Bridging the gap: assessing the integration of robotic-assisted surgery into Canadian surgical training programs.

SummaryThe adoption of robotic surgery has surged globally across multiple surgical specialties, but uptake in Canada has unfolded at a slower pace. Surgical educators and trainees in Canada face potential challenges related to sufficient exposure, experience, and competence in robotic surgical procedures. We conducted a cross-sectional national survey to gain insight into the perspectives of program directors overseeing general surgery residency and fellowship programs on the integration of robotic surgery into Canadian surgical training programs. Despite the presence of robotic surgery platforms at most academic and academic-affiliated hospitals, few trainees have exposure to any robotic surgery. Furthermore, a gap exists between the training provided in robotic surgery and its anticipated relevance to trainees upon graduation. Increased focus on the integration of robotic surgery within general surgical training in Canada is required to equip trainees for their careers.

The Effect of Cryotherapy Application on Postoperative Pain: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review and meta-analyze whether the application of cryotherapy on closed incisions reduces postoperative pain and opioid consumption. BACKGROUND: Reduction of acute pain and opioid use is important in the postoperative phase of patient care. ''Cryotherapy'' refers to the use of low temperatures for therapeutic purposes. METHODS: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Online registries of clinical trial were search until October 2019. RCT that examined postoperative application of cryotherapy over surgical incisions in adults compared to no cryotherapy were eligible. Selection, extraction, and risk of bias appraisal were completed in duplicate. Data were synthesized using random effects meta-analyses. The outcomes of interest were postoperative pain, opioid use, hospital length of stay (LOS) and surgical site infection (SSI). RESULTS: Fifty-one RCTs (N = 3425 patients) were included. With moderate certainty evidence, patients treated with cryotherapy experienced a reduction in pain on postoperative day 1 (standardized mean differences -0.50, 95% CI -0.71 to -0.29, l 2= 74%) and day 2 (standardized mean differences -0.63, 95% CI -0.91 to -0.35, I 2 = 83%) relative to without cryotherapy application. With moderate certainty of evidence, cryotherapy reduces opioid consumption in morphine milliequivalents and morphine milliequivalents/kg, (mean differences -7.43, 95% CI -12.42, -2.44, I 2 = 96%) and (mean differences -0.89, 95% CI -1.45, -0.33, I 2 = 99%), respectively. With low certainty evidence, cryotherapy does not affect hospital LOS or rate of SSI. CONCLUSION: Cryotherapy is a pragmatic, noncostly intervention that reduces postoperative pain and opioid consumption with no effect on SSI rate or hospital LOS.

Incidence of Cirrhosis Among Recent Immigrants and Refugees to Ontario, Canada.

The epidemiology of cirrhosis among immigrants to North America has not been described. Using population-level data from Ontario, Canada, recent immigrant and refugees with incident cirrhosis were identified and stratified by World Bank region of origin and cirrhosis etiology. Incidence rates were described based on region of origin and etiology and compared with those in Canadian-born/long-term residents. A total of 25,054 immigrants/refugees were identified with rates of cirrhosis lower compared with those in Canadian-born/long-term residents for all etiologies except hepatitis B virus likely explained by the healthy immigrant effect. Nonalcoholic fatty liver disease was the most common etiology of cirrhosis among immigrants and refugees.

Association between social determinants of health and rates of liver transplantation in individuals with cirrhosis.

BACKGROUND AND AIMS: This study evaluated the association between neighborhood-level social determinants of health (SDOH) and liver transplantation (LT) among patients with cirrhosis who have universal access to health care. APPROACH AND RESULTS: This was a retrospective population-based cohort study from 2000-2019 using administrative health care data from Ontario, Canada. Adults aged 18-70 years with newly decompensated cirrhosis and/or HCC were identified using validated coding. The associations between five neighborhood level SDOH quintiles and LT were assessed with multivariate Fine-Gray competing risks regression to generate subdistribution HRs (sHRs) where death competes with LT. Overall, n = 38,719 individuals formed the cohort (median age 57 years, 67% male), and n = 2788 (7%) received LT after a median of 23 months (interquartile range 3-68). Due to an interaction, results were stratified by sex. After multivariable regression and comparing those in the lowest versus highest quintiles, individuals living in the most materially resource-deprived areas (female sHR, 0.61; 95% CI, 0.49-0.76; male sHR, 0.55; 95% CI, 0.48-0.64), most residentially unstable neighborhoods (female sHR, 0.61; 95% CI, 0.49-0.75; male sHR, 0.56; 95% CI, 0.49-0.65), and lowest-income neighborhoods (female sHR, 0.57; 95% CI, 0.46-0.7; male sHR, 0.58; 95% CI, 0.50-0.67) had ~40% reduced subhazard for LT (p < 0.01 for all). No associations were found between neighborhoods with the most diverse immigrant or racial minority populations or age and labor force quintiles and LT. CONCLUSIONS: This information highlights an urgent need to evaluate how SDOH influence rates of LT, with the overarching goal to develop strategies to overcome inequalities.

