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Background: This study investigates the impact of certification training and liver transplant experience on procurement outcomes of deceased donor liver procurement in the Netherlands., Methods: Three groups (trainee, certified, and master) were formed, with further subdivision based on liver transplant experience. Three key outcomes-surgical injury, graft discard after injury, and donor hepatectomy duration-were analyzed., Results: There were no significant differences in surgical graft injury in the three groups (trainee, 16.9%; certified, 14.8%; master, 18.2%; P  = 0.357; 2011 to 2018). The only predictor for surgical graft injury was donation after circulatory death (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.10-2.02). Of the three groups, the master group had the highest discard rate after surgical injury (trainee, 0%; certified, 1.3%; master, 2.8%; P  = 0.013). Master group without liver transplant experience (OR, 3.16; 95% CI, 1.21-8.27) and male donor sex (OR, 3.58; 95% CI, 1.32-9.73) were independent risk factors for discarding livers after surgical injury. Independent predictors for shorter hepatectomy durations included donors older than 50 years (coefficient [Coeff], -7.04; 95% CI, -8.03 to -3.29; P  < 0.001), and master group (Coeff, -9.84; 95% CI, -14.37 to -5.31; P  < 0.001) and certified group with liver transplant experience (Coeff, -6.54; 95% CI, -10.83 to -2.26; P  = 0.003). On the other hand, master group without liver transplant experience (Coeff, 5.00; 95% CI, 1.03-8.96; P  = 0.014) and donation after circulatory death (Coeff, 10.81; 95% CI, 8.32-13.3; P  < 0.001) were associated with longer hepatectomy durations., Conclusions: Training and certification in abdominal organ procurement surgery were associated with a reduced discard rate for surgical injured livers and shorter hepatectomy times. The contrast between master group with and without liver transplant experience underscores the need for specialized training in this field., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Approximately 70% of patients with colorectal liver metastases (CRLM) experiences intrahepatic recurrence after initial liver resection. This study assessed outcomes and hospital variation in repeat liver resections (R-LR)., Methods: This population-based study included all patients who underwent liver resection for CRLM between 2014 and 2022 in the Netherlands. Overall survival (OS) was collected for patients operated on between 2014 and 2018 by linkage to the insurance database., Results: Data of 7479 liver resections (1391 (18.6%) repeat and 6088 (81.4%) primary) were analysed. Major morbidity and mortality were not different. Factors associated with major morbidity included ASA 3+, major liver resection, extrahepatic disease, and open surgery. Five-year OS after repeat versus primary liver resection was 42.3% versus 44.8%, P = 0.37. Factors associated with worse OS included largest CRLM >5 cm (aHR 1.58, 95% CI: 1.07-2.34, P = 0.023), >3 CRLM (aHR 1.33, 95% CI: 1.00-1.75, P = 0.046), extrahepatic disease (aHR 1.60, 95% CI: 1.25-2.04, P = 0.001), positive tumour margins (aHR 1.42, 95% CI: 1.09-1.85, P = 0.009). Significant hospital variation in performance of R-LR was observed, median 18.9% (8.2% to 33.3%)., Conclusion: Significant hospital variation was observed in performance of R-LR in the Netherlands reflecting different treatment decisions upon recurrence. On a population-based level R-LR leads to satisfactory survival., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The aim of this study was to investigate the incidence and risk factors of primary and secondary liver failure after major liver resection for perihilar cholangiocarcinoma., Methods: All patients who underwent a major liver resection for presumed perihilar cholangiocarcinoma between 2000 and 2020 at 2 tertiary-referral hospitals were included. Liver failure was defined according to the International Study Group for Liver Surgery criteria, and only grade B/C was considered clinically relevant. Primary liver failure was defined as failure without any underlying postoperative cause, and secondary liver failure was defined as liver failure with an onset after an underlying postoperative complication as a cause., Results: The incidence of liver failure and 90-day mortality were 20.9% and 17.0% in the 253 included patients, respectively. The incidences of primary liver failure was 9.1% and secondary liver failure was 11.9%. Abdominal sepsis, portal vein thrombosis, and arterial thrombosis were the most frequent causes. The absence of preoperative remnant liver assessment and blood loss were independent risk factors for primary liver failure. Independent risk factors for secondary liver failure were Eastern Cooperative Oncology group performance status, percutaneous biliary drainage, and preoperative cholangitis., Conclusion: Liver failure after major liver resection for perihilar cholangiocarcinoma occurred in 1 of every 5 patients. The proposed subdivision into primary and secondary liver failure could help to understand differences in outcomes between centers and help to reduce liver failure., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Data on surgical outcomes of laparoscopic liver resection (LLR) versus open liver resection (OLR) of benign liver tumour (BLT) are scarce. This study aimed to provide a nationwide overview of postoperative outcomes after LLR and OLR of BLT., Methods: This was a nationwide retrospective study including all patients who underwent liver resection for hepatocellular adenoma, haemangioma and focal nodular hyperplasia in the Netherlands from 2014 to 2019. Propensity score matching (PSM) was applied to compare 30-day overall and major