<i  >Introduction</i>. Hepatocellular carcinoma (HCC) is a rare pediatric cancer accounting for 0.5&#x25; of all pediatric malignancies. This study examines a large cohort of HCC patients in an effort to define the factors impacting clinical outcomes in pediatric HCC patients compared to adults.<i  > Methods</i>. Demographic and clinical data on 63,771 HCC patients (257 pediatric patients &#x2264; 19 and 63,514 adult patients age &#x2265; 20) were abstracted from the SEER database (1973&#x2013;2011).<i  > Results</i>. HCC was more common among males (59.5&#x25; pediatric and 75.1&#x25; adults) and Caucasians (50.4&#x25; and 50.5&#x25;), <svg  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"   style="vertical-align:-3.32502pt" id="M1" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 45.37 11.6608" width="45.37pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="597" vert-adv-y="597" /></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-91" d="M530 -6V57L144 261V263L530 468V530L81 290V234L530 -6Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="611" vert-adv-y="611" /></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="237" vert-adv-y="237" /></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,38.799,0)"><path id="g50-54" d="M158 548H390L417 615L410 623H122L83 318C105 326 143 337 185 337C296 337 350 275 350 188C350 116 308 42 225 42C164 42 122 74 100 93C90 101 82 99 72 92C60 82 51 68 50 59C48 46 52 38 66 24C82 9 125 -12 172 -12C225 -11 292 15 346 59C408 108 437 166 437 226C437 309 371 397 242 397C214 397 170 382 133 369L158 548Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g></svg>. Children more often presented with fibrolamellar variant HCC (24.1&#x25; versus 0.3&#x25;, <svg  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"   style="vertical-align:-3.32502pt" id="M2" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 45.37 11.6608" width="45.37pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="597" vert-adv-y="597" /></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-34" d="M556 331V384H55V331H556ZM556 140V193H55V140H556Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="611" vert-adv-y="611" /></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="237" vert-adv-y="237" /></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-56" d="M453 623H65C60 580 56 530 46 472H80C103 538 110 548 175 548H389C310 380 195 168 90 0L98 -12L175 -2C273 206 366 408 462 610L453 623Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,38.801,0)"><path id="g50-50" d="M389 0V32C297 38 291 46 291 118V635C234 613 175 595 109 583V556L161 554C203 552 207 547 207 497V118C207 46 201 38 110 32V0H389Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g></svg>) and advanced HCC, including distant disease (33.1&#x25; versus 20.8&#x25;, <svg  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"   style="vertical-align:-3.32502pt" id="M3" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 51.7247 11.6608" width="51.7247pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="597" vert-adv-y="597" /></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-91" d="M530 -6V57L144 261V263L530 468V530L81 290V234L530 -6Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="611" vert-adv-y="611" /></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="237" vert-adv-y="237" /></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,38.799,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,45.13,0)"><path id="g50-50" d="M389 0V32C297 38 291 46 291 118V635C234 613 175 595 109 583V556L161 554C203 552 207 547 207 497V118C207 46 201 38 110 32V0H389Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g></svg>), and tumors &#x3e; 4&#x2009;cm in size (79.6&#x25; versus 62.0&#x25;, <svg  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"   style="vertical-align:-3.32502pt" id="M4" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 45.37 11.6608" width="45.37pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="597" vert-adv-y="597" /></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-34" d="M556 