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  • Preoperative imaging characteristics predict poor survival and inadequate resection for left-sided pancreatic adenocarcinoma: a multi-institutional analysis
    HPB (IF 3.047) Pub Date : 2020-01-11
    Farzad Alemi; Zeljka Jutric; George R. Marshall; Elliot J. Scott; Jan Grendar; Alexandra M. Roch; Lucio L. Pereira; An-Lin Cheng; Paul D. Hansen; Eugene P. Ceppa; Horacio J. Asbun; Susanne Warner; Adnan A. Alseidi

    Background Optimal treatment of pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) necessitates R0 surgical resection. Preoperative radiographic identification of patients likely to achieve successful oncologic resection remains difficult. This study seeks to identify preoperative imaging characteristics predictive of non-R0 resections or impaired survival for PDAC-NBT. Methods Patients at five high-volume centers who underwent resection for PDAC-NBT were retrospectively analyzed. The most immediate preoperative cross-sectional scan was assessed along with outcome measures of overall survival and margin status. Results 330 patients were treated between 2001 and 2016. Margin status included 247 R0 (78.2%), 67 R1 (21.2%), and 2 R2 (0.6%). A non-R0 resection predicted worse survival (p = 0.0002). On preoperative imaging, patients with tumors greater than 20 mm, tumor attenuation greater than 70 Hounsfield units, or who demonstrated pancreatic atrophy and/or calcifications also had worse survival (p = 0.010, p = 0.036, p = 0.025 respectively). Patients with tumors interfacing with the splenic artery or vein or extending posteriorly achieved fewer R0 resections (p = 0.0006, p = 0.0004, p = 0.001, respectively). Conclusion Preoperative cross-sectional imaging can identify tumor characteristics associated with poor survival and non-R0 resection. Further investigation is needed to identify the appropriate surgical and treatment modifications necessary to clinically benefit this subset of patients.

    更新日期:2020-01-13
  • Treatment of hepatocarcinoma beyond the milan criteria. A weighted comparative study of surgical resection versus chemoembolization
    HPB (IF 3.047) Pub Date : 2020-01-10
    Simone Famularo; Stefano Di Sandro; Alessandro Giani; Davide P. Bernasconi; Andrea Lauterio; Cristina Ciulli; Antonio G. Rampoldi; Rocco Corso; Riccardo De Carlis; Fabrizio Romano; Marco Braga; Luca Gianotti; Luciano De Carlis

    Background Optimal treatment of hepatocarcinoma (HCC) beyond the Milan criteria (MC) is debated. The aim of the study was to assess overall-survival (OS) and disease-free-survival (DFS) for HCC beyond MC when treated by trans-arterial-chemoembolization (TACE) or surgical resection (SR). Method between 2005 and 2015, all patients with a first diagnosis of HCC beyond MC(1 nodule>5 cm, or 3 nodules>3 cm without macrovascular invasion) were evaluated. Analyses were carried out through Kaplan–Meier, Cox models and the inverse probability weighting (IPW) method to reduce allocation bias. Sub-analyses have been performed for multinodular and single large tumors compared with a MC-IN cohort. Results 226 consecutive patients were evaluated: 118 in SR group and 108 in TACE group. After IPW, the two pseudo-populations were comparable for tumor burden and liver function. In the SR group, 1–5 years OS rates were 72.3% and 35% respectively and 92.7% and 39.3% for TACE (p = 0.500). The median DFS was 8 months (95%CI:8–9) for TACE, and 11 months (95%CI:9–12) for SR (p < 0.001). TACE was an independent predictor for recurrence (HR 1.5; 95%CI: 1.1–2.1; p = 0.015). Solitary tumors > 5 cm and multinodular disease had comparable OS and DFS as Milan-IN group (p > 0.05). Conclusion Surgery allowed a better control than TACE in patient bearing HCC beyond MC. This translated into a significant benefit in terms of DFS but not OS.

    更新日期:2020-01-11
  • Correlating serum alpha-fetoprotein in hepatocellular carcinoma with response to Yttrium-90 transarterial radioembolization with glass microspheres (TheraSphere™)
    HPB (IF 3.047) Pub Date : 2020-01-06
    Neal Bhutiani; Stephen J. O'Brien; Erin E. Priddy; Michael E. Egger; Young K. Hong; Megan K. Mercer; Kelly M. McMasters; Robert C.G. Martin; Melissa H. Potts; Charles R. Scoggins

    Background Few studies have assessed the relationship between serum alpha-fetoprotein (AFP) and yttrium-90 (Y-90) radioembolization response in hepatocellular carcinoma (HCC). The objective of the study was to evaluate whether peri-procedural serum AFP was correlated with Y-90 therapy response in HCC. Methods Patients undergoing Y-90 radioembolization with glass microspheres (TheraSphere™) for HCC between 2006 and 2013 at a single center were evaluated. The relationship between AFP and 6-month radiographic improvement (complete or partial response by modified RECIST criteria), overall (OS), and disease-specific survival (DSS) were analyzed. Results Seventy-four patients underwent a total of 124 Y-90 infusions. Median age was 65 years, median AFP was 37 ng/mL (range: 2–112,593 ng/mL) and median model for end-stage liver disease score was 6.2 (range:1.8–11.2). Increased AFP was not associated with radiographic improvement (odds ratio (OR) = 0.99, 95% confidence interval (CI) = 0.75–1.30, p = 0.92). Median OS was 15.2 months and was increased in patients with low AFP compared to high AFP (30.8 months vs. 7.8 months, p < 0.001). On multivariable regression analysis, increased AFP was associated with worse OS (OR = 1.11, 95%CI = 1.01–1.22, p = 0.034) and DSS (OR = 1.13, 95%CI = 1.03–1.25, p = 0.018). Conclusion Pre-infusion AFP independently predicted survival after Y-90 treatment for HCC, but not radiographic response, and can help guide treatment decisions.

    更新日期:2020-01-06
  • Hepatopancreatoduodenectomy –a controversial treatment for bile duct and gallbladder cancer from a European perspective
    HPB (IF 3.047) Pub Date : 2019-12-30
    Melroy A. D'Souza; Valentinus T. Valdimarsson; Tommaso Campagnaro; Francois Cauchy; Nikolaos A. Chatzizacharias; Mathieu D'Hondt; Bobby Dasari; Alessandro Ferrero; Lotte C. Franken; Giuseppe Fusai; Alfredo Guglielmi; Jeroen Hagendoorn; Camila Hidalgo Salinas; Frederik J.H. Hoogwater; Rosa Jorba; Nariman Karanjia; Wolfram T. Knoefel; Philipp Kron; Christian Sturesson

    Background Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. Method Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. Results In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. Conclusion HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

    更新日期:2019-12-30
  • A systematic review and network meta-analysis of phase III randomised controlled trials for adjuvant therapy following resection of pancreatic ductal adenocarcinoma (PDAC)
    HPB (IF 3.047) Pub Date : 2019-12-29
    Sivesh K. Kamarajah; James R. Bundred; Wasfi Alrawashdeh; Derek Manas; Steven A. White

    Background Several randomised controlled trials (RCTs) have reported various systemic adjuvant therapy regimens following resection of pancreatic ductal adenocarcinoma (PDAC). The most commonly applied include modified FOLFRINOX (mFFX), Gemcitabine/Capecitabine (GemCap) and S1, usually compared to gemcitabine (Gem) alone. However, many of these regimens have not been directly compared in RCTs. This network meta-analysis aims to characterise the impact of adjuvant therapies on overall and disease-free survival in patients having resection of PDAC. Methods A systematic review was conducted using MEDLINE, EMBASE, Cochrane Central and American Society of Clinical Oncology (ASCO) abstracts to identify published phase III RCTs articles up to 9th May 2019 that examined adjuvant systemic therapy in resected pancreatic cancer. Data including study characteristics and outcomes including overall survival (OS) and disease-free survival (DFS) were extracted. Indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analyses (NMA) which maintains randomisation within trials. Results Twelve phase III RCTs involving 4947 patients and nine different regimens (5-Flourouracil/Folinic acid (5-FU/FA), Gemcitabine, Gemcitabine/Erlotinib (GemErl), GemCap), mFFX, S1, chemoradiotherapy (CRT), CRT with either 5-FU or Gemcitabine) were identified. S1 was ranked best for overall and disease-free survival followed by mFFX. Whilst there were no significant difference between S1 and mFFX for overall survival (mean difference: 1.6 months, p = 0.8), S1 had significantly longer disease-free survival than mFFX (mean difference: 2.8 months, p < 0.001). Furthermore, S1 was ranked best for lowest overall and haematological grade 3/4 toxicities. Conclusion This network meta-analysis demonstrates that chemotherapy with S1 or mFFX is superior to GemCap for adjuvant treatment for PDAC, improves survival after surgical resection and should be considered as reasonable standard treatment options in the adjuvant setting and as control arm for future adjuvant clinical trials.

    更新日期:2019-12-29
  • Pulmonary metastases in newly diagnosed hepatocellular carcinoma: a population-based retrospective study
    HPB (IF 3.047) Pub Date : 2019-12-28
    Jincheng Feng; Ying He; Junhua Wan; Zhishui Chen

    Background Hepatocellular carcinoma (HCC) is a major form of primary liver cancer with steadily increasing incidence for the decades, and has propensity to have extrahepatic metastases, especially pulmonary metastases (PM). This study aimed to investigate temporal incidence trends, treatment, and survival of patients with HCCPM. Methods Patients with HCCPM were retrospectively reviewed from 2010 to 2016 in US National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results registry (SEER). Results 2242 patients with HCCPM were identified. Overall HCCPM incidence did not change from 2010 to 2016, with an annual percent change (APC) of 0.87% (95% CI = −2.50%–4.35%, P = 0.542). Similar incidence trends patterns were found in subgroup analyses of sex, age, and race. 1-year observed survival for HCCPM was 10.8% (95%CI = 8.9%–12.8%) and relative survival was 11.0% (95%CI = 9.1%–13.1%). Better outcomes were noted among patients who underwent liver-directed surgery, those who treated with chemotherapy, and those who received radiation. Conclusions The incidence of HCCPM does not increase with the increasing incidence of HCC. Patients with HCCPM have a dismal prognosis with low survival rates. Liver-directed surgery, use of chemotherapy, and radiation may be associated with improved outcomes.

    更新日期:2019-12-29
  • The impact of hepatic arterial infusion pump chemotherapy on hepatic recurrences and survival in patients with resected colorectal liver metastases
    HPB (IF 3.047) Pub Date : 2019-12-27
    Florian E. Buisman; Boris Galjart; Eric P. van der Stok; Nancy E. Kemeny; Vinod P. Balachandran; Thomas Boerner; Andrea Cercek; Dirk J. Grünhagen; William R. Jarnagin; T. Peter Kingham; Cornelis Verhoef; B. Groot Koerkamp; Michael I. D'Angelica

    Background The objective was to investigate the impact of adjuvant hepatic arterial infusion pump (HAIP) chemotherapy on the rates and patterns of recurrence and survival in patients with resected colorectal liver metastases (CRLM). Methods Recurrence rates, patterns, and survival were compared between patients treated with and without adjuvant HAIP using competing risk analyses. Results 2128 patients were included, of which 601 patients (28.2%) received adjuvant HAIP and systemic chemotherapy (HAIP + SYS). The overall recurrence rate was similar with HAIP + SYS or SYS (63.5% versus 64.2%,p = 0.74). The 5-year cumulative incidence of initial intrahepatic recurrences was lower with HAIP + SYS (22.9% versus 38.4%,p < 0.001). The 5-year cumulative incidence of initial extrahepatic recurrences was higher with HAIP + SYS (48.5% versus 40.3%,p = 0.005), because patients remained at risk for extrahepatic recurrence in the absence of intrahepatic recurrence, which was largely attributable to more pulmonary recurrences with HAIP + SYS (33.6% versus 23.7%,p < 0.001). HAIP was an independent prognostic factor for DFS (adjusted HR 0.69, 95% CI 0.60–0.79, p < 0.001), and OS (adjusted HR 0.67, 95% CI 0.57–0.78,p < 0.001). Conclusion Adjuvant HAIP chemotherapy is associated with lower intrahepatic recurrence rates and better DFS and OS after resection of CRLM.

