Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Geneeskundeonderwijs over etnische diversiteit in de zorg: wat kunnen we leren van de VS?

In April 2012, 20 medical students took part in a study tour to San Francisco, themed 'ethnic diversity in health care'. In this article we discuss four lessons learned from the perspective of these students. The delivery of culturally sensitive healthcare is becoming more important in the Netherlands as the ethnic minority population rate will continue to grow over the coming years. However, diversity education is not a structural component of medical curricula in the Netherlands to the same degree as in the USA where medical education pays a lot of attention to differences in health between ethnic minorities; and where there is also extensive research on this subject. We emphasize that diversity education should create awareness of differences in health outcomes between ethnic groups and awareness of one's own bias and stereotypical views. The implementation of diversity education is a challenge, which requires a change of image and the involvement of teachers from diverse medical discipline

The use of a NHS-PEG coated, collagen-based sealant in a patient undergoing Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)

Introduction: ALPPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy) is a new two-stage hepatectomy for patients in whom conventional treatment is not feasible due to insufficient future liver remnant (FLR). During stage one of ALPPS, accelerated growth of the FLR is induced by ligation of the portal vein and in situ split of the liver, which prevents interlobar collateral portal circulation and attributes to the accelerated hypertrophy response. This can present a risk for postoperative haemorrhage. Furthermore, adhesion of the adjacent resection surfaces might complicate the second stage of the procedure. Hemopatch® is a flexible, NHS-PEG coated, absorbable collagen-based sealant that provides haemostasis. This paper illustrates the use of Hemopatch during ALPPS for hemostasis and prevention of adhesions between the cut-surfaces of the liver. Presentation of case: An 81-year-old patient requiring right hemihepatectomy for synchronous liver metastases underwent ALPPS. During stage one, Hemopatch was applied according to the manufacturer's instructions to the hepatic resection surfaces. Stage-2 was performed uneventfully, with no adhesions observed in the resection plane 18 days after the first stage. The patient was discharged without any major complications. Discussion: Hemopatch is a useful tool in prevention of postoperative haemorrhage in patients undergoing ALPPS procedure as well as in the prevention of adhesions between the cut-surfaces after transection. This facilitates stage-2 of the procedure which potentially improves postoperative outcomes. Conclusion: Topic haemostatic agents to cover the transection surface during stage one of ALPPS could help to prevent adverse interstage events

Current Modalities for the Assessment of Future Remnant Liver Function

While imaging studies such as computed tomography or magnetic resonance imaging allow the volumetric assessment of the liver segments, only indirect information is provided concerning the quality of the liver parenchyma and its actual functional capacity. Assessment of liver function is therefore crucial in the preoperative workup of patients who require extensive liver resection and in whom portal vein embolization is considered. This review deals with the modalities currently available for the measurement of liver function. Passive liver function tests include biochemical parameters and clinical grading systems such as the Child-Pugh and MELD scores. Dynamic quantitative tests of liver function can be based on clearance capacity tests such as the indocyanine green (ICG) clearance test. Although widely used, discrepancies have been reported for the ICG clearance test in relation with clinical outcome. Nuclear imaging studies have the advantage of providing simultaneous morphologic (visual) and physiologic (quantitative functional) information about the liver. In addition, regional (segmental) differentiation allows specific functional assessment of the future remnant liver. Technetium-99m (99mTc)-galactosyl human serum albumin scintigraphy and 99mTc-mebrofenin hepatobiliary scintigraphy potentially identify patients at risk for post-resectional liver failure who might benefit from liver-augmenting techniques. As there is no one test that can measure all the components of liver function, liver functional reserve is estimated based on a combination of clinical parameters and quantitative liver function test

Reoperative aortic valve replacement in the octogenarians-minimally invasive technique in the era of transcatheter valve replacement

