Quality of life after curative liver resection: A single center analysis

AIM: To evaluate quality of life (QoL) after curative liver resection and identify variables associated with decreased QoL. METHODS: From October 2001 to July 2004, 323 patients underwent liver resection. At 3-36 mo after discharge, 188 patients were disease free. QoL was assessed using the Short Form (SF)-12 Health Survey with mental and physical component scales (SF-12 MCS and PCS), supplemented with generic questions concerning pain and liver-specific items. RESULTS: Sixty-eight percent (128/188) returne...     

Liver regeneration after liver resection: Clinical aspects and correlation with infective complications

AIM:To investigate whether early liver regeneration after resection in patients with hepatic tumors might be influenced by post-operative infective complications.METHODS:A retrospective analysis of 27 liver resections for tumors performed in a single referral center from November 2004 to January 2010.Regeneration was evaluated by multidetector computed tomographyat a mean follow-up of 43.85 d.The Clavien-Dindo classification was used to evaluate postoperative events in the first 6 mo after transplantation,and Centers for Disease Control and Prevention definitions were used for healthcare associated infections data.Generalized linear regression models with Gaussian family distribution and log link function were used to reveal the principal promoters of early liver regeneration.RESULTS:Ten of the 27 patients(37%)underwent chemotherapy prior to surgery,with a statistically significant prevalence of patients with metastasis(P=0.007).Eight patients(30%)underwent embolization,3 with primary tumors,and 5 with secondary tumors.Twenty patients(74%)experienced complications,with 12(60%)experiencing Clavien-Dindo Grade 3a to 5 complications.Regeneration≥100%occurred in 10(37%)patients.The predictors were smaller future remnant liver volume(-0.002;P<0.001),and a greater spleen volume/future remnant liver volume ratio(0.499;P=0.01).Patients with a resection of≥5 Couinaud segments experienced greater early regeneration(P=0.04).Nine patients experienced surgical site infections,and in 7 cases Clavien-Dindo Grade 3a to 4 complications were detected(P=0.016).There were no significant differences between patients with primary or secondary tumors,and either onset or infections or severity of surgical complications.CONCLUSION:Regardless of the onset of infective complications,future remnant liver and spleen volumes may be reliable predictors of early liver regeneration after hepatic resection on an otherwise healthy liver.     

Androgen receptors in hepatocellular carcinoma and surrounding liver: relationship with tumor size and recurrence rate after surgical resection

Background/Aims: This study aimed to evaluate the parameters associated with the presence of androgen receptors in hepatocellular carcinoma and surrounding non-tumoral liver. Furthermore, we have assessed whether androgen receptor positively influences disease recurrence after surgical resection.Methods: Androgen receptor concentration was calculated by receptor binding assay in tumoral and non-tumoral liver in 43 patients (40 of them with cirrhosis) with hepatocellular carcinoma who underwent surgical resection.Results: Androgen receptors were found in 28 of the tumoral and in 30 of the non-tumoral samples, at concentrations ranging between 5 and 211 fmol/mg protein. The presence of androgen receptors within the tumor was significantly related to a smaller tumor size. Thereby, 22 of the 29 nodules ≤3 cm contained androgen receptors, while this occurred in only six of the 14 tumors larger than 3 cm (p<0.05). In contrast, the only parameter associated with the presence of androgen receptors in the non-tumoral liver was a lower gamma-glutamyltranspeptidase concentration. Disease recurrence after surgical resection was not only related to some tumor characteristics (increased alfa-fetoprotein concentration, presence of satellites, differentiation degree), but also to the presence of androgen receptors in the surrounding liver. Thus, the probability of recurrence after 1- and 2-year follow up in patients with androgen-positive livers was 33% and 50%, respectively, while it was 0% and 20% in those with androgen-negative livers (p<0.05). In contrast, the presence of androgen receptors within the tumor was not associated with a higher recurrence rate.Conclusions: These results show that only two thirds of hepatocellular carcinomas contained androgen receptors and that this feature was more frequent in small tumors. In addition, our data indicate that the presence of androgen receptors within the tumor does not imply a different outcome after surgical resection. In contrast, the presence of these receptors in the surrounding non-tumoral liver may be considered a risk factor for a higher incidence of disease recurrence.     

Risk factors for short recurrence-free survival after resection of pancreatic neuroendocrine tumor (PanNET) liver metastases: which patients should undergo resection?

