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No difference in mortality between pancreaticoduodenectomy +/- vein resection or bypass in head of the pancreas cancer   


This UK multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection (PDVR), standard pancreaticoduodenectomy (PD), and surgical bypass (SB) in 9 high-volume UK centers. All consecutive patients with T3 (stage IIA to III) adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. One thousand five hundred and eighty-eight patients underwent surgery for borderline resectable pancreatic cancer; 840 PD, 230 PDVR, and 518 SB. Of 230 PDVR patients, 129 had primary closure (56%), 65 had end to end anastomosis (28%), and 36 had interposition grafts (16%). Both resection groups had greater complication rates than the bypass group, but with no difference between PD and PDVR. In-hospital mortality was similar across all 3 surgical groups. Median survival was 18 months for PD, 18.2 months for PDVR, and 8 months for SB (p = 0.0001).

J Am Coll Surg. 2014 Mar;218(3):401-11. doi: 10.1016/j.jamcollsurg.2013.11.017. Epub 2013 Nov 27.













Use of segmental allografts is essential to offer timely liver transplantation and decrease waiting list mortality


This report describes the use of segmental allograft in the current era of donor scarcity, minimizing vascular complications using innovative surgical techniques. Of 69 segmental transplants, 47 were living donor liver transplants: 13 grafts (27.7%) were right lobes, 22 (46.8%) were left lobes, and 12 (25.5%) were left lateral segments. Twenty-two patients received deceased donor segmental grafts; of these, 11 (50.0%) were extended right lobes, 9 (40.9%) were left lateral segments, 1 (4.5%) was a right lobe, and 1 (4.5%) was a left lobe. Arterial anastomoses were done using 8-0 monofilament sutures in an interrupted fashion for living donor graft recipients and for pediatric patients. Most patients received a prophylactic dose of low-molecular-weight heparin for a week and aspirin indefinitely. There was no incidence of hepatic artery or portal vein thrombosis. Two patients developed hepatic artery stenosis and were treated with balloon angioplasty by radiology. Graft and patient survivals were 96% and 98%, respectively.

JAMA Surg. 2014 Jan 1;149(1):63-70. doi: 10.1001/jamasurg.2013.3384.







Anatomic resection for early hepatocellular carcinoma can lead to lower early recurrences in cirrhotic patients


The outcomes following anatomic resection (AR) for hepatocellular carcinoma (HCC) were compared to non-AR (NAR) in Child-Pugh class A cirrhotic patients. The 5-year recurrence-free and overall survivals of the 543 patients were 32.3% and 60.0%, respectively, without differences between the 2 centers (P = .635 and .479, respectively). AR conferred better overall and recurrence-free survival than NAR (P = .009 and .041, respectively), but NAR patients suffered from significantly worse hepatic dysfunction. After 1-to-1 match, AR (n = 149) and NAR (n = 149) patients had similar covariate distributions. In this matched sample, AR still conferred better recurrence-free survival over NAR (P = .044) but the beneficial effect of AR was limited to the reduction of early recurrence (<2 years) of poorly differentiated tumors and of tumors with microvascular invasion (P < .05), resulting in better overall survival (P = .018).

Surgery. 2014 Mar;155(3):512-21. doi: 10.1016/j.surg.2013.10.009. Epub 2013 Oct 14.






Complement-binding capacity of donor-specific antibodies is useful in identifying #kidney allograft loss


This cohort study investigated whether the complement-binding capacity of anti-HLA antibodies plays a role in kidney-allograft failure. The primary analysis included 1016 patients. Patients with complement-binding donor-specific anti-HLA antibodies after transplantation had the lowest 5-year rate of graft survival (54%), as compared with patients with non-complement-binding donor-specific anti-HLA antibodies (93%) and patients without donor-specific anti-HLA antibodies (94%) (P<0.001 for both comparisons). The presence of complement-binding donor-specific anti-HLA antibodies after transplantation was associated with a risk of graft loss that was more than quadrupled (hazard ratio, 4.78; 95% confidence interval [CI], 2.69 to 8.49) when adjusted for clinical, functional, histologic, and immunologic factors. These antibodies were also associated with an increased rate of antibody-mediated rejection, a more severe graft injury phenotype with more extensive microvascular inflammation, and increased deposition of complement fraction C4d within graft capillaries. Adding complement-binding donor-specific anti-HLA antibodies to a traditional risk model improved the stratification of patients at risk for graft failure (continuous net reclassification improvement, 0.75; 95% CI, 0.54 to 0.97).

N Engl J Med. 2013 Sep 26;369(13):1215-26. doi: 10.1056/NEJMoa1302506.











Live kidney donors have an increased risk of ESRD


The aim of this study was to compare the risk of ESRD in kidney donors with that of a healthy cohort of nondonors who are at equally low risk of renal disease and free of contraindications to live donation and to stratify these comparisons by patient demographics. Among live donors, with median follow-up of 7.6 years (maximum, 15.0), ESRD developed in 99 individuals in a mean (SD) of 8.6 (3.6) years after donation. Among matched healthy nondonors, with median follow-up of 15.0 years (maximum, 15.0), ESRD developed in 36 nondonors in 10.7 (3.2) years, drawn from 17 ESRD events in the unmatched healthy nondonor pool of 9364. Estimated risk of ESRD at 15 years after donation was 30.8 per 10,000 (95% CI, 24.3-38.5) in kidney donors and 3.9 per 10,000 (95% CI, 0.8-8.9) in their matched healthy nondonor counterparts (P < .001). This difference was observed in both black and white individuals, with an estimated risk of 74.7 per 10,000 black donors (95% CI, 47.8-105.8) vs 23.9 per 10,000 black nondonors (95% CI, 1.6-62.4; P < .001) and an estimated risk of 22.7 per 10,000 white donors (95% CI, 15.6-30.1) vs 0.0 white nondonors (P < .001). Estimated lifetime risk of ESRD was 90 per 10,000 donors, 326 per 10,000 unscreened nondonors (general population), and 14 per 10,000 healthy nondonors.

JAMA. 2014 Feb 12;311(6):579-86. doi: 10.1001/jama.2013.285141.







Prediction of intraop blood product requirements based on preop variables is unreliable in liver transplantation


The primary aim in this study was to determine which patient variables best predict recipient risk for large blood transfusion requirements during orthotopic liver transplant (OLT). Several preoperative factors were highly statistically significant predictors of intraoperative blood product usage in each of the analyses, namely lower platelet count and higher Model for End-Stage Liver Disease Score or one or more of its components (creatinine, total bilirubin, international normalized ratio). Despite these highly significant associations, the models were unable to predict reliably that patients might require the largest amount of blood products during OLT. For example, the classification and regression tree analyses were able to predict only 32% and 11% of patients requiring >20 and >30 units of RBC + CS, respectively. Survival analysis demonstrated poorer survival among patients receiving larger amounts of RBC + CS during OLT.

Anesth Analg. 2014 Feb;118(2):428-37. doi: 10.1213/ANE.0b013e3182a76f19.












Right hepatic trisectionectomy produces better negative proximal ductal margins in perihilar cholangiocarcinoma


Patients who underwent right hemihepatectomy were compared with those undergoing anatomical right hepatic trisectionectomy for perihilar cholangiocarcinoma were reviewed retrospectively. Thirty-three patients underwent right trisectionectomy and 141 had a right hemihepatectomy. Patients having a trisectionectomy had more advanced tumours and so required combined portal vein resection more frequently. Duration of surgery and blood loss were similar in the two groups. Morbidity and mortality rates tended to be higher following hemihepatectomy than after trisectionectomy. The mean(s.d.) length of resected left hepatic duct was significantly greater in trisectionectomy than in hemihepatectomy (25·0(6·9) versus 14·8(5·3) mm; P < 0·001). In patients with Bismuth type IV tumours, the percentage of negative left hepatic duct margins was significantly higher for trisectionectomy than for hemihepatectomy (89 versus 57 per cent; P = 0·021). Achievement of R0 resection was similar and survival did not differ between the two groups, despite different tumour load.

Br J Surg. 2014 Feb;101(3):261-8. doi: 10.1002/bjs.9383. Epub 2014 Jan 8.







Preop radiation therapy is associated with lower rates of lymph node positivity at resection of pancreatic adenocarcinoma


The role for for PAC versus postoperative RT (poRT) remains uncertain. The authors used the National Cancer Data Base (NCDB) to report preoperative radiation therapy (prRT) outcomes from pancreatic adenocarcinoma (PAC). A total of 5414 patients were identified. Of these, 277 received prRT and 5137 received postoperative RT (poRT). Overall, 92.9% received chemotherapy and 7.1% received RT alone; 56% (2990 of 5307) of patients had stage III disease, according to American Joint Commission on Cancer (AJCC) staging manual, 5th edition. Median tumor size was 3 cm (range: 0-9.9 cm); 82% (199 of 244) of patients with prRT had negative surgical margins; 72% (3383 of 4699) of patients with poRT had negative margins. Forty-one percent (71 of 173) of patients with prRT were lymph node (LN)-positive; 65% (3159 of 4833) of patients with poRT were LN-positive. Median OS for patients with prRT was 18 months (95% CI = 18-19 months) and for patients with poRT, 19 months (95% CI = 17-22 months).

Cancer. 2014 Feb 15;120(4):499-506. doi: 10.1002/cncr.28530. Epub 2014 Jan 3.










Margin-negative resection may require multivisceral resection at time of pancreatoduodenectomy for pancreatic cancer


Improvements in outcomes after pancreatoduodenectomy (PD) have permitted more complex resections and the effects of multivisceral resection (MVR-PD) were investigated in the National Surgical Quality Improvement Project database. Of 9,927 PDs, MVR-PD was performed in 273 patients (3%). MVR included colon (58%), small bowel (30%), and gastric (12%) resections. Preoperative comorbidities were similar between groups. Pancreatic, duodenal, or periampullary cancer was present in 75% of patients. Mortality (8.8% vs 2.9%) and major morbidity (56.8% vs 30.8%) were much greater for MVR-PD versus PD alone (P < .001). MVR-PD patients also experienced greater rates of wound, pulmonary, cardiac, thromboembolic, renal, and septic complications. On multivariable regression, MVR was an independent predictor of death (odds ratio [OR], 3.4; P < .001), overall morbidity (OR, 3.01; P < .001), major morbidity (OR, 3.21; P < .001), and minor morbidity (OR, 1.65; P = .03). Among patients undergoing PD+MVR, colectomy was an independent predictor of increased overall morbidity (OR, 1.96; P = .03) and major morbidity (OR, 1.90; P = .02).

Surgery. 2014 Mar;155(3):567-74. doi: 10.1016/j.surg.2013.12.020. Epub 2013 Dec 25.






Stapler transection does not reduce intraop blood loss in liver resection compared with the clamp-crushing technique


This randomized clinical trial compared the effectiveness and safety of stapler transection with that of clamp-crushing during open liver resection. A total of 130 patients were enrolled, 65 to clamp-crushing and 65 to stapler transection. There was no difference between groups in total intraoperative blood loss: median (i.q.r.) 1050 (525-1650) versus 925 (450-1425) ml respectively (P = 0·279). The difference in total intraoperative blood loss normalized to the transection surface area was not statistically significant (P = 0·092). Blood loss during parenchymal transection was significantly lower in the stapler transection group (P = 0·002), as were the parenchymal transection time (mean(s.d.) 30(21) versus 9(7) min for clamp-crushing and stapler transection groups respectively; P < 0·001) and total duration of operation (mean(s.d.) 221(86) versus 190(85) min; P = 0·047). There were no significant differences in postoperative morbidity (P = 0·863) or mortality (P = 0·684) between groups.

Br J Surg. 2014 Feb;101(3):200-7. doi: 10.1002/bjs.9387. Epub 2014 Jan 8.











Emergency liver transplants for bile duct injury after laparoscopic cholecystectomy is associated with a poor outcome


The aim of this national survey was to review the indications and outcome of liver transplantation (LT) for bile duct injury (BDI) after open and laparoscopic cholecystectomy. Some 27 patients with BDI after cholecystectomy in whom surgical and non-surgical management for BDI failed were scheduled for LT over the 24-year interval. Emergency LT for acute liver failure was indicated in seven patients, all after laparoscopic cholecystectomy. Two patients died while on the waiting list and only one patient survived more than 30 days after LT. Elective LT for secondary biliary cirrhosis after a failed hepaticojejunostomy was performed in 13 patients after open and seven after laparoscopic cholecystectomy. One patient from the elective transplantation group died within 30 days of LT. The estimated 5-year overall survival rate was 68 per cent.

Br J Surg. 2014 Jan;101(2):63-8. doi: 10.1002/bjs.9349. Epub 2013 Dec 9.







Chemotherapy-linked parenchymal inflammation is linked to complications following colorectal cancer liver metastases resection


The aim of this study was to define all kinds of chemotherapy-associated liver injury and to examine its impact on postoperative morbidity following resection of colorectal cancer liver metastases. On univariate analysis severity (P = .004) and localization of parenchymal inflammation (P = .04) were associated with morbidity. Steatosis did not correlate with postoperative outcome (P = .69), whereas steatohepatitis (as assessed by the nonalcoholic fatty liver disease activity score score) was related with morbidity (P = .03). On multivariate analysis, the severity of inflammation (95% confidence interval, 1.008-6.526; odds ratio, 2.56; P = .04) was significantly correlated with postoperative morbidity. The newly developed liver injury risk score was highly associated with postoperative complications (P = .006).

Surgery. 2014 Feb;155(2):245-54. doi: 10.1016/j.surg.2013.07.022. Epub 2013 Dec 5.














Early plasma Angiopoietin-2 is accurate predictor of severe acute pancreatitis


This study assessed whether early plasma Angiopoietin-2 (Ang-2) was associated with adverse outcomes in patients with predicted severe acute pancreatitis (SAP) in a substudy of the PROPATRIA trial (probiotics vs placebo in patients with predicted SAP). The Ang-2 levels were measured prospectively in plasma in the first 5 days after admission in 115 patients. Early Ang-2 levels were higher in patients who developed SAP and also were higher in patients who developed multiorgan failure in the first week and after the first week. Furthermore, high Ang-2 levels were associated with infectious complications in the first week and after the first week. Finally, plasma Ang-2 was significantly higher in patients who died and in patients who developed bowel ischemia. As a predictor of adverse outcomes, plasma Ang-2 was superior to a number of current scores, such as the APACHE II score, the Imrie score, C-reactive protein, lipopolysaccharide binding protein, and procalcitonin.

