Incidence,risk factors and consequences of bile leakage following laparoscopic major hepatectomy

Background

Bile leakage (BL) remains a common cause of major morbidity after open major liver resection but has only been poorly described in patients undergoing laparoscopic major hepatectomy (LMH). The present study aimed to determine the incidence, risk factors and consequences of BL following LMH.

Methods

All 223 patients undergoing LMH between 2000 and 2013 at two tertiary referral centres were retrospectively analysed. BL was defined according to the International Study Group of Liver Surgery, and its incidence and consequences were assessed. Risk factors for BL were determined on multivariate analysis.

Results

BL occurred in 30 (13.5 %) patients, and its incidence remained stable over time (p = 0.200). BL was diagnosed following the presence of bile into the abdominal drain in 14 (46.7 %) patients and after drainage of symptomatic abdominal collections in 16 (53.3 %) patients without intra-operative drain placement. Grade A, B and C BL occurred in 3 (10.0 %), 23 (76.6 %) and 4 (13.4 %) cases, respectively. Interventional procedures for BL included endoscopic retrograde cholangiography, percutaneous and surgical drainage in 10 (33.3 %), 23 (76.7 %) and 4 (13.3 %) patients, respectively. BL was associated with significantly increased rates of symptomatic pleural effusion (30.0 vs. 11.4 %, p = 0.006), multiorgan failure (13.3 vs. 3.6 %, p = 0.022), postoperative death (10.0 vs. 1.6 %, p = 0.008) and prolonged hospital stay (18 vs. 8 days, p < 0.001). On multivariable analysis, BMI > 28 kg/m² (OR 2.439, 95 % CI 1.878–2.771, p = 0.036), history of hepatectomy (OR 1.675, 95 % CI 1.256–2.035, p = 0.044) and biliary reconstruction (OR 1.975, 95 % CI 1.452–2.371, p = 0.039) were significantly associated with increased risk of BL.

Conclusions and relevance

After LMH, BL occurred in 13.5 % of the patients and was associated with significant morbidity. Patients with one or several risk factors for BL should benefit intra-operative drain placement.

     

Treatment Strategy to Improve Long-Term Survival for Hepatocellular Carcinoma Smaller than 5 cm: Major Hepatectomy vs Minor Hepatectomy

Background

The extent of hepatectomy for solitary hepatocellular carcinoma (HCC) <5 cm is controversial.

Methods

This is a retrospective review of patients with solitary HCC <5 cm, who underwent liver resection in a tertiary referral centre in Hong Kong between January 1989 and December 2009. Baseline demographics, liver function, peri-operative outcomes, and overall survival were compared.

Results

A total of 348 cirrhotic patients with a solitary HCC <5 cm underwent either major hepatectomy (n = 93) or minor hepatectomy (n = 255). Child-Pugh status did not differ, 98.9 vs. 96.1 % (p = 0.319); all patients who underwent major and minor hepatectomy were classified as Child-Pugh status A. Patients who underwent major hepatectomy had a larger median tumor size (4.0 vs. 2.5 cm, p < 0.001) and they also had more advanced stage of disease (stage I/II/IIIa: 10.8/55.9/33.3 vs. 26.7/52.9/20.4 %, p = 0.002). Median operative time for major hepatectomy was significantly longer (415 vs. 248 min, p < 0.001) and entailed greater blood loss (0.9 vs. 0.5 l, p < 0.001). Despite larger tumor size and more advanced stage of disease in the major hepatectomy group, hospital mortality (5.4 vs. 2.0 %, p = 0.185), complication rates (30.1 vs. 23.1 %, p = 0.234), and transfusion rate (10.8 vs. 11.4 %, p = 0.862) were the same between the two groups. Overall survival was significantly better for those who underwent major hepatectomy, with a median survival of 147.5 vs. 92.1 months (p = 0.043), and they had a better 5- and 10-year disease-free survival rate (57.3 vs. 40.2, 38.1 vs. 18.9 %, p = 0.003). In subgroup analysis, the 10-year survival for patients with stage II HCC and tumor <5 cm was 68.6 vs. 36.6 % in those who received minor hepatectomy alone (p = 0.027).

Conclusions

Major hepatectomy provided better long-term survival benefit in patients with HCC <5 cm, particularly in those with stage II disease.     

