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The Dutch hepato biliary audit: Nationwide implementation and first results
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Electronic Poster Abstracts
FP01-09 - Table 1. Intraoperative Data and Short-term Outcome
Variables
Initial experience
Late experience
13
17
P value
Operative feasibility Duration of operation, Median (range), min First Stage
409 (321–480)
400 (294–560)
0.39
second Stage
129 (50–204)
120 (60–215)
0.87
Blood loss, Median (range), mL First Stage
800 (500–1500)
800 (400–2500)
0.1
second Stage
200 (50–400)
100 (50–200)
0.0125
7 (58%)
6 (35%)
First Stage
0 (0–2)
0 (0–3)
0.9
second Stage
1 (0–3)
0
0.0156
Right trisectionectomy
12 (92%)
13 (76%)
0.37
Mono segment ALPPS
1 (8%)
4 (24%)
RBC transfusion. n (%) Packs per patient, mean (range)
Type of Liver resection, n (%)
Reversed Approach
2 (15 %)
0
0.16
Extrahepatic simultaneous procedures, n (%)
4 (31%)
5 (30%)
1
Plastic bag used, n (%)
4 (31%)
0
0.02
Interval Phase in days, Median (range)
8 (7–10)
9 (7–12)
0.07
%FLR/TLV, mean (SD)
19.3(±3.98)
22.7 (±5.4)
0.89
%FLR/TLV after stage 1, mean (SD)
37.9 (±6.4)
38.5 (±9.8)
0.85
Major Complication ‡ IIIa, n (%)
4 (31%)
8 (0.47%)
0.71
Sever Complication > IIIb, n (%)
2 (15%)
2 (12%)
1
90 Days Mortality
0
0
1
Total length of hospital stay in days, Median (range)
17 (14–49)
17 (13–29)
0.28
R0
12
16
1
R1
1
1
Resection Margin
[Intraoperative Data and Short-term Outcomes]
Conclusion: There was a trend of more complex cases in the late era with a slight improvement in outcomes. This shows the effect of the learning curve. However, patient selection seems to be a key factor in achieving good results.
FP01-10 THE DUTCH HEPATO BILIARY AUDIT: NATIONWIDE IMPLEMENTATION AND FIRST RESULTS L. A. D. Busweiler1,2, C. I. Buis3, M. den Dulk4, M. T. de Boer3, M. S. L. Liem5, J. M. Klaase6, R. J. Porte3, R. van Hillegersberg7, C. Verhoef8, C. H. C. Dejong4 and Dutch Hepato Biliary Audit Group 1 Department of Surgery, Leiden University Medical Centre, 2Dutch Institute for Clinical Auditing, 3Department of Surgery, University Medical Centre, Groningen, 4 Department of Surgery, Maastricht University Medical Centre, 5Department of Surgery, Deventer Hospital, 6 Department of Surgery, Medisch Spectrum Twente, 7 Department of Surgery, University Medical Centre Utrecht, and 8Department of Surgery, Erasmus Medical Centre, Netherlands
Introduction: The Dutch Hepato Biliary Audit (DHBA) was initiated in 2013 to evaluate and improve the care for all patients undergoing liver surgery in the Netherlands. The aim of this study was to describe the development and nationwide implementation of the DHBA and to provide an overview of the first results. Method: The DHBA was initiated by the Dutch Liver Working Group in collaboration with the Dutch Institute for Clinical Auditing. Mandatory nationwide prospective data registration took place via an online registration system. Emphasis is on relevant quality measures and clinical information essential for case-mix adjustment. Weekly updated and benchmarked feedback is available for all participating hospitals. Results: Between July 2013 and December 2014, 1658 patients who underwent a liver resection were registered in the DHBA by 28 different hospitals: 1165 procedures for colorectal liver metastases, 227 procedures for primary malignant liver tumours, 145 procedures for benign liver tumours and 121 procedures for liver metastases of other origin. In 431 patients (26%) this was a major liver resection. A postoperative complication was registered in 481 patients (29%) and in 131 patients (27%) this was a grade III-V complication (Clavien Dindo classification). Thirty-
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts six patients (2.2%) died during the hospital stay or within 30 days after the primary operation. Conclusions: The DHBA has been successfully implemented and will provide valuable insight in the quality of care of patients undergoing liver surgery in the Netherlands. Initial outcomes seem comparable with international standards. Reducing variation between individual hospitals could lead to further improvement.
