Summary
Background
Non‐alcoholic fatty liver disease (NAFLD) is an increasing cause of hepatocellular carcinoma (HCC) worldwide. NAFLD‐HCC often occurs in noncirrhotic liver raising important ...surveillance issues.
Aim
To determine the temporal trends for prevalence, clinical characteristics and outcomes of NAFLD‐HCC in patients undergoing liver resection.
Methods
Consecutive patients with histologically confirmed HCC who underwent liver resection over a 20‐year period (1995‐2014). NAFLD was diagnosed based on past or present exposure to obesity or diabetes without other causes of chronic liver disease.
Results
A total of 323 HCC patients were included, 12% with NAFLD. From 1995‐1999 to 2010‐2014, the prevalence of NAFLD‐HCC increased from 2.6% to 19.5%, respectively, P = .003, and followed the temporal trends in the prevalence of metabolic risk factors (28% vs 52%, P = .017), while hepatitis C‐HCC decreased (from 43.6% to 19.5%, P = .003). NAFLD‐HCC occurred more frequently in the absence of bridging fibrosis/cirrhosis (63% of cases, P < .001 compared to other aetiologies). Within the NAFLD group, tumour characteristics were similar between F0‐F2 and F3‐F4 patients, except for a higher proportion of single nodules (95% vs 54%, P < .01).
A total of 53% patients had tumour recurrence and 40% died. NAFLD‐HCC had similar time to recurrence and survival as HCCs of other aetiologies. Satellite nodules, tumour size, microvascular invasion and male sex but not the aetiology were independently associated with recurrence.
Conclusion
Non‐alcoholic fatty liver disease increased substantially over the past 20 years among resectable HCCs. It is now the leading cause of HCC occuring without/or with only minimal fibrosis. NAFLD patients are older, with larger tumours while survival and recurrence rates are as severe as in other aetiologies.
Linked ContentThis article is linked to Balakrishnan and El‐Serag paper. To view this article visit https://doi.org/10.1111/apt.14464.
After reporting the first laparoscopic hepatectomy in a living donor for pediatric liver transplantation, we now report a case of pure laparoscopic right hepatectomy for adult transplantation. A ...50‐year‐old female volunteered for living donation to her sister who suffered from primary biliary cirrhosis. The volume of the planned hepatic graft (segments 5–8) was 620 cm3, representing 56% of her entire liver. Five ports were used in the donor to perform the operative procedure. The right hepatic artery and portal vein were isolated. Parenchymal division was performed using an ultrasonic dissector, bipolar coagulation and clips for hemostasis. Cholangiography was performed and the right bile duct was cut at the level of a marker thread. The right liver graft was placed in a bag and removed through a 10‐cm suprapubic incision. The veins of segments 5 and 8 were recanalized and the graft was transplanted in the recipient. The postoperative course was uneventful for both the donor and recipient. This case offers evidence that the right liver can be procured via a total laparoscopic approach. This technique may allow for an early rehabilitation for the living donor.
The authors report the technical details of a case of pure laparoscopic right hepatectomy in a live liver donor for intra‐familial adult‐to‐adult transplantation. See editorial by Akoad and Pomfret on page 2243 and case reports on pages 2462 and 2472.
Background
Although recent reports have suggested potential benefits of the laparoscopic approach in patients requiring major hepatectomy, it remains unclear whether conversion to open surgery could ...offset these advantages. This study aimed to determine the risk factors for and postoperative consequences of conversion in patients undergoing laparoscopic major hepatectomy (LMH).
Methods
Data for all patients undergoing LMH between 2000 and 2013 at two tertiary referral centres were reviewed retrospectively. Risk factors for conversion were determined using multivariable analysis. After propensity score matching, the outcomes of patients who underwent conversion were compared with those of matched patients undergoing laparoscopic hepatectomy who did not have conversion, operated on at the same centres, and also with matched patients operated on at another tertiary centre during the same period by an open laparotomy approach.
