most common complications after hepatectomy. This study evaluated the effect of transcystic biliary drainage during hepatectomy on the occurrence of postoperative biliary fistula.

Methods

This multicentre RCT was carried out from 2009 to 2016 in nine centres. Patients were randomized to transcystic biliary drainage or no transcystic drainage (control). Patients underwent hepatectomy (more than 2 segments) of non-cirrhotic livers. The primary endpoint was the occurrence of biliary fistula after surgery. Secondary endpoints were morbidity, postoperative mortality, duration of hospital stay, reoperation, readmission to hospital, and complications caused by catheters. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 310 patients were randomized. In intention-to-treat analysis, there were 158 patients in the transcystic group and 149 in the control group. Seven patients were removed from the per-protocol analysis owing to protocol deviations. The biliary fistula rate was 5·9 per cent in intention-to-treat and 6·0 per cent in per-protocol analyses. The rate was similar in the transcystic and control groups (5·7 versus 6·0 per cent; P = 1·000). There were no differences in terms of morbidity (49·4 versus 46·3 per cent; P = 0·731), mortality (2·5 versus 4·7 per cent; P = 0·367) and reoperations (4·4 versus 10·1 per cent; P = 1·000). Median duration of hospital stay was longer in the transcystic group (11 versus 10 days; P = 0·042). The biliary fistula risk was associated with the width and length of the hepatic cut surface.

Conclusion

This randomized trial did not demonstrate superiority of transcystic drainage during hepatectomy in preventing biliary fistula. The use of transcystic drainage during hepatectomy to prevent postoperative biliary fistula is not recommended. Registration number: NCT01469442 ( http://www.clinicaltrials.gov).

Major hepatectomy for intrahepatic cholangiocarcinoma or colorectal liver metastases. Are we talking about the same story?

INTRODUCTION

Major hepatectomy (MH) is often needed in the curative management of intrahepatic cholangiocarcinoma (IHCC) and colorectal liver metastases (CRLM). While similar outcomes could be expected after MH for IHCC and CRLM, outcomes seem worse after MH for IHCC. A better understanding of such differences might help improving perioperative outcomes but comprehensive analysis are lacking.

METHODS

All patients undergoing curative intent MH for IHCC or CRLM from 2003 to 2009 were included from two dedicated multi-institutional datasets. Preoperative management and short-term outcomes after MH were first compared. Independent predictors of postoperative mortality and morbidity were identified.

RESULTS

Among 827 patients, 333 and 494 patients underwent MH for IHCC and CRLM, respectively. Preoperative portal vein embolization was more frequently performed in the CRLM group (p < 0.001). MH in the IHCC group required more extended resection (p < 0.001). Postoperative mortality and severe morbidity rates were significantly higher in the IHCC group (7.2% vs. 1.2% and 29.7% vs. 11.1%, p < 0.001, respectively). Main causes for mortality were postoperative liver failure and deep surgical site infection. MH for IHCC was an independent risk factor for mortality (p < 0.001) and severe morbidity (p < 0.001). After propensity score matching (212 patients in each group), the aforementioned differences regarding outcomes remained statistically significant.

CONCLUSION

This study suggests that IHCC patients are inherently more at risk after MH as compared to CRLM patients. Considering that postoperative liver failure was the most frequent cause of death, preoperative planning might have been inadequate in the setting of IHCC while more complex/extended resections should be expected.

Efficacy of the bile leak test using contrast-enhanced intraoperative ultrasonic cholangiography in liver resection: a study protocol for a non-randomised, prospective, off-label, single-arm trial

INTRODUCTION

Bile leak is still a major complication after liver resection to be improved. To intraoperatively detect this adverse complication, leak test is commonly performed after hepatic resection. However, by the conventional leak test, it is often difficult to know whether the test reagent reaches to intrahepatic bile duct near cut surface of liver with adequate volume and pressure to identify the existence of bile leak. Thus, in order to perform leak test more accurately, this study aims to evaluate the efficacy and safety of the leak test using contrast-enhanced intraoperative ultrasonic cholangiography (CE-IOUSC), which was reported by our group as a procedure for detection of bile duct.