FP01-11 ACCURATE CALCULATION OF FUTURE REMNANT LIVER FUNCTION BY VOLUME/FUNCTION ANALYSIS BEFORE LIVER RESECTION M. Stockmann, M. Malinowski, M. Jara, J. Bednarsch, A. Kirchstein, S. -C. Schmidt and J. Pratschke Dep. of General, Visceral and Transplantation Surgery, University Hospital Charité, Germany Background: The future remnant liver function (FRLF) is the crucial factor for the outcome of patients undergoing liver resection. Especially in extended resections or patients after chemotherapy or with NASH preoperative calculation of FRLF is of high importance. We investigated here the accuracy of preoperative calculation of FRLF by volume/ function analysis. Methods: A prospective clinical study was performed. The preoperative functional capacity of the liver was determined by the LiMAx test, based on a cytochrome P450 1A2 metabolism of 13C-methacetin. Prior to resection virtual hepatectomy with volumetric analysis was performed using a 3-dimensional reconstruction of a 4-phase contrastenhanced computer tomography (3D-CT). FRLF was calculated from preoperative function and predicted remnant volume. This analysis fixed prior to operation in cooperation with the responsible surgeon. Again, directly after the operation (1e4 hours) an additional CT-scan and LiMAx test was performed and values compared to preoperative calculations. Results: 28 patients undergoing liver resection have been enrolled in this study. Predicted FRLV correlates with the measured postoperative liver volume (r = 0.95, p < .001). The actual postoperative measured liver function by LiMAx also showed a good correlation with the predicted FRLF (r = 0.89, p < .001). Mean LiMAx difference between estimated and measured function was 33 mg/h/kg. Conclusion: Volume/function analysis using the LiMAx test and virtual liver resection with 3D-CT has the potential to accurately predict FRLF and could improve the preoperative evaluation of the patients. Thus, individual point-ofcare calculation of FRLF enables liver resection of larger number of patients with increased safety.
FP01-12 IS LAPAROSCOPIC ALPPS SAFER THAN OPEN ALPPS? M. A. Machado1, R. C. Surjan1, T. C. Basseres1, F. F. Makdissi1 and E. Schadde2 1 Surgery, Sirio Libanes Hospital, Brazil, and 2Department of Surgery, University of Zurich, Switzerland
HPB 2016, 18 (S1), e1ee384
e13
Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a highly complex liver resection in two stages with a high complication rate. Totally laparoscopic ALPPS was first described by us in 2012. This study addresses the question if laparoscopic ALPPS is a promising modification of ALPPS to reduce the operative severity and improve outcomes. Methods: This is a single center prospective observational study to compare laparoscopic ALPPS with open ALPPS. Our primary endpoint is postoperative complications, secondary enpdoints are degree of hypertrophy. Results: Between July 2011 and August 2015, 27 patients with liver malignancies considered unresectable due to an insufficient future liver remnant (FLR) underwent ALPPS procedure. Eight patients underwent laparoscopic ALPPS and 19 open ALPPS. Median age was 57 years (range:28e69). The median FLR was 130% (range:42e309). Twenty-five patients completed the second stage (feasibility 92.6%). Morbidity rate was 28% (Dindo-Clavien gradeIIIa). Mortality rate was 3.7%. Morbidity was significantly lower (p = 0.017) in laparoscopic ALPPS. Interestingly, FLR hypertrophy after laparoscopic ALPPS (median 118%) showed a trend, however not significant, to be lower from open ALPPS (median 152%), however without clinical relevance (p = 0.11). All but two patients were discharged between stages. Median total hospital stay was 14 days. Hospital stay was significantly shorter in the laparoscopic ALPPS group (p = 0.03). Conclusion: This prospective study is the largest reported single-center experience with laparoscopic ALPPS and shows that laparoscopic ALPPS reduces complications and hospital stay without clinically significant impact on FLR hypertrophy.
FP01-13 ASSOCIATING LIVER TOURNIQUET AND PORTAL VEIN LIGATION FOR STAGED HEPATECTOMY. AN ALPPS TECHNIQUE MODIFICATION R. Robles Campos, A. López Conesa, R. Brusadin, V. López López, P. J. Gil González and P. Parrilla Paricio Virgen de la Arrixaca University Hospital, Spain Objetive: We carried out a “modification of ALPPS technique” combining right intraoperative portal vein ligation with the application of a tourniquet on the parenchymal section line. We analyze the grade of hypertrophy obtained with at 7th PO day, intraoperative results, morbidity and mortality at 3 months. Patients and method: From September 2011 we have performed a TSLR in 41 ALTPS. In 19 cases the tourniquet was positioned around the falciform ligament to achieve hypertrophy in segments II-III, and in 22 cases, on Cantlie’s line after resecting the left hepatic lobe tumors. In the second operation a right trisectionectomy was performed in 19 cases (7 of these the IVC was resected) and in 22 cases a right hepatectomy was performed.
