Impact of Metabolic Syndrome on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Hepatectomy

Use of textbook outcome as a quality metric in hepatopancreaticobiliary surgery: a systematic review and meta-analysis

BACKGROUND

Textbook outcomes (TOs) represent the optimal course after surgery. To date, no meta-analysis has assessed the pooled TOs of patients undergoing hepatopancreatobiliary (HPB) surgery and the effect of TO achievement on patient outcomes. This systematic review and meta-analysis aimed to assess TO achievement across different studies and to characterize the effect of TO achievement on patient-related outcomes, including disease-free survival (DFS) and overall survival (OS).

METHODS

PubMed, Embase, and Scopus databases were searched (1990-2024). The criteria used to define TO and the median overall TO in HPB surgery were obtained. In addition, a random-effects meta-analysis was conducted to assess the effect of TO achievement on 5-year OS and DFS.

RESULTS

A total of 27 studies involving 517,304 patients met inclusion criteria. The main criteria used to define TO included absence of readmission and mortality within 30 days after discharge, severe postoperative complications, prolonged hospital stay, and negative surgical margin (R0). Of note, the main factors related to TO achievement were younger patient age and lower American Society of Anesthesiologists score. Overall, the median rates of TOs achieved across procedures were 62.0% (IQR, 48.0%-69.0%) for hepatic procedure, 54.0% (IQR, 41.0%-68.0%) for biliary procedure, 46.0% (IQR, 42.0%-46.5%) for combined hepatopancreatic procedure, 45.0% (IQR, 30.5%-59.0%) for pancreatic procedure, 33.0% (IQR, 32.2%-34.0%) for liver transplantation, and 19.5% (IQR, 16.8%-22.3%) for combined hepatobiliary procedure. TO achievement was associated with improved odds of 5-year OS (odds ratio [OR], 1.22 [95% CI, 1.20-1.24]) and 5-year DFS (OR, 1.26 [95% CI, 1.16-1.37]).

CONCLUSION

Overall, hepatic and biliary operations had the highest TO achievement, followed by pancreatic procedures. In contrast, hepatobiliary surgery and liver transplantation had the lowest TO. There was a significant discrepancy in the definition of TO across different studies, highlighting the need for consensus on the definition of TO.

Cell Homeostasis or Cell Death-The Balancing Act Between Autophagy and Apoptosis Caused by Steatosis-Induced Endoplasmic Reticulum (ER) Stress

Metabolic-dysfunction-associated steatotic liver disease (MASLD) is a prevalent liver condition with potential progression to cirrhosis and impaired regeneration post-resection. A key mechanism underlying lipotoxicity is endoplasmic reticulum (ER) stress, particularly the activation of the unfolded protein response (UPR). This study investigates the interplay between lipid accumulation, endoplasmic reticulum (ER) stress, and cellular outcomes, focusing on the balance between autophagy and apoptosis. We cultured primary human hepatocytes (PHH) in a free fatty acid (FFA)-enriched medium for 120 h, assessing lipid accumulation, metabolism, and the expression of selected UPR markers. Additionally, we investigated the effects of lipid load on cell activity and growth in proliferating HepG2 cells. We observed that FFA uptake consistently induced ER stress, shifting cellular responses toward apoptosis under high lipid loads. Donor-specific differences were evident, particularly in lipid storage, excretion, and sensitivity to lipotoxicity. Some donors exhibited limited triglyceride (TAG) storage and excretion, leading to an excess of FFA whose metabolic fate remains unclear. Proliferation was more sensitive to lipid accumulation than overall cell activity, with even low FFA concentrations impairing growth, highlighting the vulnerability of regenerative processes to steatosis. The study elucidates how ER stress pathways, such as PERK-CHOP and IRE1α-JNK, are differentially activated in response to lipid overload, tipping the balance toward apoptosis in severe cases. The limited activation of repair mechanisms, such as autophagy, further emphasizes the critical role of ER stress in determining hepatocyte fate. The donor-dependent variability highlights the need for personalized strategies to mitigate lipotoxic effects and enhance liver regeneration in steatosis-related conditions.

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Analysis of the Short-Term Complications of Laparoscopic Pancreaticoduodenectomy in Patients with Metabolic Syndrome

Objective: To investigate the impact of metabolic syndrome (MetS) on short-term complications of laparoscopic pancreaticoduodenectomy (LPD). Materials and Methods: We retrospectively analyzed perioperative data of patients who underwent LPD in our department from January 2020 to January 2022. The patients were divided into the MetS group and non-MetS group based on whether they had MetS. The incidence of postoperative complications and mortality rate was compared between the two groups. Results: The study involved 279 patients, with 30 having MetS and 249 without. However, the MetS and non-MetS groups differed significantly in terms of postoperative pancreatic fistula rate (26.6% versus 8.4%), abdominal infection rate (33.3% versus 10.0%), pulmonary complications rate (16.7% versus 6.42%), Clavien-Dindo ≥3 rate (20% versus 8.0%), multiple complications rate (23.3% versus 9.6%), percutaneous drainage rate (33.3% versus 10.0%), 90-day mortality rate (6.7% versus 1.2%), and length of postoperative hospital stay (15.00 ± 12.78 versus 10.63 ± 5.23 days). However, the two groups differed no significantly with respect to age, gender, American Society of Anesthesiologists score, preoperative CA125/CA199 levels, surgery time, specimen removal time, and intraoperative blood loss. Conclusion: MetS increases the incidence of postoperative complications and perioperative mortality rate in LPD.