Association of Viral Hepatitis Status and Post-hepatectomy Outcomes in the Era of Direct-Acting Antivirals.

BACKGROUND: The role of viral hepatitis status in post-hepatectomy outcomes has yet to be delineated. This large, multicentred contemporary study aimed to evaluate the effect of viral hepatitis status on 30-day post-hepatectomy complications in patients treated for hepatocellular carcinoma (HCC). METHODS: Patients from the National Surgical Quality Improvement Program (NSQIP) database with known viral hepatitis status, who underwent hepatectomy for HCC between 2014 and 2018, were included. Patients were classified as HBV-only, HCV-only, HBV and HCV co-infection (HBV/HCV), or no viral hepatitis (NV). Multivariable models were used to assess outcomes of interest. The primary outcome was any 30-day post-hepatectomy complication. The secondary outcomes were major complications and post-hepatectomy liver failure (PHLF). Subgroup analyses were performed for cirrhotic and noncirrhotic patients. RESULTS: A total of 3234 patients were included. The 30-day complication rate was 207/663 (31.2%) HBV, 356/1077 (33.1%) HCV, 29/81 (35.8%) HBV/HCV, and 534/1413 (37.8%) NV (p = 0.01). On adjusted analysis, viral hepatitis status was not associated with occurrence of any 30-day post-hepatectomy complications (ref: NV, HBV odds ratio (OR) 0.89 [95% confidence interval (CI): 0.71-1.12]; HCV OR 0.91 [95% CI: 0.75-1.10]; HBV/HCV OR 1.17 [95% CI: 0.71-1.93]). Similar results were found in cirrhotic and noncirrhotic subgroups, and for secondary outcomes: occurrence of any major complications and PHLF. CONCLUSIONS: In patients with HCC managed with resection, viral hepatitis status is not associated with 30-day post-hepatectomy complications, major complications, or PHLF compared with NV. This suggests that clinical decisions and prognostication of 30-day outcomes in this population likely should not be made based on viral hepatitis status.

The evolving use of robotic surgery: a population-based analysis.

INTRODUCTION: Robotic surgery has integrated into the healthcare system despite limited evidence demonstrating its clinical benefit. Our objectives were (i) to describe secular trends and (ii) patient- and system-level determinants of the receipt of robotic as compared to open or laparoscopic surgery. METHODS: This population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent one of four commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy, partial nephrectomy. Patients were categorized based on the surgical approach as robotic, open, or laparoscopic for each procedure. Multivariable regression models were used to estimate the temporal trend in robotic surgery use and associations of patient and system characteristics with the surgical approach. RESULTS: The cohort included 24,741 radical prostatectomy, 75,473 total hysterectomy, 18,252 thoracic lobectomy, and 4608 partial nephrectomy patients, of which 6.21% were robotic. After adjusting for patient and system characteristics, the rate of robotic surgery increased by 24% annually (RR 1.24, 95%CI 1.13-1.35): 13% (RR 1.13, 95%CI 1.11-1.16) for robotic radical prostatectomy, 9% (RR 1.09, 95%CI 1.05-1.13) for robotic total hysterectomy, 26% (RR 1.26, 95%CI 1.06-1.50) for thoracic lobectomy and 26% (RR 1.26, 95%CI 1.13-1.40) for partial nephrectomy. Lower comorbidity burden, earlier disease stage (among cancer cases), and early career surgeons with high case volume at a teaching hospital were consistently associated with the receipt of robotic surgery. CONCLUSION: The use of robotic surgery has increased. The study of the real-world clinical outcomes and associated costs is needed before further expanding use among additional providers and hospitals.

