Learning curve of radical hepatectomy in treating hepatic alveolar echinococcosis with vascular infiltration: a cumulative sum analysis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

PAN Yilin ¹ , PANG Huasheng ² ,  WANG Wentao ¹

1. Division of Liver Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. Tibet Center of Disease Control and Prevention, Lhasa 850000, P. R. China;

Corresponding author：

WANG Wentao, Email: wwtdoctor02@163.com

Keywords：

hepatic alveolar echinococcosis; liver resection; vascular reconstruction; bile duct reconstruction; cumulative sum analysis; risk-adjusted cumulative sum analysis

DOI：

10.7507/1007-9424.202402068

Video：

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Objectives To evaluate the learning curve of radical hepatectomy combined with vascular and/or bile duct reconstruction (RHVBR) in the treatment of hepatic alveolar echinococcosis (HAE), and to explore the feasibility and safety of RHVBR. Methods The clinical data of 203 patients who received RHVBR treatment for HAE complicated with vascular invasion in West China Hospital from 2010 to 2018 were analyzed retrospectively. Cumulative sum (CUSUM) and risk-adjusted cumulative sum (RA-CUSUM) were used to analyze the learning curve of RHVBR, determine the learning stage, and compare the differences of intraoperative and postoperative outcome indexes in different learning stages. Results The average operative time was (537.9±207.6) minutes, with blood loss amounted to 617.3 (138.9, 1 094.2) mL. Postoperative complications occurred in 65 cases, and the incidence of complications was 32.0%. Among them, 29 cases (14.3%) had serious complications. Three cases (1.5%) died within 90 days after operation. The results of RA-CUSUM analysis showed that 54 cases of surgery were the cut-off point of learning curve for serious postoperative complications. According to the results of CUSUM analysis, the whole queue was divided into the first stage (n=53) and the second stage (n=150) based on the completion of 53 operations. Compared with the first stage, the operative time and total postoperative hospital stay in the second stage was shortened, the incidence of serious complications was reduced, and the number of resected liver segments was increased. The differences were statistically significant (P<0.05). Conclusion It is feasible and safe to treat HAE with RHVBR, and the incidence of serious complications is obviously reduced after 54 cases of operation.

Citation： PAN Yilin, PANG Huasheng, WANG Wentao. Learning curve of radical hepatectomy in treating hepatic alveolar echinococcosis with vascular infiltration: a cumulative sum analysis. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2024, 31(12): 1474-1481. doi: 10.7507/1007-9424.202402068 Copy