Electronic Poster Abstracts
FP01-09 - Table 1. Intraoperative Data and Short-term Outcome
Variables
Initial experience
Late experience
13
17
P value
Operative feasibility Duration of operation, Median (range), min First Stage
409 (321–480)
400 (294–560)
0.39
second Stage
129 (50–204)
120 (60–215)
0.87
Blood loss, Median (range), mL First Stage
800 (500–1500)
800 (400–2500)
0.1
second Stage
200 (50–400)
100 (50–200)
0.0125
7 (58%)
6 (35%)
First Stage
0 (0–2)
0 (0–3)
0.9
second Stage
1 (0–3)
0
0.0156
Right trisectionectomy
12 (92%)
13 (76%)
0.37
Mono segment ALPPS
1 (8%)
4 (24%)
RBC transfusion. n (%) Packs per patient, mean (range)
Type of Liver resection, n (%)
Reversed Approach
2 (15 %)
0
0.16
Extrahepatic simultaneous procedures, n (%)
4 (31%)
5 (30%)
1
Plastic bag used, n (%)
4 (31%)
0
0.02
Interval Phase in days, Median (range)
8 (7–10)
9 (7–12)
0.07
%FLR/TLV, mean (SD)
19.3(±3.98)
22.7 (±5.4)
0.89
%FLR/TLV after stage 1, mean (SD)
37.9 (±6.4)
38.5 (±9.8)
0.85
Major Complication ‡ IIIa, n (%)
4 (31%)
8 (0.47%)
0.71
Sever Complication > IIIb, n (%)
2 (15%)
2 (12%)
1
90 Days Mortality
0
0
1
Total length of hospital stay in days, Median (range)
17 (14–49)
17 (13–29)
0.28
R0
12
16
1
R1
1
1
Resection Margin
[Intraoperative Data and Short-term Outcomes]
Conclusion: There was a trend of more complex cases in the late era with a slight improvement in outcomes. This shows the effect of the learning curve. However, patient selection seems to be a key factor in achieving good results.
FP01-10 THE DUTCH HEPATO BILIARY AUDIT: NATIONWIDE IMPLEMENTATION AND FIRST RESULTS L. A. D. Busweiler1,2, C. I. Buis3, M. den Dulk4, M. T. de Boer3, M. S. L. Liem5, J. M. Klaase6, R. J. Porte3, R. van Hillegersberg7, C. Verhoef8, C. H. C. Dejong4 and Dutch Hepato Biliary Audit Group 1 Department of Surgery, Leiden University Medical Centre, 2Dutch Institute for Clinical Auditing, 3Department of Surgery, University Medical Centre, Groningen, 4 Department of Surgery, Maastricht University Medical Centre, 5Department of Surgery, Deventer Hospital, 6 Department of Surgery, Medisch Spectrum Twente, 7 Department of Surgery, University Medical Centre Utrecht, and 8Department of Surgery, Erasmus Medical Centre, Netherlands
Introduction: The Dutch Hepato Biliary Audit (DHBA) was initiated in 2013 to evaluate and improve the care for all patients undergoing liver surgery in the Netherlands. The aim of this study was to describe the development and nationwide implementation of the DHBA and to provide an overview of the first results. Method: The DHBA was initiated by the Dutch Liver Working Group in collaboration with the Dutch Institute for Clinical Auditing. Mandatory nationwide prospective data registration took place via an online registration system. Emphasis is on relevant quality measures and clinical information essential for case-mix adjustment. Weekly updated and benchmarked feedback is available for all participating hospitals. Results: Between July 2013 and December 2014, 1658 patients who underwent a liver resection were registered in the DHBA by 28 different hospitals: 1165 procedures for colorectal liver metastases, 227 procedures for primary malignant liver tumours, 145 procedures for benign liver tumours and 121 procedures for liver metastases of other origin. In 431 patients (26%) this was a major liver resection. A postoperative complication was registered in 481 patients (29%) and in 131 patients (27%) this was a grade III-V complication (Clavien Dindo classification). Thirty-
HPB 2016, 18 (S1), e1ee384
Electronic Poster Abstracts six patients (2.2%) died during the hospital stay or within 30 days after the primary operation. Conclusions: The DHBA has been successfully implemented and will provide valuable insight in the quality of care of patients undergoing liver surgery in the Netherlands. Initial outcomes seem comparable with international standards. Reducing variation between individual hospitals could lead to further improvement.