Implementation of Critical Care Response Teams in Ontario: Impact on the Outcomes of Surgical Patients.

OBJECTIVE: To evaluate whether introduction of CCRTs reduced mortality rates among patients who developed a postoperative complication, also referred to as FTR. BACKGROUND: CCRTs were introduced to improve patients' postoperative outcomes. Its effect on FTR continues to be actively investigated. METHODS: We conducted a population-based retrospective cohort study using administrative data from Ontario, Canada. We identified 810,279 patients admitted to hospital for major surgical procedures between January 2004 and December 2014, with a washout period consisting of the 9 months before and after the implementation of CCRTs in January 2007. Difference-in-differences analysis among patients who developed a postoperative complication (n = 148,882) was used to estimate the association between CCRT implementation and FTR before and after CCRT implementation in hospitals that did - versus did not - implement CCRT during the study period. RESULTS: A total of 810,279 patients were included, of whom 148,882 (18.4%) developed a postoperative surgical complication. Among patients who developed a postoperative complication, the overall proportion of FTR was 9.2% (n = 13,659). Among patients in hospitals that introduced CCRT, the RR of FTR was 0.84, [95% confidence interval (CI) 0.78-0.90] after implementation of CCRT, while over the same time period, the RR was 0.85 (95% CI 0.80-0.91) in hospitals that did not implement CCRT. The RR ratio (difference-indifferences) was 0.99 (95% CI 0.89-1.09). Among patients undergoing orthopedic surgery, the RR ratio was 0.84 (95% CI 0.75-0.95). CONCLUSION: Although implementation of CCRTs in hospitals in Ontario, Canada, did not reduce FTR among all surgical patients having surgery, CCRTs may reduce the risk of FTR among patients having orthopedic surgery.

Adverse events following robotic surgery: population-based analysis.

BACKGROUND: Robotic surgery was integrated into some healthcare systems despite there being few well designed, real-world studies on safety or benefit. This study compared the safety of robotic with laparoscopic, thoracoscopic, and open approaches in common robotic procedures. METHODS: This was a population-based, retrospective study of all adults who underwent prostatectomy, hysterectomy, pulmonary lobectomy, or partial nephrectomy in Ontario, Canada, between 2008 and 2018. The primary outcome was 90-day total adverse events using propensity score overlap weights, and secondary outcomes were minor or major morbidity/adverse events. RESULTS: Data on 24 741 prostatectomy, 75 473 hysterectomy, 18 252 pulmonary lobectomy, and 6608 partial nephrectomy operations were included. Relative risks for total adverse events in robotic compared with open surgery were 0.80 (95 per cent c.i. 0.74 to 0.87) for radical prostatectomy, 0.44 (0.37 to 0.52) for hysterectomy, 0.53 (0.44 to 0.65) for pulmonary lobectomy, and 0.72 (0.54 to 0.97) for partial nephrectomy. Relative risks for total adverse events in robotic surgery compared with a laparoscopic/thoracoscopic approach were 0.94 (0.77 to 1.15), 1.00 (0.82 to 1.23), 1.01 (0.84 to 1.21), and 1.23 (0.82 to 1.84) respectively. CONCLUSION: The robotic approach is associated with fewer adverse events than an open approach but similar to a laparoscopic/thoracoscopic approach. The benefit of the robotic approach is related to the minimally-invasive approach rather than the platform itself.

Cost-Effectiveness Analysis of Negative Pressure Wound Therapy to Prevent Surgical Site Infection After Elective Colorectal Surgery.