morbidity and 30-day mortality after OLR and LLR., Results: In total, 415 patients underwent BLT resection of whom 230 (55.4%) underwent LLR. PSM for OLR and LLR resulted in 250 matched patients. Median (IQR) length of stay was shorter after LLR than OLR (4 versus 6 days, 5.0-8.0, p < 0.001). Postoperative 30-day overall morbidity was lower after LLR than OLR (12.0% vs. 22.4%, p = 0.043). LLR was associated with reduced 30-day overall morbidity in multivariable analysis (aOR:0.46, CI:0.22-0.95, p = 0.043). Both 30-day major morbidity and 30-day mortality were not different., Conclusions: LLR for BLT is associated with shorter hospital stay and reduced overall morbidity and is preferred if technically feasible., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Portal vein embolization (PVE) is performed to reduce the risk of liver failure and subsequent mortality after major liver resection. Although a cut-off value of 2·7 per cent per min per m 2 has been used with hepatobiliary scintigraphy (HBS) for future remnant liver function (FRLF), patients with perihilar cholangiocarcinoma (PHC) potentially benefit from an additional cut-off of 8·5 per cent/min (not corrected for body surface area). Since January 2016 a more liberal approach to PVE has been adopted, including this additional cut-off for HBS of 8·5 per cent/min. The aim of this study was to assess the effect of this approach on liver failure and mortality., Methods: This was a single-centre retrospective study in which consecutive patients undergoing liver resection under suspicion of PHC in 2000-2015 were compared with patients treated in 2016-2019, after implementation of the more liberal approach. Primary outcomes were postoperative liver failure (International Study Group of Liver Surgery grade B/C) and 90-day mortality., Results: Some 191 patients with PHC underwent liver resection. PVE was performed in 6·4 per cent (9 of 141) of the patients treated in 2000-2015 and in 32 per cent (16 of 50) of those treated in 2016-2019. The 90-day mortality rate decreased from 16·3 per cent (23 of 141) to 2 per cent (1 of 50) (P = 0·009), together with a decrease in the rate of liver failure from 19·9 per cent (28 of 141) to 4 per cent (2 of 50) (P = 0·008). In 2016-2019, 24 patients had a FRLF greater than 8·5 per cent/min and no liver failure or death occurred, suggesting that 8·5 per cent/min is a reliable cut-off for patients with suspected PHC., Conclusion: The major decrease in liver failure and mortality rates in recent years and the simultaneous increased use of PVE suggests an important role for PVE in reducing adverse outcomes after surgery for PHC., (© 2020 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Background: Evidence for an association between hospital volume and outcomes for liver surgery is abundant. The current Dutch guideline requires a minimum volume of 20 annual procedures per centre. The aim of this study was to investigate the association between hospital volume and postoperative outcomes using data from the nationwide Dutch Hepato Biliary Audit., Methods: This was a nationwide study in the Netherlands. All liver resections reported in the Dutch Hepato Biliary Audit between 2014 and 2017 were included. Annual centre volume was calculated and classified in categories of 20 procedures per year. Main outcomes were major morbidity (Clavien-Dindo grade IIIA or higher) and 30-day or in-hospital mortality., Results: A total of 5590 liver resections were done across 34 centres with a median annual centre volume of 35 (i.q.r. 20-69) procedures. Overall major morbidity and mortality rates were 11·2 and 2·0 per cent respectively. The mortality rate was 1·9 per cent after resection for colorectal liver metastases (CRLMs), 1·2 per cent for non-CRLMs, 0·4 per cent for benign tumours, 4·9 per cent for hepatocellular carcinoma and 10·3 per cent for biliary tumours. Higher-volume centres performed more major liver resections, and more resections for hepatocellular carcinoma and biliary cancer. There was no association between hospital volume and either major morbidity or mortality in multivariable analysis, after adjustment for known risk factors for adverse events., Conclusion: Hospital volume and postoperative outcomes were not associated., (© 2020 The Authors. British Journal of Surgery published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Background: This study aims to evaluate the feasibility and safety of resection of sarcoma liver metastases, and to identify possible prognostic factors for long-term survival., Methods: All patients who underwent resection of liver metastases of sarcoma in the Netherlands from 1998 to 2014 were included. Study data was retrospectively collected from patient files. Survival rates were calculated using Kaplan-Meier survival analysis., Results: Some 38 patients treated in 16 hospitals were included (15 male, 23 female). The median age was 57 years (37-80 years). The most common histological subtype was leiomyosarcoma (63%). The predominant site of primary tumour was the abdomen (59%). R0 resection was achieved in 16 patients. Mortality was 3 and 16% of included patients had 1 or more complications. The median follow-up period was 18 months (range 1-161). After liver resection, 1-, 3-, and 5-year survival were 88, 54, and 42% respectively. Median overall survival was 46 months (1-161 months). One- and three-year progression-free survival (PFS) after liver resection were 54 and 19% respectively. Median PFS was 16 months (1-61 months)., Conclusions: Liver surgery for sarcoma metastases is safe and leads to a relatively good survival. The choice for surgical treatment should always be discussed in a multidisciplinary sarcoma and liver team., (The Author(s). Published by S. Karger AG, Basel.)

