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The impact of chronic kidney disease (CKD) on surgery is still not well defined. We sought to characterize the association of preoperative CKD with 30-day mortality after hepatic resection.Patients included in the American College of Surgeons (ACS) NSQIP who underwent hepatectomy between 2014 and 2018 were identified. Kidney function was stratified according to the "Kidney Disease: Improving Global Outcomes" (KDIGO) Classification: G1, normal/high function (estimated glomerular-filtration-rate ≥ 90 ml/min/1.73m2); G2-3, mild/moderate CKD (89-30 ml/min/1.73m2); G4-5, severe CKD (≤ 29 ml/min/1.73m2).Overall, 18,321 patients were included. Older patients (ie more than 70 years old) and those with serious medical comorbidities (ie American Society of Anesthesiologists [ASA] class 3) had an increased incidence of severe CKD (both p0.001). Patients with G2-3 and G4-5 CKD were more likely to have a prolonged length of stay and to experience postoperative complications (both p0.001). Adjusted odds of 30-day mortality increased with the worsening CKD (p = 0.03). The degree of CKD was able to stratify patients within the NSQIP risk calculator. Among patients who underwent major hepatectomy for primary cancer, the rate of 30-day mortality was 2-fold higher with G2-3 and G4-5 CKD vs normal kidney function (p = 0.03).The degree of CKD was related to the risk of complications and 30-day mortality after hepatectomy. CKD classification should be strongly considered in the preoperative risk estimation of these patients.

BACKGROUND: The prognostic impact of major postoperative complications (POCs) for intrahepatic cholangiocarcinoma (ICC) remains ill-defined. We sought to analyze the relationship between POCs and outcomes relative to lymph node metastases (LNM) and tumor burden score (TBS).METHODS: Patients who underwent resection of ICC between 1990-2020 were included from an international database. POCs were defined according to Clavien-Dindo classification ≥ 3. The prognostic impact of POCs was estimated relative to TBS categories (i.e., high and low) and lymph node status (i.e., N0 or N1).RESULTS: Among 553 patients who underwent curative-intent resection for ICC, 128 (23.1%) individuals experienced POCs. Low TBS/N0 patients who experienced POCs presented with a higher risk of recurrence and death (3-year cumulative recurrence rate; POCs: 74.8% vs. no POCs: 43.5%, p = 0.006; 5-year overall survival [OS], POCs 37.8% vs. no POCs 65.8%, p = 0.003), while POCs were not associated with worse outcomes among high TBS and/or N1 patients. The Cox regression analysis confirmed that POCs were significant predictors of poor outcomes in low TBS/N0 patients (OS, hazard ratio [HR] 2.91, 95%CI 1.45-5.82, p = 0.003; recurrence free survival [RFS], HR 2.42, 95%CI 1.28-4.56, p = 0.007). Among low TBS/N0 patients, POCs were associated with early recurrence (within 2 years) (Odds ratio [OR] 2.79 95%CI 1.13-6.93, p = 0.03) and extrahepatic recurrence (OR 3.13, 95%CI 1.14-8.54, p = 0.03), in contrast to patients with high TBS and/or nodal disease.CONCLUSIONS: POCs were independent, negative prognostic determinants for both OS and RFS among low TBS/N0 patients. Perioperative strategies that minimize the risk of POCs are critical to improving prognosis, especially among patients harboring favorable clinicopathologic features.

The presence of microvascular invasion (MVI) has been highlighted as an important determinant of hepatocellular carcinoma (HCC) prognosis. We sought to build and validate a novel model to predict MVI in the preoperative setting.

Post-hepatectomy liver failure (PHLF) is a dreaded complication following liver resection for hepatocellular carcinoma (HCC) with a high mortality rate. We sought to develop a score based on preoperative factors to predict PHLF.Patients who underwent resection for HCC between 2000 and 2020 were identified from an international multi-institutional database. Factors associated with PHLF were identified and used to develop a preoperative comorbidity-tumor burden-liver function (CTF) predictive score.Among 1785 patients, 106 (5.9%) experienced PHLF. On multivariate analysis, several factors were associated with PHLF including high Charlson comorbidity index (CCI ≥ 5) (OR 2.80, 95%CI, 1.08-7.26), albumin-bilirubin (ALBI) (OR 1.99, 95%CI, 1.10-3.56), and tumor burden score (TBS) (OR 1.06, 95%CI, 1.02-1.11) (all p 0.05). Using the beta-coefficients of these variables, a weighted predictive score was developed and made available online ( https://alaimolaura.shinyapps.io/PHLFriskCalculator/ ). The CTF score (c-index = 0.67) performed better than Child-Pugh score (CPS) (c-index = 0.53) or Barcelona clinic liver cancer system (BCLC) (c-index = 0.57) to predict PHLF. A high CTF score was also an independent adverse prognostic factor for survival (HR 1.61, 95%CI, 1.12-2.30) and recurrence (HR 1.36, 95%CI, 1.08-1.71) (both p = 0.01).Roughly 1 in 20 patients experienced PHLF following resection of HCC. Patient (i.e., CCI), tumor (i.e., TBS), and liver function (i.e., ALBI) factors were associated with risk of PHLF. These preoperative factors were incorporated into a novel CTF tool that was made available online, which outperformed other previously proposed tools.