    更新日期:2019-12-29
  • Hospital variation in Textbook Outcomes following curative-intent resection of hepatocellular carcinoma: an international multi-institutional analysis
    HPB (IF 3.047) Pub Date : 2019-12-27
    Diamantis I. Tsilimigras; Rittal Mehta; Katiuscha Merath; Fabio Bagante; Anghela Z. Paredes; Ayesha Farooq; Francesca Ratti; Hugo P. Marques; Silvia Silva; Olivier Soubrane; Vincent Lam; George A. Poultsides; Irinel Popescu; Razvan Grigorie; Sorin Alexandrescu; Guillaume Martel; Aklile Workneh; Alfredo Guglielmi; Timothy M. Pawlik

    Background Composite measures such as “Textbook Outcome” (TO) may be superior to individual quality metrics to assess surgical care and hospital performance. However, the incidence and factors associated with TO after resection of HCC remain poorly defined. Methods Hospital variation in the rates of TO, factors associated with achieving a TO and the impact of TO on long-term survival following resection for HCC were examined using an international multi-institutional database. Results Among 605 patients who underwent curative-intent resection of HCC, the unadjusted incidence of TO ranged from 50.9% to 77.7%. While achievement of each individual quality metric was relatively high (range, 74.5–98.0%), an overall TO was achieved among only 62.3% (n = 377) of patients. At the hospital level, TO ranged from 54.3% to 72.9%. Patients with BCLC-0 HCC (referent BCLC-B/C; OR: 4.17, 95%CI: 1.62–10.7) and ALBI grade 1 (referent ALBI grade 2/3; OR: 1.49, 95%CI: 1.06–2.11) had higher odds of achieving a TO. On multivariable analysis, TO was associated with improved overall survival (HR: 0.60, 95% CI: 0.42–0.85). Conclusion Roughly 6 in 10 patients achieved a TO following resection for HCC. When achieved, TO was associated with better long-term outcomes. TO is a simple composite measure of both short- and long-term outcomes among patients undergoing resection for HCC.

    更新日期:2019-12-29
  • The cardiac output optimisation following liver transplant (COLT) trial: a feasibility randomised controlled trial
    HPB (IF 3.047) Pub Date : 2019-12-23
    Daniel Martin; Rahul Koti; Kurinchi Gurusamy; Louise Longworth; Jeshika Singh; Farid Froghi; Fiammetta Soggiu; Susan Mallett; Nick Schofield; Linda Selves; Douglas Thorburn; Christine Eastgate; Helder Filipe; Margaret McNeil; Zacharias Anastasiou; Brian Davidson

    Background Perioperative goal directed fluid therapy (GDFT) has been shown to reduce postoperative complications following major surgery; this intervention has not been formally evaluated in the setting of liver transplantation. Methods We conducted a prospective trial of GDFT following liver transplantation randomising patients with liver cirrhosis to either 12 h of GDFT using non-invasive cardiac output monitoring or standard care (SC). The primary outcome was feasibility. Secondary outcomes included survival, postoperative complications (Clavien-Dindo), quality of life (by EQ-5D-5L) and resource use. Trial specific follow up occurred at 90 and 180 days after surgery. Results The study was feasible. Of 224 eligible patients, 122 were approached, 114 consented to participate and 60 were enrolled into the trial. The mean (SD) volume of IV crystalloid administered to the GDFT group during the 12-h study period was 3968 (2073) ml for the GDFT group and 2510 (1026) ml for the SC group. As regards secondary outcomes there was no difference in survival or overall complication rates. There was no significant difference in quality of life scores and resource use between the groups. Conclusion A randomised study of GDFT following liver transplantation is feasible. A post-trial stakeholder meeting supported proceeding with a full multi-centre trial.

    更新日期:2019-12-23
  • Pancreaticoduodenectomy in a low-resection volume region: a population-level study examining the impact of hospital-volume on surgical quality and longer-term survival
    HPB (IF 3.047) Pub Date : 2019-12-14
    Aaditya Narendra; Peter D. Baade; Joanne F. Aitken; Jonathan Fawcett; Bernard Mark Smithers

    Background An association between higher hospital-volume and better “quality of surgery” and long-term survival has not been reported following pancreatic cancer surgery in low resection-volume regions such as in Australia. Using a population-level study, we compare “quality of surgery” and two-year survival following pancreaticoduodenectomy between Australian hospitals grouped by resection-volume. Methods Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma in the Australian state of Queensland, between 2001 and 2015, were obtained from the Queensland Oncology Repository. Hospitals were grouped into high (≥6 resections annually) and low (<6) volume centres. Following adjustment for case-mix, “quality-of-treatment” indicators were compared between hospital groups using multivariate logistic regression and Poisson regression analysis; and two-year cancer-specific and overall survival were compared using multivariate Cox proportional hazard models. Results Compared with high-volume centres, low-volume centres had worse two-year cancer-specific survival (Adjusted HR = 1.31; 95% CI:1.03–1.68), higher 30-day mortality (Adjusted IRR = 3.81; 95% CI: 1.36–10.62) and fewer patients received “high-quality surgery” (Adjusted OR = 0.55; 95% CI: 0.33–0.90). Differences in 30-day mortality, or “quality-of-treatment” indicators did not entirely explain the observed survival difference between hospital-volume groups. Conclusion In an Australian environment, a “high” hospital-volume was significantly associated with better quality surgery and two-year survival following pancreaticoduodenectomy.

    更新日期:2019-12-17
  • Arterial hyperenhancement of small intrahepatic cholangiocarcinomas correlates with microvessel counts and patient survival
    HPB (IF 3.047) Pub Date : 2019-12-14
    Xiang-Hua Zhang; Lei Huo; Cai-Feng Liu; Feng Xu; Xin-Yuan Lu; Bin Huang; Ning-Yang Jia; Lu Wu; Feng Shen

    Background To compare outcomes of patients with arterially hyperenhancing intrahepatic cholangiocarcinomas (ICC) and arterially hypoenhancing ICCs after partial hepatectomy in a cohort with an analysis of prognostic factors. Methods From June 2009 to October 2011, a prospective cohort of 68 patients with single resectable ICCs (≤5 cm in diameter) underwent gadolinium contrast–enhanced dynamic-phase magnetic resonance imaging and were treated with partial hepatectomy. Patients were divided into those with arterially hyperenhancing ICCs (n = 28) or arterially hypoenhancing ICCs (n = 40). Clinic-radiologic-pathologic results and survival of these patients were compared and statistically analyzed. Results The median overall survival (OS) time was significantly longer in the arterially hyperenhancing ICCs (56.8 vs. 37.0 months) (p = 0.044). At pathologic evaluation, arterially hyperenhancing ICCs showed significantly higher microvessel count (MVC) than arterially hypoenhancing ICCs (106.2 ± 47.5 vs. 46.9 ± 21.6/mm2, p = 0.001). Arterial enhancement of ICCs was found to be an independent prognostic factor for longer survival. Conclusion The presence of arterially hyperenhancing ICCs is related to higher MVC and exhibit a better OS time than arterially hypoenhancing ICCs after partial hepatectomy.

    更新日期:2019-12-17
  • Cholecystitis and risk of pancreatic, liver, and biliary tract cancer in patients undergoing cholecystectomy
    HPB (IF 3.047) Pub Date : 2019-12-13
    Nanna M. Uldall Torp; Simon B. Kristensen; Frank V. Mortensen; Jakob Kirkegård

    Background Cholecystitis before cholecystectomy may increase risk of cancers in the hepato-pancreato-biliary area. Methods A population-based cohort study of all patients undergoing cholecystectomy in Denmark during 1996–2015, using nationwide healthcare registries. We retrieved information on cholecystitis within two years before the date of surgery and information on pancreatic cancer, hepatocellular carcinoma (HCC), and biliary tract cancer. We examined cancer risk using a Cox model to calculate the hazard ratios (HRs). We also computed cumulative incidence functions with 95% CIs, comparing patients with and without cholecystitis before cholecystectomy. Results We included 132,794 patients, of which 73.0% were women. In the first five years of follow-up, we observed an increased risk of biliary tract cancer, but not pancreatic cancer or HCC, in patients with prior cholecystitis. After more than five years of follow-up, patients with prior cholecystitis had an increased risk of pancreatic cancer (adjusted HR: 1.26; 95% CI: 0.98–1.63) and possibly biliary tract cancer (adjusted HR: 1.33; 95% CI: 0.64–2.77). Long-term risk of HCC was decreased in patients with prior cholecystitis. For all cancers, the 20-year absolute risks were less than 1%. Conclusion In patients undergoing cholecystectomy, prior cholecystitis was associated with increased risk of pancreatic and possibly biliary tract cancer.

    更新日期:2019-12-17
  • The effect of performing two pancreatoduodenectomies by a single surgical team in one day on surgeons and patient outcomes
    HPB (IF 3.047) Pub Date : 2019-12-13
    Jin-Ming Wu; Hung-Hsuan Yen; Te-Wei Ho; Chien-Hui Wu; Ting-Chun Kuo; Ching-Yao Yang; Yu-Wen Tien

    Background The centralization of pancreatoduodenectomy (PD) has been shown to improve patient outcomes. The scheduling of two PDs in one day is one option to shorten the waiting time for patients referred to high volume centers. The effect on the surgical team or patient outcomes of such an approach have not previously been explored. This study aimed to investigate the effect of scheduling two PDs in one day on the surgeon's workload and patient outcomes. Methods A retrospective review of patients undergoing PD by a single surgeon between 2007 and 2018 was performed. Patients were allocated into: first PD (FIRSTPD group) or second PD (SECONDPD group) according to the position on the surgical operating list. The intraoperative, postoperative outcomes, and workload (the Surgery Task Load Index; SURG-TLX) were assessed between two groups. Results A total of 967 (91%) and 101 (9%) patients were included in the FIRSTPD and SECONDPD group, respectively. There were no differences in the duration of surgery (coefficient = −9.65; 95% confidence interval: −29.26 to 9.94; P = 0.334), incidence of major complications (odds ratio = 1.08; 95% confidence interval: 0.67–1.73; P = 0.739), or 90-day mortality (odds ratio = 1.03; 95% confidence interval: 0.12–8.53; P = 0.978) for those patients in the SECONDPD group as compared to the FIRSTPD group. The mean scores of two (physical and temporal demand) of the six SURG-TLX subscales of surgical workload were recorded as significantly higher by surgeons following two PD's as compared to one PD. Conclusions Although scheduling a second PD in one day shows no association with adverse patient outcomes, there is an increase in the physical and temporal subscales of surgical workload and consideration should be given to how this could be minimized.

    更新日期:2019-12-17
  • Does tumor size influence the outcome of laparoscopic distal pancreatectomy?
    HPB (IF 3.047) Pub Date : 2019-12-13
    Airazat M. Kazaryan; Ingeborg Solberg; Davit L. Aghayan; Mushegh A. Sahakyan; Ola Reiertsen; Vasiliy I. Semikov; Alexander M. Shulutko; Bjørn Edwin

    Background Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned. Methods Patients who underwent LDP for pancreatic solitary tumors in 1997–2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III). Results 218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II – 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar – 38.5, 32 and 34% in the group I, II and III. Conclusion LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.

