Establishing the clinical relevance of grade A post-hepatectomy liver failure

INTRODUCTION

The International Study Group of Liver Surgery's criteria stratifies post-hepatectomy liver failure (PHLF) into grades A, B, and C. The clinical significance of these grades has not been fully established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) hepatectomy-targeted database was analyzed. Outcomes between patients without PHLF, with grade A PHLF, and grade B or C PHLF were compared. Univariate and multivariable logistic regression were performed.

RESULTS

Six thousand two hundred seventy-four adults undergoing elective major hepatectomy were included in the analysis. The incidence of grade A PHLF was 4.3% and grade B or C was 5.3%. Mortality was similar between patients without PHLF (1.2%) and with grade A PHLF (1.1%), but higher in those with grades B or C PHLF (25.4%). Overall morbidities rates were 19.3%, 41.7%, and 72.8% in patients without PHLF, with grade A PHLF, and with grade B or C PHLF, respectively (p < 0.001). Grade A PHLF was associated with increased morbidity (grade A: odds ratios [OR] 2.7 [95% CI: 2.0-3.5]), unplanned reoperation (grade A: OR 3.4 [95% CI: 2.2-5.1]), nonoperative intervention (grade A: OR 2.6 [95% CI: 1.9-3.6]), length of stay (grade A: OR 3.1 [95% CI: 2.3-4.1]), and readmission (grade A: OR 1.8 [95% CI: 1.3-2.5]) compared to patients without PHLF.

CONCLUSIONS

Although mortality was similar between patients without PHLF and with grade A PHLF, other postoperative outcomes were notably inferior. Grade A PHLF is a clinically distinct entity with relevant associated postoperative morbidity.

Development of a conceptual framework to detect perioperative symptom burden following abdominal surgery for cancer

BACKGROUND

Abdominal surgery for gastrointestinal malignancies has a significant impact on patients' health-related quality of life. However, there is so far no patient-reported outcome measures (PROM) in the immediate postoperative period to detect the perioperative symptom burden and patients' needs which may precede occult and severe complications. The aim of the study was to create a conceptual framework for the development of a PROM to measure perioperative symptom burden in abdominal cancer patients.

METHODS

This mixed method study was performed between March 2021, and July 2021 as part of a multiphase approach to develop a new PROM. A systematic review of the literature was performed health domains were identified. The relevance of the health domains was assessed in a two-round Delphi study with clinical experts. Qualitative interviews were performed in patients who underwent abdominal surgery for cancer.

RESULTS

The systematic literature review yielded 12 different PROM with 168 items and 55 health domains. The most common health domains involved the "digestive system" and "pain". In total, 30 patients (median age 66 years, 20 men [60%]) were included for qualitative patient interviews. Of 16 health domains identified by the Delphi study, a total 15 health domains were confirmed during patients' interviews. The final conceptual framework included 20 health domains.

CONCLUSION

This study provides the essential groundwork to develop and validate a new PROM for the immediate postoperative period of patients undergoing abdominal surgery for cancer.

Stereotactic Body Radiation Therapy versus Surgical Resection for Stage I/II Hepatocellular Carcinoma

SBRT is an emerging locoregional treatment modality for hepatocellular carcinoma (HCC). Although local tumor control rates seem encouraging, large-scale survival data comparing SBRT to surgical resection are lacking. We identified patients with stage I/II HCC from the National Cancer Database amenable for potential surgical resection. Patients undergoing hepatectomy were matched by propensity score (1:2) with patients who underwent SBRT as primary treatment. A total of 3787 (91%) and 366 (9%) patients underwent surgical resection or SBRT between 2004 and 2015, respectively. After propensity matching, the 5-year overall survival was 24% (95% CI 19-30%) in the SBRT group versus 48% (95% CI 43-53%) in the surgery group (p < 0.001). The association of surgery with overall survival was consistent in all subgroups. In patients treated with SBRT, a biologic effective dose (BED) of ≥100 Gy (31%, 95% CI 22%-40%) compared with BED < 100 Gy (13%, 95% CI 8-22%) was associated with a higher 5-year overall survival rate (hazard ratio of mortality of 0.58, 95% CI 0.43-0.77; p < 0.001). Surgical resection may be associated with prolonged overall survival compared with SBRT in patients with stage I/II HCC.

