Background
Traditional classifications for open liver resection are not always associated with surgical complexity and postoperative morbidity. The aim of this study was to test whether a three‐level ...classification for stratifying surgical complexity based on surgical and postoperative outcomes, originally devised for laparoscopic liver resection, is superior to classifications based on a previously reported survey for stratifying surgical complexity of open liver resections, minor/major nomenclature or number of resected segments.
Methods
Patients undergoing a first open liver resection without simultaneous procedures at MD Anderson Cancer Center (Houston cohort) or the University of Tokyo (Tokyo cohort) were studied. Surgical and postoperative outcomes were compared among three grades: I (wedge resection for anterolateral or posterosuperior segment and left lateral sectionectomy); II (anterolateral segmentectomy and left hepatectomy); III (posterosuperior segmentectomy, right posterior sectionectomy, right hepatectomy, central hepatectomy and extended left/right hepatectomy).
Results
In both the Houston (1878 patients) and Tokyo (1202) cohorts, duration of operation, estimated blood loss and comprehensive complication index score differed between the three grades (all P < 0·050) and increased in stepwise fashion from grades I to III (all P < 0·001). Left hepatectomy was associated with better surgical and postoperative outcomes than right hepatectomy, extended right hepatectomy and right posterior sectionectomy, although these four procedures were categorized as being of medium complexity in the survey‐based classification. Surgical outcomes of minor open liver resections also differed between the three grades (all P < 0·050). For duration of operation and blood loss, the area under the curve was higher for the three‐level classification than for the minor/major or segment‐based classification.
Conclusion
The three‐level classification may be useful in studies analysing open liver resection at Western and Eastern centres.
Antecedentes
Las clasificaciones tradicionales de la resección hepática abierta (open liver resection, OLR) por número de segmentos resecados, no siempre se asocian con la complejidad quirúrgica y la morbilidad postoperatoria. El objetivo de este estudio fue comprobar si una clasificación de 3 niveles para estratificar la complejidad quirúrgica en función de los resultados quirúrgicos y postoperatorios, ideada originalmente para la resección hepática laparoscópica, es superior a las clasificaciones basadas en una encuesta descrita previamente para estratificar la complejidad quirúrgica de los procedimientos de OLR, nomenclatura menor/mayor, o número de segmentos resecados.
Métodos
Se estudiaron pacientes sometidos a una primera OLR sin otros procedimientos quirúrgicos concomitantes en el hospital MD Anderson (cohorte de Houston) o en la Universidad de Tokio (cohorte de Tokio). Se compararon los resultados quirúrgicos y postoperatorios entre 3 grados: I (resección limitada para el segmento anterolateral o posterosuperior y seccionectomía izquierda); II (segmentectomía anterolateral y hepatectomía izquierda); III (segmentectomía posterosuperior, seccionectomía posterior derecha, hepatectomía derecha, hepatectomía central y hepatectomía ampliada izquierda/derecha).
Resultados
En ambas cohortes de Houston (n = 1.878) y Tokio (n = 1.202), el tiempo operatorio, las pérdidas estimadas de sangre, y el índice de complejidad integral (comprehensive complication index) variaba en los 3 grados (todos P < 0,05) y aumentaba paso a paso desde los grados I a III (todos P < 0,05). La hepatectomía izquierda se asociaba con mejores resultados quirúrgicos y postoperatorios que la hepatectomía derecha, hepatectomía derecha ampliada, y seccionectomía posterior derecha, aunque estos cuatro procedimientos fueron categorizados como de complejidad intermedia en la clasificación basada en la encuesta. Los resultados quirúrgicos de las OLRs menores también variaron en los 3 grados (todos P < 0,05). Para el tiempo operatorio y la pérdida sanguínea, el área bajo la curva fue mayor para la clasificación de 3 niveles en el estudio actual, que para la clasificación menor/mayor o la clasificación basada en los segmentos.
Conclusión
La clasificación en 3 niveles puede ser útil en estudios que analizan las resecciones hepáticas abiertas en centros occidentales y orientales.
In cohorts from the USA and Japan, the three‐level classification, originally reported for the complexity of laparoscopic liver resection, effectively stratified 11 different open liver resection procedures regarding surgical complexity and postoperative morbidity, and was superior to minor/major‐ or segment‐based classifications in stratifying procedures by surgical complexity.
