Hepatic Lobectomy Research Articles

The Role of a Community Surgeon in the Care of Hepatopancreatobiliary Patients: Short-Term Outcomes and Learning Curve.

Background Owing to the well-established volume-outcome relationship, hepatopancreatobiliary (HPB) surgery is commonly regionalized to academic, teaching hospitals. However, regionalization is associated with decreased access for some populations in need, as well as geographic and financial barriers for patients. If high surgeon and institutional volumes can be achieved, the community, non-teaching HPB surgical practice could help alleviate some issues associated with regionalization. The HPB experience of a community surgeon immediately after surgical oncology training was reviewed, hypothesizing that high volumes with acceptable short-term outcomes could be achieved, although a learning curve may be observed. Materials and methods Electronic medical records from 2013 to 2023 were reviewed. Data included patient demographics, perioperative details, pathology, complications, and deaths over 90 postoperative days. Perioperative quality metrics were assessed for trends over time in pancreaticoduodenectomy (PD) and liver resection subgroups. Results A total of 295 patients underwent 176 (59.7%) pancreatic and 119 (40.3%) hepatobiliary operations. The most common operations were PD (n=87; 49.4%) and partial hepatic lobectomy (n=56; 41.1%). In the pancreas group, morbidity was 25% (n=44), and mortality was 4.5% (n=8). In the hepatobiliary group, morbidity and mortality were 19.3% (n=23) and 5.0% (n=6), respectively. Within the PD and liver resection subgroups, operative time, estimated blood loss, and hospital length of stay (LOS) trended downward over time, with LOS decreasing significantly. Conclusion High HPB volumes with acceptable short-term outcomes can be achieved by a solo practitioner in the community, non-teaching setting. For PDs and liver resections, perioperative metrics trended downward over time, illustrating the learning curve encountered after training.

Caudate lobe and posterosuperior segment hepatectomy using the robotic approach. Outcome analysis of liver resection in difficult locations

BackgroundCaudate and posterosuperior hepatectomy are technically challenging resections, especially in a minimally invasive approach. We aimed to analyze the outcomes of isolated caudate resection (ICR), en-bloc caudate resection with right/left hepatic lobectomy (ECR), and posterosuperior segment resection (PSR) using our institutional database. MethodsFollowing IRB approval, we prospectively followed 500 consecutive patients between 2013 and 2023 who underwent robotic hepatectomy. Posterosuperior segments include segment 4 ​A, 7, and 8. The data are presented as median (mean ​± ​standard deviation). ResultsOf the 500 patients included in this study, 19 (4 ​%) underwent ICR, 65 (13 ​%) underwent ECR, and 131 (26 ​%) patients underwent PSR. ECR was associated with significantly longer operative time, increased EBL, and longer LOS when compared with those of ICR and PSR. The patients who underwent ICR had the shortest operation duration, lowest EBL, and shortest LOS compared to ECR and PSR. ConclusionsRobotic resection of liver tumors located in difficult segments is safe and feasible with excellent clinical and oncological outcomes. With appropriate expertise, a minimally invasive approach to those operations should not be avoided.

S4454 Postoperative Sequelae in Giant Cavernous Hemangioma: Recurrent Cholangitis and Enlargement of Residual Hemangioma Following Hepatic Lobectomy

S4454 Postoperative Sequelae in Giant Cavernous Hemangioma: Recurrent Cholangitis and Enlargement of Residual Hemangioma Following Hepatic Lobectomy

Insulin-like growth factor-1 deficiency caused by hepatocellular adenoma leads to growth arrest, primary amenorrhea and metabolic syndrome: a case report and 4 years follow up