J Am Coll Surg. 2014 Jan;218(1):26-32. doi: 10.1016/j.jamcollsurg.2013.09.021. Epub 2013 Oct 3.









Preservation of the spleen should be considered when treating benign or borderline distal pancreas tumours


This retrospective study aimed to investigate the clinical relevance of splenic vein thrombosis (SVT) in the splenic vein remnant following minimally invasive distal pancreatosplenectomy (DPS). Seventy-nine patients had DPS, of whom 38 (48%) developed SVT in the splenic vein remnant. DPS was associated with postoperative pancreatic fistula (POPF) and SVT. SVT length was closely related to the amount of peripancreatic fluid collection and POPF. In a comparison of splenic vessel-sacrificing, spleen-preserving DP and DPS, postoperative platelet count was significantly higher in the DPS group.

Br J Surg. 2014 Jan;101(2):114-9. doi: 10.1002/bjs.9366. Epub 2013 Dec 10.











Mesohepatectomy is a safe alternative to extended hepatectomy in centrally located liver tumours


The aim of this study was to compare the results of mesohepatectomy (MH) with those of extended hepatectomy (EH) in the management of centrally located liver tumours (CLLTs). MH was performed in 292 patients and EH in 138. MH was associated with a longer duration of operation (P < 0·001), higher intraoperative transfusion rate (P < 0·001) and lower complication rates (P = 0·001) compared with EH. There were no significant differences in hepatic inflow occlusion rate (P = 0·075), blood loss (P = 0·241) and length of hospital stay (P = 0·804) between the two groups. Type IV lesions had the longest duration of operation, greatest blood loss, and highest intraoperative transfusion and morbidity rates (all P < 0·050).

Br J Surg. 2013 Nov;100(12):1620-6. doi: 10.1002/bjs.9286.








Intraop air leak test can reduce rate of postoperative bile leaks after hepatectomy


This study was designed to determine if a novel intraoperative air leak test (ALT) would reduce the incidence of post-hepatectomy biliary complications among 103 patients who underwent ALT and 120 matched patients operated on before ALT was used. The 2 groups were similar in diagnosis, chemotherapy use, tumor number and size, resection extent, surgery duration, and blood loss (all, p > 0.05). Single or multiple uncontrolled bile ducts were intraoperatively detected and repaired in 62.1% of ALT vs 8.3% of non-ALT patients (p < 0.001). This resulted in a lower rate of postoperative bile leaks in ALT (1.9%) vs non-ALT patients (10.8%; p = 0.008). Independent risk factors for postoperative bile leaks included extended hepatectomy (p = 0.031), caudate resection (p = 0.02), and not performing ALT (p = 0.002) (odds ratio = 3.8; 95% CI, 1.3-11.8; odds ratio = 4.0; 95% CI, 1.1-14.3; and odds ratio = 11.8; 95% CI, 2.4-58.8, respectively).

J Am Coll Surg. 2013 Dec;217(6):1028-37. doi: 10.1016/j.jamcollsurg.2013.07.392.








Chronic pancreatitics exhibit altered central pain processing after pain-relieving pancreatic surgery


This study evaluated the relationship between pain processing and pain outcome after pancreatic duct decompression and/or pancreatic resection in patients with chronic pancreatitis (CP). Forty-eight patients with CP had lower electrical pain detection (ePDT) and electrical pain tolerance (ePTT) and conditioned pain modulation (CPM) responses compared with values in 15 healthy controls (P < 0·030). The sum of ePDT values was lower in patients with a poor pain outcome than in those with a good outcome (median 7·1 versus 11·2 mA; P = 0·008). There was a correlation with the VAS score and the sum of ePDT values (rs  = -0·45, P = 0·016) and ePTT values (rs  = -0·46, P = 0·011), and CPM response (rs  = -0·43, P = 0·006) in patients with CP.

Br J Surg. 2013 Dec;100(13):1797-804. doi: 10.1002/bjs.9322.












Preop portal vein embolization enables curative resection 2/3 of patients with colorectal liver metz


The clinical and oncological impact of preoperative portal vein embolization (PVE) in patients requiring an extended right hepatectomy (ERH) for colorectal liver metastases (CLM) was assessed at M. D. Anderson Cancer Center. Of the 265 patients requiring ERH, 126 (47·5 per cent) had an adequate standardized future liver remnant (sFLR) at presentation, of whom 123 underwent a curative resection. Of the 139 patients (52·5 per cent) who had an inadequate sFLR and underwent PVE, 87 (62·6 per cent) had a curative resection. Thus, the curative resection rate was increased from 46·4 per cent (123 of 265) at baseline to 79·2 per cent (210 of 265) following PVE. Among patients who underwent ERH, major complication and 90-day mortality rates were similar in the no-PVE and PVE groups (22·0 and 4·1 per cent versus 31 and 7 per cent respectively); overall and disease-free survival rates were also similar in these two groups. Of patients with an inadequate sFLR at presentation, those who underwent ERH had a significantly better median overall survival (50·2months) than patients who had non-curative surgery (21·3months) or did not undergo surgery (24·7months) (P=0·002).

Br J Surg. 2013 Dec;100(13):1777-83. doi: 10.1002/bjs.9317.






Resistive index reflects characteristics of the recipient but not those of the graft following renal transplant


This single-center, prospective study investigated the role of the intrarenal resistive index in 321 renal-allograft recipients and the outcomes of such patients. Allograft recipients with a resistive index of at least 0.80 had higher mortality than those with a resistive index of less than 0.80 at 3, 12, and 24 months after transplantation. The need for dialysis did not differ significantly between patients with a resistive index of at least 0.80 and those with a resistive index of less than 0.80 at 3, 12, and 24 months after transplantation. At protocol-specified biopsy time points, the resistive index was not associated with renal-allograft histologic features. Older recipient age was the strongest determinant of a higher resistive index (P<0.001). At the time of biopsies performed because of graft dysfunction, antibody-mediated rejection or acute tubular necrosis, as compared with normal biopsy results, was associated with a higher resistive index.

N Engl J Med. 2013 Nov 7;369(19):1797-806. doi: 10.1056/NEJMoa1301064.





Positive peritoneal cytology is not clinically equivalent to gross peritoneal metastasis in pancreatic cancer


This prospective study investigated the clinical significance of positive peritoneal cytology (CY+) results in patients with pancreatic cancer is yet to be determined. Of 523 included patients, 390 underwent resection. Patients with tumours at least 2cm in diameter were more likely to have CY+ status than patients with tumours smaller than 2and there was a significant correlation between CY+ status and tumour invasion of the anterior pancreatic. Although the overall survival of patients with resected CY+ tumours was worse than that of patients with resected CY- tumours, it was significantly better than the survival of unresected patients regardless of CY status. Multivariable analysis of all patients who had pancreatectomy did not identify CY+ as an independent prognostic factor. Patients with CY+ tumours tended to develop peritoneal metastasis more often than those with CY- tumours, although not significantly so. The median survival time of 34 patients with resected CY+ tumours who received adjuvant chemotherapy was better than that of 17 patients who had surgery alone, although this was not statistically significant (15·3 versus 10·0months; P=0·057).

Br J Surg. 2013 Dec;100(13):1791-6. doi: 10.1002/bjs.9307.











CUSA with a bipolar sealer is superior to CUSA with standard bipolar cautery for various hepatectomy


The aim of this prospective randomized study of 109 patients was to compare the use of the Cavitron Ultrasonic Surgical Aspirator (CUSA) with a radiofrequency-based bipolar hemostatic sealer versus CUSA with standard bipolar cautery (BC) in patients undergoing hepatic resection. Compared with the BC group, the bipolar sealer showed lesser blood loss during transection and blood loss divided by resection area (P = .0079 and .0008, respectively), shorter transection time (P = .0025), faster speed of transection (P < .0001), and fewer ties and ties divided by resection area required during transection (P < .0001).

Surgery. 2013 Nov;154(5):1046-52. doi: 10.1016/j.surg.2013.04.053.





Steatosis has a protective effect on survival in liver resection for colorectal metastases after preop chemo


This retrospective study analyzed the impact of chemotherapy-related liver injuries (CALI), pathological tumor regression grade (TRG), and micrometastases on long-term prognosis in patients undergoing liver resection for colorectal metastases after preoperative chemotherapy. A total of 323 patients were included. Grade 2-3 sinusoidal obstruction syndrome (SOS) was present in 124 patients (38.4%), grade 2-3 steatosis in 73 (22.6%), and steatohepatitis in 30 (9.3%). Among all patients, 22.9% had TRG 1-2 (major response), whereas 55.7% had TRG 4-5 (no response). Microvascular invasion was detected in 37.8% of patients and microscopic biliary infiltration in 5.6%.The higher the SOS grade the lower the pathological response: TRG 1-2 occurred in 16.9% of patients with grade 2-3 SOS versus 26.6% of patients with grade 0-1 SOS (P = 0.032).After a median follow-up of 36.9 months, 5-year survival was 38.6%. CALI did not negatively impact survival. Multivariate analysis showed that grade 2-3 steatosis was associated with better survival than grade 0-1 steatosis (5-year survival rate of 52.5% vs 35.2%, P = 0.002). TRG better than the percentage of viable cells stratified patient prognosis: 5-year survival rate of 60.4% in TRG 1-2, 40.2% in TRG 3, and 29.8% in TRG 4-5 (P = 0.0001). Microscopic vascular and biliary invasion negatively impacted outcome (5-year survival rate of 23.3% vs 45.7% if absent, P = 0.017; 0% vs 42.3%, P = 0.032, respectively).

Ann Surg. 2013 Nov;258(5):731-42. doi: 10.1097/SLA.0b013e3182a6183e.




Sarcopenia was predictive of worse overall survival in HCC after liver resection


The present study investigated the effect of sarcopenia on short- and long-term outcomes following partial hepatectomy for hepatocellular carcinoma (HCC), and aimed to identify prognostic factors. Sarcopenia was present in 75 (40·3 per cent) of 186 patients, and was significantly correlated with female sex, lower body mass index and liver dysfunction, as indicated by abnormal serum albumin levels and indocyanine green retention test at 15 min values. In patients with, and without sarcopenia, the 5-year overall survival rate was 71 and 83·7 per cent respectively, and the 5-year recurrence-free survival rate was 13 and 33·2 per cent respectively. Multivariable analysis revealed that reduced skeletal muscle mass was predictive of an unfavourable prognosis.

Br J Surg. 2013 Oct;100(11):1523-30. doi: 10.1002/bjs.9258.










World's largest reported single-institution experience with orthotopic liver transplantation

This group describe their 28-year single-center experience with orthotopic liver transplantation (OLT) for patients with irreversible liver failure. Outcomes and factors affecting survival were analyzed in 5347 consecutive OLTs performed in 3752 adults and 822 children between 1984 and 2012, including comparisons of recipient and donor characteristics, graft and patient outcomes, and postoperative morbidity before (n = 3218) and after (n = 2129) implementation of the MELD allocation system. Overall, 1-, 5-, 10-, and 20-year patient and graft survival estimates were 82%, 70%, 63%, 52%, and 73%, 61%, 54%, 43%, respectively. Post-MELD era recipients were older, more likely to be hospitalized and receiving pretransplant renal replacement therapy, and had significantly greater laboratory MELD scores, longer wait-list times and pretransplant hospital stays. Despite increased acuity, post-MELD era recipients achieved superior 1-, 5-, and 10-year patient survival and graft survival compared with pre-MELD recipients. Of 17 recipient and donor variables, era of transplantation, etiology of liver disease, recipient and donor age, prior transplantation, MELD score, hospitalization at time of OLT, and cold and warm ischemia time were independent predictors of survival.

Ann Surg. 2013 Sep;258(3):409-21. doi: 10.1097/SLA.0b013e3182a15db4.





RAS mutation predicts worse survival after curative resection of colorectal liver metastases

This study determined the impact of RAS mutation status on survival and patterns of recurrence in patients undergoing curative resection of colorectal liver metastases (CLM) after preoperative modern chemotherapy in 193 patients. Detected somatic mutations included RAS in 34 (18%), PIK3CA in 13 (7%), and BRAF in 2 (1%) patients. 3-year overall survival (OS) rates were 81% in patients with wild-type versus 52.2% in patients with mutant RAS. Liver and lung recurrences were observed in 89 and 83 patients, respectively. Patients with RAS mutation had a lower 3-year lung recurrence free rate (34.6% vs 59.3%) but not a lower 3-year liver recurrence free rate (43.8% vs 50.2%). In multivariate analyses, RAS mutation predicted worse overall survival.

Ann Surg. 2013 Oct;258(4):619-27. doi: 10.1097/SLA.0b013e3182a5025a.





No association between intraop cholangiography and CBD injury during cholecystectomy when confounders controlled

This study investigated the association between intraoperative cholangiography use during cholecystectomy and common duct injury in a retrospective cohort study of all Texas Medicare claims data from 2000 through 2009. Of 92,932 patients undergoing cholecystectomy, 37,533 (40.4%) underwent concurrent intraoperative cholangiography and 280 (0.30%) had a common duct injury. The common duct injury rate was 0.21% among patients with intraoperative cholangiography and 0.36% among patients without it. In a logistic regression model controlling for patient, surgeon, and hospital characteristics, the odds of common duct injury for cholecystectomies performed without intraoperative cholangiography were increased compared with those performed with it. When confounding was controlled with instrumental variable analysis, the association between cholecystectomy performed without intraoperative cholangiography and duct injury was no longer significant.

JAMA. 2013 Aug 28;310(8):812-20. doi: 10.1001/jama.2013.276205.












Multifocal hepatocellular carcinoma with well preserved liver function can be treated with liver resection

The role of liver resection in patients with multifocal hepatocellular carcinoma (HCC) with well preserved liver function was conducted to evaluate the outcomes in this retrospective analysis of 46 such patients. Major hepatectomy was performed in 27 patients, and major complications occurred in nine (20 per cent). The 90-day postoperative mortality rate was 7 per cent. Overall 1-, 2-, 3- and 5-year survival rates were 78, 64, 59 and 53 per cent respectively, whereas corresponding recurrence-free survival rates were 53, 32, 30 and 27 per cent. Recurrence developed in 28 (61 per cent) of the 46 patients, affecting the liver only in 22. Three-quarters of patients with recurrence underwent further therapy. Major hepatectomy, microvascular and macrovascular invasion, and cirrhosis were associated with overall survival.

Br J Surg. 2013 Oct;100(11):1516-22. doi: 10.1002/bjs.9263.