Pure laparoscopic liver resection reduces surgical site infections and hospital stay. Results of a case-matched control study in 50 patients

Background

Laparoscopic resection is an emerging tool in surgical oncology, but its role in liver tumors is far from being universally accepted.

Methods

We designed a case-matched control study, comparing laparoscopic (LAP) vs. open hepatectomies (OP) performed in the same center during the same period of time. Fifty LAP were performed (34 liver metastases, 7 hepatocellular carcinomas, 2 hydatid cysts, and 5 benign tumors). Cases were compared with 100 OP matched according to: diagnosis, number of lesions, type of resection, age, ASA score, and ECOG performance status. We evaluated intraoperative and postoperative parameters, focusing on morbidity and mortality.

Results

Preoperative data were comparable in both groups. Operative features were similar in terms of overall morbidity 18 (36 %) vs. 36 (36 %), p?=?1; intraoperative bleeding, 401 (18–2192) vs. 475 (20–2000) mL, p?=?0.89; pedicle clamping, 37 (74 %) vs. 88 (88 %), p?=?0.55; margin, 0.6 (0–5) vs. 0.65 (0–5) cm, p?=?0.94, and mortality p?=?0.65 for the LAP and OP groups, respectively. There was a significant decrease in surgical site infections 1 (2 %) vs. 18 (18 %) p?=?0.007 in the LAP group. Operative time was longer: 295 (120–600) vs. 200 (70–450) min (p?=?0.0001), and hospital stay significantly shorter: 4 (1–60) vs. 7 (3–44) days, p?=?0.0001 with less readmissions (0 vs. 7 %) in the LAP.

Discussion

In adequately selected patients, laparoscopic hepatectomy is feasible, safe, shortens hospital stay, and decreases surgical site infections.     

Hepatectomy in Elderly Patients: Does Age Matter?

Background

With the increase in average life expectancy in recent decades, the proportion of elderly patients requiring liver surgery is rising. The aim of the meta-analysis reported here was to evaluate the safety and efficacy of hepatectomy in elderly patients.

Methods

An extensive electronic search was performed for relevant articles that compare the outcomes of hepatectomy in patients ≥70 years of age with those in younger patients prior to October 2012. Analysis of pooled data was performed with RevMan 5.0.

Results

Twenty-eight observational studies involving 15,480 patients were included in the analysis. Compared with the younger patients, elderly patients experienced more complications (31.8 vs 28.7 %; P = 0.002), mainly as a result of increased cardiac complications (7.5 vs 1.9 %; P < 0.001) and delirium (11.7 vs 4.5 %; P < 0.001). Postoperative major surgical complications (12.6 vs 11.3 %; P = 0.55) and mortality (3.6 vs 3.3 %; P = 0.68) were comparable between elderly and younger patients. For patients with malignancies, both the 5-year disease-free survival (26.5 vs 26.3 %; P = 0.60) and overall survival (39.5 vs 40.7 %; P = 0.29) did not differ significantly between the two groups.

Conclusions

Postoperative major surgical complications, mortality, and long-term results in elderly patients seem to be comparable with those in younger patients, suggesting that age alone should not be considered a contraindication for hepatectomy.     

Morbidity and radiographic outcomes of severe scoliosis of 90° or more: a comparison of hybrid with total pedicle screw instrumentation

Objectives

Untreated severe scoliosis is associated with increased mortality and remains a significant surgical challenge. Few studies have reported mortality after the surgical treatment of severe scoliosis beyond a 2-year follow-up. The objectives of this study were to evaluate mortality beyond standard 2-year follow-up and compare radiographic outcomes using hybrid or pedicle screw instrumentation for severe scoliosis.

Methods

We evaluated 32 consecutive patients [11 males, mean age at surgery 15.3 (range 10.7–20.7) years] operated for a scoliosis of 90° or more using either hybrid (n = 15) or pedicle screw (n = 17) instrumentation. The follow-up time averaged 2.9 (2.0–6.6) years for radiographic and quality of life measurements and 5.5 years (2.0–9.0) years for mortality data. Of these patients, one had adolescent idiopathic scoliosis, three secondary scoliosis, and 28 neuromuscular scoliosis. Twelve patients in the hybrid and two patients in the pedicle screw groups underwent anteroposterior surgery (p < 0.001), and three patients in both groups had an apical vertebral column resection.

