Learning Curve of Ex Vivo Liver Resection and Autotransplantation in Treating End-Stage Hepatic Alveolar Echinococcosis: A RA-CUSUM Analysis.

Yiwen Qiu,Tao Wang,Wentao Wang,Yi Yang,Xianwei Yang,Bin Huang,Shu Shen

doi:10.3389/fsurg.2021.753968

Abstract

Background: This retrospective study aimed to evaluate the safety and learning curve of ex vivo liver resection and autotransplantation (ELRA).Methods: A total of 102 consecutive end-stage HAE patients who underwent ELRA between 2014 and 2020 in West China Hospital were enrolled. The primary endpoint was major postoperative complications (comprehensive complication index, CCI > 26). The ELRA learning curve was evaluated using risk-adjusted cumulative sum (RA-CUSUM) methods. The learning phases were determined based on RA-CUSUM analysis and tested for their association with intra- and post-operative endpoints.Results: The median surgery time was 738 (659–818) min, with a median blood loss of 2,250 (1,600–3,000) ml. The overall incidence of major morbidity was 38.24% (39/102). Risk-adjusted cumulative sum analysis demonstrated a learning curve of 53 ELRAs for major postoperative complications. The learning phase showed a significant association with the hemodynamic unstable time (HR −30.29, 95% CI −43.32, −17.25, P < 0.0001), reimplantation time (HR −13.92, 95% CI −23.17, −4.67, P = 0.004), total postoperative stay (HR −6.87, 95% CI −11.33, −2.41, P = 0.0033), and postoperative major morbidity (HR 0.25, 95% CI 0.09, 0.68, p = 0.007) when adjusted for age, disease course, liver function, and remote metastasis.Discussion: Ex vivo liver resection and autotransplantation is feasible and safe with a learning curve of 53 cases for major postoperative complications.

Highlights

Ex vivo liver resection and autotransplantation (ELRA) was introduced in recent years to treat end-stage hepatic alveolar echinococcosis (HAE)
The learning phase showed a significant association with the hemodynamic unstable time (HR −30.29, 95% CI −43.32, −17.25, P < 0.0001), reimplantation time (HR −13.92, 95% CI −23.17, −4.67, P = 0.004), total postoperative stay (HR −6.87, 95% CI −11.33, −2.41, P = 0.0033), and postoperative major morbidity (HR 0.25, 95% CI 0.09, 0.68, p = 0.007) when adjusted for age, disease course, liver function, and remote metastasis
End-stage HAE was defined as an HAE lesion extending along vessels, including the inferior vena cava (IVC), portal vein (PV), and Abbreviations: ELRA, ex vivo liver resection and autotransplantation; LT, liver transplantation; IVC, inferior vena cava; PV, portal vein; HV, hepatic vein; HAE, hepatic alveolar echinococcosis; Em, Echinococcus multilocularis; AE, alveolar echinococcosis; RLV, remnant liver volume; Standard liver volume (SLV), standard liver volume; CCI, comprehensive complication index; RA-CUSUM, risk-adjusted cumulative sum

Summary

Introduction

Ex vivo liver resection and autotransplantation (ELRA) was introduced in recent years to treat end-stage hepatic alveolar echinococcosis (HAE). While ELRA became a promising alternative for treating endstage HAE, the complexity and safety of this technique hampered its further application. Pioneered by Pilchmayr in 1988 [3], ELRA is a series of procedures involving complete hepatectomy, extracorporeal liver resection followed by hepatic vessel repair, and autologous transplantation of the remnant liver graft. This retrospective study aimed to evaluate the safety and learning curve of ex vivo liver resection and autotransplantation (ELRA)

Methods

Results

Conclusion