HPB Surgery https://www.hindawi.com The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Child-Pugh Parameters and Platelet Count as an Alternative to ICG Test for Assessing Liver Function for Major Hepatectomy Tue, 29 Aug 2017 07:02:05 +0000 http://www.hindawi.com/journals/hpb/2017/2948030/ Objective. To study the correlations and discrepancies between Child-Pugh system and indocyanine green (ICG) clearance test in assessing liver function reserve and explore the possibility of combining two systems to gain an overall liver function assessment. Design. Retrospective analysis of 2832 hepatocellular carcinoma (HCC) patients graded as Child-Pugh A and Child-Pugh B with ICG clearance test being performed was conducted. Results. ICG retention rate at 15 minutes (ICG15) correlates with Child-Pugh score, however, with a large variance. Platelet count improves the correlation between Child-Pugh score and ICG15. ICG15 can be estimated using the following regression formula: estimated ICG15 (eICG15) = 45.1 + 0.435 × bilirubin − 0.917 × albumin + 0.491 × prothrombin time − 0.0283 × platelet (). Patients with eICG15 >20.0% who underwent major hepatectomy had a tendency towards more posthepatectomy liver failure (4.1% versus 8.0%, ) and higher in-hospital mortality (3.7% versus 8.0%, ). They also had shorter median overall survival ( versus years, ) and disease-free survival ( versus years, ). Conclusion. eICG15 can be predicted from Child-Pugh parameters and platelet count. eICG15 correlates with in-hospital mortality after major hepatectomy and predicts long-term survival. Kin-Pan Au, See-Ching Chan, Kenneth Siu-Ho Chok, Albert Chi-Yan Chan, Tan-To Cheung, Kelvin Kwok-Chai Ng, and Chung-Mau Lo Copyright © 2017 Kin-Pan Au et al. All rights reserved. Gallbladder Carcinoma in the United States: A Population Based Clinical Outcomes Study Involving 22,343 Patients from the Surveillance, Epidemiology, and End Result Database (1973–2013) Tue, 30 May 2017 08:54:29 +0000 http://www.hindawi.com/journals/hpb/2017/1532835/ Introduction. Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and the third most common gastrointestinal tract malignancy. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical, and pathologic features impacting clinical outcomes. Methods. Demographic and clinical data on 22,343 GBC patients was abstracted from the SEER database (1973–2013). Results. GBC was presented most often among Caucasian (63.9%) females (70.7%) as poorly or moderately differentiated (42.5% and 38.2%) tumors, with lymph node involvement (88.2%). Surgery alone was the most common treatment modality for GBC patients (55.0%). Combination surgery and radiation (10.6%) achieved significantly longer survival rates compared to surgery alone ( versus years, ). Overall mortality was 87.0% and cancer-specific mortality was 75.4%. Conclusions. GBC is an uncommon malignancy that presents most often among females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients. Christine S. M. Lau, Aleksander Zywot, Krishnaraj Mahendraraj, and Ronald S. Chamberlain Copyright © 2017 Christine S. M. Lau et al. All rights reserved. Mediastinal Pseudocyst: Varied Presentations and Management—Experience from a Tertiary Referral Care Centre in India Tue, 14 Mar 2017 06:38:09 +0000 http://www.hindawi.com/journals/hpb/2017/5247626/ Pseudocysts are a recognised complication following acute or chronic pancreatitis. Usually located in peripancreatic areas, they have also been reported to occur in atypical regions like liver, pelvis, spleen, and mediastinum. Mediastinal pseudocysts are a rare entity and present with myriad of symptoms due to their unique location. They are a clinical challenge to diagnose and manage. In this paper, we describe the clinical and radiological characteristics of mediastinal pseudocysts in 7 of our patients, as well as our experience in managing these patients along with their clinical outcome. Durairaj Segamalai, Abdul Rehman Abdul Jameel, Naveen Kannan, Amudhan Anbalagan, Benet Duraisamy, Prabhakaran Raju, and Kannan Devy Gounder Copyright © 2017 Durairaj Segamalai et al. All rights reserved. Bovine Serum Albumin-Glutaraldehyde Sealed Fish-Mouth Closure of the Pancreatic Remnant during Distal Pancreatectomy Tue, 17 Jan 2017 09:25:57 +0000 http://www.hindawi.com/journals/hpb/2017/9747421/ Introduction. Postoperative pancreatic fistula formation remains the major complication after distal pancreatectomy. At our institution, we have recently developed a novel bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure technique of the pancreatic remnant during distal pancreatectomy. The aim of this study was to analyze the impact of this approach with regard to technical feasibility and overall postoperative outcome. Patients and Methods. 