Hospital variation and outcomes after repeat hepatic resection for colorectal liver metastases: a nationwide cohort study

BACKGROUND

Approximately 70% of patients with colorectal liver metastases (CRLM) experiences intrahepatic recurrence after initial liver resection. This study assessed outcomes and hospital variation in repeat liver resections (R-LR).

METHODS

This population-based study included all patients who underwent liver resection for CRLM between 2014 and 2022 in the Netherlands. Overall survival (OS) was collected for patients operated on between 2014 and 2018 by linkage to the insurance database.

RESULTS

Data of 7479 liver resections (1391 (18.6%) repeat and 6088 (81.4%) primary) were analysed. Major morbidity and mortality were not different. Factors associated with major morbidity included ASA 3+, major liver resection, extrahepatic disease, and open surgery. Five-year OS after repeat versus primary liver resection was 42.3% versus 44.8%, P = 0.37. Factors associated with worse OS included largest CRLM >5 cm (aHR 1.58, 95% CI: 1.07-2.34, P = 0.023), >3 CRLM (aHR 1.33, 95% CI: 1.00-1.75, P = 0.046), extrahepatic disease (aHR 1.60, 95% CI: 1.25-2.04, P = 0.001), positive tumour margins (aHR 1.42, 95% CI: 1.09-1.85, P = 0.009). Significant hospital variation in performance of R-LR was observed, median 18.9% (8.2% to 33.3%).

CONCLUSION

Significant hospital variation was observed in performance of R-LR in the Netherlands reflecting different treatment decisions upon recurrence. On a population-based level R-LR leads to satisfactory survival.

Implementation and Outcome of Robotic Liver Surgery in the Netherlands: A Nationwide Analysis

OBJECTIVE

To determine the nationwide implementation and surgical outcome of minor and major robotic liver surgery (RLS) and assess the first phase of implementation of RLS during the learning curve.

BACKGROUND

RLS may be a valuable alternative to laparoscopic liver surgery. Nationwide population-based studies with data on implementation and outcome of RLS are lacking.

METHODS

Multicenter retrospective cohort study including consecutive patients who underwent RLS for all indications in 9 Dutch centers (August 2014-March 2021). Data on all liver resections were obtained from the mandatory nationwide Dutch Hepato Biliary Audit (DHBA) including data from all 27 centers for liver surgery in the Netherlands. Outcomes were stratified for minor, technically major, and anatomically major RLS. Learning curve effect was assessed using cumulative sum analysis for blood loss.

RESULTS

Of 9437 liver resections, 400 were RLS (4.2%) procedures including 207 minor (52.2%), 141 technically major (35.3%), and 52 anatomically major (13%). The nationwide use of RLS increased from 0.2% in 2014 to 11.9% in 2020. The proportion of RLS among all minimally invasive liver resections increased from 2% to 28%. Median blood loss was 150 mL (interquartile range 50-350 mL] and the conversion rate 6.3% (n=25). The rate of Clavien-Dindo grade ≥III complications was 7.0% (n=27), median length of hospital stay 4 days (interquartile range 2-5) and 30-day/in-hospital mortality 0.8% (n=3). The R0 resection rate was 83.2% (n=263). Cumulative sum analysis for blood loss found a learning curve of at least 33 major RLS procedures.

CONCLUSIONS

The nationwide use of RLS in the Netherlands has increased rapidly with currently one-tenth of all liver resections and one-fourth of all minimally invasive liver resections being performed robotically. Although surgical outcomes of RLS in selected patient seem favorable, future prospective studies should determine its added value.

Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3)

OBJECTIVE

To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation.

BACKGROUND

Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking.

METHODS

A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit.

RESULTS

Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%.

CONCLUSIONS

This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.

Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in the Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial

BACKGROUND

Early recognition and management of postoperative complications, before they become clinically relevant, can improve postoperative outcomes for patients, especially for high-risk procedures such as pancreatic resection.

