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Khajeh E, Fakour S, Ünal UK, Sabetkish N, Leins J, Ramouz A, Mieth M, Sabagh M, Abbasi Dezfouli S, Golriz M, Büchler MW, Mehrabi A. Assessing textbook outcomes following major liver surgery in association with obesity at a referral academic center. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107080. [PMID: 37738873 DOI: 10.1016/j.ejso.2023.107080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Outcomes of major surgeries in tertiary educational hospitals have been complicated by the referral of high-risk patients and the participation of trainees in surgical procedures. We analyzed outcomes of major hepatectomies in a tertiary academic setting emphasizing the role of training and obesity on textbook outcomes (TO). MATERIALS AND METHODS 971 adult patients who underwent open major hepatectomy (Mesohepatectomy [n = 111], hemihepatectomy [n = 610], and extended hepatectomy [n = 250]) were evaluated. A TO was defined as: a negative resection margin, no grade B/C bile leak, no major complications, no in-hospital mortality, and no 30-day readmission. TOs were compared following operations performed by senior surgeons and those performed by junior surgeons under the supervision of senior surgeons and between patients with and without obesity. RESULTS TO was achieved in 70.1% of patients overall (78.4% in mesohepatectomy, 73.1% in hemihepatectomy, and 59.2% in extended hepatectomy). The rate of TO was similar following operations performed by and supervised by a senior surgeon (69.3% vs 71.0%, p = 0.570). The rate of TO was significantly lower in patients with obesity (41.5% vs 74.6%, p < 0.001). Factors including increased age (odds ratio [OR] for 10-year increase = 0.83, 95% confidence interval [CI]: 0.73-0.96, p = 0.009), obesity (OR = 0.25, 95%CI: 0.16-0.37, p < 0.001), biliodigestive anastomosis (OR = 0.27, 95%CI: 0.19-0.40, p < 0.001), and portal vein resection (OR = 0.49, 95%CI: 0.28-0.87, p = 0.014) lower the rate of TO. CONCLUSION Promising outcomes are possible after major hepatectomy in an academic setting. Obese patients and those undergoing more complex surgeries had a higher risk of poor postoperative outcomes.
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Affiliation(s)
- Elias Khajeh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Sanam Fakour
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Umut Kaan Ünal
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Nastaran Sabetkish
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Johannes Leins
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Mohammadsadegh Sabagh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Sepehr Abbasi Dezfouli
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany; Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany.
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Yu M, Lu L, Wu R. Perihilar cholangiocarcinoma resection: Is it beneficial for survival in elderly patients? GASTROENTEROLOGIA Y HEPATOLOGIA 2023:S0210-5705(23)00441-7. [PMID: 37806347 DOI: 10.1016/j.gastrohep.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION As the population ages, surgeons are growing frequently faced with hard choices among a vast array of treatment options for the elderly. This study was to investigate safety and efficacy of resection in elderly patients with perihilar cholangiocarcinoma (PHCC). PATIENTS AND METHODS Literature reading and meta-analysis unveiled that elderly PHCC patients held a higher risk of death within 90 days after hepatectomy relative to younger patients, but their 5-year overall survival and disease-free survival were comparable. Among PHCC patients who underwent hepatectomy, the proportion of elderly patients with tumor classification Bismuth I-II and tumor stage pStage 1-3 was significantly higher than that of younger patients. RESULTS Curative resection R0 was more common in elderly patients than younger patients, but the difference was not statistically significant. Because of more comorbidities and less physiological reserve of elderly patients, they seemed to suffer more postoperative complications. CONCLUSION Considering improved life expectancy, it is crucial to treat elderly PHCC patients appropriately and attempts should be made to radical surgery based on comorbidities and functional status.