Background: The feasibility of the liver-first approach for synchronous colorectal liver metastases (CRLM) has been established. We sought to assess the short-term and long-term outcomes for these patients., Methods: Outcomes of patients who underwent a liver-first approach for CRLM between 2005 and 2015 were retrospectively evaluated from a prospective database., Results: Of the 92 patients planned to undergo the liver-first strategy, the paradigm could be completed in 76.1%. Patients with concurrent extrahepatic disease failed significantly more often in completing the protocol (67% versus 21%; p = 0.03). Postoperative morbidity and mortality were 31.5% and 3.3% following liver resection and 30.9% and 0% after colorectal surgery. Of the 70 patients in whom the paradigm was completed, 36 patients (51.4%) developed recurrent disease after a median interval of 20.9 months. The median overall survival on an intention-to-treat basis was 33.1 months (3- and 5-year overall survival: 48.5% and 33.1%). Patients who were not able to complete their therapeutic paradigm had a significantly worse overall outcome (p = 0.03)., Conclusion: The liver-first approach is feasible with acceptable perioperative morbidity and mortality rates. Despite the considerable overall-survival-benefit, recurrence rates remain high. Future research should focus on providing selection tools to enable the optimal treatment sequence for each patient with synchronous CRLM., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Although surgical resection has been considered the only curative option for colorectal liver metastases (CLM), thermal ablation has recently been suggested as an alternative curative treatment. A prospective randomised trial is required to define the efficacy of resection vs ablation for the treatment of colorectal liver metastases., Methods: Design and setting: This is a multicentre, open, randomised controlled non-inferiority trial design with internal pilot and will be performed in tertiary liver centres in UK and The Netherlands., Participants: Eligible patients will be those with colorectal liver metastases at high surgical risk because of their age, co-morbidities or tumour burden and who would be suitable for liver resection or thermal ablation., Intervention: Thermal ablation as per local policy., Control: Surgical liver resection performed as per centre protocol. Co-interventions: Further chemotherapy will be offered to patients as per current practice. Outcomes Pilot study: Same as main study and in addition patients and clinicians' acceptability of the trial to assist in optimisation of recruitment., Primary Outcome: Disease-free survival (DFS) at two years post randomisation., Secondary Outcomes: Overall survival, timing and site of recurrence, additional therapy after treatment failure, quality of life, complications, length of hospital stay, costs, trial acceptability, DFS measured from end of intervention., Follow-Up: 24 months from randomisation; five-year follow-up for overall survival., Sample Size: 330 patients to demonstrate non-inferiority of thermal ablation., Discussion: This trial will determine the effectiveness and cost-effectiveness of thermal ablation vs surgical resection for high-risk people with colorectal liver metastases, and guide the optimal treatment for these patients., Trial Registration: ISRCTN Registry, ISRCTN52040363 . Registered on 9 March 2016.