32 patients who underwent a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant during distal pancreatectomy between 2012 and 2014 at our institution were analyzed for clinically relevant postoperative pancreatic fistula formation (Grades B and C according to ISGPF definition) and overall postoperative morbidity. Results. Three out of 32 patients (9.4%) developed Grade B pancreatic fistula, which could be treated conservatively. No Grade C pancreatic fistulas were observed. Postpancreatectomy hemorrhage occurred in 1 patient (3.1%). Overall postoperative complications > Clavien II were observed in 5 patients (15.6%). There was no postoperative mortality. Conclusion. The performance of a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant was shown to be technically feasible and may lead to a significant decrease of postoperative pancreatic fistula formation after distal pancreatectomy. Fritz Klein, Igor Maximilian Sauer, Johann Pratschke, and Marcus Bahra Copyright © 2017 Fritz Klein et al. All rights reserved. Pancreatic Cancer: 80 Years of Surgery—Percentage and Repetitions Tue, 25 Oct 2016 07:06:15 +0000 http://www.hindawi.com/journals/hpb/2016/6839687/ Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%. Birgir Gudjonsson Copyright © 2016 Birgir Gudjonsson. All rights reserved. Evaluation of Early Cholecystectomy versus Delayed Cholecystectomy in the Treatment of Acute Cholecystitis Mon, 10 Oct 2016 09:39:23 +0000 http://www.hindawi.com/journals/hpb/2016/4614096/ Objective. To evaluate if early cholecystectomy (EC) is the most appropriate treatment for acute cholecystitis compared to delayed cholecystectomy (DC). Patients and Methods. A retrospective cohort study of 1043 patients was carried out, with a group of 531 EC cases and a group of 512 DC patients. The following parameters were recorded: (1) postoperative hospital morbidity, (2) hospital mortality, (3) days of hospital stay, (4) readmissions, (5) admission to the Intensive Care Unit (ICU), (6) type of surgery, (7) operating time, and (8) reoperations. In addition, we estimated the direct cost savings of implementing an EC program. Results. The overall morbidity of the EC group (29.9%) was significantly lower than the DC group (38.7%). EC demonstrated significantly better results than DC in days of hospital stay (8.9 versus 15.8 days), readmission percentage (6.8% versus 21.9%), and percentage of ICU admission (2.3% versus 7.8%), which can result in reducing the direct costs. The patients who benefited most from an EC were those with a Charlson index > 3. Conclusions. EC is safe in patients with acute cholecystitis and could lead to a reduction in the direct costs of treatment. Miguel Sánchez-Carrasco, Juan C. Rodríguez-Sanjuán, Fernando Martín-Acebes, Francisco J. Llorca-Díaz, Manuel Gómez-Fleitas, Rocío Zambrano Muñoz, and F. Javier Sánchez-Manuel Copyright © 2016 Miguel Sánchez-Carrasco et al. All rights reserved. Intraoperative Fluid Excess Is a Risk Factor for Pancreatic Fistula after Partial Pancreaticoduodenectomy Wed, 21 Sep 2016 13:11:10 +0000 http://www.hindawi.com/journals/hpb/2016/1601340/ Background. After pancreaticoduodenectomy (PD), pancreatic fistulas (PF) are a frequent complication. Infusions may compromise anastomotic integrity. This retrospective analysis evaluated associations between intraoperative fluid excess and PF. Methods. Data on perioperative parameters including age, sex, laboratory findings, histology, infusions, surgery time, and occurrence of grade B/C PF was collected from all PD with pancreaticojejunostomy (PJ) performed in our department from 12/2011 till 02/2015. The glomerular filtration rate (GFR), infusion rate, and the ratio of both and its association with PF were calculated. ROC analysis was employed to identify a threshold. Results. Complete datasets were available for 83 of 86 consecutive cases. Median age was 66 years (34–84; 60% male), GFR was 93 mL/min (IQR 78–113), and surgery time was 259 min (IQR 217–307). Intraoperatively, 13.6 mL/min (7–31) was infused. In total, (21%) PF occurred. When the infusion : GFR ratio exceeded 0.15, PF increased from 11% to 34% (). No significant association was detected for any of the other parameters. Conclusions. This analysis demonstrates for the first time an association between intraoperative fluid excess and PF after PD with PJ even in patients with normal renal function. A carefully patient-adopted fluid management with due regard to renal function may help to prevent postoperative PF. Helge Bruns, Veronika Kortendieck, Hans-Rudolf Raab, and Dalibor Antolovic Copyright © 2016 Helge Bruns et al. All rights reserved. Hepatectomy Based on Future Liver Remnant Plasma Clearance Rate of Indocyanine Green Thu, 23 Jun 2016 11:34:50 +0000 http://www.hindawi.com/journals/hpb/2016/7637838/ Background. Hepatectomy, an important treatment modality for liver malignancies, has high perioperative morbidity and mortality rates. Safe, comprehensive criteria for selecting patients for hepatectomy are needed. Since June 2011, we have used a cut-off value of ≧ 0.05 for future liver remnant plasma clearance rate of indocyanine green as a criterion for hepatectomy. The aim of this study was to verify the validity of this criterion. Methods. From June 2011 to December 2015, 212 hepatectomies were performed in Tenri Yorozu Hospital. Of these 212 patients, 107 who underwent preoperative computed tomography imaging volumetry, indocyanine green clearance test, and hepatectomy (excluding partial resection or enucleation) were retrospectively analyzed. Results. There was no postoperative mortality. Posthepatectomy liver failure occurred in 59 patients (55.1%) (International Study Group of Liver Surgery Grade A: 43 cases (40.2%), Grade B: 16 cases (15.0%), and Grade C: no cases). Operative morbidity greater than Clavien-Dindo Grade 3 occurred in 23 patients (21.5%). A low future liver remnant plasma clearance rate of indocyanine green was a good predictor for Grade B cases (area under curve = 0.804; 95% confidence interval, 0.712–0.895). Conclusion. Liver remnant plasma clearance rate of indocyanine green is a valid criterion for hepatectomy. Yuichiro Uchida, Hiroaki Furuyama, Daiki Yasukawa, Hiroto Nishino, Yasuhisa Ando, Toshiyuki Hata, Takafumi Machimoto, and Tsunehiro Yoshimura Copyright © 2016 Yuichiro Uchida et al. All rights reserved. Extended Perioperative Antibiotic Coverage in Conjunction with Intraoperative Bile Cultures Decreases Infectious Complications after Pancreaticoduodenectomy Mon, 11 Apr 2016 11:33:35 +0000 http://www.hindawi.com/journals/hpb/2016/3031749/ Background. Bile contamination from the digestive tract is a well-known risk factor for postoperative complications. Despite the literature concerning prevalence of bacterobilia and fungobilia in patients with biliary pathologies, there are no specific recommendations for perioperative antimicrobial coverage for biliary/pancreatic procedures. We evaluated the effect of at least 72 hours of perioperative broad spectrum antibiotic coverage on outcomes of pancreaticoduodenectomy (PD). Materials and Methods. A retrospective review of all patients at Case Medical Center of Case Western Reserve University undergoing PD procedure, from 2006 to 2011, was performed (). Perioperative data including demographics, comorbidities, biliary instrumentation, antibiotic coverage, culture results, and postoperative outcomes were analyzed. Propensity score matching method was used to match the patients according to duration of antibiotic coverage into two groups: 72 hours (A72) and 24 hours (A24). Results. Longer broad spectrum antibiotic coverage in group A72 resulted in significantly less surgical site infections after PD, compared to routine 24 hours of perioperative antibiotics in group A24. This study did not reveal a statistically significant decrease in postoperative fungal infections in patients receiving preoperative antifungals. Conclusion. Prolonged perioperative antibiotic therapy in conjunction with intraoperative bile cultures decreases the short-term infectious complications of PD, with no significant increase in Clostridium difficile colitis incidence. Amir H. Fathi, Terence Jackson, Mehdi Barati, Babak Eghbalieh, Kelly A. Siegel, and Christopher T. Siegel Copyright © 2016 Amir H. Fathi et al. All rights reserved. Quality of Life in Hepatocellular Carcinoma Patients Treated with Transarterial Chemoembolization Thu, 07 Apr 2016 14:07:16 +0000 http://www.hindawi.com/journals/hpb/2016/6120143/ Hepatocellular carcinoma (HCC) is one of the most commonly diagnosed cancers worldwide. Majority of patients with HCC are diagnosed in the advanced stages of disease and hence they are only suitable for palliative therapy. TACE (transarterial chemoembolization) is the most commonly used treatment for unresectable HCC. It is however unclear if TACE improves the quality of life (QoL) in patients with HCC. The aim of this review is to evaluate the impact of TACE on QoL of HCC patients. Saleem Ahmed, Nurun Nisa de Souza, Wang Qiao, Meidai Kasai, Low Jee Keem, and Vishal G. Shelat Copyright © 2016 Saleem Ahmed et al. All rights reserved. Diagnostic Laparoscopy with Ultrasound Still Has a Role in the Staging of Pancreatic Cancer: A Systematic Review of the Literature Wed, 30 Mar 2016 07:15:36 +0000 http://www.hindawi.com/journals/hpb/2016/8092109/ Background. The reported incidence of noncurative laparotomies for pancreatic cancer using standard imaging (SI) techniques for staging remains high. The objectives of this study are to determine the diagnostic accuracy of diagnostic laparoscopy with ultrasound (DLUS) in assessing resectability of pancreatic tumors. Study Design. We systematically searched the literature for prospective studies investigating the accuracy of DLUS in determining resectability of pancreatic tumors. Results. 104 studies were initially identified and 19 prospective studies (1,573 patients) were included. DLUS correctly predicted resectability in 79% compared to 55% for SI. DLUS prevented noncurative laparotomies in 33%. Of those, the most frequent DLUS findings precluding resection were liver metastases, vascular involvement, and peritoneal metastases. DLUS had a morbidity rate of 0.8% with no mortalities. DLUS remained superior to SI when analyzing studies published only in the last five years (100% versus 81%), enrolling patients after the year 2000 (74% versus 58%), or comparing DLUS to modern multidimensional CT (100% versus 78%). Conclusion. DLUS seems to still have a role in the preoperative staging of pancreatic cancer. With its ability to detect liver metastases, vascular involvement, and peritoneal metastases, the use of DLUS leads to less noncurative laparotomies. Jordan Levy, Mehdi Tahiri, Tsafrir Vanounou, Geva Maimon, and Simon Bergman Copyright © 2016 Jordan Levy et al. All rights reserved. The Role of Eugenol in the Prevention of Acute Pancreatitis-Induced Acute Kidney Injury: Experimental Study Sun, 17 Jan 2016 13:46:43 +0000 http://www.hindawi.com/journals/hpb/2016/3203147/ Aim. Acute pancreatitis is an inflammatory intra-abdominal disease, which takes a severe form in 15–20% of patients and can result in high mortality especially when complicated by acute renal failure. The aim of this study is to assess the possible reduction in the extent of acute kidney injury after administration of eugenol in an experimental model of acute pancreatitis. Materials and Methods. 