Abstract

Background: In the treatment of metastatic pancreatic neuroendocrine tumors (PanNETs), surgical resection is the first choice if curative resection is expected. However, most patients develop recurrence after resection of liver metastasis. Because one of the benefits of resection is to gain a tumor-free period for the patients, it is important to identify which patients achieve longer recurrence-free survival (RFS) by resection. In this study, the clinicopathological factors associated with RFS after resection of metastatic PanNETs in the liver were evaluated to identify the patient group that is suitable for resection.

Methods: Consecutively diagnosed patients with PanNET liver metastasis with resection at our hospital from January 2000 to July 2019 were evaluated. A total of 26 metastatic PanNET patients with primary liver resections were evaluated. The median follow-up time was 48.3?months.

Results: There were 18 NET recurrences of the total 26 resections, with a median RFS of 17.9?months. Independent risk factors for short RFS were a high Ki67 index (p?=?.009) and the number of resected tumors (p?=?.045). When the cut-off value for the Ki67 index was 5.0% and that for the number of resected tumors was 6, Ki67?>?5.0% tumors had shorter RFS (4.9?months vs. 38.2?months p?=?.006), and patients with tumors >?= 7 tumors had shorter RFS (4.7?months vs. 27.5?months p?=?.001).

Conclusions: These findings indicate that good candidates for resection of metastatic tumors of PanNETs could be patients with low Ki67 tumors and a small number of metastatic tumors.     

Colorectal liver metastasis surgery: analysis of risk factors predicting postoperative complications in relation to the extent of resection

Background/aims  Despite advances in diagnosis and treatment, the rate of complications after resection for colorectal liver metastases remains high. An awareness of risk factors is essential for the rates of morbidity and mortality to fall to optimal levels. Materials and methods  Of the 240 patients who underwent resection for the first manifestation of colorectal liver metastases, 49 patients with lobectomy or extended hepatectomy (major resections) and 58 with wedge resections within only one liver segment (minor resections) form the basis of this report. A total of 16 variables were analyzed to find the risk factors linked to postoperative morbidity and mortality. Results/findings  Thirty-four patients (31.8%) suffered postoperative complications, and one patient died during the hospital stay (0.9%). In the major resection group, multivariate analysis showed that neoadjuvant chemotherapy [odds ratio (OR): 2.4; p = 0.005], vascular clamping (OR: 1.4; p = 0.008), and intraoperative blood loss with transfusion of three to six packed red cell units (OR: 1.2; p = 0.029) were significantly associated with postoperative morbidity. Vascular clamping was an independent predictor for biliary fistula (OR: 1.2; p = 0.029). Postoperative temporary liver failure was influenced by neoadjuvant chemotherapy (OR: 3.4; p = 0.010), vascular clamping (OR: 1.5; p = 0.015), and requirement of blood transfusion (OR: 2.1; p = 0.016). After minor resections, only a decreased postoperative serum cholinesterase B level was an independent predictor for complications (OR: 2.2; p = 0.001), as well as for hemorrhage (OR: 1.6; p = 0.023). Postoperative mortality was not predicted by any of the factors that were analyzed. Interpretation/conclusion  Factors for complications differ depending on the extent of colorectal liver metastasis resection. Only knowledge and particular consideration of these factors may provide for an optimal postoperative outcome for the individual patient. Ralf Konopke and Stephan Kersting contributed equally to this work     

Role of quantification of hepatic steatosis and future remnant volume in predicting hepatic dysfunction and complications after liver resection for colorectal metastases: a pilot study

Objectives

Accurate prediction of safe remnant liver volume to minimize complications following liver resection remains challenging. The aim of this study was to assess whether quantification of steatosis improved the predictive value of preoperative volumetric analysis.

Methods

Thirty patients undergoing planned right or extended right hemi-hepatectomy for colorectal metastases were recruited prospectively. Magnetic resonance imaging was used to assess the level of hepatic steatosis and future remnant liver volume. These data were correlated with data on postoperative hepatic insufficiency, complications and hospital stay. Correlations of remnant percentage, remnant mass to patient mass and remnant mass to body surface area with and without steatosis measurements were assessed.

Results

In 10 of the 30 patients the planned liver resection was altered. Moderate–severe postoperative hepatic dysfunction was seen in 17 patients. Complications arose in 14 patients. The median level of steatosis was 3.8% (range: 1.2–17.6%), but was higher in patients (n= 10) who received preoperative chemotherapy (P= 0.124), in whom the median level was 4.8% (range: 1.5–17.6%). The strongest correlation was that of remnant liver mass to patient mass (r= 0.77, P < 0.001). However, the addition of steatosis quantification did not improve this correlation (r= 0.76, P < 0.001).

