The significant impact of age on the clinical outcomes of laparoscopic appendectomy : results from the Polish Laparoscopic Appendectomy multicenter large cohort study

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults. Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1- 8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days). The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome

Risk factors for serious morbidity, prolonged length of stay and hospital readmission after laparoscopic appendectomy : results from Pol-LA (Polish Laparoscopic Appendectomy) multicenter large cohort study

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95%CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95%CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes

Assessing the impact of COVID-19 on liver cancer management (CERO-19).

BACKGROUND & AIMS: The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to healthcare systems and it may have heavily impacted patients with liver cancer (LC). Herein, we evaluated whether the schedule of LC screening or procedures has been interrupted or delayed because of the COVID-19 pandemic. METHODS: An international survey evaluated the impact of the COVID-19 pandemic on clinical practice and clinical trials from March 2020 to June 2020, as the first phase of a multicentre, international, and observational project. The focus was on patients with hepatocellular carcinoma or intrahepatic cholangiocarcinoma, cared for around the world during the first COVID-19 pandemic wave. RESULTS: Ninety-one centres expressed interest to participate and 76 were included in the analysis, from Europe, South America, North America, Asia, and Africa (73.7%, 17.1%, 5.3%, 2.6%, and 1.3% per continent, respectively). Eighty-seven percent of the centres modified their clinical practice: 40.8% the diagnostic procedures, 80.9% the screening programme, 50% cancelled curative and/or palliative treatments for LC, and 41.7% modified the liver transplantation programme. Forty-five out of 69 (65.2%) centres in which clinical trials were running modified their treatments in that setting, but 58.1% were able to recruit new patients. The phone call service was modified in 51.4% of centres which had this service before the COVID-19 pandemic (n = 19/37). CONCLUSIONS: The first wave of the COVID-19 pandemic had a tremendous impact on the routine care of patients with liver cancer. Modifications in screening, diagnostic, and treatment algorithms may have significantly impaired the outcome of patients. Ongoing data collection and future analyses will report the benefits and disadvantages of the strategies implemented, aiding future decision-making. LAY SUMMARY: The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to healthcare systems globally. Herein, we assessed the impact of the first wave pandemic on patients with liver cancer and found that routine care for these patients has been majorly disrupted, which could have a significant impact on outcomes

Prediction of Survival in Patients with Unresectable Colorectal Liver Metastases

Liver metastases are diagnosed synchronously with the primary tumour in 25% of patients with colorectal cancer. A half of the remaining patients develop liver metastases within 3 years following colectomy. At present, the only radical treatment of metastases is liver resection. Only 2.6% of patients survive 3 years if such treatment is not implemented. The aim of the study was to assess predictive factors of long-term survival in the group of patients with unresectable colorectal liver metastases carcinoma. Material and methods. Of 1029 patients with colorectal liver metastases, who were treated in the Department of General, Transplant and Liver Surgery of the Medical University of Warsaw in the years 2006-2012, cases of liver metastases assessed intraoperatively as unresectable were selected. The retrospective analysis included 85 patients. Based on the medical documentation, information concerning age, sex, characteristics of primary and secondary tumours, reasons for unresectability, neoadjuvant chemotherapy as well as local treatment of liver tumours was collected. Preoperative serum concentrations of CEA and CA 19-9 markers were considered. The Cox regression model, Kaplan- Meier estimator and log-rank test were applied in the statistical analyses. Results. The most common reason for unresectability were: number of metastases in 31 patients (36.5%) and extrahepatic metastases in 19 cases (22.4%). Overall survival in the entire group was 56.1% and 15.5% after 1 and 3 years respectively. A single-factor analysis showed that CEA serum levels (p=0.032; HR=1.002 per increase by 1 ng/ml) and the presence of extrahepatic metastases (p=0.037; HR=2.06) were predictors of worse survival. In a multivariate analysis, CEA concentration (p=0.017; HR=1.002 per increase by 1 ng/ml) was an independent predictor of death whereas the presence of extrahepatic metastases were not statistically significant (p=0.059; HR=2.09). Conclusions. Serum concentration of CEA marker is an independent predictor of worse survival, but the presence of extrahepatic metastases shows a similar tendenc

Minimizing blood loss and transfusion rate in laparoscopic liver surgery: a review

