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Influence of age on surgical approach for hepatectomy: an analysis of the National Surgical Quality Improvement Program Database
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Mini Oral Session Abstracts
Methods: TRIPOD guidelines were followed. A validation cohort (VC) was created with the 2014 hepatectomy ACSNSQIP dataset. Characteristics of the VC and development cohort (DC) were compared. Risk groups for RBCT within 72 hours of surgery were created using anemia (hematocrit 36%), major liver resection (4 segments) and primary liver malignancy according to the TRS. The association between TRS variables and RBCT was examined with multivariable logistic regression. Area under the receiver operating characteristic curve (AUROC) assessed discrimination. HosmereLemeshow test for goodness of fit assessed calibration. Results: Of 3064 hepatectomies in VC, 18.9% received RBCT, compared to 23.3% in DC. The TRS stratified patients from low (8.5%) to very high risk (40.6%) of RBCT (Figure 1). All TRS variables were independently associated with RBCT in VC and DC. The final TRS was associated with RBCT in VC (odds ratio OR: 2.23; 95% confidence interval 95% CI: 1.99e2.51) and DC (OR 2.29; 95% CI 1.92e2.73). AUROC was 0.68 (95% CI 0.66e 0.70) in VC compared to 0.66 (95% CI 0.63e0.69) in DC. HosmereLemeshow test and calibration curves supported good predictive performance of the model in VC. Conclusion: The TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify pre-operatively patients at high transfusion risk. Tailored patient blood management initiatives can be utilized to reduce the use of RBCT.
metastases; however, newer reports suggest that simultaneous resection is feasible and safe. This systematic review seeks to determine differences in overall post-operative complications (primary outcome) between staged and simultaneous resections. Methods: We searched Medline, Embase, and PubMed for all study designs comparing simultaneous (intervention) versus staged (control) resection of synchronous rectal cancer with liver metastases. Study selection, data abstraction, risk of bias and quality of the evidence assessment were carried out in duplicate. Major complications were a secondary outcome. Risk of bias was assessed using the tool designed by the CLARITY Group. The quality of evidence was assessed using GRADE. Statistical heterogeneity was calculated using chi-squared and I2. Clinical heterogeneity was explored via subgroup analyses. The protocol was published in PROSPERO. Results: Of the 4456 abstracts retrieved, 17 studies were analyzed and 6 reported the primary outcome (all retrospective cohort studies). There were 288 intervention and 287 control patients in total. The odds ratio (OR) for overall complications (Intervention vs. Control) was 0.93, 95% confidence interval (CI) 0.64e1.35; the OR for major complications was 0.83, 95% CI 0.41e1.65. There wsas no significant statistical or clinical heterogeneity. Overall, the risk of bias for the included studies was moderate and the quality of the evidence (GRADE) was very low. Conclusion: Simultaneous resection of synchronous rectal cancer with liver metastases carries a similar risk of overall and major complications compared to the staged approach. Evidence from randomized trials is needed.