Background: Posthepatectomy liver failure (PHLF) is a threatening complication after liver surgery, especially in perihilar cholangiocarcinoma (PHC). This study aimed to assess the value of preoperative assessment of liver function using 99m Tc-mebrofenin hepatobiliary scintigraphy (HBS) to predict PHLF in comparison with liver volume in PHC patients., Methods: All patients who underwent resection of suspected PHC in a single center between 2000 and 2015 were included in the analysis. PHLF was graded according to the ISGLS criteria with grade B/C considered clinically relevant. A cut-off value for the prediction of PHLF was calculated using the receiver operating characteristic curve (ROC) analysis., Results: A total of 116 patients were included of which 27 (23%) suffered of PHLF. ROC values for the prediction of PHLF were 0.74 (0.63-0.86) for future liver remnant function and 0.63 (0.47-0.80) for volume. A cut-off for liver function was set at 8.5%/min, which resulted in a negative predictive value of 94% and positive predictive value of 41%., Conclusions: Assessment of liver function with HBS had better predictive value for PHLF than liver volume in patients undergoing major liver resection for suspected PHC. The cut-off of 8.5%/min can help to select patients for portal vein embolization and might help to reduce postoperative liver failure., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Uncontrolled introduction of laparoscopic liver surgery (LLS) could compromise postoperative outcomes. A stepwise introduction of LLS combined with structured training is advised. This study aimed to evaluate the impact of such a stepwise introduction., Methods: A retrospective, single-center case series assessing short term outcomes of all consecutive LLS in the period November 2006-January 2017. The technique was implemented in a stepwise fashion. To evaluate the impact of this stepwise approach combined with structured training, outcomes of LLS before and after a laparoscopic HPB fellowship were compared., Results: A total of 135 laparoscopic resections were performed. Overall conversion rate was 4% (n = 5), clinically relevant complication rate 13% (n = 18) and mortality 0.7% (n = 1). A significant increase in patients with major LLS, multiple liver resections, previous abdominal surgery, malignancies and lesions located in posterior segments was observed after the fellowship as well as a decrease in the use of hand-assistance. Increasing complexity in the post fellowship period was reflected by an increase in operating times, but without comprising other surgical outcomes., Conclusion: A stepwise introduction of LLS combined with structured training reduced the clinical impact of the learning curve, thereby confirming guideline recommendations., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Introduction: Postoperative liver failure (PLF) is a dreaded complication after partial hepatectomy. The peak bilirubin criterion (>7.0 mg/dL or ≥120 μmol/L) is used to define PLF. This study aimed to validate the peak bilirubin criterion as postoperative risk indicator for 90-day liver-related mortality., Methods: Characteristics of 956 consecutive patients who underwent partial hepatectomy at the Maastricht University Medical Centre or Royal Free London between 2005 and 2012 were analyzed by uni- and multivariable analyses with odds ratios (OR) and 95% confidence intervals (95%CI)., Results: Thirty-five patients (3.7%) met the postoperative peak bilirubin criterion at median day 19 with a median bilirubin level of 183 [121-588] μmol/L. Sensitivity and specificity for liver-related mortality after major hepatectomy were 41.2% and 94.6%, respectively. The positive predictive value was 22.6%. Predictors of liver-related mortality were the peak bilirubin criterion (p < 0.001, OR = 15.9 [95%CI 5.2-48.7]), moderate-severe steatosis and fibrosis (p = 0.013, OR = 8.5 [95%CI 1.6-46.6]), ASA 3-4 (p = 0.047, OR = 3.0 [95%CI 1.0-8.8]) and age (p = 0.044, OR = 1.1 [95%CI 1.0-1.1])., Conclusion: The peak bilirubin criterion has a low sensitivity and positive predictive value for 90-day liver-related mortality after major hepatectomy., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Currently, resection criteria for colorectal cancer liver metastases (CRCLM) are only limited by remnant liver function. Morbidity and survival after a partial hepatectomy with limited or extended indication criteria were compared., Methods/design: Between 1991 and 2010, patients undergoing a liver resection for CRCLM with limited (n = 169) or extended indication criteria (n = 129) were retrospectively identified in a prospectively collected single-centre database. Limited indication criteria were defined as less than three unilateral, not centrally located liver metastases in the absence of extra hepatic metastases. The extended criteria were only limited by predicted remnant liver volume and patients fitness. Data on co-morbidity, resection margin, short- and long-term morbidity, disease-free (DFS) and overall survival were compared., Results: Patients with limited indications had less major complications (19.5% vs. 33.1%, P < 0.01), longer overall survival of 68.8 months [confidence interval (CI) 46.5-91.1] vs. 41.4 months (CI 33.4-49.0, P ≤ 0.001) and longer median DFS of 22.0 months [confidence interval (CI) 15.8-28.2] vs 10.2 months (CI 8.4-11.9, P < 0.001) compared with the extended indication group. Cure rates, defined as 10-year DFS, were 35.5% and 15.8%, respectively. Fewer patients in the extended indication group underwent an R0 resection (92.9% vs. 77.5%, P < 0.001). Only 17% of all R1 resected patients had recurrences at the transection plane., Conclusion: A partial hepatectomy for CRCLM with extended indications seems justified but is associated with higher complication rates, earlier recurrence and lower overall survival compared with limited indications. However, the median 5-year survival was substantial and a cure was achieved in 15.8% of patients., (© 2013 International Hepato-Pancreato-Biliary Association.)