METHODS

We did an open-label, nationwide, stepped-wedge cluster-randomised trial that included all patients having pancreatic resection during a 22-month period in the Netherlands. In this trial design, all 17 centres that did pancreatic surgery were randomly allocated for the timing of the crossover from usual care (the control group) to treatment given in accordance with a multimodal, multidisciplinary algorithm for the early recognition and minimally invasive management of postoperative complications (the intervention group). Randomisation was done by an independent statistician using a computer-generated scheme, stratified to ensure that low-medium-volume centres alternated with high-volume centres. Patients and investigators were not masked to treatment. A smartphone app was designed that incorporated the algorithm and included the daily evaluation of clinical and biochemical markers. The algorithm determined when to do abdominal CT, radiological drainage, start antibiotic treatment, and remove abdominal drains. After crossover, clinicians were trained in how to use the algorithm during a 4-week wash-in period; analyses comparing outcomes between the control group and the intervention group included all patients other than those having pancreatic resection during this wash-in period. The primary outcome was a composite of bleeding that required invasive intervention, organ failure, and 90-day mortality, and was assessed by a masked adjudication committee. This trial was registered in the Netherlands Trial Register, NL6671.

FINDINGS

From Jan 8, 2018, to Nov 9, 2019, all 1805 patients who had pancreatic resection in the Netherlands were eligible for and included in this study. 57 patients who underwent resection during the wash-in phase were excluded from the primary analysis. 1748 patients (885 receiving usual care and 863 receiving algorithm-centred care) were included. The primary outcome occurred in fewer patients in the algorithm-centred care group than in the usual care group (73 [8%] of 863 patients vs 124 [14%] of 885 patients; adjusted risk ratio [RR] 0·48, 95% CI 0·38-0·61; p<0·0001). Among patients treated according to the algorithm, compared with patients who received usual care there was a decrease in bleeding that required intervention (47 [5%] patients vs 51 [6%] patients; RR 0·65, 0·42-0·99; p=0·046), organ failure (39 [5%] patients vs 92 [10%] patients; 0·35, 0·20-0·60; p=0·0001), and 90-day mortality (23 [3%] patients vs 44 [5%] patients; 0·42, 0·19-0·92; p=0·029).

INTERPRETATION

The algorithm for the early recognition and minimally invasive management of complications after pancreatic resection considerably improved clinical outcomes compared with usual care. This difference included an approximate 50% reduction in mortality at 90 days.

FUNDING

The Dutch Cancer Society and UMC Utrecht.

Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage

BACKGROUND

Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication.

METHODS

All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage.

RESULTS

Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2).

CONCLUSION

Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.

Pancreatoduodenectomy for distal cholangiocarcinoma 13 years after oesophagectomy with gastric tube reconstruction: report of a case

Advancements in cancer management have led to improved survival in patients with oesophageal cancer. This has resulted in an increased incidence of second primary malignancies with the pancreas as a common secondary cancer site. Resectable pancreatic and periampullary cancers are treated by pancreatoduodenectomy, including resection of the gastroduodenal artery which provides the blood supply to the gastric conduit in patients who underwent oesophagectomy. A 77-year-old man with a history of distal oesophageal cancer, for which an oesophagectomy with gastric tube reconstruction was performed, presented in the emergency department. Extensive workup showed a lesion suspected for a distal cholangiocarcinoma. Pancreatoduodenectomy was deemed feasible after arterial angiography revealed that the gastric conduit was dominantly vascularised by the right gastric artery. Adequate imaging of the blood supply is essential to determine eligibility for pancreatoduodenectomy in patients with a second primary malignancy in the pancreas or periampullary region after oesophagectomy with gastric tube reconstruction.

Hospital variation and outcomes of simultaneous resection of primary colorectal tumour and liver metastases: a population-based study

BACKGROUND

The optimal treatment sequence for patients with synchronous colorectal liver metastases (CRLM) remains uncertain. This study aimed to assess factors associated with the use of simultaneous resections and impact on hospital variation.

METHOD

This population-based study included all patients who underwent liver surgery for synchronous colorectal liver metastases between 2014 and 2019 in the Netherlands. Factors associated with simultaneous resection were identified. Short-term surgical outcomes of simultaneous resections and factors associated with 30-day major morbidity were evaluated.