Liver resection should include the original site of colorectal liver metastasis when disappeared following neoadjuvant therapy

Owing to expanded surgical indications for colorectal liver metastasis (CRLM) and improved systemic therapy, hepatic surgeons are faced with the issue of liver metastasis that have disappeared on imaging (DLM). A review of relevant studies was performed. A complete response on imaging does not necessarily equate with a complete clinical or pathological response. Rather, residual macroscopic disease is found in about 25-45 per cent of patients at the time of operation. Even among patients with a complete pathological response, long-term remission occurs in only 20-50 per cent of those treated with systemic therapy. A durable response of DLM is more common following the use of hepatic artery infusion therapy.

Br J Surg. 2013 Oct;100(11):1414-20. doi: 10.1002/bjs.9213. Epub 2013 Aug 16.





Almost all bile leaks and many bile duct injuries after lap chole can be managed successfully by endoscopists

The objectives of this analysis in 528 patients were to compare the outcomes of bile duct injuries by specialist over time and the role of management timing and biliary stents. Mean age was 52 years; 69% were women and 95% had a cholecystectomy and/or bile duct exploration. Patients were classified by the Strasberg system as having bile leaks (type A, n = 239, 45%) or bile duct injuries (types B-E, n = 289, 55%). Injury outcomes from 1993 to 2003 (n = 132) were compared with those from 2004 to 2010 (n = 157). Patients with bile leaks were managed almost exclusively by endoscopists (96%) with a 96% success rate. Patients with bile duct injuries were managed most often by endoscopists (N = 115, 40%) followed by surgeons (N = 104, 36%) and interventional radiologists (N = 70, 24%). Overall success rates were best for surgery (88%, P < 0.05) followed by endoscopy (76%) and interventional radiology (50%). Outcomes were best for surgery in recent years (95% vs 80%, P < 0.05).

Ann Surg. 2013 Sep;258(3):490-9. doi: 10.1097/SLA.0b013e3182a1b25b.







Preoperative biliary stenting delays time to pancreatic cancer operations

This study investigates the current trends in preoperative biliary stenting in pancreatic cancer. Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001).

Surgery, 2013;154(2):179-89.




Intensity of imaging does not affect median survival after treatment of colorectal liver metastasis

This study sought to define current surveillance patterns after treatment of colorectal liver metastasis (CRLM) and whether the intensity of surveillance correlates with outcome. 1,739 patients with CRLM treated with surgery were identified; median age was 73 years, and the majority were male (52.6%). CRLM treatment consisted of liver resection (61%), ablation (32%), or both simultaneously (6%). CT (97%) was utilized more often for post-treatment surveillance compared with MRI (7%) and PET (18%). A temporal trend was noted with more frequent surveillance imaging obtained in post-treatment year 1 (2.4 scans/year) versus year 5 (0.6 scans/year; P = .01); 66% of living patients had no imaging after 2 years. Frequency of surveillance imaging correlated with procedure type (total number of scans/5 years: resection, 5.0; ablation, 4.6; resection and ablation, 6.2; P = .01). Other factors associated with a greater frequency of surveillance included younger age at diagnosis, geographic location in the South, and CRLM directed surgery in 2000 through 2005 (all P < .05). Overall survival did not differ by intensity of surveillance imaging (3-4 scans/yr, 43 months vs 2 scans/yr, 57 months vs 1 scan/yr, 54 months; P = .08).

Surgery, 2013;154(2):256-65.




Central venous oxygen saturation can predict postoperative liver dysfunction after hepatectomy

This study examined whether the data obtained by monitoring central venous oxygen saturation (ScvO2) and/or stroke volume variation (SVV) during hepatectomy can predict postoperative liver dysfunction in 33 patients. The cutoff values for ScvO2 and mean SVV for predicting the highest postoperative total bilirubin level to be ≥3.0 mg/dL with the highest sensitivity and specificity were found to be 10.2% and 13.6%, respectively. The areas under curve in receiver-operating-characteristic analysis of ScvO2 and mean SVV were 0.797 and 0.757, respectively, showing significant differences.

Surgery, 2013;154(2):351-62.




Intraop lap USS can be used to detect gallstones during lap Roux-en-Y gastric bypass

This study tested if laparoscopic ultrasound (LUS) would have a sensitivity and specificity similar to transabdominal ultrasound (TAU) for detecting cholelithiasis and polyps in morbidly obese patients presenting for laparoscopic Roux-en-Y gastric bypass. Two hundred and fifty-three patients were prospectively enrolled during a 6-year period. Seventy-six percent were female, mean age and preoperative body mass index was 43.5 years and 48, respectively. Mean time to complete the LUS was 4 minutes. Mean common bile duct diameter measured 3.7 mm via LUS and 4.0 mm via TAU. Transabdominal ultrasound and LUS identified 61 and 60 patients with cholelithiasis, respectively (p = 0.763). The sensitivity and specificity of LUS for cholelithiasis was 90.2% and 97.4%. Laparoscopic ultrasound identified polyps in 41 patients, and TAU identified polyps in 6 patients, 5 of which had polyps identified on LUS as well (p < 0.001). Sensitivity and specificity of LUS for polyps was 83.3% and 85.4%.

J Am Coll Surg, 2013;216(6):1057-62.




Liver transplant is an effective treatment of unresectable metz in neuroendocrine tumors

The purpose of this retrospective study was to assess outcomes and indications in a large cohort of patients who underwent liver transplantation (LT) for liver metastases (LM) from neuroendocrine tumors (NET) over a 27-year period. Three-month postoperative mortality was 10%. At 5 years after LT, overall survival (OS) was 52% and disease-free survival was 30%. At 5 years from diagnosis of LM, OS was 73%. Multivariate analysis identified 3 predictors of poor outcome, that is, major resection in addition to LT, poor tumor differentiation, and hepatomegaly. Since 2000, 5-year OS has increased to 59% in relation with fewer patients presenting poor prognostic factors. Multivariate analysis of the 106 cases treated since 2000 identified the following predictors of poor outcome: hepatomegaly, age more than 45 years, and any amount of resection concurrent with LT.

Ann Surg, 2013;257(5):807-15.




Risk score based on INR, bilirubin, creatinine can predict 90-day mortality after hepatectomy

This retrospective study sought to identify factors associated with 90-day mortality, as well as validate the "50-50" and peak bilirubin of >7 mg/dL prediction rules for mortality after liver resection from 2,056 patients who underwent liver resection at 2 major hepatobiliary centers between 1990 and 2011. Indications for liver resection included colorectal metastasis (39%), hepatocellular carcinoma (19%), benign mass (17%), or noncolorectal metastasis (14%). Most patients had normal underlying liver parenchyma (71%) and resection involved ≥3 segments (36%). Overall morbidity and mortality were 19% and 2%, respectively. Only 1 patient fulfilled the 50-50 criteria; this patient survived and was discharged on day 8. Twenty patients had a peak bilirubin concentration >7 mg/dL and 5 died within 90 days; the sensitivity and specificity of the >7-mg/dL rule were 25% and 99.3%, respectively, but overall accuracy was poor (area under the curve 0.574). Factors associated with 90-day mortality included international normalized ratio (odds ratio = 11.87), bilirubin (odds ratio = 1.16), and serum creatinine (odds ratio = 1.87) on postoperative day 3, as well as grade of postoperative complications (odds ratio = 5.08; all p < 0.05). Integer values were assigned to each factor to develop a model that predicted 90-day mortality (area under the curve 0.89). A score of ≥11 points had a sensitivity and specificity of 83.3% and 98.8%, respectively.

J Am Coll Surg, 2013;216(6):1049-56.





Resection of liver and IVC for cancer can yield promising results

Involvement of the IVC has traditionally been considered a relative contraindication to resection for advanced tumors of the liver.  Sixty patients undergoing hepatic and IVC resection by the primary author from 1996 to 2012 were reviewed. Median age was 52 years. Resections were carried out for cholangiocarcinoma (n = 26), hepatocellular carcinoma (n = 16), colorectal metastases (n = 13), gastrointestinal stromal tumor (n = 2), hepatoblastoma (n = 2), and squamous cell carcinoma (n = 1). Resections performed included 27 right and 5 left trisegmentectomies and 25 right and 3 left lobectomies, including the caudate lobe. Ex vivo procedures were performed in 6 patients using veno–venous bypass and the other 54 procedures were performed using varying degrees of vascular isolation. The IVC was reconstructed using a tube graft (n = 38) primarily (n = 8) or with patches (n = 14). There were 5 perioperative deaths (8%). Three patients died of liver failure, 1 patient died of pulmonary hemorrhage, and 1 patient died of massive pulmonary embolism. With a median follow-up of 31 months, 14 patients have died of recurrent malignancy between 22 and 44 months, and an additional 4 patients are alive with disease at 16 to 33 months. Actuarial 1- and 5-year survival rates were 89% and 35%, respectively.  Inferior vena cava involvement by malignancy does not obviate liver resection. The procedure's increased risk is balanced by the possible benefits, given the lack of alternative curative approaches and very poor prognosis without intervention.

J Am Coll Surg. 2013 Jan 31. doi:pii: S1072-7515(12)01380-4.




Significant numbers of patients with liver cancer are still not being assessed by liver surgeons

There remains great variability in access to liver surgery for suitable patients.  The authors conducted a study to examine the effect of patient and nonpatient factors on the place of HCC diagnosis, referral, and treatment in Veterans Administration (VA) hospitals in the United States. Using the VA Hepatitis C Clinical Case Registry, hepatitis C virus (HCV)-infected patients who developed HCC during 1998-2006 were identified. Approximately 37.2% of the 1,296 patients with HCC were diagnosed during hospitalization, 31.0% were seen by a surgeon or oncologist, and 34.3% received treatment. Being seen by a surgeon or oncologist was associated with surveillance (adjusted odds ratio [aOR] = 1.47; 95% CI: 1.20-1.80) and varied by geography (1.74;1.09-2.77). Seeing a surgeon or oncologist was predictive of treatment (aOR = 1.43; 95% CI: 1.24-1.66). There was a significant increase in treatment among patients who received surveillance (aOR = 1.37; 95% CI: 1.02-1.71), were seen by gastroenterology (1.65;1.21-2.24), or were diagnosed at a transplant facility (1.48;1.15-1.90). The authors concluded that most patients were not seen by a surgeon or oncologist for treatment evaluation and only 34% received treatment. Only receipt of HCC surveillance was associated with increased likelihood of outpatient diagnosis, being seen by a surgeon or oncologist, and treatment.

Hepatology, 2013;57:1858–1868






Intraoperative repair of bile duct injury by specialists yields good results

Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). The best strategy in terms of timing of repair is still controversial. The authors performed a single-institution retrospective analysis of prospectively collected data between October 1991 and November 2010.  Among 10,123 LC performed during this period, 19 patients had a BDI. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.  This series represents one of the largest single-center experiences in terms of intraoperative repair of BDI sustained during LC. The results suggest that a high level of intraoperative diagnosis is possible, where intraoperative cholangiography is a useful tool.

Journal of the American College of Surgeons, 2013;216(5):894-901




World’s first report of hepatectomy without general anaesthesia

Local anesthesia, including epidural anesthesia, has merit over general anesthesia for the reduction of perioperative cardiac and respiratory complications. This is the first report of hepatectomy performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation.  The following protocol was used for hepatectomy under epidural anesthesia with conscious sedation: the patient received 10 mg diazepam orally 1 hour before surgery, followed by 10 mg diazepam and 15 mg pentazocine intravenously just before surgery. An epidural catheter was inserted via the thoracic vertebra 7 to 9 interspaces. Intraoperatively, the patient received a bolus of 7 mL 2% mepivacaine hydrochloride every 40 minutes through the epidural catheter. Four left hepatectomies, 1 left lateral sectorectomy, and 5 partial hepatectomies were completed under this protocol. The efficacy and safety of hepatectomy under epidural anesthesia with conscious sedation was assessed.  Every patient was managed without endotracheal intubation and laryngeal masks. There was no perioperative mortality. Median intraoperative blood loss was 453.0 mL (range 144.0 to 1292.0 mL) and median surgical time was 273.0 minutes (range 137.0 to 440.0 minutes). Median total amount of 2% mepivacaine hydrochloride used was 52.0 mL (range 23.0 to 95.0 mL). Central venous pressure values were significantly lower during the Pringle maneuver than at preclamp.  The traditional belief is that liver resection should be performed under general anesthesia. This article reports world's first series of liver resections for malignant tumors performed under epidural anesthesia with conscious sedation to avoid general anesthesia with endotracheal intubation.

Journal of the American College of Surgeons, 2013;216(5):908-914





Number rather than location of +ve LN is more important in prognosis of perihilar cholangiocarcinoma

The authors analysed lymph node status in resected perihilar cholangiocarcinoma, to clarify which index (ie, location, number, or ratio of involved nodes) was better for staging in 320 patients.  Total lymph node counts averaged 12.9 ± 8.3 (range: 1–59). Lymph node metastasis was found in 45.6% patients and was an independent prognostic factor. The survival for patients with multiple node metastases was significantly worse than that for patients with single metastasis (12.1% vs 27.6% at 5 years), regardless of the presence or absence of distant lymph node metastasis. The survival for patients with lymph node ratios (LNRs) of 0.2 or less was significantly better than that for patients with LNRs greater than 0.2 (21.4% vs 13.5% at 5 years. Multivariate analysis of the 146 patients with lymph node metastasis, the number of involved nodes was identified as an independent prognostic factor.  

Annals of Surgery, 2013;257(4):718–725




Hepatic steatosis increases recurrence rate following resection of colorectal liver metastases

The authors analysed the influence of hepatic steatosis on recurrence following resection of colorectal liver metastases in a prospective cohort of primary resection of colorectal liver metastases (n= 2715). The cumulative local (liver) diseasefree survival rate was significantly better in the group without steatosis. On multivariable analysis, hepatic steatosis was an independent risk factor for local liver recurrence. After onetoone matching of cases (steatotic, 902) with controls (nonsteatotic, 902), local (liver) diseasefree survival remained significantly better in the group without steatosis.  In addition, patients with steatosis had a greater risk of developing postoperative liver failure.

