Synchronous major vessel resection during pancreaticoduodenectomy (PD) for borderline resectable pancreatic adenocarcinoma remains controversial. In the 1970s, regional pancreatectomy advocated by Fortner was associated with unacceptably high morbidity and mortality rates, with no impact on long-term survival. With the establishment of a multidisciplinary approach, improvements in preoperative staging techniques, surgical expertise, and perioperative care reduced mortality rates and improved 5-year-survival rates are now achieved following resection in high-volume centres. Perioperative morbidity and mortality following PD with portal vein resection are comparable to standard PD, with reported 5-year-survival rates of up to 17%. Segmental resection and reconstruction of the common hepatic artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA). PD with concomitant major vessel resection for borderline resectable tumours should be performed when a margin-negative resection is anticipated at high-volume centres with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation as part of a clinical trial should be offered to all patients.

Olga N. Tucker

Mohamed Rela

Controversies in the Management of Borderline Resectable Proximal Pancreatic Adenocarcinoma with Vascular Involvement

Annual volume of pancreatic resections has been shown to affect mortality rates, prompting recommendations to regionalize these procedures to high-volume hospitals. Implementation has been difficult, given the paucity of high-volume centers and the logistical hardships facing patients. Some studies have shown that low-volume hospitals achieve good outcomes as well, suggesting that other factors are involved. We sought to determine whether variations in annual volume affected patient outcomes in 511 patients who underwent pancreatic resections at the University of California, San Francisco between 1990 and 2005. We compared postoperative mortality and complication rates between low, medium, or high volume years, designated by the number of resections performed, adjusting for patient characteristics. Postoperative mortality rates did not differ between high volume years and medium/low volume years. As annual hospital volume of pancreatic resections may not predict outcome, identification of actual predictive factors may allow low-volume centers to achieve excellent outcomes.

Rita A. Mukhtar

Omar M. Kattan

Hobart W. Harris

Variation in Annual Volume at a University Hospital Does Not Predict Mortality for Pancreatic Resections

Pyloric preservation (PP) can frequently be performed at the time of pancreatoduodenectomy (PD), although some reports have linked it to inferior outcomes such as delayed gastric emptying (DGE). We reviewed records in a single-surgeon practice to assess outcomes after PD with or without PP. There were 133 PDs with 67 PPPDs and 66 PDs. Differences between PPPD and PD groups included cancer frequency, tumor size, OR time, blood loss, and transfusion rate. However, postoperative morbidity rate and grade, NG tube duration, NGT reinsertion rate, DGE, and length of stay were similar. There was no difference among patients with pancreatic cancer. No detrimental outcomes are associated with pyloric preservation during PD. Greater intraoperative ease and superior survival in the PPPD group are due to confounding, tumor-related variables in this nonrandomized comparison. Nevertheless, we intend to continue the use of PP with our technique in patients who meet the stated criteria.

Sean P. Dineen

Christina L. Roland

Roderich E. Schwarz

Pancreatoduodenectomy with or without Pyloric Preservation: A Clinical Outcomes Comparison