BackgroundHepatocellular adenoma (HCA) is a rare benign neoplasm, seldom ascribed as the cause of endocrine and metabolic derangement. We herein report a case of primary amenorrhea, growth arrest and metabolic syndrome. En bloc resection of the tumor normalized all the disturbances.Case presentationA 16-year-old girl complained of primary amenorrhea and growth arrest for the past 2 years. Her height and weight were at the 3rd percentile, whereas waist circumference was at the 90th percentile for chronological age. She was hypertensive on admission. Plasma cholesterol, triglyceride and uric acid were elevated. Evaluation of GH/IGF-1 axis showed extremely low IGF-1 concentration, which was unresponsive to hGH stimulation. Computer tomography identified a huge liver mass (18.2 cm×13.7 cm×21 cm). The patient underwent an uneventful open right hepatic lobectomy. The tumor was en bloc resected. Immunohistochemistry indicated an unclassified HCA, which was confirmed by genetic screening. IGF-1 concentration, blood pressure, lipid profile and ovarian function were all normalized after surgery, and the girl had reduction in waist circumference and gain in height during the follow up.ConclusionWe provide evidence that liver-derived IGF-1 has a direct effect on skeletal and pubertal development, blood pressure, visceral adiposity and dyslipidemia independent of insulin resistance and obesity in the circumstance of undernutrition. Though rare, we propose the need to look into HCA cases for the existence of IGF-1 deficiency and its impact on metabolic derangement.

Laparoscopic caudate lobe resections: How I do it: tips and pitfalls (with video).

The caudate lobe (S1) of the liver, due to its deep central position, presents a formidable challenge for laparoscopic resection. Historical skepticism about laparoscopic approaches has been overshadowed by advancements in technology and technique, with recent studies showing comparable outcomes to open surgery. This paper introduces the "Easy First" technique and the Sextet strategies for laparoscopic hepatic caudate lobectomy. The strategies include meticulous preoperative planning, optimal trocar placement, and team positioning, tailored to the anatomical complexities of the caudate lobe. With a 0% conversion and mortality rate, our series demonstrates the safety of the "Easy First" technique. The Sextet strategies have been instrumental in navigating the technical challenges, emphasizing the importance of patient selection and surgeon expertise. The "Easy First" technique, with its structured approach and the Sextet strategies, offers a replicable method for laparoscopic caudate lobectomy. It underscores the need for stringent patient selection, advanced technical skill, and high-volume center expertise to ensure procedural success and patient safety.

A rare case report: multiple intrahepatic masses in a pediatric patient with citrin deficiency

Deficiency of citrin, the liver-type aspartate-glutamate carrier, arises from biallelic mutations of the gene SLC25A13. Although citrin deficiency (CD) is associated with higher risk of hepatocellular carcinoma (HCC) in adult patients, this association remains inconclusive in pediatric cases. The patient in this paper had been diagnosed to have CD by SLC25A13 analysis at the age 10 months, and then in response to dietary therapy, her prolonged jaundice and marked hepatosplenomegaly resolved gradually. However, she was referred to the hospital once again due to recurrent abdominal distention for 2 weeks at her age 4 years and 9 months, when prominently enlarged liver and spleen were palpated, along with a strikingly elevated serum alpha-fetoprotein (AFP) level of 27605 ng/mL as well as a large mass in the right liver lobe and a suspected tumor thrombus within the portal vein on enhanced computed tomography. After 4 rounds of adjuvant chemotherapy, right hepatic lobectomy and portal venous embolectomy were performed at her age 5 years and 3 months, and metastatic hepatoblastoma was confirmed by histopathological analysis. Afterwards, the patient underwent 5 additional cycles of chemotherapy and her condition remained stable for 7 months after surgery. Unfortunately, hepatoblastoma recurred in the left lobe at the age 5 years and 10 months, which progressed rapidly into liver failure, and led to death at the age 6 years and 1 month. As far as we know, this is the the first case of hepatoblastoma in a patient with CD, raising the possibility of an association between these two conditions.

Amelioration of NAFLD by sleeve gastrectomy-triggered hepatocyte regeneration in mice - experimental research.