Conclusions

This is the first study to combine volumetric with steatosis quantifications. No significant benefit was seen in this small pilot. However, these techniques may be useful in operative planning, particularly in patients receiving preoperative chemotherapy.     

Bile leakage test in liver resection: A systematic review and meta-analysis

AIM:To assess systematically the safety and efficacy of bile leakage test in liver resection.METHODS:Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search.Two authors independently assessed the studies for inclusion and extracted the data.A meta-analysis was conducted to estimate postoperative bile leakage,intraoperative positive bile leakage,and complications.We used either the fixed-effects or random-effects model.RESULTS:Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection.The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group(RR=0.39,95%CI:0.23-0.67;I2=3%).The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test(RR=2.38,95%CI:1.24-4.56,P=0.009).No significant intergroup differences were observed in total number of complications,ileus,liver failure,intraperitoneal hemorrhage,pulmonary disorder,abdominal infection,and wound infection.CONCLUSION:The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications.Fat emulsion is the best choice of solution for the test.     

内镜治疗较大胃间质瘤的安全性及长期疗效的多中心回顾性分析

目的评价内镜切除直径＞2～4 cm胃间质瘤的安全性和长期疗效。方法收集2014年1月—2019年12月在福建省立医院、福建省立金山医院和福建省老年医院接受内镜或外科治疗,经术后病理证实为胃间质瘤且直径≤4 cm的病例307例,将肿瘤直径＞2～4 cm的病例采用倾向性评分（1∶1）匹配后,对内镜组（41例）和外科组（41例）病例的手术相关不良事件发生情况及临床治疗结果进行对照分析。结果内镜组较外科组中位手术时间明显缩短（580 min比1080 min,Z=-4789,P＜0001）,中位住院费用明显减少（227万元比420万元,Z=-7164,P＜0001）,术后禁食时间、术后住院时间2组间比较差异无统计学意义（P＞005）。内镜组有7例（171%）发生并发症,包括术后急性感染5例、术后穿孔和术后出血各1例;外科组有9例（220%）发生并发症,均为术后急性感染。2组并发症总体发生率比较,差异无统计学意义（χ2=0311,P=0577）。2组均为完全切除（切缘无肿瘤残留）,内镜组随访时间（343±156）个月,外科组随访时间（422±202）个月,2组随访期间均无复发或远处转移病例。结论内镜切除较大胃间质瘤（直径＞2～4 cm）是一种安全且长期有效的治疗方法,可作为治疗胃肠间质瘤的手段之一。 目的评价内镜切除直径＞2～4 cm胃间质瘤的安全性和长期疗效。方法收集2014年1月—2019年12月在福建省立医院、福建省立金山医院和福建省老年医院接受内镜或外科治疗,经术后病理证实为胃间质瘤且直径≤4 cm的病例307例,将肿瘤直径＞2～4 cm的病例采用倾向性评分（1∶1）匹配后,对内镜组（41例）和外科组（41例）病例的手术相关不良事件发生情况及临床治疗结果进行对照分析。结果内镜组较外科组中位手术时间明显缩短（580 min比1080 min,Z=-4789,P＜0001）,中位住院费用明显减少（227万元比420万元,Z=-7164,P＜0001）,术后禁食时间、术后住院时间2组间比较差异无统计学意义（P＞005）。内镜组有7例（171%）发生并发症,包括术后急性感染5例、术后穿孔和术后出血各1例;外科组有9例（220%）发生并发症,均为术后急性感染。2组并发症总体发生率比较,差异无统计学意义（χ2=0311,P=0577）。2组均为完全切除（切缘无肿瘤残留）,内镜组随访时间（343±156）个月,外科组随访时间（422±202）个月,2组随访期间均无复发或远处转移病例。结论内镜切除较大胃间质瘤（直径＞2～4 cm）是一种安全且长期有效的治疗方法,可作为治疗胃肠间质瘤的手段之一。     

Prognostic factors of survival and a new scoring system for liver resection of colorectal liver metastasis

BACKGROUNDHepatic resection has become the preferred treatment of choice for colorectal liver metastasis (CLM) patients.AIMTo identify the prognostic factors and to formulate a new scoring system for management of CLM.METHODSClinicopathologic and long-term survival data were analyzed to identify the significant predictors of survival by univariate and multivariate analyses with the Cox model. A clinical score was constructed based on the analysis results.RESULTSThree factors of worse overall survival were identified in the multivariate analysis. They were number of liver metastases ≥ 5, size of the largest liver lesion ≥ 4 cm, and the presence of nodal metastasis from the primary tumor. These three factors were chosen as criteria for a clinical risk score for overall survival. The clinical score highly correlated with median overall survival and 5-year survival (P = 0.002).CONCLUSIONPriority over surgical resection should be given to the lowest score groups, and alternative oncological treatment should be considered in patients with the highest score.     