<i  >Background</i>.
                   The management of patients with colorectal liver metastases and loop ileostomies remains controversial. This study was performed to assess the outcome of combined liver resection and loop ileostomy closure.
                  <i  >Methods</i>.
                  Analysis of prospectively collected perioperative data, including morbidity and mortality, of 283 consecutive hepatectomies for colorectal liver metastases was undertaken. Consecutive liver resections were performed from 1996 to 2006 in one centre by a single surgeon (NDK).  Fourteen of these patients had combined liver resection and ileostomy closure. Case-matched analysis was undertaken.
                  <i  >Results</i>. 
                 Six (2.2&#x25;) patients died in the hepatectomy only group and none died in the combined group. There was no difference in operative blood loss between the two groups (0.09). Perioperative morbidity was 36&#x25; in the combined group and 23&#x25; in the hepatectomy alone group (<svg     style="vertical-align:-0.1638pt;width:58.712502px;" id="M1" height="11.375" version="1.1" viewBox="0 0 58.712502 11.375" width="58.712502"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.112)"><path id="x1D443" d="M619 482q0 -69 -40.5 -119t-96 -72.5t-118.5 -26.5h-44l-70 20l-31 -151q-14 -67 0.5 -83t89.5 -22l-5 -28h-287l8 28q65 7 81.5 22t29.5 83l79 398q12 56 0.5 70.5t-78.5 20.5l7 28h255q108 0 164 -43t56 -125zM524 478q0 141 -146 141q-25 0 -47 -8q-16 -6 -20.5 -13.5&#xA;t-10.5 -39.5l-43 -241q37 -13 83 -13q67 0 125.5 45t58.5 129z" /></g><g transform="matrix(.017,-0,0,-.017,15.582,11.112)"><path id="x3D" d="M535 323h-483v50h483v-50zM535 138h-483v50h483v-50z" /></g><g transform="matrix(.017,-0,0,-.017,30.286,11.112)"><path id="x30" d="M241 635q53 0 94 -28.5t63.5 -76t33.5 -102.5t11 -116q0 -58 -11 -112.5t-34 -103.5t-63.5 -78.5t-94.5 -29.5t-95 28t-64.5 75t-34.5 102.5t-11 118.5q0 58 11.5 112.5t34.5 103t64.5 78t95.5 29.5zM238 602q-32 0 -55.5 -25t-35.5 -68t-17.5 -91t-5.5 -105&#xA;q0 -76 10 -138.5t37 -107.5t69 -45q32 0 55.5 25t35.5 68.5t17.5 91.5t5.5 105t-5.5 105.5t-18 92t-36 68t-56.5 24.5z" /></g><g transform="matrix(.017,-0,0,-.017,38.446,11.112)"><path id="x2E" d="M113 -12q-24 0 -39.5 16t-15.5 42q0 24 16 40.5t40 16.5t40 -16.5t16 -40.5q0 -26 -16 -42t-41 -16z" /></g><g transform="matrix(.017,-0,0,-.017,42.321,11.112)"><path id="x33" d="M285 378v-2q65 -13 102 -54.5t37 -97.5q0 -57 -30.5 -104.5t-74 -75t-85.5 -42t-72 -14.5q-31 0 -59.5 11t-40.5 23q-19 18 -16 36q1 16 23 33q13 10 24 0q58 -51 124 -51q55 0 88 40t33 112q0 64 -39 96.5t-88 32.5q-29 0 -64 -11l-6 29q77 25 118 57.5t41 84.5&#xA;q0 45 -26.5 69.5t-68.5 24.5q-67 0 -120 -79l-20 20l43 63q51 56 127 56h1q66 0 107 -37t41 -95q0 -42 -31 -71q-22 -23 -68 -54z" /></g><g transform="matrix(.017,-0,0,-.017,50.481,11.112)"><use xlink:href="#x33"/></g>

		
	
</svg>). Mean hospital stay was 14 days in the combined group and 11 days in the hepatectomy only group (<svg     style="vertical-align:-0.1638pt;width:66.875px;" id="M2" height="11.375" version="1.1" viewBox="0 0 66.875 11.375" width="66.875"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.112)"><use xlink:href="#x1D443"/></g><g transform="matrix(.017,-0,0,-.017,15.582,11.112)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,-0,0,-.017,30.286,11.112)"><use xlink:href="#x30"/></g><g transform="matrix(.017,-0,0,-.017,38.446,11.112)"><use xlink:href="#x2E"/></g><g transform="matrix(.017,-0,0,-.017,42.321,11.112)"><use xlink:href="#x30"/></g><g transform="matrix(.017,-0,0,-.017,50.481,11.112)"><path id="x34" d="M456 178h-96v-72q0 -51 12.5 -62.5t72.5 -16.5v-27h-256v27q65 5 78 17t13 62v72h-260v28q182 271 300 426h40v-407h96v-47zM280 225v295h-2q-107 -148 -196 -295h198z" /></g><g transform="matrix(.017,-0,0,-.017,58.64,11.112)"><path id="x36" d="M137 343l67 33q37 17 63 17q79 0 129.5 -53t50.5 -131q0 -92 -58 -156.5t-147 -64.5t-147 68t-58 182q0 63 17 119t43 95.5t61.5 72t69 52t67.5 31.5q62 22 128 33l6 -32q-56 -11 -108 -35q-149 -71 -184 -231zM227 337q-47 0 -95 -27q-6 -23 -6 -70q0 -93 36 -155.5&#xA;t96 -62.5q53 0 78 45.5t25 105.5q0 68 -35 116t-99 48z" /></g>