Impact of post-hepatectomy liver failure on morbidity and short- and long-term survival after major hepatectomy

Background

Post-hepatectomy liver failure (PHLF) is one of the most serious postoperative complications after hepatectomy. The aim of this study was to assess the impact of the International Study Group of Liver Surgery (ISGLS) definition of PHLF on morbidity and short- and long-term survival after major hepatectomy.

Methods

This was a retrospective review of all patients who underwent major hepatectomy (three or more liver segments) for various liver tumours between 2010 and 2018 at two Swedish tertiary centres for hepatopancreatobiliary surgery. Descriptive statistics, regression models, and survival analyses were used.

Results

A total of 799 patients underwent major hepatectomy, of which 218 patients (27 per cent) developed ISGLS-defined PHLF, including 115 patients (14 per cent) with ISGLS grade A, 76 patients (10 per cent) with grade B, and 27 patients (3 per cent) with grade C. The presence of cirrhosis, perihilar cholangiocarcinoma, and gallbladder cancer, right-sided hemihepatectomy and trisectionectomy all significantly increased the risk of clinically relevant PHLF (grades B and C). Clinically relevant PHLF increased the risk of 90-day mortality and was associated with impaired long-term survival. ISGLS grade A had more major postoperative complications compared with no PHLF but failed to be an independent predictor of both 90-day mortality and long-term survival. The impact of PHLF grade B/C on long-term survival was no longer present in patients surviving the first 90 days after surgery.

Conclusions

The presently used ISGLS definition for PHLF should be reconsidered regarding mortality as only PHLF grade B/C was associated with a negative impact on short-term survival; however, even ISGLS grade A had clinical implications.

Predictors of discharge timing and unplanned readmission after laparoscopic liver resection

BACKGROUND

The aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR).

METHODS

Consecutive LLR performed at the "Institut Mutualiste Montsouris" between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission.

RESULTS

Early discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75-125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98-12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60-11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12-15.8, p = 0.045).

CONCLUSION

Concomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.

Minimally invasive mesohepatectomy for centrally located liver lesions-a case series

BACKGROUND

Resection of centrally located liver lesions remains a technically demanding procedure. To date, there are limited data on the effectiveness and safety of minimally invasive mesohepatectomy for benign and malignant lesions. It was therefore the objective of this study to evaluate the perioperative outcomes of minimally invasive mesohepatectomy for liver tumors at a tertiary care hospital.

METHODS

Consecutive patients who underwent a minimally invasive anatomic mesohepatectomy using a Glissonean pedicle approach from April 2018 to November 2021 were identified from a prospective database. Demographics, operative details, and postoperative outcomes were analyzed using descriptive statistics for continuous and categorical variables.

RESULTS

A total of ten patients were included, of whom five patients had hepatocellular carcinoma, one patient had cholangiocarcinoma, three patients had colorectal liver metastases, and one patient had a hydatid cyst. Two and eight patients underwent robotic-assisted and laparoscopic resections, respectively. The median operative time was 393 min (interquartile range (IQR) 298-573 min). Conversion to laparotomy was required in one case. The median lesion size was 60 mm and all cases had negative resection margins on final histopathological analysis. The median total blood loss was 550 ml (IQR 413-850 ml). One patient had a grade III complication. The median length of stay was 7 days (IQR 5-12 days). Time-to-functional recovery was achieved after a median of 2 days (IQR 1-4 days). There were no readmissions within 90 days after surgery.

CONCLUSION

Minimally invasive mesohepatectomy is a feasible and safe approach in selected patients with benign and malignant liver lesions.

Modified median hepatic fissure approach for resection of liver tumours located in the angle between the root of the middle and right hepatic veins

Background

Liver tumours between the root angle of the middle and right hepatic veins are a special type of liver segment VIII tumour. In this study, we designed a modified median hepatic fissure approach to remove these tumours. The safety and effectiveness of the approach were evaluated.

Materials and methods

From April 2015 to November 2019, 11 patients with liver tumours between the angle of the middle and right hepatic veins underwent this modified median hepatic fissure approach. We retrospectively analysed data from the perioperative periods of these 11 patients, including general condition, operation time, intraoperative bleeding, and postoperative complications. Disease-free survival and overall survival were assessed.

Results

Of the 11 patients, 9 patients had primary hepatocellular carcinoma and 2 had colorectal liver metastases. The average intraoperative blood loss was 285 mL (150–450 mL). Two patients developed postoperative bile leakage, but there were no significant serious complications, such as intraabdominal bleeding and liver failure, in any of the patients. The liver function returned to the normal range on the 5th day after surgery. Of the 11 patients, 5 have survived for more than 3 years (45.5%), and 4 have been disease-free for more than 3 years (36.3%).

