Background
Several investigators have advocated for extending the Barcelona Clinic Liver Cancer (BCLC) resection criteria to select patients with BCLC-B and even BCLC-C hepatocellular carcinoma ...(HCC). The objective of the current study was to define the outcomes and recurrence patterns after resection within and beyond the current resection criteria.
Patients and Methods
Patients who underwent resection for HCC within (i.e., BCLC 0/A) and beyond (i.e. BCLC B/C) the current resection criteria between 2005 and 2017 were identified from an international multi-institutional database. Overall survival (OS), disease-free survival (DFS), as well as patterns of recurrence of patients undergoing HCC resection within and beyond the BCLC guidelines were examined.
Results
Among 756 patients, 602 (79.6%) patients were BCLC 0/A and 154 (20.4%) were BCLC B/C. Recurrences were mostly intrahepatic (within BCLC: 74.3% versus beyond BCLC: 70.8%,
p
= 0.80), with BCLC B/C patients more often having multiple tumors at relapse (69.6% versus 49.4%,
p
= 0.001) and higher rates of early (< 2 years) recurrence (88.0% versus 75.5%,
p
= 0.011). During the first postoperative year, annual recurrence was 38.3% and 21.3% among BCLC B/C and BCLC 0/A patients, respectively; 5-year OS among BCLC 0/A and BCLC B/C patients was 76.9% versus 51.6% (
p
= 0.003). On multivariable analysis, only a-fetoprotein (AFP) > 400 ng/mL (HR = 1.84, 95% CI 1.07–3.15) and R1 resection (HR = 2.36, 95% CI 1.32–4.23) were associated with higher risk of recurrence among BCLC B/C patients.
Conclusions
Surgery can provide acceptable outcomes among select patients with BCLC B/C HCC. The data emphasize the need to further refine the BCLC treatment algorithm as well as highlight the need for surveillance protocols with a particular focus on the liver, especially for patients undergoing resection outside the BCLC criteria.
Introduction
The objective of the current study was to comprehensively assess the change of practice in hepatobiliary surgery by determining the rates and the trends of textbook outcomes (TO) among ...patients undergoing surgery for primary liver cancer over time.
Methods
Patients undergoing curative-intent resection for primary liver malignancies, including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) between 2005 and 2017 were analyzed using a large, international multi-institutional dataset. Rates of TO were assessed over time. Factors associated with achieving a TO and the impact of TO on long-term survival were examined.
Results
Among 1829 patients, 944 (51.6%) and 885 (48.4%) individuals underwent curative-intent resection for HCC and ICC, respectively. Over time, patients were older, more frequently had ASA class > 2, albumin-bilirubin grade 2/3, major vascular invasion and more frequently underwent major liver resection (all
p
< 0.05). Overall, a total of 1126 (62.0%) patients achieved a TO. No increasing trends in TO rates were noted over the years (
p
trend
= 0.90). In addition, there was no increasing trend in the TO rates among patients undergoing either major (
p
trend
= 0.39) or minor liver resection (
p
trend
= 0.63) over the study period. Achieving a TO was independently associated with 26% and 37% decreased hazards of death among ICC (HR 0.74, 95%CI 0.56–0.97) and HCC patients (HR 0.63, 95%CI 0.46–0.85), respectively.
Conclusion
Approximately 6 in 10 patients undergoing surgery for primary liver tumors achieved a TO. While TO rates did not increase over time, TO was associated with better long-term outcomes following liver resection for both HCC and ICC.
Innovative imaging methods help to investigate the complex relationship between brain activity and behavior in freely moving animals. Functional ultrasound (fUS) is an imaging modality suitable for ...recording cerebral blood volume (CBV) dynamics in the whole brain but has so far been used only in head-fixed and anesthetized rodents. We designed a fUS device for tethered brain imaging in freely moving rats based on a miniaturized ultrasound probe and a custom-made ultrasound scanner. We monitored CBV changes in rats during various behavioral states such as quiet rest, after whisker or visual stimulations, and in a food-reinforced operant task. We show that fUS imaging in freely moving rats could efficiently decode brain activity in real time.
Purpose
Estimated blood loss (EBL) is an important tool in clinical decision-making and surgical outcomes research. It guides perioperative transfusion practice and serves as a key predictor of ...short-term perioperative risks and long-term oncologic outcomes. Despite its widespread clinical and research use, there is no gold standard for blood loss estimation. We sought to systematically review and compare techniques for intraoperative blood loss estimation in major non-cardiac surgery with the objective of informing clinical estimation and research standards.
Source
A structured search strategy was applied to Ovid Medline, Embase, and Cochrane Library databases from inception to March 2020, to identify studies comparing methods of intraoperative blood loss in adult patients undergoing major non-cardiac surgery. We summarized agreement between groups of pairwise comparisons as visual estimation
vs
formula estimation, visual estimation
vs
other, and formula estimation
vs
other. For each of these comparisons, we described tendencies for higher or lower EBL values, consistency of findings, pooled mean differences, standard deviations, and confidence intervals.