		
	
</svg>). Case-matched analysis showed a significant increase in hospital stay (<svg     style="vertical-align:-0.1638pt;width:58.712502px;" id="M3" height="11.375" version="1.1" viewBox="0 0 58.712502 11.375" width="58.712502"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.112)"><use xlink:href="#x1D443"/></g><g transform="matrix(.017,-0,0,-.017,15.582,11.112)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,-0,0,-.017,30.286,11.112)"><use xlink:href="#x30"/></g><g transform="matrix(.017,-0,0,-.017,38.446,11.112)"><use xlink:href="#x2E"/></g><g transform="matrix(.017,-0,0,-.017,42.321,11.112)"><use xlink:href="#x30"/></g><g transform="matrix(.017,-0,0,-.017,50.481,11.112)"><use xlink:href="#x33"/></g>

		
	
</svg>) and complications  (<svg     style="vertical-align:-0.20474pt;width:66.875px;" id="M4" height="11.425" version="1.1" viewBox="0 0 66.875 11.425" width="66.875"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.112)"><use xlink:href="#x1D443"/></g><g transform="matrix(.017,-0,0,-.017,15.582,11.112)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,-0,0,-.017,30.286,11.112)"><use xlink:href="#x30"/></g><g transform="matrix(.017,-0,0,-.017,38.446,11.112)"><use xlink:href="#x2E"/></g><g transform="matrix(.017,-0,0,-.017,42.321,11.112)"><use xlink:href="#x30"/></g><g transform="matrix(.017,-0,0,-.017,50.481,11.112)"><use xlink:href="#x34"/></g><g transform="matrix(.017,-0,0,-.017,58.64,11.112)"><path id="x39" d="M244 635q90 0 143 -72t53 -177q0 -133 -65 -229.5t-171 -139.5q-79 -32 -140 -32l-5 30q109 18 185 91t101 186l-68 -36q-29 -16 -60 -16q-79 0 -129 51.5t-50 130.5q0 80 57 146.5t149 66.5zM228 602q-52 0 -78 -45.5t-26 -98.5q0 -69 36.5 -115.5t97.5 -46.5&#xA;q53 0 90 28q4 31 4 66q0 51 -9.5 95.5t-39 80.5t-75.5 36z" /></g>

		
	
</svg>)  in the combined group.
<i  >Conclusion</i>. 
In patients with CRLM, combined liver resection and closure of ileostomy may be associated with a higher operative morbidity and a prolonged hospital stay. 


