Cost burden following esophagectomy:A single centre observational study

BACKGROUND Cost analyses of patients undergoing esophagectomy is valuable for identifying modifiable expenditure drivers to target and curtail costs while improving the quality of care.We aimed to define the cost-complication relationship after esophagectomy and delineate the incremental contributions to costs.AIM To assess the relationship between the hospital costs and potential cost drivers post esophagectomy and investigate the relationship between the cost-driving variables(predicting variables)and hospital costs(dependent variable).METHODS In this retrospective single center study,the severity of complications was graded using the Clavien-Dindo(CD)classification system.Key esophagectomy complications were categorized and defined according to consensus guidelines.Raw costing data included the in-hospital costs of the index admission and any unplanned admission within 30 postoperative days.We used correlation analysis to assess the relationship between key clinical variables and hospital costs(in United States dollars)to identify cost drivers.A mediation model was used to investigate the relationship between these variables and hospital costs.RESULTS A total of 110 patients underwent primary esophageal resection.The median admission cost was $47822.7(interquartile range:35670.2-68214.0).The total effects on costs were $13593.9(95%CI:10187.1-17000.8,P<0.001)for each increase in CD severity grade,$4781(95%CI:3772.7-5789.3,P<0.001)for each increase in the number of complications,and $42552.2(95%CI:8309-76795.4,P=0.015)if a key esophagectomy complication developed.Key esophagectomy complications drove the costs directly by $11415.7(95%CI:992.5-21838.9,P=0.032).CONCLUSION The severity and number of complications,and the development of key esophagectomy complications significantly contributed to total hospital costs.Continuous institutional initiatives and strategies are needed to enhance patient outcomes and minimize costs.

Statin, aspirin and metformin use and risk of hepatocellular carcinoma related outcomes following liver transplantation: A retrospective study

BACKGROUND Liver transplantation(LT)is a potentially curative therapy for patients with hepatocellular carcinoma(HCC).HCC-recurrence following LT is associated with reduced survival.There is increasing interest in chemoprophylaxis to improve HCC-related outcomes post-LT.AIM To investigate whether there is any benefit for the use of drugs with proposed chemoprophylactic properties against HCC,and patient outcomes following LT.METHODS This was a retrospective study of adult patients who received Deceased Donor LT for HCC from 2005-2022,from a single Australian centre.Drug use was defined as statin,aspirin or metformin therapy for≥29 days,within 24 months post-LT.A cox proportional-hazards model with time-dependent covariates was used for survival analysis.Outcome measures were the composite-endpoint of HCC-recurrence and all-cause mortality,HCC-recurrence and HCC-related mortality.Sensitivity analysis was performed to account for immortality time bias and statin dosing.RESULTS Three hundred and five patients were included in this study,with 253(82.95%)males with a median age of 58.90 years.Aetiologies of liver disease were 150(49.18%)hepatitis C,73(23.93%)hepatitis B(HBV)and 33(10.82%)non-alcoholic fatty liver disease(NAFLD).56(18.36%)took statins,51(16.72%)aspirin and 50(16.39%)metformin.During a median follow-up time of 59.90 months,34(11.15%)developed HCC-recurrence,48(15.74%)died,17(5.57%)from HCC-related mortality.Statin,aspirin or metformin use was not associated with statistically significant differences in the composite endpoint of HCC-recurrence or all-cause mortality[hazard ratio(HR):1.16,95%CI:0.58-2.30;HR:1.21,95%CI:0.28-5.27;HR:0.61,95%CI:0.27-1.36],HCC-recurrence(HR:0.52,95%CI:0.20-1.35;HR:0.51,95%CI:0.14-1.93;HR 1.00,95%CI:0.37-2.72),or HCC-related mortality(HR:0.32,95%CI:0.033-3.09;HR:0.71,95%CI:0.14-3.73;HR:1.57,95%CI:0.61-4.04)respectively.Statin dosing was not associated with statist-ically significant differences in HCC-related outcomes.CONCLUSION Statin,metformin or aspirin use was not associated with improved HCC-related outcomes post-LT,in a largely historical cohort of Australian patients with a low proportion of NAFLD.Further prospective,multicentre studies are required to clarify any potential benefit of these drugs to improve HCC-related outcomes.

