Three-day postoperative antibiotics reduces post-hepatectomy infection rate in hepatitis B virus-related hepatocellular carcinoma

Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

Influencing factors and predictive model of postoperative infection in patients with primary hepatic carcinoma

BACKGROUND

The purpose of this study was to explore the risk factors for postoperative infection in patients with primary hepatic carcinoma (PHC), build a nomogram prediction model, and verify the model to provide a better reference for disease prevention, diagnosis and treatment.

METHODS

This single-center study included 555 patients who underwent hepatobiliary surgery in the Department of Hepatobiliary Surgery of Tianjin Third Central Hospital from January 2014 to December 2021, and 32 clinical indicators were selected for statistical analysis. In this study, Lasso logistic regression was used to determine the risk factors for infection after liver cancer resection, establish a predictive model, and construct a visual nomogram. The consistency index (C-index), calibration curve, and receiver operating characteristic (ROC) curve were used for internal validation, and decision curve analysis (DCA) was used to analyze the clinical applicability of the predictive model. The bootstrap method was used for intramodel validation, and the C-index was calculated to assess the model discrimination.

RESULTS

Among the 555 patients, 279 patients met the inclusion criteria, of whom 48 had a postoperative infection, with an incidence rate of 17.2%. Body mass index (BMI) (P = 0.022), alpha-fetoprotein (P = 0.023), total bilirubin (P = 0.016), intraoperative blood loss (P < 0.001), and bile leakage (P < 0.001) were independent risk factors for infection after liver cancer surgery. The nomogram was constructed and verified to have good discriminative and predictive ability. DCA showed that the model had good clinical applicability. The C-index value verified internally by the bootstrap method results was 0.818.

CONCLUSION

Postoperative infection in patients undergoing hepatectomy may be related to risk factors such as BMI, preoperative AFP level, TBIL level, intraoperative blood loss and bile leakage. The prediction model of the postoperative infection nomogram established in this study can better predict and estimate the risk of postoperative infection in patients undergoing hepatectomy.

Pre- and postoperative C-reactive protein as a risk factor of organ/space surgical site infection after hepatectomy

BACKGROUND

Organ/space surgical site infection (SSI) is one of the most common complications of liver resection, with significant impact on morbidity and mortality, so patients at high risk should be identified early. This study aimed to determine whether pre- and postoperative C-reactive protein (CRP) levels could predict organ/space SSIs.

METHODS

The hospital records of consecutive patients who underwent hepatectomy without biliary reconstruction at our institutions between 2008 and 2015 were reviewed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between patients with or without organ/space SSIs. Its risk factors were also determined.

RESULTS

Among 443 identified patients, 55 cases (12.5%) developed organ/space SSIs; they more frequently experienced other complications and bile leakage (47.3% vs. 16.6%, p = 0.001; 40.0% vs. 8.5%, p < 0.001, respectively). Postoperative CRP elevation from postoperative day (POD) 3 to 5 was significantly more frequent in the SSI group (21.8% vs. 4.9%, p < 0.001). Multivariate analysis identified preoperative CRP ≥ 0.2 mg/dL (odds ratio (OR), 2.01, p = 0.044], preoperative cholangitis (OR, 15.7; p = 0.020), red cell concentrate (RCC) transfusion (OR, 2.61, p = 0.018), bile leakage (OR, 9.51; p < 0.001), and CRP level elevation from POD 3 to 5 (OR, 3.81, p = 0.008) as independent risk factors for organ/space SSIs.

CONCLUSIONS

Preoperative CRP elevation and postoperative CRP trajectory are risk factors for organ/space SSIs after liver resection. A prolonged CRP level elevation at POD 5 indicates its occurrence. If there were no risk factors and no CRP elevation at POD 5, its presence could be excluded.

Routine Postoperative Antibiotic Prophylaxis Offers No Benefit after Hepatectomy-A Systematic Review and Meta-Analysis

BACKGROUND

Prophylactic antibiotics are frequently administered after major abdominal surgery including hepatectomies aiming to prevent infective complications. Yet, excessive use of antibiotics increases resistance in bacteria. The aim of this systematic review and meta-analysis is to assess the efficacy of prophylactic antibiotics after hepatectomy (postoperative antibiotic prophylaxis, POA).

METHOD

This systematic review and meta-analysis were completed according to the current PRISMA guidelines. The protocol has been registered prior to data extraction (PROSPERO registration Nr: CRD42021288510). MEDLINE, Web of Science and CENTRAL were searched for clinical reports on POA in hepatectomy restrictions. A random-effects model was used for synthesis. Methodological quality was assessed with RoB2 and ROBINS-I. GRADE was used for the quality of evidence assessment.

RESULTS

Nine comparative studies comprising 2987 patients were identified: six randomized controlled trials (RCTs) and three retrospectives. POA did not lead to a reduction in postoperative infective complications or have an effect on liver-specific complications-post-hepatectomy liver failure and biliary leaks. POA over four or more days was associated with increased rates of deep surgical site infections compared to short-term administration for up to two days (OR 1.54; 95% CI [1.17;2.03]; p = 0.03). Routine POA led to significantly higher MRSA incidence as a pathogen (p = 0.0073). Overall, the risk of bias in the studies was low and the quality of evidence moderate.

CONCLUSION

Routine POA cannot be recommended after hepatectomy since it does not reduce postoperative infection or liver-specific complications but contributes to resistance in bacteria. Studies into individualized risk-adapted antibiotic prophylaxis strategies are needed to further optimize perioperative treatment in liver surgery.