Objective: Reoperative aortic valve replacement (re-AVR) in octogenarians is considered high risk and therefore might be indicated for transcatheter AVR. The minimally invasive technique for re-AVR limits dissection and might benefit this patient population. We report the outcomes of re-AVR in high-risk octogenarians who might be considered candidates for transcatheter AVR to assess the safety of re-AVR and minimally invasive operative techniques. Methods: We identified 105 patients, aged >= 80 years, who underwent open re-AVR at our institution from July 1997 to December 2011. Patients requiring concomitant coronary bypass surgery and/or other valve surgery were excluded. The outcomes of interest included operative mortality, postoperative complications, and midterm postoperative survival. Results: Of the 105 patients, 51 underwent minimally re-AVR through upper hemisternotomy (Mre-AVR) and 54 standard full sternotomy (Fre-AVR). The mean patient age was 82.8 +/- 3.8 years. No significant differences were found in the patient risk factors. Postoperatively, 6 patients (5.7%) underwent reoperation for bleeding, 4 (3.8%) experienced permanent stroke, 4 (3.8%) developed new renal failure, and 22 (21.0%) had new-onset atrial fibrillation. Overall, the operative mortality was 6.7%, and the 1- and 5-year survival was 87% and 53%, respectively. When Mre-AVR and Fre-AVR were compared, the operative mortality was 9.2% in the Fre-AVR group and 3.9% in the Mre-AVR group (P = .438). Kaplan-Meier analysis showed a survival benefit at both 1 year (79% +/- 11.7% vs 92% +/- 7.8%) and 5 years (38% +/- 17.6% vs 65% +/- 15.7%, P = .028) favoring Mre-AVR. Cox regression analysis identified heparin-induced thrombocytopenia, reoperation for bleeding, older age, full sternotomy, and an infectious complication as predictors of mortality. Conclusions: Octogenarians who undergo re-AVR are thought to be high-risk surgical candidates. The present single-center series revealed acceptable in-hospital outcomes and operative mortality. Mre-AVR was associated with better survival compared with Fre-AVR and might benefit this populatio

Practical guidelines for the use of technetium-99m mebrofenin hepatobiliary scintigraphy in the quantitative assessment of liver function

Surgical resection remains the most important curative treatment for liver tumors; however, it harbors the risk of developing posthepatectomy liver failure. The principal risk is associated with the quality and quantity of the future remnant liver. Therefore, preoperative assessment of the future remnant liver is essential in patients scheduled for major liver resection. Technetium-99m mebrofenin hepatobiliary scintigraphy (HBS) in combination with single-photon emission computed tomography/computed tomography is increasingly applied for the quantitative assessment of liver function before major liver surgery. This dynamic quantitative liver function test allows assessment of both total and regional liver function, represented by the hepatic mebrofenin uptake rate, thereby assisting in adequate patient selection. Since routine implementation, it has shown to reduce the risk of posthepatectomy liver failure and has proven to be more valuable than volumetric assessment. To ensure optimal and reproducible results that can be compared across different centers, it is crucial to standardize the methodology and ensure practical applicability of this technique, thereby facilitating external validation and multicenter trials. This article provides an overview of the HBS methodology used at some of the largest HBS centers and covers practical details in the application of HBS for the quantitative scintigraphic assessment of liver function

Stress test of liver function using technetium-99m-mebrofenin hepatobiliary scintigraphy

Technetium-99m (Tc) mebrofenin hepatobiliary scintigraphy (HBS) enables a quantitative assessment of liver function. This is normally performed in a fasting state and might therefore reflect the resting liver function. We evaluated the change in liver function using HBS after stimulation with an oral metabolic challenge. Healthy volunteers aged 50-60 (n=12) or older than or equal to 75 (n=12) years underwent two sequential HBS. The first scan was performed after an overnight fast and the second scan was performed after the administration of chocolate milk. Hepatic Tc-mebrofenin uptake rate (cMUR) was calculated and the difference was expressed as percentage. cMUR after fasting was 10.9±2.5%/min/m (mean±SD) and increased by 20% to 13.0±3.1%/min/m after stimulation with chocolate milk (P<0.001). cMUR increased markedly after the administration of an oral metabolic challenge in comparison with fasting. This may be a consequence of hepatocyte stimulation, reflecting the hepatic functional reserve capacity