106 male Wistar rats weighing 220–350 g were divided into 3 groups: (1) Sham, with sham surgery; (2) Control, with induction of acute pancreatitis, through ligation of the biliopancreatic duct; and (3) Eugenol, with induction of acute pancreatitis and eugenol administration at a dose of 15 mg/kg. Serum urea and creatinine, histopathological changes, TNF-α, IL-6, and MPO activity in the kidneys were evaluated at predetermined time intervals. Results. The group that was administered eugenol showed milder histopathological changes than the Control group, TNF-α activity was milder in the Eugenol group, and there was no difference in activity for MPO and IL-6. Serum urea and creatinine levels were lower in the Eugenol group than in the Control group. Conclusions. Eugenol administration was protective for the kidneys in an experimental model of acute pancreatitis in rats. Charalampos Markakis, Alexandra Tsaroucha, Apostolos E. Papalois, Maria Lambropoulou, Eleftherios Spartalis, Christina Tsigalou, Konstantinos Romanidis, and Constantinos Simopoulos Copyright © 2016 Charalampos Markakis et al. All rights reserved. Hepatocellular Carcinoma in the Pediatric Population: A Population Based Clinical Outcomes Study Involving 257 Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1973–2011) Wed, 18 Nov 2015 06:49:42 +0000 http://www.hindawi.com/journals/hpb/2015/670728/ Introduction. Hepatocellular carcinoma (HCC) is a rare pediatric cancer accounting for 0.5% 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. Methods. Demographic and clinical data on 63,771 HCC patients (257 pediatric patients ≤ 19 and 63,514 adult patients age ≥ 20) were abstracted from the SEER database (1973–2011). Results. HCC was more common among males (59.5% pediatric and 75.1% adults) and Caucasians (50.4% and 50.5%), . Children more often presented with fibrolamellar variant HCC (24.1% versus 0.3%, ) and advanced HCC, including distant disease (33.1% versus 20.8%, ), and tumors > 4 cm in size (79.6% versus 62.0%, ). Pediatric HCC patients undergoing surgery (13.107 versus 8.324 years, ) had longer survival than adult HCC patients. Overall mortality was lower (65.8% versus 82.0%, ) in the pediatric HCC group. Conclusion. HCC is a rare pediatric malignancy that presents most often as an advanced tumor, >4 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, and Ronald S. Chamberlain Copyright © 2015 Christine S. M. Lau et al. All rights reserved. Preoperative Diagnostic Angiogram and Endovascular Aortic Stent Placement for Appleby Resection Candidates: A Novel Surgical Technique in the Management of Locally Advanced Pancreatic Cancer Mon, 28 Sep 2015 08:12:12 +0000 http://www.hindawi.com/journals/hpb/2015/523273/ Background. 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. Methods. 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. Results. 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. Conclusion. 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, and T. Vanounou Copyright © 2015 N. Trabulsi et al. All rights reserved. Effect of the Human Amniotic Membrane on Liver Regeneration in Rats Thu, 17 Sep 2015 11:54:44 +0000 http://www.hindawi.com/journals/hpb/2015/706186/ Introduction. 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. Methods. Twenty female Wistar albino rats were divided into control and experimental groups and underwent a 70% 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. Results. 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. Conclusion. 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, Sevinç Şahin, Ergin Arslan, Hasan Börekci, Bayram Metin, and Nuh Zafer Cantürk Copyright © 2015 Mesut Sipahi et al. All rights reserved. The Surgical Management of Concomitant Gallbladder and Common Bile Duct Stones Tue, 01 Sep 2015 06:34:54 +0000 http://www.hindawi.com/journals/hpb/2015/165068/ Background. 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. Aim. To review 5-year results of bile duct exploration in an UGI unit. Methods. 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. Results. 