From minimal to maximal surgery in the treatment of hepatocarcinoma:A review

Hepatocellular carcinoma represents one of the most challenging frontiers in liver surgery. Surgeons have to face a broad spectrum of aspects,from the underlying liver disease to the new surgical techniques. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function witha 5-year survival rate of 50%,offering good longterms results in selected patients. With the advances in laparoscopic surgery,major liver resections can be performed with minimal harm,avoiding the wound and leak complications related to the laparotomies. Studies have shown that oncological margins are the same as in open surgery. In patients submitted to liver resection(either laparoscopic or open) who experience recurrence,re-resection or salvage liver transplantation has been showing to be an alternative approach in well selected cases. The decision making approach to the cirrhotic patient is becoming more complex and should involve hepatologists,liver surgeons,radiologists and oncologists. Better understanding of the different risk factors for recurrence and survival should be aimed in these multidisciplinary discussions. We here in discuss the hot topics related to surgical risk factors regarding the surgical treatment of hepatocellular carcinoma: anatomical resection,margin status,macrovascular tumor invasion,the place of laparoscopy,salvage liver transplantation and liver transplantation.

Stereotactic radiotherapy and the potential role of magnetic resonance-guided adaptive techniques for pancreatic cancer

BACKGROUND Pancreatic cancer is a malignancy with one of the poorest prognoses amongst all cancers.Patients with unresectable tumours either receive palliative care or undergo various chemoradiotherapy regimens.Conventional techniques are often associated with acute gastrointestinal toxicities,as adjacent critical structures such as the duodenum ultimately limits delivered doses.Stereotactic body radiotherapy(SBRT)is an advanced radiation technique that delivers highly ablative radiation split into several fractions,with a steep dose fall-off outside target volumes.AIM To discuss the latest data on SBRT and whether there is a role for magnetic resonance-guided techniques in multimodal management of locally advanced,unresectable pancreatic cancer.METHODS We conducted a search on multiple large databases to collate the latest records on radiotherapy techniques used to treat pancreatic cancer.Out of 1229 total records retrieved from our search,36 studies were included in this review.RESULTS Studies indicate that SBRT is associated with improved clinical efficacy and toxicity profiles compared to conventional radiotherapy techniques.Further dose escalation to the tumour with SBRT is limited by the poor soft-tissue visualisation of computed tomography imaging during radiation planning and treatment delivery.Magnetic resonance-guided techniques have been introduced to improve imaging quality,enabling treatment plan adaptation and re-optimisation before delivering each fraction.CONCLUSION Therefore,SBRT may lead to improved survival outcomes and safer toxicity profiles compared to conventional techniques,and the addition of magnetic resonance-guided techniques potentially allows dose escalation and conversion of unresectable tumours to operable cases.

Donor-specific cell-free DNA as a biomarker in liver transplantation:A review

Due to advances in modern medicine,liver transplantation has revolutionised the prognosis of many previously incurable liver diseases.This progress has largely been due to advances in immunosuppressant therapy.However,despite the judicious use of immunosuppression,many liver transplant recipients still experience complications such as rejection,which necessitates diagnosis via invasive liver biopsy.There is a clear need for novel,minimally-invasive tests to optimise immunosuppression and improve patient outcomes.An emerging biomarker in this‘‘precision medicine’‘liver transplantation field is that of donorspecific cell free DNA.In this review,we detail the background and methods of detecting this biomarker,examine its utility in liver transplantation and discuss future research directions that may be most impactful.

Outcomes of central hepatectomy versus extended hepatectomy

Background: Central hepatectomy(CH) is more difficult than extended hepatectomy(EH) and is associated with greater morbidity. In this modern era of liver management with aims to prevent posthepatectomy liver failure(PHLF), there is a need to assess outcomes of CH as a parenchyma-sparing procedure for centrally located liver tumors. Methods: A total of 178 major liver resections performed by specialist surgeons from two Australian tertiary institutions between June 2009 and March 2017 were reviewed. Eleven patients had CH and 24 had EH over this study period. Indications and perioperative outcomes were compared between the groups. Results: The main indication for performing CH was colorectal liver metastases. There was no perioperative mortality in the CH group and four(16.7%) in the EH group( P = 0.285). No group differences were found in median operative time [CH vs. EH: 450 min(290–840) vs. 523 min(310–860), P = 0.328], intraoperative blood loss [850 mL(40 0–150 0) vs. 650 mL(10 0–20 0 0), P = 0.746] or patients requiring intraoperative blood transfusion [1(9.1%) vs. 7(30.4%), P = 0.227]. There was a trend towards fewer hepatectomyspecific complications in the CH group [3(27.3%) vs. 13(54.2%), P = 0.167], including PHLF(CH vs. EH: 0 vs. 29.2%, P = 0.072). Median length of stay was similar between groups [CH vs. EH: 9 days(5–23) vs. 12 days(4–85), P = 0.244]. Conclusions: CH has equivalent postoperative outcomes to EH. There is a trend towards fewer hepatectomy-specific complications, including PHLF. In appropriate patients, CH may be considered as a safe parenchyma-sparing alternative to EH.