Results

One (3.1 %) patient died during follow-up for severe pneumonia. Preoperatively, the mean magnitude of the major curve was 109° (90°–127°) in the hybrid and 100° (90°–116°) in the pedicle screw groups (p = 0.015), and was corrected to 45° (19°–69°) in the hybrid and 27° (18°–40°) in the pedicle screw groups at the 2-year follow-up (p < 0.001), with a mean correction of the major curve of 59 % (37–81 %) in the hybrid versus 73 % (60–81 %) in the pedicle screw groups, respectively (p = 0.0023). There were six postoperative complications, including one transient spinal cord deficit necessitating reoperation in the hybrid group as compared with five complications in the pedicle screw group (p = 0.53).

Conclusions

The mid-term mortality rate after the surgical treatment of severe scoliosis was low. Severe scoliosis can be treated safely with significantly better correction of the spinal deformity using pedicle screws than hybrid instrumentation.     

Interest of intra-operative 3D imaging in spine surgery: a prospective randomized study

Purpose

We report a single-center, prospective, randomized study for pedicle screw insertion in opened and percutaneous spine surgeries, using a computer-assisted surgery (CAS) technique with three-dimensional (3D) intra-operative images intensifier (without planification on pre-operative CT scan) vs conventional surgical procedure.

Material and method

We included 143 patients: Group C (conventional, 72 patients) and Group N (3D Fluoronavigation, 71 patients). We measured the pedicle screw running time, and surgeon’s radiation exposure. All pedicle runs were assessed according to Heary by two independent radiologists on a post-operative CT scan.

Results

3D Fluoronavigation appeared less accurate in percutaneous procedures (24 % of misplaced pedicle screws vs 5 % in Group C) (p = 0.007), but more accurate in opened surgeries (5 % of misplaced pedicle screws vs 17 % in Group C) (p = 0.025). For one vertebra, the average surgical running time reached 8 min in Group C vs 21 min in Group N for percutaneous surgeries (p = 3.42 × 10^?9), 7.33 min in Group C vs 16.33 min in Group N (p = 2.88 × 10^?7) for opened surgeries. The 3D navigation device delivered less radiation in percutaneous procedures [0.6 vs 1.62 mSv in Group C (p = 2.45 × 10^?9)]. For opened surgeries, it was twice higher in Group N with 0.21 vs 0.1 mSv in Group C (p = 0.022).

Conclusion

The rate of misplaced pedicle screws with conventional techniques was nearly the same as most papers and a little bit higher with CAS. Surgical running time and radiation exposure were consistent with many studies. Our work hypothesis is partially confirmed, depending on the type of surgery (opened or closed procedure).

     

Improved Long-Term Survival after Major Resection for Hepatocellular Carcinoma: A Multicenter Analysis Based on a New Definition of Major Hepatectomy

Background

Advances in the surgical management of hepatocellular carcinoma (HCC) have expanded the indications for curative hepatectomy, including more extensive liver resections. The purpose of this study was to examine long-term survival trends for patients treated with major hepatectomy for HCC.

Patients and Methods

Clinicopathologic data for 1,115 patients with HCC who underwent hepatectomy between 1981 and 2008 at five hepatobiliary centers in France, China, and the USA were assessed. In addition to other performance metrics, outcomes were evaluated using resection of ≥4 liver segments as a novel definition of major hepatectomy.

Results

Major hepatectomy was performed in 539 patients. In the major hepatectomy group, median tumor size was 10 cm (range: 1–27 cm) and 22 % of the patients had bilateral lesions. The TNM Stage distribution included 29 % Stage I, 31 % Stage II, 38 % Stage III, and 2 % Stage IV. The postoperative histologic examination indicated that chronic liver disease was present in 35 % of the patients and tumor microvascular invasion was identified in 60 % of the patients. The 90-day postoperative mortality rate was 4 %. After a median follow-up time of 63 months, the 5-year overall survival rate was 40 %. Patients treated with right hepatectomy (n?=?332) and those requiring extended hepatectomy (n?=?207) had similar 90-day postoperative mortality rates (4 % and 4 %, respectively, p?=?0.976) and 5-year overall survival rates (42 % and 36 %, respectively, p?=?0.523). Postoperative mortality and overall survival rates after major hepatectomy were similar among the participating countries (p?>?0.1) and improved over time with 5-year survival rates of 30 %, 40 %, and 51 % for the years 1981–1989, 1990–1999, and the most recent era of 2000–2008, respectively (p?=?0.004). In multivariate analysis, factors that were significantly associated with worse survivals included AFP level >1,000 ng/mL, tumor size >5 cm, presence of major vascular invasion, presence of extrahepatic metastases, positive surgical margins, and earlier time period in which the major hepatectomy was performed.

