Practice variation and outcomes of minimally invasive minor liver resections in patients with colorectal liver metastases:a population-based study

Introduction: In 2017, the Southampton guideline stated that minimally invasive liver resections (MILR) should considered standard practice for minor liver resections. This study aimed to assess recent implementation rates of minor MILR, factors associated with performing MILR, hospital variation, and outcomes in patients with colorectal liver metastases (CRLM). Methods: This population-based study included all patients who underwent minor liver resection for CRLM in the Netherlands between 2014 and 2021. Factors associated with MILR and nationwide hospital variation were assessed using multilevel multivariable logistic regression. Propensity-score matching (PSM) was applied to compare outcomes between minor MILR and minor open liver resections. Overall survival (OS) was assessed with Kaplan–Meier analysis on patients operated until 2018. Results: Of 4,488 patients included, 1,695 (37.8%) underwent MILR. PSM resulted in 1,338 patients in each group. Implementation of MILR increased to 51.2% in 2021. Factors associated with not performing MILR included treatment with preoperative chemotherapy (aOR 0.61 CI:0.50–0.75, p &lt; 0.001), treatment in a tertiary referral hospital (aOR 0.57 CI:0.50–0.67, p &lt; 0.001), and larger diameter and number of CRLM. Significant hospital variation was observed in use of MILR (7.5% to 93.0%). After case-mix correction, six hospitals performed fewer, and six hospitals performed more MILRs than expected. In the PSM cohort, MILR was associated with a decrease in blood loss (aOR 0.99 CI:0.99–0.99, p &lt; 0.01), cardiac complications (aOR 0.29, CI:0.10–0.70, p = 0.009), IC admissions (aOR 0.66, CI:0.50–0.89, p = 0.005), and shorter hospital stay (aOR CI:0.94–0.99, p &lt; 0.01). Five-year OS rates for MILR and OLR were 53.7% versus 48.6%, p = 0.21. Conclusion: Although uptake of MILR is increasing in the Netherlands, significant hospital variation remains. MILR benefits short-term outcomes, while overall survival is comparable to open liver surgery. Graphical abstract: [Figure not available: see fulltext.].</p

A nationwide assessment of hepatocellular adenoma resection:Indications and pathological discordance

Hepatocellular adenomas (HCAs) are benign liver tumors associated with bleeding or malignant transformation. Data on the indication for surgery are scarce. We analyzed indications and outcome of patients operated for HCAs 50 mm (52%), suspicion of (pre)malignancy (28%), and (previous) bleeding (5.1%). No difference was observed in HCA-subtype distribution between small and large tumors. Ninety-six (43%) patients had a postoperative change in diagnosis. Independent risk factors for change in diagnosis were tumor size <50 mm (adjusted odds ratio [aOR], 3.4; p < 0.01), male sex (aOR, 3.7; p = 0.03), and lack of hepatobiliary contrast-enhanced magnetic resonance imaging (CE-MRI) (aOR, 1.8; p = 0.04). Resection for small (suspected) HCAs was mainly indicated by suspicion of (pre)malignancy, whereas for large (suspected) HCAs, tumor size was the most prevalent indication. Male sex, tumor size <50 mm, and lack of hepatobiliary CE-MRI were independent risk factors for postoperative change in tumor diagnosis

Pregnant patient with acute abdominal pain and previous bariatric surgery

Pregnant women who previously had bariatric surgery may develop acute abdominal pain during pregnancy. Two patients, 38-year-old twin primigravida (gestational age of 24+6 weeks) and a 26-year-old woman (gestational age of 24+0 weeks), both of whom had laparoscopic gastric bypass surgery previously, developed abdominal pain. The patients both had diffuse abdominal pain in combination with normal blood tests and imaging. Patient B had undergone laparoscopy at another centre after 5 weeks of gestation for internal herniation. After referral to our multidisciplinary bariatric-obstetric-neonatal (MD-BON) team, diagnostic laparoscopy was advised as internal herniation was deemed possible. In both patients, internal herniation was indeed found in Petersen's space and jejunal mesenteric defect, which was closed using laparoscopic surgery. Both women delivered healthy offspring afterwards. The presence of an MD-BON team allows for an increased awareness of potential long-term complications associated with earlier bariatric surgery in pregnancy

Abdominal pain in a pregnant woman who had gastric reduction surgery:Risks associated with a history of bariatric surgery

