Postoperative collections after liver surgery: Risk factors and impact on long-term outcomes

First-intention EUS-guided transluminal drainage with LAMS: an effective and safe method for management of fluid collections after any kind of surgery

BACKGROUND

Symptomatic postoperative collections (PCs) frequently complicate surgery with significant morbidity and mortality. In contrast with pancreatic inflammatory collections, little is known about endoscopic ultrasound-guided drainage of PCs (EUS-PCD). The aim of this study is to evaluate the safety and efficacy of EUS-PCD using lumen-apposing metal stent (LAMS) as the first-line drainage approach for PCs of any kind.

METHODS

This is a monocentric retrospective study. We retrieved all consecutive symptomatic PCs treated at our center between February 2019 and September 2024. All cases were considered suitable for EUS-PCD after multidisciplinary discussion. Rates of technical success, clinical success, and AEs were calculated.

RESULTS

We retrieved 66 PCs, mainly resulting from pancreatic and lower gastrointestinal tract surgery. The median size of collections was 7.6 cm and infection occurred in 54 of the cases. The median time from surgery to drainage was 19 days (IQR 13-29); in 10 cases, this occurred ≤ 7 days after surgery. 51 drainages were performed from the gastric/duodenal window, 15 transrectally. LAMS were removed after a median time of 18.5 days (IQR 12-27). After removal, double-pigtail stents were placed in 25 PCs and at least one necrosectomy session was performed in 13. Technical success was achieved in 97.0% of cases. Clinical success was achieved in 95.2%; in 3 cases, collection recurrence occurred and retreatment with LAMS was successful. Overall AEs rate was 9.1%, but only one was severe, requiring surgery. Rates of technical and clinical failure and AEs were not affected by surgery type (pancreatic, non-pancreatic), timing of drainage (≤ 7, 7-10, > 10 days), size of collections (≤ 4, 4-10, > 10 cm), and access window (transgastric/duodenal/rectal). Necrosectomy performance was the only predictor of AEs occurrence (OR 6.9, C.I.: 1.1-46.9, p = 0.048) at univariable analysis.

CONCLUSION

First-intention EUS-PCD seems to be a safe and effective treatment, regardless of the origin and size of the collection and drainage timing.

Optimal results through enhanced recovery: Achieving textbook outcomes with high compliance in elective liver surgery

BACKGROUND

Existing studies suggest a positive correlation between high compliance with enhanced recovery programs (ERP) and improved outcomes. While individual outcome measures have advantages, composite benchmarks, such as textbook outcome (TO), offer a more comprehensive assessment of healthcare performance. Given the link between ERP and postoperative outcomes, this study aims to investigate the impact of ERP on TO attainment after liver surgery (LS).

METHODS

A prospective multicenter cohort of patients undergoing LS and exposed to ERP from 2016 to 2022 in France was analyzed. The primary outcome was to compare the rates of TO achieved between patients with high ERP compliance (>70%) and those with low ERP compliance (<70%) after LS.

RESULTS

A total of 706 patients were included in the study, and 217 (30.7%) achieved TO: 170 patients with high ERP compliance (24%) versus 47 patients (6.6%) with low ERP compliance attained TO (p < 0.001). High ERP compliance was associated to an increased likelihood of achieving TO [odds ratio (OR) = 1.49 (95% CI: 1.01, 2.24); p = 0.049], while cholangiocarcinoma [OR = 0.11 (95% CI: 0.02, 0.39); p = 0.003], high complexity LS [OR = 0.22 (95% CI: 0.13, 0.36); p < 0.001], intraoperative hypotension requiring vasopressors [OR = 0.29 (95% CI: 0.10, 0.68); p = 0.010], and post-operative ileus [OR = 0.08 (95% CI: 0.00, 0.37); p = 0.013] were negatively associated to the likelihood of achieving TO.

CONCLUSIONS

Patients with high ERP compliance after LS experience elevated rates of TO, compared to those with low ERP compliance.

