Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS)
Heidelberg University1, University of Edinburgh2, Flinders Medical Centre3, University of Adelaide4, Royal North Shore Hospital5, University of Hong Kong6, Nagoya University7, University of Girona8, University of Texas MD Anderson Cancer Center9, Memorial Sloan Kettering Cancer Center10, Toronto General Hospital11, Alfred Hospital12, St. Vincent's Health System13, Royal Prince Alfred Hospital14, University of Melbourne15, University of Tokyo16
TL;DR: The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies and should be applied in future trials to standardize reporting of complications.
Abstract: Background A standardized definition of post-hepatectomy haemorrhage (PHH) has not yet been established. Methods An international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients' clinical management. Results The definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level >3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBC, whereas the need for invasive re-intervention such as embolization and/ or re-laparotomy defines Grade C PHH. Conclusion The proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications. A proposed international definition and grading of severity of post hepatectomy haemorrhage which may enable better comparison of outcomes from future published studies
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TL;DR: The following Clinical Practice Guidelines will give up-to-date advice for the clinical management of patients with hepatocellular carcinoma, as well as providing an in-depth review of all the relevant data leading to the conclusions herein.
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TL;DR: This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes, and offers many advantages commonly attributed to laparoscopy and is well suited for H CC with cirrhosis when performed by experienced surgeons.
Abstract: Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy. From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated. Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy. This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.
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TL;DR: The available consensus definitions were increasingly cited and facilitate scientific comparability and transparency if appropriately applied and update the incidences of major pancreatic complications.
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Cites methods from "Post-hepatectomy haemorrhage: a def..."
...Final conclusions for the International Study Group of Liver Surgery and ISREC definitions of PHLF, BL, PHH, and AL could not be drawn because of the recent publication and a consecutive shortage of available citations....
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...Yet, these numbers suggest that the consensus definitions were accepted successfully by academic surgeons, although the other and only recently published definitions of AL, PHLF, BL, and PHH had numbered fewer citations in the first year after publication....
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...Following this example, the International Study Group of Rectal Cancer (ISREC) and the International Study Group of Liver Surgery developed consensus definitions for anastomotic leakage (AL) after anterior resection of the rectum, posthepatectomy liver failure (PHLF), biliary leakage (BL), and posthepatectomy hemorrhage (PHH).9-12 These consensus definitions all precisely define the respective complication using biochemical, radiographical or clinical criteria and provide three severity grades (Supplementary Table S1, available online): A : (subclinical with no change in management), B : (change inmanagement or intervention required), and C : (invasive treatment or reoperation required)....
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...Following this example, the International Study Group of Rectal Cancer (ISREC) and the International Study Group of Liver Surgery developed consensus definitions for anastomotic leakage (AL) after anterior resection of the rectum, posthepatectomy liver failure (PHLF), biliary leakage (BL), and posthepatectomy hemorrhage (PHH).(9-12) These consensus definitions all precisely define the respective complication using biochemical, radiographical or clinical criteria and provide three severity grades (Supplementary Table S1, available online):...
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...Of note, the consensus definitions of AL, PHLF, BL, and PHH were only recently published in the years 2010 and 2011; thus, the number of citations per year (total number of citations: AL, 12 times; PHLF, BL, and PHH each 1 time) for these definitions was not representative....
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TL;DR: The definition and severity grading of AL after anterior resection of the rectum proposed by the ISREC provides a simple, easily applicable, and valid classification and may facilitate comparison of results from different studies on AL after sphincter-preserving rectal surgery.
103 citations
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...08 Leukocytosis (>20/nL) 0 2 (15) 6 (18) ....
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...N 9 13 34 Leukopenia (<4/nL) 0 0 6 (18) ....
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TL;DR: Mortality rates after liver surgery are not well documented in Germany, but there is no central regulation of infrastructure requirements or outcome quality.
Abstract: BACKGROUND Mortality rates after liver surgery are not well documented in Germany. More than 1000 hospitals offer liver resection, but there is no central regulation of infrastructure requirements or outcome quality. METHODS Hospital mortality rates after liver resection were analysed using the standardized hospital discharge data (Diagnosis-Related Groups, ICD-10 and German operations and procedure key codes) provided by the Research Data Centre of the Federal Statistical Office and Statistical Offices of the Lander in Wiesbaden, Germany. RESULTS A total of 110 332 liver procedures carried out between 2010 and 2015 were identified. The overall hospital mortality rate for all resections was 5·8 per cent. The mortality rate among 17 574 major hepatic procedures was 10·4 per cent. Patients who had surgery for colorectal liver metastases (CRLMs) had the lowest mortality rate among those with malignancy (5·5 per cent), followed by patients with gallbladder cancer (7·1 per cent), hepatocellular carcinoma (9·3 per cent) and intrahepatic cholangiocarcinoma (11·0 per cent). Patients with extrahepatic cholangiocarcinoma had the highest mortality rate (14·6 per cent). The mortality rate for extended hepatectomy was 16·2 per cent and the need for a biliodigestive anastomosis increased this to 25·5 per cent. Failure to rescue after complications led to mortality rates of more than 30 per cent in some subgroups. There was a significant volume-outcome relationship for CRLM surgery in very high-volume centres (mean 26-60 major resections for CRLMs per year). The mortality rate was 4·6 per cent in very high-volume centres compared with 7·5 per cent in very low-volume hospitals (odds ratio 0·60, 95 per cent c.i. 0·42 to 0·77; P < 0·001). CONCLUSION This analysis of outcome data after liver resection in Germany suggests that hospital mortality remains high. There should be more focused research to understand, improve or justify factors leading to this result, and consideration of centralization of liver surgery.
96 citations
References
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TL;DR: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4
Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature.
The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification.
Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.
23,435 citations
"Post-hepatectomy haemorrhage: a def..." refers background or methods in this paper
...Moreover, the approach to grade the severity of PHH based on the clinical sequelae is in line with the grading of other complications as well as a general classification of operative complications.(38,39) From a clinical point of view we are therefore convinced that the impact of a haemorrhage on a patient’s management is of primary relevance to the patient and the surgeon and should be used to grade the severity of PHH....
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...surgical complications in general was published.(39) There is, however, no generally accepted, specific definition of PHH as a major complication after a hepatic resection....
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TL;DR: In this article, an international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easy-to-apply definition of postoperative pancreatic fistula, graded primarily on clinical impact.
3,622 citations
01 Jan 2005
TL;DR: The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed.
Abstract: Background. Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences. Methods. An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easyto-apply definition of POPF, graded primarily on clinical impact. Results. A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient’s hospital course. Conclusions. The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed. (Surgery 2005;138:8-13.)
3,617 citations
TL;DR: The International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of delayed gastric emptying (DGE) based primarily on severity and clinical impact as discussed by the authors.
2,150 citations
TL;DR: An objective, universally accepted definition and clinical grading of PPH is important for the appropriate management and use of interventions in PPH and would allow comparisons of results from future clinical trials.
1,790 citations