METHODS AND ANALYSIS

The current study is a non-randomised, prospective, off-label, single-arm clinical trial for patients who undergo liver resection. A total of 100 patients will be enrolled. After completion of liver resection, the leak test is performed with CE-IOUSC using Sonazoid as a contrast agent to visualise dye injection into the intrahepatic bile duct. The primary endpoint is the success of the leak test, defined as clear visualisation of intrahepatic bile duct around cut surface by ultrasonography that indicates enough volume of dye injection. Secondary endpoints are postoperative bile leak and all adverse events related to CE-IOUSC. The findings obtained through this study will establish this procedure to assist surgeons for adequately performing the leak test, precisely detecting intraoperative biliary leak strictly and reducing postoperative bile leak.

ETHICS AND DISSEMINATION

The protocol is approved by Institutional Review Boards of Kobe University Hospital (No.290069). Our findings will be widely disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

UMIN000031236 and jRCTs051180027.

Radiofrequency-assisted liver resection: Technique and results

BACKGROUND

Radiofrequency (RF)-assisted liver resection allows non-anatomical liver resection with reduced blood loss and offers the opportunity for a combination of resection and ablation. However, there are still concerns with regard to postoperative complications related to this technique. In the present study, we discuss the technical aspects of RF-assisted liver resections and analyse the rate of perioperative complications, focusing on post-hepatectomy liver failure (PLF), bile leak and abscess, and mortality.

METHODS

Between 2001 and 2015, 857 consecutive open and laparoscopic elective RF-assisted liver resections for benign and malignant liver tumours were reviewed retrospectively to assess perioperative outcomes.

RESULTS

Median intraoperative blood loss was 130 mL, with 9.8% of patients requiring blood transfusion. Intra-abdominal collections requiring percutaneous drainage developed in 8.7% of all patients, while bile leak at resection margin developed in 2.8% of the cases. Major liver resection was performed in 34% of patients and the incidence of PLF was 1.5% with one directly related mortality (0.1%).

CONCLUSION

RF-assisted liver resection has evolved into a feasible and safe technique of liver resection with an acceptable incidence of perioperative morbidity and a low incidence of PLF and related mortality.

Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

External Validation and Optimization of the French Association of Hepatopancreatobiliary Surgery and Transplantation's Score to Predict Severe Postoperative Biliary Leakage after Open or Laparoscopic Liver Resection

BACKGROUND

Biliary leakage is a major contributor to morbidity after hepatectomy. A score to predict severe posthepatectomy biliary leakage (PHBL) was recently developed by the French Association of Hepatopancreatobiliary Surgery and Transplantation (ACHBT). The aim of the study was to validate and optimize the score on an external cohort.

STUDY DESIGN

The ACHBT score uses 5 factors (blood loss, remnant ischemia, anatomic resection of segment 8, transection along right aspect of the left intersectional plane and associating liver partition and portal vein ligation for staged hepatectomy) to predict severe PHBL. The score was tested on an external cohort of patients undergoing hepatectomy without hepaticojejunostomy between 1994 and 2016 at a single center. Association between the score, pre- and intraoperative variables, and severe PHBL was assessed in an attempt to improve the score.

RESULTS

Among 778 procedures performed (including 679 [87.3%] laparoscopic and 260 [34.3%] major hepatectomies), 31 (4.0%) were complicated with severe PHBL. The ACHBT score showed good discrimination (AUROC [area under the receiver operating characteristic curve] 0.747, 95% CI 0.652 to 0.841), calibration and accuracy (diagnostic odds ratio for a score ≥1: 6.217 [95% CI 2.642 to 14.627], for a score ≥2: 6.059 [95% CI 2.858 to 12.846],and for a score ≥3: 9.589 [95% CI 2.868 to 32.066]). On multivariable analysis, the ACHBT score was the only predictor of severe PHBL. A model combining the ACHBT score and conversion to open surgery was significantly more discriminating than the ACHBT score alone (AUROC 0.790 [95% CI 0.711 to 0.870], Delong's test p = 0.002).