Conclusions

This multinational, long-term HCC survival analysis indicates that expansion of surgical indications to include major hepatectomy is justified by the significant improvement in outcomes over the past three decades observed in both the East and the West.     

Predictors of intraoperative blood loss in patients undergoing hepatectomy

Purpose

Despite recent advances in surgical techniques, blood loss can still determine the postoperative outcome of hepatectomy. Thus, the preoperative identification of risk factors predicting increased blood loss is important.

Methods

We studied retrospectively the clinical records of 482 patients who underwent elective hepatectomy for liver disease, and analyzed the clinicopathological and surgical parameters influencing intraoperative blood loss.

Results

Red cell transfusion was required for 165 patients (35 %). Based on blood transfusion requirement and hepatic failure, we estimated predictive cut-off values at 850 and 1500 ml. The factors found to be significantly associated with increased blood loss were as follows: male gender, obstructive jaundice, non-metastatic liver carcinoma, Child-Pugh B disease, decreased uptake ratio on liver scintigraphy, platelet count, or prothrombin activity, longer hepatic transection time, operating time, the surgeon’s technique, J-shape or median incision, major hepatectomy, and not using hemostatic devices (p < 0.05). Multivariate analysis identified male gender, low prothrombin activity, longer transection time, longer operation time, and not using hemostatic devices as factors independently associated with increased blood loss (p < 0.05).

Conclusions

Male gender and low prothrombin activity represent risk factors for increased blood loss during hepatectomy. Moreover, every effort should be made to reduce the transection and operating times using the latest hemostatic devices.     

Risk Factors for Massive Bleeding during Major Hepatectomy

Background

Massive bleeding during hepatectomy is a risk for mortality and morbidity. We examined the risk factors for massive bleeding and their correlations with outcomes.

Methods

The study was a retrospective case series. Among 353 consecutively hepatectomized patients, the mean estimated blood loss (EBL) was 825 ml. Ten patients (2.8%) experienced EBL of between 3000 and 5000 ml. Five patients (1.4%) experienced massive EBL defined as more than 5000 ml, and all five patients had undergone right major hepatectomy (RMH) for primary liver cancer (PLC). All the patients with PLC who underwent RMH were divided into two groups: group I with EBL ≤ 5000 ml (n = 19) and group II with EBL > 5000 ml (n = 5). Perioperative factors regarding massive bleeding and operative mortality and morbidity were compared between the two groups.

Results

Among the ten patients who experienced EBL of between 3000 and 5000 ml, three had partial hepatectomy of no more than subsegmentectomy of the paracaval portion of the caudate lobe and three had central bisegmentectomy. The mean tumor size was 7.9 ± 4.7 cm in group I and 15.1 ± 2.2 cm in group II (P = 0 .0034). Tumor compression of the inferior vena cava (IVC) on CT scans was observed in all patients in group II, but in no patients in group I (P < 0.0001). Four of five patients in group II received surgery through an anterior approach. The liver-hanging maneuver (LHM) was applied in 14 of 19 patients (74%) in group I but could not be applied in group II (P = 0.0059). No postoperative and in-hospital mortalities occurred in group II and there were no significant differences in the incidence of mortality and morbidity between the groups.

Conclusions

RMH for large PLCs, tumor compression of the IVC, and an anterior approach without the LHM are risks for massive bleeding during hepatectomy. Preparation of rapid infusion devices in these cases is necessary to avoid prolonged hypotension.     

Diabetes Mellitus and Increased Postoperative Risk of Acute Renal Failure After Hepatectomy for Hepatocellular Carcinoma: A Nationwide Population-Based Study

Background

This study aimed to determine the effects of diabetes mellitus (DM) on the risk of surgical mortality and morbidity in patients undergoing hepatectomy for hepatocellular carcinoma (HCC).