MO 96 INFLUENCE OF AGE ON SURGICAL APPROACH FOR HEPATECTOMY: AN ANALYSIS OF THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM DATABASE
MO 95 RECTAL AND HEPATIC RESECTION FOR RECTAL CANCER WITH SYNCHRONOUS LIVER METASTASES (RESECT): SIMULTANEOUS VS. STAGED. A SYSTEMATIC REVIEW A. Giles, M. Valencia, E. Fu, J. Hawkins, L. Ruo, M. Simunovic and P. Serrano McMaster University, Hamilton, Canada Objective: Staged surgical resection has been the preferred approach to treat synchronous rectal cancer with liver
J. Silva, N. Berger, S. Tsai, K. Christians, C. Clarke, H. Mogal and T. C. Gamblin Medical College of Wisconsin, Milwaukee, WI, USA Objective: This study sought to analyze the role of age in hepatectomy; specifically focused on the intended surgical approach and perioperative outcomes. Methods: The National Surgical Quality Improvement Program Database identified patients undergoing hepatectomy between January 1, 2014 and December 31, 2014. Patients were divided into age cohorts of <50 years, 50e74 years, and 75 years. Demographic information, intended surgical approach, perioperative characteristics, and shortterm postoperative outcomes were compared. Results: A total of 3,064 patients were included in the study. Hepatectomy was performed most frequently on patients 50e74 years (64.5%, n = 1,975), followed by those HPB 2017, 19 (S1), S40eS108
Mini Oral Session Abstracts <50 years (24.4%, n = 748), and 75 years (11.1%, n = 340). Patients <50 years were more likely to have benign pathology (p < 0.001). Significant differences in gender, race, body mass index, diabetes, hepatitis, hypertension, and American Society of Anesthesia classification were found among age groups. No significant difference in intended surgical approach (minimally invasive vs. open) existed between groups (p = 0.369), and rates of conversion were similar (p = 0.527). Younger patients experienced the longest operative time (249 vs. 227 vs. 206 minutes, p < 0.001), but shorter length of stay (5 vs. 6 days, p < 0.001). Morbidity was lowest in patients <50 years (p = 0.031), but similar in the remaining cohorts. No significant difference existed in 30-day mortality (p = 0.079) or readmission (p = 0.261). Conclusion: Operative approaches for hepatectomy showed no variation between age groups despite differences in underlying tumor pathology, patient demographics, and comorbidities. Hepatectomy is a safe and effective procedure for selective patients regardless of age. Age does not appear to contribute to intended operative approach for hepatectomy.
MO 97 DETERMINANTS OF OUTCOME AND SURVIVAL FOLLOWING TREATMENT OF RECURRENT HEPATOCELLULAR CARCINOMA: A SYSTEMATIC REVIEW & META-ANALYSIS S. Erridge, P. H. Pucher, S. R. Markar, G. Malietzis, T. Athanasiou, A. Darzi, M. H. Sodergren and L. R. Jiao Imperial College London, London, United Kingdom Objective: This review aimed to identify the optimum treatment strategies for hepatocellular carcinoma (HCC) recurrence. Methods: A systematic review, up to July 2015, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of differing treatment modalities was carried out using a random effects model with further assessment of additional prognostic factors for survival. Results: 18 cohort studies (2662 patients) were included in final data analysis. The median 5-year survival of repeat hepatectomy (RH; n = 481 pts), ablation (n = 389) and transarterial chemoembolization (TACE; n = 878) were 43.0%, 52.7% and 9.0% respectively. Pooled analysis of 10 studies demonstrated no significant difference between overall survival after RH or ablation (HR = 1.03; p = 0.897). Median tumor size across these studies was 23.0 mm (RH) and 20.5 mm (ablation). Pooled analysis of 7 studies comparing TACE with RH showed a non-significant trend to improved survival from RH (HR = 1.61; p = 0.056). Review of prognostic factors identified those negatively associated with overall survival includes: recurrence of HCC within one year (HR 6.8; p < 0.05), presence of more than 3 recurrent tumors (HR 3.78; p < 0.05) and tumors greater than 3 cm in size (HR 4.01; p < 0.05). Conclusion: There was significant heterogeneity in the reporting of these studies preventing the implementation of formal meta-regression. Despite a paucity of available data,
HPB 2017, 19 (S1), S40eS108
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these results suggest a non-significant trend to improved survival following RH compared with TACE and identification of important negative prognostic factors, which may influence choice of treatment modality.