CONCLUSIONS

The ACHBT score represents an externally validated tool to predict severe PHBL. Inclusion of conversion to open surgery as an additional factor to the score allowed it to improve its performance to predict severe PHBL after laparoscopic hepatectomy.

Risk score to predict biliary leakage after elective liver resection

Background

Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL.

Methods

In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated.

Results

A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P &lt; 0·001; 15 versus 3·1 per cent in the validation cohort, P &lt; 0·001).

Conclusion

The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.

Impact of intraoperative blood loss on the short-term outcomes of laparoscopic liver resection

BACKGROUND

Intraoperative blood loss is one of the predictors of outcome of open hepatectomy. But the impact of blood loss in laparoscopic hepatectomy (LH) on postoperative outcomes is poorly understood. The aim of this study is to analyze the association between blood loss and postoperative outcomes after LH.

METHODS

A retrospective analysis of prospectively maintained database of patients undergoing LH from 1995 to 2016 was performed. The data were divided into two groups based on the extent of blood loss: Group 1 (<250 ml) and Group 2 (≥250 ml). The basic characteristics and postoperative outcomes were compared between these groups.

RESULTS

A total of 504 patients underwent 611 LH (Group 1: 414 and Group 2: 197). The mean age was 62.4 years. The most common indication was liver secondaries (71.7%). Major hepatectomy was performed in 37% cases. Mean operative time was 225 ± 110.5 min and estimated blood loss was 239 ± 399.4 ml (range 0-4500 ml). Group 2 had significantly higher number of patients with malignant lesions undergoing major hepatectomy, anatomical resection with higher requirement for blood transfusion, and longer hospital stay. The incidence of conversion rate, overall complications including liver failure, renal failure, and postoperative mortality, was significantly higher in Group 2. However, the bile leak rate was similar in the two groups.

CONCLUSION

Intraoperative blood loss is most frequent in patients undergoing major LH. Blood loss ≥250 ml during LH may adversely affect the postoperative outcomes.

Diaphragmatic hernia following liver resection: case series and review of the literature

BACKGROUNDS/AIMS

Postoperative diaphragmatic hernia, following liver resection, is a rare complication.

METHODS

Data of patients who underwent major hepatectomy for liver tumors, between 2011 and 2015 were retrospectively reviewed. The literature was searched for studies reporting the occurrence of diaphragmatic hernia following liver resection.

RESULTS

Diaphragmatic hernia developed in 2.3% of patients (3/131) with a median delay of 14 months (4-31 months). One patient underwent emergency laparotomy for bowel obstruction and two patients underwent elective diaphragmatic hernia repair. At last follow-up, no recurrences were observed. Fourteen studies including 28 patients were identified in the literature search (donor hepatectomy, n=11: hepatectomy for liver tumors, n=17). Diaphragmatic hernia was repaired emergently in 42.9% of cases and digestive resection was necessary in 28.5% of the cases. One patient died 3 months after hepatectomy, secondary to sepsis, from a segment of small bowel that perforated into the diaphragmatic hernia.

CONCLUSIONS

Although rare, diaphragmatic hernia should be considered as an important complication, especially in living donor liver transplant patients. Diaphragmatic hernia should be repaired surgically, even for asymptomatic patients.

Hepatic resection: a safe and effective surgery

INTRODUCTION

We analyze major liver resections performed in 10 years, with the objective of evaluating perioperative results. As secondary objectives, factors related to major complications and comparative analyses of 25-year periods are evaluated.

METHODS

Retrospective analysis of patients undergoing major hepatic resection (3 or more segments) from January 2005 to December 2014, from pre, intra and postoperative data. The Clavien classification is used for postoperative morbidity.

RESULTS

A total of 416 major hepatectomies were performed. Transfusions were performed in 38 patients (9.1%). A Pringle maneuver was used in 47.7% of the cases. Half of the patients had no complications, and only 96 patients (23%) had a major complication. Bile leakage was the most frequent complication (n=72, 17.3% of patients), especially due to malignant disease and biliary reconstruction, high risk ASA (III-IV) and prolonged surgical time. Thirteen patients met criteria for liver failure, of which 7died (5 associated a bacterial infection). The mean hospital stay was 12.5 days, with an 11,8% readmission rate. When comparing 25-year periods, at present more complex patients are operated on, with a lower incidence of transfusions and complications (ns).