Minimally Invasive Versus Open Liver Resections for Hepatocellular Carcinoma in Patients With Metabolic Syndrome

OBJECTIVE

To compare minimally invasive (MILR) and open liver resections (OLRs) for hepatocellular carcinoma (HCC) in patients with metabolic syndrome (MS).

BACKGROUND

Liver resections for HCC on MS are associated with high perioperative morbidity and mortality. No data on the minimally invasive approach in this setting exist.

MATERIAL AND METHODS

A multicenter study involving 24 institutions was conducted. Propensity scores were calculated, and inverse probability weighting was used to weight comparisons. Short-term and long-term outcomes were investigated.

RESULTS

A total of 996 patients were included: 580 in OLR and 416 in MILR. After weighing, groups were well matched. Blood loss was similar between groups (OLR 275.9±3.1 vs MILR 226±4.0, P =0.146). There were no significant differences in 90-day morbidity (38.9% vs 31.9% OLRs and MILRs, P =0.08) and mortality (2.4% vs 2.2% OLRs and MILRs, P =0.84). MILRs were associated with lower rates of major complications (9.3% vs 15.3%, P =0.015), posthepatectomy liver failure (0.6% vs 4.3%, P =0.008), and bile leaks (2.2% vs 6.4%, P =0.003); ascites was significantly lower at postoperative day 1 (2.7% vs 8.1%, P =0.002) and day 3 (3.1% vs 11.4%, P <0.001); hospital stay was significantly shorter (5.8±1.9 vs 7.5±1.7, P <0.001). There was no significant difference in overall survival and disease-free survival.

CONCLUSIONS

MILR for HCC on MS is associated with equivalent perioperative and oncological outcomes to OLRs. Fewer major complications, posthepatectomy liver failures, ascites, and bile leaks can be obtained, with a shorter hospital stay. The combination of lower short-term severe morbidity and equivalent oncologic outcomes favor MILR for MS when feasible.

Textbook Outcomes in Liver Surgery: a Systematic Review

BACKGROUND

Assessment of the quality of care among patients undergoing hepatectomy may be inadequate using traditional "siloed" postoperative surgical outcome metrics. In turn, the combination of several quality metrics into a single composite Textbook Outcome in Liver Surgery (TOLS) may be more representative of "ideal" surgical care.

METHODS

Adhering to PRISMA guidelines, a search for primary articles on post-operative TOLS evaluation after hepatectomy was performed. Studies that did not present hepatectomy outcomes, pediatric or transplantation populations, duplicated series, and editorials were excluded. Studies were evaluated in aggregate for methodological variation, TOLS rates, factors associated with TOLS, hospital variation, and overall findings.

RESULTS

Among 207 identified publications, 32 observational cohort studies were selected for inclusion in the review. There was a total of 90,077 hepatic resections performed from 1993 to 2020 in the analytic cohort. While TOLS definitions varied widely, all studies used an "all-or-none" composite structure combining a median of 5 (range: 4-7) discrete parameters. Observed TOLS rates varied in the different reported populations from 11.2 to 77.0%. TOLS was associated with patient, hospital, and operative factors.

CONCLUSIONS

This systematic review summarizes the contemporary international experience with TOLS to assess surgical performance following hepatobiliary surgery. TOLS is a single composite metric that may be more patient-centered, as well as better suited to quantify "optimal" care and compare performance among centers performing liver surgery.

Model to predict major complications following liver resection for HCC in patients with metabolic syndrome

BACKGROUND

Metabolic syndrome (MS) is rapidly growing as risk factor for HCC. Liver resection for HCC in patients with MS is associated with increased postoperative risks. There are no data on factors associated with postoperative complications.

AIMS

The aim was to identify risk factors and develop and validate a model for postoperative major morbidity after liver resection for HCC in patients with MS, using a large multicentric Western cohort.

MATERIALS AND METHODS

The univariable logistic regression analysis was applied to select predictive factors for 90 days major morbidity. The model was built on the multivariable regression and presented as a nomogram. Performance was evaluated by internal validation through the bootstrap method. The predictive discrimination was assessed through the concordance index.