RESULTS

Of 2146 patients included, 589 (27%) underwent simultaneous resection in 28 hospitals. Simultaneous resection was associated with age, sex, BMI, number, size and bilobar distribution of CRLM, and administration of preoperative chemotherapy. More minimally invasive and minor resections were performed in the simultaneous group. Hospital variation was present (range 2.4%-83.3%) with several hospitals performing simultaneous procedures more and less frequently than expected. Simultaneous resection resulted in 13% 30-day major morbidity, and 1% mortality. ASA classification ≥3 was independently associated with higher 30-day major morbidity after simultaneous resection (aOR 1.97, CI 1.10-3.42, p = 0.018).

CONCLUSION

Distinctive patient and tumour characteristics influence the choice for simultaneous resection. Remarkable hospital variation is present in the Netherlands.

Surgical outcomes of laparoscopic and open resection of benign liver tumours in the Netherlands: a nationwide analysis

BACKGROUND

Data on surgical outcomes of laparoscopic liver resection (LLR) versus open liver resection (OLR) of benign liver tumour (BLT) are scarce. This study aimed to provide a nationwide overview of postoperative outcomes after LLR and OLR of BLT.

METHODS

This was a nationwide retrospective study including all patients who underwent liver resection for hepatocellular adenoma, haemangioma and focal nodular hyperplasia in the Netherlands from 2014 to 2019. Propensity score matching (PSM) was applied to compare 30-day overall and major morbidity and 30-day mortality after OLR and LLR.

RESULTS

In total, 415 patients underwent BLT resection of whom 230 (55.4%) underwent LLR. PSM for OLR and LLR resulted in 250 matched patients. Median (IQR) length of stay was shorter after LLR than OLR (4 versus 6 days, 5.0-8.0, p < 0.001). Postoperative 30-day overall morbidity was lower after LLR than OLR (12.0% vs. 22.4%, p = 0.043). LLR was associated with reduced 30-day overall morbidity in multivariable analysis (aOR:0.46, CI:0.22-0.95, p = 0.043). Both 30-day major morbidity and 30-day mortality were not different.

CONCLUSIONS

LLR for BLT is associated with shorter hospital stay and reduced overall morbidity and is preferred if technically feasible.

Stepwise implementation of robotic surgery in a high volume HPB practice in the Netherlands

BACKGROUND

Aims of this study were to describe the stepwise implementation and expansion of robotic HPB surgery in a high volume HPB unit in the Netherlands and to analyze clinical outcomes of all robotic liver resections and robotic pancreatoduodenectomies performed within this program.

METHODS

After proctoring by expert international surgeons, HPB surgeons were introduced to robotic liver resection and robotic pancreatoduodenectomy in a stepwise fashion. Data from two prospective databases containing all consecutive patients who underwent robotic liver resection or robotic pancreatoduodenectomy between August 1st, 2015 and March 1st, 2019 were analyzed post hoc.

RESULTS

In total, 77 consecutive robotic liver resections and 68 consecutive robotic pancreatoduodenectomies were performed. Five surgeons were consecutively introduced to robotic HPB surgery. Mean operative time for robotic liver resection was 160 ± 78 min. Mean operative time for robotic pancreatoduodenectomy was 420 ± 67 min. Operative times remained stable over time and were not affected by the introduction of new surgeons.

CONCLUSION

Stepwise implementation and expansion of robotic HPB surgery within one unit over a three-and-half year period is feasible and associated with good clinical outcomes. Despite introducing new surgeons to the technique, operative times, an indicator of the learning process, remained stable over time.

Population-based study on practice variation regarding preoperative systemic chemotherapy in patients with colorectal liver metastases and impact on short-term outcomes

INTRODUCTION

Definitions regarding resectability and hence indications for preoperative chemotherapy vary. Use of preoperative chemotherapy may influence postoperative outcomes. This study aimed to assess the variation in use of preoperative chemotherapy for CRLM and related postoperative outcomes in the Netherlands.