BACKGROUND: Surgical site infection is common after colorectal surgery and is associated with increased costs. Prophylactic negative pressure wound therapy has previously been shown to reduce surgical site infection compared with conventional dressings. However, negative pressure wound therapy application is met with hesitancy because of its additional cost. OBJECTIVE: This study aims to determine whether the application of prophylactic negative pressure wound therapy after elective colorectal surgery is cost-effective. DESIGN: A cost-effectiveness analysis comparing prophylactic negative pressure wound therapy versus conventional dressing was completed using a Markov microsimulation model. A publicly funded single health care payer perspective was adopted across a lifetime horizon. SETTING: This study was conducted using in-hospital elective colorectal surgery. PATIENTS: The base case was an age-, sex-, and comorbidity-standardized patient undergoing open elective colorectal surgery. INTERVENTION: Negative pressure wound therapy was applied postoperatively over closed incisions. MAIN OUTCOMES: The primary outcomes of interest were the number of surgical site infections, total costs, and quality-adjusted life-years gained. Secondary outcomes included emergency department presentation, hospital readmission, nursing wound care utilization, fascial dehiscence, incisional hernia, and non-surgical site infection-related complications. RESULTS: We found that prophylactic negative pressure wound therapy, standardized to 1000 patients, prevented 51 surgical site infections, 3 fascial dehiscences, 10 incisional hernias, 22 emergency department presentations, and 6 hospital readmissions. This resulted in a total cost saving of $17,066 and 92.2 quality-adjusted life-years gained ($17.07 and 0.09 quality-adjusted life-years gained on average per patient). When the patients' risk of surgical site infections was greater than 3.2%, negative pressure wound therapy was a cost-effective strategy at a willingness to pay of $50,000/quality-adjusted life-years. LIMITATIONS: We did not model for societal perspective, emergent presentations of incarcerated hernias, or complications with hernia repair. The results of this model are reliant on the published negative pressure wound therapy efficacy and may change when additional data arise. CONCLUSION: The use of negative pressure wound therapy is the dominant strategy with improved outcomes and reduced costs compared with conventional dressing in patients undergoing colorectal surgery, particularly in at-risk patients. See Video Abstract at http://links.lww.com/DCR/B782. ANLISIS DE RENTABILIDAD DE LA TERAPIA DE PRESIN NEGATIVA PARA PREVENIR INFECCIN DEL SITIO QUIRRGICO DESPUS DE CIRUGA COLORRECTAL ELECTIVA: ANTECEDENTES:La infección del sitio quirúrgico es común después de la cirugía colorrectal y se asocia con un aumento de los costos. Anteriormente se demostró que la terapia profiláctica con presión negativa reduce la infección del sitio quirúrgico en comparación con los apósitos convencionales. Sin embargo, el uso de la terapia de presión negativa se encuentra en dudas debido a su costo adicional.OBJETIVO:Determinar si la aplicación de la terapia profiláctic con presión negativa después de la cirugía colorrectal electiva es rentable.DISEÑO:Se completó un análisis de costo-efectividad comparando la terapia profiláctica con presión negativa versus apósito convencional utilizando un modelo de microsimulación de Markov. Se adoptó una perspectiva de pagador único de asistencia sanitaria financiada con fondos públicos a lo largo de toda la vida.AJUSTE:Cirugía colorrectal electiva intrahospitalaria.PACIENTES:El caso base fue un paciente estandarizado por edad, sexo y comorbilidad sometido a cirugía colorrectal abierta electiva.INTERVENCIÓN:Aplicación postoperatoria de terapia de presión negativa sobre incisiones cerradas.RESULTADOS PRINCIPALES:Los resultados primarios de interés fueron el número de infecciones del sitio quirúrgico, los costos totales y los años de vida ganados ajustados por calidad. Los resultados secundarios incluyeron presentación en la sala de emergencias, reingreso al hospital, la utilización del cuidado de heridas por enfermería, dehiscencia fascial, hernia incisional y complicaciones relacionadas con infecciones del sitio no quirúrgico.RESULTADOS:Estandarizado para 1,000 pacientes, encontramos que la terapia profiláctica con presión negativa previno 51 infecciones del sitio quirúrgico, 3 dehiscencias fasciales, 10 hernias incisionales, 22 presentaciones en la sala de emergencias y 6 reingresos al hospital. Esto resultó en un ahorro total de costos de $ 17.066 y 92.2 años de vida ganados ajustados por calidad ($ 17.07 y 0.09 años de vida ganados ajustados por calidad en promedio por paciente). Cuando el riesgo de infección del sitio quirúrgico de los pacientes era superior al 3,2%, la terapia de presión negativa era una estrategia rentable con una disposición a pagar de 50.000 dólares por años de vida ajustados por calidad.LIMITACIONES:No modelamos para la perspectiva social, presentaciones emergentes de hernias encarceladas o complicaciones con la reparación de hernias. Los resultados de este modelo dependen de la eficacia publicada de la terapia de presión negativa y pueden cambiar cuando surjan más datos.CONCLUSIONES:El uso de la terapia de presión negativa es la estrategia dominante con mejores resultados y costos reducidos en comparación con el apósito convencional en pacientes sometidos a cirugía colorrectal, particularmente en pacientes de riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B782. (Traducción- Dr. Francisco M. Abarca-Rendon).

