Should Cell Salvage Be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND: Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS: Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS: Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%]. CONCLUSION: IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.

Feasibility and Safety of a "Shared Care" Model in Complex Hepatopancreatobiliary Surgery: A 5-year Observational Study of Outcomes in Pancreaticoduodenectomy.

OBJECTIVE: To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy. BACKGROUND: SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery. METHODS: Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative. RESULTS: Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals. CONCLUSIONS: SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.

Prevention of postoperative pancreatic fistula after pancreatectomy: results of a Canadian RAND/UCLA appropriateness expert panel.

BACKGROUND: We aimed to define the appropriateness of interventions for the prevention of postoperative pancreatic fistulas (POPF) after pancreatectomy, given the lack of consistent data on this topic. METHODS: Using the RAND/UCLA appropriateness method, we assembled an expert panel to rate clinical scenarios for interventions to prevent POPF after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). RESULTS: The following interventions were rated appropriate: individualized risk prediction for all patients; perioperative pasireotide administration for patients undergoing PD who have a soft pancreatic gland and a pancreatic duct size of less 3 mm and for patients undergoing DP; pancreaticogastrostomy for patients undergoing PD who have a soft pancreatic gland and pancreaticojejunostomy for PD for patients with a pancreatic duct size of 6 mm or greater regardless of pancreatic gland texture; duct-to-mucosa anastomosis for all patients undergoing PD and dunking anastomosis for patients undergoing PD who have a pancreatic duct size of less than 3 mm with a firm pancreatic gland; simple stapled and reinforced stapled transection for all DP; surgical drains for PD and DP in patients with a soft pancreatic gland; and open and minimally invasive surgery for DP and open surgery for PD. The following were rated inappropriate: gastrointestinal anastomosis for stump closure in all DP and omission of surgical drain in PD for patients with a pancreatic duct diameter less than 3 mm and a soft pancreatic gland. CONCLUSION: The expert panel identified appropriate and inappropriate scenarios for POPF prevention following pancreatectomy, to provide guidance to clinicians. However, the appropriateness of the interventions in the majority of the clinical scenarios was rated as uncertain, demonstrating equipoise.

The impact of prophylactic negative pressure wound therapy on surgical site infections in pancreatic resection: A systematic review and meta-analysis.

BACKGROUND: Surgical site infections (SSI) cause significant morbidity. Prophylactic negative pressure wound therapy (NPWT) may promote wound healing and decrease SSI. The objective is to evaluate the effect of prophylactic NPWT on SSI in patients undergoing pancreatectomy. METHODS: Electronic databases were searched from inception until April 2022. Randomized controlled trials (RCTs) comparing prophylactic NPWT to standard dressings in patients undergoing pancreatectomy were included. The primary outcome was the risk of SSI. Secondary outcomes included the risk of superficial and deep SSI and organ space infection (OSI). Random effects models were used for meta-analysis. RESULTS: Four single-centre RCTs including 309 patients were identified. Three studies were industry-sponsored, and two were at high risk of bias. There was no significant difference in the risk of SSI in patients receiving NPWT vs. control (14% vs. 21%, RR = 0.72, 95%CI = 0.32-1.60, p = 0.42, I2 = 53%). Likewise, there was no significant difference in the risk of superficial and deep SSI or OSI. No significant difference was found on subgroup analysis of patients at high risk of wound infection or on sensitivity analysis of studies at low risk of bias. CONCLUSION: Prophylactic NPWT does not significantly decrease the risk of SSI among patients undergoing pancreatectomy. Insufficient evidence exists to justify the routine use of NPWT.

Passive Versus Active Intra-Abdominal Drainage Following Pancreatic Resection: Does A Superior Drainage System Exist? A Systematic Review and Meta-Analysis.

Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation.

The safety and efficacy of hypovolemic phlebotomy on blood loss and transfusion in liver surgery: a systematic review and meta-analysis.