CONCLUSIONS

Liver surgery has increased significantly in recent years. Surgical management of the liver now allows safe and effective surgery, with a very low complication rate. The limit of resectability depends on the residual hepatic volume.

Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge

BACKGROUND

Bile leakage is a common complication after hepatic resection [1-4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5-9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011).

METHODS

Considering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection.

RESULTS

We performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8-42 months).

CONCLUSIONS

The described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.

Abandoning Prophylactic Abdominal Drainage after Hepatic Surgery: 10 Years of No-Drain Policy in an Enhanced Recovery after Surgery Environment

BACKGROUND

Routine prophylactic abdominal drainage after hepatic surgery is still being debated, as it may be unnecessary, possibly harmful, and uncomfortable for patients. This study evaluated the safety of a no-drain policy after liver resection within an Enhanced Recovery after Surgery (ERAS) programme.

METHODS

All hepatectomies performed without prophylactic drainage during 2005-2014 were included. Primary end points were resection-surface-related (RSR) morbidity, defined as the presence of postoperative biloma, hemorrhage or abscess, and reinterventions. Secondary end points were length of stay, total postoperative morbidity, the composite end point of liver surgery-specific complications, readmissions, and 90-day mortality. Uni- and multivariate analyses were performed to identify independent risk factors for RSR morbidity. A systematic search was performed to compare the results of this study to literature.

RESULTS

A total of 538 resections were included in the study. The RSR complication and reintervention rate was 15 and 12%, respectively. Major liver resection (≥3 segments) was an independent risk factor for the development of RSR morbidity (OR 3.01, 95% CI 1.61-5.62; p = 0.001) and need for RSR reintervention (OR 3.02, 95% CI 1.59-5.73; p = 0.001).

CONCLUSION

RSR morbidity, mortality, and reintervention rates after liver surgery without prophylactic drainage in patients, treated within an ERAS programme, were comparable to previously published data. A no-drain policy after partial hepatectomy seems safe and feasible.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Association of Remnant Liver Ischemia With Early Recurrence and Poor Survival After Liver Resection in Patients With Hepatocellular Carcinoma

Importance

The remnant liver after hepatectomy may have inadequate blood supply, especially following nonanatomical resection or vascular damage.

Objective

To evaluate whether remnant liver ischemia (RLI) may have an adverse effect on long-term survival and morbidity after liver resection in patients with hepatocellular carcinoma.

Design, Setting, and Participants

This study was a retrospective analysis at Seoul National University Bundang Hospital. Remnant liver ischemia was graded on postoperative computed tomographic scans in 328 patients who underwent hepatectomy for hepatocellular carcinoma between January 1, 2004, and December 31, 2013.

Main Outcomes and Measures

Remnant liver ischemia was defined as reduced or absent contrast enhancement during the venous phase. Remnant liver ischemia was classified as minimal (none or marginal) or severe (partial, segmental, or necrotic).

Results

Among 328 patients (252 male and 76 female; age range, 26-83 years [mean age, 58.2 years]), radiologic signs of severe RLI were found in 98 patients (29.9%), of whom 63, 16, and 19 had partial, segmental, or necrotic RLI, respectively. These patients experienced more complications and longer hospital stay than patients with minimal RLI. Preoperative history of transarterial embolization (odds ratio [OR], 1.77; 95% CI, 1.02-3.03; P = .04), use of the Pringle maneuver (OR, 1.96; 95% CI, 1.08-3.58; P = .03), and longer operative time (OR, 1.003; 95% CI, 1.002-1.005; P < .001) were independent risk factors for severe RLI. Early recurrence rates within 6 (60.2% vs 9.6%) or 12 (79.6% vs 18.7%) months after hepatectomy were higher in patients with severe RLI than in patients without RLI (P < .001). Severe remnant liver ischemia was an independent risk factor for overall survival (OR, 6.98; 95% CI, 4.27-11.43; P < .001) and disease-free survival (OR, 5.15; 95% CI, 3.62-7.35; P < .001).