Fear of innovation: public's perception of robotic surgery.

BACKGROUND: Robotic surgery is used in several surgical procedures with limited evidence of clinical benefit. In some jurisdictions, the demand for robotic surgery may have been fueled by public perception of this novel technology. Therefore, we sought to investigate the public's perception of robotic surgery. STUDY DESIGN: We conducted a cross-sectional survey using a series of vignette-associated questions designed to examine the public's perception of robotic surgery. Eligible participants were recruited through Amazon Mechanical Turk's system and randomized to one of two pairs of vignettes: laparoscopic surgery compared to (1) robotic surgery, or (2) "novel surgical technology" (without using the term "robotic"). Outcomes of interest were anticipated postoperative outcomes using the surgical fear questionnaire, procedure preference, perception of error, trust, and competency of the surgeon. RESULTS: The survey included 362 respondents; 64.1% were male with median age of 53 years. There were no differences in the distribution of responses of the questionnaire based on use of the term "robotic" or "novel surgical technology"; therefore, the two cohorts were combined to examine perception of robotic compared to laparoscopic surgery. More respondents feared outcomes of robotic surgery than laparoscopic surgery (78.2% vs 14.9%, p < 0.001). Participants preferred laparoscopic to robotic surgery (64.4% vs 35.6%, p < 0.001). CONCLUSION: The public fears recovery after robotic surgery and prefers laparoscopic surgery. The propagation of robotic surgery is unlikely based on public demand and may be more related to institutional or surgeon perceptions. Surgeons who provide robotic surgery should ensure their patients are comfortable with and understand this technology.

The effect of perioperative packed red blood cells transfusion on patient outcomes after liver transplant for hepatocellular carcinoma.

BACKGROUND: The impact of packed Red Blood Cell (pRBC) transfusion on oncological outcomes after liver transplantation (LT) for Hepatocellular Carcinoma (HCC) remains controversial. We evaluated the impact of pRBC transfusion on HCC recurrence and overall survival (OS) after LT for HCC. METHODS: Patients with HCC transplanted between 2000 and 2018 were included and stratified by receipt of pRBC transfusion. Outcomes were HCC recurrence and OS. Propensity score matching was performed to account for confounders. RESULTS: Of the 795 patients, 234 (29.4%) did not receive pRBC transfusion. After matching the 1-, 3-, and 5-year cumulative incidence of recurrence was 6.6%, 12.5% and 14.8% for no-pRBC transfusion, and 8.6%, 18.8% and 21.3% (p = 0.61) for pRBC transfusion. The OS at 1-, 3-, 5-year was 93.0%, 84.6% and 75.8% vs 92.0%, 79.7% and 73.5% (p = 0.83) for no-pRBC transfusion and pRBC transfusion, respectively. There were no differences in recurrence (HR 1.13, 95%CI 0.71-1.78, p = 0.61) or OS (HR 1.04, 95%CI 0.71-1.54, p = 0.83). CONCLUSION: Perioperative administration of pRBC in liver transplant recipients for HCC resulted in a nonsignificant increase of HCC recurrence and death after accounting for confounder. Surgeons should continue to exercise cation and optimize patients iron stores medically preoperatively.

Clinical Outcomes of Robotic Surgery Compared to Conventional Surgical Approaches (Laparoscopic or Open): A Systematic Overview of Reviews.