Conclusions

For liver tumours between the root angle of the middle and right hepatic veins, the modified median hepatic fissure approach is a safe and feasible method.

A postresection perfusion deficit in the right colon is an independent predictor of perioperative outcome after major hepatectomy

BACKGROUND

There is a strong interaction between hepatic hemodynamics and perfusion in the splanchnic system. However, little is known about differences in perfusion in different splanchnic compartments and their changes after hepatectomy.

METHODS

Perfusion in various splanchnic compartments (ie, stomach, small intestine, right and left colon, liver) was assessed pre- and post-hepatectomy by intraoperative laser Doppler flowmetry. Differences of splanchnic perfusion between compartments were evaluated by ANOVA, and risk factors of postoperative complications (graded by the comprehensive complication index [CCI]) were analyzed by univariate and multivariate analyses. A prediction model of postoperative complications was developed.

RESULTS

A total of 50 and 29 patients with major and minor hepatectomy were enrolled. Splanchnic perfusion at baseline varied significantly across different splanchnic compartments with highest values in the small bowel and right colon (P < .001). Major hepatectomy induced a significant perfusion decrease in the stomach (P = .006), right colon (P < .001) and small bowel (P = .035). A postresection perfusion deficit in the right colon with values below 254 perfusion units (PU) was identified as an independent predictor of clinically relevant complications after major hepatectomy (concordance index: 0.79, 95% CI 0.66-0.87, P = .002). Bootstrap validation confirmed internal validity and excellent calibration.

CONCLUSIONS

Major hepatectomy causes significant reduction of splanchnic perfusion. An intraoperative posthepatectomy microcirculatory perfusion deficit of the right colon is a strong and independent predictor of clinically relevant postoperative complications after major hepatectomy.

Pre- vs. postoperative initiation of thromboprophylaxis in liver surgery

BACKGROUND

Thromboprophylaxis protocols in liver surgery vary greatly worldwide. Due to limited research, there is no consensus whether the administration of thromboprophylaxis should be initiated pre- or postoperatively.

METHODS

Patients undergoing liver resection in Helsinki University Hospital between 2014 and 2017 were reviewed retrospectively. Initiation of thromboprophylaxis was changed in the institution in the beginning of 2016 from postoperative to preoperative. Patients were classified into two groups for analyses: thromboprophylaxis initiated preoperatively (Preop-group) or postoperatively (Postop-group). The incidences of VTE and haemorrhage within 30 days of surgery were compared between these groups. Patients with permanent anticoagulation were excluded.

RESULTS

A total of 512 patients were included to the study (Preop, n = 253, Postop, n = 259). The incidence of VTE was significantly lower in the Preop-group compared to the Postop-group (3 (1.2%) vs. 25 (9.7%), P = <.0001), mainly due to a lower incidence of pulmonary embolisms in the Preop-group (3 (1.2%) vs. 24 (9.3%), P < .0001). The rates of posthepatectomy haemorrhage within 30 days of surgery were similar (Preop 38 (15.0%) vs. Postop 36 (13.9%), p = .719).

CONCLUSION

Initiating thromboprophylaxis preoperatively may reduce the incidence of postoperative VTE without affecting the incidence of posthepatectomy haemorrhage in patients undergoing liver resection.

Infrahepatic Inferior Vena Cava Clamping does not Increase the Risk of Pulmonary Embolism Following Hepatic Resection

BACKGROUND

Infrahepatic inferior vena cava (IVC) clamping reduces central venous pressure. However, controversies remain regarding its impact on postoperative complications, particularly, the incidence of postoperative pulmonary embolism (PE). The aim of the study was to determine the impact of IVC clamping on the incidence of PE in patients undergoing hepatectomy.

METHODS

A pooled analysis of five prospective trials on patients who underwent hepatic resection over a period of 10 years was performed. Patients with infrahepatic IVC clamping were compared to patients without infrahepatic IVC clamping. Outcomes were studied by univariate and multivariate analyses.