Principle findings
We included 26 studies involving 3,297 patients in this review. We found that visual estimation is the most frequently studied technique. In addition, visual techniques tended to provide lower EBL values than formula-based estimation or other techniques, though this effect was not statistically significant in pooled analyses likely due to sample size limitations. When accounting for the contextual mean blood loss, similar case-to-case variation exists for all estimation techniques.
Conclusions
We found that significant case-by-case variation exists for all methods of blood loss evaluation and that there is significant disagreement between techniques. Given the importance placed on EBL, particularly for perioperative prognostication models, clinicians should consider the universal adoption of a practical and reproducible method for blood loss evaluation.
Trial registration
PROSPERO (CRD42015029439); registered: 18 November 2015.PROSPERO (CRD42015029439); registered: 18 November 2015.
Composite measures may be superior to individual measures for the analysis of hospital performance and quality of surgical care.
To determine the incidence of a so-called textbook outcome, a ...composite measure of the quality of surgical care, among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma.
This cohort study involved an analysis of a multinational, multi-institutional cohort of patient from 15 major hepatobiliary centers in North America, Europe, Australia, and Asia who underwent curative-intent resection of intrahepatic cholangiocarcinoma between 1993 and 2015. Data analysis was conducted from April 2018 to May 2018.
Hospital variation in the composite end point of textbook outcome, defined as negative margins, no perioperative transfusion, no postoperative surgical complications, no prolonged length of stay, no 30-day readmissions, and no 30-day mortality. Secondary end points were factors associated with achieving textbook outcomes.
Among 687 patients (of whom 370 53.9% were men; median patient age, 61 range, 18-86 years) undergoing curative-intent resection of intrahepatic cholangiocarcinoma, a textbook outcome was achieved in 175 patients (25.5%). Being 60 years or younger (odds ratio OR, 1.61 95% CI, 1.04-2.49; P = .03), absence of preoperative jaundice (OR, 4.40 95% CI, 1.28-15.15; P = .02), no neoadjuvant chemotherapy (OR, 2.57 95% CI, 1.05-6.29; P = .04), T1a/T1b-stage disease (OR, 1.58 95% CI, 1.01-2.49; P = .049), N0 status (OR, 3.89 95% CI, 1.77-8.54; P = .001), and no bile duct resection (OR, 2.46 95% CI, 1.25-4.84; P = .009) were independently associated with achieving a textbook outcome after resection. A prolonged length of stay had the greatest negative association with a textbook outcome. A nomogram to assess the probability of textbook outcome was developed and had good accuracy in both the training data set (area under the curve, 0.755) and validation data set (area under the curve, 0.763).
In this study, while hepatic resection for intrahepatic cholangiocarcinoma was performed with less than 5% mortality in specialized centers, a textbook outcome was achieved in only approximately 26% of patients. A textbook outcome may be useful for the reporting of patient-level hospital performance and hospital variation, leading to quality improvement efforts after resection of intrahepatic cholangiocarcinoma.
To critically assess centralization policies for highly specialized surgeries in Europe and North America and propose recommendations.
Most countries are increasingly forced to maintain quality ...medicine at a reasonable cost. An all-inclusive perspective, including health care providers, payers, society as a whole and patients, has ubiquitously failed, arguably for different reasons in environments. This special article follows 3 aims: first, analyze health care policies for centralization in different countries, second, analyze how centralization strategies affect patient outcome and other aspects such as medical education and cost, and third, propose recommendations for centralization, which could apply across continents.
Conflicting interests have led many countries to compromise for a health care system based on factors beyond best patient-oriented care. Centralization has been a common strategy, but modalities vary greatly among countries with no consensus on the minimal requirement for the number of procedures per center or per surgeon. Most national policies are either partially or not implemented. Data overwhelmingly indicate that concentration of complex care or procedures in specialized centers have positive impacts on quality of care and cost. Countries requiring lower threshold numbers for centralization, however, may cause inappropriate expansion of indications, as hospitals struggle to fulfill the criteria. Centralization requires adjustments in training and credentialing of general and specialized surgeons, and patient education.
There is an obvious need in most areas for effective centralization. Unrestrained, purely "market driven" approaches are deleterious to patients and society. Centralization should not be based solely on minimal number of procedures, but rather on the multidisciplinary treatment of complex diseases including well-trained specialists available around the clock. Audited prospective database with monitoring of quality of care and cost are mandatory.
Background
Although the Barcelona Clinic Liver Cancer (BCLC) staging system has been largely adopted in clinical practice, recent studies have questioned the prognostic stratification of this ...classification schema, as well as the proposed treatment allocation of patients with a single large tumor.
Methods
Patients who underwent curative-intent hepatectomy for histologically proven hepatocellular carcinoma (HCC) between 1998 and 2017 were identified using an international multi-institutional database. Overall survival (OS) among patients with BCLC stage 0, A, and B was examined. Patients with a single large tumor were classified as BCLC stage A1 and were independently assessed.