Sleeve gastrectomy (SG) is known to alleviate non-alcoholic fatty liver disease (NAFLD) and restore liver function; however, its underlying mechanism remains unclear. We investigated the effect of SG on the metabolic phenotype of diet-induced obese (DIO) mice. Postoperative stained liver images were analyzed to determine the hepatocyte proliferation phenotype. Single-cell RNA sequencing was used to characterize the regeneration signals of the liver after SG in DIO mice, and qRT PCR was performed to verify the above results. We employed Olink proteomics to capture serum element changes and investigated the role of Yes1 protein in liver regeneration and carcinogenesis through the Hippo-YAP pathway. DIO mice were treatment with YAP inhibitor verteporfin after SG mice to clarify whether SG-induced liver regeneration is related to the YAP signaling pathway. SG significantly reduced NAFLD-associated dysfunction in hepatocytes and replaced them with fully functional hepatocytes, which have a high regenerative capacity across the entire liver. SG also enhanced the hepatic regenerative capacity, as demonstrated by SG combined with hepatic lobectomy in healthy mice. Yes1 protein was identified as the signaling molecule most closely related to classical regeneration signals. Our study showed that SG-enhanced proliferation and improved metabolism did not depend on YAP signaling. SG can enhance hepatic regenerative capacity and improve liver metabolism. This study provides a better understanding of the mechanisms underlying SG-induced metabolic improvements.

Impact of Frailty on Short-Term Outcomes of Hepatic Lobectomy in Patients with Intrahepatic Cholangiocarcinoma: Evidence from the US Nationwide Inpatient Sample 2005–2018

Introduction: This study aimed to evaluate associations between frailty and outcomes in patients with intrahepatic cholangiocarcinoma (ICC) undergoing hepatic lobectomy using a large, nationally representative sample. Methods: This population-based, retrospective observational study extracted the data of adults ≥20 years old with ICC undergoing hepatic lobectomy from the US Nationwide Inpatient Sample database between 2005 and 2018. Frailty was assessed by the validated Hospital Frailty Risk Score (HFRS). Associations between frailty and surgical outcomes were analyzed using logistic regression analyses. Results: After exclusions, 777 patients were enrolled, including 427 frail and 350 non-frail. Patients’ mean age was 64.5 (±0.4) years and the majority were males (51.1%) and whites (76.5%). Frailty was significantly associated with increased odds of in-hospital mortality (aOR: 18.51, 95% CI: 6.70, 51.18), non-home discharge (aOR: 3.58, 95% CI: 2.26, 5.66), prolonged LOS (aOR: 5.56, 95% CI: 3.87, 7.99), perioperative cardiac arrest/stroke (aOR: 5.44, 95% CI: 1.62, 18.24), acute respiratory distress syndrome (ARDS)/respiratory failure (aOR: 3.88, 95% CI: 2.40, 6.28), tracheostomy/ventilation (aOR: 3.83, 95% CI: 2.23, 6.58), bleeding/transfusion (aOR: 1.67, 95% CI: 1.24, 2.26), acute kidney injury (AKI) (aOR: 14.37, 95% CI: 7.13, 28.99), postoperative shock (aOR: 4.44, 95% CI: 2.54, 7.74), and sepsis (aOR: 11.94, 95% CI: 6.90, 20.67). Discussion/Conclusion: Among patients with ICC undergoing hepatic lobectomy, HFRS-defined frailty is a strong predictor of worse in-patient outcomes, including in-hospital death, prolonged LOS, unfavorable discharge, and complications (perioperative cardiac arrest/stroke, ARDS/respiratory failure, tracheostomy/ventilation, bleeding/transfusion, AKI, postoperative shock, and sepsis). Study results may help stratify risk in frail patients undergoing hepatic resection for ICC.