    更新日期:2019-12-13
  • Preoperative opioid use is associated with increased length of stay after pancreaticoduodenectomy
    HPB (IF 3.047) Pub Date : 2019-12-12
    EeeLN. Buckarma; Cornelius A. Thiels; Elizabeth B. Habermann; Amy Glasgow; Travis E. Grotz; Sean P. Cleary; Rory L. Smoot; Michael L. Kendrick; David M. Nagorney; Mark J. Truty

    Background Preoperative opioid use in patients undergoing low complexity operations has been associated with increased complications, but its relationship to procedures of greater complexity is unclear. We aimed to assess this impact on outcomes following pancreaticoduodenectomy (PD). Methods A single institution, retrospective cohort of adults undergoing elective PD for cancer (1/2009-9/2015). Preoperative opioid users were defined as patients documented as taking opioids up to 90 days preoperatively. Discharge prescriptions were converted into Oral Morphine Equivalents (OME) and ten-point pain scores were abstracted. Univariate and multivariable analyses compared outcomes of naïve and preoperative opioid users overall and for laparoscopic vs open surgery. Results Of 661 PD patients, 131 (19.8%) were preoperative opioid users. These patients had greater mean pain scores over the first three days after surgery (3.4 ± 1.6, vs 2.8 ± 1.4, p < 0.001), max pain (7.9 ± 1.9 vs 7.2 ± 2.0, p < 0.001), and discharge pain (2.3 ± 1.9 vs 1.8 ± 1.6, p = 0.01) than naïve patients. Preoperative opioid users received more opioids at discharge (mean 496 ± 764 OME) than naïve (320 ± 489 OME, p = 0.03). Thirty-day refill rates were 12.6% (19.1% preoperative vs 10.9% naïve, p = 0.02). After controlling for tumor type, pancreas texture, and duct size, naïve patients had similar odds of clinically significant post-operative pancreatic fistulas (grade B or C) (OR 1.13, p = 0.68) and delayed gastric emptying (OR 1.05, p = 0.87). After controlling for age and complications, preoperative opioid use was associated with increased odds of LOS ≥9 days (OR 1.59, p = 0.04). Conclusion Following PD, preoperative opioid users had worse pain scores, received more opioids at discharge, refilled prescriptions more frequently, and were more likely to have prolonged LOS. As most opioid utilization research has been focused on low complexity surgery, additional work aimed at optimizing opioid use in complex oncologic operations is warranted.

    更新日期:2019-12-13
  • Clinicopathologic analysis of intraductal papillary neoplasm of bile duct: Korean multicenter cohort study
    HPB (IF 3.047) Pub Date : 2019-12-11
    Jae Ri Kim, Kee-Taek Jang, Jin-Young Jang, Kyungbun Lee, Jung Hoon Kim, Haeryoung Kim, Sun-Whe Kim, Wooil Kwon, Dong Wook Choi, JinSeok Heo, In Woong Han, Shin Hwang, Wan-Joon Kim, Seung-Mo Hong, Dong-Sik Kim, Young-Dong Yu, Joo Young Kim, Yang Won Nah, Kang Min Han

    Background IPNB is very rare disease and most previous studies on IPNB were case series with a small number due to low incidence. The aim of this study is to validate previously known clinicopathologic features of intraductal papillary neoplasm of bile duct (IPNB) based on the first largest multicenter cohort. Methods Among 587 patients previously diagnosed with IPNB and similar diseases from each center in Korea, 387 were included in this study after central pathologic review. We also reviewed all preoperative image data. Results Of 387 patients, 176 (45.5%) had invasive carcinoma and 21 (6.0%) lymph node metastasis. The 5-year overall survival was 80.9% for all patients, 88.8% for IPNB with mucosal dysplasia, and 70.5% for IPNB with invasive carcinoma. According to the “Jang & Kim's modified anatomical classification,” 265 (68.5%) were intrahepatic, 103 (26.6%) extrahepatic, and 16 (4.1%) diffuse type. Multivariate analysis revealed that tumor invasiveness was a unique predictor for survival analysis. (p = 0.047 [hazard ratio = 2.116, 95% confidence interval 1.010–4.433]). Conclusions This is the first Korean multicenter study on IPNB through central pathologic and radiologic review process. Although IPNB showed good long-term prognosis, relatively aggressive features were also found in invasive carcinoma and extrahepatic/diffuse type.

    更新日期:2019-12-11
  • Safe implementation of minimally invasive pancreas resection: a systematic review
    HPB (IF 3.047) Pub Date : 2019-12-10
    Alma L. Moekotte, Arab Rawashdeh, Horacio J. Asbun, Felipe J. Coimbra, Barish H. Edil, Nicolás Jarufe, D. Rohan Jeyarajah, Michael L. Kendrick, Patrick Pessaux, Herbert J. Zeh, Marc G. Besselink, Mohammed Abu Hilal, Melissa E. Hogg

    Background Minimally invasive pancreas resection (MIPR) has been expanding in the past decade. Excellent outcomes have been reported, however, safety concerns exist. The aim of this study was to define prerequisites for performing MIPR with the objective to guide safe implementation of MIPR into clinical practice. Methods This systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). PubMed, Embase and Cochrane databases were searched for literature concerning the implementation of MIPR between 1946 and November 2018. Quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). Results Overall, 1150 studies were screened, of which 32 studies with 8519 patients were included in this systematic review. Training programs for minimally invasive distal pancreatectomy, laparoscopic pancreatoduodenectomy and robotic pancreatoduodenectomy have been described with acceptable outcomes during the learning curve and improved outcomes after training. Learning curve studies have revealed an association between growing experience and improving perioperative outcomes. In addition, the association between higher center volume and lower mortality and morbidity has been reported by several studies. Conclusion When embarking on MIPR, it is recommended to participate in a dedicated training program, to assure a sufficient volume, especially when implementing minimally invasive pancreatoduodenectomy, (20 procedures recommended annually), and prospectively collect and closely monitor outcomes for continuous quality assessment, this can be achieved through institutional databases and participation in national or international registries.

    更新日期:2019-12-11
  • Safety and feasibility of laparoscopic liver resection in patients with a history of abdominal surgeries
    HPB (IF 3.047) Pub Date : 2019-12-09
    Linda Feldbrügge, Simon Wabitsch, Christian Benzing, Felix Krenzien, Anika Kästner, Philipp K. Haber, Georgi Atanasov, Andreas Andreou, Robert Öllinger, Johann Pratschke, Moritz Schmelzle

    Background Laparoscopic techniques have become the standard approach for most liver resections. Clinical studies providing conclusive evidence which patients benefit most from minimal-invasive surgery remain limited. Methods We retrospectively analyzed data of all consecutive cases of laparoscopic liver resection between 2015 and 2018 at our center. We compared patients with and without prior abdominal surgeries with respect to postoperative complications (Clavien-Dindo score), length of operation, length of ICU stay and length of hospitalization in univariate and multivariate analyses. Results Within the study period 319 patients underwent laparoscopic liver resections, 44% of which had a history of abdominal surgeries. Pre-operative characteristics were similar to patients without prior surgeries. Both groups showed comparable rates of post-operative complications (Clavien-Dindo score ≥3a; 12% in patients without vs. 16% with prior surgeries, p = 0,322). There were no significant differences in length of surgery or length of stay in the ICU or in the hospital. Conclusion Our data suggest that history of prior abdominal surgery is not a risk factor for post-operative complications after laparoscopic liver resection. We conclude that prior abdominal surgery should not be considered a contra-indication for laparoscopic approach in liver resection.

    更新日期:2019-12-09
  • Tumor burden score predicts tumor recurrence of non-functional pancreatic neuroendocrine tumors after curative resection
    HPB (IF 3.047) Pub Date : 2019-12-09
    Ding-Hui Dong, Xu-Feng Zhang, Alexandra G. Lopez-Aguiar, George Poultsides, Eleftherios Makris, Flavio Rocha, Zaheer Kanji, Sharon Weber, Alexander Fisher, Ryan Fields, Bradley A. Krasnick, Kamran Idrees, Paula M. Smith, Cliff Cho, Megan Beems, Carl R. Schmidt, Mary Dillhoff, Shishir K. Maithel, Timothy M. Pawlik

    Background To investigate the feasibility of Tumor Burden Score (TBS) to predict tumor recurrence following curative-intent resection of non-functional pancreatic neuroendocrine tumors (NF-pNETs). Method The TBS cut-off values were determined by a statistical tool, X-tile. The influence of TBS on recurrence-free survival (RFS) was examined. Results Among 842 NF-pNETs patients, there was an incremental worsening of RFS as the TBS increased (5-year RFS, low, medium, and high TBS: 92.0%, 73.3%, and 59.3%, respectively; P < 0.001). TBS (AUC 0.74) out-performed both maximum tumor size (AUC 0.65) and number of tumors (AUC 0.5) to predict RFS (TBS vs. maximum tumor size, p = 0.05; TBS vs. number of tumors, p < 0.01). The impact of margin (low TBS: R0 80.4% vs. R1 71.9%, p = 0.01 vs. medium TBS: R0 55.8% vs. R1 37.5%, p = 0.67 vs. high TBS: R0 31.9% vs. R1 12.0%, p = 0.11) and nodal (5-year RFS, low TBS: N0 94.9% vs. N1 68.4%, p < 0.01 vs. medium TBS: N0 81.8% vs. N1 55.4%, p < 0.01 vs. high TBS: N0 58.0% vs. N1 54.2%, p = 0.15) status on 5-year RFS outcomes disappeared among patients who had higher TBS. Conclusions TBS was strongly associated with risk of recurrence and outperformed both tumor size and number alone.

    更新日期:2019-12-09
  • Development and validation of a real-time mortality risk calculator before, during and after hepatectomy: an analysis of the ACS NSQIP database
    HPB (IF 3.047) Pub Date : 2019-12-04
    Kota Sahara, Diamantis I. Tsilimigras, Anghela Z. Paredes, Syeda A. Farooq, J. Madison Hyer, Amika Moro, Rittal Mehta, Lu Wu, Itaru Endo, Aslam Ejaz, Jordan Cloyd, Timothy M. Pawlik

    Background Although most conventional risk prediction models have been based on preoperative information, intra- and post-operative events may be more relevant to mortality after surgery. We sought to develop a mortality risk calculator based on real time characteristics associated with hepatectomy. Methods Patients who underwent hepatectomy between 2014 and 2017 were identified in the ACS-NSQIP dataset. Three prediction models (pre-, intra-, post-operative) were developed and validated using perioperative data. Results Among 14,720 patients, 197 (1.3%) experienced 30-day mortality. The predictive ability of the real-time mortality risk calculator was very good based on only preoperative factors (AUC; training cohort: 0.813, validation cohort: 0.731). Incorporating intra-operative variables into the model increased the AUC (training: 0.838, validation: 0.777), while the post-operative model achieved an AUC of 0.922 in the training and 0.885 in the validation cohorts, respectively. While patients with low preoperative risk had only very small fluctuations in the estimated 30-day mortality risk during the intraoperative (Δ0.4%) and postoperative (Δ0.6%) phases, patients who were already deemed high risk preoperatively had additional increased mortality risk based on factors that occurred in the intraoperative (Δ5.4%) and postoperative (Δ9.3%) periods. Conclusion A real-time mortality risk calculator may better help clinicians identify patients at risk of death at the different stages of the surgical episode.