BJS, 2013;DOI: 10.1002/bjs.9057



Simultaneous or staged operations can be performed in synchronous colorectal liver metastases

The order of operative approaches in patients presenting with synchronous colorectal cancer and operable liver metastases was studied using a multi-institutional database. Of 1004 patients studied, a simultaneous CRC and liver operation was performed in 329 (33%) patients; 675 (67%) underwent a staged approach (“classic” staged approach, n = 647; liver-first strategy, n = 28). Patients managed with the liver-first approach had more hepatic lesions and were more likely to have bilateral disease than those in the other 2 groups. The use of staged operative strategies increased over the time of the study from 58% to 75%. Liver-directed therapy included hepatectomy (90%) or combined resection + ablation (10%). A major resection (>3 segments) was more common with a staged approach. There were 197 patients (20%) who had a complication in the postoperative period, with no difference in morbidity between staged and simultaneous groups or major vs minor hepatectomies (p > 0.05). Ninety-day postoperative mortality was 3.0%, with no difference between simultaneous and staged approaches (p = 0.94). The overall median and 5-year survivals were 50.9 months and 44%, respectively.

Journal of the American College of Surgeons, 2013;216(4):707-716.





Significant numbers of patients with early HCC do not have access to surgical therapies

The authors utilised the SEER database to examine the use of and analyze the factors predictive of receipt of surgical therapy for patients with early hepatocellular carcinoma (HCC).  This retrospective cohort study performed using data from 1998-2007. Data were analyzed for patients 66 years of age and older with early HCC (tumours <=5 cm without metastatic disease, nodal metastasis, extrahepatic extension, or major vascular invasion). The authors identified 1745 patients within these criteria. Most patients had tumours between 2 and 5 cm in size (83%). Solitary tumours (64%) were more common than multiple tumours (36%). A total of 820 patients (47%) with early HCC received no surgical therapy. Among 741 patients with solitary, unilobar tumours and microscopic confirmation of HCC, 246 (33%) received no surgical therapy. Of 535 patients with no liver-related comorbidities, 273 (51%) did not receive surgical therapy. In multivariable analysis, patient age, income, tumour factors, liver-related comorbidities, and hospital factors were associated with receipt of surgical therapy.  The authors concluded that although some patients with early HCC may not be candidates for surgical therapy, these data suggest that there is a significant missed opportunity to improve survival of patients with early HCC through the use of surgical therapy.

Annals of Surgery, 2013;doi:10.1097/SLA.0b013e31827da749




Radical resection improves survival in patients with intrahepatic cholangiocarcinoma

The authors examined the outcomes of hepatectomy for intrahepatic cholangiocarcinoma (IHC) aiming to clarify the prognostic impact of a lymphadenectomy and the surgical margin. This was a prospective study of patients who were surgically treated for IHC identified from a multi-institutional registry of 16 centres (1990-2008).  A total of 434 patients were included in the analysis. Most underwent a major or extended hepatectomy (70.0%) and a systematic lymphadenectomy (62.2%). The incidence of lymph node metastases (overall, 36.9%) increased with increased tumor size, with 24.4% of patients with a small IHC (diameter ≤3 cm) having N1 disease. In patients with an R0 resection, the median time of survival was 39 months, and the 5-year survival rate was 39.8%. Lymph node metastases, multiple tumors and an elevated preoperative cancer antigen 19.9 level independently predicted an adverse prognosis. Conversely, survival was not influenced by the width of a negative resection margin (P = 0.61). The potential survival benefit of a lymphadenectomy was assessed with the therapeutic value index, which was calculated to be 5.9 points. The authors conclude that these data support an aggressive approach to radical resection. Lymph node metastases and multiple tumors are associated with decreased survival rates, but should not be considered a barrier to potentially curative resection. Lymphadenectomy should be considered for all patients.

Arch Surg. 2012;147(12):1107-1113.




Surgery prior to periop chemo produces better results in resectable colorectal liver metastases 

The optimal timing of perioperative chemotherapy in the management of patients with resectable colorectal liver metastases remains a matter of debate.  The authors report the outcomes of patients treated with up-front liver resection followed by post–liver resection chemotherapy.  This was a retrospective review of all patients undergoing liver resection for CRC metastases over a 5-year period (2002–2007). A total of 320 patients underwent 336 liver resections. Ninety-day mortality was 2.1 %, and perioperative morbidity was 20.2 %. Actual disease-free survival at 3 and 5 years was 46.2 % and 42 %, respectively. Actual overall survival (OS) at 3 and 5 years was 63.7 % and 55 %, respectively. Multivariate analysis identified four factors that were independently associated with differences in OS (hazard ratio; 95 % confidence interval): size of metastasis >6 cm (2.2; 1.3–3.5), positive lymph node status of the primary CRC (N1 (2.0; 1.0–3.8), N2 (2.4; 1.2–4.9)), synchronous disease (2.1; 1.3–3.5), and treatment with chemotherapy after liver resection (0.42; 0.23–0.75).  This study supports the use of up-front surgery followed by chemotherapy for patients with resectable colorectal liver metastases which leads to favorable survival outcomes.

Ann Surg Oncol, 2013;20(1):295-304.







Lap primary CBD closure may be associated with fewer complications than T-tube drainage

This meta-analysis compares T-Tube drainage (TTD) with a T-tube free (TTF) group including primary common bile duct closure alone or with other non-T-Tube drainage method for choledocotomy closure after laparoscopic common bile duct exploration (LCBDE) for choledocolithiasis. 12 studies were identified (956 patients) including 3 randomised controlled trails and 9 observational studies. The study demonstrates a significant reduction in postoperative complications in the TTF group compared with the TTD group and although there was a trend to reduced biliary specific complications this did not reach statistical significance. Both operative time and length of hospital stay were reduced in the TTF group, however there were high levels of heterogeneity between studies. The study is limited by the small number of randomized control trials on which the meta-analysis is based and methodological problems with the individual studies including lack of an intention to treat analysis in all studies.

Annals of Surgery, 2013;257(1):54–66



Lymph node ratio is a better predictor of outcome than number of +ve nodes after pancreatic adenocarcinoma resection

This study aimed to evaluate the prognostic efficiency of lymph node ratio (LNR) against numbers of positive lymph nodes (PLN) using a large national population based dataset. They then validated the results in a single tertiary referral institution to evaluate the effect of the number of examined lymph nodes (ELN) on the prognostic capability of these lymph node variables. Higher numbers of ELN improved the overall survival for N0 patients; this is explained by improved staging. The authors found that the prognostic significance of N0/N1 status of PLN were variable within and between datasets as the importance of a single PLN depended on the denominator number of ELN. LNR however consistently correlated with survival once a threshold number of lymph nodes (13-16) had been dissected. The authors conclude that a threshold of 13-16 lymph nodes must be examined to allow accurate nodal staging and that LNR is a better predictor of outcome than PLN.

J Gastroint Surg 2013;DOI 10.1007/s11605-012-1974-7



Age, comorbidity, hospital volume of procedures and type of intervention all affect mortality and morbidity rates following ERCP

In this prospective multicentre cohort study the objectives were to evaluate complication patterns and rates in routine ERCP practice and to identify risk factors for these complications. 11 hospitals were included in the analysis and 2808 ERCP procedures performed of which 2573 (91.6%) were therapeutic. Complications occurred in 327 (11.6%) of the procedures. Multivariable regression demonstrated that older age, increasing American Society of Anaesthetists fitness score, centre ERCP volumes of more than 150 procedures annually and precut sphincterotomy were predictive factors for complications. In this study the overall 30-day mortality rate was 2.2% (63 patients) and the procedure-related mortality rate was 1.4% (39 patients). 73% (46) of the patients who died had a diagnosis of malignancy.

British Journal of Surgery, 2013; DOI: 10.1002/bjs.8992






Liver transplantation gives improved survival compared to resection for patients with HCC

The authors, from this major liver centre aimed to determine the optimal oncological strategy for patients with early hepatocellular carcinoma who may be eligible for either liver resection or transplantation.  A total of 198 patients were included on an intention to treat basis, 97 resected and 101 transplanted.  Postoperative mortality was actually higher in the resection although major morbidity was higher in the transplantation group.  Of note was the significant difference in tumour recurrence; 10% in the transplant group versus 62% in those resected.  In addition, those transplanted had significantly better overall and disease free survival.  The authors go on to show that in a selected group of patients, resection may demonstrate comparable outcomes.  In conclusion, the authors have clearly shown the benefits of transplantation over resection for patients eligible for either.  The utility of this approach in the era of organ shortage and increasing use of marginal organs may need further investigation.

Annals of Surgery, December 2012;256(6):883–891




Technical approach to laparoscopic resection of any liver segment

The authors who are international figures in the field of liver surgery review their experience with 342 patients who underwent laparoscopic liver resection.  This is a technical paper describing various approaches for anatomical segmental resections.  The authors conclude with the refinements that they have developed, that laparoscopic segmentectomies are already an essential liver resectional procedure to minimize loss of liver volume while not compromising the oncological outcome.  However they also feel that further advances will continue to improve the accuracy of this technique, in particular with regards superior and posterior segments.

Annals of Surgery, December 2012;256(6):959–964




Two-stage liver resections are not associated with any increase in morbidity/mortality compared to one-stage

Two stage resections for patients with borderline operable liver tumours are increasingly being used to push the boundaries of liver resection. In this study the authors aimed to determine whether a two stage procedure was associated with a higher complication rate.  This group was well suitable to carry out this study as they developed the now widely used Clavien-Dindo classification of morbidity.  The authors analysed 200 patients in whom a fifth of whom had a two stage resection after portal vein embolization.  They showed that a two stage resection was not associated with any significant increase in morbidity or mortality. 

HPB, 2012; DOI: 10.1111/hpb.12001






Splenic vessels preservation is recommended during spleen preserving left pancreatectomy in select patients

This retrospective study focuses on surgical techniques directed at spleen preservation during laparoscopic distal pancreatectomy. It compares the Warshaw technique (n=55) with splenic vessel preservation (SVP; n=85), combining patients from two centres (France and Spain). The 2 groups were largely similar, except for tumour size which was significantly more in the Warshaw group. There were no differences between the 2 groups in terms of operating time, blood loss and conversion to open surgery. Splenic preservation was significantly better in the SVP group compared to the Warshaw technique group (96.4% versus 84.7%; p=0.03). Length of stay was shorter in the SVP group (8.2 days versus 10.5 days; p=0.01). Based on these short term benefits, SVP is recommended over the Warshaw technique during laparoscopic spleen preserving left pancreatectomy in select patients with benign/low grade malignant tumours in the body/tail of pancreas.

Arch Surg, 2012 Nov;19:1-7.



Response to preop chemo before resection of colorectal liver metz is surrogate marker of postop survival

The prognostic impact of optimal CT morphological response to preoperative chemotherapy (either oxaliplatin or irinotecan based, with or without bevacizumab) for colorectal liver metastases (CRLM) was evaluated. Two hundred and nine patients treated between January 2001 and December 2011 with liver resection following preoperative chemotherapy were included. The 3 and 5 year overall survival rates were superior in the optimal morphological response group (82% and 74%) compared to the suboptimal response group (60% and 45%; p<0.001). Major pathological response rate was better predicted by morphological response (92% in optimal response group versus 59% in suboptimal response group; p<0.001) than RECIST criteria (83% in partial response versus 66% in stable/progressive disease; p=0.04). The correlation of optimal morphological response with overall survival has led to authors to conclude that this could be employed as a surrogate therapeutic end point for patients with CRLM.

J Clin Oncol. 2012 Nov;doi:10.1200/JCO.2012.45.2854



Enhanced recovery principles can be safely applied in the management of liver resection

This prospective Dutch study assessed the effect of using enhanced recovery principles in laparoscopic and open liver resections. The first hundred patients enrolled in this programme between January to August 2011 were evaluated. The median length of stay (LOS) for all patients was 5 days, and this was further reduced to 2 days in the laparoscopic surgery group compared to 5 days in the open surgery group (p<0.001). The readmission rate was 6% and no patient died within 30 days of surgery. Thus enhanced recovery principles can be safely applied in the perioperative management of liver resection. 

Br J Surg. 2012 Nov;doi: 10.1002/bjs.8996. 






International consensus should promote universal reporting of acute pancreatitis

This international working group led, web based consultation updates the 1992 Atlanta classification of acute pancreatitis. Members of 11 national and international pancreatic associations were invited to participate and three rounds of web-based consultation were performed. This consensus proposes new definitions for the diagnosis of pancreatitis and categorises pancreatitis into interstitial oedematous pancreatitis and necrotizing pancreatitis. Two stages of disease (early and late) are identified. Severity is now classified clinically into 3 groups: mild, moderate and severe. Mild acute pancreatitis the most common form is not associated with organ failure, local or systemic complications and usually resolves within a week. Moderately severe acute pancreatitis involves transient (< 48 h) organ failure, development of local complications or the exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure (> 48 h). Local complications are classified as: acute peripancreatic fluid collection (APFC), pancreatic pseudocyst, acute necrotic collection (ANC) and walled-off necrosis (WON). The morphological features of these complications are described and standardised CT reporting criteria are proposed. These internationally agreed definitions should lead to standardised reporting of acute pancreatitis within the published literature and clear up some of the ambiguities of the previous classification system.

GUT, doi:10.1136/gutjnl-2012-302779



Aggressive diagnosis and management of postpancreatectomy bleeding can result in low mortality

The objective of this study was to analyse the rate, management and outcome of postpancreatectomy haemorrhage (PPH) in a single centre over a recent 5-year period. Data was collected by retrospective review of a prospectively maintained database of 1122 pancreatectomies during the study period. The International Study Group of Pancreatic Surgery (ISGPS) definitions and categories of haemorrhage were used and episodes divided up into early (<24 hr post operation) and late (>24 hr post operation). The overall incidence of PPH was 3%. Early haemorrhage occurred in 21%, all cases involved extraluminal bleeding and all required immediate reoperation. Late haemorrhage occurred in 26 (79%) patients and was intraluminal in the majority (69%) of cases. Most patients with late haemorrhage were managed endoscopically (50%) or angiographically (38%) with only 10% requiring return to theatre. PPH increased length of hospital stay but not mortality. Median time to haemorrhage in the late group was 12 days (4-13 days), occurring after discharge in 39% of cases. The authors conclude that PPH can be managed successfully with a low mortality and advocate an aggressive approach to diagnosis and management. Early hemorrhage requires urgent reoperation, and management of delayed hemorrhage should be guided by location (intra- vs extraluminal).

Journal of the American College of Surgeons, 2012;215(5):616-621.