Results
Conversion was needed in 30 (13·5 per cent) of the 223 patients undergoing LMH. The most frequent reasons for conversion were bleeding and failure to progress, in 14 (47 per cent) and nine (30 per cent) patients respectively. On multivariable analysis, risk factors for conversion were patient age above 75 years (hazard ratio (HR) 7·72, 95 per cent c.i. 1·67 to 35·70; P = 0·009), diabetes (HR 4·51, 1·16 to 17·57; P = 0·030), body mass index (BMI) above 28 kg/m2 (HR 6·41, 1·56 to 26·37; P = 0·010), tumour diameter greater than 10 cm (HR 8·91, 1·57 to 50·79; P = 0·014) and biliary reconstruction (HR 13·99, 1·82 to 238·13; P = 0·048). After propensity score matching, the complication rate in patients who had conversion was higher than in patients who did not (75 versus 47·3 per cent respectively; P = 0·038), but was not significantly different from the rate in patients treated by planned laparotomy (79 versus 67·9 per cent respectively; P = 0·438).
Conclusion
Conversion during LMH should be anticipated in patients with raised BMI, large lesions and biliary reconstruction. Conversion does not lead to increased morbidity compared with planned laparotomy.
Conversion does not increase morbidity
Background
The aim was to analyse the impact of cirrhosis on short‐term outcomes after laparoscopic liver resection (LLR) in a multicentre national cohort study.
Methods
This retrospective study ...included all patients undergoing LLR in 27 centres between 2000 and 2017. Cirrhosis was defined as F4 fibrosis on pathological examination. Short‐term outcomes of patients with and without liver cirrhosis were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection.
Results
Among 3150 patients included, LLR was performed in 774 patients with (24·6 per cent) and 2376 (75·4 per cent) without cirrhosis. Severe complication and mortality rates in patients with cirrhosis were 10·6 and 2·6 per cent respectively. Posthepatectomy liver failure (PHLF) developed in 3·6 per cent of patients with cirrhosis and was the major cause of death (11 of 20 patients). After matching, patients with cirrhosis tended to have higher rates of severe complications (odds ratio (OR) 1·74, 95 per cent c.i. 0·92 to 3·41; P = 0·096) and PHLF (OR 7·13, 0·91 to 323·10; P = 0·068) than those without cirrhosis. They also had a higher risk of death (OR 5·13, 1·08 to 48·61; P = 0·039). Rates of cardiorespiratory complications (P = 0·338), bile leakage (P = 0·286) and reoperation (P = 0·352) were similar in the two groups. Patients with cirrhosis had a longer hospital stay than those without (11 versus 8 days; P = 0·018). Centre expertise was an independent protective factor against PHLF in patients with cirrhosis (OR 0·33, 0·14 to 0·76; P = 0·010).
Conclusion
Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing LLR, even in expert centres.
Antecedentes
El objetivo de este estudio fue analizar el impacto de la cirrosis en los resultados a corto plazo después de la resección hepática laparoscópica (laparoscopic liver resection, LLR) en un estudio de cohortes multicéntrico nacional.
Métodos
Este estudio retrospectivo incluyó todos los pacientes sometidos a LLR en 27 centros entre 2000 y 2017. La cirrosis se definió como fibrosis F4 en el examen histopatológico. Los resultados a corto plazo de los pacientes con hígado cirrótico (cirrhotic liver CL) (pacientes CL) y los pacientes con hígado no cirrótico (non‐cirrhotic liver, NCL) (pacientes NCL) se compararon después de realizar un emparejamiento por puntaje de propension del volumen del centro, las características demográficas y del tumor, y la extensión de la resección.
Resultados
Del total de 3.150 pacientes incluidos, se realizó LLR en 774 (24,6%) pacientes CL y en 2.376 (75,4%) pacientes NCL. Las tasas de complicaciones graves y mortalidad en el grupo de pacientes CL fueron del 10,6% y 2,6%, respectivamente. La insuficiencia hepática posterior a la hepatectomía (post‐hepatectomy liver failure, PHLF) fue la principal causa de mortalidad (55% de los casos) y se produjo en el 3,6% de los casos en pacientes CL. Después del emparejamiento, los pacientes CL tendieron a tener tasas más altas de complicaciones graves (razón de oportunidades, odds ratio, OR 1,74; i.c. del 95% 0,92‐0,41; P = 0,096) y de
PHLF (OR 7,13; i.c. del 95% 0,91‐323,10; P = 0,068) en comparación con los pacientes NCL. Los pacientes CL estuvieron expuestos a un mayor riesgo de mortalidad (OR 5,13; i.c. del 95% 1,08‐48,6; P = 0,039) en comparación con los pacientes NCL. Los pacientes CL presentaron tasas similares de complicaciones cardiorrespiratorias graves (P = 0,338), de fuga biliar (P = 0,286) y de reintervenciones (P = 0,352) que los pacientes NCL. Los pacientes CL tuvieron una estancia hospitalaria más larga (11 versus 8 días; P = 0,018) que los pacientes NCL. La experiencia del centro fue un factor protector independiente de PHLF (OR 0,33; i.c. del 95% 0,14‐0,76; P = 0,010) pacientes CL.
