Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma.

BACKGROUND: Enhanced recovery after surgery (ERAS) program has been proved to improve postoperative outcome for many surgical procedures, including liver resection. There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma. AIM: To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes. METHODS: We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital, Khon Kaen University between January 2015 and December 2016. The primary outcome was the compliance with ERAS. To determine the association between ERAS compliance and patient outcomes. the patients were categorized into those adhering more than and equal to 50% (ERAS ≥ 50), and below 50% (ERAS < 50) of all components. Details on type of surgical procedure, preoperative and postoperative care, tumor location, postoperative laboratory results, and survival time were evaluated. The compliance with ERAS was measured by the percentage of ERAS items achieved. The Kaplan-Meier curve was used for survival analysis. RESULTS: The median percentage of ERAS goals achieved was 40% (± 12%). Fourteen patients (12.1%) were categorized into the ERAS ≥ 50 group, and 102 patients were in the ERAS < 50 group. Postoperative hospital stay was significantly shorter in the ERAS ≥ 50 group [8.9 d, 95% confidence interval (CI): 7.3-10.4 d] than in the ERAS < 50 group (13.7 d, 95%CI: 12.2-15.2 d) (P = 0.0217). No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS ≥ 50 group. Overall survival was significantly higher in the ERAS ≥ 50 group. The median survival of the patients in the ERAS < 50 group was 1257 d (95%CI: 853.2-1660.8 d), whereas that of the patients in the ERAS ≥ 50 group was not reached. CONCLUSION: Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor. Greater ERAS compliance could predict in-hospital, short-term, and long-term outcomes of the patients.

Infrahepatic Inferior Vena Cava Clamping Reduces Blood Loss during Liver Transection for Cholangiocarcinoma.

BACKGROUND: Major hepatectomy is the mainstay of the treatment for cholangiocarcinoma. Infrahepatic inferior vena cava (IVC) clamping is an effective maneuver for reducing blood loss during liver transection. The impact of this procedure on major hepatectomy for cholangiocarcinoma is unknown. This study evaluated the effect of infrahepatic IVC clamping on blood loss during liver transection. METHODS: Clinical and pathological data were collected retrospectively for 116 cholangiocarcinoma patients who underwent major hepatectomy between January 2015 and December 2016, to investigate the benefit of infrahepatic IVC clamping. Two of five surgeons adapted the policy performing infrahepatic IVC clamping during liver transection in all cases. Patients, therefore, were divided into those (n = 39; 33.6%) who received infrahepatic IVC clamping during liver transection (C1) and those (n = 77; 66.4%) who did not (C0). RESULTS: The patients' backgrounds, operative parameters, and extent of hepatectomy did not differ significantly between the 2 groups, except for gender. A significantly lower blood loss (p = 0.028), blood transfusion (p = 0.011), and rate of vascular inflow occlusion requirement (p < 0.001) were observed in the C1 group. The respective blood losses in the C1 group and the C0 group were 498.9 (95% CI: 375.8-622.1) and 685.6 (95% CI: 571-800.2) millilitres. CONCLUSIONS: The current study found infrahepatic IVC clamping during liver transection for cholangiocarcinoma reduces blood loss, blood transfusion, and rate of vascular inflow occlusion requirement.

Re-Rising of Total Bilirubin Level after Postoperative Day 3 (The V Pattern) Predicting Liver Failure and Survival of Patients who Underwent Hepatectomy for Cholangiocarcinoma.

OBJECTIVE: All types of cholangiocarcinoma (CCA) require a major hepatectomy, which has many post-operative complications. All complications usually present with persistent hyperbilirubinemia; however, studies on the prediction of post-operative hyperbilirubinemia after hepatectomy for patients with CCA are lacking. We evaluated the causes and patterns of persistent hyperbilirubinemia among the patients who underwent hepatectomy for CCA. METHODS: We retrospectively reviewed the records of 216 CCA patients who underwent curative-intent hepatic resection between January 2015 and December 2016. We identified five patterns of hyperbilirubinemia for predicting the cause of persistent hyperbilirubinemia and the respective patient outcome. All clinical parameters and outcomes were analyzed for any significant associations. RESULTS: Twenty-eight patients (24%) had post-operative persistent hyperbilirubinemia. Of these, liver failure was the most common cause (42.9%), followed by bile leakage (14.3%), then cholangitis (3.6%). Re-rising of the bilirubin level after post-operative day 3(the 'V' pattern), very well predicted liver failure. Moreover, this pattern was associated with poor survival of the patient. CONCLUSION: The current study provided a picture of persistent hyperbilirubinemia after hepatectomy for CCA. The proportion of post-operative liver failure was 12 percent. The pattern of serum bilirubin level could be used as a predictor of liver failure and long-term outcomes of CCA patients. The 'V' pattern was significantly associated with a high rate of liver failure and poor survival.