331V384H55V331H556ZM556 140V193H55V140H556Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="611" vert-adv-y="611" /></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="237" vert-adv-y="237" /></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,38.799,0)"><path id="g50-51" d="M414 144C384 79 371 75 317 75H135L276 221C367 316 408 376 408 465C408 570 327 635 237 635C179 635 131 609 100 575L42 494L67 471C94 510 138 565 205 565C277 565 321 517 321 435C321 348 258 270 195 195C146 137 88 81 33 26V0H411C423 44 433 88 446 135L414 144Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g></svg>). Pediatric HCC patients undergoing surgery (13.107 versus 8.324 years, <svg  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"   style="vertical-align:-3.32502pt" id="M5" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 51.7247 11.6608" width="51.7247pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="597" vert-adv-y="597" /></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-91" d="M530 -6V57L144 261V263L530 468V530L81 290V234L530 -6Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="611" vert-adv-y="611" /></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="237" vert-adv-y="237" /></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,38.799,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,45.13,0)"><path id="g50-50" d="M389 0V32C297 38 291 46 291 118V635C234 613 175 595 109 583V556L161 554C203 552 207 547 207 497V118C207 46 201 38 110 32V0H389Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g></svg>) had longer survival than adult HCC patients. Overall mortality was lower (65.8&#x25; versus 82.0&#x25;, <svg  xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg"   style="vertical-align:-3.32502pt" id="M6" height="11.6608pt" version="1.1" viewBox="-0.0498162 -8.33578 51.7247 11.6608" width="51.7247pt"><g transform="matrix(.013,0,0,-0.013,0,0)"><path id="g50-113" d="M573 302C573 402 527 451 414 451C386 451 343 446 313 437L330 513L320 522C295 508 261 484 243 463L230 415C194 400 159 383 126 359L131 330C159 344 187 357 222 368L109 -147C96 -204 80 -214 18 -223L13 -255L256 -244L259 -212L236 -210C184 -205 180 -195 191 -141L219 -1C240 -10 268 -12 284 -12C352 4 431 48 484 104C543 166 573 240 573 302ZM481 290C481 165 381 37 305 37C280 37 249 56 235 71L302 395C328 399 353 402 372 402C427 402 481 378 481 290Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="597" vert-adv-y="597" /></g><g transform="matrix(.013,0,0,-0.013,11.438,0)"><path id="g54-91" d="M530 -6V57L144 261V263L530 468V530L81 290V234L530 -6Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="611" vert-adv-y="611" /></g><g transform="matrix(.013,0,0,-0.013,23.056,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,29.387,0)"><path id="g50-47" d="M117 -12C153 -12 178 12 178 50C178 84 153 110 118 110C84 110 59 84 59 50C59 12 84 -12 117 -12Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="237" vert-adv-y="237" /></g><g transform="matrix(.013,0,0,-0.013,32.468,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,38.799,0)"><path id="g50-49" d="M245 635C92 635 37 457 37 312C37 149 91 -12 244 -12C395 -12 449 166 449 312C449 469 395 635 245 635ZM243 598C332 598 358 454 358 312C358 173 334 26 245 26C158 26 128 174 128 313S152 598 243 598Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g><g transform="matrix(.013,0,0,-0.013,45.13,0)"><path id="g50-50" d="M389 0V32C297 38 291 46 291 118V635C234 613 175 595 109 583V556L161 554C203 552 207 547 207 497V118C207 46 201 38 110 32V0H389Z" /><glyph.data ascent="3443" descent="-2856" horiz-adv-x="487" vert-adv-y="487" /></g></svg>) in the pediatric HCC group.<i  > Conclusion</i>. HCC is a rare pediatric malignancy that presents most often as an advanced tumor, &#x3e;4&#x2009;cm in Caucasian males. Children with HCC achieve significantly longer mean overall survival compared to adults with HCC, primarily attributable to the more favorable fibrolamellar histologic variant, and more aggressive surgical intervention, which significantly improves survival. 