Een nadeel van bariatrische chirurgie is dat de ingreep een risico geeft op complicaties op de lange termijn. Tijdens de zwangerschap kunnen deze complicaties leiden tot ernstige foetale en maternale morbiditeit en mortaliteit.1 In deze klinische les beschrijven we aan de hand van twee casussen het belang van multidisciplinaire expertise bij een zwangere patiënte met buikpijn door complicaties van eerdere bariatrische chirurgie.Patiënt A, een 38-jarige primigravida die 3 jaar eerder een laparoscopische ‘Roux-en-Y gastric bypass’ (RYGB) had ondergaan, was elders opgenomen met postprandiale buikpijn bij een tweelingzwangerschap met een amenorroeduur van 24/6 weken. Patiënte was normotensief, had een licht pijnlijke, niet-geprikkelde buik en een niet-afwijkend bloedbeeld. Het ongeboren kind was in goede conditie en er waren geen tekenen van dreigende vroeggeboorte. Differentiaaldiagnostisch werd gedacht aan obstipatie, galsteenlijden en inwendige herniatie van de dunne darm. Er werd een echo abdomen gemaakt waarop geen aanwijzingen waren voor galstenen of stuwing van de galwegen. Tevens ...In Nederland ondergaan jaarlijks ongeveer 6500 vrouwen in de vruchtbare levensfase een bariatrische operatie, waarbij de ‘Roux-en-Y gastric bypass’ (RYGB) de meest uitgevoerde operatie is. Gewichtsverlies na bariatrische chirurgie leidt tot een reductie van cardiovasculaire risico’s, verbeterde fertiliteit en vermindering van obesitas-gerelateerde complicaties tijdens de zwangerschap. Toch zijn er ook nadelen, zoals blijkt uit deze klinische les

Buikpijn bij een zwangere die een maagverkleining heeft gehad: de risico's van bariatrische chirurgie op de lange termijn

Een nadeel van bariatrische chirurgie is dat de ingreep een risico geeft op complicaties op de lange termijn. Tijdens de zwangerschap kunnen deze complicaties leiden tot ernstige foetale en maternale morbiditeit en mortaliteit.1 In deze klinische les beschrijven we aan de hand van twee casussen het belang van multidisciplinaire expertise bij een zwangere patiënte met buikpijn door complicaties van eerdere bariatrische chirurgie. Patiënt A, een 38-jarige primigravida die 3 jaar eerder een laparoscopische ‘Roux-en-Y gastric bypass’ (RYGB) had ondergaan, was elders opgenomen met postprandiale buikpijn bij een tweelingzwangerschap met een amenorroeduur van 24/6 weken. Patiënte was normotensief, had een licht pijnlijke, niet-geprikkelde buik en een niet-afwijkend bloedbeeld. Het ongeboren kind was in goede conditie en er waren geen tekenen van dreigende vroeggeboorte. Differentiaaldiagnostisch werd gedacht aan obstipatie, galsteenlijden en inwendige herniatie van de dunne darm. Er werd een echo abdomen gemaakt waarop geen aanwijzingen waren voor galstenen of stuwing van de galwegen. Tevens ..

Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial

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Personalised perioperative care by E-health after intermediate-grade abdominal surgery:A multicentre, single-blind, randomised, placebo-controlled trial

Background: Instructing and guiding patients after surgery is essential for successful recovery. However, the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven, shortened hospital stays. We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery. Methods: A multicentre, single-blind, randomised controlled trial was done at seven teaching hospitals in the Netherlands. Patients aged 18–75 years who were scheduled for laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication were recruited. An independent researcher randomly allocated participants to either the intervention or control group using computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised, e-health-care programme, which managed recovery expectations and provided postoperative guidance tailored to the patient. The control group received usual care and access to a placebo website containing standard general recovery advice. Participants were unaware of the study hypothesis and were asked to complete questionnaires at five timepoints during the 6-month period after surgery. The primary outcome was time between surgery and return to normal activities, measured using personalised patient-reported outcome measures. Intention-to-treat and per-protocol analyses were done. This trial is registered in the Netherlands National Trial Register, number NTR4699. Findings: Between Aug 24, 2015, and Aug 12, 2016, 344 participants were enrolled and randomly allocated to either the intervention (n=173) or control (n=171) group. 14 participants (4%) were lost to follow-up, with 330 participants included in the primary outcome analysis. Median time until return to normal activities was 21 days (95% CI 17–25) in the intervention group and 26 days (20–32) in the control group (hazard ratio 1·38, 95% CI 1·09–1·73; p=0·007). Complications did not differ between groups. Interpretation: A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care. Implementation of this e-health programme is recommended in patients undergoing intermediate-grade abdominal, gynaecological, or general surgical procedures. Funding: ZonMw

Personalised perioperative care by E-health after intermediate-grade abdominal surgery: A multicentre, single-blind, randomised, placebo-controlled trial

(Abstracted from Lancet 2018;392:51–59) Instructing and guiding patients are essential for successful recovery after surgery. Because of efficiency-driven, shortened hospital stays, the amount of time health care professionals spend, before and after surgery with their patients, has been reduced