Quantitative assessment of liver function using hepatobiliary scintigraphy: The effect of microcirculatory alterations after portal vein embolization

ObjectivesHepatobiliary scintigraphy using technetium-99m mebrofenin has been validated as a quantitative liver function test. Preoperative portal vein embolization (PVE) is performed in patients to increase future remnant liver function and volume. Changes in hepatic microcirculation after PVE remain largely unknown and may influence the uptake of mebrofenin. The aim was to evaluate microcirculatory changes after PVE to examine differences in perfusion that might influence the uptake of mebrofenin, and consequently, assessment of function.Patients and methodsPatients undergoing liver resection with or without preoperative PVE were included. Future remnant liver volume and function were measured before and after PVE. Hepatic microcirculation was measured in the embolized and the nonembolized lobes during resection. Microcirculatory flow index, perfused vessel density, sinusoidal diameter and red blood cell velocity were assessed.ResultsA total of 16 patients, eight with preoperative PVE and eight control patients without PVE, were included. After PVE, both function and volume of the nonembolized lobe were significantly increased, and the functional increase exceeded the increase in volume. Perfused vessel density and sinusoidal diameter were significantly higher in the nonembolized liver lobe (P<0.002 and <0.04). No significant differences between both lobes were found concerning microcirculatory flow index or red blood cell velocity.ConclusionAfter PVE, the nonembolized lobe had a significantly higher (functional) microvascular density compared with the embolized lobe, without differences in microvascular flow. These findings indicate that the measured functional increase using hepatobiliary scintigraphy, which exceeded the volumetric increase, was not the consequence of an increase in hepatic perfusion, therefore, providing adequate representation of the liver function

Increased Hepatic Microvascular Density, Oxygenation, and VEGF in the Hypertrophic Lobe following Portal Vein Embolization in Rabbits

Introduction: The microvascular events following portal vein embolization (PVE) are poorly understood despite the pivotal role of the microcirculation in liver regeneration and tumor progression. We aimed to assess the changes in hepatic microvascular perfusion and neo-angiogenesis after experimental PVE. Methods: PVE of the cranial liver lobes was performed in 12 New Zealand White rabbits divided into 2 groups of permanent (P-PVE) and reversible PVE (R-PVE), respectively. Hepatobiliary scintigraphy and CT were used to evaluate hepatic function and volume. Hepatic microcirculation was assessed using a handheld vital microscope (Cytocam) to measure microvascular density (total vessel density; TVD) before PVE, right after PVE, and 20 min after PVE, as well as at 14 days (D14 post-PVE) and 35 days (D35 post-PVE). Additionally, on D35, microvascular PO and liver parenchymal VEGF were assessed. Results: Eleven rabbits were included after PVE (R-PVE, n = 5; P-PVE, n = 6). TVD in the nonembo-lized (hypertrophic) lobes was higher than in the embolized (atrophic) lobes of the P-PVE group at D35 post-PVE (36.7 ± 7.2 vs. 23.4 ± 4.9 mm/mm p < 0.05). In the R-PVE group, TVD in the nonembolized lobes was not increased at D35. Function and volume were increased in the nonembolized lobes of the P-PVE group compared to the embolized lobes, but not in the R-PVE group. Likewise, the mmicrovascular PO2 and VEGF staining rate were higher in the nonembolized lobes of the P-PVE group at D35 post-PVE. Discussion/Conclusion: Successful volumetric and functional hypertrophy of the nonembolized lobe was accompanied by microvascular alterations featuring increased neo-angiogenesis, microvascular density, and microvascular oxygen pressure following P-PVE