Christine S. M. Lau

Krishnaraj Mahendraraj

Ronald S. Chamberlain

Hepatocellular Carcinoma in the Pediatric Population: A Population Based Clinical Outcomes Study Involving 257 Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1973&#x2013;2011)

<i>Background</i>. Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. The modified Appleby procedure allows resection of pancreatic body carcinoma with celiac axis (CA) invasion. Given that the feasibility of this technique is based on the presence of collateral circulation, it is crucial to confirm the presence of an anatomical and functional collateral system.<i> Methods</i>. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course.<i> Results</i>. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. Moreover, extra length on the CA margin may be gained, as the artery can be transected at its origin without the need for vascular clamp placement.<i> Conclusion</i>. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care.

N. Trabulsi

J. S. Pelletier

C. Abraham

T. Vanounou

Preoperative Diagnostic Angiogram and Endovascular Aortic Stent Placement for Appleby Resection Candidates: A Novel Surgical Technique in the Management of Locally Advanced Pancreatic Cancer

<i>Introduction</i>. Operations are performed for broader liver surgery indications for a better understanding of hepatic anatomy/physiology and developments in operation technology. Surgery can cure some patients with liver metastasis of some tumors. Nevertheless, postoperative liver failure is the most feared complication causing mortality in patients who have undergone excision of a large liver mass. The human amniotic membrane has regenerative effects. Thus, we investigated the effects of the human amniotic membrane on regeneration of the resected liver.<i> Methods</i>. Twenty female Wistar albino rats were divided into control and experimental groups and underwent a 70&#x25; hepatectomy. The human amniotic membrane was placed over the residual liver in the experimental group. Relative liver weight, histopathological features, and biochemical parameters were assessed on postoperative day 3.<i> Results</i>. Total protein and albumin levels were significantly lower in the experimental group than in the control group. No difference in relative liver weight was observed between the groups. Hepatocyte mitotic count was significantly higher in the experimental group than in the control group. Hepatic steatosis was detected in the experimental group.<i> Conclusion</i>. Applying the amniotic membrane to residual liver adversely affected liver regeneration. However, mesenchymal stem cell research has the potential to accelerate liver regeneration investigations.

Mesut Sipahi

Sevin&#xe7; &#x15e;ahin

Ergin Arslan

Hasan B&#xf6;rekci

Bayram Metin

Nuh Zafer Cant&#xfc;rk

Effect of the Human Amniotic Membrane on Liver Regeneration in Rats

<i>Background</i>. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. <i>Aim</i>. To review 5-year results of bile duct exploration in an UGI unit. <i>Methods</i>. Common bile duct explorations (CBDEs) performed between January 2008 and January 2013 were identified from a prospectively collected clinical audit system and results reviewed retrospectively. <i>Results</i>. 216 CBDEs were performed, 119 (55&#x25;) as an emergency and 52 (24&#x25;) following failed ERCP. Open CBDE (OCBDE) was performed primarily in 34/216 (16&#x25;) patients and attempted laparoscopically in 182 (84&#x25;). Fifty nine (32&#x25;) Laparoscopic CBDEs (LCBDEs) were converted to OCBDE. Of the remaining 123 LCBDEs, 51 (41&#x25;) primary choledochotomies and 72 (59&#x25;) primary transcystic CBDEs (TC-CBDEs) were performed. Forty nine (68&#x25;) TC-CBDEs were considered successful and 23 (32&#x25;) failed. Fifteen failed TC-CBDEs were converted to a successful laparoscopic choledochotomy. Ductal clearance was achieved in 187/216 (87&#x25;) patients and retained stones were identified in 20/123 (16&#x25;) LCBDEs. Complications occurred in 52/216 (24&#x25;) patients. There were 8/216 (4&#x25;) bile leaks requiring further intervention. Postoperative ERCP was carried out in 32/216 (15&#x25;) patients and 9/216 (4&#x25;) required relaparoscopy/laparotomy. No patient died. <i>Conclusions</i>. Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise.

J. H. Darrien

K. Connor

A. Janeczko

J. J. Casey

S. Paterson-Brown

The Surgical Management of Concomitant Gallbladder and Common Bile Duct Stones

<i>Background.</i> Indicators of operative outcomes could be used to identify underperforming surgeons for support and training. The feasibility of identifying HPB surgeons with poor operative performance (&#x201c;outliers&#x201d;) based on the results of pancreatic resections is not known. <i>Methods.</i> A systematic review of Medline, Embase, and the Cochrane library was performed to identify studies on pancreatic resection including at least 100 patients and published between 2004 and 2014. Proportions that lay outside the upper 95&#x25; and 99.8&#x25; confidence intervals based on results of the systematic reviews were considered as &#x201c;outliers.&#x201d; <i>Results.</i> In total, 30 studies reporting on 10712 patients were eligible for inclusion in this review. The average short-term mortality after pancreatic resections was 3.1&#x25; and proportion of patients with procedure-related complications was 47.0&#x25;. None of the classification systems assessed the long-term impact of the complications on patients. The surgeon-specific mortality should be 5 times the average mortality before he or she can be identified as an outlier with 0.1&#x25; false positive rate if he or she performs 50 surgeries a year. <i>Conclusions.</i> A valid risk prognostic model and a classification system of surgical complications are necessary before meaningful comparisons of the operative performance between pancreatic surgeons can be made.

