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Purpose: To identify perioperative factors that are significantly associated with complications requiring interventional radiology (IR) treatment after hepatectomy., Methods: We retrospectively reviewed data from 11,243 patients in the USA who underwent hepatectomy from 2014 to 2016 using the National Surgical Quality Improvement Program database. Data on the following IR procedures were extracted: abscess drain placement, endovascular treatment for bleeding, and postoperative percutaneous biliary drain (PBD) placement up to 30 days postoperatively. Patients' clinical and intraoperative factors were examined. Population, univariate, and multivariable analyses were performed. P < 0.05 was considered significant., Results: A total of 704 patients (6%) required IR treatment postoperatively, and 10,539 patients (94%) did not. On multivariable analysis, biliary reconstruction was a significant predictor of postoperative abscess drain placement (hazard ratio (HR), 3.5; 95% confidence interval (CI) 1.8, 6.5; P < .001), endovascular treatment for bleeding (HR, 3.3; 95% CI 1.4, 7.8 P = .006), and postoperative PBD placement (HR, 2.9; 95% CI 1.9, 4.2; P < .001). Compared with hepatectomy without biliary reconstruction, hepatectomy with biliary reconstruction was associated with significantly higher rates of complications treated with IR procedures (26% vs. 4.9%) and death within 30 days (6.0% vs. 1.2%) (both, P < .001)., Conclusion: Biliary reconstruction is a strong predictor of the need for postoperative IR treatment after hepatectomy. One in four patients who underwent biliary reconstruction required IR treatment of a complication during the first 30 days after hepatectomy.

Background: Sarcopenia is a surrogate marker of patient frailty that estimates the physiologic reserve of an individual patient. We sought to investigate the impact of sarcopenia on short- and long-term outcomes in patients having undergone surgical intervention for primary hepatic malignancies., Methods: Ninety-six patients who underwent hepatic resection or liver transplantation for HCC or ICC at the John Hopkins Hospital between 2000 and 2013 met inclusion criteria. Sarcopenia was assessed by the measurement of total psoas major volume (TPV) and total psoas area (TPA). The impact of sarcopenia on perioperative complications and survival was assessed., Results: Mean age was 61.9 years and most patients were men (61.4 %). Mean adjusted TPV was lower in women (23.3 cm(3)/m) versus men (34.9 cm(3)/m) (P < 0.01); 47 patients (48.9 %) had sarcopenia. The incidence of a postoperative complication was 40.4 % among patients with sarcopenia versus 18.4 % among patients who did not have sarcopenia (P = 0.01). Of note, all Clavien grade ≥3 complications (n = 11, 23.4 %) occurred in the sarcopenic group. On multivariable analysis, the presence of sarcopenia was an independent predictive factor of postoperative complications (OR = 3.06). Sarcopenia was not associated with long-term survival (HR = 1.23; P = 0.51)., Conclusions: Sarcopenia, as assessed by TPV, was an independent factor predictive of postoperative complications following surgical intervention for primary hepatic malignancies.

Background: Although the LigaSure device is widely used, its use in liver transplantation, where compounding factors of portal hypertension, coagulopathy, and thrombocytopenia exist, is poorly described., Methods: From October 1, 2011, to December 31, 2011, 6 patients underwent liver transplantation with recipient hepatectomy utilizing the LigaSure device. Outcomes using the device were compared with 6 contemporaneous patients in whom the device was not used., Results: Patient demographics, preoperative laboratory values, and Model for End-Stage Liver Disease scores were not different. Recipient hepatectomy was performed, on average, 43 minutes faster using the LigaSure device (P = .02). Although total operative time and intraoperative blood product usage were lower when the LigaSure was used, these differences did not attain statistical significance. Duration of stay and recipient readmission rates were similar., Conclusions: LigaSure vessel sealing is an efficient method for recipient hepatectomy in liver transplantation. Vessel sealing of caval, portal, and other structures can be safely performed in the setting of end-stage liver disease., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Major hepatic necrosis (MHN) is a common complication after angioembolization (AE) for severe liver injuries. We compared the outcomes of two treatment modalities., Methods: Patients with MHN were retrospectively reviewed from January 2002 to October 2007. Demographics, Injury Severity Scale score, length of stay, admission Glasgow Coma Scale Score, mortality, transfusion requirements, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal procedures (operative or nonoperative) were collected. These patients were then divided into two groups-those treated with hepatic lobectomy (HL) and those treated with multiple procedures including serial operative debridements and/or percutaneous drainage (IR/OR)., Results: Thirty patients (41%) with MHN were identified from 71 patients who had AE. Sixteen patients with MHN underwent HL and 14 patients underwent multiple IR/OR procedures. The two groups were similar at baseline, except that the HL group had a higher Injury Severity Scale score. Outcomes between the two groups were similar. There was a significantly higher complication rate and increased number of procedures in the IR/OR group. There were no deaths in patients who had early HL (<5 days). There was one death in the later lobectomy group., Conclusion: MHN is a common complication after AE. This complication can be safely managed with a series of operative debridements in conjunction with interventional procedures or with HL. Lobectomy is associated with a lower complication rate and a fewer number of procedures. Early lobectomy may be better than a delayed procedure.