Jeffrey T. Lordan

Angela T. Riga

Nariman D. Karanjia

Liver Resections Combined with Closure of Loop Ileostomies: A Retrospective Analysis

<i  >Objective</i>. This series describes a developing experience in laparoscopic liver surgery presenting results from 40 procedures including right hemihepatectomy, left lateral lobectomy, and microwave ablation therapy. <i  >Methods</i>. Forty patients undergoing laparoscopic liver surgery between September 1997 and November 2006 were included. The data set includes: operative procedure and duration, intraoperative blood loss, conversion to open operation rates, length of hospital stay, complications, mortality, histology of lesions/resection margins, and disease recurrence. <i  >Results</i>. Mean age of patient: 59 years, 17/40 male, 23/40 female, 23/40 of lesions were benign, and 17/40 malignant. Operations included: laparoscopic anatomical resections <svg     style="vertical-align:-0.1638pt;width:44.400002px;" id="M1" height="11.125" version="1.1" viewBox="0 0 44.400002 11.125" width="44.400002"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
    
        
            <g transform="matrix(.017,-0,0,-.017,.062,10.862)"><path id="x1D45B" d="M495 86q-46 -47 -87 -72.5t-63 -25.5q-43 0 -16 107l49 210q7 34 8 50.5t-3 21t-13 4.5q-35 0 -109.5 -72.5t-115.5 -140.5q-21 -75 -38 -159q-50 -10 -76 -21l-6 8l84 340q8 35 -4 35q-17 0 -67 -46l-15 26q44 44 85.5 70.5t64.5 26.5q35 0 10 -103l-24 -98h2&#xA;q42 56 97 103.5t96 71.5q46 26 74 26q9 0 16 -2.5t14 -11.5t9.5 -24.5t-1 -44t-13.5 -68.5q-30 -117 -47 -200q-4 -19 -3.5 -25t6.5 -6q21 0 70 48z" /></g><g transform="matrix(.017,-0,0,-.017,13.305,10.862)"><path id="x3D" d="M535 323h-483v50h483v-50zM535 138h-483v50h483v-50z" /></g><g transform="matrix(.017,-0,0,-.017,28.008,10.862)"><path id="x31" d="M384 0h-275v27q67 5 81.5 18.5t14.5 68.5v385q0 38 -7.5 47.5t-40.5 10.5l-48 2v24q85 15 178 52v-521q0 -55 14.5 -68.5t82.5 -18.5v-27z" /></g><g transform="matrix(.017,-0,0,-.017,36.168,10.862)"><path id="x35" d="M153 550l-26 -186q79 31 111 31q90 0 141.5 -51t51.5 -119q0 -93 -89 -166q-85 -69 -173 -71q-32 0 -61.5 11.5t-41.5 23.5q-18 17 -17 34q2 16 22 33q14 9 26 -1q61 -50 124 -50q60 0 93 43.5t33 104.5q0 69 -41.5 110t-121.5 41q-53 0 -102 -20l38 305h286l6 -8&#xA;l-26 -65h-233z" /></g>

        
    
</svg>, nonanatomical resections <svg     style="vertical-align:-0.1638pt;width:44.400002px;" id="M2" height="11.125" version="1.1" viewBox="0 0 44.400002 11.125" width="44.400002"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
    
        
            <g transform="matrix(.017,-0,0,-.017,.062,10.862)"><use xlink:href="#x1D45B"/></g><g transform="matrix(.017,-0,0,-.017,13.305,10.862)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,-0,0,-.017,28.008,10.862)"><use xlink:href="#x31"/></g><g transform="matrix(.017,-0,0,-.017,36.168,10.862)"><use xlink:href="#x31"/></g>

        
    
</svg>, microwave ablations <svg     style="vertical-align:-0.1638pt;width:36.237499px;" id="M3" height="11.125" version="1.1" viewBox="0 0 36.237499 11.125" width="36.237499"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
    
        
            <g transform="matrix(.017,-0,0,-.017,.062,10.862)"><use xlink:href="#x1D45B"/></g><g transform="matrix(.017,-0,0,-.017,13.305,10.862)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,-0,0,-.017,28.008,10.862)"><path id="x38" d="M249 635q70 0 116 -43t46 -105q0 -46 -28 -80q-22 -25 -80 -64q62 -35 97 -75t35 -99q0 -81 -63 -131t-135 -50q-83 0 -137.5 45.5t-54.5 123.5q0 52 45 95q29 28 89 64q-109 62 -109 155q0 66 50.5 115t128.5 49zM238 603q-42 0 -67.5 -31t-25.5 -72q0 -50 32.5 -79.5&#xA;t98.5 -62.5q61 48 61 124q0 59 -29.5 90t-69.5 31zM248 20q46 0 76.5 33.5t30.5 89.5q0 50 -39 85.5t-110 71.5q-81 -54 -81 -137q0 -67 35.5 -105t87.5 -38z" /></g>