Statin use in patients with cancer is associated with reduced cancer-related mortality

This large national study with 100% follow-up aimed to test the hypothesis that statin use begun before a cancer diagnosis is associated with reduced cancer related mortality. The study assessed mortality amongst the entire Danish population, over the age of 40, who received a cancer diagnosis during a 12-year period. 18,721 patients had used statins regularly before cancer diagnosis, 277,204 had not used statins. Multi-variable adjusted hazard ratios for stain users, as compared with patients who had never used statins, were 0.85 (95% confidence interval [CI], 0.83 to 0.87) for death from any cause and 0.85 (95% CI, 0.82 to 0.87) for death from cancer. This reduction in mortality amongst statin users was seen irrespective of dose of statins taken. Reduced mortality in the statin group was observed for 13 different types of cancer, including pancreatic cancer. The authors conclude Statin use in patients with cancer is associated with reduced cancer-related mortality and suggest clinical trials are warranted.

N Engl J Med 2012;367:1792-1802




Either the liver metz or the colorectal cancer can be treated first in patients with synchronous disease

This study compared the management of patients presenting with synchronous colorectal liver metastases (CRLM). Reverse management (RM, liver-directed chemotherapy, the resection of the CRLM, and the subsequent resection of the primary cancer) was compared to classical management retrospectively. 787 patients were included: 729 in the CM group and 58 in the RM group. Patients in the 2 groups had similar numbers of metastases and Fong scores of >3. Rectal cancer, neoadjuvant rectal radiotherapy, and the use of combined irinotecan/oxaliplatin chemotherapy were more frequent in the RM group, whereas colorectal lymph node involvement was more frequent in the CM group. Overall survival and disease-free survival were similar in the RM and CM groups.

Annals of Surgery November 2012;256(5):772–779


Efficient centralisation of liver resections may improve numbers performed and outcomes

The authors aimed to evaluate the incidence of liver resection, postoperative mortality, and variables that predict this outcome by analysing French health care database to identify all patients who had undergone elective hepatectomy. Overall, 28,708 hepatectomies were performed between 2007-10. The annual incidence (13.2 per 105 adult inhabitants) varied between regions. Hospitals performed a median of only 4 resections per year but 53% of all resections were performed in institutions with a volume of more than 50 per year. Treatment for primary tumors and major resections correlated with hepatectomy caseload. In-hospital and 90-day mortality were 3.4% and 5.8%, respectively. 

Annals of Surgery, November 2012;256(5);697–705



Slow response to chemo in initially unresectable colorectal liver metz may not benefit from liver resection

The authors aimed to determine short- and long-term outcomes of major hepatectomy in patients with downstaged colorectal liver metastases considered initially unresectable (IU). Data was analysed from 257 patients who underwent major hepatectomy for colorectal liver metastases. Compared with fast responders (requiring <12 cycles of chemotherapy), slow responders (>12 cycles) had increased mortality (0% vs 19%) and major morbidity rates (20% vs 55%). In multivariate analysis, the only factor associated with increased major morbidity was the existence of a number of chemotherapy cycles of 12 or more. One-, 3-, and 5-year disease-free survival rates for the entire population were 48%, 17.5%, and 13%, respectively. Multivariate analysis found that slow responders and patients without adjuvant chemotherapy had a significantly decreased disease-free survival. All slow responders postoperatively recurred within 3 years. 

Annals of Surgery, November 2012;256(5):746–754




Specialist multidisciplinary management is needed after failed biliary reconstruction following bile duct injury

Roux-en-Y hepaticojejenostomy (RYHJ) is commonly employed in the repair of post cholecystectomy bile duct injuries. Failure of RYHJ is a complex situation, and a multidisciplinary approach with operative, radiologic or endoscopic techniques is required. The authors review a single centre retrospective series of 44 patients managed over a 12 year period. Primary revisional surgery was undertaken in 29 patients (either revision RYHJ or hepatectomy), and percutanous procedures in 18 (biliary interventions or portal vein embolisation). Thirty nine patients (89%) were free of incapacitating biliary symptoms following treatment. The authors advocate immediate multidisciplinary management in a tertiary hepatobiliary centre for satisfactory long term outcome following failed RYHJ.

Surgery 2012;doi:10.1016/j.surg.2012.06.028.



Surgical treatment strategies in chronic pancreatitis: A meta-analysis

Both pancreaticoduodenectomy (PD) and duodenum preserving pancreatic head resections (DPPHR) are employed in the management of chronic pancreatitis. The authors conducted a systematic review of randomized and non randomized studies which compared PD with DPPHR (Beger or Frey procedures). Fifteen studies involving 1007 patients were included in the meta-analyses. Post operative pain relief was significantly better in patients undergoing Beger’s procedure compared to PD. This was not the case in patients who had Frey’s procedure, though postoperative morbidity for this group compared favorably against PD. Outcomes of pancreatic exocrine insufficiency, delayed gastric emptying and quality of life favored DPPHR.

Arch Surg 2012;147(10):961-8.



Preop detected indeterminate pulmonary nodules may represent lung metz in those with hepatic malignancy

Inderterminate pulmonary nodules (IPN) are identified on preoperative imaging for hepatic malignancies, and their impact on management is unclear due to a lack of knowledge of their natural history. The authors evaluated how often IPN represent lung metastases in a retrospective series of patients undergoing liver resection and/or radiofrequency ablation between 2000 - 2010. Ninety patients were studied, and 20 developed isolated lung recurrence following treatment of hepatic malignancy. This was significantly more common in patients with colorectal cancer liver metastases compared to hepatobiliary or other cancers (42.9 vs. 9.4 vs. 14.3 %, p=0.004).

J Gastrointest Surg 2012;DOI 10.1007/s11605-012-2051-y




Tumour Infiltration in the Medial Resection Margin Predicts Survival After Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

Microscopic tumour involvement at the circumferential resection margins (R1) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) has been debated. In this retrospective analysis of prospectively collected data the authors investigated the rates of anterior, posterior, medial and pancreatic transection margin involvement and their prognostic influence on survival. The overall R1 rate at any margin was 57.1% (48/84). The rates of involvement at the anterior, posterior, medial and transection margins were 31.0% 42.9%, 29.8% and 7.1% respectively. Only medial margin involvement had a significant impact on survival (13.8 vs. 28.0 months, P<0.001). The authors conclude that the medial resection margin is the most important after PD for PDAC and involvement predicts poor survival.

Journal of Gastrointestinal Surgery 2012;16:1875-1882



Endoscopic Versus Surgical Ampullectomy – An Algorhythm to Treat Disease of the Ampulla of Vater

This retrospective study of a prospectively collected database compared the effectiveness, morbidity and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA) performed for benign ampullary lesions. Over the 20-year study period 68 patients underwent EA and 41 underwent SA.  Demographic and co-morbidity data were similar between groups with the exception that the EA group had significantly higher rate of severe obesity (BMI>35). EA had significantly reduced length of stay, lower morbidity and readmission rates, but had similar rates of mortality, positive margins and re-interventions. The authors suggest that patients would likely benefit from an aggressive endoscopic approach before consideration of surgery and present a suggested algorithm for management.

Annals of Surgery 2012; doi: 10.1097/SLA.0b013e318269d010



Hepaticocholecystoenterostomy as an alternative to hepaticojejenostomy for biliary bypass

The authors report the use of the technique Hepaticocholecystenterostomy (HCE) as an alternative to hepaticojejenostomy that can be used bo bypass periampullary cancer when trial dissection reveals unresectable disease or after failure of endoscopic stenting. This procedure uses the gallbladder as a conduit and involves two anastomoses. Over the study period 30 patients underwent HCE. Mean operative time was 92 minutes. Mean postoperative length of hospital stay was 9 days. Complications included a single readmission for delayed gastric emptying and one reintervention for bile leak. No patients developed recurrent biliary obstruction. The authors conclude HCE is a safe and effective procedure in selected patients with similar morbidity, patency and overall survival to those reported in the literature for hepaticojejenostomy. The authors feel that the two anastomoses involved are less demanding than the single anastomosis of hepaticojejenostomy.

Annals of the Royal College of Surgeons of England 2012;94(7):472-475.




External biliary drainage and liver regeneration after major hepatectomy

This prospective study investigated the association between serum bile acid levels and extent of liver regeneration after major hepatectomy. Patients undergoing hemi-hepatectomy were divided into two groups: with or without external bilary drainage by a cystic duct tube. Mean serum bile acid levels and regenerated liver volumes on day 3 were significantly greater in those who did not have a external bilary drain. The incidence of bile leakage was similar in the two groups.  

Br J Surg 2012;99(11):1569-74.



KRAS status and outcome of liver resection after neoadjuvant chemotherapy including bevacizumab

The prognostic value of KRAS mutation in patients with colorectal cancer liver metastases (CLM) receiving neoadjuvant chemotherapy following liver resection was investigated. The response rate to neoaduvant therapy was similar in patients with a KRAS mutation and those with the wildtype gene. KRAS mutation had a negative prognostic effect on recurrencefree survival.

Br J Surg 2012;99(11):1575-82



A survey of the accuracy of interpretation of intraoperative cholangiograms

The aim of this study was to determine the accuracy of surgeons' interpretations of intraoperative cholangiograms (IOCs) during laparoscopic cholecystectomy (LC). Fifteen IOCs were sent electronically in random sequence to 20 surgical trainees and 20 consultant general surgeons. The accuracy of IOC interpretation was poor. Only nine surgeons and nine trainees correctly interpreted the cholangiograms showing normal anatomy. Six consultant surgeons and five trainees correctly identified variants of normal anatomy on cholangiograms. Interestingly, abnormal anatomy on cholangiograms was identified correctly by 18 consultant surgeons and 19 trainees. Routine IOC was practised by seven consultants and six trainees.

HPB 2012;14(10):673–676




Risk and Cost-effectiveness of Surveillance Followed by Cholecystectomy for Gallbladder Polyps

This retrospective study of patients with ultrasonography-detected gallbladder polyps investigated the detection rates for potentially and frankly neoplastic polyps.  These were compared with complication rates from cholecystectomy and cost-effectiveness of cholecystectomy and surveillance were analysed. Of 986 patients identified with gallbladder polyps only 467 (47.3%) were followed up and only 53 (5.4%) were discussed at a HPB multidisciplinary meeting. 6.6% of polyps increased in size during surveillance and these had a significantly greater diameter at first presentation (7mm vs. 5mm; P<0.05). 134 patients underwent laparoscopic cholecystectomy with only 5 patients demonstrating malignant (1 patient, 0.7%) or potentially malignant (4 patients, 3%) disease. Polyps greater than 10mm and increase in size during surveillance predicted neoplastic potential. Making the assumption that all potentially malignant polyps would eventually progress to malignancy the authors discuss that surveillance with or without a selective surgery policy could potentially prevent 5.4 gallbladder cancers per 1000 individuals and save more than £130 000 (US $201 676) per year compared with the cancer associated treatment costs.

Arch Surg. 2012; doi:10.1001/archsurg.2012.1948



Effect of Billroth II or Roux-en-Y Reconstruction for the Gastrojejenostomy on Delayed Gastric Emptying After Pancreaticoduodenectomy: A Randomized Control Study

Delayed gastric emptying (DGE) is one of the commonest causes of morbidity and prolonged hospital stay after pancreaticoduodenectomy. In this prospective randomized controlled trial the authors compare antecolic Billroth II (B-II) and Roux-en-Y (R-Y) reconstructions after subtotal stomach preserving pancreaticoduodenectomy (SSPPD). Following power calculation 101 patients were randomized pre-operatively to either B-II (49) or R-Y (52) reconstruction groups. The primary endpoint was grade B or C DGE as defined by the International Study Group of Pancreatic Surgery (ISGPS). The incidence of DGE was 5.7% in the B-II group and 20.4% in the R-Y group (P=0.028) and patients in the B-II group had significantly shorter hospital stays (31.6 +/- 15.0 days vs. 41.4 +/- 20.5 days, P=0.037).Consistent with previous reports pancreatic fistula was also significantly associated with DGE (P=0.037). The authors conclude that the incidence of DGE after SSPPD can be reduced by using B-II rather than R-Y reconstruction for gastrojejenostomy.

Annals of Surgery. 2012;doi: 10.1097/SLA.0b013e31826c3f90



Should Portal Vein Be Routinely Resected During Pancreaticoduodenectomy For Adenocarcinoma?

The authors performed a retrospective cohort study using a matched control group to compare 19 patients undergoing pancreaticoduodenectomy with en-bloc portal vein/superior mesenteric vein (PV/SMV) resection without histological evidence of venous involvement with 19 matched patients undergoing standard pancreaticoduodenectomy. All en-bloc PV/SMV resections included were performed for suspected intra-operative venous invasion but later found to be histologically negative. There was no difference in the immediate postoperative course of the patients between groups with regard to morbidity, mortality, reoperation rate and length of hospital stay. Median survival (42 months vs. 22 months, P=0.02) and overall 3-year survival (60% vs. 31%, P=0.03) were significantly longer in the en-bloc PV/SMV group compared with the control group. The authors discuss that this may relate to a loco-regional clearance effect, however given the retrospective cohort design and relatively small patient sample size selection bias and confounding cannot be excluded. The authors plan to analyse frozen sections of resection margins of the PV bed in patients undergoing standard pancreaticoduodenectomy for evidence of K-ras or other mutations, which may support a randomized controlled trial of routine PV/SMV resection during pancreaticoduodenectomy for resectable pancreatic adenocarcinoma.

Annals of Surgery 2012;doi: 10.1097/SLA.0b013e318269d23c




Preoperative Endoscopic Nasobiliary Drainage in 164 Consecutive Patients With Suspected Perihilar Cholangiocarcinoma: A Retrospective Study of Efficacy and Risk Factors Related to Complications

The optimal method of obtaining biliary drainage prior to carrying out major liver resection in patients with perhilar cholangiocarcinoma remains a matter of some debate.  In this paper the Nagoya group study the clinical benefits of preoperative endoscopic nasobiliary drainage (ENBD) in patients with perihilar cholangiocarcinoma.  A total of 164 consecutive patients with suspected perihilar cholangiocarcinoma between January 2007 and December 2010 were studied. ENBD was successful in 153 (93.3%) patients. Of the 164, only 65 had serum total bilirubin levels of 2.0 mg/dL (34 µmol/L) or more before the drainage. The first unilateral ENBD was successfully performed in 60 of the 65 patients, and the bilirubin level decreased to less than 2.0 mg/dL after ENBD in 50 of these 60 patients (83.3%). The significant predictive factors for ENBD efficacy included the pre-ENBD bilirubin level (P = 0.032) and post-ENBD cholangitis (P = 0.012). Post-ENBD cholangitis occurred in 47 (28.8%) of the 163 patients, and a previous endoscopic sphincterotomy was found to be a significant risk factor for post-ENBD cholangitis (P = 0.008). Post-ENBD pancreatitis occurred in 33 (20.1%) of the 164 patients. The significant risk factors included undergoing pancreatography (P < 0.001) and the absence of previous shoncterotomy or ENBD (P < 0.001).  The authors conclude that unilateral ENBD of the future remnant lobe(s) exhibited a high success rate, suggesting that it is an effective and suitable preoperative drainage method for perihilar cholangiocarcinoma even in patients with extensive tumours. To reduce the postprocedural complications, ENBD should be performed without sphincterotomy or pancreatography.