216 CBDEs were performed, 119 (55%) as an emergency and 52 (24%) following failed ERCP. Open CBDE (OCBDE) was performed primarily in 34/216 (16%) patients and attempted laparoscopically in 182 (84%). Fifty nine (32%) Laparoscopic CBDEs (LCBDEs) were converted to OCBDE. Of the remaining 123 LCBDEs, 51 (41%) primary choledochotomies and 72 (59%) primary transcystic CBDEs (TC-CBDEs) were performed. Forty nine (68%) TC-CBDEs were considered successful and 23 (32%) failed. Fifteen failed TC-CBDEs were converted to a successful laparoscopic choledochotomy. Ductal clearance was achieved in 187/216 (87%) patients and retained stones were identified in 20/123 (16%) LCBDEs. Complications occurred in 52/216 (24%) patients. There were 8/216 (4%) bile leaks requiring further intervention. Postoperative ERCP was carried out in 32/216 (15%) patients and 9/216 (4%) required relaparoscopy/laparotomy. No patient died. Conclusions. Successful management of choledocholithiasis requires a breadth of laparoscopic and endoscopic expertise. J. H. Darrien, K. Connor, A. Janeczko, J. J. Casey, and S. Paterson-Brown Copyright © 2015 J. H. Darrien et al. All rights reserved. Feasibility of Comparing the Results of Pancreatic Resections between Surgeons: A Systematic Review and Meta-Analysis of Pancreatic Resections Mon, 17 Aug 2015 14:05:56 +0000 http://www.hindawi.com/journals/hpb/2015/896875/ Background. 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 (“outliers”) based on the results of pancreatic resections is not known. Methods. 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% and 99.8% confidence intervals based on results of the systematic reviews were considered as “outliers.” Results. 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% and proportion of patients with procedure-related complications was 47.0%. 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% false positive rate if he or she performs 50 surgeries a year. Conclusions. 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, and Brian Davidson Copyright © 2015 Kurinchi Gurusamy et al. All rights reserved. Assessment of Liver Remnant Using ICG Clearance Intraoperatively during Vascular Exclusion: Early Experience with the ALIIVE Technique Wed, 27 May 2015 06:15:46 +0000 http://www.hindawi.com/journals/hpb/2015/757052/ Background. 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 ALIIVE technique which assesses the liver remnant with ICG clearance intraoperatively during vascular exclusion. Methods. 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. Results. 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%/min versus 14.4 ± 4.9). Routine preoperative CT and standardized volumetry did not predict outcome. Discussion/Conclusion. 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, and Vijayaragavan Muralidharan Copyright © 2015 Lawrence Lau et al. All rights reserved. The Changing Spectrum of Surgically Treated Cystic Neoplasms of the Pancreas Mon, 30 Mar 2015 11:39:57 +0000 http://www.hindawi.com/journals/hpb/2015/791704/ Introduction. While the incidence of pancreatic cystic lesions has steadily increased, we sought to evaluate the changes in their surgical management. Methods. 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. Results. 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% underwent EUS and 63% 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. Conclusion. 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, and Gerard V. Aranha Copyright © 2015 Jennifer K. Plichta et al. All rights reserved. Surgery for Cystic Pancreatic Lesions in the Post-Sendai Era: A Single Institution Experience Thu, 19 Mar 2015 13:36:39 +0000 http://www.hindawi.com/journals/hpb/2015/847837/ Introduction. 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. Methods. Retrospective analysis of a cohort of 86 patients operated for cystic pancreatic lesions during a seven-year period (2007–2014). Results. 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% and 2.3%, respectively. The preoperative diagnosis of a specific cystic tumor was accurate in 79% of patients and 9 patients (10%) could have avoided surgery with the correct preoperative diagnosis. Conclusion. 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. Jörg Kleeff, Christoph Michalski, Bo Kong, Mert Erkan, Susanne Roth, Jens Siveke, Helmut Friess, and Irene Esposito Copyright © 2015 Jörg Kleeff et al. All rights reserved. The Impact of Changed Strategies for Patients with Cholangiocarcinoma in This Millenium Wed, 18 Feb 2015 11:38:14 +0000 http://www.hindawi.com/journals/hpb/2015/736049/ Background. Cholangiocarcinoma is a cancer with a poor prognosis. In this millennium there are new diagnostic and therapeutic strategies for these patients. Aim. The aim of this study was to find if these changes influenced survival of individuals with proximal cholangiocarcinoma. Material. 627 individuals with a diagnosis of cholangiocarcinoma (not including distal common duct cancer) during the period from 2000 to 2011 were registered in Sweden’s Western Region. The material was divided into three consecutive time periods. Results. The overall survival curves for individuals with cholangiocarcinoma improved over the three time periods . Median survival increased from 2.6 months in the first period (2000–2003) to 3.6 months in the final four years (2008–2011). Patients with perihilar cholangiocarcinoma (PHC) had longer median survival than those with intrahepatic cholangiocarcinoma (IHC): 6.8 versus 3.2 months . An improvement in the survival curves over time was seen for those with IHC but not for patients with PHC . 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% and 60% after liver transplantation. Among patients with PHC, 15.3% had potential curative bile duct resection with a concomitant liver resection and 6.1% bile duct resection alone. The three-year survival rate for these two groups was 32% and 20%, respectively. Conclusion. 