Novel Benchmark Values for Open Major Anatomic Liver Resection in Non-cirrhotic Patients: A Multicentric Study of 44 International Expert Centers

OBJECTIVE

This study aims at establishing benchmark values for best achievable outcomes following open major anatomic hepatectomy for liver tumors of all dignities.

BACKGROUND

Outcomes after open major hepatectomies vary widely lacking reference values for comparisons among centers, indications, types of resections, and minimally invasive procedures.

METHODS

A standard benchmark methodology was used covering consecutive patients, who underwent open major anatomic hepatectomy from 44 high-volume liver centers from 5 continents over a 5-year period (2016-2020). Benchmark cases were low-risk non-cirrhotic patients without significant comorbidities treated in high-volume centers (≥30 major liver resections/year). Benchmark values were set at the 75th percentile of median values of all centers. Minimum follow-up period was 1 year in each patient.

RESULTS

Of 8044 patients, 2908 (36%) qualified as benchmark (low-risk) cases. Benchmark cutoffs for all indications include R0 resection ≥78%; liver failure (grade B/C) ≤10%; bile leak (grade B/C) ≤18%; complications ≥grade 3 and CCI ® ≤46% and ≤9 at 3 months, respectively. Benchmark values differed significantly between malignant and benign conditions so that reference values must be adjusted accordingly. Extended right hepatectomy (H1, 4-8 or H4-8) disclosed a higher cutoff for liver failure, while extended left (H1-5,8 or H2-5,8) were associated with higher cutoffs for bile leaks, but had superior oncologic outcomes, when compared to formal left hepatectomy (H1-4 or H2-4). The minimal follow-up for a conclusive outcome evaluation following open anatomic major resection must be 3 months.

CONCLUSION

These new benchmark cutoffs for open major hepatectomy provide a powerful tool to convincingly evaluate other approaches including parenchymal-sparing procedures, laparoscopic/robotic approaches, and alternative treatments, such as ablation therapy, irradiation, or novel chemotherapy regimens.

HPB P01 Volatile Organic Compounds for the Detection of Hepatocellular Carcinoma – a Scoping Review

Background

Hepatocellular carcinoma (HCC) is an increasingly common disease and is classified as one of the most common cancers leading to mortality worldwide. Only a small percentage of patients with this disease are eligible to curative treatment. Quite often the main reason is the late diagnosis of the disease. In the last decade, a Nobel prize awarded discovery of the volatile organic compounds in the breath opened the frontiers for new diagnostic tools and methods for several diseases. Cancer is one of the target diseases that appears to have unique biomarkers in the breath of the affected individuals. This have been found true in colorectal, breast, lung cancers. This systematic review aims to answer the question if markers specific to hepatocellular carcinoma exist in exhaled breath and what is the current knowledge regarding its detection.

Methods

A systematic search was conducted by two reviewers and the Royal College of Surgeons of Edinburgh librarian using the Embase, Medline, PubMed and Web od Science databases. Search strategy included all studied published until the 24th of March 2021 containing combination of keywords (Hepatocellular carcinoma, hepatocellular neoplasm, hepatocellular cancer, hepatocellular tumor, hepatocellular tumour, HCC, liver cancer, liver carcinoma, liver neoplasm, liver tumor, liver tumour AND volatile organic compound, VOC, volatilome, volatilomics, metabolome, metabolomics, breath analysis).

Results

The search yielded 6 publications using PRISMA pathway. Two of the studies described in vitro experiments and four were conducted on a small number of groups of patients. Overall, in the in vitro studies 42 headspace gases were analysed. Clinical studies included 164 patients with HCC and as control groups - 110 patients with cirrhosis and 130 healthy individuals.

Multiple VOCs were found in the studies. Following their identification in PubChem library, a pathway analysis was performed using the Kyoto Encyclopaedia of Genes and Genomes (KEGG). Only three VOCs were annotated in the KEGG maps and out of those, two could be traced back to their biological pathways. These are acetaldehyde and ethanol which participate in glycolysis and gluconeogenesis (Figure 1).

Conclusions

At present time there are no specific volatile biomarker in exhaled breath characterising hepatocellular carcinoma. Data on extracted studies emphasised lack of unified methodology. This review, however, highlighted metabolic pathway which might be the source of VOCs produced by cancerous hepatocytes. Large population studies are required to verify this finding.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Primary hepatic leiomyoma: unusual cause of an intrahepatic mass

Leiomyomas are benign lesions arising from the smooth muscle layer. They are most commonly detected either within the gastrointestinal or genitourinary tracts. Primary hepatic leiomyoma (PHL) is a rare pathology. It is an isolated pathology within the liver, without evidence of any other coexisting leiomyomas. Very few cases have been described in literature. PHL may occur in healthy individuals although an association with immunodeficiency and Epstein-Barr virus (EBV) infection has been observed. Majority of the reported cases have been in females. A 20-year-old female patient presented with abdominal symptoms. MRI confirmed an 8 cm mass, with very low signal intensity on T2 images and peripheral rim enhancement on gadolinium. A laparoscopic left lateral sectorectomy was performed. Final histopathology confirmed the presence of benign lesion with spindle cell and smooth muscle proliferation and a fibro-vascular stroma compatible with a leiomyoma. There was no evidence of any leiomyomatous lesion elsewhere in the body. A rare diagnosis of PHL was therefore established. Acknowledging the rare incidence of this lesion, we report the same and review the relevant literature. PHL is usually a retrospective diagnosis, confirmed on histo-pathology assessment of the resected specimen. Liver resection is required in these patients due to the presence of symptoms, in the presence of a solid mass lesion within the liver. Surgery is thus definitive, diagnostic cum therapeutic.