Cardiac complications and diabetes in thalassaemia major: a large historical multicentre study

The relationship between diabetes mellitus (DM) and cardiac complications has never been systematically studied in thalassaemia major (TM). We evaluated a large retrospective historical cohort of TM to determine whether DM is associated with a higher risk of heart complications. We compared 86 TM patients affected by DM with 709 TM patients without DM consecutively included in the Myocardial Iron Overload in Thalassaemia database where clinical/instrumental data are recorded from birth to the first cardiovascular magnetic resonance (CMR) exam. All of the cardiac events considered were developed after the DM diagnosis. In DM patients versus non‐DM patients we found a significantly higher frequency of cardiac complications (46·5% vs. 16·9%, P < 0·0001), heart failure (HF) (30·2% vs. 11·7%, P < 0·0001), hyperkinetic arrhythmias (18·6% vs. 5·5%, P < 0·0001) and myocardial fibrosis assessed by late gadolinium enhancement (29·9% vs. 18·4%, P = 0·008). TM patients with DM had a significantly higher risk of cardiac complications [odds ratio (OR) 2·84, P < 0·0001], HF (OR 2·32, P = 0·003), hyperkinetic arrhythmias (OR 2·21, P = 0·023) and myocardial fibrosis (OR 1·91, P = 0·021), also adjusting for the absence of myocardial iron overload assessed by T2* CMR and for the covariates (age and/or endocrine co‐morbidity). In conclusion, DM significantly increases the risk for cardiac complications, HF, hyperkinetic arrhythmias and myocardial fibrosis in TM patients.     

Laparoscopic liver resection for malignancy: A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed.RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection.CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.     

Use of a saline-coupled bipolar sealer open liver resection for hepatic malignancy: Medical resource use and costs

AIM To evaluate outcomes associated with use of a saline coupled bipolar sealer during open partial liver resection.METHODS This retrospective analysis utilized the United States Premier? insurance claims database(2010-2014). Patients were selected with codes for liver malignancy and partial hepatectomy or lobectomy. Cases were defined by use the saline-coupled bipolar sealer; controls had no use. A Propensity Score algorithm was used to match one case to five controls. A deviationbased cost modeling(DBCM) approach provided an estimate of cost-effectiveness.RESULTS One hundred and forty-four cases and 720 controls were available for analysis. Patients in the case cohort received fewer transfusions vs controls(18.1% vs 29.4%, P = 0.007). In DBCM, more patients in the case cohort experienced "on-course" hospitalizations(53.5% vs 41.9%, P = 0.009). The cost calculation showed an average savings in total hospitalization costs of $1027 for cases vs controls. In multivariate analysis, cases had lower odds of receiving a transfusion(OR = 0.44, 95%CI: 0.27-0.71, P = 0.0008).CONCLUSION Use of a saline-coupled bipolar sealer was associated with a greater proportion of patients with an "on course" hospitalization.     

Risk factors for postoperative complications after lung resection for non-small cell lung cancer in elderly patients at a single institution in China

Objective

The purpose of this study was to assess the postoperative complications after lung resection for non-small cell lung cancer (NSCLC) in elderly patients and to identify possible associated risk factors.

Methods

All patients aged 70 years or older who underwent pulmonary resection for NSCLC by either an open approach or by a thoracoscopic approach between January 2003 and December 2013 at our institution were reviewed. Postoperative events were divided into minor and major complications. Risk factors for complications were assessed by univariate and multivariate logistic regression analysis. A matched case-control study was performed to determine if the utilization of video-assisted thoracic surgery (VATS) for lung resection for NSCLC in elderly patients’ results in decreased complications compared with thoracotomy.

Results

During the study period, 476 consecutive patients (410 thoracotomy, 66 thoracoscopy) older than 70 years underwent resection for NSCLC. Postoperative complications occurred in 169 patients (35.5%) and the overall operative mortality was 2.3% (11 patients). Univariate predictors of complications included history of smoking (P=0.032), CCI scores ≥3 (P<0.001), pneumonectomy (P=0.016), as well as the duration of surgery (P=0.003). After multiple logistic regression analysis, CCI scores ≥3 [odds ratio (OR) =29.95, P<0.001], pneumonectomy (OR =2.26, P=0.029) and prolonged surgery (≥180 min) (OR =1.93, P=0.003) remained the only independent risk factors. After matching based on age, gender, the Charlson Comorbidity Index (CCI), pathologic stage, and the type of resection, there were 60 patients in each group. Patients had similar preoperative characteristics. A VATS approach resulted in a significantly lower rate of complications (25.0% vs. 43.3%, P=0.034) and a shorter median length of stay (19 days, range, 12 to 35 vs. 21 days, range, 13 to 38, P=0.013) compared with thoracotomy.