Kurinchi Gurusamy

Clare Toon

Bhavisha Virendrakumar

Steve Morris

Brian Davidson

Feasibility of Comparing the Results of Pancreatic Resections between Surgeons: A Systematic Review and Meta-Analysis of Pancreatic Resections

<i>Background</i>. The most significant risk following major hepatectomy is postoperative liver insufficiency. Current preoperative assessment of the future liver remnant relies upon assumptions which may not be valid in the setting of advanced resection strategies. This paper reports the feasibility of the <i>ALIIVE</i> technique which assesses the liver remnant with ICG clearance intraoperatively during vascular exclusion. <i>Methods</i>. 10 patients undergoing planned major liver resection (hemihepatectomy or greater) were recruited. Routine preoperative assessment included CT and standardized volumetry. ICG clearance was measured noninvasively using a finger spectrophotometer at various time points including following parenchymal transection during inflow and outflow occlusion before vascular division, the ALIIVE step. <i>Results</i>. There were one case of mortality and three cases of posthepatectomy liver failure. The patient who died had the lowest ALIIVE ICG clearance (7.1&#x25;/min versus 14.4 &#xb1; 4.9). Routine preoperative CT and standardized volumetry did not predict outcome. <i>Discussion/Conclusion</i>. The novel ALIIVE technique is feasible and assesses actual future liver remnant function before the point of no return during major hepatectomy. This technique may be useful as a check step to offer a margin of safety to prevent posthepatectomy liver failure and death. Further confirmatory studies are required to determine a safety cutoff level.

Lawrence Lau

Christopher Christophi

Mehrdad Nikfarjam

Graham Starkey

Mark Goodwin

Laurence Weinberg

Loretta Ho

Vijayaragavan Muralidharan

Assessment of Liver Remnant Using ICG Clearance Intraoperatively during Vascular Exclusion:  Early Experience with the ALIIVE Technique

<i>Introduction</i>. While the incidence of pancreatic cystic lesions has steadily increased, we sought to evaluate the changes in their surgical management. <i>Methods</i>. Patients with pancreatic cystic lesions who underwent surgical resection from 2003 to 2013 were identified. Clinicopathologic factors were analyzed and compared to a similar cohort from 1992 to 2002. <i>Results</i>. There were 134 patients with pancreatic cystic lesions who underwent surgical resection from 2003 to 2013, compared to 73 from 1992 to 2002. The most common preoperative imaging was a CT scan, although 66&#x25; underwent EUS and 63&#x25; underwent biopsy. Pathology included 18 serous, 47 mucinous, 11 pseudopapillary, and 58 intraductal papillary mucinous neoplasms (IPMN). In comparing cohorts, there were significantly fewer serous lesions and more IPMN. Postoperative complication rates were similar, and perioperative mortality rates were comparable. <i>Conclusion</i>. There has been a dramatic change in surgically treated pancreatic cystic tumors over the past two decades. Our data suggests that the incorporation of new imaging and diagnostic tests has led to greater detection of cystic tumors and a decreased rate of potentially unnecessary resections. Therefore, all patients with cystic pancreatic lesions should undergo a focused CT-pancreas, and an EUS biopsy should be considered, in order to best select those that would benefit from surgical resection.