BACKGROUND: Hypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7-10 mL/kg) without volume replacement. The subsequent central venous pressure (CVP) reduction is hypothesized to decrease blood loss and the need for blood transfusion. The objective was to conduct a systematic assessment of the safety and efficacy of HP on blood loss and transfusion in the liver surgery literature. METHODS: MEDLINE, EMBASE, and Cochrane Library databases were searched. Outcomes of interest included blood loss, allogenic red blood cell transfusion, postoperative adverse events, and CVP change. A qualitative synthesis and meta-analysis were performed as appropriate. RESULTS: Four cohort studies, one case series, and three randomized controlled trials involving 2255 patients were included. Meta-analysis of studies involving liver resections for any indication (n = 6) found no difference in transfusion (OR 0.38, p = 0.12) or incidence of adverse events with HP compared to non-use. Pooling of studies involving liver resections for an underlying pathology (n = 4) revealed HP was associated with significant reduction in transfusion (OR 0.25, p = 0.03) but no differences in blood loss (-173 mL, p = 0.17). CONCLUSION: This review suggests HP is safe and associated with decreased transfusion in patients undergoing liver surgery. It supports further investigation.

Hypovolemic phlebotomy in liver surgery is associated with decreased red blood cell transfusion.

BACKGROUND: Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis. METHODS: Consecutive patients who underwent liver resection at one institution (2010-2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression. RESULTS: A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H2O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068-0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64-5.18, p = 0.0003), preoperative hemoglobin < 125 g/L (OR 6.02, 95% CI 3.44-10.56, p < 0.0001), and underlying liver disease (OR 2.24, 95% CI 1.27-3.95, p = 0.0051) were significantly associated with perioperative RBC transfusion. CONCLUSION: Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.

Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching.

BACKGROUND: Recent studies demonstrated reduced postoperative complications using combined mechanical bowel and oral antibiotic preparation before elective colorectal surgery. OBJECTIVE: The aim of this study was to assess the impact of these 2 interventions on surgical site infections, anastomotic leak, ileus, major morbidity, and 30-day mortality in a large cohort of elective colectomies. DESIGN: This is a retrospective comparison of 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program colectomy-targeted database with coarsened exact matching. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: Adult patients who underwent elective colectomy from 2012 to 2014 were included. INTERVENTIONS: Preoperative bowel preparations were evaluated. MAIN OUTCOME MEASURES: The primary outcomes measured were surgical site infections, anastomotic leak, postoperative ileus, major morbidity, and 30-day mortality. RESULTS: A total of 40,446 patients were analyzed: 13,219 (32.7%), 13,935 (34.5%), and 1572 (3.9%) in the no-preparation, mechanical bowel preparation alone, and oral antibiotic preparation alone groups, and 11,720 (29.0%) in the combined preparation group. After matching, 9800, 1461, and 8819 patients remained in the mechanical preparation, oral antibiotic preparation, and combined preparation groups for comparison with patients without preparation. On conditional logistic regression of matched patients, oral antibiotic preparation alone was protective of surgical site infection (OR, 0.63; 95% CI, 0.45-0.87), anastomotic leak (OR, 0.60; 95% CI, 0.34-0.97), ileus (OR, 0.79; 95% CI, 0.59-0.98), and major morbidity (OR, 0.73; 95% CI, 0.55-0.96), but not mortality (OR, 0.32; 95% CI, 0.08-1.18), whereas a regimen of combined oral antibiotics and mechanical bowel preparation was protective for all 5 major outcomes. When directly compared with oral antibiotic preparation alone, the combined regimen was not associated with any difference in any of the 5 postoperative outcomes. LIMITATIONS: This study was limited by its retrospective design with heterogeneous data. CONCLUSIONS: Oral antibiotic preparation alone significantly reduced surgical site infection, anastomotic leak, postoperative ileus, and major morbidity after elective colorectal surgery. A combined regimen of oral antibiotics and mechanical bowel preparation offered no superiority when compared with oral antibiotics alone for these outcomes. See Video Abstract at http://links.lww.com/DCR/A358.

Surgical strategies and novel therapies for locally advanced pancreatic cancer.

Many patients with pancreatic cancer are not candidates for surgical resection due to involvement of critical mesenteric vascular structures. We compare and contrast the commonly used classification systems for borderline resectable and locally advanced pancreatic cancer. We describe the current strategies in managing venous and arterial involvement, as well as the role of neoadjuvant chemotherapy and chemoradiation, before explanding on a novel clinical trial in this patient population.

Sigmoid Colectomy for Acute Diverticulitis in Immunosuppressed vs Immunocompetent Patients: Outcomes From the ACS-NSQIP Database.