MO 98 INTERSTAGE ASSESSMENT OF REMNANT LIVER FUNCTION IN ALPPS USING HEPATOBILIARY SCINTIGRAPHY: PREDICTION OF POSTHEPATECTOMY LIVER FAILURE AND INTRODUCTION OF THE HIBA INDEX M. Serenari, C. Collaud, F. Alvarez, M. De Santibañes, D. Giunta, J. Pekolj, V. Ardiles and E. De Santibañes Hospital Italiano de Buenos Aires, Bologna, Italia Objective: The aim of the present study was to evaluate interstage liver function in associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) using hepatobiliary scintigraphy and whether this may help to predict clinically significant PHLF. Methods: Between 2011 and 2016, 20 out of 39 patients (51.3%) underwent SPECT-HBS before completion of ALPPS stage 2 for primary (n = 3) or secondary liver tumors (n = 17) at the Hospital Italiano de Buenos Aires (HIBA). PHLF was defined by the International Study Group of Liver Surgery (ISGLS) criteria, 50e50 criteria or peak bilirubin >7 mg/dl. Grade A PHLF was excluded, as it requires no change in clinical management. Receiver operating characteristic curves were used to determine cutoff for HBS parameters. Results: Interstagely, 3 HBS parameters differed significantly between patients with (n = 4) and without PHLF (n = 16) after stage 2. Among these, the HIBA index best predicted PHLF, with a cutoff value of 15%. The risk of PHLF in patients with <15% was 80%, whereas no patient with 15% developed PHLF. Conclusion: Interstage HBS could help to predict clinically significant PHLF after ALPPS stage 2. An HIBA index cutoff of 15% seemed to give the best diagnostic performance. Even though further studies are needed to confirm our findings, the routine application of this non-invasive low-cost exam could be useful to facilitate decision-making in every institution willing to safely perform the ALPPS approach.
MO 99 ARE ANTERIOR AND POSTERIOR SECTIONECTOMIES REALLY MINOR LIVER RESECTIONS? RETROSPECTIVE COMPARISON TO RIGHT HEPATECTOMY AND MINOR HEPATIC RESECTION M. Al-Temimi, A. Mousa and A. DiFronzo Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA Objective: Classically, right anterior and posterior sectionectomies (RAPS) are considered minor resections; however, these operations are technically complex. We
Mini Oral Session Abstracts
Methods: TRIPOD guidelines were followed. A validation cohort (VC) was created with the 2014 hepatectomy ACSNSQIP dataset. Characteristics of the VC and development cohort (DC) were compared. Risk groups for RBCT within 72 hours of surgery were created using anemia (hematocrit 36%), major liver resection (4 segments) and primary liver malignancy according to the TRS. The association between TRS variables and RBCT was examined with multivariable logistic regression. Area under the receiver operating characteristic curve (AUROC) assessed discrimination. HosmereLemeshow test for goodness of fit assessed calibration. Results: Of 3064 hepatectomies in VC, 18.9% received RBCT, compared to 23.3% in DC. The TRS stratified patients from low (8.5%) to very high risk (40.6%) of RBCT (Figure 1). All TRS variables were independently associated with RBCT in VC and DC. The final TRS was associated with RBCT in VC (odds ratio OR: 2.23; 95% confidence interval 95% CI: 1.99e2.51) and DC (OR 2.29; 95% CI 1.92e2.73). AUROC was 0.68 (95% CI 0.66e 0.70) in VC compared to 0.66 (95% CI 0.63e0.69) in DC. HosmereLemeshow test and calibration curves supported good predictive performance of the model in VC. Conclusion: The TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify pre-operatively patients at high transfusion risk. Tailored patient blood management initiatives can be utilized to reduce the use of RBCT.