OBJECTIVE: Describe clinical outcomes (eg, postoperative complications, survival) after robotic surgery compared to open or laparoscopic surgery. BACKGROUND: Robotic surgery utilization has increased over the years across a wide range of surgical procedures. However, evidence supporting improved clinical outcomes after robotic surgery is limited. METHODS: We systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of systematic reviews from inception to January 2019 for systematic reviews describing postoperative outcomes after robotic surgery. We qualitatively described patient outcomes of commonly performed robotic procedures: radical prostatectomy, hysterectomy, lobectomy, thymectomy, rectal resection, partial nephrectomy, distal gastrectomy, Roux-en-Y gastric bypass, hepatectomy, distal pancreatectomy, and cholecystectomy. RESULTS: One hundred fifty-four systematic reviews included 336 studies and 18 randomized controlled trials reporting on patient outcomes after robotic compared to laparoscopic or open procedures. Data from the randomized controlled trials demonstrate that robotic-assisted radical prostatectomy offered fewer biochemical recurrence and improvement in quality of recovery and pain scores only up to 6 weeks postoperatively compared to open radical prostatectomy. When compared to laparoscopic prostatectomy, robotic surgery offered improved urinary and sexual functions. Robotic surgery for endometrial cancer had fewer conversion to open compared to laparoscopic. Otherwise, robotic surgery outcomes were similar to conventional surgical approaches for other procedures except for radical hysterectomy where minimally invasive approaches may result in patient harm compared to open approach. CONCLUSION: Robotic surgery has been widely incorporated into practise despite limited supporting evidence. More rigorous research focused on patient-important benefits is needed before further expansion of robotic surgery.

Blood Cell Salvage and Autotransfusion Does Not Worsen Oncologic Outcomes Following Liver Transplantation with Incidental Hepatocellular Carcinoma: A Propensity Score-Matched Analysis.

BACKGROUND: Intraoperative blood cell salvage and autotransfusion (IBSA) during liver transplantation (LT) for hepatocellular carcinoma (HCC) is controversial for concern regarding adversely impacting oncologic outcomes. OBJECTIVE: We aimed to evaluate the long-term oncologic outcomes of patients who underwent LT with incidentally discovered HCC who received IBSA compared with those who did not receive IBSA. METHODS: Patients undergoing LT (January 2001-October 2018) with incidental HCC on explant pathology were retrospectively identified. A 1:1 propensity score matching (PSM) was performed. HCC recurrence and patient survival were compared. Kaplan-Meier survival analyses were performed, and univariable Cox proportional hazard analyses were performed for risks of recurrence and death. RESULTS: Overall, 110 patients were identified (IBSA, n = 76 [69.1%]; non-IBSA, n = 34 [30.9%]). Before matching, the groups were similar in terms of demographics, transplant, and tumor characteristics. Overall survival was similar for IBSA and non-IBSA at 1, 3, and 5 years (96.0%, 88.4%, 83.0% vs. 97.1%, 91.1%, 87.8%, respectively; p = 0.79). Similarly, the recurrence rate at 1, 3, and 5 years was not statistically different (IBSA 0%, 1.8%, 1.8% vs. non-IBSA 0%, 3.2%, 3.2%, respectively; p = 0.55). After 1:1 matching (26 IBSA, 26 non-IBSA), Cox proportional hazard analysis demonstrated similar risk of death and recurrence between the groups (IBSA hazard ratio [HR] of death 1.26, 95% confidence interval [CI] 0.52-3.05, p = 0.61; and HR of recurrence 2.64, 95% CI 0.28-25.30, p = 0.40). CONCLUSIONS: IBSA does not appear to adversely impact oncologic outcomes in patients undergoing LT with incidental HCC. This evidence further supports the need for randomized trials evaluating the impact of IBSA use in LT for HCC.

When is a Ghost Really Gone? A Systematic Review and Meta-analysis of the Accuracy of Imaging Modalities to Predict Complete Pathological Response of Colorectal Cancer Liver Metastases After Chemotherapy.