Methods

We identified 2,962 DM patients who underwent a hepatectomy for HCC from 2000 to 2010. The non-DM control cohort consisted of 2,962 patients who also received a hepatectomy during the same period. Age, sex, comorbidities, and year of admission were all matched between the 2 cohorts.

Results

The prevalence of preoperative coexisting medical conditions was comparable between the DM and non-DM cohorts, except the percentage of patients undergoing major hepatectomy (lobectomy; 18.1 % in the DM cohort vs. 20.4 % in the non-DM cohort; p = 0.02).The hazard ratio (HR) of 30-day postoperative mortality in the DM patients after hepatectomy was 1.17 [95 % confidence interval (CI) 0.75–1.84] after adjustment. The DM cohort exhibited a significantly higher risk of postoperative septicemia (adjusted hazard ratio, 1.45; 95 % CI 1.06–2.00) and acute renal failure (adjusted hazard ratio, 1.70; 95 % CI 1.01–2.84) compared with that of the non-DM cohort, but this higher risk was not associated with the increased risk of other major morbidities, including pneumonia, stroke, and myocardial infarction. Further analysis showed that major hepatectomy (lobectomy) in DM patients carried higher risks of septicemia and acute renal failure. In multiple regression models, preoperative diabetes-related comorbidities were not significantly associated with 30-day postoperative mortality.

Conclusions

DM is associated with a significantly high risk of septicemia and acute renal failure, but not with other major complications or mortality, after hepatectomy for HCC.     

Greater Complexity of Liver Surgery is Not Associated with an Increased Incidence of Liver-Related Complications Except for Bile Leak: An Experience with 2,628 Consecutive Resections

Background

Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.

Methods

A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.

Results

Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p?<?0.001), two-stage resection (4.0 vs 1 %; p?<?0.001), extended right hepatectomy (17.6 vs 14.6 %; p?=?0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p?<?0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p?=?0.02) and hemorrhage (0.9 vs 0.3 %; p?=?0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p?=?0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p?=?0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.

Conclusions

The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.     

Surgical Outcomes in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis

Background

Different approaches to surgical treatment of portal vein tumor thrombosis (PVTT) have been advocated. This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma (HCC) patients with PVTT.

Methods

We reviewed prospectively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010. Patients were excluded from analysis if they had extrahepatic disease, PVTT reaching the level of the superior mesenteric vein, or hepatectomy with a positive resection margin. The remaining patients were divided into three groups for comparison: group 1, with ipsilateral PVTT resected in a hepatectomy; group 2, with PVTT extending to or beyond the portal vein bifurcation, treated by en bloc resection followed by portal vein reconstruction; group 3, with PVTT extending to or beyond the portal vein bifurcation, treated by thrombectomy.

Results

A total of 88 patients, with a median age of 54 years, were included in the analysis. Group 2 patients were younger, with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 (p = 0.017). Group 1 patients had higher preoperative serum alpha-fetoprotein levels, with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 (p = 0.004), and shorter operation time, with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 (p = 0.018). No patient had thrombus in the main portal vein. Two (2.8 %) hospital deaths occurred in group 1 and one (10 %) in group 2, but none in group 3 (p = 0.440). The rates of complication in groups 1, 2, and 3 were 31.9, 50.0, and 71.4 %, respectively (p = 0.079). The median overall survival durations were 10.91, 9.4, and 8.58 months, respectively (p = 0.962), and the median disease-free survival durations were 4.21, 3.78, and 1.51 months, respectively (p = 0.363). The groups also had similar patterns of disease recurrence (intrahepatic: 33.8 vs. 28.6 vs. 40.0 %; extrahepatic: 16.9 vs. 14.3 vs. 0 %; both: 28.2 vs. 42.9 vs. 40.0 %; no recurrence: 21.1 vs. 14.3 vs. 20.0 %; p = 0.836).

Conclusions

The three approaches have similar outcomes in terms of survival, complication, and recurrence. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.     

Reoperative Surgery After Repair of Postcholecystectomy Bile Duct Injuries: Is it Worthwhile?