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Affiliation(s)
- Min Yu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China.
| | - Lina Lu
- Digestive Department, Jinhua Wenrong Hospital, Jinhua, China
| | - Rongjin Wu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
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Mazzola M, Ripamonti L, Giani A, Carnevali P, Origi M, Alampi B, Giusti I, Achilli P, Bertoglio CL, Magistro C, Ferrari G. Should Laparoscopic Complete Mesocolic Excision Be Offered to Elderly Patients to Treat Right-Sided Colon Cancer? Curr Oncol 2023; 30:4979-4989. [PMID: 37232834 DOI: 10.3390/curroncol30050376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Despite its potential oncologic benefit, complete mesocolic excision (CME) has rarely been offered to elderly patients. The present study evaluated the effect of age on postoperative outcomes among patients undergoing laparoscopic right colectomies with CME for right-sided colon cancer (RCC). METHODS Data of patients undergoing laparoscopic right colectomies with CME for RCC between 2015 and 2018 were retrospectively analyzed. Selected patients were divided into two groups: the under-80 group and the over-80 group. Surgical, pathological, and oncological outcomes among the groups were compared. RESULTS A total of 130 patients were selected (95 in the under-80 group and 35 in the over-80 group). No difference was found between the groups in terms of postoperative outcomes, except for median length of stay and adjuvant chemotherapy received, which were in favor of the under-80 group (5 vs. 8 days, p < 0.001 and 26.3% vs. 2.9%, p = 0.003, respectively). No difference between the groups was found regarding overall survival and disease free survival. Using multivariate analysis, only the ASA score > 2 (p = 0.01) was an independent predictor of overall complications. CONCLUSIONS laparoscopic right colectomy with CME for RCC was safely performed in elderly patients ensuring similar oncological outcomes compared to younger patients.
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Affiliation(s)
- Michele Mazzola
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Lorenzo Ripamonti
- Department of General Surgery, IRCCS san Gerardo dei Tintori, 20900 Monza, Italy
| | - Alessandro Giani
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Pietro Carnevali
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Matteo Origi
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - BrunocDomenico Alampi
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Irene Giusti
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | - Pietro Achilli
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
| | | | - Carmelo Magistro
- Division of General Surgery, ASST Melegnano e Martesana, Hospital of Vizzolo Predabissi, 20070 Vizzolo Predabissi, Italy
| | - Giovanni Ferrari
- Division of Minimally-Invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy
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Rocca A, Porfidia C, Russo R, Tamburrino A, Avella P, Vaschetti R, Bianco P, Calise F. Neuraxial anesthesia in hepato-pancreatic-bilio surgery: a first western pilot study of 46 patients. Updates Surg 2023; 75:481-491. [PMID: 36607598 PMCID: PMC9817460 DOI: 10.1007/s13304-022-01437-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/04/2022] [Indexed: 01/07/2023]
Abstract
The most common anesthetic approach in hepato-pancreatic-biliary (HPB) surgery is general anesthesia (GA), but it may result in increased morbidity and mortality and peri-operative risks especially in frail patients. The aim of this study was to assess the safety and effectiveness of neuraxial anesthesia (NA) in HPB in a pilot clinical series. This analysis was conducted on 46 consecutive patients undergoing HPB surgery in an Italian Tertial referral center. Data were prospectively collected and retrospectively analyzed. continuous spinal anesthesia (CSA), combined spino-epidural anesthesia (CSEA) and peridural anesthesia (PA) were used in major and minor hepatectomies and bilio-pancreatic surgery instead of GA. NA was evaluated by analyzing the surgical and anesthesiological short-term outcomes. 46 patients were considered eligible for the study between February 2018 and May 2020. The average age was 69.07 (± 9.95) years. 22 were males and 24 were females. According to the ASA score, 19 (41.30%) patients had ASA II, 22 (47.83%) had ASA III and 5 (10.87%) had ASA IV. 22 (47.83%) patients underwent CSA, 20 (43.48%) CSEA and 4 (8.69%) PA. We performed 8 major and 19 minor hepatectomies, 7 bilio-digestive derivations, 5 Whipple procedures, 4 iatrogenic biliary duct injuries, 2 splenopancreatectomies and 1 hepatic cyst fenestration. Clavien-Dindo ≥ 3 was observed in 3 patients. The conversion rate to endotracheal intubation occurring in 3 of 46 (6.52%) patients. After surgery, no local or pulmonary complications and delirium were reported in our series. The present study demonstrates that NA is a safe and feasible option in selected patients, if performed in referral centers by well-trained anaesthesiologists and surgeons.