Maybe useful in stratifying liver surgery
Background
High morbidity and mortality rates after pancreaticoduodenectomy (PD) have led to concentration of this surgery in high‐volume centres, with improved outcomes. The extent to which better ...outcomes might be apparent in a healthcare system where the mortality rate is already low is unclear.
Methods
The Japanese Diagnosis Procedure Combination database was used to identify patients undergoing PD between 2007 and 2010. Patient data included age, sex, co‐morbidities at admission, type of hospital, type of PD, and the year in which the patient was treated. Hospital volume was defined as the number of PDs performed annually at each hospital, and categorized into quintiles: very low‐, low‐, medium‐, high‐ and very high‐volume groups. The Charlson co‐morbidity index was calculated using the International Classification of Diseases, tenth revision, codes of co‐morbidities.
Results
A total of 10 652 patients who underwent PD in 848 hospitals were identified. The overall in‐hospital mortality rate after PD was 3·3 per cent (350 of 10 652), and for the groups ranged from 5·0 per cent for the very low‐volume group to 1·4 per cent for the very high‐volume group (P < 0·001). Multivariable analysis revealed a significant linear relationship between higher hospital volume and shorter postoperative length of stay compared with the very low‐volume group, and between increasing hospital volume and lower total costs.
Conclusion
A significant relationship exists between increasing hospital volume, lower in‐hospital mortality, shorter length of stay and lower costs for patients undergoing PD in Japan. Centralization of PD in this healthcare system is therefore justified.
The volume effect is important even when mortality is low
Background
The International Union Against Cancer (UICC) staging system for perihilar cholangiocarcinoma changed in 2009. The aim of this study was to validate and optimize the UICC system for these ...tumours.
Methods
This retrospective study was conducted in eight Japanese hospitals between 2001 and 2010. Perihilar cholangiocarcinoma was defined as a cholangiocarcinoma that involves the hilar bile duct, independent of the presence or absence of a liver mass component. The stratification ability of the UICC tumour node metastasis (TNM) system was compared with that of a modified system.
Results
Of 1352 patients, 35·9, 44·8 and 12·6 per cent had Bismuth type IV tumours, nodal metastasis (N1) and distant metastasis (M1) respectively. T4 tumours (43·2 per cent) and stage IVA (T4 Nany M0; 36·3 per cent) disease were most common. Survival was not significantly different between patients with T3 versus T4 tumours (P = 0·284). Survival for patients with stage IVA disease was comparable to that for patients with stage IIIB tumours (T1–3 N1 M0) (P = 0·426). Vascular invasion, pancreatic invasion, positive margin, N1 and M1 status were identified as independent predictors of survival. When Bismuth type IV tumours were removed from the T4 determinants and N1 tumours grouped together, the modified grouping had a higher linear trend χ2 and likelihood ratio χ2 compared with the original system (245·6 versus 170·3 respectively and 255·8 versus 209·3 respectively).
Conclusion
The present data suggest that minimal modification with removal of Bismuth type IV tumours from the T4 determinants and bundling of N1 disease may enhance the prognostic ability of the UICC system. However, this requires validation on an independent data set.
Seems to improve staging
To investigate the impact of random survival forest (RSF) classifier trained by radiomics features over the prediction of the overall survival of patients with resectable hepatocellular carcinoma ...(HCC).
The dynamic computed tomography data of 127 patients (97 men, 30 women; mean age, 68 years) newly diagnosed with resectable HCC were retrospectively analyzed. After manually setting the region of interest to include the tumor within the slice at its maximum diameter, texture analyses were performed with or without a Laplacian of Gaussian filter. Using the extracted 96 histogram based texture features, RSFs were trained using 5-fold cross-validation to predict the individual risk for each patient on disease free survival (DFS) and overall survival (OS). The associations between individual risk and DFS or OS were evaluated using Kaplan-Meier analysis. The effects of the predicted individual risk and clinical variables upon OS were analyzed using a multivariate Cox proportional hazards model.
Among the 96 histogram based texture features, RSF extracted 8 of high importance for DFS and 15 for OS. The RSF trained by these features distinguished two patient groups with high and low predicted individual risk (P=1.1×10−4 for DFS, 4.8×10−7 for OS). Based on the multivariate Cox proportional hazards model, high predicted individual risk (hazard ratio=1.06 per 1% increase, P=8.4×10−8) and vascular invasion (hazard ratio=1.74, P=0.039) were the only unfavorable prognostic factors.
The combination of radiomics analysis and RSF might be useful in predicting the prognosis of patients with resectable HCC.