Background

Repeat repair of bile duct injuries (BDIs) after cholecystectomy is technically challenging, and its success remains uncertain. We retrospectively evaluated the short- and long-term outcomes of patients requiring reoperative surgery for BDI at a major referral center for hepatobiliary surgery.

Methods

Between January 1991 and May 2011, we performed surgical BDI repairs in 46 patients. Among them, 22 patients had undergone a previous surgical repair elsewhere (group 1), and 24 patients had no previous repair (group 2). We compared the early and late outcomes in the two groups.

Results

The patients in group 1 were younger (48.6 vs. 54.8 years, p = 0.0001) and were referred after a longer interval (>1 month) from BDI (72.7 vs. 41.7 %, p = 0.042). Intraoperative diagnosis of BDI (59.1 vs. 12.5 %, p = 0.001), ongoing cholangitis (45.4 vs. 12.5 %; p = 0.02), and delay of repair after referral to our institution (116 ± 34 days vs. 23 ± 9 days; p = 0.001) were significantly more frequent in group 1 than in group 2. No significant differences were found for postoperative mortality, morbidity, or length of stay between the groups. Patients with associated vascular injuries had a higher postoperative morbidity rate (p = 0.01) and associated hepatectomy rate (p = 0.045). After a mean follow-up of 96.6 ± 9.7 months (range 5–237.2 months, median 96 months), the rate of recurrent cholangitis (6.5 %) was comparable in the two groups.

Conclusions

This study demonstrates that short- and long-term outcomes after surgical repair of BDI are comparable regardless of whether the patient requires reoperative surgery for a failed primary repair. Associated vascular injuries increase postoperative morbidity and the need for liver resection.     

Role of Major Vascular Resection in Patients with Intrahepatic Cholangiocarcinoma

Background

Historically, direct vascular extension of intrahepatic cholangiocarcinoma (ICC) has often been considered a contraindication to resection. However, recent studies have suggested safety and efficacy of hepatectomy with major vascular resection in this patient population. The aim of this study was to investigate the short and long-term clinical outcomes of patients with ICC treated with hepatectomy with or without major vascular resection.

Methods

This retrospective cohort study included all patients with ICC who underwent major liver resection between 1997 and 2011. Clinical outcomes were compared between patients treated with major hepatectomy and vascular resection (VR) and those without vascular resection (NVR). Kaplan–Meier survival estimates were used to compare overall survival (OS) between patients in VR and NVR groups.

Results

A total of 121 patients (median age 60; 42 % male) underwent major hepatectomy for ICC. Major vascular resection was performed in 14 (12 %) patients (IVC = 9, PV = 5). Age, sex, American Society of Anesthesiology (ASA) class, tumor size, lymph node status, and CA-19 9 were comparable (all p ≥ 0.184) between VR and NVR groups. Major postoperative complications (Dindo-Clavien ≥3) occurred in four (29 %) patients in the VR group and 17 (16 %) in the NVR group (p = 0.263). Postoperative death occurred in one patient in the VR group due to liver failure. Median OS did not differ between patients treated with and without vascular resection (32 vs. 49 months, respectively, p = 0.268).

Conclusions

Hepatectomy combined with IVC or PV resection can be safely performed in patients with ICC. Major vascular resection does not affect short and long-term outcomes in this patient population.     

Hepatectomy based on the tumor hemodynamics for hepatocellular carcinoma: a comparison among the hybrid and pure laparoscopic procedures and open surgery

Purpose

This study was designed to evaluate the surgical parameters and treatment outcomes of tumor hemodynamics-based pure laparoscopic (PURE) and laparoscopy-assisted (HYBRID) hepatectomy for small hepatocellular carcinoma (HCC) compared with those of open hepatectomy.

Methods

Using a prospectively collected database from 1997 to 2011, we analyzed the data of 56 consecutive cases of laparoscopic hepatectomy for HCC (PURE, n = 24; HYBRID, n = 29; HALS, n = 3) from among 102 cases undergoing laparoscopic hepatectomy. We employed 27 cases treated by open hepatectomy during the same period as controls.