Conclusions and Relevance

Preventive management and technical refinements in hepatectomy are important to decrease the risk of RLI and to improve survival of patients with hepatocellular carcinoma.

Albumin-Bilirubin Score: Predicting Short-Term Outcomes Including Bile Leak and Post-hepatectomy Liver Failure Following Hepatic Resection

INTRODUCTION

Post-operative bile leak (BL) and post hepatectomy liver failure (PHLF) are the major potential sources of morbidity among patients undergoing liver resection. We sought to define the incidence of BL and PHLF among a large cohort of patients, as well as examine the prognostic impact of model for end-stage liver disease (MELD) and albumin-bilirubin (ALBI) scores to predict these short-term outcomes.

MATERIALS AND METHODS

Patients who underwent a hepatectomy between January 1, 2014 and December 31, 2014 were identified using the National Surgical Quality Improvement Program (NSQIP) liver-targeted database. Risk factors for BL and PHLF were identified using multivariable logistic regression.

RESULTS

Among the 3064 patients identified, median age was 60 years (IQR 50-68). Most patients underwent surgery (78.9 %) for malignant lesions. Post-operatively, 250 (8.5 %) patients experienced a BL while PHLF occurred in 149 cases (4.9 %). Both MELD (MELD <10 4.9 %; MELD ≥10, 10 %; P = 0.001) and ALBI (grade 1, 4.0 %; grade 2, 7.2 %; grade 3, 10.0 %; P = 0.001) were associated with PHLF occurrence, while only ALBI predicted PHLF severity (P = 0.008). Moreover, ALBI was associated with BL (grade 1, 7.1 %; grade 2, 11.5 %; grade 3, 14.0 %; P < 0.001), whereas MELD was not (MELD <10, 8.4 %; MELD ≥10, 11.2 %; P = 0.13). On multivariable analysis, ALBI grade 2/3 was associated with PHLF (OR 1.57, 95 % CI 1.08-2.27; P = 0.02), PHLF severity (OR 3.06, 95 % CI 1.50-6.23; P = 0.003), and the development of a BL (OR 1.35, 95 % CI 1.02-1.80; P = 0.04).

CONCLUSION

The ALBI score was associated with short-term post-operative outcomes following hepatic resection and represents a useful pre-operative risk-assessment tool to identify patients at risk for adverse post-operative outcomes.

Hepatic resection using ultrasonic surgical aspirator

Background

Hepatic resections conducted for malignant tumors can be difficult because of the need to create cancer-free margins.

Objectives

To examine the outcome of hepatic resections after the introduction of a Cavitron Ultrasonic Surgical Aspirator (CUSA).

Methods

A retrospective study of patients who underwent hepatic resection by a single surgeon between April 1999 to March 2013.

Results

We included 101 patients with 104 hepatectomies. Most hepatic parenchymal transections were performed using a CUSA under intermittent hepatic inflow occlusion (Pringle maneuver). Thirty-five patients underwent a right hepatectomy, 11 a left hepatectomy, 6 a right hepatectomy and segment I resection, 6 a right lobectomy, and 46 underwent segmentectomies, wedge resections, or other types of hepatic resections. Biliary-enteric reconstruction with a Roux-en-Y limb of the jejunum to a hepatic duct of the hepatic remnant was performed in 28 patients. Operative time was 90–720 min (median 300 min, mean 327 ± 149 min). Operative blood transfusion was 0–17 units (median 3 units, mean 3.9 ± 3.6 units). Twenty-one hepatectomies were conducted without blood transfusion. Thirty-four postoperative complications occurred in 30 patients with a 9% reoperation rate. Perioperative mortality was 6%. Age, operative time, operative blood transfusion, reoperation, and complications were significantly associated with mortality.

Conclusion

Careful preoperative diagnosis and evaluation of patients, faultless surgical techniques, and excellent postoperative care are important to avoid potentially serious postoperative complications and mortality. The CUSA is an effective assisting device during hepatic parenchymal transection with a concomitant Pringle maneuver, apparently reducing operative blood loss.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Iatrogenic, blunt, and penetrating trauma to the biliary tract

Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.