Jennifer K. Plichta

Jacqueline A. Brosius

Sam G. Pappas

Gerard J. Abood

Gerard V. Aranha

The Changing Spectrum of Surgically Treated Cystic Neoplasms of the Pancreas

<i>Introduction</i>. The management of cystic pancreatic lesions has changed in recent years as a result of increasing knowledge of their biological behaviour, better diagnostic options, and international guidelines. <i>Methods</i>. Retrospective analysis of a cohort of 86 patients operated for cystic pancreatic lesions during a seven-year period (2007&#x2013;2014). <i>Results</i>. Final histopathology revealed 53 intraductal papillary mucinous neoplasms (19 branch duct IPMNs, 15 mixed type IPMNs, and 19 main duct IPMNs), 14 serous and 13 mucinous cystic neoplasms, 3 solid pseudopapillary neoplasms, and 3 other lesions. 4 cases displayed high grade intraepithelial neoplasia and 2 cases displayed invasive cancer. A pylorus-preserving partial duodenopancreatectomy was carried out in 27 patients, a total pancreatectomy was carried out in 9 patients, a left resection was carried out in 42 patients, and segmental resections and enucleations were carried out in 4 patients each. Overall postoperative morbidity and mortality were 40&#x25; and 2.3&#x25;, respectively. The preoperative diagnosis of a specific cystic tumor was accurate in 79&#x25; of patients and 9 patients (10&#x25;) could have avoided surgery with the correct preoperative diagnosis. <i>Conclusion</i>. Cystic pancreatic lesions are still a diagnostic challenge, requiring a dedicated multidisciplinary approach. The rate of malignancy is relatively small, whereas postoperative morbidity is substantial, underscoring the importance of adequate patient selection considering both the risk of surgery and the long term risk of malignancy.

J&#xf6;rg Kleeff

Christoph Michalski

Bo Kong

Mert Erkan

Susanne Roth

Jens Siveke

Helmut Friess

Irene Esposito

Surgery for Cystic Pancreatic Lesions in the Post-Sendai Era: A Single Institution Experience

