Nisha Narula

Portal vein embolization in extended liver resection

BackgroundLiver resection of benign, primary, and metastatic tumors is challenging and places patients at risk of postoperative liver insufficiency. This risk is largely dependent on the volume and function of the future liver remnant (FLR). It is, therefore, critical that hepatobiliary surgeons are well versed in the measurement of liver volume and function, as well as various techniques for preoperative liver volume augmentation.PurposeThis comprehensive review of portal vein embolization (PVE) begins with an overview of FLR measurement and progresses to patient factors to consider when choosing PVE and assessment of hypertrophy. PVE techniques and complications are subsequently discussed.ConclusionsThe absolute volume of FLR required to avoid postoperative liver insufficiency is dependent on the patient, disease, and anatomic factors. Rapid expansion of the FLR can be achieved with PVE of contralateral liver segments. Although multiple metrics have been used to correlate hypertrophy with postoperative outcomes after PVE, the kinetic growth rate (KGR) is the most reliable predictor of freedom from postoperative liver insufficiency. PVE is now considered a safe and effective procedure when performed at high-volume hepatobiliary centers. It is an effective tool that, by lowering the risk of liver failure, increases the number of patients who can undergo potential curative hepatectomy.

A proactive outreach intervention that decreases readmission after hepatectomy

Background. After hepatectomy, 7%–19% of patients are readmitted within 30 days, accounting for substantial cost and poor patient experience. The purpose of this study was to analyze the impact of a proactive outreach intervention on readmissions. Methods. Consecutive patients undergoing hepatectomy by a single surgeon 2012–2016 were identified in a prospectively maintained database. In August 2013 a postoperative intervention was implemented; an advanced practice provider called each patient within 72 hours of discharge. Readmission rates were compared pre‐ and postintervention using standard statistics. Results. Two hundred thirty‐one patients met the inclusion criteria and major hepatectomy was performed in 45.5% of patients. Although the complication rate was similar (25.0% preintervention and 19.4% postintervention, P = .324), readmissions within 30 days of operation decreased from 14.5% pre‐ to 6.5% postintervention (P = .046). Approximately 30% of outreach interactions required outpatient intervention. Factors associated with readmission on univariate analysis included increased operative time (P = .007), major hepatectomy (P = .012), hemi or extended hepatectomy (P = .032), second stage operation (P = .031), bile leak (P = 0.022), and any complication/modified Accordion complication ≥ 3 within 30 days (P <.0001). On multivariate analysis, lack of post‐discharge intervention (P = .012) and bile leak (P = .031) were independently associated with readmission. Conclusion. These data demonstrate the efficacy of a proactive communication intervention after discharge to decrease readmissions after hepatectomy. The additional work created by the intervention is likely offset by decreased inpatient care needs and costs. Identification of high‐risk populations and application of technology are likely to lead to further improvements.

Extended Pharmacologic Thromboprophylaxis in Oncologic Liver Surgery is Safe and Effective

Essentials The risk for venous thromboembolism after liver surgery remains high in the modern era. We evaluated the safety/efficacy of extended anticoagulation in liver surgery. This protocol reports zero venous thromboembolism events in 124 liver surgery patients. Extended anticoagulation after oncologic liver surgery is safe and effective.