Annals of Surgery 2012;doi: 10.1097/SLA.0b013e318262b2e9



Pathologic Response to Preoperative Chemotherapy in Colorectal Liver Metastases: Fibrosis, not Necrosis, Predicts Outcome

Predicting which patients with colorectal liver metastases (CLM) will benefit from major surgical resection remains a goal for researchers in order to minimize unnecessary surgery and the morbidity and mortality that entails.  Pathological response is thought to be associated with survival after hepatectomy. Different histological, dominant response patterns include fibrosis, necrosis and/or acellular mucin, but some of these changes can appear without previous chemotherapy and their individual correlation with outcome is unknown.  The aim of this paper was to investigate the relationship between the different pathological responses to chemotherapy and overall outcome.  Pathology slides from 366 patients who underwent CLM resection between 2003 and 2007 (irrespective of preoperative chemotherapy status) were rereviewed by a blinded pathologist.  Preoperative chemotherapy was administered in 249 (68 %) patients, who, when compared to no preoperative chemotherapy patients, had higher rates of overall pathologic response (57 vs. 46 %, P < .01), fibrosis (21 vs. 12 %, P < .01) and acellular mucin (6 vs. 3 %, P = .05) but similar rates of necrosis (30 vs. 31 %, P = .30). In patients receiving preoperative chemotherapy, overall pathologic response ≥75 % (5 year, 83 vs. 47 %, P < .01) and fibrosis ≥40 % (5 year, 87 vs. 51 %, P < .01) independently correlated with disease-specific survival after hepatectomy.  In summary, the authors found fibrosis to be the predominant chemotherapy-related pathologic alteration driving the association of treatment response with survival after CLM resection. Necrosis in CLM is not related to chemotherapy or outcome.

Ann Surg Oncol 2012;19(9):2797-804.



Progression while Receiving Preoperative Chemotherapy Should Not Be an Absolute Contraindication to Liver Resection for Colorectal Metastases

The authors used the multicenter international registry LiverMetSurvey to investigate whether progression of colorectal liver metastases while undergoing chemotherapy should be seen as a contraindication to liver resection.  Tumor progression while receiving neoadjuvant chemotherapy has been associated with poor outcome and has been seen as a contraindication to liver resection previously. Patients undergoing liver resection for colorectal metastases without extrahepatic disease after neoadjuvant chemotherapy between 1990 and 2009 were reviewed.  Among 2143 patients, progression on chemotherapy occurred in 176 (8.2 %). Risk of progression was increased after 5-FU or irinotecan (22.7 % vs. 6.8 %), while it was reduced after oxaliplatin (5.6 % vs. 12.0 %) and still diminished among patients receiving targeted therapies (2.6 %). Progression on chemotherapy was an independent prognostic factor of survival at multivariate analysis (35 % vs. 49 %, p = 0.0006). In the progression group, 3 independent prognostic factors were identified: carcinoembryonic antigen (CEA) ≥200 ng/mL (p = 0.003), >3 metastases (p = 0.028), and tumor diameter ≥50 mm (p = 0.002). A survival predictive model showed that patients without any risk factors had 5-year survival rates of 53.3 %; good survival results were still observed if metastases were >3 or ≥50 mm (29.9 and 19.1 %, respectively). On the contrary, survival was less than 10 % at 3 years in the presence of >1 prognostic factor or CEA of ≥200 ng/mL.  In summary the authors concluded that while progression while on chemotherapy is a negative prognostic factor, it is not an absolute contraindication to liver resection.

Ann Surg Oncol 2012;19(9):2786-96



Risk factors associated with delayed haemorrhage after pancreatic resection

Delayed haemorrhage (occurring > 5 days) after pancreatic resection is a life-threatening complication commonly related to anastomotic leak or local infection. In this study of 457 patients the incidence of delayed haemorrhage was 2.4% with an associated mortality of 63.6%. Logistic regression identified age >60 years and a diagnosis of malignant disease were risk factors for delayed haemorrhage. Prognostic factors in patients who experienced delayed haemorrhage included shock index (heart rate/systolic blood pressure) ³ 0.7 and SIRS at the onset of delayed haemorrhage.

HPB 2012;14(10):684-678.



Effects of low cardiopulmonary reserve on pancreatic leak following pancreaticoduodenectomy

The authors highlight that postoperative complications are increased in patients with reduced cardiopulmonary reserve undergoing major surgery. Pancreatic leak following pancreaticoduodenectomy is a major contributor to postoperative complictions. The aim of the study was to determine whether reduced cardiopulmonary reserve was a risk factor for pancreatic leak. All patients requiring pancreaticoduodenectomy with a metabolic equivalent (MET) score < 7 were selected for preoperative cardiopulmonary exercise testing (CPET) and included in the study (n=124). An anaerobic threshold (AT) of 10.1 ml/kg/min was used to identify patients with reduced cardiopulmonary reserve. Low AT was significantly associated with pancreatic leak (45% v 19.2%; P = 0.020), postoperative complications (70% v 38.5%; P = 0.013) and prolonged hospital stay (29.4% v 17.5 days; P = 0.001). The authors conclude that AT seems a useful tool for stratifying the risk postoperative complications.

Br J Surg 2012;99:1290-1294



The association between body mass index and severe biliary infections: a multivariate analysis

Obesity is both a risk factor for cholesterol gallstones and associated with worse infectious disease outcomes. In this study the authors investigate the relationship between BMI, biliary sepsis and severity of illness. The study population being predominantly male (86%) is unusual in a study of biliary disease and limits generalization of the findings to typical populations with biliary disease. Gallstones, bile and blood were cultured. BMI inversely correlated with pigment stones, biliary bacteria, bacteraemia, and increased severity using bivariate and multivariate analysis.  The authors conclude that obesity is associated with less severe biliary infections and may actually be protective of biliary infection.  

Am. J. Surg 2012;doi:10.1016/j.amjsurg.2012.07.002



Factors Influencing Readmission After Pancreaticoduodenectomy: A Multi-Institutional Study of 1302 Patients

Although mortality, morbidity and length of hospital stay are reducing after pancreaticoduodenectomy (PD) readmission rates remain relatively high. This multicentre, retrospective analysis of standardized, prospectively maintained databases aimed to delineate factors associated with readmission. 1302 patients were included and 30 and 90-day readmission rates were 15% and 19% respectively. Infective complications were the most common reason for readmission at both 30 and 90-days followed by nutritional factors/failure to thrive. Preoperative chronic pancreatitis, higher transfusion requirements and postoperative complications (including intra-abdominal abscess and pancteatic fistula) were identified as factors associated with readmission on multivariate analysis (all P < 0.02). Advanced age, BMI, cardiovascular/pulmonary co-morbidities, diabetes, steroid use, Whipple type, preoperative endobiliary stenting and vascular reconstruction were not associated with higher readmission rates.

Ann Surg 2012;256(3):529-537.



Clinical Outcome in Relation to Timing of Surgery in Chronic Pancreatitis – A Normogram to Predict Pain Relief

The aim of this retrospective multicentre cohort study was to evaluate the effect of the timing of surgery on the long-term clinical outcome in chronic pancreatitis. Interventions included both pancreatic drainage procedures and resections performed for pain relief. The study primary outcome was pain relief with secondary outcomes including pancreatic endocrine and exocrine insufficiency and quality of life. Of the 266 patients included, pain relief was achieved in 149 (58%). Univariate and multivariate analysis identified surgery within 3 years of symptom onset, avoidance of preoperative opiate use and fewer than 5 preoperative endoscopic treatments as significantly associated with pain relief. A normogram is presented predicting the probability of post-operative long-term pain relief based on these risk factors. The authors conclude that the timing of surgery is an important risk factor for clinical outcome in chronic pancreatitis and that surgery may need to be considered earlier than current practice.

Arch Surg 2012;doi:10.1001/archsurg.2012.1094



Gemcitabine plus erlotinib followed by capecitabine versus capcitabine plus erlotinib followed by gencitabine in advanced pancreatic cancer: final results of a randomized phase 3 trial of the ‘Arbeitsgemeinschaft Internistische Onkologie’ (AIO-PK0104)

This prospective, multicentre, two-arm, phase 3 clinical trial is the first trial to evaluate predefined sequential first and second line therapies in advanced pancreatic cancer. 1st line gemcitabine/erlotinib followed by 2nd line capecitabine was compared with the reverse experimental sequence of capecitabine/erlotinib followed by gemcitabine. Following a power calculation 281 patients with advanced pancreatic cancer were randomized to a treatment
arm. Treatment failure (disease progression or toxicity) was an indicator for allocation to 2nd line therapy. The primary endpoints were time to treatment failure of the 1st and 2nd line therapies. KRAS mutations were analyzed in a subset of patients. Of 274 eligible patients 43
had locally advanced and 231 had metastatic disease. 140 (51%) received 2nd line chemotherapy. Time to 2nd line chemotherapy failure and median overall survival were not significantly different between arms. Time for 1st line chemotherapy failure was significantly prolonged in the gemcitabine/erlotinib compared with the capecitabine/erlotinib arm (3.2 vs 2.2 months; HR 0.69, p=0.0034). Skin rash was associated with both improved time to 2nd line treatment failure and overall survival. These results demonstrate that both treatment arms are safe, feasible and have similar efficacy in pancreatic cancer. Skin rash is strongly correlated with efficacy outcome measures in pancreatic cancer patients treated with erlotinib. KRAS wild-type status was associated with an improved overall survival (HR 1.68, p=0.005) however the study is unable to distinguish whether this is a prognostic phenomenon of the disease or a predictive marker for erlotinib efficacy as erlotinib was included in both trial arms.  

Gut 2012;doi:10.1136/gutjnl-2012-302759



Effect of specialist decisionmaking on treatment strategies for colorectal liver metastases

The authors retrospectively review imaging of 53 patients with colorectal cancer liver metastases who were not referred to a specialist but who were instead sent for palliative chemotherapy.  The imaging was reviewed by six specialist liver surgeons who found that 63% of patients were potentially resectable.  Drawbacks of this study are the small numbers of patients and the unknown reasons for the decisions for palliative treatment alone.  However this study was carried out in a cancer network known to already have a relatively high rate of liver resections for colorectal cancer and this suggests there may still be a very high number of patients with potentially resectable liver metastases who are being denied potentially curative treatment.

Br J Surg. 2012 Sep;99(9):1263-9.



Repeat hepatic resection for colorectal liver metastases

The authors present the largest series reported of repeat hepatic resections for colorectal liver metastases.  Over a 17-year period, 195 repeat resections were carried out with low 30-day morbidity and mortality of 20% and 1.5% respectively and excellent outcomes with a 5-year survival rate of 29.4%.  A tumour size greater than 5 cm was the only factor studied associated with a poorer overall survival.  The authors conclude that repeat resection remains the only curative option for patients with recurrent colorectal liver metastases.  This is an impressive series, one drawback being the study period with significant changes in practice likely over this time.  It also begs the question as to the optimal follow-up strategy to identify recurrent disease before the metastasis is greater than 5 cm or is there something that could be identified biologically from the initial resection that could identify patients likely to have a poor outcome from repeat resection.

Br J Surg. 2012 Sep;99(9):1278-83



Resection of liver metastases in patients with breast cancer: Survival and prognostic factors

This study describes the outcomes of 32 patients from 11 institutions collected over 20 years in the Netherlands, who had a liver resection for metastatic breast cancer.  Without such surgery, the median survival is 4-33 months but following a resection the median survival was 55 months with a 5-year overall and disease-free survival of 37% and 19% respectively.  There was no peri-operative mortality.  The only significant prognostic factor on multivariate analysis was if the metastasis was solitary or not.  While this is a highly selected group, this study shows that liver resection for such patients is safe and offers some benefit, particularly in patients with solitary metastases.  As the multimodal treatment of metastatic breast cancer continues to evolve, the surgical options for treatment of liver metastases may be increasingly beneficial.  

Eur J Surg Oncol. 2012;[Epub ahead of print]



New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo guidelines

Diagnostic and severity assessment criteria for acute cholangitis were first produced in 2006 and in this paper, a large group of senior international experts have revised this criteria.  This is a difficult task as unlike most surgical diseases, there is no organ or tissue which can be removed for pathological analysis.  By analysing 1432 patients with acute biliary tract pathology, the diagnostic criteria have been modified to improve both sensitivity and specificity by removing pain from the criteria and focussing more on imaging findings.  The stratification of patients is useful to guide patient management, in particular, the timing of definitive treatment or biliary tract drainage. 

J Hepatobiliary Pancreat Sci. 2012; In Press



Effect of Adjuvant Chemotherapy With Fluorouracil Plus Folinic Acid or Gemcitabine vs Observation on Survival in Patients With Resected Periampullary Adenocarcinoma - The ESPAC-3 Periampullary Cancer Randomized Trial

This multicentre, phase 3, randomized controlled trial was carried out to determine whether adjuvant chemotherapy (with fluorouracil or gemcitabine) provides improved overall survival following resection of periampullary adenocarcinoma. 428 patients with periampullary (pancreatic, biliary, ampullary and duodenal) adenocarcinoma were randomized to observation (145 patients), fluorouracil plus folinic acid (143 patients) or gemcitabine (146 patients). Overall survival, the primary outcome measure, did not differ significantly between observation and chemotherapy groups. Median survival was 35.2 months (95% CI, 27.2-43.0 months) in the observation group and was 43.1 (95% CI, 34.0-56.0) in the 2 chemotherapy groups (Hazard ratio, 0.86; 95% CI, 0.66-1.11; c2=1.33; P=0.25). Multivariate analysis, however, correcting for prognostic variables (age, bile duct cancer, poor tumour differentiation and positive lymph nodes) found a statistically significant survival benefit to chemotherapy (HR 0.7; 95% CI, 0.57-0.98; Wald c2=4.53, P=0.03) and specifically for gemcitabine compared with observation. The authors conclude that the evidence supporting adjuvant chemotherapy is modest, and the testing of combination chemotherapies is warranted. 