metastases; however, newer reports suggest that simultaneous resection is feasible and safe. This systematic review seeks to determine differences in overall post-operative complications (primary outcome) between staged and simultaneous resections. Methods: We searched Medline, Embase, and PubMed for all study designs comparing simultaneous (intervention) versus staged (control) resection of synchronous rectal cancer with liver metastases. Study selection, data abstraction, risk of bias and quality of the evidence assessment were carried out in duplicate. Major complications were a secondary outcome. Risk of bias was assessed using the tool designed by the CLARITY Group. The quality of evidence was assessed using GRADE. Statistical heterogeneity was calculated using chi-squared and I2. Clinical heterogeneity was explored via subgroup analyses. The protocol was published in PROSPERO. Results: Of the 4456 abstracts retrieved, 17 studies were analyzed and 6 reported the primary outcome (all retrospective cohort studies). There were 288 intervention and 287 control patients in total. The odds ratio (OR) for overall complications (Intervention vs. Control) was 0.93, 95% confidence interval (CI) 0.64e1.35; the OR for major complications was 0.83, 95% CI 0.41e1.65. There wsas no significant statistical or clinical heterogeneity. Overall, the risk of bias for the included studies was moderate and the quality of the evidence (GRADE) was very low. Conclusion: Simultaneous resection of synchronous rectal cancer with liver metastases carries a similar risk of overall and major complications compared to the staged approach. Evidence from randomized trials is needed.
MO 96 INFLUENCE OF AGE ON SURGICAL APPROACH FOR HEPATECTOMY: AN ANALYSIS OF THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM DATABASE
MO 95 RECTAL AND HEPATIC RESECTION FOR RECTAL CANCER WITH SYNCHRONOUS LIVER METASTASES (RESECT): SIMULTANEOUS VS. STAGED. A SYSTEMATIC REVIEW A. Giles, M. Valencia, E. Fu, J. Hawkins, L. Ruo, M. Simunovic and P. Serrano McMaster University, Hamilton, Canada Objective: Staged surgical resection has been the preferred approach to treat synchronous rectal cancer with liver
J. Silva, N. Berger, S. Tsai, K. Christians, C. Clarke, H. Mogal and T. C. Gamblin Medical College of Wisconsin, Milwaukee, WI, USA Objective: This study sought to analyze the role of age in hepatectomy; specifically focused on the intended surgical approach and perioperative outcomes. Methods: The National Surgical Quality Improvement Program Database identified patients undergoing hepatectomy between January 1, 2014 and December 31, 2014. Patients were divided into age cohorts of <50 years, 50e74 years, and 75 years. Demographic information, intended surgical approach, perioperative characteristics, and shortterm postoperative outcomes were compared. Results: A total of 3,064 patients were included in the study. Hepatectomy was performed most frequently on patients 50e74 years (64.5%, n = 1,975), followed by those HPB 2017, 19 (S1), S40eS108
Mini Oral Session Abstracts <50 years (24.4%, n = 748), and 75 years (11.1%, n = 340). Patients <50 years were more likely to have benign pathology (p < 0.001). Significant differences in gender, race, body mass index, diabetes, hepatitis, hypertension, and American Society of Anesthesia classification were found among age groups. No significant difference in intended surgical approach (minimally invasive vs. open) existed between groups (p = 0.369), and rates of conversion were similar (p = 0.527). Younger patients experienced the longest operative time (249 vs. 227 vs. 206 minutes, p < 0.001), but shorter length of stay (5 vs. 6 days, p < 0.001). Morbidity was lowest in patients <50 years (p = 0.031), but similar in the remaining cohorts. No significant difference existed in 30-day mortality (p = 0.079) or readmission (p = 0.261). Conclusion: Operative approaches for hepatectomy showed no variation between age groups despite differences in underlying tumor pathology, patient demographics, and comorbidities. Hepatectomy is a safe and effective procedure for selective patients regardless of age. Age does not appear to contribute to intended operative approach for hepatectomy.