BACKGROUND: Administration of chemotherapy to patients with colorectal liver metastases may result in disappearing liver metastases (DLM). This poses a therapeutic dilemma due to the uncertainty of true complete (pathological) response. OBJECTIVE: We aimed to examine the diagnostic performance of imaging modalities in detecting true complete response in patients with DLM after chemotherapy. METHODS: We performed a systematic search for articles assessing the diagnostic performance of imaging modalities in evaluating DLM following chemotherapy. True complete response was defined as 1-year recurrence-free survival in non-resected patients or complete pathological response on histologic examination in resected patients. We calculated the negative predictive value (NPV) for detecting true complete response of each imaging modality using a random effects model. RESULTS: Thirteen studies comprising 332 patients with at least one DLM were included. The number of DLMs after chemotherapy was 955 with computed tomography (CT), 104 with positron emission tomography (PET), 50 with intraoperative ultrasound (IOUS), 585 with magnetic resonance imaging (MRI), and 175 with contrast-enhanced IOUS (CEIOUS). Substantial variation in study design, patient characteristics, and imaging features was observed. Pooled NPV was 0.79 (95% confidence interval [CI] 0.53-0.96), 0.73 (95% CI 0.58-0.85), 0.54 (95% CI 0.37-0.7), 0.47 (95% CI 0.34-0.61), and 0.22 (95% CI 0.11-0.39) for CEIOUS, MRI, IOUS, CT, and PET, respectively. CONCLUSION: After chemotherapy, MRI or CEIOUS are the most accurate imaging modalities for assessment of DLM and should be used routinely in this context. Given the high NPV of these two modalities, surgical resection of visible CRLM is warranted if technically possible, even if DLM remain.

Safety and feasibility of initiating a hepatic artery infusion pump chemotherapy program for unresectable colorectal liver metastases: A multicenter, retrospective cohort study.

INTRODUCTION: Hepatic artery infusion pump (HAIP) chemotherapy is a specialized therapy for patients with unresectable colorectal liver metastases (uCRLM). Its effectiveness was demonstrated from a high volume center, with uncertainty regarding the feasibility and safety at other centers. Therefore, we sought to assess the safety and feasibility of HAIP for the management of uCRLM at other centers. METHODS: We conducted a multicenter retrospective cohort study of patients with uCRLM treated with HAIP from January 2003 to December 2017 at six North American centers initiating the HAIP program. Outcomes included the safety and feasibility of HAIP chemotherapy. RESULTS: We identified 154 patients with HAIP insertion and the median age of 54 (48-61) years. The burden of disease was >10 intra-hepatic metastatic foci in 59 (38.3%) patients. Patients received at least one cycle of systemic chemotherapy before HAIP insertion. Major complications occurred in 7 (4.6%) patients during their hospitalization and 13 (8.4%) patients developed biliary sclerosis during follow-up. A total of 148 patients (96.1%) received at least one-dose of HAIP chemotherapy with a median of 5 (4-7) cycles. 78 patients (56.5%) had a complete or partial response and 12 (7.8%) received a curative liver resection. CONCLUSION: HAIP programs can be safely and effectively initiated in previously inexperienced centers with good response.

Trends in indications and outcomes of liver transplantation in Canada: A multicenter retrospective study.

The liver transplantation (LT) landscape is continuously evolving. We sought to evaluate trends in indications for LT in Canada and the impact of primary liver disease on post-LT outcomes using a national transplant registry. Adult patients who underwent a primary LT between 2000 and 2018 were retrospectively identified in the Canadian Organ Replacement Registry. Outcomes included post-LT patient and graft survival. A total of 5,722 LTs were identified. The number of LT per year increased from 251 in 2000 to 349 in 2018. The proportion of patients transplanted for HCV decreased from 31.5% in 2000 to 3.4% in 2018. In contrast, the percentage of transplants for HCC increased from 2.3% in 2000 to 32.4% in 2018, and those performed for NASH increased from 0.4% in 2005 to 12.6% in 2018. Year of transplant (per 1 year) was protective for both patient (HR:0.96,95%CI:0.94-0.97; P < 0.001) and graft survival (HR:0.97, 95%CI: 0.96-0.99; P = 0.001). Post-LT outcomes have improved over time in this nationwide analysis spanning 18 years. Moreover, trends in the indications for LT have changed, with HCC becoming the leading etiology. The decrease in the proportion of HCV patients and increase in those with NASH has implications on the evolving management of LT patients.

Outcomes of radiofrequency ablation as first-line therapy for hepatocellular carcinoma less than 3 cm in potentially transplantable patients.