    更新日期:2019-12-05
  • Impact of perioperative blood transfusion on survival in pancreatic neuroendocrine tumor patients: analysis from the US Neuroendocrine Study Group
    HPB (IF 3.047) Pub Date : 2019-12-02
    Paula Marincola Smith, Jordan Baechle, Carmen C. Solórzano, Marcus Tan, Alexandra G. Lopez-Aguiar, Mary Dillhoff, Eliza Beal, George Poultsides, John G.D. Cannon, Flavio G. Rocha, Angelena Crown, Clifford Cho, Megan Beems, Emily R. Winslow, Victoria R. Rendell, Bradley A. Krasnick, Ryan C. Fields, Shishir K. Maithel, Kamran Idrees

    Background Packed red blood cell (PRBC) transfusion has been associated with worse survival in multiple malignancies but its impact on pancreatic neuroendocrine tumors (PNETs) is unknown. The aim of this study was to determine the impact of PRBC transfusion on survival following PNET resection. Methods A retrospective cohort study of PNET patients was performed using the US Neuroendocrine Tumor Study Group database. Demographic and clinical factors were compared. Kaplan–Meier and log-rank analyses were performed. Factors associated with transfusion, overall (OS), recurrence-free (RFS) and progression-free survival (PFS) were assessed by logistic regression. Results Of 1129 patients with surgically resected PNETs, 156 (13.8%) received perioperative PRBC transfusion. Transfused patients had higher ASA Class, lower preoperative hemoglobin, larger tumors, more nodal involvement, and increased major complications (all p < 0.010). Transfused patients had worse median OS (116 vs 150 months, p < 0.001), worse RFS (83 vs 128 months, p < 0.01) in curatively resected (n = 1047), and worse PFS (11 vs 24 months, p = 0.110) in non-curatively resected (n = 82) patients. On multivariable analysis, transfusion was associated with worse OS (HR 1.80, p = 0.011) when controlling for TNM stage, tumor grade, final resection status, and pre-operative anemia. Conclusion PRBC transfusion is associated with worse survival for patients undergoing PNET resection.

    更新日期:2019-12-02
  • Systematic review of liver directed therapy for uveal melanoma hepatic metastases
    HPB (IF 3.047) Pub Date : 2019-11-30
    Alistair Rowcroft, Benjamin P.T. Loveday, Benjamin N.J. Thomson, Simon Banting, Brett Knowles

    Background Uveal melanoma (UM) is a rare malignancy with a propensity for metastasis to the liver. Systemic chemotherapy is typically ineffective in these patients with liver metastases and overall survival is poor. There are no evidence-based guidelines for management of UM liver metastases. The aim of this study was to review the evidence for management of UM liver metastases. Methods A systematic review of English literature publications was conducted across Ovid Medline, Ovid MEDLINE and Cochrane CENTRAL databases until April 2019. The primary outcome was overall survival, with disease free survival as a secondary outcome. Results 55 studies were included in the study, with 2446 patients treated overall. The majority of these studies were retrospective, with 17 of 55 including comparative data. Treatment modalities included surgery, isolated hepatic perfusion (IHP), hepatic artery infusion (HAI), transarterial chemoembolization (TACE), selective internal radiotherapy (SIRT) and Immunoembolization (IE). Survival varied greatly between treatments and between studies using the same treatments. Both surgery and liver-directed treatments were shown to have benefit in selected patients. Conclusion Predominantly retrospective and uncontrolled studies suggest that surgery and locoregional techniques may prolong survival. Substantial variability in patient selection and study design makes comparison of data and formulation of recommendations challenging.

    更新日期:2019-11-30
  • Enucleation for branch duct intraductal papillary mucinous neoplasms: a systematic review and meta-analysis
    HPB (IF 3.047) Pub Date : 2019-05-29
    Chathura BB. Ratnayake, Christine Biela, John A. Windsor, Sanjay Pandanaboyana

    Background The role of enucleation (EN) for branch duct intraductal papillary mucinous neoplasms (BD-IPMN) is poorly defined. This systematic review aims to review EN for BD-IPMN and compare it with pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy and central pancreatectomy). Methods A systematic review of published literature was performed using PRISMA guidelines, and included a search of PubMed, MEDLINE and SCOPUS databases. Results Sixteen studies were included in the final analysis comprising 991 patients with 293 EN patients and 698 resected patients. EN was most often performed for low grade (77%, 151/197) BD-IPMN's (99%, 251/253) of the pancreatic head (64%, 106/165), with a pooled mean diameter of 21 mm (SD 28 mm). EN was a shorter procedure (MD −115.8 min, CI −142.2 to −89.5 min, P=<0.001) with a lower rate of post-pancreatectomy haemorrhage (EN 1% 2/144, Resection 5% 10/186, RR 0.32, CI 0.11 to 0.94, P = 0.043) and postoperative exocrine and endocrine insufficiency (P = <0.001 and P = 0.003 respectively) than resection. Conclusion EN for BD-IPMN's appears to be a reasonable alternative to resection in low risk BD-IPMN's, allowing preservation of exocrine and endocrine function with comparable reoperation and recurrence rates to resection. However, surveillance was indicated in these low risk patients based on current published guidelines.

    更新日期:2019-11-29
  • Body composition assessment and sarcopenia in patients with pancreatic cancer: a systematic review and meta-analysis
    HPB (IF 3.047) Pub Date : 2019-06-29
    James Bundred, Sivesh K. Kamarajah, Keith J. Roberts

    Background Numerous studies have suggested an association between sarcopenia in pancreatic cancer and adverse outcomes. This systematic review examines the evidence for the impact of sarcopenia on post-operative complications and survival Methods A systematic literature search was conducted to identify randomised and non-randomised studies of sarcopenia in pancreatic cancer. Meta-analyses of intra- and post-operative outcomes were performed (operating time, all complications, major complications, pancreatic fistulae, peri-operative mortality, overall survival). Results Forty-two studies reported the assessment of body composition in 7619 patients. Methods used to assess body composition in patients with pancreatic cancers were computerized tomography (n = 34), bioelectrical impedance analysis (n = 7), and dual-energy-X-ray-absorptiometry (n = 1). Only 10 studies reported the impact of pre-operative sarcopenia upon post-operative outcomes. Sarcopenia was associated with increased peri-operative mortality (OR: 2.40, CI95%:1.19–4.85, p < 0.01) and decreased overall survival by univariable (HR: 1.95, CI95%:1.35–2.81, p < 0.001) and multivariable analysis (HR: 1.78, CI95%:1.54–2.05). Sarcopenia was not significantly associated with all complications (OR: 0.96, CI95%:0.78–1.19) or pancreatic fistula (OR: 0.95, CI95%: 0.59–1.54). Conclusions Assessment of sarcopenia in pancreatic cancer provides prognostic value but, more importantly, may provide a basis for therapeutic intervention. However, variation in the methods of assessing and reporting sarcopenia in this patient group limits the assessment of post-operative outcomes currently.

    更新日期:2019-11-29
  • A meta-analysis of randomized controlled trials comparing laparoscopic vs open pancreaticoduodenectomy
    HPB (IF 3.047) Pub Date : 2019-06-25
    Fabio Ausania, Filippo Landi, Aleix Martínez-Pérez, Constantino Fondevila

    Background Recent randomized controlled trials (RCTs) reported conflicting results regarding the safety of laparoscopic pancreaticoduodenectomy (LPD). The aim of this study was to perform a meta-analysis of the available RCTs concerning the short-term outcomes of LPD versus open pancreaticoduodenectomy (OPD). Methods The Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, Scopus databases and ClinicalTrials.gov register were searched. Only RCTs published up to February 2019 were eligible for inclusion. Random-effect models were used to summarize the relative risks (RR) and mean differences. Results 3 RCTs were identified, including a total number of 114 and 110 patients who underwent LPD and OPD, respectively. The rate of major postoperative complications (Clavien-Dindo ≥3) was 29% in LPD vs 31% in OPD group (RR 0.80 (95% CI: 0.36–1.79); p = 0.592). Complication-related mortality occurred in 5% (LPD) vs 4% (OPD) patients (RR 1.22 (95% CI: 0.19–8.02); p = 0.841). LPD was significantly associated with longer operative time [95 min (95% CI: 24–167; p = 0.009)] and lower perioperative blood loss [−151 ml (95% CI: 169–133; p < 0.001)]. Conclusions There are no statistically significant differences between LPD and OPD in terms of postoperative complications and mortality. However, these findings should be interpreted with caution due to high clinical and statistical heterogeneity of pooled data. Further studies with different outcome measures are needed to clarify the future of LPD.

    更新日期:2019-11-29
  • Pre-, peri- and post-operative factors for the development of pancreatic fistula after pancreatic surgery
    HPB (IF 3.047) Pub Date : 2019-07-27
    Kjetil Søreide, Andrew J. Healey, Damian J. Mole, Rowan W. Parks

    Background The most hazardous complication to pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures. Methods Systematic literature search using the English PubMed literature up to April 2019, with emphasis on the past 5 years. Results Several risk scores have been developed but none are perfect in predicting POPF risk. A conceptual framework of factors that contribute to the pathophysiology of pancreatic fistulae is still developing but incomplete. Recognized factors include those related to the patient, the pathology and the perioperative care. Interventions such as use of drains, stents and various drugs to mediate risk is still debated. Emerging data suggest that both the microbiome and the inflammation in the post-operative phase may play important roles in risk for POPF. Available risk scores allow for stratification of risk and mitigation strategies tailored to reduce this. However, accurate estimation of risk remains a challenge and mechanisms are only partially understood. Conclusions The pathophysiology of POPF remains poorly understood. Current models only partially explain risks or associated mechanisms. Novel areas of investigation need to be explored for better prediction.

    更新日期:2019-11-29
  • Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy – an E-AHPBA multi-center study1
    HPB (IF 3.047) Pub Date : 2019-11-28

    Background Treatment of bile duct injuries (BDI) during cholecystectomy depends on the severity of injury and the timing of diagnosis. Standard of care for severe BDIs is hepaticojejunostomy. The aim of this retrospective multi-center study was to assess the optimal timing for repair of BDI with hepaticojejunostomy. Methods Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients with hepaticojejunostomy after BDI from January 2000 to June 2016. Patients were stratified according to the timing of biliary reconstruction with hepaticojejunostomy: early (day 0–7), intermediate (1–6 weeks) and late (6 weeks–6 months). Primary endpoint was re-intervention >90 days after the hepaticojejunostomy and secondary endpoints were severe 90-day complications and liver-related mortality. Results In total 913 patients from 48 centers were included in the analysis. In 401 patients (44%) the bile duct injury was diagnosed intraoperatively, and 126 patients (14%) suffered from concomitant vascular injury. In multivariable analysis the timing of hepaticojejunostomy had no impact on postoperative complications, the need for re-intervention after 90 days nor liver-related mortality. The rate of re-intervention more than 90 days after the hepaticojejunostomy was significantly increased in male patients but decreased in older patients. Severe co-morbidity increased the risk for liver-related mortality (HR 3.439; CI 1.37–8.65; p = 0.009). Conclusion After BDI occurring during cholecystectomy, the timing of biliary reconstruction with hepaticojejunostomy did not have any impact on severe postoperative complications, the need for re-intervention or liver-related mortality. Individualised treatment after iatrogenic bile duct injury is still advisable.

    更新日期:2019-11-29
  • Quality assessment of patient information on the management of gallstone disease in the internet – A systematic analysis using the modified ensuring quality information for patients tool
    HPB (IF 3.047) Pub Date : 2019-06-05
    Dimitri A. Raptis, Milena Sinanyan, Shahi Ghani, Fiammetta Soggiu, Jack J. Gilliland, Charles Imber

    Introduction The internet has become a fundamental source of medical information for patients, however, little is known about the quality of patient information regarding the management of gallstone disease (GD). Methods A systematic review of information on GD in the internet was performed. The top 100 websites for every different search term and search engine were assessed using the validated EQIP tool (Score 0–36). Results A total of 2000 websites were identified and 212 (11%) were eligible for analysis. The overall median EQIP score of all websites was 15 (IQR 13–18). Of all websites, 63% originated from North America however, these represented the lowest median EQIP score of 15. Only 41% of the websites differentiated between clinical presentations and 19% provided emergency information. Only 3% of the websites reported complication rates, ranging from 3 to 36%. Conclusion This is a comprehensive assessment of online patient information on GD using the EQIP tool. The assessment of the quality of websites concerning GD by the EQIP tool indicates that the majority of sites were of low-quality information. There is an immediate need for better informative and educational websites regarding GD that are compatible with international quality standards.