Purpose To investigate recurrence patterns after surgery for intrahepatic cholangiocarcinoma (ICC) relative to lymph node status, tumor extension, tumor burden score (TBS), and adjuvant chemotherapy. Methods Patients who underwent curative-intent resection for ICC from 1990 to 2020 were enrolled from a multi-institutional database. The hazard function was applied to plot the hazard rates over time, with further stratification by T and N AJCC 8th edition categories, TBS, and adjuvant chemotherapy. Results A total of 1192 patients underwent curative-intent resection for ICC and 59.9% experienced recurrence. Overall, the peak of recurrence occurred at 6.6 months. Among patients with negative lymph nodes, the T4-category had a higher peak rate of recurrence (0.1199 at 10.2 months) compared with other T-categories, while high TBS had an earlier peak of recurrence (4.2 months) compared with lower TBS. Among patients with N1 disease, T2-T4 categories had multipeak patterns of recurrence with higher hazard rates during the first 3 years after surgery in comparison with T1-category, while patients with high TBS had an earlier (4.0 months) and higher hazard peak rate compared with lower TBS groups. The administration of adjuvant chemotherapy was associated with delayed hazard rates of recurrence for N1 (4 months) and NX (6 months) categories. Discussion The novel application of the hazard function to assess hazard rates and timing patterns of recurrence following resection for ICC demonstrated that recurrence varied based on T- and N-categories, as well as TBS. Hazard function-based recurrence data may be helpful to tailor counseling, surveillance, and adjuvant therapy recommendations.

The ability to predict the incidence, timing, and site of recurrence can be beneficial to select surgical candidates and inform appropriate postoperative surveillance. We sought to identify factors associated with risk and timing of recurrence after resection of hepatocellular carcinoma based on differences in tumor burden score.Patients who underwent curative-intent liver resection for hepatocellular carcinoma between 2000 and 2020 were identified from an international multi-institutional database. The incidence, timing, and pattern of recurrence was examined relative to traditional clinicopathological factors, as well as tumor burden score using hazard rates and multivariable analysis.Among 1,994 patients (tumor burden score, low: n = 511, 25.6% vs medium: n = 1,286, 64.5% vs high: n = 197, 9.9%), the incidence of recurrence at 5 years was 50.4% (95% confidence interval 47.9-53.0); risk of recurrence varied relative to hepatocellular carcinoma tumor burden score (low: 36.0% vs medium: 54.4% vs high: 62.5%, Plt; .001). Although intrahepatic recurrence was much more common in low tumor burden score (low: n = 106, 84.1% vs medium: n = 335, 71.7% vs high: n = 48, 56.5%; Plt; .001), extrahepatic recurrence was more common in high tumor burden score (low: n = 18, 14.3% vs medium: n = 121, 25.9% vs high: n = 37, 43.5%; Plt; .001). The peak hazard rate for intrahepatic recurrence among patients with a high tumor burden score was almost double the peak hazard noted among patients with a low tumor burden score (low: 0.047, 42.0 months vs medium: 0.051, 6.6 months vs high: 0.094, 15.0 months). Of note, the patients with high tumor burden score were also more likely to recur earlier (≤24 months) (low: n = 227, 44.4% vs medium: n = 686, 53.3% vs high: n = 144, 73.1%) with multiple tumors (low: n = 50, 36.5% vs medium: n = 271, 56.1% vs high: n = 52, 70.3%) and larger lesions (low: 1.8 [interquartile range 1.2-3.0] cm vs medium: 2.0 [interquartile range 1.3-3.0] cm vs high: 2.5 [interquartile range 1.6-4.4] cm) (all Plt; .001). On multivariable analysis, high tumor burden score remained independently associated with risk of recurrence (referent, low; medium: hazard ratio = 1.49 [95% confidence interval 1.19-1.88], P = .001; high: hazard ratio = 1.95 [95% confidence interval 1.41-2.69]; Plt; .001].Tumor burden score was independently associated with higher risk of recurrence. Patients who underwent resection of high tumor burden score lesions were more likely to recur early with multiple tumors and at an extrahepatic site. Tumor burden score is an important tool in assessing risk, timing, and pattern of recurrence after resection of hepatocellular carcinoma.