RESULTS

Of 505 included patients, 141 patients had IVC clamping and 364 patients served as control group. The rate of postoperative PE was comparable between groups (3% vs. 3%; P = 0.762), as were postoperative morbidity (P = 0.932), bile leakage (P = 0.272), posthepatectomy hemorrhage (P = 0.095), and posthepatectomy liver failure (P = 0.605), respectively. No clinicopathological and intraoperative risk factors were found to predict the onset of PE. Subgroup analyses of patients with major hepatectomy and vascular resections confirmed no adverse perioperative outcomes to be associated with IVC clamping.

CONCLUSIONS

Infrahepatic IVC clamping does not increase the incidence of postoperative PE.

BestFLR Trial: Liver Regeneration at CT before Major Hepatectomies for Liver Cancer-A Randomized Controlled Trial Comparing Portal Vein Embolization with N-Butyl-Cyanoacrylate Plus Iodized Oil versus Polyvinyl Alcohol Particles Plus Coils

Background In patients with liver cancer, portal vein embolization (PVE) is recommended to promote liver growth before major hepatectomies. However, the optimal embolization strategy has not been established. Purpose To compare liver regeneration as seen at CT in participants with liver cancer, before major hepatectomies, with N-butyl-cyanoacrylate (NBCA) plus iodized oil versus standard polyvinyl alcohol (PVA) particles plus coils, for PVE. Materials and Methods In this single-center, prospective, randomized controlled trial (Best Future Liver Remnant, or BestFLR, trial; International Standard Randomized Controlled Trial Number 16062796), PVE with NBCA plus iodized oil was compared with standard PVE with PVA particles plus coils in participants with liver cancer. Participant recruitment started in November 2017 and ended in March 2020. Participants were randomly assigned to undergo PVE with PVA particles plus coils or PVE with NBCA plus iodized oil. The primary end point was liver growth assessed with CT 14 days and 28 days after PVE. Secondary outcomes included posthepatectomy liver failure, surgical complications, and length of intensive care treatment and hospital stay. The Mann-Whitney U test was used to compare continuous outcomes according to PVE material, whereas the Χ² test or Fisher exact test was used for categoric variables. Results Sixty participants (mean age, 61 years ± 11 [standard deviation]; 32 men) were assigned to the PVA particles plus coils group (n = 30) or to the NBCA plus iodized oil group (n = 30). Interim analysis revealed faster and superior liver hypertrophy for the NBCA plus iodized oil group versus the PVA particles plus coils group 14 days and 28 days after PVE (absolute hypertrophy of 46% vs 30% [P < .001] and 57% vs 37% [P < .001], respectively). Liver growth for the proposed hepatectomy was achieved in 87% of participants (26 of 30) in the NBCA plus iodized oil group versus 53% of participants (16 of 30) in the PVA particles plus coils group (P = .008) 14 days after PVE. Liver failure occurred in 13% of participants (three of 24) in the NBCA plus iodized oil group and in 27% of participants (six of 22) in the PVA particles plus coils group (P = .27). Conclusion Portal vein embolization with N-butyl-cyanoacrylate plus iodized oil produced greater and faster liver growth as seen at CT in participants with liver cancer, compared with portal vein embolization with polyvinyl alcohol particles plus coils, allowing for earlier surgical intervention. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Arellano in this issue.

Analysis of economic impact of laparoscopic liver resection according to surgical difficulty

INTRODUCTION

The advantages of laparoscopic liver resection (LLR) are well known, but their financial costs are poorly evaluated. The aim of this study was to analyze the economic impact of surgical difficulty on LLR costs, and to identify clinical factors that most affect global charges.

METHODS

All patients who underwent LLR from 2014 to 2018 in a single French center were included. The IMM classification was used to stratify surgical difficulty, from group I through group III. The costing method was done combining top-down and bottom-up approaches. A multivariate analysis was performed in order to identify clinical factors that most affect global charges.

RESULTS

Two hundred seventy patients were included (Group I: n = 136 (50%), Group II: n = 60 (22%), Group III: n = 74 (28%)). Total expenses significantly increased (p < 0.001) from Group I to Group III, but there was no difference regarding financial income (p = 0.133). Technical platform expenses significantly increased (p < 0.001) from Group I to Group III and represented the main expense among all costs with a total of 4 930 ± 2 601€. Among technical platform expenses, the anesthesia platform represented the main expense. In multivariate analysis, the four clinical factors that affected global charges in the whole study population were operating time (p < 0.001), length of stay (p < 0.001), admission in ICU (p < 0.001) and the occurrence of major complication (p < 0.05). An admission in ICU was the clinical factor that affected most global charges, as an ICU stay had a 39.1% increase effect on global charges in the whole study population.