1.	Siles-Lucas M, Casulli A, Conraths FJ, et al. Laboratory diagnosis of echinococcus spp. in Human Patients and Infected Animals. Adv Parasitol, 2017, 96: 159-257.
2.	Brunetti E, Kern P, Vuitton DA, et al. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop, 2010, 114(1): 1-16.
3.	Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group on Echinococcosis. Bulletin World Health Organ, 1996, 74(3): 231-242.
4.	McManus DP, Gray DJ, Zhang W, et al. Diagnosis, treatment, and management of echinococcosis. BMJ, 2012, 344: e3866. doi: 10.1136/bmj.e3866.
5.	Bresson-Hadni S, Koch S, Miguet JP, et al. Indications and results of liver transplantation for Echinococcus alveolar infection: an overview. Langenbecks Arch Surg, 2003, 388(4): 231-238.
6.	Du C, Liu Z, Yang X, et al. Hepatectomy for patients with alveolar echinococcosis: Long-term follow-up observations of 144 cases. Int J Surg, 2016, 35: 147-152.
7.	Kadry Z, Renner EC, Bachmann LM, et al. Evaluation of treatment and long-term follow-up in patients with hepatic alveolar echinococcosis. Br J Surg, 2005, 92(9): 1110-1116.
8.	Buttenschoen K, Gruener B, Carli Buttenschoen D, et al. Palliative operation for the treatment of alveolar echinococcosis. Langenbecks Arch Surg, 2009, 394(1): 199-204.
9.	Akbulut S, Sahin TT. Comment on surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients. Parasitology, 2020, 147(13): 1408-1410.
10.	Maimaitinijiati Y, AJi T, Jiang TM, et al. Approaches to reconstruction of inferior vena cava by ex vivo liver resection and autotransplantation in 114 patients with hepatic alveolar echinococcosis. World J Gastroenterol, 2022, 28(31): 4351-4362.
11.	Yang GJ, Liu L, Zhu HR, et al. China’s sustained drive to eliminate neglected tropical diseases. Lancet Infect Dis, 2014, 14(9): 881-892.
12.	Shen S, Kong J, Qiu Y, et al. Ex vivo liver resection and autotransplantation versus allotransplantation for end-stage hepatic alveolar echinococcosis. Int J Infect Dis, 2019, 79: 87-93.
13.	Yang X, Qiu Y, Huang B, et al. Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis: A study of 31 cases. Am J Transplant, 2018, 18(7): 1668-1679.
14.	Qiu Y, Huang B, Yang X, et al. Evaluating the benefits and risks of ex vivo liver resection and autotransplantation in treating hepatic end-stage alveolar echinococcosis. Clin Infect Dis, 2022, 75(8): 1289-1296.
15.	Kern P, Wen H, Sato N, et al. WHO classification of alveolar echinococcosis: principles and application. Parasitol Int, 2006, 55 Suppl: S283- S287. doi: 10.1016/j.parint.2005.11.041.
16.	He YB, Bai L, Aji T, et al. Application of 3D reconstruction for surgical treatment of hepatic alveolar echinococcosis. World J Gastroenterol, 2015, 21(35): 10200-10207.
17.	Shen S, Kong J, Zhao J, et al. Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion. HPB (Oxford), 2019, 21(9): 1219-1229.
18.	Ran B, Maimaitinijiati Y, Yasen A, et al. Feasibility of retrohepatic inferior vena cava resection without reconstruction for hepatic alveolar echinococcosis. Am Surg, 2021, 87(3): 443-449.
19.	Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg, 2009, 250(2): 187-196.
20.	Slankamenac K, Nederlof N, Pessaux P, et al. The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg, 2014, 260(5): 757-762.
21.	Working to overcome the global impact of neglected tropical diseases–Summary. Wkly Epidemiol Rec, 2011, 86(13): 113-120.
22.	Li T, Chen X, Zhen R, et al. Widespread co-endemicity of human cystic and alveolar echinococcosis on the eastern Tibetan Plateau, northwest Sichuan/southeast Qinghai, China. Acta Trop, 2010, 113(3): 248-256.
23.	Feng X, Qi X, Yang L, et al. Human cystic and alveolar echinococcosis in the Tibet Autonomous Region (TAR), China. J Helminthol, 2015, 89(6): 671-679.
24.	Kern P, Menezes da Silva A, Akhan O, et al. The echinococcoses: diagnosis, clinical management and burden of disease. Adv Parasitol, 2017, 96: 259-369.
25.	Chen KF, Tang YY, Wang R, et al. The choose of different surgical therapies of hepatic alveolar echinococcosis: A single-center retrospective case-control study. Medicine (Baltimore), 2018, 97(8): e0033. doi: 10.1097/MD.0000000000010033.
26.	李航, 滕飞, 孔庆研, 等. 保留肝后下腔静脉的在体肝切除术治疗侵犯下腔静脉的复杂泡型肝包虫病. 中国普外基础与临床杂志, 2022, 29(10): 1279-1283.
27.	Addeo P, Schaaf C, Noblet V, et al. The learning curve for piggyback liver transplantation: identifying factors challenging surgery. Surgery, 2021, 169(4): 974-982.