The Effect of Preoperative Administration of Glucocorticoids on the Postoperative Complication Rate in Liver Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Glucocorticoids may grant a protective effect against postoperative complications. The evidence on their efficacy, however, has been inconclusive thus far. We investigated the effects of preoperatively administered glucocorticoids on the overall postoperative complication rate, and on liver function recovery in patients undergoing major liver surgery. Methods: We performed a systematic literature search on PubMed, Embase, and CENTRAL in October 2021, and repeated the search in April 2023. Pre-study protocol was registered on PROSPERO (ID: CRD42021284559). Studies investigating patients undergoing liver resections or transplantation who were administered glucocorticoids preoperatively and reported postoperative complications were eligible. Meta-analyses were performed using META and DMETAR packages in R with a random effects model. Risk of bias was assessed using RoB2. Results: The selection yielded 11 eligible randomized controlled trials (RCTs) with 964 patients. Data from nine RCTs (n = 837) revealed a tendency toward a lower overall complication rate with glucocorticoid administration (odds ratio: 0.71; 95% confidence interval: 0.38-1.31, p = 0.23), but it was not statistically significant. Data pooled from seven RCTs showed a significant reduction in wound infections with glucocorticoid administration [odds ratio: 0.64; 95% confidence interval: 0.45-0.92 p = 0.02]. Due to limited data availability, meta-analysis of liver function recovery parameters was not possible. Conclusions: The preoperative administration of glucocorticoids did not significantly reduce the overall postoperative complication rate. Future clinical trials should investigate homogenous patient populations with a specific focus on postoperative liver recovery.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: Report of an international multicenter cohort study with propensity score matching

BACKGROUND

Intrahepatic cholangiocarcinoma is a rare disease with a poor prognosis. In patients where surgical resection is possible, outcome is influenced by perioperative morbidity and lymph node status. Laparoscopic liver resection is associated with improved clinical and oncological outcomes in primary and metastatic liver cancer compared with open liver resection, but evidence on intrahepatic cholangiocarcinoma is still insufficient. The primary aim of this study was to compare overall survival for a large series of patients treated for intrahepatic cholangiocarcinoma by open or laparoscopic approach. Secondary objectives were to compare disease-free survival, predictors of death, and recurrence.

METHODS

Patients treated with laparoscopic or open liver resection for intrahepatic cholangiocarcinoma from 2000 to 2018 from 3 large international databases were analyzed retrospectively. Each patient in the laparoscopic resection group (case) was matched with 1 open resection control (1:1 ratio), through a propensity score calculated on clinically relevant preoperative covariates. Overall and disease-free survival were compared between the matched groups. Predictors of mortality and recurrence were analyzed with Cox regression, and the Textbook Outcomes were described.

RESULTS

During the study period, 855 patients met the inclusion criteria (open liver resection = 709, 82.9%; laparoscopic liver resection = 146, 17.1%). Two groups of 89 patients each were analyzed after propensity score matching, with no significant difference regarding pre- and postoperative variables. Overall survival at 1, 3, and 5 years was 92%, 75%, and 63% in the laparoscopic liver resection group versus 92%, 58%, and 49% in the open liver resection group (P = .0043). Adjusted Cox regression revealed severe postoperative complications (hazard ratio: 10.5, 95% confidence interval [1.01-109] P = .049) and steatosis (hazard ratio: 13.8, 95% confidence interval [1.23-154] P = .033) as predictors of death, and transfusion (hazard ratio: 19.2, 95% confidence interval [4.04-91.4] P < .001) and severe postoperative complications (hazard ratio: 4.07, 95% confidence interval [1.15-14.4] P = .030) as predictors of recurrence.

CONCLUSION

The survival advantage of laparoscopic liver resection over open liver resection for intrahepatic cholangiocarcinoma is equivocal, given historical bias and missing data.

Absence of abdominal drainage after surgery for secondary lower gastrointestinal tract peritonitis is a valid strategy

BACKGROUND

Management of abdominal drainage after surgery for secondary lower gastrointestinal tract peritonitis (LGTP) is not a standardized procedure. A monocentric study was carried out in 2016 in our centre. (PI study) to evaluate the interest of drainage. Our objective was to revaluate, our actual use of abdominal drainage after peritonitis (PII study).

