Amanda B. Cooper

Predictors of morbidity and mortality after hepatectomy in elderly patients: analysis of 7621 NSQIP patients

OBJECTIVES Increasingly, surgeons are performing hepatectomies in older patients. This study was designed to analyse the incidences of and risk factors for post-hepatectomy morbidity and mortality in elderly patients. METHODS All elective hepatectomies for the period 2005-2010 recorded in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database were evaluated. Factors associated with 30-day rates of morbidity and mortality were compared between patients aged ≥75 years and those aged <75 years. RESULTS Elderly patients accounted for 894 of 7621 (11.7%) hepatectomies. These patients more frequently had comorbidities (diabetes, cardiovascular or lung disease, lower albumin, elevated creatinine, anaesthesia risk; all P < 0.05) and were more likely to undergo partial or left rather than right or extended hepatectomies (P = 0.013). Despite the lesser surgical magnitude of these procedures, elderly patients experienced higher rates of severe complications (23.9% versus 18.4%; P < 0.001) and overall postoperative mortality (4.8% versus 2.0%; P < 0.001). The occurrence of any severe complication was associated with a mortality rate of 20.1% in elderly patients and 10.8% in non-elderly patients (P < 0.001). This disparity in mortality was more pronounced in patients with two or more (31.7% versus 20.2%; P < 0.001) and three or more (46.3% versus 31.1%; P < 0.001) severe complications. Independent risk factors for severe complications and/or mortality included an albumin level of < 4 g/dl, lung disease, intraoperative transfusion, a concurrent intra-abdominal operation, and an operative time of >240 min (all P < 0.05). CONCLUSIONS Given their lower physiologic reserve, elderly patients are at much greater risk for mortality after severe complications. To improve outcomes, surgeons should balance age and preoperative comorbidities with magnitude of hepatectomy.

Is Autotaxin (ENPP2) the Link between Hepatitis C and Hepatocellular Cancer

IntroductionHepatitis C is the most significant risk factor for development of hepatocellular carcinoma. Inflammation, fibrosis, and liver cell proliferation may contribute to cancer development either through malignant hepatocyte transformation or extracellular matrix remodeling within the tumor microenvironment. The study objective was to investigate differences in gene expression between patients with Hepatitis C (± cancer) and normal that might explain the increased cancer risk.MethodsLiver tissue was collected from three patient groups: 1) healthy patients, 2) Hepatitis C patients without cancer, 3) patients with Hepatitis C and hepatocellular carcinoma. Microarray analysis was performed on samples from each group. Western blot and real-time polymerase chain reaction (PCR) analyses corroborated the microarray data. A p value of 0.05 was set as significant.ResultsMicroarray analysis showed overexpression of autotaxin in patients with cancer versus hepatitis patients or normal patients. Rho GTPase binding proteins (Cdc42s) associated with lysophosphatidic acid signaling were also overexpressed in cancer patients. Real-time polymerase chain reaction showed overexpression of several factors associated with autotaxin in patients with Hepatitis C (± cancer) versus normal patients.ConclusionsPatients with Hepatitis C and hepatocellular carcinoma show differential expression of various components of the autotaxin pathway versus normal patients. This merits further investigation in the context of early diagnosis.

Use of the piggyback hepatectomy technique in liver transplant recipients with hepatocellular carcinoma.

The piggyback hepatectomy technique (PGB) is avoided in liver transplant patients with hepatocellular carcinoma (HCC) to decrease the theoretical risk of a positive vena cava margin or hematologic metastases. This study reports the routine use of PGB in 138 consecutive adult, deceased donor liver transplant recipients with HCC. Piggyback hepatectomy technique was used in 119 subjects, with 19 recipients receiving the conventional bicaval technique (CONV). Median follow-up was 34 months. There were 95 patients (69%) within and 43 patients (31%) outside, Milan criteria at transplant. Hepatocellular carcinoma recurrence rate was 13% and survival was 84.1% (1-year) and 77.4% (2-years). The PGB and CONV study groups did not differ in survival within or outside Milan criteria. Cox proportional hazards modeling of posttransplant survival demonstrated statistically similar survival for PGB and CONV. In conclusion, the presence of HCC in liver transplant patients should not preclude the use of PGB.

Is strength training associated with mortality benefits? A 15 year cohort study of US older adults

BACKGROUND The relationship between strength training (ST) behavior and mortality remains understudied in large, national samples, although smaller studies have observed that greater amounts of muscle strength are associated with lower risks of death. We aimed to understand the association between meeting ST guidelines and future mortality in an older US adult population. METHODS Data were analyzed from the 1997-2001 National Health Interview Survey (NHIS) linked to death certificate data in the National Death Index. The main independent variable was guideline-concordant ST (i.e. twice each week) and dependent variable was all-cause mortality. Covariates identified in the literature and included in our analysis were demographics, past medical history, and other health behaviors (including other physical activity). Given our aim to understand outcomes in older adults, analyses were limited to adults age 65years and older. Multivariate analysis was conducted using multiple logistic regression analysis. RESULTS During the study period, 9.6% of NHIS adults age 65 and older (N=30,162) reported doing guideline-concordant ST and 31.6% died. Older adults who reported guideline-concordant ST had 46% lower odds of all-cause mortality than those who did not (adjusted odds ratio: 0.64; 95% CI: 0.57, 0.70; p<0.001). The association between ST and death remained after adjustment for past medical history and health behaviors. CONCLUSIONS Although a minority of older US adults met ST recommendations, guideline-concordant ST is significantly associated with decreased overall mortality. All-cause mortality may be significantly reduced through the identification of and engagement in guideline-concordant ST interventions by older adults.

Is Resection of Colorectal Liver Metastases after a Second-Line Chemotherapy Regimen Justified?

Patient outcomes following resection of colorectal liver metastases (CLM) after second‐line chemotherapy regimen is unknown.

Costs of hepato-pancreato-biliary surgery and readmissions in privately insured US patients

BACKGROUND Surgical costs are influenced by perioperative care, readmissions, and further therapies. We aimed to characterize costs in hepato-pancreato-biliary surgery in the United States. METHODS The MarketScan database (2008-2010) was used to identify privately insured patients undergoing pancreatectomy (n = 2254) or hepatectomy (n = 1702). Costs associated with the index surgery, readmissions, and total short-term costs were assessed from a third party payer perspective using generalized linear regression models. RESULTS Mean total costs of pancreatectomy and hepatectomy were

Borderline operability in hepatectomy patients is associated with higher rates of failure to rescue after severe complications

107,600 (95% confidence interval [CI], 101,200-114,000) and

Local Ablation for Solid Tumor Liver Metastases: Techniques and Treatment Efficacy

81,300 (95% CI, 77,600-85,000), respectively, with corresponding surgical costs of 69.2% and 60.9%. Ninety-day readmission costs were

Marital Status and Survival in Patients with Carcinoid Tumors

36,200 (95% CI, 32,000-40,400) and

Hepatic resection is associated with reduced postoperative opioid requirement

34,100 (95% CI, 28,100-40,100), respectively. In multivariate analysis, readmissions were associated with an almost two-fold increase in total costs in both pancreatectomy (cost ratio = 1.98; P < 0.001) and hepatectomy (cost ratio = 1.92; P < 0.001). CONCLUSIONS Hepato-pancreato-biliary surgery is associated with significant economic burden in the privately insured population. Substantial costs are incurred beyond the index surgical admission, with readmissions representing a major source of potentially preventable health care spending. Sustained efforts in defining high-risk populations and decreasing the burden of postoperative complications through a combination of prevention and improved outpatient management offer promising strategies to reduce readmissions and control costs.