Laparoscopic liver resection has become a standard practice in many surgical wards in elective liver surgery, due to its positive impact on reducing hospital stay and postoperative complications, including lower blood loss and transfusion rate. However, achieving proper hemostasis in liver surgery, due to its vast blood supply, still remains a main concern to surgeons. Therefore, numerous techniques were and are still being developed to further reduce blood loss and transfusion rate. The aim of this literature review was to summarize the best available methods for achieving the minimal blood loss and transfusion rate in laparoscopic liver surgery, according to the newest data

Comparison of Total Tumor Volume, Size and Number of Colorectal Liver Metastases in Prediction of Survival in Patients after Liver Resection

Liver is the most common location of the colorectal cancer metastases occurrence. Liver resection is the only curative method of treatment. Unfortunately it is feasible only in 25% of patients with colorectal liver metastases, often because of the extensiveness of the disease. The aim of the study was to evaluate the predictive value of total tumor volume, size and number of colorectal liver metastases in patients treated with right hemihepatectomy. Material and methods. A retrospective analysis was performed in a group of 135 patients with colorectal liver metastases, who were treated with right hemihepatectomy. Total tumor volume was estimated based on the formula (4/3)πr3. Moreover, the study included an analysis of data on the number and size of tumors, radicality of the resection, time between primary tumor resection and liver resection, pre-operative blood serum concentration of carcinoembryonal antigen (CEA) and carcinoma antigen Ca19-9. The predictive value of the factors was evaluated by applying a Cox proportional hazards model and the area under the ROC curve. Results. The univariate analysis has shown the predictive value of size of the largest tumor (p=0.033; HR=1.065 per each cm) on the overall survival, however no predictive value of number of tumors (p=0.997; HR=1.000) and total tumor volume (p=0.212; HR=1.002) was observed. The multivariate analysis did not confirm the predictive value of the size of the largest tumor (p=0.141; HR=1.056). In the analysis of ROC curves, AUROC for the total tumor volume, the size of the largest tumor and the number of tumors were 0.629, 0.608, 0.520, respectively. Conclusions. Total tumor volume, size and number of liver metastases are not independent risk factors for the worse overall survival of patients with colorectal liver metastases treated with liver resection, therefore increased values of these factors should not be a contraindication for surgical treatmen

Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes?

peer reviewed[en] INTRODUCTION: Prognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM. METHODS: All patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed. RESULTS: A total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R1 resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022). CONCLUSION: The higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence

Short and Long-Term Outcomes After Primary Liver Transplantation in Elderly Patients

The number of elderly patients undergoing liver transplantation (LT) is increasing worldwide. The aim of the study was to evaluate the impact of recipient age exceeding 60 years on early and long-term outcomes after LT. Material and methods. This study comprised data of 786 patients after primary LT performed at a single center between January 2005 and October 2012. Patients over and under 60 years of age were compared with respect to baseline characteristics and outcomes: postoperative mortality (90-day) and 5-year patient (PS) and graft (GS) survival. Associations between recipient age exceeding 60 years and LT results were assessed in multiple Cox regression models. Results. Recipients older than 60 years (n=107; 13.6%) were characterized by more frequent hepatitis C virus infections (p<0.001), malignancies (p<0.001), and cardiovascular comorbidities (p<0.001); less frequent primary sclerosing cholangitis (p=0.002) and Roux-en-Y hepaticojejunostomy (p<0.001); lower Model for End-stage Liver Disease (MELD; p=0.043); and increased donor age (p=0.012). Fiveyear PS of older and younger recipients was 72.7% and 80.6% (p=0.538), while the corresponding rates of GS were 70.3% and 77.5% (p=0.548), respectively. Recipient age exceeding 60 years was not significantly associated with postoperative mortality (p=0.215), PS (p=0.525) and GS (p=0.572) in multivariate analyses. The list of independent predictors comprised MELD (p<0.001) for postoperative mortality; malignancies (p=0.003) and MELD (p<0.001) for PS; and malignancies (p=0.003), MELD (p<0.001) and donor age (p=0.017) for GS. Conclusions. Despite major differences between elderly and young patients, chronological age exceeding 60 years alone should not be considered as a contraindication for LT