Background
Indications for hepatectomy in patients with hepatocellular carcinoma (HCC) who have portal hypertension (PH) have been controversial. Some studies have concluded that PH is a ...contraindication to hepatectomy, whereas others have suggested that perioperative prophylactic management (PPM) can help overcome complications after hepatectomy associated with PH. The objective of this retrospective study was to assess the short‐ and long‐term outcomes after hepatectomy for HCC in patients with PH, with or without PPM.
Methods
Records were reviewed of consecutive patients who underwent hepatectomy for HCC, with or without PPM of PH, in a single institution from 1994 to 2015. Patients were divided into three groups: those who received PPM for PH (PPM group), patients who had PH but did not receive PPM (no‐PPM group) and those without PH (no‐PH group).
Results
A total of 1259 patients were enrolled, including 123 in the PPM group, 181 in the no‐PPM group and 955 in the no‐PH group. Three‐ and 5‐year overall survival rates were 74·3 and 53·1 per cent respectively in the PPM group, 69·2 and 54·9 per cent in the no‐PPM group, and 78·1 and 64·2 per cent in the no‐PH group (P = 0·520 for PPM versus no PPM, P = 0·027 for PPM versus no PH, and P < 0·001 for no PPM versus no PH). Postoperative morbidity and mortality rates were 26·0 and 0·8 per cent respectively in the PPM group, 29·8 and 1·1 per cent in the no‐PPM group, and 20·3 and 0 per cent in the no‐PH group.
Conclusion
The present study has demonstrated acceptable outcomes among patients with HCC who received appropriate management for PH in an Asian population. Enhancement of the safety of hepatic resection through use of PPM may provide a rationale for expansion of indications for hepatectomy in patients with PH.
This study clarified the prognosis after hepatectomy in patients with hepatocellular carcinoma and portal hypertension. Enhancement of the safety of hepatic resection through use of perioperative prophylactic management may provide a rationale for expansion of indications for hepatectomy in patients with portal hypertension.
Portal hypertension is not a contraindication
Background
The impact of a wide surgical margin on the outcome of patients with hepatocellular carcinoma (HCC) has not been evaluated in relation to the type of liver resection performed, anatomical ...or non‐anatomical. The aim of this study was to evaluate the impact of surgical margin status on outcomes in patients undergoing anatomical or non‐anatomical resection for solitary HCC.
Methods
Data from patients with solitary HCC who had undergone non‐anatomical partial resection (Hr0 group) or anatomical resection of one Couinaud segment (HrS group) between 2000 and 2007 were extracted from a nationwide survey database in Japan. Overall and recurrence‐free survival associated with the surgical margin status and width were evaluated in the two groups.
Results
A total of 4457 patients were included in the Hr0 group and 3507 in the HrS group. A microscopically positive surgical margin was associated with poor overall survival in both groups. A negative but 0‐mm surgical margin was associated with poorer overall and recurrence‐free survival than a wider margin only in the Hr0 group. In the HrS group, the width of the surgical margin was not associated with patient outcome.
Conclusion
Anatomical resection with a negative 0‐mm surgical margin may be acceptable. Non‐anatomical resection with a negative 0‐mm margin was associated with a less favourable survival outcome.
Antecedentes
El impacto de un margen quirúrgico (surgical margin, SM) amplio en el resultado de pacientes con carcinoma hepatocelular (hepatocellular carcinoma, HCC) no ha sido evaluado en relación con el tipo de resección hepática realizada: anatómica o no anatómica. El objetivo del presente estudio fue evaluar el impacto del estado del SM en los resultados en pacientes sometidos a resección anatómica o no anatómica por un HCC solitario.
Métodos
Los datos de pacientes con un HCC solitario sometidos a resección parcial no anatómica (grupo Hr0) o resección anatómica de un segmento de Couinaud (grupo HrS) entre 2000 y 2007 se obtuvieron a partir de una base de datos nacional de Japón. En los grupos Hr0 y HrS se evaluaron la supervivencia global y la supervivencia libre de recidiva asociadas al estado microscópico del SM y a la amplitud del SM.
Resultados
Se incluyeron un total de 4.457 pacientes en el grupo Hr0 y 3.507 en el grupo HrS. Un SM microscópico positivo se asoció con una pobre supervivencia global en ambos grupos. Un SM negativo, pero a una distancia de 0 mm se asoció con una peor supervivencia global y libre de recidiva en comparación con aquellos asociados a un SM más amplio, solo en el grupo Hr0. En el grupo HrS, la amplitud del SM no se asoció con los resultados del paciente.