CONCLUSION

LLR is a cost-effective procedure. The more complex is the LLR, the higher is the hospital cost. An admission in ICU was the clinical factor that most affected global charges.

Preoperative leukocytosis and the resection severity index are independent risk factors for survival in patients with intrahepatic cholangiocarcinoma

PURPOSE

The incidence of intrahepatic cholangiocarcinoma is increasing worldwide. Despite advances in surgical and non-surgical treatment, reported outcomes are still poor and surgical resection remains to be the only chance for long-term survival of affected patients. The identification and validation of prognostic factors and scores, such as the recently introduced resection severity index, for postoperative morbidity and mortality are essential to facilitate optimal therapeutic regimens.

METHODS

This is a retrospective analysis of 269 patients undergoing resection of histologically confirmed intrahepatic cholangiocarcinoma between February 1996 and September 2018 at a tertiary referral center for hepatobiliary surgery. Regression analyses were performed to evaluate potential prognostic factors, including the resection severity index.

RESULTS

Median postoperative follow-up time was 22.93 (0.10-234.39) months. Severe postoperative complications (≥ Clavien-Dindo grade III) were observed in 94 (34.9%) patients. The body mass index (p = 0.035), the resection severity index (ASAT in U/l divided by Quick in % multiplied by the extent of liver resection graded in points; p = 0.006), additional hilar bile duct resection (p = 0.005), and number of packed red blood cells transfused during operation (p = 0.036) were independent risk factors for the onset of severe postoperative complications. Median Kaplan-Meier survival after resection was 27.63 months. Preoperative leukocytosis (p = 0.003), the resection severity index (p = 0.005), multivisceral resection (p = 0.001), and T stage ≥ 3 (p = 0.013) were identified as independent risk factors for survival.

CONCLUSION

Preoperative leukocytosis and the resection severity index are useful variables for preoperative risk stratification since they were identified as significant predictors for postoperative morbidity and mortality, respectively.

In-hospital mortality and failure to rescue following hepatobiliary surgery in Germany - a nationwide analysis

BACKGROUND

Recent observational studies on volume-outcome associations in hepatobiliary surgery were not designed to account for the varying extent of hepatobiliary resections and the consequential risk of perioperative morbidity and mortality. Therefore, this study aimed to determine the risk-adjusted in-hospital mortality for minor and major hepatobiliary resections at the national level in Germany and to examine the effect of hospital volume on in-hospital mortality, and failure to rescue.

METHODS

All inpatient cases of hepatobiliary surgery (n = 31,114) in Germany from 2009 to 2015 were studied using national hospital discharge data. After ranking hospitals according to increasing hospital volumes, five volume categories were established based on all hepatobiliary resections. The association between hospital volume and in-hospital mortality following minor and major hepatobiliary resections was evaluated by multivariable regression methods.

RESULTS

Minor hepatobiliary resections were associated with an overall mortality rate of 3.9% and showed no significant volume-outcome associations. In contrast, overall mortality rate of major hepatobiliary resections was 10.3%. In this cohort, risk-adjusted in-hospital mortality following major resections varied widely across hospital volume categories, from 11.4% (95% CI 10.4-12.5) in very low volume hospitals to 7.4% (95% CI 6.6-8.2) in very high volume hospitals (risk-adjusted OR 0.59, 95% CI 0.41-0.54). Moreover, rates of failure to rescue decreased from 29.38% (95% CI 26.7-32.2) in very low volume hospitals to 21.38% (95% CI 19.2-23.8) in very high volume hospitals.

CONCLUSIONS

In Germany, patients who are undergoing major hepatobiliary resections have improved outcomes, if they are admitted to higher volume hospitals. However, such associations are not evident following minor hepatobiliary resections. Following major hepatobiliary resections, 70-80% of the excess mortality in very low volume hospitals was estimated to be attributable to failure to rescue.