Spontaneous intra-abdominal hematomas in a hepatocellular carcinoma patient treated with lenvatinib: a case report

Abstract A 44-year-old patient was admitted with tumor rupture in the left hepatic lateral lobe, and he underwent emergent exploratory laparotomy and proceeded for hepatic left lateral lobectomy on September 19, 2021. The final diagnosis of hepatocellular carcinoma was confirmed by histopathological examination of the surgical specimen. Afterward, the patient received hepatic arterial infusion chemotherapy with FOLFOX (oxaliplatin, fluorouracil, and leucovorin) for 5 cycles. Subsequently, recurrence of the hepatocellular carcinoma was diagnosed in the abdominal cavity. The patient was then treated with lenvatinib. Within less than 1 month of the treatment with lenvatinib, the patient was admitted to the emergency room on June 2, 2022, because of acute intra-abdominal bleeding (hematomas). Percutaneous intra-abdominal angiography found that the bleeding vessels were the right gastroepiploic artery and left gastric artery. The patient was stabilized after arterial embolization using gelatin sponges. The diagnosis and management of spontaneous intra-abdominal hematomas are discussed.

Poorly differentiated hepatocellular carcinoma with sarcomatous change causing intraparenchymal rupture and rapid turnaround: a case report

The patient was a 73-year-old man who had undergone surgery for gastric cancer in January 2020 and was subsequently attending an outpatient clinic. In May, he presented with right upper abdominal pain. A computed tomography (CT) scan revealed an intraparenchymal rupture of a pseudoaneurysm in a segmental branch of the hepatic artery, and a transcatheter arterial embolization was performed. A follow-up CT scan in August showed a tumor in the same area. Retrospectively, the pseudoaneurysm in the segmental branch of the hepatic artery, which had experienced intraparenchymal rupture, was identified as the feeding artery for the tumor. In October, a right hepatic lobectomy was performed. Pathological examination confirmed a diagnosis of poorly differentiated hepatocellular carcinoma (HCC). This case highlights a rare instance of HCC causing intraparenchymal rupture.

Right hepatectomy under cardiopulmonary bypass for hepatocellular carcinoma with inferior vena cava tumor thrombus: a case report

BackgroundThe prognosis of hepatocellular carcinoma (HCC) with vascular invasion is extremely poor, especially in patients with tumor thrombus (TT) of the inferior vena cava (IVC), which is an oncological emergency with a high risk of sudden death due to TT extension or migration. Herein, we describe a case of HCC with TT of the IVC that rapidly extended into the right atrium (RA), in which right hepatectomy was performed under cardiopulmonary bypass.Case presentationA 64-year-old man was diagnosed with HCC with IVC TT, and right hepatic lobectomy was scheduled. While awaiting surgery, he complained of respiratory distress and rushed to the emergency room. The TT had reached the RA, and the patient was in a state of oncologic emergency. We requested the cooperation of the cardiovascular surgery department, and under artificial cardiopulmonary support, the right atrium was incised, and a part of the TT was removed. The IVC was clamped to prevent tumor dispersal, and right hepatic lobectomy was performed. The remaining thrombus was excised along with the right lobe of the liver by incising the IVC. There were no serious postoperative complications, and the patient is alive 1 year and 5 months postoperatively.ConclusionHepatic resection with cardiopulmonary bypass could be an option for HCC with TT reaching the RA.

S3639 A Novel Case of Non-Cirrhotic Portal Hypertension After Hepatic Lobectomy

S3639 A Novel Case of Non-Cirrhotic Portal Hypertension After Hepatic Lobectomy

Early-stage sigmoid colon cancer resection followed by liver metastasis recurrence 1 year later and mesenteric recurrence more than 5 years later: a case report