<i>Background.</i> Cholangiocarcinoma is a cancer with a poor prognosis. In this millennium there are new diagnostic and therapeutic strategies for these patients. <i>Aim.</i> The aim of this study was to find if these changes influenced survival  of individuals with proximal cholangiocarcinoma. <i>Material.</i> 627 individuals with a diagnosis of cholangiocarcinoma (not including distal common duct cancer) during the period from 2000 to 2011 were registered in Sweden&#x2019;s Western Region. The material was divided into three consecutive time periods. <i>Results.</i> The overall survival curves for individuals with cholangiocarcinoma improved over the three time periods <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-2.3616pt" id="M1" height="12.0395pt" version="1.1" viewBox="-0.0498162 -9.6779 122.835 12.0395" width="122.835pt"><g transform="matrix(.0135,0,0,-0.0135,0,0)"><path id="g113-41" d="M300 -147C201 -63 143 98 143 270S200 602 300 686L282 710C136 610 70 450 70 271V270C70 89 136 -72 282 -170L300 -147Z"/></g><g transform="matrix(.0135,0,0,-0.0135,4.688,0)"><path id="g113-111" d="M495 86L479 114C446 82 419 66 409 66C401 66 401 72 406 97C420 166 436 231 453 297C489 435 454 448 428 448C406 448 384 439 354 422C305 394 222 327 161 247H159L183 345C200 415 194 448 173 448C143 448 82 410 23 351L38 325C64 349 95 371 105 371C111 371 116 365 109 336L25 -4L31 -12C50 -4 77 3 107 9C119 69 132 122 145 168C197 254 321 381 370 381C387 381 393 374 378 305L329 95C309 17 320 -12 345 -12C372 -12 430 19 495 86Z"/></g><g transform="matrix(.0135,0,0,-0.0135,15.274,0)"><path id="g117-34" d="M535 323V373H52V323H535ZM535 138V188H52V138H535Z"/></g><g transform="matrix(.0135,0,0,-0.0135,27.012,0)"><path id="g113-55" d="M137 343C167 482 260 545 321 574C357 591 397 603 429 609L423 641C382 634 335 622 295 608C189 570 37 457 37 238C37 84 125 -12 242 -12C362 -12 447 89 447 209C447 311 374 393 267 393C247 393 226 386 204 376L137 343ZM227 337C318 337 361 256 361 173C361 105 336 22 258 22C176 22 126 120 126 240C126 266 127 291 132 310C155 323 189 337 227 337Z"/></g><g transform="matrix(.0135,0,0,-0.0135,33.515,0)"><path id="g113-51" d="M412 140C382 77 369 73 315 73H129L270 222C362 320 402 379 402 466C402 571 322 635 234 635C177 635 130 609 99 576L42 495L64 475C90 514 133 568 201 568C274 568 318 519 318 435C318 349 255 267 193 193C144 135 87 78 32 23V0H405C417 45 427 89 440 131L412 140Z"/></g><g transform="matrix(.0135,0,0,-0.0135,40.018,0)"><path id="g113-56" d="M447 623H65C61 580 56 530 47 475H76C100 541 106 550 172 550H388C308 376 196 170 91 -1L98 -12L172 -2C268 204 360 408 455 611L447 623Z"/></g><g transform="matrix(.0135,0,0,-0.0135,46.524,0)"><path id="g113-42" d="M275 270C275 450 212 609 64 710L45 686C145 604 203 442 203 270S147 -63 45 -147L64 -170C213 -68 275 89 275 270Z"/></g><g transform="matrix(.0135,0,0,-0.0135,53.482,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.0135,0,0,-0.0135,58.17,0)"><path id="g113-81" d="M600 480C600 590 528 650 384 650H143L137 622C222 614 225 607 210 531L130 127C113 41 106 36 23 28L17 0H294L300 28C204 36 195 42 212 127L243 284L314 263C327 263 339 263 352 264C465 271 600 337 600 480ZM508 481C508 351 402 304 329 304C289 304 265 311 250 317L295 559C302 594 310 606 323 611C335 616 350 619 367 619C455 619 508 573 508 481Z"/></g><g transform="matrix(.0135,0,0,-0.0135,70.32,0)"><use xlink:href="#g117-34"/></g><g transform="matrix(.0135,0,0,-0.0135,82.058,0)"><path id="g113-49" d="M241 635C89 635 35 457 35 312C35 153 89 -12 240 -12C390 -12 443 166 443 312C443 466 390 635 241 635ZM238 602C329 602 354 454 354 312C354 172 330 22 240 22C152 22 124 173 124 313S148 602 238 602Z"/></g><g transform="matrix(.0135,0,0,-0.0135,88.561,0)"><path id="g113-47" d="M113 -12C146 -12 170 11 170 46C170 78 146 103 114 103S58 78 58 46C58 11 82 -12 113 -12Z"/></g><g transform="matrix(.0135,0,0,-0.0135,91.65,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,98.153,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,104.656,0)"><path id="g113-50" d="M384 0V27C293 34 287 42 287 114V635C232 613 172 594 109 583V559L157 557C201 555 205 550 205 499V114C205 42 199 34 109 27V0H384Z"/></g><g transform="matrix(.0135,0,0,-0.0135,111.159,0)"><path id="g113-52" d="M285 378C315 398 338 416 353 432C373 451 384 474 384 503C384 579 325 635 236 635H235C182 635 136 610 108 579L65 516L85 496C110 533 150 575 205 575C258 575 300 543 300 481C300 407 232 369 141 339L147 310C163 315 188 321 211 321C268 321 338 284 338 192C338 94 288 40 217 40C160 40 119 68 93 91C85 98 77 97 69 91C60 84 47 71 46 58C44 46 48 35 62 22C75 