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 Lindnér, Magnus Rizell, and Lo Hafström Copyright © 2015 Per Lindnér et al. All rights reserved. Laparoscopic versus Open Liver Resection: Differences in Intraoperative and Early Postoperative Outcome among Cirrhotic Patients with Hepatocellular Carcinoma—A Retrospective Observational Study Thu, 04 Dec 2014 12:07:55 +0000 http://www.hindawi.com/journals/hpb/2014/871251/ Introduction. Laparoscopic liver resection is considered risky in cirrhotic patients, even if minor surgical trauma of laparoscopy could be useful to prevent deterioration of a compromised liver function. This study aimed to identify the differences in terms of perioperative complications and early outcome in cirrhotic patients undergoing minor hepatic resection for hepatocellular carcinoma with open or laparoscopic technique. Methods. In this retrospective study, 156 cirrhotic patients undergoing liver resection for hepatocellular carcinoma were divided into two groups according to type of surgical approach: laparoscopy (LS group: 23 patients) or laparotomy (LT group: 133 patients). Perioperative data, mortality, and length of hospital stay were recorded. Results. Groups were matched for type of resection, median number of nodules, and median diameter of largest lesions. Groups were also homogeneous for preoperative liver and renal function tests. Intraoperative haemoglobin decrease and transfusions of red blood cells and fresh frozen plasma were significantly lower in LS group. MELD score lasted stable after laparoscopic resection, while it increased in laparotomic group. Postoperative liver and renal failure and mortality were all lower in LS group. Conclusions. Lower morbidity and mortality, maintenance of liver function, and shorter hospital stay suggest the safety and benefit of laparoscopic approach. Antonio Siniscalchi, Giorgio Ercolani, Giulia Tarozzi, Lorenzo Gamberini, Lucia Cipolat, Antonio D. Pinna, and Stefano Faenza Copyright © 2014 Antonio Siniscalchi et al. All rights reserved. Risk Factors Associated with Reoperation for Bleeding following Liver Transplantation Thu, 20 Nov 2014 09:25:30 +0000 http://www.hindawi.com/journals/hpb/2014/816246/ Introduction. This study’s objective was to identify risk factors associated with reoperation for bleeding following liver transplantation (LTx). Methods. A retrospective study was performed at a single institution between 2001 and 2012. Operative reports were used to identify patients who underwent reoperation for bleeding within 2 weeks following LTx (operations for nonbleeding etiologies were excluded). Results. Reoperation for bleeding was observed in 101/928 (10.8%) of LTx patients. The following characteristics were associated with reoperation on multivariable analysis: recipient MELD score (OR 1.06/MELD unit, 95% CI 1.03, 1.09), number of platelets transfused (OR 0.73/platelet unit, 95% CI 0.58, 0.91), and aminocaproic acid utilization (OR 0.46, 95% CI 0.27, 0.80). LTx patients who underwent reoperation for bleeding had a longer ICU stay (5 days ± 7 versus 2 days ± 3, ) and hospitalization (18 days ± 9 versus 10 days ± 18, ). The risk of death increased in patients who underwent reoperation for bleeding (HR 1.89, 95% CI 1.26, 2.85). Conclusion. Reoperation for bleeding following LTx was associated with increased resource utilization and recipient mortality. A lower threshold for intraoperative platelet transfusion and antifibrinolytics, especially in patients with high lab-MELD score, may decrease the incidence of reoperation for bleeding following LTx. Maxwell A. Thompson, David T. Redden, Lindsey Glueckert, A. Blair Smith, Jack H. Crawford, Keith A. Jones, Devin E. Eckhoff, Stephen H. Gray, Jared A. White, Joseph Bloomer, and Derek A. DuBay Copyright © 2014 Maxwell A. Thompson et al. All rights reserved. Primary Leiomyoma of the Liver: A Review of a Rare Tumour Wed, 19 Nov 2014 08:50:51 +0000 http://www.hindawi.com/journals/hpb/2014/959202/ Context. Primary leiomyoma of the liver is a rare tumour with uncertain pathogenesis with similar presentation with other tumours of the liver. Little is known about its clinical course. Objectives. To review the literature for case reports of primary leiomyoma of the liver. Methods. Extensive literature search was carried out for case reports of primary leiomyoma of the liver. Results. A total of 36 cases of primary leiomyoma of the liver were reviewed. The mean age of presentation is 43 years with slight female sex affectation; females accounted for 55.6% of the cases reported in the literature. The average size of the tumour is 8.7 cm. 34.4% of the cases reviewed were incidental finding with the mean follow-up time of 33 months with most cases reporting no evidence of disease. Conclusions. Primary leiomyoma of the liver is very rare tumour with complex pathogenesis which remains largely unknown. Imaging of the tumour does not allow for a tissue specific diagnosis; hence histological review of the tissue specimen and immunohistochemical stains are imperative for diagnosis. Surgical resection is both diagnostic