BackgroundEarly-stage colorectal cancer (CRC) is often treated endoscopically, but additional surgical resection may be considered depending on pathological findings.Case presentationA 73-year-old man was found to have early-stage sigmoid colon cancer by colonoscopy during a medical examination, and endoscopic mucosal resection (EMR) was performed. The lesion was a 7-mm-sized sessile polyp, and the pathological diagnosis was well-differentiated tubular adenocarcinoma, pT1 (submucosal invasion of 400 μm), with no lymphovascular invasion, low budding grade, and negative horizontal and vertical margins. Therefore, the patient was observed without postoperative treatment. One year later, a computed tomography (CT) scan showed multiple liver metastases. After five courses of preoperative chemotherapy with folinic acid, 5-fluorouracil and oxaliplatin (FOLFOX) and panitumumab, liver metastases were reduced. The patient underwent extended right hepatic lobectomy. The pathological finding was well-to-moderately differentiated tubular adenocarcinoma, and immunohistochemistry findings were consistent with liver metastases from sigmoid colon cancer. Postoperatively, the patient received five courses adjuvant chemotherapy with FOLFOX. Although the patient had been recurrence-free for 5 years after liver resection, a CT scan revealed a nodular lesion in the sigmoid mesentery. Positron emission tomography (PET) showed abnormal accumulation in the same lesion. Therefore, the mesenteric nodules diagnosed as lymph metastasis and recurrence of sigmoid colon cancer and performed laparoscopic sigmoid colon resection with lymph node dissection. The pathological findings showed that the recurrent lesion in the mesentery formed a nodular infiltrate with venous, lymphatic, and neural invasion, but lymph node structures were not found, and it was assumed to be metastasis or recurrence due to lymphovascular invasion. The pathologic specimen of the sigmoid colon had no neoplastic lesions, which are considered to be a local recurrence on the mucosal surface. After sigmoid colectomy, adjuvant chemotherapy with CapeOX was conducted, and the patient has been recurrence-free for 13 months at present.ConclusionEven early-stage CRCs that have no pathological indications for additional resection have risks of metastases and recurrences, and we may need to consider that the criteria for additional resection should not be limited to pathological findings alone.

Long-term survival after multidisciplinary treatments for HER2-positive advanced gastric cancer with multiple liver and lung metastases

BackgroundTrastuzumab-based chemotherapy is a standard treatment regimen for human epithelial growth factor 2 (HER2)-positive gastric cancer. This is a case of a patient who has survived 12 years after being diagnosed with advanced gastric cancer with multiple liver and lung metastases.Case presentationA woman in her 70s underwent total gastrectomy, cholecystectomy, and left hepatic lobectomy for gastric cancer with liver metastasis. One month after the surgery, multiple liver metastases appeared. After two courses of S-1 + CDDP chemotherapy, the liver metastases disappeared, and new lung metastases occurred. Because the primary tumor was HER2 positive, S-1 + CDDP + trastuzumab chemotherapy was performed. After one course of chemotherapy, the blood test showed pancytopenia, and CDDP was discontinued. S-1 + trastuzumab chemotherapy was then initiated, and as a result, the lung metastases disappeared. The patient is alive without recurrence 12 years after the surgery.ConclusionsWe encountered a case of long-term survival after multidisciplinary treatments for HER2-positive advanced gastric cancer with multiple liver and lung metastases.

Hepatic lobectomy in dogs using a stapling device with a vascular cartridge: a retrospective study of 13 cases

ABSTRACT Case history Medical records of two veterinary hospitals in Canada were reviewed to identify cases of dogs that underwent liver lobectomy via open laparotomy using the Endo GIA surgical stapling device with a vascular cartridge (height of open and closed staples: 2.5 and 1.0 mm, respectively) between January 2016 and June 2018. Mean age at the time of surgery of the dogs (n = 13) included in the study was 10.4 (SD 1.5; min 7.9, max 12.8) years and mean body weight was 14 (min 3.9, max 37.8) kg. Clinical findings Liver masses requiring hepatic lobectomy were identified in 12 dogs by abdominal ultrasound examination. The remaining dog required a lobectomy of the right medial liver lobe to address leakage from the right medial lobe hepatic duct that occurred as a complication of cholecystectomy to treat a ruptured gallbladder mucocoele. Treatment and outcome Complete liver lobectomy of 14 lobes (11 from the left hepatic division) in 12 dogs and partial lobectomy of one lobe in one dog was performed via open laparotomy using the Endo GIA device. The mean surgical time, including concurrent procedures, was 50 (SD 17; median 45, min 28, max 91) minutes. The most common intra-operative complication was oozing from the transected liver parenchyma in 6/13 dogs, which was mild in all cases. Five dogs experienced minor post-operative complications. No major peri- or post-operative complications occurred, and no patients required surgical re-exploration. All patients survived until discharge and were alive at the 2-week follow-up for suture removal. Clinical relevance Use of the Endo GIA stapling device with a vascular cartridge is feasible for liver lobectomy of the left hepatic division and in this study had low rates of intra-operative and post-operative complications. The Endo GIA stapling device is a viable option for this type of liver lobectomy in dogs. Though successful, the small number of central (two lobes) and right (one lobe) hepatic division lobectomies in this study precludes us from drawing definitive conclusions about the feasibility of this technique on these divisions.