    更新日期:2019-11-29
  • Patterns of gene mutations in bile duct cancers: is it time to overcome the anatomical classification?
    HPB (IF 3.047) Pub Date : 2019-05-20
    Fabio Bagante, Andrea Ruzzenente, Simone Conci, Borislav C. Rusev, Michele Simbolo, Tommaso Campagnaro, Timothy M. Pawlik, Claudio Luchini, Calogero Iacono, Aldo Scarpa, Alfredo Guglielmi

    Background Two recent studies based on multi-omics data analysis identified distinct subtypes of bile-duct cancers (BDC) with important implications in terms of disease classification and patients' treatment. Methods Patients with mutations in KRAS, NRAS, TP53, and ARID1A genes were classified in KRAS/TP53 group while patients with mutations in IDH1-2, BAP1, and PBRM1 were classified in IDH1-2/BAP1/PBRM1 group. The aim of this study was to define long-term outcomes among patients stratified by patterns of genes mutated. Results Among 105 patients who underwent surgical resection for BDCs, 71 (68%) patients were classified in two groups based on patterns of genes mutated. While in IDH1-2/BAP1/PBRM1 group there were 58%, 22%, and 10% of patients with intrahepatic-cholangiocarcinoma (ICC), perihilar-cholangiocarcinoma (PHCC), and gallbladder cancer (GBC), in KRAS/TP53 group there were 42%, 78%, and 90% of patients with ICC, PHCC, and GBC (p = 0.003), respectively. Patients in IDH1-2/BAP1/PBRM1 group had a 5-year OS of 40% compared with 13% for KRAS/TP53 group (p = 0.032). In a multivariable model adjusted for margins, lymph-node status, microvascular invasion, and tumor grade, patients in KRAS/TP53 group had a 2.1-fold increased risk of death compared with patients in IDH1-2/BAP1/PBRM1 group (p = 0.028). Conclusions Genetic data were able to overcome the clinical based staging system in predicting patients' prognosis.

    更新日期:2019-11-29
  • Modifications of the AJCC 8th edition staging system for intrahepatic cholangiocarcinoma and proposal for a new staging system by incorporating serum tumor markers
    HPB (IF 3.047) Pub Date : 2019-07-13
    Zhangjun Cheng, Zhengqing Lei, Anfeng Si, Pinghua Yang, Tao Luo, Guangmeng Guo, Jiahua Zhou, Xuan Wang, Zheng Li, Yong Xia, Jun Li, Kui Wang, Zhenlin Yan, Wenxin Wei, Daniel Hartmann, Norbert Hüser, Wan Y. Lau, Feng Shen

    Background Several studies have noted that the discriminatory ability and stratification performance of the AJCC 8th edition staging system is not entirely satisfactory. We aimed to improve the American Joint Committee on Cancer (AJCC) 8th edition staging system for intrahepatic cholangiocarcinoma (ICC). Methods A multicentric database from three Chinese mainland centers (n = 1601 patients) was used to modify the 8th edition staging system. This modified TNM (mTNM) staging system was then validated using the SEER database (n = 761 patients). A new TNM staging system, by incorporating serum tumor markers (TNMIS) into the mTNM staging system was then proposed. Results The 8th edition staging system did not provide an adequate stratification of prognosis in the Chinese multicentric cohort. The mTNM staging system offered a better discriminatory capacity in the multicentric cohort than the original 8th edition. External validation in the SEER cohort showed that the mTNM staging system also had a good stratification performance. After further incorporating a serum marker stage into the mTNM staging, the TNMIS staging system was able to stratify prognosis even better. Conclusion The proposed mTNM staging system resulted in better stratification performance and the TNMIS staging system provided even more accurate prognostic classification than the conventional TNM system.

    更新日期:2019-11-29
  • Prognostic significance of primary tumor sidedness in patients undergoing liver resection for metastatic colorectal cancer
    HPB (IF 3.047) Pub Date : 2019-05-30
    Emily K. Elizabeth McCracken, Gregory P. Samsa, Deborah A. Fisher, Norma E. Farrow, Karenia Landa, Kevin N. Shah, Dan G. Blazer, Sabino Zani

    Background Approximately 38% of patients with colorectal cancer will develop isolated liver metastases. Sidedness of colon tumor is identified in non-metastatic and unresected metastatic cancers as predictive of survival, yet its dedicated analysis in resected liver metastases is minimal. Our primary aim was to assess whether left-sided primary tumors improve prognosis in stage IV cancer patients undergoing curative-intent liver metastasectomy; it was hypothesized that it would. Methods This is a retrospective, observational cohort study from 1996 to 2016 in a single tertiary-care facility. Survival from diagnosis was calculated via Kaplan–Meier method and compared between the right and left sides via log-rank analysis. Results Median survival differs significantly between colorectal tumors of the right and left origins after hepatic metastasectomy in 612 patients. In patients with right-sided tumors, median survival from diagnosis was 4.5 years (IQR 4.1–5.3), and 6.3 years (IQR 5.6–6.9) in those with left tumors (HR 1.5, 95% CI 1.38–1.60, p < 0.001). Conclusion As in studies on earlier-stage or unresected metastatic disease, tumor sidedness is an important prognostic factor in patient survival with liver metastasectomy. Clinical risk scores should include side of primary tumor. Further work is needed to determine the molecular basis for this difference.

    更新日期:2019-11-29
  • Laparoscopic or open approaches for posterosuperior and anterolateral liver resections? A propensity score based analysis of the degree of advantage
    HPB (IF 3.047) Pub Date : 2019-06-14
    Federica Cipriani, Francesca Ratti, Michele Paganelli, Raffaella Reineke, Marco Catena, Luca Aldrighetti

    Background Benefits over the open technique are demonstrated for laparoscopic liver resections. Whether the degree of advantage is different for anterolateral and posterosuperior resections is investigated in this retrospective study. Methods Laparoscopic anterolateral and posterosuperior resections (Lap-AL/Lap-PS) were compared with open (Open-AL/Open-PS) after propensity score matching. Mean/median differences of relevant parameters were calculated after bootstrap sampling. The degree of advantage was compared between anterolateral and posterosuperior resections and expressed as delta of differences (Δ-difference). Results 239 Lap-AL were compared with 239 matched Open-AL, and 176 Lap-PS with 176 matched Open-PS. Lap-AL showed reduced blood loss, morbidity, time to orally-controlled pain, mobilization and total stay; Lap-PS showed reduced blood loss, transfusions, morbidity, time to orally-controlled pain, mobilization, functional recovery and total stay. The degree of advantage of Lap-PS resulted significantly greater than Lap-AL blood loss (Δ-difference: 101 mL, p 0.017), transfusions (Δ-difference: 6.3%, p 0.008), morbidity (Δ-difference: 7.6%, p 0.034), time to orally-controlled pain (Δ-difference: 1 day, p 0.020) and functional recovery (Δ-difference: 1 day, p 0.042). Conclusions While both resulting in benefit, the advantage of laparoscopy is greater for posterosuperior than anterolateral resections. Despite their technical difficulty, these should be considered among the most worthwhile laparoscopic liver resections.

    更新日期:2019-11-29
  • Expanding the Liver Imaging Reporting and Data System (LI-RADS) v2018 diagnostic population: performance and reliability of LI-RADS for distinguishing hepatocellular carcinoma (HCC) from non-HCC primary liver carcinoma in patients who do not meet strict LI-RADS high-risk criteria
    HPB (IF 3.047) Pub Date : 2019-06-28
    Daniel R. Ludwig, Tyler J. Fraum, Roberto Cannella, Richard Tsai, Muhammad Naeem, Maverick LeBlanc, Amber Salter, Allan Tsung, Jaquelyn Fleckenstein, Anup S. Shetty, Amir A. Borhani, Alessandro Furlan, Kathryn J. Fowler

    Background Hepatocellular carcinoma (HCC) can be diagnosed using imaging criteria in patients at high-risk for HCC, according to Liver Imaging Reporting and Data System (LI-RADS) guidelines. The aim of this study was to determine the diagnostic performance and inter-rater reliability (IRR) of LI-RADS v2018 for differentiating HCC from non-HCC primary liver carcinoma (PLC), in patients who are at increased risk for HCC but not included in the LI-RADS ‘high-risk’ population. Methods This retrospective HIPAA-compliant study included a 10-year experience of pathologically-proven PLC at two liver transplant centers, and included patients with non-cirrhotic hepatitis C infection, non-cirrhotic non-alcoholic fatty liver disease, and fibrosis. Two readers evaluated each lesion and assigned an overall LI-RADS diagnostic category, additionally scoring all major, LR-M, and ancillary features. Results The final study cohort consisted of 27 HCCs and 104 non-HCC PLC in 131 patients. The specificity of a ‘definite HCC’ designation was 97% for reader 1 and 100% for reader 2. The IRR was fair for overall LI-RADS category and substantial for most major features. Conclusion In a population at increased risk for HCC but not currently included in the LI-RADS ‘high-risk’ population, LI-RADS v2018 demonstrated very high specificity for distinguishing pathologically-proven HCC from non-HCC PLC.

    更新日期:2019-11-29
  • Postoperative adjuvant sorafenib improves survival outcomes in hepatocellular carcinoma patients with microvascular invasion after R0 liver resection: a propensity score matching analysis
    HPB (IF 3.047) Pub Date : 2019-05-29
    Xiu-Ping Zhang, Zong-Tao Chai, Yu-Zhen Gao, Zhen-Hua Chen, Kang Wang, Jie Shi, Wei-Xing Guo, Teng-Fei Zhou, Jin Ding, Wen-Ming Cong, Dong Xie, Wan Y. Lau, Shu-Qun Cheng

    Background Microvascular invasion (MVI) is a major determinant of survival outcome for hepatocellular carcinoma (HCC). This study aimed to investigate the efficacy of postoperative adjuvant Sorafenib (PA-Sorafenib) in HCC patients with MVI after R0 liver resection (LR). Methods The data of patients who underwent R0 LR for HCC with histologically confirmed MVI at the Eastern Hepatobiliary Surgery Hospital were retrospectively analyzed. The survival outcomes for patients who underwent PA-Sorafenib were compared with those who underwent R0 LR alone. Propensity score matching (PSM) analysis was performed. Results 728 HCC patients had MVI in the resected specimens after R0 resection, with 581 who underwent LR alone and 147 patients who received in additional adjuvant sorafenib. PSM matched 113 patients in each of these two groups. The overall survival (OS) and recurrence free survival (RFS) were significantly better for patients in the PA-sorafenib group (for OS: before PSM, P = 0.003; after PSM, P = 0.007), (for RFS: before PSM, P = 0.029; after PSM, P = 0.001), respectively. Similar results were obtained in patients with BCLC 0-A, BCLC B and Child-Pugh A stages of disease. Conclusions PA-Sorafenib was associated with significantly better survival outcomes than LR alone for HCC patients with MVI.

    更新日期:2019-11-29
  • The AKI Prediction Score: a new prediction model for acute kidney injury after liver transplantation
    HPB (IF 3.047) Pub Date : 2019-05-29
    Marit Kalisvaart, Andrea Schlegel, Ilaria Umbro, Jubi E. de Haan, Wojciech G. Polak, Jan N. IJzermans, Darius F. Mirza, M.Thamara PR. Perera, John R. Isaac, James Ferguson, Anna P. Mitterhofer, Jeroen de Jonge, Paolo Muiesan

    Background Acute kidney injury (AKI) is a frequent complication after liver transplantation. Although numerous risk factors for AKI have been identified, their cumulative impact remains unclear. Our aim was therefore to design a new model to predict post-transplant AKI. Methods Risk analysis was performed in patients undergoing liver transplantation in two centres (n = 1230). A model to predict severe AKI was calculated, based on weight of donor and recipient risk factors in a multivariable regression analysis according to the Framingham risk-scheme. Results Overall, 34% developed severe AKI, including 18% requiring postoperative renal replacement therapy (RRT). Five factors were identified as strongest predictors: donor and recipient BMI, DCD grafts, FFP requirements, and recipient warm ischemia time, leading to a range of 0–25 score points with an AUC of 0.70. Three risk classes were identified: low, intermediate and high-risk. Severe AKI was less frequently observed if recipients with an intermediate or high-risk were treated with a renal-sparing immunosuppression regimen (29 vs. 45%; p = 0.007). Conclusion The AKI Prediction Score is a new instrument to identify recipients at risk for severe post-transplant AKI. This score is readily available at end of the transplant procedure, as a tool to timely decide on the use of kidney-sparing immunosuppression and early RRT.