RESULTS

A total of 1087 patients were gathered from 24 centers between 2001 and 2021. Four hundred and eighty-four patients (45.2%) were obese. Most liver resections were performed using an open approach (59.1%), and 743 (68.3%) underwent minor hepatectomies. Three hundred and seventy-six patients (34.6%) developed postoperative complications, with 13.8% major morbidity and 2.9% mortality rates. Seven hundred and thirteen patients had complete data and were included in the prediction model. The model identified obesity, diabetes, ischemic heart disease, portal hypertension, open approach, major hepatectomy, and changes in the nontumoral parenchyma as risk factors for major morbidity. The model demonstrated an AUC of 72.8% (95% CI: 67.2%-78.2%) ( https://childb.shinyapps.io/NomogramMajorMorbidity90days/ ).

CONCLUSIONS

Patients undergoing liver resection for HCC and MS are at high risk of postoperative major complications and death. Careful patient selection, considering baseline characteristics, liver function, and type of surgery, is key to achieving optimal outcomes.

Does metabolic syndrome affect perioperative outcomes in patients undergoing robotic hepatectomy? A propensity score-matched analysis

BACKGROUND

Metabolic syndrome is a known risk factor for postoperative complications after general surgical procedures. Literature analyzing perioperative outcomes of patients with metabolic syndrome undergoing a minimally invasive hepatectomy is limited. We sought to investigate if metabolic syndrome significantly impacts the perioperative course and outcomes of patients undergoing robotic hepatectomy.

METHODS

With IRB, we prospectively followed patients who underwent robotic hepatectomy from 2016 through 2020. A 1:1 propensity score-matched (PSM) analysis was applied to patients with and without metabolic syndrome. Demographic and clinical data were analyzed for those cohorts before and after PSM. Metabolic syndrome was defined as BMI ≥ 28.8 kg/m², diabetes, and hypertension.

RESULTS

A total of 272 patients underwent robotic hepatectomy, 39 (14%) of whom had metabolic syndrome. After performing PSM, we ended up with 74 patients, 37 in each cohort, 28% of them had liver cirrhosis. Patients with metabolic syndrome had higher BMI (34 ± 5.6 vs. 28 ± 5.9 kg/m², p < 0.001) and MELD scores (10 ± 4.5 vs. 8 ± 3.2, p < 0.001) compared to patients without metabolic syndrome. Additionally, patients with metabolic syndrome had an increased incidence of liver cirrhosis (33% vs. 9%, p = 0.0002). Following PSM, BMI (34 ± 5.7 vs. 26 ± 4.4 kg/m², p < 0.001) was the only preoperative variables associated with metabolic syndrome. There were no statistical differences before and after PSM between patients with and without metabolic syndrome in terms of intraoperative metrics including operative time, blood loss, conversion to 'open,' and intraoperative complications. All postoperative outcomes metrics before and after PSM did not correlate with the presence or absence of metabolic syndrome.

CONCLUSIONS

Metabolic syndrome had no impact on intra- or postoperative metrics, complications, or outcomes after robotic hepatectomy. We believe that the robotic approach may mitigate the adverse effects of metabolic syndrome for patients undergoing robotic hepatectomy.

Does Metabolic Syndrome Effect the Perioperative Course and Costs of Patients with Hepatocellular Carcinoma Undergoing Robotic Hepatectomy? A Propensity Score-Matched Analysis

BACKGROUND

This study was undertaken to examine the postoperative outcomes, costs, and survival after robotic hepatectomy for hepatocellular carcinoma (HCC) in patients with or without metabolic syndrome.

METHODS

Following IRB approval, we prospectively followed 56 patients undergoing robotic hepatectomy for HCC from 2016-2020. Patients with metabolic syndrome were compared to patients without metabolic syndrome regarding postoperative clinical outcomes, costs, and survival. Propensity score matching of a 1:1 ratio matched patients with and without metabolic syndrome according to 6 variables.

RESULTS

17 patients were matched to each arm. Mean age was 64 ± 14.0 years and 30 patients (88%) had operations that were classified as advanced (IWATE 7-9) or expert (IWATE 10-12). There were no differences between patients with metabolic syndrome versus patients without metabolic syndrome in terms of operative duration (306 [301 ± 76.2] vs 239 [260 ± 116.9] minutes; P = 0.23), estimated blood loss (300 [321 ± 195.5] vs 200 [214 ± 151.4] ml; P = 0.08), conversion to "open" operation (1 [6%] vs 1 [6%]; p = 1.00), tumor size (5 [5 ± 3.0] vs 3 [4 ± 2.2] cm; P = 0.28), postoperative complications with Clavien-Dindo Score (≥III) (0 vs 1; P = 1.00), in-hospital mortality (0 [0%] vs 1 [6%]; P = 1.00), length of stay (5 [5 ± 1.7] vs 4 [5 ± 4.4] days; P = 1.00), and 30-day readmissions (1 [6%] vs 1 [6%]; P = 1.00). There were no differences in overall costs and profit. There was no difference in 1-year, 2-year, and 3- year overall survival in patients with or without metabolic syndrome after robotic HCC resection (84% vs 77%, 84% vs 61%, and 45% vs 61%, P = 0.42).

CONCLUSION

For patients with and without metabolic syndrome, robotic advanced/expert hepatectomy for HCC resulted in similar intra-operative metrics, postoperative outcomes, costs, and survival.