Conclusión
La presencia de cirrosis subyacente sigue siendo un factor de riesgo independiente de peores resultados en pacientes sometidos a resección hepática laparoscópica, incluso en centros con experiencia.
The aim was to analyse the impact of cirrhosis on short‐term outcomes after laparoscopic liver resection in a multicentre national cohort study. Short‐term outcomes of patients with and without cirrhotic liver were compared after propensity score matching by centre volume, demographic and tumour characteristics, and extent of resection. Underlying cirrhosis remains an independent risk factor for impaired outcomes in patients undergoing laparoscopic liver resection, even in expert centres.
Cirrhosis leads to impaired outcomes even in expert centers
Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history ...of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.
Abstract Background Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) was recently developed to induce rapid hypertrophy and reduce post-hepatectomy liver failure in ...patients with insufficient remnant liver volume (RLV). However, mortality rates >12% have been reported. This study aimed to analyze the perioperative course of ALPPS and to identify factors associated with morbi-mortality. Methods Between April 2011 and September 2013, 62 patients operated in 9 Franco-Belgian hepatobiliary centres underwent ALPPS for colorectal metastases (N = 50) or primary tumors, following chemotherapy (N = 50) and/or portal vein embolization (PVE; N = 9). Results Most patients had right (N = 31) or right extended hepatectomy (N = 25) (median RLV/body weight ratio of 0.54% 0.21–0.77%). RLV increased by 48.6% −15.3 to 192% 7.8 ± 4.5 days after stage1, but the hypertrophy decelerated beyond 7 days. Stage2 was cancelled in 3 patients (4.8%) for insufficient hypertrophy, portal vein thrombosis or death and delayed to ≥9 days in 32 (54.2%). Overall, 25 patients (40.3%) had major complication(s) and 8 (12.9%) died. Fourteen patients (22.6%) had post-stage1 complication of whom 5 (35.7%) died after stage2. Factors associated with major morbi-mortality were obesity, post-stage1 biliary fistula or ascites, and infected and/or bilious peritoneal fluid at stage2. The latter was the only predictor of Clavien ≥3 by multivariate analysis (OR: 4.9; 95% CI: 1.227–19.97; p = 0.025). PVE did not impact the morbi-mortality rates but prevented major cytolysis that was associated with poor outcome. Conclusions The inter-stages course was crucial in determining ALPPS outcome. The factors of high morbi-mortality rates associated with ALPPS are linked to the technique complexity.
Background
The impact of chemotherapy‐associated liver injury (CALI) on postoperative outcome in patients undergoing partial hepatectomy for colorectal liver metastases (CRLM) remains controversial. ...The objective of this study was to clarify the effect of CALI (sinusoidal dilatation (SD), steatosis and steatohepatitis) on postoperative morbidity and mortality by investigating a large data set from multiple international centres.
Methods
PubMed and Embase were searched for studies published between 1 January 2004 and 31 December 2013 with keywords ‘chemotherapy’, ‘liver resection’, ‘outcome’ and ‘colorectal metastases’ to identify potential collaborating centres. Univariable and multivariable analyses were performed using binary logistic regression models, with results presented as odds ratios (ORs) with 95 per cent confidence intervals.