Response to: Comment on: Textbook Outcomes following Open Live Donor Right Hepatectomy and Open Right Hepatic Lobectomy for Cancer in 686 patients: Re-defining the Benchmark.

We read the letter to the editor by Liu et al regarding our recently published study on right hepatectomy (RH) textbook outcomes (TO) with great interest.1,2 We want to thank Liu et al for acknowledging our work and for their insightful comments, which we are hoping to address below. First, the authors mention that in their experience, “real-world” RH for cancer is more commonly performed for hepatocellular carcinoma (HCC), while in our study, the most common indication was colorectal cancer liver metastasis (CRLM) in 58.4% of patients. Consequently, we observed a low rate of cirrhosis (5.4%) in our RH population, whereas Liu et al argue that the rate of cirrhosis could be higher in their patient population where RH is more often performed for HCC. We acknowledge that liver resection is often performed for HCC in Eastern centers, but in Western countries CRLM remains the most common indication for liver resection, including RH.2–5 The authors point that the presence of cirrhosis could affect the patient’s ability to achieve a TO is well taken. In fact, this could be one of the reasons why we observed a much higher rate of TO (92.2%) in live donor patients, where the prevalence of cirrhosis was zero, compared to TO in cancer patients (53.7%), where cirrhosis was present in 5.4% of patients. Second, we agree with the authors that abnormal BMI, either too low, indicating malnutrition, or too high, indicating obesity, is an important marker of patient’s baseline health. Liu et al have previously published on the association of abnormal BMI with failure of TO after liver resection for HCC.6 Although, in our study, logistic regression did not reveal BMI to be associated with TO in either the cancer or the live donor patients, this could be due to fact that we analyzed BMI as a continuous variable. However, similar to the discussion about cirrhosis above, live donor patients had lower BMI on average compared cancer patients, and this difference could partially account for the higher TO rates in the live donor cohort. We certainly aim to investigate the association of BMI with TO rates in a more granular fashion in the future, by grouping BMI similarly to the methodology described by Liu et al. Third, the authors make the interesting suggestion of using advanced statistical methods, such as propensity score matching, to balance the baseline clinicopathologic factors of the cancer and live donor patients and then compare TO rates between the 2 groups. They argue that the baseline large differences in the 2 populations may not make direct TO comparisons statistically appropriate without matching. Although we definitely considered the above when designing our study, we decided that our main goal was to report on our entire and unedited experience with 686 RH patients over a decade and we did not want to exclude patients that could not be matched. Consequently, the data reported in our article represent true “real-world” TO rates after RH performed either for cancer or live donor purposes in a high-volume Western center. We acknowledge that the live donor group consisted of younger, healthier, and thinner patients, and we discuss how these factors likely contributed to the much higher TO rates in that group. However, we believe that this unique population of patients that underwent RH while otherwise healthy, gave us the opportunity to uncover the “best-achievable” TO results following this operation. In summary, we want to thank Liu et al for their thoughtful appraisal of our work and we are content that our study is generating productive discussion amongst liver surgeons with the ultimate goal of improving outcomes for our patients. Acknowledgments E.D., D.G., and A.H. contributed equally to this work.

Immunotherapy combined with chemotherapy in the treatment for rare primary mucoepidermoid carcinoma of the liver: a case report.