        
    
</svg> and deroofing of cysts <svg     style="vertical-align:-0.1638pt;width:36.237499px;" id="M4" height="10.925" version="1.1" viewBox="0 0 36.237499 10.925" width="36.237499"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
    
        
            <g transform="matrix(.017,-0,0,-.017,.062,10.65)"><use xlink:href="#x1D45B"/></g><g transform="matrix(.017,-0,0,-.017,13.305,10.65)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,-0,0,-.017,28.008,10.65)"><path id="x37" d="M447 623l8 -12l-283 -613l-74 -10l-7 11q174 283 297 551h-216q-48 0 -62.5 -12t-33.5 -63h-29q10 60 18 148h382z" /></g>

        
    
</svg>.  Median anaesthetic time: 120 minutes (range 40&#x2013;240), mean blood loss 78&#x2009;mL and 1/40  conversions to open. Median resection margins were 10&#x2009;mm (range 1&#x2013;14) and median length of stay 3 days (range 1&#x2013;10). Operative and 30-day mortality were zero with no local disease recurrence. <i  >Conclusion</i>. Laparoscopic liver surgery appears safe and effective and is associated with reduced hospital stay. Larger studies are required to confirm it is oncologically sound.

Laura Spencer

Matthew S. Metcalfe

Andrew D. Strickland

Elisabeth J. Elsey

Gavin S. Robertson

David M. Lloyd

Lessons from Laparoscopic Liver Surgery: A Nine-Year Case Series

Spontaneous perforation of the extrahepatic biliary system is a rare presentation of ductal stones. We report the case of a twenty-year-old woman presenting at term with biliary peritonitis caused by common bile duct (CBD) perforation due to an impacted stone in the distal common bile duct. The patient had suffered a single herald episode of acute gallstone pancreatitis during the third trimester. The patient underwent an emergency laparotomy, bile duct exploration, and removal of the ductal stone. The postoperative course was uneventful.

N. Dabbas

M. Abdelaziz

K. Hamdan

B. Stedman

M. Abu Hilal

Gallstone-Induced Perforation of the Common Bile Duct in Pregnancy

Intra-abdominal abscesses formation in patients with no preceding symptoms is rare. Infection of the pancreas occurs in 5–9% of patients with acute pancreatitis, more commonly as a complication of necrotising or severe pancreatitis. We have reported a case of a 64-year-old almost entirely asymptomatic man who underwent a Whipple's procedure following extensive investigation of a pancreatic mass. The pathology and histology showed no evidence of malignancy, and instead a true pancreatic abscess, centred around an impacted cholesterol calculus in the distal CBD. Of suspicious pancreatic masses that are resected, chronic choledocholithiasis is the aetiology in less than 5% of nonmalignant or false positives. This report describes such a case.

Andrew J. Healey

Anna Reed

Long R. Jiao

Pancreatic Mass with an Unusual Pathology: A Case Report

Although cases of lymphoplasmacytic sclerosing pancreatitis (LSP) associated with idiopathic retroperitoneal fibrosis have been reported, the association is rare. We describe a 74-year-old man who presented with obstructive jaundice and weight loss. Nineteen months earlier, he had been diagnosed with idiopathic retroperitoneal fibrosis and treated with bilateral ureteric stents.  Initial investigations were suggestive of a diagnosis of LSP, however, a malignant cause could not be ruled out. He underwent an exploratory laparotomy and frozen sections confirmed the diagnosis of LSP. An internal biliary bypass was performed using a Roux loop of jejunum, and the patient made an uneventful recovery. This case illustrates the difficulty in distinguishing LSP from pancreatic carcinoma preoperatively.