BACKGROUND: The management of acute diverticulitis in immunosuppressed patients is increasingly debated. The appropriate timing and type of operation remains controversial. OBJECTIVE: This study examines the impact of immunosuppression on mortality and morbidity following colectomies for diverticulitis in the emergency and elective settings. DESIGN SETTINGS: With the use of the American College of Surgeons National Surgical Quality Improvement Program database, the outcomes of immunosuppressed compared with immunocompetent patients who underwent colectomy for acute diverticulitis were compared. PATIENTS: The multi-institutional database was queried for patients who underwent colectomy for acute diverticulitis from 2005 to 2012. MAIN OUTCOMES MEASURES: The impact of immunosuppression on mortality, major morbidity, organ space infection, infectious complications, and wound dehiscence was assessed. RESULTS: Of 26,987 patients, 1332 were immunosuppressed and 25,655 were immunocompetent; 4271 patients had emergency (596 immunosuppressed and 3675 immunocompetent) and 22,716 patients had elective (736 immunosuppressed and 21,980 immunocompetent) colectomies for diverticulitis. In both groups, mortality and major morbidity were significantly higher in the emergency (immunosuppressed 16% and 45%, immunocompetent 4% and 28%) compared with the elective setting (immunosuppressed 2% and 25%, immunocompetent 0.4% and 12%), p < 0.001. On multivariate regression for the emergency setting, immunosuppression significantly increased mortality (OR, 1.79; 95% CI, 1.17-2.75) and did not significantly increase morbidity. On multivariate regression for the elective setting, mortality was similar in immunosuppressed and immunocompetent groups; however, major morbidity (OR, 1.46; 95% CI, 1.17-1.83) and wound dehiscence (OR, 2.69; 95% CI, 1.63-4.42) were significantly increased in immunosuppressed compared with immunocompetent patients. LIMITATIONS: The retrospective design and standardized outcomes are based on heterogeneous data. CONCLUSIONS: Emergency colectomy for diverticulitis is associated with higher mortality in immunosuppressed than in immunocompetent patients, whereas elective colectomy is associated with comparable mortality. In the elective setting, immunosuppressed compared with immunocompetent patients are at increased risk of major morbidity and wound dehiscence.

Pancreatic fistulae after a pancreatico-duodenectomy: are pancreatico-gastrostomies safer than pancreatico-jejunostomies? An expertise-based trial and propensity-score adjusted analysis.

BACKGROUND: A pancreatic fistula (PF) is a major contributor to morbidity and mortality after a pancreaticoduodenectomy (PD). There remains debate as to whether re-establishing pancreaticoenteric continuity by a pancreatico-gastrostomy (PG) can decrease the risk of a PF and complications compared with a pancreatico-jejunostomy (PJ). The outcomes of patients undergoing these reconstructions after a PD were compared. METHOD: Patients undergoing a PD between 1999 and 2011 were selected from a prospective database and having undergone either a PG or PJ reconstruction. A propensity-score adjusted multivariate logistic regression was performed to identify the effect of surgical technique on outcomes of PF, delayed gastric emptying (DGE) and total complications. RESULTS: Twenty-three out of 103 and 20 out of 103 (P = 0.49) patients had PF and 74 out of 103 and 55 out of 103 patients had all-grades DGE in the PG and PJ groups, respectively (P = 0.02). The groups did not differ with regards to Clavien-Dindo grade of complications (P = 0.29) but did differ with regards to the Comprehensive Complication Index (CCI) (38.4 versus 31.4 for PG versus PG, respectively, P = 0.02.) Propensity-score adjusted multivariate analysis showed no effect of PG on PF (P = 0.89), DGE grades B/C (P = 0.9) or CCI (P = 0.41). There remained an effect on all-grades of DGE (P = 0.012.) DISCUSSION: Patients undergoing PG reconstruction had a similar rate of PF as those undergoing a PJ after a PD.

Hepatopancreaticobiliary Resection Arginine Immunomodulation (PRIMe) trial: protocol for a randomised phase II trial of the impact of perioperative immunomodulation on immune function following resection for hepatopancreaticobiliary malignancy.

INTRODUCTION: Surgical stress results in immune dysfunction, predisposing patients to infections in the postoperative period and potentially increasing the risk of cancer recurrence. Perioperative immunonutrition with arginine-enhanced diets has been found to potentially improve short-term and cancer outcomes. This study seeks to measure the impact of perioperative immunomodulation on biomarkers of the immune response and perioperative outcomes following hepatopancreaticobiliary surgery. METHODS AND ANALYSIS: This is a 1:1:1 randomised, controlled and blinded superiority trial of 45 patients. Baseline and perioperative variables were collected to evaluate immune function, clinical outcomes and feasibility outcomes. The primary outcome is a reduction in natural killer cell killing as measured on postoperative day 1 compared with baseline between the control and experimental cohorts. ETHICS AND DISSEMINATION: This trial has been approved by the research ethics boards at participating sites and Health Canada (parent control number: 223646). Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov (identifier: NCT04549662). Any modifications to the protocol will be communicated via publications and ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov identifier: NCT04549662.

Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial.

INTRODUCTION: Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS: This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION: The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.

Exploring human factors in the operating room: scoping review of training offerings for healthcare professionals.

BACKGROUND: Human factors (HF) integration can improve patient safety in the operating room (OR), but the depth of current knowledge remains unknown. This study aimed to explore the content of HF training for the operative environment. METHODS: We searched six bibliographic databases for studies describing HF interventions for the OR. Skills taught were classified using the Chartered Institute of Ergonomics and Human Factors (CIEHF) framework, consisting of 67 knowledge areas belonging to five categories: psychology; people and systems; methods and tools; anatomy and physiology; and work environment. RESULTS: Of 1851 results, 28 studies were included, representing 27 unique interventions. HF training was mostly delivered to interdisciplinary groups (n = 19; 70 per cent) of surgeons (n = 16; 59 per cent), nurses (n = 15; 56 per cent), and postgraduate surgical trainees (n = 11; 41 per cent). Interactive methods (multimedia, simulation) were used for teaching in all studies. Of the CIEHF knowledge areas, all 27 interventions taught 'behaviours and attitudes' (psychology) and 'team work' (people and systems). Other skills included 'communication' (n = 25; 93 per cent), 'situation awareness' (n = 23; 85 per cent), and 'leadership' (n = 20; 74 per cent). Anatomy and physiology were taught by one intervention, while none taught knowledge areas under work environment. CONCLUSION: Expanding HF education requires a broader inclusion of the entirety of sociotechnical factors such as contributions of the work environment, technology, and broader organizational culture on OR safety to a wider range of stakeholders.

Exploring human factors in the operating room: a protocol for a scoping review of training offerings for healthcare professionals.

INTRODUCTION: Applying human factors principles in surgical care has potential benefits for patient safety and care delivery. Although different theoretical frameworks of human factors exist, how providers are being trained in human factors and how human factors are being understood in vivo in the operating room (OR) remain unknown. The aim of this scoping review is to evaluate the application of human factors for the OR environment as described by education and training offerings for healthcare professionals. METHODS AND ANALYSIS: This scoping review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. MEDLINE, Embase, PsycINFO, CINAHL, Health and Psychosocial Instruments and ERIC databases were searched on August 2020 from inception to identify relevant studies that describe the content, application and impact of human factors training for healthcare professionals or trainees who work in or interface with the OR environment. Titles, abstracts and full texts will be independently screened by two authors for eligible studies. Any disagreements will be resolved by discussion or by a third author when disagreement persists. Study information and training characteristics, such as the training tool used and type of learners and teachers, will be charted and summarised, and key themes in human factors training will be identified. Each training offering will be classified under the appropriate knowledge area(s) of human factors described by the Chartered Institute of Ergonomics & Human Factors (CIEHF). Themes that are not captured by the CIEHF framework will be independently recorded by two authors and included based on group discussion and consensus. ETHICS AND DISSEMINATION: Research ethics board approval is not required for this scoping review. The findings of this study will be disseminated at local and national conferences and will be published in a peer-reviewed journal.

Unresectable pancreatic adenocarcinoma: do we know who survives?

BACKGROUND: This study attempts to define clinical predictors of survival in patients with unresectable pancreatic adenocarcinoma (UPA). METHODS: A retrospective study of 94 consecutive patients diagnosed with UPA from 2001 to 2006 was performed. Using data for these patients, a symptom score was devised through a forward stepwise Cox proportional hazards model based on four weighted criteria: weight loss of >10% of body weight; pain; jaundice, and smoking. The symptom score was subsequently validated in a distinct cohort of 32 patients diagnosed with UPA in 2007. RESULTS: In the original cohort, the overall median survival was 9.0 months (95% confidence interval [CI] 7.6-10.4). This altered to 10.3 months (95% CI 6.1-14.5) in patients with locally advanced disease, and 6.6 months (95% CI 4.2-9.0) in patients with distant metastasis. Median survival was 14.6 months (95% CI 13.1-16.1) in patients with a low symptom (LS) score and 6.3 months (95% CI 4.1-8.5) in patients with a high symptom (HS) score. A total of 73% of LS score patients survived beyond 9 months, compared with only 38% of HS score patients (P<0.001). The discrimination of the LS score was greater than that of any conventional method, including imaging. The validation cohort confirmed the discriminative ability of the symptom score for survival. CONCLUSIONS: A simple and clinically meaningful point-based symptom score can successfully predict survival in patients with UPA.