Results

PURE was associated with lesser blood loss, lower weight of the resected liver, and a shorter skin incision than HYBRID and open hepatectomy [median blood loss (mL): PURE 7, HYBRID 380, Open 450; P < 0.05]. On the other hand, HYBRID hepatectomy was associated with a longer operation time [operation time (min): HYBRID 232, Open 185; P = 0.0226]. The length of hospitalization in the cases treated by PURE and HYBRID hepatectomy was shorter than that in the cases treated by open hepatectomy [length of hospitalization (days): PURE 11, HYBRID 12, Open 17; P < 0.05]. One case each of transfusion and morbidity was recorded in this series. There was no significant difference of the overall (OS) or disease-free survival (DFS) between the patients treated by laparoscopic and open hepatectomy (3-year OS: 100 vs. 100 %; DFS 50 vs. 62 %, respectively).

Conclusions

Neither the surgical parameters nor the treatment outcomes of hemodynamics-based laparoscopic hepatectomy were inferior to those of open hepatectomy.     

Laparoscopic Major Hepatectomies: Clinical Outcomes and Classification

Background

According to the Louisville Statement, laparoscopic major hepatectomy is a heterogeneous category that includes “traditional” trisectionectomies/hemi-hepatectomies and the technically challenging resection of segments 4a, 7, and 8. The aims of this study were to assess differences in clinical outcomes between laparoscopic “traditional” major hepatectomy and resection of “difficult-to-access” posterosuperior segments and to define whether the current classification is clinically valid or needs revision.

Methods

We reviewed a prospectively collected single-center database of 390 patients undergoing pure laparoscopic liver resection. A total of 156 patients who had undergone laparoscopic major hepatectomy according to the Louisville Statement were divided into two subcategories: laparoscopic “traditional” major hepatectomy (LTMH), including hemi-hepatectomies and trisegmentectomies, and laparoscopic “posterosuperior” major hepatectomy (LPMH), including resection of posterosuperior segments 4a, 7, and 8. LTMH and LPMH subgroups were compared with respect to demographics, intraoperative variables, and postoperative outcomes.

Results

LTMH was performed in 127 patients (81 %) and LPMH in 29 (19 %). Operation time was a median 330 min for LTMH and 210 min for LPMH (p < 0.0001). Blood loss was a median 500 ml for LTMH and 300 ml for LPMH (p = 0.005). Conversion rate was 9 % for LTMH and nil for LPMH (p = 0.219). In all, 28 patients (22 %) developed postoperative complications after LTMH and 5 (17 %) after LPMH (p = 0.801). Mortality rate was 1.6 % after LTMH and nil after LPMH. Hospital stay was a median 5 days after LTMH and 4 days after LPMH (p = 0.026).

Conclusions

The creation of two subcategories of laparoscopic major hepatectomy seems appropriate to reflect differences in intraoperative and postoperative outcomes between LTMH and LPMH.     

Prospective comparative study between straight and curved probe for pedicle screw insertion

Purpose

To evaluate difference in accuracy of pedicle screw insertion in thoracic and lumbosacral spine using a straight pedicle probe vis-à-vis a curved one.

Methods

Prospective, comparative, non-randomized, single-blind study. Straight and curved pedicle probes used on opposite sides of same vertebra in patients undergoing thoracolumbar pedicle screw fixation for various indications. Postoperative blinded evaluation for pedicle breaches done with a CT scan. Pedicle breaches graded as grade 0: no breach, grade 1: <2 mm, grade 2: 2–4 mm and grade 3: >4 mm breach.

Results

After appropriate statistical power analysis, 300 screws inserted in 59 patients from T4–L5 levels. No significant differences noted between the two probes in terms of screw length [two-tailed p = 0.16]; grade 0 screws [two-tailed p = 0.49] or screws with grade 2/3 breaches [two-tailed  p = 0.68]. With the right-hand-dominant operating-surgeon standing to left of patient during surgery, no difference noted between the two probes for either the right or left-side pedicle screw insertion [two-tailed p = 1]. Repeating these tests in the subset of thoracic pedicle screws too, revealed no significant difference.

Conclusions

No significant difference in outcome of pedicle screw insertion with either a straight or a curved pedicle probe.     

Predictors for Early Recurrence After Hepatectomy for Initially Unresectable Colorectal Liver Metastasis

Background

Early recurrence correlates with poor survival following various cancer surgeries and puts considerable stress on patients both physically and mentally. This retrospective study investigated the predictive factors for early recurrence after surgical resection for initially unresectable colorectal liver metastasis to elucidate indications for conversion strategies.