Conclusión
La resección anatómica con un SM negativo a una distancia de 0 mm puede ser aceptable. La resección no anatómica con un SM negativo a una distancia de 0 mm se asoció con resultados de supervivencia menos favorables.
Data of patients in Japan with hepatocellular carcinoma who had undergone a non‐anatomical or anatomical resection were extracted from a nationwide survey database. A microscopically positive margin was associated with poorer overall survival. The outcome of patients with a negative but 0‐mm margin was poor only in the non‐anatomical resection group, suggesting that anatomical resection with a negative 0‐mm margin is acceptable.
Difference between anatomic and non‐anatomic resection
Background
Three‐dimensional (3D) imaging has facilitated liver resection with excision of hepatic veins by estimating the liver volume of portal and hepatic venous territories. However, 3D imaging ...cannot be used for real‐time navigation to determine the liver transection line. This study assessed the value of indocyanine green (ICG) fluorescence imaging with hepatic vein clamping for navigation during liver transection.
Methods
Consecutive patients who underwent liver resection with excision of major hepatic veins between 2012 and 2013 were evaluated using ICG fluorescence imaging after clamping veins and injecting ICG. Regional fluorescence intensity (FI) values of non‐veno‐occlusive regions (FINon), veno‐occlusive regions (FIVO) and ischaemic regions (FIIS) were calculated using luminance analysing software.
Results
Of the 21 patients, ten, four and seven underwent limited resection, monosegmentectomy/sectionectomy and hemihepatectomy respectively, with excision of major hepatic veins. Median veno‐occlusive liver volume was 80 (range 30–458) ml. Fluorescence imaging visualized veno‐occlusive regions as territories with lower FI compared with non‐veno‐occlusive regions, and ischaemic regions as territories with no fluorescence after intravenous ICG injection. Median FIIS/FINon was lower than median FIVO/FINon (0·22 versus 0·59; P = 0·002). There were no deaths in hospital or within 30 days, and only one major complication.
Conclusion
ICG fluorescence imaging with hepatic vein clamping visualized non‐veno‐occlusive, veno‐occlusive and ischaemic regions. This technique may guide liver transection by intraoperative navigation, enhancing the safety and accuracy of liver resection.
To see or not to see
Surgery for esophageal carcinoma is known to be associated with high morbidity. Recent studies have reported a correlation of nutritional and inflammatory parameters with postoperative course. This ...study aims to clarify the risk factors for operative morbidity after resection of esophageal carcinoma. Consecutive patients who underwent esophagectomy for esophageal squamous cell carcinoma at our institute were included (n = 102; 89 males and 13 females; mean age: 67.3 years). Clinicopathological characteristics, presence or absence of sarcopenia, and modified Glasgow prognostic score were assessed, and their correlation with postoperative complications was investigated using univariate and multivariate analyses. Sarcopenia was defined using a combination of muscle mass area and body mass index. Of the included 102 patients, 45 (44.1%) exhibited sarcopenia (sarcopenia group), while 57 (55.9%) did not (non-sarcopenia group). No significant difference was observed between the groups regarding surgical procedures and tumor stage; furthermore, there was no mortality. Twenty-six patients developed respiratory complications (including 20 cases of pneumonia). On univariate analysis, sarcopenia, modified Glasgow prognostic score, and American Society of Anesthesiologists physical status were found to be significantly associated with the development of postoperative respiratory complications. On multivariate analysis, sarcopenia was found to be an independent risk factor for postoperative respiratory complications after esophagectomy. We believe that identifying patients at risk and providing preoperative nutritional support as well as physical therapy aimed at strengthening of body muscles may help reduce the incidence of postoperative respiratory complications in such patients.
The efficacy of hepatic arterial infusion chemotherapy for the treatment of advanced hepatocellular carcinoma (HCC) remains unclear.
The outcome of 476 patients with HCC who underwent hepatic ...arterial infusion chemotherapy with 5-fluorouracil and cisplatin (HAIC) were compared with 1466 patients who did not receive active therapy.
A survival benefit of the therapy after adjusting for known risk factors was observed (hazard ratio, 0.48; 95% CI, 0.41-0.56; P<0.0001). In propensity score-matched analysis (n=682), median survival time was longer for patients who underwent chemotherapy (14.0 months) than for patients who did not receive active treatment (5.2 months, P<0.0001).
For advanced HCC, HAIC is considered to be an effective treatment.
PDF