Use of Propensity Score Methodology in Contemporary High-Impact Surgical Literature.

BACKGROUND: Propensity score (PS) analysis is a statistical method commonly used in observational trials to account for confounding. Improper use of PS analysis can bias the effect estimate. The aim of this study is to review the use and reporting of PS methods in high-impact surgical journals with a focus on propensity score matching (PSM). STUDY DESIGN: The 10 surgical journals with the highest impact factors were searched to identify studies using PS analysis from January 1, 2016 to December 14, 2018. We selected evaluation criteria for the conduct of PS analysis based on previous reports. Two authors systematically appraised the quality of reporting of PS analyses. Univariate and multivariate regression was performed to determine the relationship between appropriate use of PSM and study conclusion. RESULTS: Three hundred and three studies using PS analysis were included. Ninety-one percent (n = 275) of studies included the covariates used to generate the PS and 79% (n = 239) included the type of regression model used. Ninety percent (n = 272) of studies did not justify the covariates included in their PS. Eighty-four percent of studies used PSM (n = 254), with 48% (n = 123) failing to assess covariate balance between groups. We found that justification of the selection of covariates included in the PS and the characterization of unmatched patients were both associated with lower odds of the study finding a significant result (odds ratio 0.37; 95% CI 0.16 to 0.87; p = 0.02 and odds ratio 0.35; 95% CI 0.17 to 0.75; p = 0.007, respectively, at multivariate logistic regression). CONCLUSIONS: This study demonstrates that even in research published in high-quality surgical journals, several studies report their PS methodology inadequately. The inadequate conduct of PS analysis can impact a study's conclusion.

Embryology, Anatomy, and Imaging of the Biliary Tree.

"The anatomy of the biliary tree is notoriously variable. This variation is the bane of the hepatobiliary surgeon, to whom an understanding of biliary anatomic variation is key to the planning and safe conduct of liver surgery, from oncological resections to split-liver transplantation. The hepatic diverticulum, also termed "the liver bud," is the first semblance of the biliary system in the human embryo. A variety of techniques used in the mid twentieth century for imaging the biliary tree have since been abandoned in favor of more practical, safer, less invasive, and more sensitive and specific contemporary methods."

Immunosuppressed Patients with Crohn's Disease Are at Increased Risk of Postoperative Complications: Results from the ACS-NSQIP Database.

BACKGROUND: The impact of immunosuppressants on postoperative complications following colon resections for Crohn's disease remains controversial. This study aimed to compare postoperative outcomes between immunosuppressed and immunocompetent patients with Crohn's disease undergoing elective colon resection. METHODS: Analysis of 30-day outcomes using a cohort from the American College of Surgeons National Surgical Quality Improvement Program colectomy-specific database was performed. The database is populated by trained clinical reviewers who collect 30-day postoperative outcomes for patients treated at participating North-American institutions. Adult patients who underwent an elective colectomy between 2011 and 2015 were included. Immunosuppression for Crohn's disease was predefined as use of regular corticosteroids or immunosuppressants within 30 days of the operation. Patients who received chemotherapy within 90 days of surgery, and patients who had disseminated cancer, preoperative shock, or emergency surgery were excluded. Primary outcome was infectious complications. RESULTS: Three thousand eight hundred sixty patients with Crohn's disease required elective colon resection and met the inclusion criteria. Of these, 2483 were immunosuppressed and 1377 were immunocompetent. On multivariate analysis, the odds of infectious complications [OR 1.25; 95% CI (1.033-1.523)], overall surgical site infection [1.40; (1.128-1.742)], organ space surgical site infection [1.47; (1.094-1.984)], and anastomotic leak [1.51; (1.018-2.250)] were significantly higher for immunosuppressed compared to immunocompetent patients with Crohn's disease. CONCLUSIONS: Patients with Crohn's disease who were on immunosuppressant medications within 30 days of elective colectomy had significantly increased rates of infectious complications, overall surgical site infection, organ space surgical site infection, and anastomotic leak compared to patients who were not on immunosuppressive agents.