MATERIALS AND METHODS

All patients who underwent liver resection for CRLM in the Netherlands between 2014 and 2018 were included from a national database. Case-mix factors contributing to the use of preoperative chemotherapy, hospital variation and postoperative outcomes were assessed using multivariable logistic regression. Postoperative outcomes were postoperative complicated course (PCC), 30-day morbidity and 30-day mortality.

RESULTS

In total, 4469 patients were included of whom 1314 patients received preoperative chemotherapy and 3155 patients did not. Patients receiving chemotherapy were significantly younger (mean age (+SD) 66.3 (10.4) versus 63.2 (10.2) p < 0.001) and had less comorbidity (Charlson scores 2+ (24% versus 29%, p = 0.010). Unadjusted hospital variation concerning administration of preoperative chemotherapy ranged between 2% and 55%. After adjusting for case-mix factors, three hospitals administered significantly more preoperative chemotherapy than expected and six administered significantly less preoperative chemotherapy than expected. PCC was 12.1%, 30-day morbidity was 8.8% and 30-day mortality was 1.5%. No association between preoperative chemotherapy and PCC (OR 1.24, 0.98-1.55, p = 0.065), 30-day morbidity (OR 1.05, 0.81-1.39, p = 0.703) or with 30-day mortality (OR 1.22, 0.75-2.09, p = 0.467) was found.

CONCLUSION

Significant hospital variation in the use of preoperative chemotherapy for CRLM was present in the Netherlands. No association between postoperative outcomes and use of preoperative chemotherapy was found.

Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands

BACKGROUND

While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale.

METHODS

Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume.

RESULTS

Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0-13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117-239) versus 200 (139-308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040).

CONCLUSION

The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.

[Robot-assisted Whipple resection; results of the first 100 procedures in the Netherlands]

OBJECTIVE

Investigation into the results of robot-assisted Whipple resection in the Netherlands. These results were compared with those of open Whipple procedures on the basis of recent large case series of patients.

DESIGN

Case series of patients and systematic literature review.

METHOD

We carried out a post hoc analysis of prospectively collected data on the first 100 consecutive patients who underwent robot-assisted Whipple procedures in the period from March 2016 until March 2018 at the Erasmus MC, the Maasstad hospital or the Regional Academic Cancer Centre Utrecht. We were mainly interested in surgery characteristics and postoperative outcomes. We compared our results with those of case series of patients with more than 500 open Whipple procedures carried out in a single hospital, published in the last 5 years.

RESULTS

There were one or more serious complications in 22 patients (22%) and 2 patients (2%) developed multiple organ failure. 7 patients (7%) underwent reoperation. There was no postoperative mortality. In 14 case series (n = 12,708), complications occurred in 38% of patients and 7% of patients underwent reoperation. Mean mortality rate was 3%.

CONCLUSION

Our findings show that robotic Whipple procedures can be carried out safely in the Netherlands. The number of complications and mortality rates are comparable with results of large case series of patients who underwent open Whipple procedures in a centre of expertise.

Pancreatoduodenectomy with colon resection for pancreatic cancer: a systematic review

BACKGROUND

Radical resection of advanced pancreatic cancer may occasionally require a simultaneous colon resection. The risks and benefits of this combined procedure are largely unknown. This systematic review aimed to assess short and long term outcome after pancreatoduodenectomy with colon resection (PD-colon) for pancreatic ductal adenocarcinoma (PDAC).

METHODS

A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies published between 1994 and 2017 concerning PD-colon for PDAC.

RESULTS

After screening 2038 articles, 5 articles with a total of 181 patients undergoing PD-colon were eligible for inclusion. Included studies showed a relatively low risk of bias. The pooled complication rate was 73% (95% CI 61-84) including a pooled colonic anastomotic leak rate of 5.5%. Pooled mortality was 10% (95% CI 6-15). Pooled mean survival (data from 86 patients) was 18 months (95% CI 13-23) with pooled 3- and 5-year survival of 31% (95% CI 20-72) and 19% (95% CI 6-38).