1. Siles-Lucas M, Casulli A, Conraths FJ, et al. Laboratory diagnosis of echinococcus spp. in Human Patients and Infected Animals. Adv Parasitol, 2017, 96: 159-257.
2. Brunetti E, Kern P, Vuitton DA, et al. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. Acta Trop, 2010, 114(1): 1-16.
3. Guidelines for treatment of cystic and alveolar echinococcosis in humans. WHO Informal Working Group on Echinococcosis. Bulletin World Health Organ, 1996, 74(3): 231-242.
4. McManus DP, Gray DJ, Zhang W, et al. Diagnosis, treatment, and management of echinococcosis. BMJ, 2012, 344: e3866. doi: 10.1136/bmj.e3866.
5. Bresson-Hadni S, Koch S, Miguet JP, et al. Indications and results of liver transplantation for Echinococcus alveolar infection: an overview. Langenbecks Arch Surg, 2003, 388(4): 231-238.
6. Du C, Liu Z, Yang X, et al. Hepatectomy for patients with alveolar echinococcosis: Long-term follow-up observations of 144 cases. Int J Surg, 2016, 35: 147-152.
7. Kadry Z, Renner EC, Bachmann LM, et al. Evaluation of treatment and long-term follow-up in patients with hepatic alveolar echinococcosis. Br J Surg, 2005, 92(9): 1110-1116.
8. Buttenschoen K, Gruener B, Carli Buttenschoen D, et al. Palliative operation for the treatment of alveolar echinococcosis. Langenbecks Arch Surg, 2009, 394(1): 199-204.
9. Akbulut S, Sahin TT. Comment on surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients. Parasitology, 2020, 147(13): 1408-1410.
10. Maimaitinijiati Y, AJi T, Jiang TM, et al. Approaches to reconstruction of inferior vena cava by ex vivo liver resection and autotransplantation in 114 patients with hepatic alveolar echinococcosis. World J Gastroenterol, 2022, 28(31): 4351-4362.
11. Yang GJ, Liu L, Zhu HR, et al. China’s sustained drive to eliminate neglected tropical diseases. Lancet Infect Dis, 2014, 14(9): 881-892.
12. Shen S, Kong J, Qiu Y, et al. Ex vivo liver resection and autotransplantation versus allotransplantation for end-stage hepatic alveolar echinococcosis. Int J Infect Dis, 2019, 79: 87-93.
13. Yang X, Qiu Y, Huang B, et al. Novel techniques and preliminary results of ex vivo liver resection and autotransplantation for end-stage hepatic alveolar echinococcosis: A study of 31 cases. Am J Transplant, 2018, 18(7): 1668-1679.
14. Qiu Y, Huang B, Yang X, et al. Evaluating the benefits and risks of ex vivo liver resection and autotransplantation in treating hepatic end-stage alveolar echinococcosis. Clin Infect Dis, 2022, 75(8): 1289-1296.
15. Kern P, Wen H, Sato N, et al. WHO classification of alveolar echinococcosis: principles and application. Parasitol Int, 2006, 55 Suppl: S283- S287. doi: 10.1016/j.parint.2005.11.041.
16. He YB, Bai L, Aji T, et al. Application of 3D reconstruction for surgical treatment of hepatic alveolar echinococcosis. World J Gastroenterol, 2015, 21(35): 10200-10207.
17. Shen S, Kong J, Zhao J, et al. Outcomes of different surgical resection techniques for end-stage hepatic alveolar echinococcosis with inferior vena cava invasion. HPB (Oxford), 2019, 21(9): 1219-1229.
18. Ran B, Maimaitinijiati Y, Yasen A, et al. Feasibility of retrohepatic inferior vena cava resection without reconstruction for hepatic alveolar echinococcosis. Am Surg, 2021, 87(3): 443-449.
19. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg, 2009, 250(2): 187-196.
20. Slankamenac K, Nederlof N, Pessaux P, et al. The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg, 2014, 260(5): 757-762.
21. Working to overcome the global impact of neglected tropical diseases–Summary. Wkly Epidemiol Rec, 2011, 86(13): 113-120.
22. Li T, Chen X, Zhen R, et al. Widespread co-endemicity of human cystic and alveolar echinococcosis on the eastern Tibetan Plateau, northwest Sichuan/southeast Qinghai, China. Acta Trop, 2010, 113(3): 248-256.
23. Feng X, Qi X, Yang L, et al. Human cystic and alveolar echinococcosis in the Tibet Autonomous Region (TAR), China. J Helminthol, 2015, 89(6): 671-679.
24. Kern P, Menezes da Silva A, Akhan O, et al. The echinococcoses: diagnosis, clinical management and burden of disease. Adv Parasitol, 2017, 96: 259-369.
25. Chen KF, Tang YY, Wang R, et al. The choose of different surgical therapies of hepatic alveolar echinococcosis: A single-center retrospective case-control study. Medicine (Baltimore), 2018, 97(8): e0033. doi: 10.1097/MD.0000000000010033.
26. 李航, 滕飞, 孔庆研, 等. 保留肝后下腔静脉的在体肝切除术治疗侵犯下腔静脉的复杂泡型肝包虫病. 中国普外基础与临床杂志, 2022, 29(10): 1279-1283.
27. Addeo P, Schaaf C, Noblet V, et al. The learning curve for piggyback liver transplantation: identifying factors challenging surgery. Surgery, 2021, 169(4): 974-982.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Learning curve of radical hepatectomy in treating hepatic alveolar echinococcosis with vascular infiltration: a cumulative sum analysis

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