Patients with hepatic metastases of melanoma have a very poor prognosis, with a median overall survival of less than 6 months. There are several small heterogeneous studies that have shown an association with prolonged survival in those patients treated with hepatic resection, but the role of surgery remains unclear. We evaluated the safety and efficacy of hepatic resection in a population-based study in the Netherlands for patients with metastatic melanoma and assessed the factors that could affect disease-free and overall survival. Patients with hepatic melanoma metastases who underwent potentially curative resection were identified between 1994 until 2010 using the PALGA database, a nation-wide network and registry of histopathology and cytopathology in the Netherlands. They were retrospectively evaluated for clinical and pathological factors with respect to recurrence and survival using Kaplan-Meier curves to assess survival and univariate regression analysis for the assessment of potential prognostic factors. A total of 32 patients were identified in 15 hospitals, 19 men and 13 women. The median age of the patients at the time of hepatic resection was 52 years (range 27-69). Postoperative complications occurred in five patients (15%), without postoperative mortality. The median follow-up was 21 months (range 3-65). The median disease-free survival was 11 months (range 0-57) and the median overall survival was 29 months (range 4-66). Significant prognostic factors for overall survival in univariate analysis were the distribution and number of metastases, as well as the type of hepatic resection (major or minor). Hepatic resection in patients with resectable metastatic melanoma is safe and might be associated with a prolonged survival in a highly selected group of patients.

Background: For patients who present with synchronous colorectal carcinoma and colorectal liver metastasis (CRLM), a reversed treatment sequence in which the CRLM are resected before the primary carcinoma has been proposed (liver-first approach). The aim of the present study was to assess the feasibility and outcome of this approach for synchronous CRLM., Methods: Between 2005 and 2010, 22 patients were planned to undergo the liver-first approach. Feasibility and outcomes were prospectively evaluated., Results: Of the 22 patients planned to undergo the liver-first strategy, the approach was completed in 18 patients (81.8%). The main reason for treatment failure was disease progression. Patients who completed treatment and patients who deviated from the protocol had a similar location of the primary tumour, as well as comparable size, number and distribution of CRLM (all P > 0.05). Post-operative morbidity and mortality were 27.3% and 0% following liver resection and 44.4% and 5.6% after colorectal surgery, respectively. On an intention-to-treat-basis, overall 3-year survival was 41.1%. However, 37.5% of patients who completed the treatment had developed recurrent disease at the time of the last follow-up., Conclusions: The liver-first approach is feasible in approximately four-fifths of patients and can be performed with peri-operative mortality and morbidity similar to the traditional treatment paradigm. Patients treated with this novel strategy derive a considerable overall-survival-benefit, although disease-recurrence-rates remain relatively high, necessitating a multidisciplinary approach., (© 2011 International Hepato-Pancreato-Biliary Association.)

Background: An extended left hepatectomy is a complex hepatic resection often performed for large tumours in close relationship to major hilar structures. Operative outcomes of this resection for colorectal liver metastases (CLM) remain unclear. The aim of the present study was to assess short- and long-term outcome for patients with CLM after an extended left hepatectomy., Methods: A retrospective analysis of consecutive patients undergoing an extended left hepatectomy for CLM in a large, single-centre cohort between January 1990 and January 2006 was performed., Results: Thirty-one patients (3.9%) from a consecutive series of 802 patients who had undergone hepatic resection were identified as having met the definition of an extended left hepatectomy and were included for further analysis. Maximum tumour size was more than 60 mm in 15 patients, with a median size of 67.5 mm for the total group (range: 20 to 160 mm). Twenty-six patients presented with initially unresectable metastases, related to large tumour size in 11 patients and to a close relation with major vascular structures in six patients. Preoperative chemotherapy was administered to 29 patients. Combined vascular resection was performed in five patients. The mortality rate at 90 days was zero and post-operative morbidity occurred in 17 patients. R0 and R1 resections were performed in 17 and 11 patients, respectively. Three- and 5-year overall survival was 38% and 27%, respectively. Disease-free survival was 9% and 4% at 3 and 5 years. Morbidity did not differ between patients with and without a caudate lobectomy (9 of 17 patients vs. 8 of 14 patients, respectively) (P= 0.815)., Conclusions: An extended left hepatectomy for CLM can provide significant long-term survival. However, morbidity is increased in this complex procedure. A caudate lobectomy does not impact surgical outcome., (© 2011 International Hepato-Pancreato-Biliary Association.)