and curative. The diagnosis of primary leiomyoma of the liver should be considered as a differential in the management of liver tumours. Ayodeji Oluwarotimi Omiyale Copyright © 2014 Ayodeji Oluwarotimi Omiyale. All rights reserved. Use of Pharmacologic Agents for Modulation of Ischaemia-Reperfusion Injury after Hepatectomy: A Questionnaire Study of the LiverMetSurvey International Registry of Hepatic Surgery Units Wed, 12 Nov 2014 07:09:48 +0000 http://www.hindawi.com/journals/hpb/2014/437159/ Objectives. This study is a questionnaire survey on the use of pharmacological agents to modify liver ischaemia-reperfusion (IR) injury in patients undergoing hepatectomy for colorectal liver metastases with the target population being those units participating in the LiverMetSurvey international registry. Methods. Members of LiverMetSurvey were sent an online questionnaire using SurveyMonkey comprising ten questions on the use of pharmacological agents to modulate hepatic IR injury in the perioperative period after hepatectomy. The questionnaire was sent to 446 clinicians registered with the LiverMetSurvey. There were 83 (19%) respondents. Results. Fifty-two (77% of 68 respondents to this question) never used pharmacological agents to modify liver IR injury during hepatectomy. Thirteen (19%) used pharmacological agents selectively. Three (4%) used these routinely. N-Acetylcysteine was the most widely used pharmacological agent with equal distribution of use around intraoperative and postoperative periods. Conclusions. This is believed to be the first survey on the use of pharmacological agents to modify liver IR injury. The target population is clinicians involved in liver resection. The results show that pharmacological modulation is used by only a minority of respondents to this questionnaire and that when this treatment is selected, N-acetylcysteine is the most frequently used. Santhalingam Jegatheeswaran, Saurabh Jamdar, Thomas Satyadas, Aali J. Sheen, Rene Adam, and Ajith K. Siriwardena Copyright © 2014 Santhalingam Jegatheeswaran et al. All rights reserved. Iatrogenic Biliary Injuries: Multidisciplinary Management in a Major Tertiary Referral Center Mon, 10 Nov 2014 11:25:26 +0000 http://www.hindawi.com/journals/hpb/2014/575136/ Background. Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcomes of such injuries have been shown in cases managed in a specialized center. Objective. To evaluate biliary injuries management in major referral hepatobiliary center. Patients & Methods. Four hundred seventy-two consecutive patients with postcholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist, and radiologist) at major Hepatobiliary Center in Egypt over 10-year period using endoscopy in 232 patients, percutaneous techniques in 42 patients, and surgery in 198 patients. Results. Endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8%). However, surgery was needed in 198 patients (42%) for major duct transection, ligation, major leakage, and massive stricture. Surgery was urgent in 62 patients and elective in 136 patients. Hepaticojejunostomy was done in most of cases with transanastomotic stents. There was one mortality after surgery due to biliary sepsis and postoperative stricture in 3 cases (1.5%) treated with percutaneous dilation and stenting. Conclusion. Management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging early referral to highly specialized hepatobiliary center. Ibrahim Abdelkader Salama, Hany Abdelmeged Shoreem, Sherif Mohamed Saleh, Osama Hegazy, Mohamed Housseni, Mohamed Abbasy, Gamal Badra, and Tarek Ibrahim Copyright © 2014 Ibrahim Abdelkader Salama et al. All rights reserved. The Interaction between Diabetes, Body Mass Index, Hepatic Steatosis, and Risk of Liver Resection: Insulin Dependent Diabetes Is the Greatest Risk for Major Complications Thu, 14 Aug 2014 08:48:31 +0000 http://www.hindawi.com/journals/hpb/2014/586159/ Background. This study aimed to assess the relationship between diabetes, obesity, and hepatic steatosis in patients undergoing liver resection and to determine if these factors are independent predictors of major complications. Materials and Methods. Analysis of a prospectively maintained database of patients undergoing liver resection between 2005 and 2012 was undertaken. Background liver was assessed for steatosis and classified as <33% and ≥33%. Major complications were defined as Grade III–V complications using the Dindo-Clavien classification. Results. 504 patients underwent liver resection, of whom 56 had diabetes and 61 had steatosis ≥33%. Median BMI was 26 kg/m2 (16–54 kg/m2). 