A falciform ligament flap surface sealing technique for laparoscopic and robotic-assisted liver surgery

Whether sealing the hepatic resection surface after liver surgery decreases morbidity is still unclear. Nevertheless, various methods and materials are currently in use for this procedure. Here, we describe our experience with a simple technique using a mobilized falciform ligament flap in minimally invasive liver surgery (MILS). We retrospectively analyzed the charts from 46 patients who received minor MILS between 2011 and 2019 from the same surgical team in a university hospital setting in Germany. Twenty-four patients underwent laparoscopic liver resection, and 22 patients received robotic-assisted liver resection. Sixteen patients in the laparoscopic group and fourteen in the robotic group received a falciform ligament flap (FLF) to cover the resection surface after liver surgery. Our cohort was thus divided into two groups: laparoscopic and robotic patients with (MILS + FLF) and without an FLF (MILS-FLF). Twenty-eight patients (60.9%) in our cohort were male. The overall mean age was 56.8 years (SD 16.8). The mean operating time was 249 min in the MILS + FLF group vs. 235 min in the MILS-FLF group (p = 0.682). The mean blood loss was 301 ml in the MILS + FLF group vs. 318 ml in the MILS-FLF group (p = 0.859). Overall morbidity was 3.3% in the MILS + FLF group vs. 18.8% in the MILS-FLF group (p = 0.114). One patient in the MILS-FLF group (overall 2.2%), who underwent robotic liver surgery, developed bile leakage, but this did not occur in the MILS + FLF group. Covering the resection surface of the liver after minor minimally invasive liver resection with an FLF is a simple and cost-effective technique that does not prolong surgical time or negatively affect other perioperative parameters. In fact, it is a safe add-on step during MILS that may reduce postoperative morbidity. Further studies with larger cohorts will be needed to substantiate our proof of concept and results.

Remote Ischemic Preconditioning in a Cirrhotic Patient Undergoing Major Hepatectomy

Remote ischemic preconditioning (RIPC) has been shown to reduce ischemic reperfusion injury for patients undergoing hepatectomy for colorectal liver metastasis. We present a case of a 69-year-old male who underwent right hepatectomy for a multifocal hepatocellular carcinoma of the right liver and concomitant liver cirrhosis (Child-Pugh stage A). We performed portal vein embolization prior to surgery and intraoperative RIPC of the iliac vessels. The postoperative course after major hepatectomy went uneventful.

Coagulation in liver surgery: an observational haemostatic profile and thromboelastography study

BACKGROUND

International normalized ratio (INR) is used as a marker of the haemostatic status following liver resection. However, the impact of liver resection on haemostasis is complex and beyond what can be measured by INR. This study aimed to prospectively assess haemostatic profile following liver resection and determine if INR measurement can safely guide post-operative thromboprophylaxis.

METHODS

In this prospective cohort study, patients undergoing liver resection had coagulation parameters (International normalised ratio (INR), prothrombin time (PT), activated partial thromboplastin time, fibrinogen, d-dimer, von Willebrand factor antigen, procoagulant activity of phospholipids and clotting factors II, VII, VIIIc, IX and X) and thromboelastogram parameters assessed perioperatively. Clinical follow-up assessed for thromboembolism and haemorrhage.

RESULTS

In the 41 patients included, INR was significantly (P < 0.0001) elevated post-operatively, and INR >1.5 was observed in seven of 41 (17.1%) on post-operative day 1 and one of 41 (2.4%) patients on post-operative day 3, respectively. Factor VII levels showed transient reduction but other factors, especially factors II and X, remained within normal range following liver resection. Thromboelastogram parameters remained normal or supranormal for all patients at all time points. One incident of post-hepatectomy haemorrhage occurred, despite a normal coagulation profile. Two patients suffered late pulmonary embolic episodes.

CONCLUSION

Post liver resection haemostasis is complex and poorly reflected by INR, which should not guide initiation of chemical thromboprophylaxis in the immediate post-operative period.

Contralateral Liver Hypertrophy and Oncological Outcome Following Radioembolization with 90Y-Microspheres: A Systematic Review

Radioembolization with ⁹⁰Y-microspheres has been reported to induce contralateral liver hypertrophy with simultaneous ipsilateral control of tumor growth. The aim of the present systematic review was to summarize the evidence of contralateral liver hypertrophy and oncological outcome following unilateral treatment with radioembolization. A systematic literature search using the MEDLINE, EMBASE, and Cochrane libraries for studies published between 2008 and 2020 was performed. A total of 16 studies, comprising 602 patients, were included. The median kinetic growth rate per week of the contralateral liver lobe was 0.7% and declined slightly over time. The local tumor control was 84%. Surgical resection after radioembolization was carried out in 109 out of 362 patients (30%). Although the available data suggest that radioembolization prior to major hepatectomy is safe with a promising oncological outcome, the definitive role of radioembolization requires assessment within controlled clinical trials.