CONCLUSION

Based on the available data, PD-colon for PDAC seems to be associated with an increased morbidity and mortality but with survival comparable with standard PD in selected patients. Future large series are needed to allow for better patient selection for PD-colon.

Systematic Review and Meta-Analysis of Liver Resection for Colorectal Metastases in Elderly Patients

BACKGROUND

This systematic review and meta-analysis evaluated the short- and long-term outcomes of liver resection for colorectal liver metastases (CRLM) in elderly patients.

METHODS

A PubMed, EMBASE, and Cochrane Library search was performed from January 1995 to April 2017, for studies comparing both short- and long-term outcomes in younger and elderly patients undergoing liver resection for CRLM.

RESULTS

Eleven studies comparing patients aged <70 years with patients aged >70 years and 4 studies comparing patients aged <75 years with patients aged >75 years were included. Postoperative morbidity was similar in patients aged >70 years (27 vs. 30%; p = 0.35) but higher in patients aged >75 years (21 vs. 32%; p = 0.001). Postoperative mortality was higher in both patients aged >70 years (2 vs. 4%; p = 0.01) and in patients aged >75 years (1 vs. 6%; p = 0.02). Mean 5-year overall survival was lower in patients aged >70 years (40 vs. 32%; p < 0.001) but equal in patients aged >75 years (42 vs. 32%; p = 0.06).

CONCLUSION

Although postoperative morbidity and mortality were increased with higher age, liver resection for CRLM seems justified in selected elderly patients.

Combined liver and extrahepatic bile duct resection for biliary invasion of colorectal metastasis: a case-cohort analysis and systematic review

BACKGROUND

Colorectal liver metastases (CRLMs) with biliary invasion can be treated with a combined liver and extrahepatic bile duct resection. The aim of this study was to analyze outcomes of this procedure in a case-cohort analysis and systematic review.

METHODS

Consecutive patients who underwent a major liver resection for CRLM between 2003 and 2013 were selected from a single center prospective database, comparing patients with and without biliary invasion. A specific and a general search strategy were used to identify relevant articles in the systematic review.

RESULTS

Ten patients (13.2%) underwent combined liver and extrahepatic bile duct resection for CLRM with biliary invasion, among 76 patients included. An R0 resection was achieved in five of ten patients (50%); one of ten patients died postoperatively. Median overall survival was 19 months among patients with biliary invasion, versus 106 months among patients without biliary invasion (P=0.12). The systematic review yielded a large variability in 5-year survival after resection of CLRM with biliary invasion, ranging between 33-80%.

CONCLUSIONS

Surgical resection of CLRM with central biliary invasion is feasible, but survival in these patients tends to be lower due to a high rate of non-radical resections.

Pelvic floor rehabilitation to improve functional outcome after a low anterior resection: a systematic review

PURPOSE

Impaired functional outcome is common after a low anterior resection (LAR). Pelvic floor rehabilitation (PFR) might improve functional outcome after a LAR. The aim of this systematic review is to evaluate the effectiveness of PFR in improving functional outcome.

METHODS

PubMed, Embase, and the Cochrane Library were searched using the terms fecal incontinence, colorectal neoplasm/surgery, LAR, rectal cancer, anterior resection syndrome, bowel habit, pelvic floor, training, therapy, physical therapy, rehabilitation and biofeedback. Of the 125 identified records, 5 articles were included.

RESULTS

The 5 included studies reported on 321 patients, of which 286 patients (89%) underwent pelvic floor training. Three studies included patients with anterior resection syndrome after a LAR while the remaining studies included a series of patients after a LAR. Functional outcome was mostly assessed by using the Wexner incontinence scale. Quality of life was assessed in one study, and in three studies, rectal manometry was performed. After PFR, the functional outcome was improved in four studies, as was the quality of life.

CONCLUSION

This systematic review demonstrated that PFR is useful for improving the functional outcome after a LAR. The data are extracted from studies of limited quality, but the available evidence points to the effectiveness of the procedure.