Nigel K. F. Koo Ng

Jin J. Bong

Robin C. Williamson

Lymphoplasmacytic Sclerosing Pancreatitis and Retroperitoneal Fibrosis

<i  >Hypothesis</i>. Smaller and lower-volume hospitals can attain surgical outcomes similar to high-volume centers if they incorporate the expertise and health care pathways of high-volume centers. <i  >Setting</i>. The academic tertiary care center, Moffit-Long Hospital (ML); the community-based Mount Zion Hospital (ZION); the San Francisco County General Hospital (SFGH); and the Veterans Affairs Medical Center of San Francisco (VAMC). <i  >Patients</i>. 369 patients who underwent pancreaticoduodenectomy between October 1989 and June 2003 at the University of California, San Francisco (UCSF) affiliated hospitals. <i  >Interventions</i>. Pancreaticoduodenectomy. <i  >Design</i>. Retrospective chart review. To correct for the potentially confounding effect of small case volumes and event rates, data for SFGH, VAMC, and ZION was combined (Small Volume Hospital Group; SVHG) and compared against data for ML.
<i  >Main Outcome Measures</i>. Complication rates; three-year and five-year survival rates. <i  >Results</i>. The average patient age and health, as determined by ASA score, were similar between ML and the SVHG. The postoperative complication rate did not differ significantly between ML and the SVGH (58.8<svg     style="vertical-align:-0.4368pt;width:12.975px;" id="M1" height="11.75" version="1.1" viewBox="0 0 12.975 11.75" width="12.975"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><path id="x25" d="M594 629l-404 -661l-31 23l402 661zM194 635q70 0 107 -56t37 -125t-37.5 -125.5t-107.5 -56.5t-107 56.5t-37 124.5q0 70 37.5 126t107.5 56zM193 605q-28 0 -45 -29t-21.5 -59.5t-4.5 -62.5t4.5 -63t22 -60t45.5 -29q22 0 37.5 16t22 42t9 48t2.5 45q0 152 -72 152z&#xA;M567 351q69 0 106 -56t37 -125t-37 -125.5t-107 -56.5t-107.5 56.5t-37.5 124.5q0 43 14.5 83t49 69.5t82.5 29.5zM566 322q-28 0 -45 -28.5t-22 -59.5t-5 -64q0 -23 3 -46t10.5 -48.5t23 -41.5t36.5 -16q28 0 45 29.5t21 59.5t4 62q0 24 -2.5 46.5t-9.5 48.5t-22 42t-37 16&#xA;z" /></g>

		
	
</svg> versus 63.1<svg     style="vertical-align:-0.4368pt;width:12.975px;" id="M2" height="11.75" version="1.1" viewBox="0 0 12.975 11.75" width="12.975"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><use xlink:href="#x25"/></g>

		
	
</svg>). Patients that experienced a complication averaged 2.5 complications in both groups. The perioperative mortality rate was <svg     style="vertical-align:-0.4368pt;width:21.137501px;" id="M3" height="11.75" version="1.1" viewBox="0 0 21.137501 11.75" width="21.137501"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><path id="x34" d="M456 178h-96v-72q0 -51 12.5 -62.5t72.5 -16.5v-27h-256v27q65 5 78 17t13 62v72h-260v28q182 271 300 426h40v-407h96v-47zM280 225v295h-2q-107 -148 -196 -295h198z" /></g><g transform="matrix(.017,-0,0,-.017,8.222,11.15)"><use xlink:href="#x25"/></g>

		
	