Results
Among 814 patients, 68 (8.4%) were BCLC-0, 310 (38.1%) were BCLC-A, 279 (34.3%) were BCLC-A1, and 157 (19.3%) were BCLC-B. Five-year OS among patients with BCLC stage 0, A, A1, and B HCC was 86.2%, 69.0%, 56.9%, and 49.9%, respectively (
p
< 0.001). Among patients with very early- and early-stage HCC (BCLC 0, A, and A1), patients with BCLC stage A1 had the worst OS (
p
= 0.0016). No difference in survival was noted among patients undergoing surgery for BCLC stage A1 and B HCC (5-year OS: 56.9% vs. 49.9%;
p
= 0.259) even after adjusting for competing factors (hazard ratio 0.83, 95% confidence interval 0.54–1.28;
p
= 0.40).
Conclusion
Prognosis following liver resection among patients with BCLC-A1 HCC was similar to patients presenting with BCLC-B tumors. Surgery provided acceptable long-term outcomes among select patients with BCLC-B HCC. Designation into BCLC stage B should not be considered an a priori contraindication to surgery.
Background
Postoperative infectious complications may be associated with a worse long-term prognosis for patients undergoing surgery for a malignant indication. The current study aimed to ...characterize the impact of postoperative infectious complications on long-term oncologic outcomes among patients undergoing resection for hepatocellular carcinoma (HCC).
Methods
Patients who underwent curative-intent resection for HCC between 2000 and 2017 were identified from an international multi-institutional database. The relationship between postoperative infectious complications, overall survival (OS), and recurrence-free survival (RFS) was analyzed.
Results
Among 734 patients who underwent HCC resection, 269 (36.6%) experienced a postoperative complication (Clavien–Dindo grade 1 or 2
n
= 197, 73.2% vs grade 3 and 4
n
= 69, 25.7%). An infectious complication was noted in 81 patients (11.0%) and 188 patients (25.6%) had non-infectious complications. The patients with infectious complications had worse OS (median: infectious complications 46.5 months vs no complications 106.4 months
p
< 0.001 and non-infectious complications 85.7 months
p
< 0.05) and RFS (median: infectious complications 22.1 months vs no complications 45.5 months
p
< 0.05 and non-infectious complications 38.3 months
p
= 0.139) than the patients who had no complication or non-infectious complications. In the multivariable analysis, infectious complications remained an independent risk factor for OS (hazard ratio HR, 1.7;
p
= 0.016) and RFS (HR, 1.6;
p
= 0.013). Among the patients with infectious complications, patients with non-surgical-site infection (SSI) had even worse OS and RFS than patients with SSI (median OS: 19.5 vs 70.9 months
p
= 0.010; median RFS: 12.8 vs 33.9 months
p
= 0.033).
Conclusion
Infectious complications were independently associated with an increased long-term risk of tumor recurrence and death. Patients with non-SSI versus SSI had a particularly worse oncologic outcome.
Background
Recurrence of intrahepatic cholangiocarcinoma (ICC) after curative resection is common.
Objective
The aim of this study was to investigate the patterns, timing and risk factors of disease ...recurrence after curative-intent resection for ICC.
Methods
Patients undergoing curative resection for ICC were identified from a multi-institutional database. Data on clinicopathological and initial operation information, timing and first sites of recurrence, recurrence management, and long-term outcomes were analyzed.
Results
A total of 920 patients were included. With a median follow-up of 38 months, 607 patients (66.0%) experienced ICC recurrence. In the cohort, 145 patients (23.9%) recurred at the surgical margin, 178 (29.3%) recurred within the liver away from the surgical margin, 90 (14.8%) recurred at extraheptatic sites, and 194 (32.0%) developed both intrahepatic and extrahepatic recurrence. Intrahepatic margin recurrence (median 6.0 m) and extrahepatic-only recurrence (median 8.0 m) tended to occur early, while intrahepatic recurrence at non-margin sites occurred later (median 14.0 m;
p
< 0.05). On multivariate analysis, surgical margin < 10 mm was associated with increased margin recurrence (hazard ratio HR 1.70, 95% confidence interval CI 1.11–2.60;
p
= 0.014), whereas female sex (HR 2.12, 95% CI 1.40–3.22;
p
< 0.001) and liver cirrhosis (HR 2.36, 95% CI 1.31–4.25;
p
= 0.004) were both associated with an increased risk of intrahepatic recurrence at other sites. Median survival after recurrence was better among patients who underwent repeat curative-intent surgery (48.7 months) versus other treatments (9.7 months)
p
< 0.001.
Conclusions
Different recurrence patterns and timing of recurrence suggest biological heterogeneity of ICC tumor recurrence. Understanding timing and risk factors associated with different types of recurrence can hopefully inform discussions around adjuvant therapy, surveillance, and treatment of recurrent disease.
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