STUDY DESIGN

We examined retrospectively patients who underwent surgery for secondary sub-mesocolic community-acquired peritonitis (January 2016-December 2019). Study exclusion criteria were primary peritonitis, peritoneal dialysis, nosocomial peritonitis, postoperative peritonitis, upper gastrointestinal tract peritonitis, peritonitis due to appendicitis, peritonitis requiring the implementation of Mikulicz's drain, and peritonitis in which the peritoneum was not described in the surgical report (i.e., the same criteria that the PI study which included 141 patients from January 2009 to January 2012). The primary endpoint was the rate of abdominal drainage. The secondary endpoints were the patient rate without a peritoneum description, major complications rate (Clavien ≥III), abscess rate, mortality rate and the length of stay in the non-drain group (D - ) and in the drain group (D + ) in PII study. Primary and secondary endpoints were also compared between PI and PII studies. Risk factors for post-operative abscess were also research.

RESULTS

Of the 150 patients included 33% were drained vs 84% of the 141 patients included in PI study (p < 0.001). In PII study peritoneum was described in 80.3% of patients vs 69% in PI study (NS, p = 0.06). Comparing the two groups D -  and D + , no significant differences were found in major complications (respectively 45% vs 32%, p = 0.1), reoperation rate (respectively 25% vs 22%, p = 0.7), death rate (respectively 25% vs 14%; p = 0.1) and mean length of stay (respectively 12 days vs 13 days, p = 0.9). The abscess rate was significantly lower in the D -  group (10% vs 30%, p = 0.002). Comparing PI and PII studies, there was no difference about major complications (35% vs 35%, p = 0.1), reoperation (16% vs 17.5%, p = 0.5), abscess rate (15% vs 8.5%, p = 0.1) and mortality (14.5% vs 17.5%, p = 0.7). The length of stay was longer in PI study than in P II (14 days vs 9 days, p = 0.03). Drainage (p = 0.005; OR = 4.357; CI [1.559-12.173]) and peritonitis type (p = 0.032; OR = 3.264; CI [1.106-9.630]) were abscess risk factors.

CONCLUSION

This study therefore showed that drainage after surgery for LGTP may not be necessary and that, at least at the local level, surgeons seem to be inclined to discontinue it systematically. It may therefore be worthwhile to conduct a randomised control trial to establish recommendations on drainage after surgery for LGTP.

CT-Guided Drainage of Fluid Collections Following Liver Resection: Technical and Clinical Outcome of 143 Patients during a 14-Year Period

Purpose: To retrospectively evaluate the technical and clinical outcome of patients with symptomatic postoperative fluid collections following liver resection treated with CT-guided drainage (CTD). Methods: 143 suitable patients were examined between 2004 and 2017. Technical success was defined as (a) sufficient drainage of the fluid collection and (b) the non-occurrence of peri-interventional complications requiring surgical treatment with minor or prolonged hospitalization. Clinical success was defined as (a) decreasing or normalization of specific blood parameters within 30 days after intervention and (b) no surgical revision in addition to intervention required. C-reactive protein (CRP), leukocytes and Total Serum Bilirubin (TSB) were assessed. Dose length product (DLP) for the intervention parts was determined. Results: Technical success was achieved in 99.5% of 189 performed interventions. Clinical success was reached in 74% for CRP, in 86.7% for Leukocytes and in 62.1% for TSB. The median of successful decrease was 6.0 days for CRP, 3.5 days for Leukocytes and 5.5 days for TSB. In 90.2%, no surgical revision was necessary. Total DLP was significantly lower in the second half of the observation period (median 536.0 mGy*cm between years 2011 and 2017 vs. median 745.5 mGy*cm between years 2004 and 2010). Conclusions: Technical success rate of CTD was very high, and clinical success rate was fair to good. Reduction of the radiation dose reflects developments of CT technology and increased experience of the interventional radiologists.