JAMA 2012; 308(2):147-156



Early Laparoscopic Cholecystectomy for Mild Gallstone Pancreatitis - Time for a Paradigm Shift

This retrospective two-centre study aimed to investigate if hospital stay could be reduced for patients with mild gallstone pancreatitis undergoing early laparoscopic cholecystectomy (< 48 h, without awaiting normalization of pancreatic and liver enzymes) without increasing morbidity and mortality. 303 patients underwent laparoscopic cholecystectomy, 117 within 48 hours and 186 delayed beyond 48 hours. The delayed group was significantly older (40 v 35 years, P=0.006). Mortality and complication rates were similar between groups (P=0.99), however median hospital stay was significant less for the early group than for the delayed group (3 vs 6 days; P<0.001). Patients who underwent early procedures were also less likely to undergo endoscopic retrograde chloangiopancreatography (P=0.02). The authors conclude that delaying laparoscopic cholecystectomy until normalization of laboratory values appears to be unnecessary.

Arch Surg. 2012; doi:10.1001/archsurg.2012.1473


Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

The aim of this systematic review was to appraise the current evidence for the incorporation of an Enhanced Recovery Programe (ERP) for major pancreatic and hepatic resections. Literature review identified 10 studies meeting defined inclusion criteria. Although the ERP protocols varied between studies the underlying principles of a multimodal clinical pathway incorporating patient education, regional anaesthesia, optimal analgesia, judicious use of surgical drains, early mobilization and early introduction of oral liquids were underlying themes. A reduction in the length of hospital stay was a consistent finding compared with historical controls, which in this limited series was not found to be at the expense of increased rates of readmission, morbidity or mortality in any of the studies reviewed. The authors point out however that as identified in the Cochrane review of ERP in colorectal surgery there is no proof that reduced length of hospital stay is a medically important parameter. They conclude that the implementation of a HPB ERP should increase awareness of goals that improve safety and clinical outcomes and highlight some of the differences from the practice in colorectal surgery. Although the evidence suggests implementing ERP appears safe and feasible RCTs will be required to clearly define evidence-based HPB specific parameters.

Annals of the Royal College of Surgeons of England 2012; 94(5): 318-326



Outcome of HCV/HIV-Coinfected Liver Transplant Recipients: A Prospective and Multicenter Cohort Study

Eighty-four HCV/HIV-coinfected and 252-matched HCV-monoinfected liver transplant recipients were included in a prospective multicenter study. Thirty- six (43%) HCV/HIV-coinfected and 75 (30%) HCV- monoinfected patients died, with a survival rate at 5 years of 54% (95% CI, 42–64) and 71% (95% CI, 66 to 77; p = 0.008), respectively. When both groups were considered together, HIV infection was an independent predictor of mortality (HR, 2.202; 95% CI, 1.420–3.413 [p < 0.001]). Multivariate analysis of only the HCV/HIV- coinfected recipients, revealed HCV genotype 1 (HR, 2.98; 95% CI, 1.32–6.76), donor risk index (HR, 9.48; 95% CI, 2.75–32.73) and negative plasma HCV RNA (HR, 0.14; 95% CI, 0.03–0.62) to be associated with mortality. When this analysis was restricted to pretransplant variables, we identified three independent factors (HCV genotype 1, pretransplant MELD score and centers with <1 liver transplantation/year in HIV-infected patients) that allowed us to identify a subset of 60 (71%) patients with a similar 5-year prognosis (69% [95% CI, 54–80]) to that of HCV-monoinfected recipients. In conclusion, 5-year survival in HCV/HIV-coinfected liver recipients was lower than in HCV-monoinfected recipients, although an important subset with a favorable prognosis was identified in the former.

American Journal of Transplantation 2012;12(7):1866–1876



Are Patients With Child’s A Cirrhosis and Hepatocellular Carcinoma Appropriate Candidates for Liver Transplantation?

Authors aimed to estimate the survival benefit derived from transplantation in patients with stage II hepatocellular carcinoma (HCC) and Child’s A cirrhosis, defined as the mean lifetime with transplantation minus the mean lifetime with treatments other than transplantation. The posttransplantation survival of all adult, first-time, deceased-donor, liver transplant recipients in the United States since the introduction of the Model for End-Stage Liver Disease based priority system in February 2002 (n = 36 791) was calculated. Authors estimated the posttreatment survival of patients with Child’s A cirrhosis and stage II HCC treated by radiofrequency ablation (RFA) ± transarterial chemoembolization (TACE) or surgical resection by conducting a systematic review of the medical literature. In patients with Child’s A cirrhosis and stage II HCC, the estimated median survival benefit of liver transplantation compared to RFA ± TACE was 1.5 months at 3 years (range −3.5 to 5.6) and 5.7 months at 5 years (range 0.7–11.4), whereas com- pared to surgical resection it was 0.7 months at 3 years (range −2.9 to 3) and 2.8 months at 5 years (range −4.4 to 5.7). Liver transplantation in patients with stage II HCC and Child’s A cirrhosis results in a very low survival benefit and may not constitute optimal use of scarce liver donor organs.

American Journal of Transplantation 2012;129(3):706–717



Resection of segment VIII for hepatocellular carcinoma

The authors describe their experience of 154 cases of anatomical segment VIII resection for hepatocellular carcinoma (HCC).  This is a technically demanding procedure but may offer advantages compared with the alternatives such as right hepatectomy or non-anatomical resection.  In this paper the outcomes were compared with patients who underwent non-anatomical resection of segment VIII lesions during the same period.  This clearly has drawbacks as there are a number of possible sources of bias as it is clearly not a randomised study.  However the results presented, from a highly respected unit, are impressive.  Despite relatively long median operating times at 378 minutes, which reflects the difficulty of the procedure, the cumulative 5-year recurrence-free and overall survival rates were 28·5 and 79·6 per cent, which were significantly better than rates of 19·4 and 64·8 per cent respectively after nonanatomical resection (P = 0·036 and P < 0·001).  This was achieved with minimal adverse events which suggests this may soon be seen as the optimal approach to patients with such lesions.

Br J Surg. 2012 Aug;99(8):1105-12



Hepatopancreatoduodenectomy for Cholangiocarcinoma: A Single-Center Review of 85 Consecutive Patients

Major liver resection combined with pancreaticoduodenectomy for cholangiocarcinoma termed hepatopancreaticoduodenectomy (HPD), is a challenging procedure reserved for patients with advanced disease encompassing both the hepatic hilum and the lower bile duct.  Initial outcomes were not good.  However in this paper the respected Nagoya group present a series of 85 patients with excellent outcomes.  A median operative time of 762 minutes with median blood loss of almost 3 litres demonstrates the gravity of the procedures. Indeed an additional vascular resection was required in almost a third of the patients. Despite this, morbidity was acceptable with peri-operative mortality only 2.4% and 5-year overall survival was 37.4%.  This paper highlights the potential of HPD to offer long term survival for patients which may previously have been considered unresectable.  

Ann Surg. 2012 Aug;256(2):297-305



Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases

Portal vein embolization (PVE) prior to hepatectomy to facilitate hypertrophy of the planned remnant liver and reduce post-operative liver failure has been increasingly used to facilitate hepatic resection.  Initially this was used in primary liver tumours but is more frequently being used for patients with colorectal liver metastases.  In this study the authors investigated the effect of PVE on both liver growth and also growth of the tumour metastases.  A putative control group were patients without PVE who had scans over the same time period.  While PVE resulted in significant hypertrophy of the planned liver remnant, it also was shown to significantly increase tumour growth.  The immediate effects of this in terms of progressive disease may make patients inoperable.  The long term effects in terms of long term recurrence-free and overall survival in patients with metastatic colorectal cancer are unknown.

HPB (Oxford). 2012 Jul;14(7):461-8



Sirolimus conversion regimen versus continues calcineurin inhibitors in Liver Allograft Recepients. A Randomised Trial

Calcinurin inhibitors (CNI) are the main stay of immunosuppression regimens following solid organ transplantation and are associated with improved patient survival and decreased acute cellular rejection (ACR) rates. Nephrotoxicity is the most common side effect of CNIs accounting for about renal impairment in upto 15% of patients post solid organ transplant. This is the first large scale RCT prospectively evaluating the safety and efficiency of Sirolimus (SRL) based regimen versus continuation of CNI-based immunosuppression in stable Liver Transplants (LT) at least 6 months post transplant. 607 LT patients were randomized to abrupt conversion from CNI to SRL based regimen or CNI continuation for up to 6 years. LT patients showed no demonstrable benefit 1 year after conversion from CNI-to-SRL-based immunosuppression

American Journal of Transplantation 2012;12(3):694-705



Diabetes Mellitus Following Liver Transplantation in Patients with Hepatitis C Virus: Risks and Consequences

HCV has gained proportions of a global endemic with an estimated 180- million people affected worldwide.  It is the leading indication for liver transplantation in the western world. Recurrent HCV infection of the allograft occurs universally following the liver transplant and evidence from last 2 decades indicates that HCV has metabolic associations – insulin resistance and diabetes mellitus (DM). Approximately half of HCV positive liver transplant recipients develop DM which is associated with accelerated fibrosis progression and poorer graft and patient survival outcomes. This review summarizes the risks and consequences of insulin resistance and post transplant DM in this subgroup of patients.

American Journal of Transplantation 2012;12(3):531-538


A modern approach to teaching pancreatic surgery: stepwise pancreaticoduodenectomy for trainees

Pancreaticoduodenectomy (PD) is a technically demanding surgical procedure. The authors suggest that a reduction in higher surgical trainees working hours have resulted in reduced surgical exposure and consequently less experience in operative procedures. Furthermore aims to improve operating room efficiency have also impacted on trainees’ exposure to procedures. In this paper the authors breakdown the PD procedure into 9 stages and classify the suitability of each stage for trainees at different levels of training. The authors conclude that breaking down PD into a number of different steps may help building up surgical expertise more quickly while maintaining patients’ safety and allowing the surgery to be expedited in a timely manner.

Journal of Gastrointestinal Surgery 2012, DOI: 10.1007/s11605-012-1934-2



Cholecystectomy-related bile duct and vasculobiliary injuries

Combined vasculobiliary injury is a serious complication of cholecystectomy. The authors aimed to assess the short to long-term outcomes after such injury. In a series of 63 patients with Bile duct injury (BDI, 45 patients) or vasculobiliary injury (VBI, 18 patients), 26 patients (45%) developed long-term biliary complications. Vasculobiliary injury and injuryrelated sepsis were independent risk factors for treatment failure: hazard ratio 7·79 (95 per cent confidence interval 2·80 to 21·70; P < 0·001) and 4·82 (1·69 to 13·68; P = 0·003) respectively.

British Journal of Surgery 2012: DOI: 10.1002/bjs.8806



Pregnancy Outcomes of Liver Transplant Recipients: A Systematic Review

The goals of this study were to systematically identify all studies of pregnancy-related outcomes for LT recipients and estimate the rates of pregnancy events, obstetric complications, and delivery outcomes and to compare these rates to those of the general pop- ulation and post-KT estimates. Eight of 578 unique studies met the inclusion criteria, and these studies represented 450 pregnancies in 306 LT recipients. The post-LT live birth rate [76.9%, 95% confidence interval (CI) 1⁄4 72.7%-80.7%] was higher than the live birth rate for the US general population (66.7%) but was similar to the post–kidney transplantation (KT) live birth rate (73.5%). The post-LT miscarriage rate (15.6%, 95% CI 1⁄4 12.3%-19.2%) was lower than the miscarriage rate for the general population (17.1%) but was similar to the post-KT miscarriage rate (14.0%). The rates of pre-eclampsia (21.9%, 95% CI 1⁄4 17.7%-26.4%), cesarean section delivery (44.6%, 95% CI 1⁄4 39.2%-50.1%), and preterm delivery (39.4%, 95% CI 1⁄4 33.1%-46.0%) were higher than the rates for the US general population (3.8%, 31.9%, and 12.5%, respectively) but lower than the post-KT rates (27.0%, 56.9%, and 45.6%, respectively). Both the mean gestational age and the mean birth weight were significantly greater (P < 0.001) for LT recipients versus KT recipients (36.5 versus 35.6 weeks and 2866 versus 2420 g). Although pregnancy after LT is feasible, the complication rates are relatively high and should be considered during patient counseling and clinical decision making.

Liver Transpl 2012;18:621-629



Outcomes of Liver Transplant Recipients with Hepatitis C and Human Immunodeficiency Virus Coinfection

Authors hypothesized that the outcomes of HCV/HIV-coinfected patients would be similar to the outcomes of other higher risk LT recipients without HIV, such as recipients who are 65 years old or older. This prospective, multicenter US cohort study compared patient and graft survival for 89 HCV/HIV-coinfected patients and 2 control groups: 235 HCV-monoinfected LT controls and all US transplant recipients who were 65 years old or older. The 3-year patient and graft survival rates were 60% [95% confidence interval (CI) 1⁄4 47%-71%] and 53% (95% CI 1⁄4 40%-64%) for the HCV/HIV patients and 79% (95% CI 1⁄4 72%-84%) and 74% (95% CI 1⁄4 66%-79%) for the HCV-infected recipients (P < 0.001 for both), and HIV infection was the only factor significantly associated with reduced patient and graft survival. Among the HCV/HIV patients, older donor age [hazard ratio (HR) 1⁄4 1.3 per decade], combined kidney-liver transplantation (HR 1⁄4 3.8), an anti-HCV–positive donor (HR 1⁄4 2.5), and a body mass index < 21 kg/m2 (HR 1⁄4 3.2) were inde- pendent predictors of graft loss. For the patients without the last 3 factors, the patient and graft survival rates were similar to those for US LT recipients. The 3-year incidence of treated acute rejection was 1.6-fold higher for the HCV/HIV patients versus the HCV patients (39% versus 24%, log rank P 1⁄4 0.02), but the cumulative rates of severe HCV disease at 3 years were not significantly different (29% versus 23%, P 1⁄4 0.21). Conclusions: First, the severity of the recipient’s illness, as reflected by a low BMI and the need for kidney transplantation, influences outcomes after LT. Thus, an early referral for the consideration of transplantation and the utilization of donor options (eg, living donor) that shorten the wait-list time are the best means of overcoming this potential barrier to transplantation. Second, donor selection is important. Older donors are already recognized as a risk for HCV-infected transplant recipients, and coinfected patients have higher rates of graft loss with older donors also. Anti- HCV–positive donors should be used cautiously because of the significant association with graft loss in our study. Third, cytomegalovirus infection was strongly associated with graft loss, and we recom- mend the use of universal prophylaxis to minimize any risk for this complication. Finally, reducing the rates of early acute rejection is highly desirable because the treatment of rejection is associated with graft loss and more severe HCV disease. Vigilance for rejection and a low threshold for performing biopsy to evaluate abnormal liver tests are recommended.