Primary mucoepidermoid carcinoma of the liver (PMCL) is rare in the hepatic system, with no standard treatment and poor prognosis with a median overall survival of only 120 days. PMCL with immunotherapy has not been reported yet. Here, we present a case of PMCL treated by immunotherapy and chemotherapy. A 64-year-old male with PMCL underwent partial right hepatectomy and liver lesion resection on 19 June 2020. Two months later, the chest computed tomography indicated the presence of multiple nodules in both lungs with higher tumor markers. Considering the presence of a tumor metastasis, the patient received four courses of immunotherapy plus mGEMOX chemotherapy from 8 September 2020. The patient tolerated the combined therapy well, with red moles on the face and chest which were considered as grade 1 reactive cutaneous capillary endothelial proliferation. He also had grade 2 thrombocytopenia and leucopenia after the first course of chemotherapy, but no neutropenia, fatigue, vomiting or diarrhea. However, his disease progressed. The patient refused further treatment and died on 20 April 2021. The overall survival time after diagnosis was 301 days. We describe here the first case report on immunotherapy treatment for PMCL. That suggested immunotherapy combined with chemotherapy may be an option after a hepatic lobectomy for PMCL.

Textbook Outcomes following Open Live Donor Right Hepatectomy and Open Right Hepatic Lobectomy for Cancer in 686 patients: Re-defining the Benchmark.

To compare textbook outcomes (TO) of open live donor right hepatectomy (RH) versus open right hepatic lobectomy for cancer in a single Western center, and to identify clinical factors associated with failure to achieve a TO. TO, a composite quality measure that captures multiple aspects of peri-operative care, has not been thoroughly studied in open RH. We hypothesized that TO rates after RH for live donor transplant could represent the "best-achievable" results of this operation and could serve as the benchmark for RH performed for an oncologic indication. A prospective database was reviewed to compare TO rates after RH for live donor purposes versus RH for cancer at a single center from 2010-2020. A TO was defined as achieving 7 metrics: no peri-operative transfusion, no major postoperative complications, no significant bile leak, no unplanned transfer to the ICU, no 30-day mortality, no 30-day re-admission, and no R1 margins for cancer cases. Amongst 686 RH patients (371 live donor and 315 cancer cases), a TO was achieved in 92.2% of RH donors and 53.7% of RH cancer cases. Live donor patients tended to be younger, healthier, and thinner. Amongst donors, increased intra-operative blood loss, and in cancer cases, male gender, tumor size, and increased intra-operative blood loss were associated with TO failure. A TO can be achieved in over 90% of patients undergoing living donor RH and in approximately half of RH cancer cases. These metrics represent a new benchmark for "real-world" TO after open RH.

RF17 | PSUN202 DICER1 Gene Mutation: Association With Thyroid Cancer and Other Endocrine Tumors