Results
A consolidated database comprising 788 patients who underwent hepatectomy for CRLM in eight centres was obtained. In multivariable analyses, severe SD was associated with increased major morbidity (Dindo–Clavien grade III–V; OR 1·73, 95 per cent c.i. 1·02 to 2·95; P = 0·043). Severe steatosis was associated with decreased liver surgery‐specific complications (OR 0·52, 95 per cent c.i. 0·27 to 1·00; P = 0·049), whereas steatohepatitis was linked to an increase in these complications (OR 2·08, 1·18 to 3·66; P = 0·012). Subgroup analysis showed that lobular inflammation was the sole component associated with increased overall morbidity (OR 2·22, 1·48 to 3·34; P = 0·001) and liver surgery‐specific complications (OR 3·35, 2·11 to 5·32; P < 0·001). Finally, oxaliplatin treatment was linked to severe SD (OR 2·74, 1·67 to 4·49; P < 0·001).
Conclusion
An increase in postoperative major morbidity and liver surgery‐specific complications was observed after partial hepatectomy in patients with severe SD and steatohepatitis. Postoperative liver failure occurred more often in patients with severe SD.
Increased complications in severe sinusoidal dilatation and steatohepatitis
Background
Data on recurrence patterns following hepatectomy for colorectal liver metastases (CRLMs) and their impact on long‐term outcomes are limited in the setting of modern multimodal management. ...This study sought to characterize the patterns of, factors associated with, and survival impact of recurrence following initial hepatectomy for CRLMs.
Methods
A retrospective cohort study of patients undergoing initial hepatectomy for CRLMs at 39 institutions (2006–2013) was conducted. Kaplan–Meier methods were used for survival analyses. Overall survival landmark analysis at 12 months after hepatectomy was performed to compare groups based on recurrence. Multivariable Cox and regression models were used to determine factors associated with recurrence.
Results
Among 2320 patients, tumours recurred in 47·4 per cent at median of 10·1 (range 0–88) months; 89·1 per cent of recurrences developed within 3 years. Recurrence was intrahepatic in 46·2 per cent, extrahepatic in 31·8 per cent and combined intra/extrahepatic in 22·0 per cent. The 5‐year overall survival rate decreased from 74·3 (95 per cent c.i. 72·2 to 76·4) per cent without recurrence to 57·5 (55·0 to 60·0) per cent with recurrence (adjusted hazard ratio (HR) 3·08, 95 per cent c.i. 2·31 to 4·09). After adjusting for clinicopathological variables, prehepatectomy factors associated with increased risk of recurrence were node‐positive primary tumour (HR 1·27, 1·09 to 1·49), more than three liver metastases (HR 1·27, 1·06 to 1·52) and largest metastasis greater than 4 cm (HR 1·19; 1·01 to 1·43).
Conclusion
Recurrence after CRLM resection remains common. Although overall survival is inferior with recurrence, excellent survival rates can still be achieved.
Survival acceptable despite recurrence
Enhanced recovery after liver surgery Brustia, R; Slim, K; Scatton, O
Journal of visceral surgery,
04/2019, Letnik:
156, Številka:
2
Journal Article
Recenzirano
Odprti dostop
In a majority of cases, enhanced recovery after surgery program (ERP) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery. The program's ...preoperative, perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team. Having shown its merits in digestive surgery, ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail. The objective of this review was to evaluate the efficacy of ERP in liver surgery.
This is a systematic narrative review of the literature on the efficacy of ERP in liver surgery by laparotomy or laparoscopy.
Notwithstanding a number of studies (n=30: 5 randomized trials, 14 cohort studies and 11 meta-analyses) less sizable than with regard to digestive surgery in general and colorectal surgery in particular, analysis of the literature confirms that in liver surgery, ERP is associated with an overall decrease in complications by 30 to 60%, but without improvement in the rates of hospital readmission and postoperative mortality. All of the studies report a reduction in average length of stay (ALOS) by 2.3 days and in functional recovery, a more objective indicator than ALOS, by 2.5 days. As of now, the economic impact of the ERP programs in liver surgery is neither positive nor negative, the above-mentioned savings being counterbalanced by heightened costs for material and equipment. Laparoscopic surgery is independently associated with better outcomes in terms of complications, functional recovery and ALOS; that is why it is important to incorporate this surgical approach in ERP as often as possible. Given a lack of robust evidence, Prehabilitation, which is a preoperative optimization process leading to improved functional reserve, has yet to be assigned a place in ERP programs pertaining to liver surgery. Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader, a motivated multidisciplinary team, training courses and dedicated teaching sessions.
ERP is a care improvement process that has a major play to play in organization of liver surgery, and its large-scale application is to be recommended.
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