Methods

We retrospectively studied 46 patients who underwent hepatectomy after chemotherapy for initially unresectable colorectal liver metastasis from 1997 to 2010.

Results

Recurrences occurred within 6 months after hepatectomy in 13 patients (37 %). The median survival time of 21.2 months and the 5-year survival rate of 0 % after hepatectomy in patients with recurrence within 6 months were significantly worse than those in patients with recurrence more than 6 months after hepatectomy. Recurrence in less than 6 months was significantly correlated with impossibility of anticancer therapy for recurrence after hepatectomy (p?=?0.01). Eight or more hepatic tumors after chemotherapy were the only predictor of recurrence within 6 months (p?=?0.01; odds ratio 9.6; 95 % confidence interval 1.5–60.6).

Conclusion

Recurrence within 6 months was significantly correlated with a poorer outcome following surgery for initially unresectable colorectal liver metastasis. Surgical indication for initially unresectable colorectal liver metastasis with eight or more hepatic tumors after chemotherapy should be considered carefully in the light of mental and physical status, co-morbidity, and alternative treatment plans.     

Financial Comparison of Laparoscopic Versus Open Hepatic Resection Using Deviation-Based Cost Modeling

Background

There is a growing body of evidence suggesting the equivalence and in some cases superiority of laparoscopic liver resection versus open resection. Fewer data exist regarding the financial impact of laparoscopic liver resection.

Methods

Retrospective review of 98 consecutive patients at a single institution from 2007 through 2011 undergoing first time hepatic resection was performed. Laparoscopic and open cases were compared primarily on OR and hospital charges. Deviation-based cost modeling and weighted average mean cost for the two procedures were used to determine both financial and clinical efficacy on the basis of differences in length of stay, complications, and charges.

Results

There were 57 laparoscopic and 41 open cases included in the study. Right hepatectomy was the most common procedure performed in both the laparoscopic (n = 23, 40.4 %) and open (n = 22, 53.7 %) groups. Patients in the laparoscopic group were significantly more likely to have an “on course” postoperative hospitalization (73.7 vs. 26.8 %; p < 0.001), which translated into a WAMC of $58,401 for the laparoscopic cases and $69,728 for the open cases. In the subset of patients undergoing right hepatectomy, patients in the laparoscopic group remained more likely to have an on course hospitalization (61.2 vs. 31.8 %; p = 0.025). WAMC for the laparoscopic right hepatectomy group, however, was higher than the open group ($69,544 vs. $68,266).

Conclusions

The cost-effectiveness of laparoscopic hepatectomy appears to vary with the complexity of the procedure. Overall, laparoscopy offers a cost advantage; however, with more complex procedures such as right hepatectomy, higher up-front operating room charges offset the financial benefits of less complicated hospitalization.     

Prediction of early postoperative cerebral hemorrhage in infective endocarditis patients using magnetic resonance imaging

Objective

To evaluate the relationship between preoperative magnetic resonance imaging (MRI) findings and the occurrence of postoperative intracranial hemorrhage (ICH) in infective endocarditis (IE) patients.

Methods

Between 2002 and 2012, 30 IE patients required surgical intervention. Four patients developed and 26 patients did not develop postoperative ICH. All patients underwent preoperative brain MRI. The presence of acute brain infarction was detected by diffusion-weighted imaging (DWI), and cerebral microbleeds were detected by T2*-weighted imaging.

Results

Two ICH(+) patients died of stroke. Preoperative patient characteristics and operative results were not significantly different. Regarding MRI findings, the presence of cerebral microbleeds or acute brain infarction alone was not significantly different between the two groups (100 vs. 29.6 %, p = 0.07; 75.0 vs. 38.5 %, p = 0.37, respectively). The concurrent presence of cerebral microbleeds and acute brain infarction was significantly correlated with the development of major ICH (75 vs. 14.8 %, p = 0.04). In multiple logistic regression analyses, the concurrent presence of cerebral microbleeds and acute brain infarction on MRI was an independent predictor of major postoperative ICH (p = 0.03, odds ratio 16.5, 95 % confidence interval 1.35–201.3).

Conclusion

The combination of T2*-weighted MRI and DWI may be useful to evaluate the risk of IE patients developing major postoperative cerebral bleeding.