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Affiliation(s)
- Aldo Rocca
- HPB Surgery Unit, Pineta Grande Hospital, 81030, Castel Volturno, CE, Italy.
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100, Campobasso, CB, Italy.
| | - Carmela Porfidia
- Intensive Care Unit, Pineta Grande Hospital, 81030, Castel Volturno, CE, Italy
| | - Raffaele Russo
- Intensive Care Unit, Pineta Grande Hospital, 81030, Castel Volturno, CE, Italy
| | | | - Pasquale Avella
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100, Campobasso, CB, Italy
| | - Roberto Vaschetti
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100, Campobasso, CB, Italy
| | - Paolo Bianco
- HPB Surgery Unit, Pineta Grande Hospital, 81030, Castel Volturno, CE, Italy
| | - Fulvio Calise
- HPB Surgery Unit, Pineta Grande Hospital, 81030, Castel Volturno, CE, Italy
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, 86100, Campobasso, CB, Italy
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Actual 10-Year Survival after Resection of Perihilar Cholangiocarcinoma: What Factors Preclude a Chance for Cure? Cancers (Basel) 2021; 13:cancers13246260. [PMID: 34944880 PMCID: PMC8699376 DOI: 10.3390/cancers13246260] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Long-term survival for patients with perihilar cholangiocarcinoma (pCCA) is rare. The median overall survival of patients undergoing curative-intent surgery for pCCA is 19 to 39 months. This multicenter study aimed to determine the cure rate and to identify clinicopathological factors that may preclude cure. Four hundred and sixty patients were included with a median follow-up of 10 years. Median OS was 29.9 months. Twenty-nine (6%) patients reached 10-year OS. The observed cure rate was 5%. Factors that virtually precluded cure (i.e., below 1%) according to the mixture cure model included age above 70, Bismuth–Corlette type IV tumors, hepatic artery reconstruction, and positive resection margins. Cure was unlikely (i.e., below 3%) in patients with positive lymph nodes or poor tumor differentiation. These factors need to be considered in patient counseling and long-term follow-up after surgery. Abstract Complete resection of perihilar cholangiocarcinoma (pCCA) is the only potentially curative treatment. Long-term survival data is rare and prognostic analyses are hindered by the rarity of the disease. This study aimed to determine the cure rate and to identify clinicopathological factors that may preclude cure. All consecutive resections for pathologically confirmed pCCA between 2000 and 2009 in 22 centers worldwide were included in a retrospective cohort study. Each center included its retrospective data series. A total of 460 patients were included with a median follow-up of 10 years for patients alive at last follow-up. Median overall survival (OS) was 29.9 months and 10-year OS was 12.8%. Twenty-nine (6%) patients reached 10-year OS. The observed cure rate was 5%. Factors that virtually precluded cure (i.e., below 1%) according to the mixture cure model included age above 70, Bismuth-Corlette type IV tumors, hepatic artery reconstruction, and positive resection margins. Cure was unlikely (i.e., below 3%) in patients with positive lymph nodes or poor tumor differentiation. These factors need to be considered in patient counseling and long-term follow-up after surgery.
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Current Surgical Management of Peri-Hilar and Intra-Hepatic Cholangiocarcinoma. Cancers (Basel) 2021; 13:cancers13153657. [PMID: 34359560 PMCID: PMC8345178 DOI: 10.3390/cancers13153657] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 01/17/2023] Open
Abstract
Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.
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