FP01-11 ACCURATE CALCULATION OF FUTURE REMNANT LIVER FUNCTION BY VOLUME/FUNCTION ANALYSIS BEFORE LIVER RESECTION M. Stockmann, M. Malinowski, M. Jara, J. Bednarsch, A. Kirchstein, S. -C. Schmidt and J. Pratschke Dep. of General, Visceral and Transplantation Surgery, University Hospital Charité, Germany Background: The future remnant liver function (FRLF) is the crucial factor for the outcome of patients undergoing liver resection. Especially in extended resections or patients after chemotherapy or with NASH preoperative calculation of FRLF is of high importance. We investigated here the accuracy of preoperative calculation of FRLF by volume/ function analysis. Methods: A prospective clinical study was performed. The preoperative functional capacity of the liver was determined by the LiMAx test, based on a cytochrome P450 1A2 metabolism of 13C-methacetin. Prior to resection virtual hepatectomy with volumetric analysis was performed using a 3-dimensional reconstruction of a 4-phase contrastenhanced computer tomography (3D-CT). FRLF was calculated from preoperative function and predicted remnant volume. This analysis fixed prior to operation in cooperation with the responsible surgeon. Again, directly after the operation (1e4 hours) an additional CT-scan and LiMAx test was performed and values compared to preoperative calculations. Results: 28 patients undergoing liver resection have been enrolled in this study. Predicted FRLV correlates with the measured postoperative liver volume (r = 0.95, p < .001). The actual postoperative measured liver function by LiMAx also showed a good correlation with the predicted FRLF (r = 0.89, p < .001). Mean LiMAx difference between estimated and measured function was 33 mg/h/kg. Conclusion: Volume/function analysis using the LiMAx test and virtual liver resection with 3D-CT has the potential to accurately predict FRLF and could improve the preoperative evaluation of the patients. Thus, individual point-ofcare calculation of FRLF enables liver resection of larger number of patients with increased safety.
FP01-12 IS LAPAROSCOPIC ALPPS SAFER THAN OPEN ALPPS? M. A. Machado1, R. C. Surjan1, T. C. Basseres1, F. F. Makdissi1 and E. Schadde2 1 Surgery, Sirio Libanes Hospital, Brazil, and 2Department of Surgery, University of Zurich, Switzerland
HPB 2016, 18 (S1), e1ee384
e13
Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a highly complex liver resection in two stages with a high complication rate. Totally laparoscopic ALPPS was first described by us in 2012. This study addresses the question if laparoscopic ALPPS is a promising modification of ALPPS to reduce the operative severity and improve outcomes. Methods: This is a single center prospective observational study to compare laparoscopic ALPPS with open ALPPS. Our primary endpoint is postoperative complications, secondary enpdoints are degree of hypertrophy. Results: Between July 2011 and August 2015, 27 patients with liver malignancies considered unresectable due to an insufficient future liver remnant (FLR) underwent ALPPS procedure. Eight patients underwent laparoscopic ALPPS and 19 open ALPPS. Median age was 57 years (range:28e69). The median FLR was 130% (range:42e309). Twenty-five patients completed the second stage (feasibility 92.6%). Morbidity rate was 28% (Dindo-Clavien gradeIIIa). Mortality rate was 3.7%. Morbidity was significantly lower (p = 0.017) in laparoscopic ALPPS. Interestingly, FLR hypertrophy after laparoscopic ALPPS (median 118%) showed a trend, however not significant, to be lower from open ALPPS (median 152%), however without clinical relevance (p = 0.11). All but two patients were discharged between stages. Median total hospital stay was 14 days. Hospital stay was significantly shorter in the laparoscopic ALPPS group (p = 0.03). Conclusion: This prospective study is the largest reported single-center experience with laparoscopic ALPPS and shows that laparoscopic ALPPS reduces complications and hospital stay without clinically significant impact on FLR hypertrophy.
FP01-13 ASSOCIATING LIVER TOURNIQUET AND PORTAL VEIN LIGATION FOR STAGED HEPATECTOMY. AN ALPPS TECHNIQUE MODIFICATION R. Robles Campos, A. López Conesa, R. Brusadin, V. López López, P. J. Gil González and P. Parrilla Paricio Virgen de la Arrixaca University Hospital, Spain Objetive: We carried out a “modification of ALPPS technique” combining right intraoperative portal vein ligation with the application of a tourniquet on the parenchymal section line. We analyze the grade of hypertrophy obtained with at 7th PO day, intraoperative results, morbidity and mortality at 3 months. Patients and method: From September 2011 we have performed a TSLR in 41 ALTPS. In 19 cases the tourniquet was positioned around the falciform ligament to achieve hypertrophy in segments II-III, and in 22 cases, on Cantlie’s line after resecting the left hepatic lobe tumors. In the second operation a right trisectionectomy was performed in 19 cases (7 of these the IVC was resected) and in 22 cases a right hepatectomy was performed.