Background: The surgical management of hepatocellular carcinoma in patients with well-compensated cirrhosis is controversial. The purpose of the current study was to compare the outcome of patients with well-compensated cirrhosis and early stage hepatocellular carcinoma treated with initial hepatic resection versus transplantation., Methods: Between 1985 and 2008, 245 patients underwent hepatic resection, and 134 patients underwent liver transplantation for early stage hepatocellular carcinoma. All patients had well-compensated cirrhosis. Prognostic factors were evaluated using univariate and multivariate analyses; survival was calculated using the Kaplan-Meier method., Results: Compared with transplantation, patients undergoing resection had larger tumors and a higher incidence of microscopic vascular invasion. Transplantation was associated with better 5-year disease-free and overall survival compared with resection. Hepatitis status, presence of microscopic vascular invasion, and tumor size were predictors for recurrence, while the presence of microscopic vascular invasion and tumor size conferred an increased risk of death. The disease-free survival advantage with transplantation was more pronounced in hepatitis C patients compared with non-hepatitis and hepatitis B patients. The overall survival advantage with transplantation persisted in cases of solitary lesions < or = 3 cm, but was attenuated in patients with a MELD score < or = 8., Conclusion: In well-compensated cirrhotic patients with early stage hepatocellular carcinoma, transplantation was associated with longer disease-free and overall survival. Patients undergoing resection did, however, have tumors with more advanced pathologic features. Patients best suited for initial resection as the treatment of hepatocellular carcinoma were those with a MELD score

Liver resection or transplantation offers the best opportunity for cure of hepatocellular carcinoma (HCC). To determine the relative roles for resection and transplantation and to evaluate the patient and tumor characteristics that might predict survival, the records of 125 patients treated for nonfibrolamellar HCC at The Toronto Hospital between 1981 and 1996 were reviewed. No adjuvant chemotherapy or antiviral protocols were used. Resection was the first operation in 67 patients; one underwent re-resection. Sixty patients underwent transplantation including two who had previously had a resection; 40 had known or suspected HCC and 20 had incidental tumors identified in the explanted liver. The incidence of cirrhosis was 49% for resection and 88% for transplantation. The incidence of hepatitis B virus (HBV) was 58% and 33%, respectively. The operative mortality rate for resection was 4.4% (9.4% in cirrhotic and 0 in noncirrhotic patients) and 13.3% for transplantation. The 5-year cumulative recurrence rate was 55% following resection and 20% following transplantation (P <0.001). The 5-year Kaplan-Meier survival rates were 38% for resection and 45% for transplantation-60% for transplanted HBV-negative and 17% for HBV-positive patients (P <0.001). After resection, recurrent HCC accounted for 86% of deaths, whereas recurrent HBV was responsible for 42% of deaths after transplantation. By univariate analysis, following resection, vascular invasion, advanced stage, multiple tumors, and lack of a capsule were predictive of survival; cirrhosis, HBV, age, tumor size, number, and grade were not. By multivariate analysis, only vascular invasion was predictive for resection and HBV for transplantation. Resection and transplantation are complementary methods of treating HCC. With the current organ shortage, resection should be considered first-line treatment. HBV-positive patients with HCC should only undergo transplantation in combination with effective antiviral therapy.