MO 97 DETERMINANTS OF OUTCOME AND SURVIVAL FOLLOWING TREATMENT OF RECURRENT HEPATOCELLULAR CARCINOMA: A SYSTEMATIC REVIEW & META-ANALYSIS S. Erridge, P. H. Pucher, S. R. Markar, G. Malietzis, T. Athanasiou, A. Darzi, M. H. Sodergren and L. R. Jiao Imperial College London, London, United Kingdom Objective: This review aimed to identify the optimum treatment strategies for hepatocellular carcinoma (HCC) recurrence. Methods: A systematic review, up to July 2015, was conducted in accordance with MOOSE guidelines. The primary outcome was the hazard ratio for overall survival of different treatment modalities. Meta-analysis of differing treatment modalities was carried out using a random effects model with further assessment of additional prognostic factors for survival. Results: 18 cohort studies (2662 patients) were included in final data analysis. The median 5-year survival of repeat hepatectomy (RH; n = 481 pts), ablation (n = 389) and transarterial chemoembolization (TACE; n = 878) were 43.0%, 52.7% and 9.0% respectively. Pooled analysis of 10 studies demonstrated no significant difference between overall survival after RH or ablation (HR = 1.03; p = 0.897). Median tumor size across these studies was 23.0 mm (RH) and 20.5 mm (ablation). Pooled analysis of 7 studies comparing TACE with RH showed a non-significant trend to improved survival from RH (HR = 1.61; p = 0.056). Review of prognostic factors identified those negatively associated with overall survival includes: recurrence of HCC within one year (HR 6.8; p < 0.05), presence of more than 3 recurrent tumors (HR 3.78; p < 0.05) and tumors greater than 3 cm in size (HR 4.01; p < 0.05). Conclusion: There was significant heterogeneity in the reporting of these studies preventing the implementation of formal meta-regression. Despite a paucity of available data,
HPB 2017, 19 (S1), S40eS108
S83
these results suggest a non-significant trend to improved survival following RH compared with TACE and identification of important negative prognostic factors, which may influence choice of treatment modality.
MO 98 INTERSTAGE ASSESSMENT OF REMNANT LIVER FUNCTION IN ALPPS USING HEPATOBILIARY SCINTIGRAPHY: PREDICTION OF POSTHEPATECTOMY LIVER FAILURE AND INTRODUCTION OF THE HIBA INDEX M. Serenari, C. Collaud, F. Alvarez, M. De Santibañes, D. Giunta, J. Pekolj, V. Ardiles and E. De Santibañes Hospital Italiano de Buenos Aires, Bologna, Italia Objective: The aim of the present study was to evaluate interstage liver function in associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) using hepatobiliary scintigraphy and whether this may help to predict clinically significant PHLF. Methods: Between 2011 and 2016, 20 out of 39 patients (51.3%) underwent SPECT-HBS before completion of ALPPS stage 2 for primary (n = 3) or secondary liver tumors (n = 17) at the Hospital Italiano de Buenos Aires (HIBA). PHLF was defined by the International Study Group of Liver Surgery (ISGLS) criteria, 50e50 criteria or peak bilirubin >7 mg/dl. Grade A PHLF was excluded, as it requires no change in clinical management. Receiver operating characteristic curves were used to determine cutoff for HBS parameters. Results: Interstagely, 3 HBS parameters differed significantly between patients with (n = 4) and without PHLF (n = 16) after stage 2. Among these, the HIBA index best predicted PHLF, with a cutoff value of 15%. The risk of PHLF in patients with <15% was 80%, whereas no patient with 15% developed PHLF. Conclusion: Interstage HBS could help to predict clinically significant PHLF after ALPPS stage 2. An HIBA index cutoff of 15% seemed to give the best diagnostic performance. Even though further studies are needed to confirm our findings, the routine application of this non-invasive low-cost exam could be useful to facilitate decision-making in every institution willing to safely perform the ALPPS approach.
MO 99 ARE ANTERIOR AND POSTERIOR SECTIONECTOMIES REALLY MINOR LIVER RESECTIONS? RETROSPECTIVE COMPARISON TO RIGHT HEPATECTOMY AND MINOR HEPATIC RESECTION M. Al-Temimi, A. Mousa and A. DiFronzo Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA Objective: Classically, right anterior and posterior sectionectomies (RAPS) are considered minor resections; however, these operations are technically complex. We