Conclusions

Pulmonary resection for NSCLC in patients older than 70 years shows acceptable morbidity and mortality. Postoperative complications are more likely to develop in patients with CCI scores ≥3, those who undergo pneumonectomy, and those with a prolonged surgery. Thoracoscopic minimally invasive surgery for NSCLC in elderly patients is associated with fewer complications as well as a shorter hospital stay compared with thoracotomy.     

Prognostic determinants for survival after resection/ablation of a large hepatocellular carcinoma

Background:

Liver resection of large hepatocellular carcinomas (HCC), measuring at least 10 cm remains a controversial debate. Multiple studies on HCCs treated with surgical resection and/or ablation had shown variable results with 5-year survival rates ranging from 0% to 54.0%. The aim of this study was to evaluate the survival of patients with HCCs measuring at least 10 cm and to identify the potential prognostic variables affecting the outcome.

Methods:

Retrospective analysis was performed on the prospectively updated HCC database. A total of 44 patients with tumours measuring 10 cm or more were ‘curatively’ treated with surgical resection with or without ablation. Patient demographics, clinical, surgical, pathology and survival data were collected and analysed.

Results:

Thirty-one patients received surgical resection alone. Thirteen other patients were treated with a combination of surgical resection and ablation. The median follow-up duration was 14.5 months. The overall median survival at 1, 3 and 5 years were 66.4%, 38.1% and 27.8%, respectively. The median time to tumour recurrence was 10.7 months and the 1, 3 and 5-year disease-free survival were 49.6%, 23.9% and 19.1%, respectively.Univariate analysis demonstrated cirrhosis, microvascular invasion, poor tumour differentiation and ethnicity to adversely affect survival. For overall survival, only cirrhosis, poor tumour differentiation and ethnicity were significant on multivariate analysis. Portal vein tumour thrombus, microvascular invasion and ethnicity were identified on univariate analysis to significantly affect disease-free survival.

Conclusion:

Surgical treatment offers good survival to patients with large HCCs (≥10 cm). Both cirrhosis and poor tumour differentiation are independent variables prognostic of adverse survival.     

Risk factors for new onset diabetes mellitus after liver transplantation: A meta-analysis

AIM: To determine the risk factors for new-onset diabetes mellitus(NODM) after liver transplantation by conducting a systematic review and meta-analysis.METHODS: We electronically searched the databases of MEDLINE, EMBASE and the Cochrane Library from January 1980 to December 2013 to identify relevant studies reporting risk factors for NODM after liver transplantation. Two authors independently assessed the trials for inclusion and extracted the data. Discrepancies were resolved in consultation with a third reviewer. All statistical analyses were performed with the Rev Man5.0 software(The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios(OR) or weighted mean differences(WMD) with 95% confidence intervals(CIs) were calculated using either a fixed effects or a random effects model, based on the presence(I2 50%) or absence(I2 50%) of significant heterogeneity. RESULTS: Twenty studies with 4580 patients were included in the meta-analysis, all of which were retrospective. The meta-analysis identified the following significant risk factors: hepatitis C virus(HCV) infection(OR = 2.68; 95%CI: 1.92-3.72); a family history of diabetes(OR = 1.69, 95%CI: 1.09-2.63, P 0.00001); male gender(OR = 1.53; 95%CI: 1.24-1.90; P 0.0001); impaired fasting glucose(IFG; OR = 3.27; 95%CI: 1.84-5.81; P 0.0001); a family history of diabetes(OR = 1.69; 95%CI: 1.09-2.63; P = 0.02); use of tacrolimus(OR = 1.34; 95%CI: 1.03-1.76; P = 0.03) and body mass index(BMI)(WMD = 1.19, 95%CI: 0.69-1.68, P 0.00001). Other factors, such as hepatitis B virus infection and alcoholism, were not found to be associated with the incidence of NODM.CONCLUSION: The study showed that HCV infection, IFG, a family history of diabetes, male gender, tacrolimus and BMI are risk factors for NODM after liver transplantation.