    更新日期:2019-11-29
  • Pathologic complete response to chemoembolization improves survival outcomes after curative surgery for hepatocellular carcinoma: predictive factors of response
    HPB (IF 3.047) Pub Date : 2019-06-03
    Keungmo Yang, Pil S. Sung, Young K. You, Dong G. Kim, Jung S. Oh, Ho J. Chun, Jeong W. Jang, Si H. Bae, Jong Y. Choi, Seung K. Yoon

    Background We identified the predictive factors and prognostic significance of transarterial chemoembolization (TACE) for achieving pathologic complete response (pCR) before curative surgery for hepatocellular carcinoma (HCC) in hepatitis B–endemic areas. Methods Among 753 HCC patients treated with surgery, 124 patients underwent preoperative TACE before liver resection (LR), and 166 before liver transplantation (LT) between 2005 and 2016. Overall survival (OS) and recurrence-free survival (RFS) were analyzed. Pathologic response (PR) was defined as the mean percentage of necrotic area, and pCR was defined as the absence of viable tumor. Results A total of 34 (27%) and 38 (23%) patients had pCR before LR and LT, respectively. Alpha-fetoprotein (AFP) < 100 ng/mL and single tumor were significant preoperative predictors of pCR. OS and RFS were significantly improved in patients with pCR or a PR ≥ 90%, but not in patients with PR ≥ 50% after LR and LT. On multivariate analyses, PR ≥ 90% remained an independent predictor of better OS and RFS in LR and LT groups. Conclusion Overall, our data clearly demonstrate that pCR predicts favorable prognosis after curative surgery for HCC, and predictors of pCR are AFP <100 ng/mL and single tumor.

    更新日期:2019-11-29
  • Effect of operative duration on infectious complications and mortality following hepatectomy
    HPB (IF 3.047) Pub Date : 2019-06-20
    Eduardo Chacon, Pedro Eman, Adam Dugan, Daniel Davenport, Francesc Marti, Alexandre Ancheta, Meera Gupta, Malay Shah, Roberto Gedaly

    Background To study mortality and infectious complications (IC) risk relative to operative duration in a large and contemporary cohort of patients undergoing hepatectomy. Methods A retrospective cohort study of 21,443 patients from the National Surgical Quality Improvement Program dataset of patients who underwent liver resection from 2012 to 2016. Results Patients undergoing hepatectomy during the study period (N = 21,443) had a mean operative duration of 243.5 min of which 16.6% (3533) developed at least one IC. The overall 30-day mortality was 1.6%. A significant increase in mortality and IC was demonstrated from 3 h of operating time (OR: 1.99 and OR: 1.94, respectively), peaking at 8 h (OR: 7.15 and OR: 6.37, respectively). Pneumonia, sepsis/septic shock, and SSI presented high prevalence and were linked to significant mortality. After case-matching, elective hepatectomy was associated with a 4-fold increased risk of infectious complications. Conclusions Operative duration was associated with a linear increased risk of mortality and IC after hepatectomy. The most critical determinants of IC were ASA class, COPD, CHF, and type of hepatectomy.

    更新日期:2019-11-29
  • Symptom trajectories and predictors of severe symptoms in pancreatic adenocarcinoma at the end-of-life: a population based analysis of 2,538 patients
    HPB (IF 3.047) Pub Date : 2019-07-10
    Ahmed Hammad, Laura E. Davis, Alyson L. Mahar, Lev D. Bubis, Haoyu Zhao, Craig C. Earle, Lisa Barbera, Julie Hallet, Natalie G. Coburn

    Background We evaluated symptom trajectories and predictors of reporting severe symptoms in the last 6 months of life among non-resected pancreatic adenocarcinoma (PAC) decedents. Methods A retrospective cohort study of non-resected PAC decedents receiving care at regional cancer centres between January 2007 and December 2015. Symptoms were measured using the Edmonton Symptom Assessment System (ESAS). We described the proportion of patients reporting severe (score ≥7) symptoms by 2-week intervals during the six months prior to death. Multivariable modified Poisson regression models identified predictors of reporting severe symptom scores in the last 6 months of life. Results 2538 non-resected PAC decedents treated at regional cancer centres had ≥1 symptom ESAS record in the last six months of life, totaling 10,893 unique symptom assessments. Tiredness was the most commonly reported symptom (59% reporting ≥1 severe score), followed by lack of appetite (57%), impaired-wellbeing (49%) and drowsiness (42%). All symptoms increased closer to death. Older age, female sex, higher comorbidity status, survival less than 6 months, and urban residence were associated with a significantly higher risk of reporting severe symptoms. Conclusion Non-resected PAC patients experience significant symptom burden nearing death. Patient subsets may benefit from personalized supportive care interventions.

    更新日期:2019-11-29
  • Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands
    HPB (IF 3.047) Pub Date : 2019-06-21
    Marcel J. van der Poel, Robert S. Fichtinger, Marc Bemelmans, Koop Bosscha, Andries E. Braat, Marieke T. de Boer, Cornelis H.C. Dejong, Pascal G. Doornebosch, Werner A. Draaisma, Michael F. Gerhards, Paul D. Gobardhan, Burak Gorgec, Jeroen Hagendoorn, Geert Kazemier, Joost Klaase, Wouter K.G. Leclercq, Mike S. Liem, Daan J. Lips, Steven Oosterling

    Background While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale. Methods Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume. Results Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0–13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117–239) versus 200 (139–308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040). Conclusion The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.

    更新日期:2019-11-29
  • Biliary microbiome in pancreatic cancer: alterations with neoadjuvant therapy
    HPB (IF 3.047) Pub Date : 2019-05-14
    Neha Goel, Ashlie Nadler, Sanjay Reddy, John P. Hoffman, Henry A. Pitt

    Background Neoadjuvant therapy for pancreatic cancer is being employed more commonly. Most of these patients undergo biliary stenting which results in bacterial colonization and more surgical site infections (SSIs). However, the influence of neoadjuvant therapy on the biliary microbiome has not been studied. Methods From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative bile cultures were studied. Patient demographics, stent placement, bile cultures, bacterial sensitivities, SSIs and clinically-relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Patients who underwent neoadjuvant therapy were compared to those who went directly to surgery. Standard statistical analyses were performed. Results Eighty-three patients received neoadjuvant therapy while 89 underwent surgery alone. Patients who received neoadjuvant therapy were more likely to have enterococci (45 vs 22%, p < 0.01), and Klebsiella (37 vs 19%, p < 0.01) in their bile. Resistance to cephalosporins was more common in those who received neoadjuvant therapy (76 vs 60%, p < 0.05). Neoadjuvant therapy did not affect the incidence of SSIs or CR-POPFs. Conclusion The biliary microbiome is altered in patients undergoing pancreatoduodenectomy (PD) after neoadjuvant therapy. Most patients undergoing PD with a biliary stent have microorganisms resistant to cephalosporins. Antibiotic prophylaxis in these patients should cover enterococci and gram-negative bacteria.

    更新日期:2019-11-29
  • Pancreatectomy and body mass index: an international evaluation of cumulative postoperative complications using the comprehensive complications index
    HPB (IF 3.047) Pub Date : 2019-05-30
    Brendan P. Lovasik, Philipp Kron, Pierre-Alain Clavien, Henrik Petrowsky, David A. Kooby

    Background Overweight and obese patients undergoing pancreatectomy are at increased risk for postoperative complications and readmission. We examined the association between body mass index (BMI) and postoperative complications following major pancreatectomy using the novel Comprehensive Complications Index (CCI), which analyzes the impact of multiple surgical complications rather than just the most severe. Methods We performed a retrospective dual institutional international review of 500 consecutive patients who underwent pancreatic resection and assessed the association of BMI with postoperative complications using the CCI and Clavien-Dindo Classification (CDC) with uni- and multivariable analyses. Results Overweight and obese patients undergoing pancreatic resection demonstrated a higher incidence and severity of CCI-measured complications (29.3 vs. 21.1, P < 0.001), more pancreatic fistulae (15.4 vs. 8.8%, 95% CI 1.005 -1.902), and an increased 30-day readmission rate (21.1 vs. 12.1%, 95% CI 1.067 -1.852) (all p < 0.05) than normal-BMI patients. The CCI was a more sensitive marker of post-pancreatectomy complications relative to the CDC, with a higher multicomplication rate in overweight/obese patients (54.8% vs. 44.5%). Conclusion Patients with overweight and obese body mass index undergoing major pancreatectomy demonstrated higher rates of postoperative complications, pancreatic fistulae, and readmissions. The CCI is a more robust and sensitive tool to assess post-pancreatectomy complications than the CDC.

    更新日期:2019-11-29
  • Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy
    HPB (IF 3.047) Pub Date : 2019-06-01
    Daniel Åkerberg, Daniel Ansari, Magnus Bergenfeldt, Roland Andersson, Bobby Tingstedt

    Background Perioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications. Methods Data from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications. Results The weight change on postoperative day 1 ranged from −1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023). Conclusions Fluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.

    更新日期:2019-11-29
  • Assessing the influence of experience in pancreatic surgery: a risk-adjusted analysis using the American College of Surgeons NSQIP database
    HPB (IF 3.047) Pub Date : 2019-05-29
    Laura Maggino, Jason B. Liu, Vanessa M. Thompson, Henry A. Pitt, Clifford Y. Ko, Charles M. Vollmer

    Background The association between higher surgical volume and better perioperative outcomes after pancreatectomy has been extensively demonstrated. However, how different notions of experience impact outcomes of surgeons operating within high-quality scenarios remains unclear. Methods Self-reported experience parameters from ACS-NSQIP HPB-Collaborative surgeons were merged with 2014–2016 ACS-NSQIP clinical data. The association of various experience parameters with outcomes was investigated through uni- and multivariable analyses. Hierarchical regression assessed surgeon performance. Results 111/151 HPB-Collaborative surgeons provided responses (73.5%). Compared to the other 532 ACS-NSQIP surgeons performing pancreatectomy, HPB-Collaborative surgeons performed 7692/16,239 of the overall pancreatectomies (47.3%), with improved outcomes of serious morbidity, pancreatic fistula, reoperation, duration of stay and readmissions. Median age of respondents was 49 years and 92.8% were fellowship-trained. Median career and annual pancreatectomy volume were 400 and 35, respectively; median annual institutional volume was 100 resections. On unadjusted analyses, several aspects of experience were associated with the outcomes studied, especially for pancreatoduodenectomy; however, none remained significant after multivariable adjustment. Surgeons’ profiling showed substantial homogeneity in performance for both pancreatoduodenectomy and distal pancreatectomy. Conclusions Contemporary data shows that for surgeons operating in high quality settings clinical outcomes are largely independent of indicators of greater experience.

    更新日期:2019-11-29
  • Circulating tumor cells in peripheral blood of pancreatic cancer patients and their prognostic role: a systematic review and meta-analysis
    HPB (IF 3.047) Pub Date : 2019-11-28
    Yang Wang, Xiaojin Yu, Daniel Hartmann, Jiahua Zhou

    Background It has been shown that circulating tumor cells in peripheral blood can be used to predict survival in patients with breast, prostate and other epithelial tumors. In the present study, we performed a meta-analysis to evaluate the prognostic role of circulating tumor cells (CTCs) in patients with pancreatic cancer. Methods A systematic literature search of the databases was conducted from the inception to Jul 20, 2019. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated under a fixed or random effect model. Results A total of 19 studies with 1320 confirmed individuals were included. Our meta-analysis showed that patients in the CTC-positive group had a significantly shorter overall survival (OS) (RR = 0.47, 95%CI = 0.33–0.61, P < 0.001) and progression-free survival (PFS) (P = 0.003) than CTC-negative patients. Moreover, subgroup analysis by ethnicity indicated that CTC-positive patients had a significantly shorter OS in both Asian and Western populations . Further subgroup analysis by detection methods, treatments, and Tumor Node Metastasis (TNM) stages also indicated that CTC-positive patients were associated with significant decreases in both OS and PFS in most subgroups. Conclusion Our meta-analysis indicates that CTC-positive patients have a worse OS and PFS than CTC-negative patients, which suggests that CTCs may act as predictive biomarkers for pancreatic cancer patients before treatment.