BACKGROUND & AIMS: Radiofrequency ablation (RFA) is an effective treatment for single hepatocellular carcinoma (HCC) ≤3 cm. Disease recurrence is common, and in some patients will occur outside transplant criteria. We aimed to assess the incidence and risk factors for recurrence beyond Milan criteria in potentially transplantable patients treated with RFA as first-line therapy. METHODS: We performed a retrospective cohort study of potentially transplantable patients with new diagnoses of unifocal HCC ≤3 cm that underwent RFA as first-line therapy between 2000-2015. We defined potentially transplantable patients as those aged <70 years without any comorbidities that would preclude transplant surgery. Incidence of recurrence beyond Milan criteria was compared across 2 groups according to HCC diameter at the time of ablation: (HCC ≤2 cm vs. HCC >2 cm). Competing risks Cox regression was used to identify predictors of recurrence beyond Milan criteria. RESULTS: We included 301 patients (167 HCC ≤2 cm and 134 HCC >2 cm). Recurrence beyond Milan criteria occurred in 36 (21.6%) and 47 (35.1%) patients in the HCC ≤2 cm and the HCC >2 cm groups, respectively (p = 0.01). The 1-, 3- and 5-year actuarial survival rates after RFA were 98.2%, 86.2% and 79.0% in the HCC ≤2 cm group vs. 93.3%, 77.6% and 70.9% in the HCC >2 cm group (p = 0.01). Tumor size >2 cm (hazard ratio 1.94; 95%CI 1.25-3.02) and alpha-fetoprotein levels at the time of ablation (100-1,000 ng/ml: hazard ratio 2.05; 95%CI 1.10-3.83) were found to be predictors of post-RFA recurrence outside Milan criteria. CONCLUSION: RFA for single HCC ≤3 cm provides excellent short- to medium-term survival. However, we identified patients at higher risk of recurrence beyond Milan criteria. For these patients, liver transplantation should be considered immediately after the first HCC recurrence following RFA. LAY SUMMARY: Radiofrequency ablation and liver transplantation are treatment options for early stages of hepatocellular carcinoma (HCC). After ablation some patients will experience recurrence or metastatic spread of the initial tumor or may develop new tumors within the liver. Despite close follow-up, these recurrences can progress rapidly and exceed transplant criteria, preventing the patient from receiving a transplant. We identified that patients with HCC >2 cm and higher serum alpha-fetoprotein are at greater risk of recurrence beyond the transplant criteria. These data suggest that liver transplantation should be considered immediately after the first HCC recurrence for these patients.

Liver Transplantation is Equally Effective as a Salvage Therapy for Patients with Hepatocellular Carcinoma Recurrence Following Radiofrequency Ablation or Liver Resection with Curative Intent.

BACKGROUND: Liver resection (LR) and radiofrequency ablation (RFA) are curative-intent therapies for early stages of hepatocellular carcinoma (HCC). If HCC recurs, salvage liver transplant (SLT) may constitute a treatment option. OBJECTIVE: We aimed to compare the outcomes of patients transplanted for recurrent HCC after curative-intent therapies with those transplanted as initial therapy. METHODS: We conducted a matched-control (1:1) cohort study comparing patients with HCC treated with primary liver transplant (PLT) with SLT after HCC recurrence. Matching was performed according to the size and number of viable tumors at explant pathology following liver transplant. RESULTS: Between November 1999 and December 2014, 687 patients with HCC were listed for transplant at our institution. A total of 559 patients were transplanted; 509 patients were treated with PLT and 50 patients were treated with SLT for HCC recurrence after primary treatment with LR (n = 25) or RFA (n = 25). The median length of follow-up from transplant was 64 months (0.5-195), and the median time from curative-intent treatment of HCC with RFA or LR to recurrence was 9.5 months (1-36) and 14.5 months (3-143), respectively (p = 0.04). The matched cohort was composed of 48 SLT patients (23 LR and 25 RFA) and 48 PLT patients. The 5-year risk of recurrence after LT was 22% in the PLT group versus 32% in the SLT group (p = 0.53), while the 5-year actuarial patient survival after PLT was 69% versus 70% in the SLT group (p = 1). CONCLUSION: Liver transplant is an effective treatment for patients with HCC recurrence following RFA or LR. Outcomes are similar in both groups.