Abstract Introduction DICER1 syndrome is a rare autosomal dominant hereditary tumor predisposition syndrome and is known to have many endocrine manifestations. Case Description A 21-year-old female with DICER1 syndrome presented to the clinic to establish care. She had a significant family history of DICER1 mutation in her father and two siblings. She was diagnosed with malignant neuroepithelioma of the uterus at the age of 12 and was treated with cisplatin/cyclophosphamide. Hepatic embryonal rhabdomyosarcoma and pleuropulmonary blastoma type 1 were diagnosed at the age of 16 and she underwent hepatic lobectomy, left lower lung lobectomy, and received additional chemotherapy. She was first diagnosed with multiple thyroid nodules at the age of 14. Surveillance thyroid ultrasounds were performed biannually over the next 6 years. She also had multiple thyroid nodule FNAs, all showing benign results. Subsequently, CT chest revealed enlarging thyroid nodules with a chest wall lesion which prompted total thyroidectomy. Surgical pathology confirmed a 0.5 cm papillary thyroid carcinoma involving the left superior thyroid lobe; there was no lymph node involvement or extrathyroidal invasion and the surgical margins were intact. Surveillance ultrasounds have not shown any residual or recurrent disease. Excision of chest wall lesion showed nodular epithelia proliferation with rare eccrine duct present in the margin. She also suffered from secondary amenorrhea from chemotherapy induced ovarian failure. She was started on estrogen patch and cyclical progesterone therapy, following which menstrual cycles resumed. Discussion DICER1 encodes an Rnase III endonuclease that processes miRNA precursor hairpins into mature miRNAs. miRNA-mediated effects that lead to this syndrome is due to loss-of-function in tumor suppressor genes or gain of function in oncogenes. This predisposes patients to a variety of different tumors, including many endocrine tumors. Multiple thyroid nodules, as was seen in our patient, is a common finding in individuals with DICER1 syndrome. Rates of thyroid cancer are 10–20% higher in these patients. Follicular variant of papillary cancer and follicular thyroid cancer are the most common histologies seen. Thyroid cancer in these patients usually follows an indolent course with thyroidectomy typically curative. For screening of thyroid cancer, recommendations include annual thyroid examination, with some authors advocating for thyroid ultrasounds starting at the age 8, with repeated scans every 3 years if normal. Other endocrine tumors that are associated with DICER1 mutations include pituitary blastomas and pineoblastoma. Patients with pituitary blastomas may present with features of Cushing disease with elevated ACTH. Pineoblastoma can be detected with surveillance brain MRI, but routine screening for these tumors is not currently recommended as these tumors are rare, even within this syndrome. References Endocr Relat Cancer. 2018 Mar;25(3): R197-R208. Presentation: Sunday, June 12, 2022 12:48 p.m. - 12:53 p.m.

Inefficiency of Care in the Hub-and-Spoke System

INTRODUCTION: Complex surgical care is often centralized at one high volume hospital within a system, commonly referred to as the hub. We hypothesized that the potential performance advantages of hub hospitals seen for complex operations would not extend to common operations. METHODS: Using the Healthcare Cost and Utilization Project’s State Inpatient Databases, adult surgical patients who underwent one of 10 general surgery operations in 13 geographically diverse states (2016 to 2018) were identified. System status was assigned using the American Hospital Association survey. Hub designation was assigned to the hospital performing the greatest number of each specific operation. Multivariable logistic regression was used to evaluate the risk-adjusted odds of death or serious morbidity (DSM) and prolonged length of stay (LOS) at hub hospitals relative to other system hospitals (spokes), stratified by operation complexity. RESULTS: A total of 128,248 patients across 44 hub-and-spoke systems, including 133 hospitals were included, and 77.9% of complex and 61.6% of common operations occurred at a hub. Overall, 22.2% of patients experienced prolonged LOS and 12.8% experienced DSM. For complex operations, risk-adjusted odds of DSM were significantly lower in hubs. For common operations, risk-adjusted odds of DSM were similar between hubs and spokes while the odds of prolonged length of stay were greater at hubs (Table). CONCLUSION: The DSM benefit of hub hospitals for complex operations did not extend to common operations. Instead, patients undergoing common operations at hub hospitals had similar rate of DSM with higher rate of prolonged LOS. This finding shows a clear opportunity for improved system efficiency. Table. - Risk-Adjusted Outcomes of Common and Complex Operations at Hub Hospitals (Reference = Spokes) Variable Death or serious morbidity for common operations Prolonged length of stay for common operations Death or serious morbidity for complex operations Prolonged length of stay for complex operations Observations (n) 118,764 118,762 9,484 9,483 Hub hospitals odds ratio 1.01 1.08* 0.84* 1.06 Confidence interval (0.97, 1.05) (1.05, 1.12) (0.72, 0.97) (0.93, 1.20) *Significance at the p < 0.05 level.Model covariates include race, age, gender, income quartile, insurance type, state, admission status, and operation type. Common operations include cholecystectomy, inguinal hernia repair, mastectomy, colon resection, and small bowel resection. Complex operations include total gastrectomy, Whipple, hepatic lobectomy, esophagectomy, and rectal resection.