    更新日期:2019-11-29
  • A systematic review of small for size syndrome after major hepatectomy and liver transplantation
    HPB (IF 3.047) Pub Date : 2019-11-27
    Georgina E. Riddiough, Christopher Christophi, Robert M. Jones, Vijayaragavan Muralidharan, Marcos V. Perini

    Background Major hepatectomy (MH) and particular types of liver transplantation (LT) (reduced size graft, living-donor and split-liver transplantation) lead to a reduction in liver mass. As the portal venous return remains the same it results in a reciprocal and proportionate rise in portal venous pressure potentially resulting in small for size syndrome (SFSS). The aim of this study was to review the incidence, diagnosis and management of SFSS amongst recipients of LT and MH. Methods A systematic review was performed in accordance with the 2010 Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. The following terms were used to search PubMed, Embase and Cochrane Library in July 2019: (“major hepatectomy” or “liver resection” or “liver transplantation”) AND (“small for size syndrome” or “post hepatectomy liver failure”). The primary outcome was a diagnosis of SFSS. Results Twenty-four articles met the inclusion criteria and could be included in this review. In total 2728 patients were included of whom 316 (12%) patients met criteria for SFSS or post hepatectomy liver failure (PHLF). Of these, 31 (10%) fulfilled criteria for PHLF following MH. 8 of these patients developed intractable ascites alongside elevated portal venous pressure following MH indicative of SFSS. Conclusion SFSS is under-recognised following major hepatectomy and should be considered as an underlying cause of PHLF. Surgical and pharmacological therapies are available to reduce portal congestion and reverse SFSS.

    更新日期:2019-11-28
  • Stepwise development of laparoscopic liver resection skill using rubber traction technique
    HPB (IF 3.047) Pub Date : 2019-11-27
    Jonathan G. Navarro, Incheon Kang, Seoung Yoon Rho, Gi Hong Choi, Dai Hoon Han, Kyung Sik Kim, Jin Sub Choi

    Background To improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes. Methods Data from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome. Results As the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed. Conclusion Standardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes.

    更新日期:2019-11-28
  • Should all pancreatic surgery be centralized regardless of patients' comorbidity?
    HPB (IF 3.047) Pub Date : 2019-11-26
    Mehdi El amrani, Guillaume Clément, Xavier Lenne, Claire Laueriere, Anthony Turpin, Didier Theis, François-René Pruvot, Stéphanie Truant

    Background It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship. Methods Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:<10, Low:10–19, High:20–49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI). Results The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates. Conclusion The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.

    更新日期:2019-11-27
  • Prognostic factors and patterns of loco-regional failure in patients with R0 resected gallbladder cancer
    HPB (IF 3.047) Pub Date : 2019-11-26
    Jung Ho Im, Woo Jung Lee, Chang Moo Kang, Ho Kyoung Hwang, Jinsil Seong

    Background In this study, risk factors for loco-regional recurrence in curative R0 resected gallbladder adenocarcinoma were investigated. Methods Patients with gallbladder adenocarcinoma with curative R0 resections between 2000 and 2016 were retrospectively reviewed. Loco-regional failure-free survival (LRFFS) and overall survival (OS) were analyzed using the Kaplan–Meier method; prognostic factors were analyzed using the Cox proportional hazards model. Based on the identified risk factors, patients were grouped for further analysis. Results A total of 272 patients were included for analysis; overall, 5-year LRFFS and OS were 83% and 81%, respectively. On multivariate analysis, 3 risk factors for LRFFS were identified; lymphovascular invasion, T3, and N1, by which patients were grouped; group 1 for 0 factor, group 2 for 1 factor and group 3 for 2 to 3 factors. The 5-year LRFFS in groups 1, 2, and 3 were 94%, 73%, and 40%, and the 5-year OS in groups 1, 2, and 3 were 90%, 75%, and 47%, respectively. LRFFS and OS differed significantly among groups (p < 0.05). Conclusion In patients with R0 resected gallbladder cancer, the presence of >1 risk factor increased the risk of loco-regional recurrence. Additional therapeutic strategy for these patients needs further consideration.

    更新日期:2019-11-27
  • A systematic review of the effectiveness of adjuvant therapy for patients with gallbladder cancer
    HPB (IF 3.047) Pub Date : 2019-03-25
    Carlos Manterola, Galo Duque, Luis Grande, Xabier de Aretxabala, Roque Conejeros, Tamara Otzen, Nayely García

    Background Equipoise exists regarding the benefit of adjuvant therapy (AT) in patients with gallbladder cancer (GBC). The aim of this study was to critically review the available evidence for the effectiveness of AT in patients with GBC following surgery with curative intent. Methods A systematic review was performed. Relevant studies were identified from Trip Database, BIREME-BVS, SciELO, Cochrane Central Register, WoS, MEDLINE, EMBASE and SCOPUS. Adjuvant therapies considered included chemotherapy, chemoradiotherapy, and radiotherapy. The primary outcome was overall survival (OS). Subgorup analysis of patients with positive lymph node disease (PLND), positive surgical margin (PSM), or advanced stage (AS) were performed. Results 748 related articles were identified; 27 met the selection criteria (3 systematic reviews and 24 observational studies). Evidence provided was moderate, poor and very poor for chemotherapy, chemoradiotherapy, and radiotherapy. Existing evidence is not robust, but suggests certain benefits with AT in improving OS, especially in patients with PLND, PSM and AS. Conclusion Results do not provide strong evidence that AT is effective in patients who undergo resection for GBC. Subgroups of PLND and PSM may have a survival advantage. Future studies with appropriate internal validity and adequate number of patients are required to better answer this question.

    更新日期:2019-11-18
  • Nomogram for predicting postoperative pancreatic fistula
    HPB (IF 3.047) Pub Date : 2019-04-11
    Yunghun You, In W. Han, Dong W. Choi, Jin S. Heo, Youngju Ryu, Dae J. Park, Seong H. Choi, Sunjong Han

    Background Previous studies analyzed risk factors for postoperative pancreatic fistula (POPF) and developed risk prediction tool using scoring system. However, no study has built a nomogram based on individual risk factors. This study aimed to evaluate individual risks of POPF and propose a nomogram for predicting POPF. Methods From 2007 to 2016, medical records of 1771 patients undergoing pancreaticoduodenctomy were reviewed retrospectively. Variables with p < 0.05 in multivariate logistic regression analysis were included in the nomogram. Internal performance validation was executed using a repeated cross validation method. Results Of 1771 patients, 222 (12.5%) experienced POPF. In multivariable analysis, sex (p = 0.004), body mass index (BMI) (p < 0.001), ASA score (p = 0.039), preoperative albumin (p = 0.035), pancreatic duct diameter (p = 0.002), and location of tumor (p < 0.001) were identified as independent predictors for POPF. Based on these six variables, a POPF nomogram was developed. The area under the curve (AUC) estimated from the receiver operating characteristic (ROC) graph was 0.709 in the train set and 0.652 in the test set. Conclusions A POPF nomogram was developed. This nomogram may be useful for selecting patients who need more intensified therapy and establishing customized treatment strategy.

    更新日期:2019-11-18
  • Use of a modified Delphi approach to develop research priorities in HPB surgery across the United Kingdom
    HPB (IF 3.047) Pub Date : 2019-04-05
    Stephen R. Knight, Samir Pathak, Alan Christie, Louise Jones, Jonathan Rees, Hayley Davies, Michael S.J. Wilson, Peter Vaughan-Shaw, Keith Roberts, Giles Toogood, Ewen M. Harrison, Mark A. Taylor

    Background Research prioritisation can help identify clinically relevant questions and encourage high-quality, patient-centred research. Delphi methodology aims to develop consensus opinion within a group of experts, with recent Delphi projects helping to define the research agenda and funding within several medical and surgical specialties. Methods All members of the Association of Upper Gastrointestinal Surgeons (AUGIS) were asked to submit clinical research questions using an online survey (Phase 1). Two consecutive rounds of Delphi prioritisation by multidisciplinary HPB healthcare professionals (Phase 2) were undertaken to establish a final list of the most highly prioritised research questions. A multidisciplinary steering committee analysed the results of each phase. Results Ninety-three HPB-focussed questions were identified in Phase 1, with thirty-seven questions of sufficient priority to enter a further prioritisation round. A final group of 11 questions considered highest priority were identified. The most highly ranked research questions related to treatment pathways, operative strategies and the impact of HPB procedures on quality of life, particularly for malignant disease. Conclusion Expert consensus has identified research priorities within the UK HPB surgical community over the coming years. Funding applications, to establish well-designed, high quality collaborative research are now required to address these questions.

    更新日期:2019-11-18
  • The inflammatory response after laparoscopic and open pancreatoduodenectomy and the association with complications in a multicenter randomized controlled trial
    HPB (IF 3.047) Pub Date : 2019-04-09
    Jony van Hilst, David J. Brinkman, Thijs de Rooij, Susan van Dieren, Michael F. Gerhards, Ignace H. de Hingh, Misha D. Luyer, Hendrik A. Marsman, Tom M. Karsten, Olivier R. Busch, Sebastiaan Festen, Michal Heger, Marc G. Besselink

    Background The systemic inflammatory response seen after surgery seems to be related to postoperative complications. A reduction of the inflammatory response through minimally invasive surgery might therefore be the mechanism via which postoperative outcome could be improved. The aim of this study was to investigate if postoperative inflammatory markers differed between laparoscopic (LPD) and open pancreatoduodenectomy (OPD) and if there was a relationship between inflammatory markers and the occurrence of postoperative complications. Methods A side study of the multicenter randomized controlled LEOPARD-2 trial comparing LPD to OPD was performed. Area under the curve (AUC) for plasma inflammatory markers, including interleukin (IL-) 6, IL-8 and C reactive protein (CRP) levels, were determined during the first 96 postoperative hours and compared between LPD and OPD, Clavien-Dindo ≥ III complications, and postoperative pancreatic fistula (POPF) grade B/C. Results Overall, 38 patients were included (18 LPD and 20 OPD). The median AUC of IL-6 was 627 (195–1378) after LPD vs. 338 (175–694)pg/mL after OPD, (p = 0.114). The AUC of IL-8 and CRP were comparable. IL-6 levels were higher in patients with a Clavien-Dindo ≥ III complication (634[309–1489] vs. 297 [171–680], p = 0.034) and POPF grade B/C (994 [534–3265] vs. 334 [173–704], p = 0.003). In patients with a POPF grade B/C, IL-6 levels tended to be higher after LPD, as compared to OPD (3533[IQR 1133–3533] vs. 715[IQR 39–1658], p = 0.053). Conclusion LPD, as compared to OPD, did not reduce the postoperative inflammatory response. IL-6 levels were associated with postoperative complications and pancreatic fistula.

    更新日期:2019-11-18
  • Peer review of mortality after pancreaticoduodenectomy in Australia
    HPB (IF 3.047) Pub Date : 2019-04-05
    Claire L. Stevens, Jessica L. Reid, Wendy J. Babidge, Guy J. Maddern

    Background The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. Methods ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. Assessor's determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. Results The study included 87 deaths reported to ANZASM after PD. Forty-two major complications were considered significant clinical events in 29/84 (35%) of patients. The assessor determined that there was a delay in recognising a significant complication in 18/84 (21%) of patients. In 14/84 (17%) of patients, ANZASM assessment questioned the decision to operate. Conclusion Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. Late recognition, and therefore delayed action to treat complications, in almost a quarter of deaths is a significant finding that warrants consideration for clinicians involved in the postoperative care of PD patients.