94 patients developed a major complication (18.7%). BMI ≥ 25 kg/m2 () and diabetes () were associated with steatosis ≥33%. Only insulin dependent diabetes was a risk factor for major complications (). Age, male gender, hypoalbuminaemia, synchronous bowel procedures, extent of resection, and blood transfusion were also independent risk factors. Conclusions. Liver surgery in the presence of steatosis, elevated BMI, and non-insulin dependent diabetes is not associated with major complications. Although diabetes requiring insulin therapy was a significant risk factor, the major risk factors relate to technical aspects of surgery, particularly synchronous bowel procedures. M. G. Wiggans, J. T. Lordan, G. Shahtahmassebi, S. Aroori, M. J. Bowles, and D. A. Stell Copyright © 2014 M. G. Wiggans et al. All rights reserved. Surgical Strategy for Isolated Caudate Lobectomy: Experience with 16 Cases Tue, 01 Jul 2014 09:35:26 +0000 http://www.hindawi.com/journals/hpb/2014/983684/ Introduction. Surgical resection is the most effective treatment for neoplasm in the caudate lobe. Isolated caudate lobectomy is still a challenge for hepatobiliary surgeons. No widely accepted surgical strategy for the procedure has been developed yet. Objective. To get a better understanding of isolated caudate lobectomy and to optimize the procedure. Materials and Methods. 16 cases of isolated caudate lobectomy were reviewed to summarize the surgical experience. Results. All the 16 cases of isolated caudate lobectomy were carried out successfully, among which left side approach was adopted in two cases (12.5%), right side approach in three cases (18.75%), and both sides approach in 11 cases (68.75%). No severe complications occurred. Conclusion. The majority of neoplasms confined to the caudate lobe can be resected safely by left and right side approach with proper anatomic surgical procedure, usually in the sequence of mobilization, outflow control, inflow control, and division of the hepatic parenchyma. Fully mobilizing the caudate lobe from the inferior vena cava (IVC) is of great importance. Division of the retrohepatic ligament and the venous ligament facilitated the procedure. Gendong Tian, Qiong Chen, Yuan Guo, Mujian Teng, and Jie Li Copyright © 2014 Gendong Tian et al. All rights reserved. The Association between Survival and the Pathologic Features of Periampullary Tumors Varies over Time Tue, 01 Jul 2014 09:32:54 +0000 http://www.hindawi.com/journals/hpb/2014/890530/ Introduction. Several histopathologic features of periampullary tumors have been shown to be correlated with prognosis. We evaluated their association with mortality at multiple time points. Methods. A retrospective chart review identified 207 patients with periampullary adenocarcinomas who underwent pancreaticoduodenectomy between January 1, 2001 and December 31, 2009. Clinicopathologic features were assessed, and the data were analyzed using univariate and multivariate methods. Results. In univariate analysis, perineural invasion had a strong association with 1-year mortality (OR 3.03, CI 1.42–6.47), and one lymph node (LN) increase in the LN ratio (LNR) equated with a 5-fold increase in mortality. In contrast, LN status (OR 6.42, CI 3.32–12.41) and perineural invasion (OR 5.44, CI 2.81–10.52) had the strongest associations with mortality at 3 years. Using Cox proportional hazards, perineural invasion (HR 2.61, CI 1.77–3.85) and LN status (HR 2.69, CI 1.84–3.95) had robust associations with overall mortality. Recursive partitioning analysis identified LNR as the most important risk factor for mortality at 1 and 3 years. Conclusions. Overall mortality was closely related to the LNR within the first year, while longer follow-up periods demonstrated a stronger association with perineural invasion and overall LN status. Therefore, the current staging for periampullary tumors may need to be updated to include the LNR. Jennifer K. Plichta, Anjali S. Godambe, Zachary Fridirici, Sherri Yong, James M. Sinacore, Gerard J. Abood, and Gerard V. Aranha Copyright © 2014 Jennifer K. Plichta et al. All rights reserved. Debakey Forceps Crushing Technique for Hepatic Parenchymal Transection in Liver Surgery: A Review of 100 Cases and Ergonomic Advantages Mon, 09 Jun 2014 11:47:29 +0000 http://www.hindawi.com/journals/hpb/2014/861829/ Introduction and Objective. Bleeding is an important complication in liver transections. To determine the safety and efficacy of Debakey forceps for liver parenchymal transection and its ergonomic advantages over clamp crushing method we analysed our data. Methods. We used Debakey crushing technique in 100 liver resections and analysed data for transection time, transfusion rate, morbidity, mortality, hospital stay, influence of different types of liver conditions, and ergonomi features of Debakey forceps. Results. Mean age, transection time and hospital stay of 100 patients were 52.38 ± 17.44 years, 63.36 ± 33.4 minutes, and 10.27 ± 5.7 days. Transection time, and hospital stay in patients with cirrhotic liver (130.4 ± 44.4 mins, 14.6 ± 5.5 days) and cholestatic liver (75.8 ± 19.7 mins, 16.5 ± 5.1 days) were significantly greater than in patients with normal liver (48.1 ± 20.1 mins, 6.7 ± 1.8 days) (). Transection time improved significantly with experience (first fifty versus second fifty cases—70.2 ± 31.1 mins versus 56.5 ± 34.5 mins, ). Qualitative evaluation revealed that Debakey forceps had ergonomic advantages over Kelly clamp. Conclusions. Debakey forceps crushing technique is safe and effective for liver parenchymal transection in all kinds of liver. Transection time improves with surgeon’s experience. It has ergonomic advantages over Kelly clamp and is a better choice for liver transection. Sundeep Jain, Bharat Sharma, Mitesh Kaushik, and Lokendra Jain Copyright © 2014 Sundeep Jain et al. All rights reserved.