</svg> for patients undergoing pancreaticoduodenectomy at either ML or the SVGH. Although the 3-year survival rate for patients with adenocarcinoma of the pancreas was nearly twice as high at ML (31.2<svg     style="vertical-align:-0.4368pt;width:12.975px;" id="M4" height="11.75" version="1.1" viewBox="0 0 12.975 11.75" width="12.975"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><use xlink:href="#x25"/></g>

		
	
</svg> versus 18.3<svg     style="vertical-align:-0.4368pt;width:12.975px;" id="M5" height="11.75" version="1.1" viewBox="0 0 12.975 11.75" width="12.975"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><use xlink:href="#x25"/></g>

		
	
</svg> at SVHG), there was no significant difference in the 5-year survival rates (<svg     style="vertical-align:-0.4368pt;width:29.299999px;" id="M6" height="11.75" version="1.1" viewBox="0 0 29.299999 11.75" width="29.299999"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><path id="x31" d="M384 0h-275v27q67 5 81.5 18.5t14.5 68.5v385q0 38 -7.5 47.5t-40.5 10.5l-48 2v24q85 15 178 52v-521q0 -55 14.5 -68.5t82.5 -18.5v-27z" /></g><g transform="matrix(.017,-0,0,-.017,8.222,11.15)"><path id="x39" d="M244 635q90 0 143 -72t53 -177q0 -133 -65 -229.5t-171 -139.5q-79 -32 -140 -32l-5 30q109 18 185 91t101 186l-68 -36q-29 -16 -60 -16q-79 0 -129 51.5t-50 130.5q0 80 57 146.5t149 66.5zM228 602q-52 0 -78 -45.5t-26 -98.5q0 -69 36.5 -115.5t97.5 -46.5&#xA;q53 0 90 28q4 31 4 66q0 51 -9.5 95.5t-39 80.5t-75.5 36z" /></g><g transform="matrix(.017,-0,0,-.017,16.381,11.15)"><use xlink:href="#x25"/></g>

		
	
</svg> at ML versus <svg     style="vertical-align:-0.4368pt;width:41.325001px;" id="M7" height="11.75" version="1.1" viewBox="0 0 41.325001 11.75" width="41.325001"  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,-0,0,-.017,.062,11.15)"><use xlink:href="#x31"/></g><g transform="matrix(.017,-0,0,-.017,8.222,11.15)"><path id="x38" d="M249 635q70 0 116 -43t46 -105q0 -46 -28 -80q-22 -25 -80 -64q62 -35 97 -75t35 -99q0 -81 -63 -131t-135 -50q-83 0 -137.5 45.5t-54.5 123.5q0 52 45 95q29 28 89 64q-109 62 -109 155q0 66 50.5 115t128.5 49zM238 603q-42 0 -67.5 -31t-25.5 -72q0 -50 32.5 -79.5&#xA;t98.5 -62.5q61 48 61 124q0 59 -29.5 90t-69.5 31zM248 20q46 0 76.5 33.5t30.5 89.5q0 50 -39 85.5t-110 71.5q-81 -54 -81 -137q0 -67 35.5 -105t87.5 -38z" /></g><g transform="matrix(.017,-0,0,-.017,16.381,11.15)"><path id="x2E" d="M113 -12q-24 0 -39.5 16t-15.5 42q0 24 16 40.5t40 16.5t40 -16.5t16 -40.5q0 -26 -16 -42t-41 -16z" /></g><g transform="matrix(.017,-0,0,-.017,20.257,11.15)"><path id="x33" d="M285 378v-2q65 -13 102 -54.5t37 -97.5q0 -57 -30.5 -104.5t-74 -75t-85.5 -42t-72 -14.5q-31 0 -59.5 11t-40.5 23q-19 18 -16 36q1 16 23 33q13 10 24 0q58 -51 124 -51q55 0 88 40t33 112q0 64 -39 96.5t-88 32.5q-29 0 -64 -11l-6 29q77 25 118 57.5t41 84.5&#xA;q0 45 -26.5 69.5t-68.5 24.5q-67 0 -120 -79l-20 20l43 63q51 56 127 56h1q66 0 107 -37t41 -95q0 -42 -31 -71q-22 -23 -68 -54z" /></g><g transform="matrix(.017,-0,0,-.017,28.416,11.15)"><use xlink:href="#x25"/></g>

		
	
</svg> at SVHG). <i  >Conclusions</i>. Low-volume hospitals can achieve similar outcomes to high-volume tertiary care centers provided they import the expertise and care pathways necessary for improved results.