10 116 -12 162 -12C234 -12 424 62 424 224C424 297 373 359 285 376V378Z"/></g><g transform="matrix(.0135,0,0,-0.0135,117.662,0)"><use xlink:href="#g113-42"/></g></svg>. Median survival increased from 2.6 months in the first period (2000&#x2013;2003) to 3.6 months in the final four years (2008&#x2013;2011). Patients with perihilar cholangiocarcinoma (PHC) had longer median survival than those with intrahepatic cholangiocarcinoma (IHC): 6.8 versus 3.2 months <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-2.3616pt" id="M2" height="12.0395pt" version="1.1" viewBox="-0.0498162 -9.6779 69.1914 12.0395" width="69.1914pt"><g transform="matrix(.0135,0,0,-0.0135,0,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.0135,0,0,-0.0135,4.688,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.0135,0,0,-0.0135,16.837,0)"><use xlink:href="#g117-34"/></g><g transform="matrix(.0135,0,0,-0.0135,28.575,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,35.078,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.0135,0,0,-0.0135,38.167,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,44.67,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,51.173,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,57.676,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.0135,0,0,-0.0135,64.18,0)"><use xlink:href="#g113-42"/></g></svg>. An improvement in the survival curves over time was seen for those with IHC <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-2.3616pt" id="M3" height="12.0395pt" version="1.1" viewBox="-0.0498162 -9.6779 62.6639 12.0395" width="62.6639pt"><g transform="matrix(.0135,0,0,-0.0135,0,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.0135,0,0,-0.0135,4.688,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.0135,0,0,-0.0135,16.837,0)"><use xlink:href="#g117-34"/></g><g transform="matrix(.0135,0,0,-0.0135,28.575,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,35.078,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.0135,0,0,-0.0135,38.167,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,44.67,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.0135,0,0,-0.0135,51.174,0)"><path id="g113-53" d="M456 178V225H360V632H320C217 496 115 347 20 206V178H280V106C280 40 276 34 189 27V0H445V27C364 34 360 39 360 106V178H456ZM280 225H82C149 335 214 431 278 520H280V225Z"/></g><g transform="matrix(.0135,0,0,-0.0135,57.677,0)"><use xlink:href="#g113-42"/></g></svg> but not for patients with PHC <svg xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg" style="vertical-align:-2.3616pt" id="M4" height="12.0395pt" version="1.1" viewBox="-0.0498162 -9.6779 56.1364 12.0395" width="56.1364pt"><g transform="matrix(.0135,0,0,-0.0135,0,0)"><use xlink:href="#g113-41"/></g><g transform="matrix(.0135,0,0,-0.0135,4.688,0)"><use xlink:href="#g113-81"/></g><g transform="matrix(.0135,0,0,-0.0135,16.837,0)"><use xlink:href="#g117-34"/></g><g transform="matrix(.0135,0,0,-0.0135,28.575,0)"><use xlink:href="#g113-49"/></g><g transform="matrix(.0135,0,0,-0.0135,35.078,0)"><use xlink:href="#g113-47"/></g><g transform="matrix(.0135,0,0,-0.0135,38.167,0)"><use xlink:href="#g113-52"/></g><g transform="matrix(.0135,0,0,-0.0135,44.67,0)"><path id="g113-57" d="M249 635C141 635 70 555 70 471C70 401 114 353 179 316C143 294 106 267 90 252C68 231 45 202 45 157C45 50 130 -12 237 -12C322 -12 435 52 435 169C435 256 372 304 303 343C349 374 375 398 383 407C401 429 411 458 411 487C411 569 344 635 249 635ZM238 603C285 603 337 567 337 482C337 422 310 385 276 358C205 393 145 426 145 500C145 552 179 603 238 603ZM248 20C183 20 125 70 125 163C125 218 158 268 206 300C284 261 355 217 355 143C355 66 308 20 248 20Z"/></g><g transform="matrix(.0135,0,0,-0.0135,51.174,0)"><use xlink:href="#g113-42"/></g></svg>. Nine percent  of the patients with IHC had potential curative surgical therapy. The three-year survival rate after liver resection for patients with IHC was 35&#x25; and 60&#x25; after  liver transplantation. Among patients with PHC, 15.3&#x25; had potential curative bile duct resection with a concomitant liver resection and 6.1&#x25; bile duct resection alone. The three-year survival rate for these two groups was 32&#x25; and 20&#x25;, respectively. <i>Conclusion.</i> Overall survival for individuals with PHC was better than for those with IHC. Over time survival in IHC patients improved but not in those with PHC.

Per Lindn&#xe9;r

Magnus Rizell

Lo Hafstr&#xf6;m

The Impact of Changed Strategies for Patients with Cholangiocarcinoma in This Millenium

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