Liver Transpl 2012;18:716-726



The Contribution of Donor Quality to Differential Graft Survival in African American and Caucasian Renal Transplant Recipients

Authors undertook this study to determine the presence of and any possible contributing factors to differences in donor quality between African American and Caucasian first time recipients of deceased donor kidney transplants. Review of UNOS (United Network for Organ Sharing) data on deceased donor renal transplantation from 2000 to 2010 was done. Donor quality was determined by the kidney donor risk index (DRI), and was compared between African Americans (AA) and Caucasian recipients. There were 33,405 Caucasians and 22,577 AA in the study, with mean DRI of 1.17 versus 1.27 (p < 0.001), respectively. In analysis 2,446 recipients of each race matched by propensity scoring (based on medical, socioeconomic and immunologic covariates), mean DRI was 1.25 for Caucasians and 1.28 (p = 0.02) for AA. The hazard ratio (HR) for graft failure asso- ciated with AA race was 1.8 (p < 0.001) on unadjusted analysis, and decreased to 1.6 (p < 0.001) after matching for DRI. These results indicate a significant disparity in quality of kidneys received by AA, which propensity analysis indicates is partially explained by differences in medical, immunologic and socioeconomic factors. Furthermore, this difference in donor quality partially accounts for poorer graft survival in AA.

American Journal of Transplantation 2012;12:1776–1783




Risk of bleeding associated with use of systemic thromboembolic prophylaxis during laparoscopic cholecystectomy

This large national cohort study aimed to assess the affects of perioperative thromboembolic prophylaxis on peroperative and postoperative bleeding during cholecystectomy. The study included 48,010 cholecystectomies recorded in a national register over a 5-year period. Bleeding was defined by clinical parameters rather than volume loss. 21,259 (44.3%) of patients received systemic thromboembolic prophylaxis however type and dose of medication was not recorded. Peroperative bleeding occurred in 1.9% and postoperative bleeding in 1.4% of patients receiving systemic thromboembolic prophylaxis compared to 0.7% for both peroperative and postoperative bleeding in the group without thromboembolic prophylaxis (adjusted OR 1.35, 95% confidence interval 1.17 to 1.55). Subgroup analysis suggested this risk was higher still in laparoscopic surgery! Interestingly at 30 day follow-up 0.2% of patients who received thromboembolic prophylaxis had developed postoperative thromboembolism compared to 0.1% of patients who did not receive prophylaxis. Thromboembolic prophylaxis increased the risk of bleeding and did not significantly reduce the risk of thromboembolism in this study however selection and reporting bias may have contributed to these findings.

British Journal of Surgery 2012; 99: 979-986



Hospital volume and patient outcomes after cholecystectomy in Scotland: retrospective, national population based study

This study attempted to define associations between hospital volume and outcomes following cholecystectomy using a national population based study. 59918 patients were identified who had a cholecystectomy in one of 37 hospitals: five hospitals had high volumes (>244 cholecystectomies/year), 10 had medium volumes (173-244), and 22 had low volumes (<173). Compared with low and medium volume hospitals, high volume hospitals performed more procedures non-electively, completed more procedures laparoscopically and used more operative cholangiography. The odds ratio for death was greater in both the low volume (odds ratio 1.45, 95% confidence interval 1.06 to 2.00, P=0.022) and medium volume (1.52, 1.11 to 2.08, P=0.010) groups than in the high volume group. However, in simulation studies, absolute risk differences between volume groups were clinically negligible for patients with average risk, but were significant in patients with higher risk. Length of stay was shorter in high volume hospitals than in low or medium volume hospitals. These differences were also only of clinical significance in patients at higher risk. The relative risk of death is lower in high volume centres, and although absolute risk differences between volume groups are significant for elderly patients and patients with comorbidity, they are clinically negligible for those at average risk.

BMJ 2012; 344 doi: 10.1136/bmj.e3330



Laparoscopic Distal Pancreatectomy Is Associated With Significantly Less Overall Morbidity Compared to the Open Technique – A Systematic Review and Meta-Analysis

The authors’ aim was to compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy by using meta-analytical techniques reporting on intraoperative outcomes, postoperative recovery, oncological safety and postoperative complications. Eighteen studies met the inclusion criteria all of which were retrospective or retrospective analysis of prospectively recorded data. Meta-analysis suggested that LDP was associated with lower blood loss by 355 mL (P < 0.001) and length of hospital stay by 4 days (P < 0.001). Overall complications were lower in the LDP group (33.9% vs 44.2%; OR = 0.73, confidence interval 0.57-0.95) as was surgical site infection (2.9% vs 8.1%; OR = 0.45, CI 0.24-0.82). There was no difference in operative time, margin positivity (complete oncological outcomes could not be analyzed), incidence of postoperative pancreatic fistula and mortality. Variations in study designs meant only a limited number of the studies could be included in each analysis. Further limitations included different inclusion criteria, different outcome definitions and timings between studies and selection bias. The authors conclude that LDP is a reasonable approach in selected cancer patients.

Annals of Surgery 2012; 255(6): 1048-1059



Mesh Reinforcement of Pancreatic Transection Decreases Incidence of Pancreatic Occlusion Failure for Left Pancreatectomy – A Single-Blinded, Randomized Controlled Trial

This single-blinded, parallel group, randomized controlled trial conducted in a single centre compared stapled left pancreatectomy with and without mesh reinforcement of the staple line. Patients were blinded and randomized intra-operatively to a treatment arm. The primary outcome measure was clinically significant pancreatic fistula as defined by the International Study Group on Pancreatic Fistula (ISGPF) pancreatic fistula grading system. One hundred patients were randomized to either mesh (54) or no-mesh (46) reinforcement on the staple line. There was one death in each group. ISGPF grade B and C leaks were seen in 1.9% (1/53) of patients undergoing resection with mesh reinforcement and 20% (11/45) of patients without mesh reinforcement (P = 0.0007). The study was terminated early at the third interim analysis because of overwhelming difference in the efficacy data. The authors conclude that mesh reinforcement of the pancreatic transection staple line significantly reduces the incidence of clinically significant pancreatic fistula.

Annals of Surgery 2012; 255(6): 1037-1042



Outcomes of simultaneous pancreas–kidney transplantation from brain-dead and controlled circulatory death donors

These authors present their experience of simultaneous pancreas–kidney (SPK) transplantation from circulatory death (DCD) donors in the British Journal of Surgery. Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors were reviewed retrospectively. During the study period SPK transplants from 20 DCD and 40 DBD donors were performed. Despite shorter pancreas cold ischaemia times in the DCD cohort, there were no episodes of delayed pancreatic graft function in either group; similar graft thrombosis rates (5% in both group) and no differences in haemoglobin A1c level at 12 months. In addition, pancreas graft survival rates were not significantly different.

British Journal of Surgery 2012; 99: 831–838



Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis

This systemic review published in the British Journal of Surgery attempted to ascertain when total pancreatectomy and islet autotransplantation (TP/IAT) for chronic pancreatitis is indicated. Five studies met the inclusion criteria. TP/IAT was successful in reducing pain in patients with chronic pancreatitis and insulin requirements. However, no study provided evidence for optimal timing of TP/IAT in relation to the evolution of chronic pancreatitis.

British Journal of Surgery 2012; 99: 761–766


Single Incision Laparoscopic Cholecystectomy vs. Conventonal Laparoscopic Cholecystectomy: a Meta-analysis of Randomized Control Trials

The authors’ aims were to compare immediate postoperative and short-term morbidity parameters like postoperative pain, hospital stay, cosmetic results, and postoperative complications between patient groups undergoing single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy. A meta-analysis of the randomized controlled trials identified 9 studies. Primary outcomes included postoperative pain at 6 and 24 hours and cosmetic result at least 2 months after the operation. Secondary outcome measures were operating time, hospital stay, overall postoperative complications (short-term), wound-related complications, and incidence of port-site hernia. Single-incision laparoscopic cholecystectomy had better cosmetic results compared to conventional laparoscopic cholecystectomy, however there was no benefit in terms of postoperative pain or length of hospital stay. Operating times were longer with single-incision surgery and although not statistically significant there was a tendancy towards more postoperative complications including increased incidence of port-site hernia and wound-related complications. Further studies and long term follow up will be required to validate these results.

Journal of gastrointestinal surgery 2012, DOI: 10.1007/s11605-012-1906-6



Response of borderline resectable pancreatic cancer to neoadjuvant therapy is not reflected by radiographic indicators

The primary objective of the study was to determine the rates at which neoadjuvant therapy is associated with a reduction in the size and anatomic extent of borderline resectable pancreatic cancer. 129 patients were included in this retrospective study over a 6-year period. All patients' pretreatment and post-treatment pancreatic protocol computed tomography images were rereviewed to determine changes in tumor size or stage using modified Response Evaluation Criteria in Solid Tumors (RECIST) and standardized anatomic criteria. Of the 122 patients who had their disease restaged after receiving preoperative therapy, 84 patients (69%) had stable disease, 15 patients (12%) had a partial response to therapy, and 23 patients (19%) had progressive disease. Although only 1 patient (0.8%) had their disease downstaged to resectable status after receiving neoadjuvant therapy, 85 patients (66%) underwent pancreatectomy. The authors suggest that, current radiographic measures of treatment response in patients with borderline resectable pancreatic cancer appear to be of little clinical value and recommend the aggressive use of surgery in patients who have borderline resectable pancreatic cancer with a suitable performance status, completely optimized comorbidities, and an absence of metastatic disease after neoadjuvant therapy.

Cancer 2012; DOI: 10.1002/cncr.27636



Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreaticoduodenectomy. The aim of this single-centre prospective observational study was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of pancreatic consistency (PC) and pancreatic duct diameter (PDD) each classified into 4 grades. PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. 110 patients were included, and PJAM and POPF were observed in 21·8% and 15·5% of patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0·001), symptomatic peripancreatic collections (P = 0·071 and P = 0·015) and PJAM (both P < 0·001). The authors propose a classification for PJAM risk stratified as ‘high’ (both risk factors, PJAM incidence 51 per cent), ‘intermediate’ (softer PC or smaller PDD, PJAM 26 per cent) or ‘low’ (no risk factors, PJAM 2 per cent). A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduodenectomy than a low-risk gland.

British Journal of Surgery 2012; DOI: 10.1002/bjs.8784



Hepatectomy for Noncolorectal Non-Neuroendocrine Metastatic Cancer: A Multi-Institutional Analysis

Liver resection has been shown to have excellent outcomes following resection of colorectal or neuroendocrine metastases but data for liver resection for metastases of other primary tumours is limited.  This study uses data from four major US hepatobiliary centres over a twenty year period to assess the safety and outcomes of such surgery.  In total 420 patients were analysed of which breast metastases were most common, closely followed by sarcomas and genitourinary primary cancers. The number of patients operated on increased steadily over the study period.  Overall Perioperative morbidity and mortality was 20% and 1.9% respectively.  Overall survival at 1-, 3-, and 5-years was 73%, 50% and 31% respectively.  Interestingly all patients who were selected for redo liver resections for local recurrence remained alive and disease free with a median of 6-years follow-up.  Although the lengthy study period and multiple institutions involved result in limitations, this is the largest reported series to date of liver resections for metastases from non-colorectal non-neuroendocrine origin and demonstrates that in selected cases it is safe and can result in excellent outcomes.

Journal of the American College of Surgeons 2012;214(5):769-77



Optimizing Clinical and Economic Outcomes of Surgical Therapy for Patients with Colorectal Cancer and Synchronous Liver Metastases

Traditional surgical practice has dictated that patients with synchronous colorectal and liver metastases shown undergo sequential operations where possible. In this study the authors evaluate from an economic perspective whether there are advantages to carrying out simultaneous resections.  In this retrospective analysis of 144 patients, split between those having staged resections or synchronous resections, overall survival and perioperative morbidity levels were comparable.  However overall post-operative stay was significantly shorter in the synchronous resection group (8 vs. 12 days) which is largely what led to an overall cost saving of 17%.  While this study has limitations, not least that in the staged patients had significantly increased tumour burden and increased proportion of major resections, it does suggest that if in a prospective study that oncologically equivalent outcomes could be achieved then there would likely be a significant economic benefit also.

Journal of the American College of Surgeons doi:10.1016/j.jamcollsurg.2012.03.021



Family history of liver cancer and hepatocellular carcinoma

Familial clustering of hepatocellular carcinoma (HCC) has been frequently reported in the East where hepatitis B infection is common. Little is known about the relationship between family history of liver cancer and HCC in Western populations. The Italian authors present a case-control study involving 229 HCC cases with 431 controls and also a meta-analysis of this subject area. After adjusting for chronic infection with hepatitis B/C viruses, family history of liver cancer was associated with increased HCC risk, (OR, 2.38; 95% CI, 1.01-5.58). Compared to subjects without family history and no chronic infection with hepatitis B/C viruses, the odds ratio for those exposed to both risk factors was 72.48 (95% CI, 21.92-239.73). In the meta-analysis, based on nine case-control and four cohort studies, for a total of approximately 3,600 liver cancer cases, the pooled relative risk for family history of liver cancer was 2.50 (95% CI, 2.06-3.03). Therefore a family history of liver cancer increases HCC risk, independently of hepatitis. The combination of family history of liver cancer and hepatitis B/C serum markers is associated with an over 70-fold elevated HCC risk.

Hepatology 2012;55(5):1416-25



Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

The advantages of using the “no-touch” technique for resection for hilar cholangiocarcinoma advocated by this unit, remains a debatable issue in hepatobiliary surgery.  In this study 50 patients treated with a conventional resection were compared with 50 subsequent patients treated with the “no-touch” technique. The 5-year survival in the most recent group, the “no touch” group was an admirable 58%, which was significantly better than in the preceding group which was 29%.  Although there are some confounding factors and limitations, this is an impressive series of patients with excellent outcomes and so adds support to their view that an en bloc resection using a “no touch” technique is oncologically superior.

Annals of Surgical Oncology 2012;19(5):1602-8




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