A novel scoring system for evaluating the difficulty of lysis of adhesion and surgical risk at repeat hepatectomy

Abstract

Background Repeat hepatectomy (ReHx) for recurrent hepatic malignancies reportedly provides oncological benefit for patients. However, severe adhesions at the time of ReHx may preclude safe and curative resection and there has been no reliable measure to estimate the surgical risk at ReHx. This study sought to create a new scoring system for evaluating the severity of adhesion after hepatectomy and tested its performance looking at the correlation with morbidity rate. Methods Operative videos of 66 patients undergoing a second hepatectomy were reviewed and the difficulty levels in lysis of adhesion around the hepatic hilum (A score) and surrounding the liver (B score) were scored by two examiners and validated by two additional reviewers. Results Very high interobserver agreement was confirmed between the two examiners (κ value, 0.960‐0.963) and reproducibility of results were validated with weighted kappa values of >0.8 in both surgical resident and hepatobiliary surgeon. Linear correlation was confirmed between the difficulty score and postoperative morbidity rate. Multivariate analyses confirmed that previous cholecystectomy or transection of visceral surface of segment 4 or 5 was an independent factor predicting hard to extreme adhesions at the hepatic hilum regardless of the use of anti‐adhesion materials. Conclusions The new difficulty scoring system for the lysis of adhesion at ReHx showed good interobserver agreement and reproducibility of the results. Given the strong correlation with postoperative morbidity rate, the present score could be used for evaluating the technical difficulties in ReHx and may offer a reliable measure for estimating the efficacy of anti‐adhesion materials in future analysis.

Adhesions as a risk factor for postoperative morbidity in patients undergoing repeat hepatectomy and the potential efficacy of adhesion barriers

“…However, a major obstacle so far has been the absence of an adequate method for objective evaluation of the degree of adhesion formation. Therefore, our group developed a novel measure to measure the degree of adhesion formation after liver surgery, ie, the TORAD (or, adhesion severity) score, and its performance in predicting the postoperative morbidity and interobserver agreement has been reported in our previous study 4 . Furthermore, preliminary studies conducted in small cohorts to determine the efficacy of use of adhesion barriers have validated the feasibility of assessment of the degree of formation of adhesions and confirmed a tendency towards a reduced extent of adhesion formation in patients who had received placement of adhesion barriers at the previous surgery 6,8 .…”

“…Repeat hepatectomy is established as an important treatment option for recurrent cancer in the multidisciplinary treatment approach, based on the evidence that the cancer‐free interval after hepatectomy may be correlated with the survival outcomes in patients undergoing resection for hepatocellular carcinoma (HCC) or colorectal liver metastasis (CLM) 1,2 . Because of the formation of adhesions around the liver after surgery, repeat hepatectomy is generally technically more demanding, especially in the 3rd or later hepatectomy, 3 and a high degree of adhesion formation at the time of repeat surgery has been reported to be correlated with an increased risk of postoperative morbidity after the repeat hepatectomy 4 …”

A new spray-type adhesion barrier (AdSpray) improves condition for surgical treatment in the reversal of Hartmann procedure

“…[ 5 ] As there has been no standard scale to evaluate the severity of adhesion, it was difficult to give a precise expression in this case. Using the TORAD score, [ 11 ] which was reported to enable accurate evaluation of the severity of adhesion at repeat hepatectomy, the (A) score was 1 point because the pelvic surgery could be performed without any problem with SILS, and the (B) score was 1 point because dissection of adhesions was not necessary, and the overall score was considered EASY in this case. Thus, the application of AdSpray onto the pelvis, including the rectal stump, may be useful in patients with HP who do not wish to have a permanent stoma.…”

Safety of a new spray‐type adhesion barrier (AdSpray®) in liver surgery

“…In cases where the ascites was refractory to such standard management, peritoneocentesis was performed and the complication was classified as a postoperative Clavien‐Dindo IIIa complication. For those who underwent repeat laparotomy, the severity of the adhesions around the liver was evaluated according to the TORAD score 9 …”