    更新日期:2019-11-18
  • Prediction of Discharge Destination Following Major Hepatectomy
    HPB (IF 3.047) Pub Date : 2019-04-05
    David A. Mahvi, Linda M. Pak, Adam C. Fields, Richard D. Urman, Jason S. Gold, Edward E. Whang

    Background Anatomic hepatectomies can be associated with complicated post-operative recoveries, often with discharge to post-acute care facilities. This study identifies preoperative and intraoperative factors associated with increased risk for non-home discharge destination after major hepatectomy. Methods Patients undergoing major hepatectomy were identified in the NSQIP Targeted Hepatectomy Dataset (2014–2016). Multivariable logistic regression was performed. Patients from 2014 to 2015 were used for training cohort with nomogram generation and 2016 for validation cohort. Results Overall, 226 of 3750 patients (6.0%) were discharged to rehab, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariable analysis were outside patient transfers, older age, presence of ascites, ASA physical status 3 or higher, and low preoperative hematocrit (all p < 0.05). Intraoperative factors significantly predictive were concurrent lysis of adhesions, Pringle maneuver, and biliary reconstruction (all p < 0.05). Predictors from testing cohort were validated in validation cohort. Nomograms based on preoperative variables alone and both preoperative and intraoperative variables were generated. Conclusion We identify several preoperative and intraoperative factors that are associated with increased risk for non-home discharge after major hepatectomy. Preoperative anemia represents a potentially modifiable risk factor. Nomograms for preoperative planning as well as immediately following surgery were generated.

    更新日期:2019-11-18
  • Is progression in the future liver remnant a contraindication for second-stage hepatectomy?
    HPB (IF 3.047) Pub Date : 2019-04-06
    Lionel Jouffret, Jacques Ewald, Ugo Marchese, Jonathan Garnier, Marine Gilabert, Djamel Mokart, Gilles Piana, Jean-Robert Delpero, Olivier Turrini

    Background Two-stage hepatectomy (TSH) strategy is used to treat patients with bilobar colorectal liver metastasis (CLM). However, many patients do not undergo the second hepatectomy owing to disease progression in the future liver remnant (FLR) after portal vein embolization (PVE). This study aimed to assess the impact of disease progression in the FLRs of patients who completed the first hepatectomy. Methods 68 consecutive patients underwent the first hepatectomy followed by PVE. Six patients (9%) dropped out after the PVE (two-stage failed [TSF] group) because of unresectable hepatic or general disease progression. Seventeen patients (25%) completed their second hepatectomy despite disease progression in the FLR (new CLM [nCLM] group) as it was considered resectable, while 45 patients (66%) underwent the second hepatectomy (control group). Results The 5-year overall survival rates in the TSF, nCLM, and control groups were 0%, 7%, and 60%, respectively (P < 0.001). The median overall survival times between the TSF and nCLM groups were 26 months and 42 months (P = 0.005). Patients in the nCLM group whose hepatic disease progression was detected preoperatively versus intraoperatively had comparable survival rates. Conclusion Resectable hepatic disease progression in the FLR after PVE should not be considered a contraindication for the second hepatectomy.

    更新日期:2019-11-18
  • Laparoscopic versus open liver resection in the posterosuperior segments: a sub-group analysis from the OSLO-COMET randomized controlled trial
    HPB (IF 3.047) Pub Date : 2019-04-05
    Davit L. Aghayan, Åsmund A. Fretland, Airazat M. Kazaryan, Mushegh A. Sahakyan, Vegar J. Dagenborg, Bjørn Atle Bjørnbeth, Kjersti Flatmark, Ronny Kristiansen, Bjørn Edwin

    Background Laparoscopic liver resection in the posterosuperior segments is technically challenging. This study aimed to compare the perioperative outcomes for laparoscopic and open resection of colorectal liver metastases located in the posterosuperior segments. Methods This was a subgroup analysis of the OSLO-COMET randomized controlled trial, where 280 patients were randomly assigned to open or laparoscopic parenchyma-sparing liver resections of colorectal metastases. Patients with tumors in the posterosuperior segments were identified, and perioperative outcomes and health related quality of life (HRQoL) were compared. Results We identified a total of 136 patients, 62 in the laparoscopic and 74 in the open group. The postoperative complication rate was 26% in the laparoscopic and 31% in the open group. The blood loss was less in the open group (500 vs. 250 ml, P = 0.006), but the perioperative transfusion rate was similar. The operative time was similar, while postoperative hospital stay was shorter in the laparoscopic group (2 vs. 4 days, P < 0.001). HRQoL was significantly better after laparoscopy at 1 month. Conclusion In patients undergoing laparoscopic or open liver resection of colorectal liver metastases in the posterosuperior segments, laparoscopic surgery was associated with shorter hospital stay and comparable perioperative outcomes.

    更新日期:2019-11-18
  • Feasibility and safety of liver transplantation or resection after transarterial radioembolization with Yttrium-90 for unresectable hepatocellular carcinoma
    HPB (IF 3.047) Pub Date : 2019-04-17
    Ismail Labgaa, Parissa Tabrizian, Joseph Titano, Edward Kim, Swan N. Thung, Sander Florman, Myron Schwartz, Emmanuel Melloul

    Background The benefit of transarterial radioembolization (TARE) in patients with unresectable hepatocellular carcinoma (HCC) is increasingly evidenced. However, data on outcome of liver transplantation or resection after TARE remain scarce. This study aimed to assess the safety and feasibility of surgery after TARE in patients with unresectable HCC. Methods Patients exclusively undergoing TARE followed by either orthotopic liver transplantation (OLT) or liver resection (LR) for HCC between 2012 and 2016 were included. Primary outcomes were postoperative morbidity and mortality. Secondary outcomes were overall survival (OS) and response to TARE. Results Among 349 patients with HCC treated with TARE, 32 (9%) underwent either OLT (n = 22) or LR (n = 10), which represent the study cohort. In this group, TARE induced decreased viable nodules (p < 0.001), an efficient downsizing (p < 0.001) as well as a significant downstaging based on BCLC classification (p < 0.001). Overall, major complications and mortality after surgery occurred in 5 (16%) and 1 (3%) patients, respectively. For the whole study cohort, OS was 47 months while survival rates at 1-, 3- and 5-years reached 97%, 86% and 86%, respectively. Discussion Liver surgery after TARE is feasible and safe. This strategy allows to offer a curative treatment in a subset of patients with unresectable HCC.

    更新日期:2019-11-18
  • Postoperative nutritional benefits of proximal parenchymal pancreatectomy for low-grade malignant lesions in the pancreatic head
    HPB (IF 3.047) Pub Date : 2019-04-05
    Kazufumi Umemoto, Takahiro Tsuchikawa, Toru Nakamura, Keisuke Okamura, Takehiro Noji, Toshimichi Asano, Yoshitsugu Nakanishi, Kimitaka Tanaka, Satoshi Hirano

    Background Outcomes of proximal parenchymal pancreatectomy (PPP) as compared to pancreatoduodenectomy (PD) have not been reported. The aim of this study was to describe the short- and long-term outcomes of patients with low-grade pancreatic head lesions who underwent PPP or PD. Methods Patients who underwent PPP or PD for low-grade lesions between 2009 and 2017 were included. Operative factors including postoperative complications and nutritional indicators during the first-year postoperatively were compared. Results A total of 13 and 14 patients underwent PPP and PD respectively. The PPP group demonstrated significantly less intraoperative blood loss and shorter postoperative hospital stay than the PD group. No significant differences were noted in the incidence of postoperative complications between the two groups. Nutritional indices were significantly better in the PPP group at 3 months post-surgery, but these nutritional indices were not significantly different at 6 months and 1-year. None of 12 patients who underwent PPP and did not require biliary resection developed postoperative cholangitis. None of the 12 PPP patients without preoperative diabetes developed impaired glucose tolerance after surgery. Discussion The complication rate of PPP is equivalent to that of PD. PPP demonstrated better short-term nutritional status than PD. Moreover, preservation of the total duodenum and bile duct may reduce the risk of developing postoperative diabetes and cholangitis.

    更新日期:2019-11-18
  • Evaluating the learning curve for laparoscopic liver resection: a comparative study between standard and learning curve CUSUM
    HPB (IF 3.047) Pub Date : 2019-04-13
    Asma Sultana, Peter Nightingale, Ravi Marudanayagam, Robert P. Sutcliffe

    Background Laparoscopic liver resection (LLR) requires training in both hepatobiliary surgery and advanced laparoscopy. Available data on LLR learning curves are derived from pioneer surgeons. The aims of this study were to evaluate the LLR learning curve for second generation surgeons, and to compare different CUSUM methodology with and without risk adjustment. Methods Retrospective analysis of a prospective database of 111 consecutive patients who underwent LLR by two surgeons at a single centre between 2011 and 2016. The LLR learning curve for minor hepatectomy (MH) was evaluated for each surgeon using standard CUSUM before and after risk-adjusting for operative difficulty using the Iwate index, and compared with Learning Curve (LC) CUSUM. The end points were operative time and conversion rate. Results Standard CUSUM analysis identified a learning curve of 50–60 MH procedures. The corresponding learning curve reduced to 25–30 after risk-adjusting for operative difficulty, whilst LC-CUSUM identified a learning curve of 17–25 procedures. Conclusions The learning curve for laparoscopic minor liver resection by second generation surgeons is shorter than that for pioneer surgeons. Laparoscopic HPB fellowship programmes may further shorten the learning curve, facilitating safe expansion of LLR. The LC-CUSUM method is an alternative technique that warrants further study.

    更新日期:2019-11-18
  • Prognostic relevance of preoperative bilirubin-adjusted serum carbohydrate antigen 19-9 in a multicenter subset analysis of 179 patients with distal cholangiocarcinoma
    HPB (IF 3.047) Pub Date : 2019-04-05
    Louisa Bolm, Ekaterina Petrova, Jürgen Weitz, Felix Rückert, Uwe A. Wittel, Frank Makowiec, Hryhoriy Lapshyn, Peter Bronsert, Bettina M. Rau, Igor E. Khatkov, Dirk Bausch, Tobias Keck, Ulrich F. Wellner, Marius Distler

    Background Distal cholangiocarcinoma (DCC) is a rare malignancy and validated prognostic markers remain scarce. We aimed to evaluate the role of serum CA19-9 as a potential biomarker in DCC. Methods Patients operated for DCC at 6 high-volume surgical centers from 1994 to 2015 were identified from prospectively maintained databases. Patient baseline characteristics, surgical and histopathological parameters, as well as overall survival after resection were assessed for correlation with preoperative bilirubin-adjusted serum carbohydrate antigen 19-9 (CA19-9). Preoperative CA19-9 to bilirubin ratio (CA19-9/BR) was classified as elevated (≥ 25 U/ml/mg/dl) according to the upper serum normal values of CA19-9 (37 U/ml) and bilirubin (1.5 mg/dl) giving a cut-off at ≥ 25 U/ml/mg/dl. Results In total 179 patients underwent resection for DCC during the study period. High preoperative CA19-9/BR was associated with advanced age and regional lymph node metastases. Median overall survival after resection was 27 months. Elevated preoperative serum CA19-9/bilirubin ratio (HR 1.6, p = 0.025), T3/4 stage (HR 1.8, p = 0.022), distant metastasis (HR 2.5, p = 0.007), tumor grade (HR 1.9, p = 0.001) and R status (HR 1.7, p = 0.023) were identified as independent negative prognostic factors following multivariable analysis. Conclusion Elevated preoperative bilirubin-adjusted serum CA19-9 correlates with regional lymph node metastases and constitutes a negative independent prognostic factor after resection of DCC.

    更新日期:2019-11-18
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