Micheal T. Schell

Anthony Barcia

Austin L. Spitzer

Pancreaticoduodenectomy: Volume is not Associated with Outcome within an Academic Health Care System

Extrahepatic hepatic ductal injuries (EHDIs) due to blunt abdominal trauma are rare. Given the rarity of these injuries and the insidious onset of symptoms, EHDI are commonly missed during the initial trauma evaluation, making their diagnosis difficult and frequently delayed. Diagnostic modalities useful in the setting of EHDI include computed tomography (CT), abdominal ultrasonography (AUS), nuclear imaging (HIDA scan), and cholangiography. Traditional options in management of EHDI include primary ductal repair with or without a T-tube, biliary-enteric anastomosis, ductal ligation, stenting, and drainage. Simple drainage and biliary decompression is often the most appropriate treatment in unstable patients. More recently, endoscopic retrograde cholangiopancreatography (ERCP) allowed for diagnosis and potential treatment of these injuries via stenting and/or papillotomy. Our review of 53 cases of EHDI reported in the English-language literature has focused on the evolving role of ERCP in diagnosis and treatment of these injuries. Diagnostic and treatment algorithms incorporating ERCP have been designed to help systematize and simplify the management of EHDI. An illustrative case is reported of blunt traumatic injury involving both the extrahepatic portion of the left hepatic duct and its confluence with the right hepatic duct. This injury was successfully diagnosed and treated using ERCP.

Nikhil P. Jaik

Brian A. Hoey

S. Peter Stawicki

Evolving Role of Endoscopic Retrograde Cholangiopancreatography in Management of Extrahepatic Hepatic Ductal Injuries due to Blunt Trauma: Diagnostic and Treatment Algorithms

<i>Background</i>. Hepatic lymph node involvement is generally considered a contraindication for liver resection performed for colorectal liver metastases. However, some advocate hepatic lymphadenectomy in the presence of macroscopic involvement and others routine lymphadenectomy. The aim of this review is to assess the role of lymphadenectomy in resection of liver metastases from colorectal cancer. <i>Methods</i>. Medline, Embase and Central databases were searched using a formal search strategy. Trials with survival data with a minimum follow-up of 1 year were considered for inclusion. Meta-analysis was performed using Revman. <i>Results</i>. A total of 4230 references were identified. Ten reports of nine studies including 926 patients qualified for the review. The prevalence of nodal metastases after routine lymphadenectomy was 16.3%. The overall 3-year and 5-year survival rates in node-positive patients were 9/151 (11.3%) and 2/137 (1.5%), respectively, compared to 3-year and 5-year survival rates of 424/787 (53.9%) and 246/767 (32.1%) in node-negative patients. The odds ratios for 3-year and 5-year survivals in node positive disease compared to node-negative disease were 0.12 (95% CI 0.06 to 0.24) and 0.08 (95% CI 0.03 to 0.22). There was no randomized controlled trial which assessed the survival benefit of routine or “selective” lymphadenectomy. <i>Conclusion</i>. Currently, there is no evidence of survival benefit for routine or selective lymphadenectomy. Survival rates are low in patients with positive lymph nodes draining the liver irrespective of whether they are detected by routine lymphadenectomy or by macroscopic involvement. Further trials in this patient group are required.

Kurinchi S. Gurusamy

Charles Imber

Brian R. Davidson

Management of the Hepatic Lymph Nodes during Resection of Liver Metastases from Colorectal Cancer: A Systematic Review

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