Inflammatory myofibroblastic tumours of the liver - a systematic review.

BACKGROUND: Hepatic inflammatory myofibroblastic tumours (HIMTs) are rare and poorly described in the literature. Most publications are single patient case reports and lack detailed reporting on characteristics, management, and outcomes. This systematic review aimed to assess the demography, clinical presentation, typical imaging features, histopathology, treatment, and outcomes of patients presenting with HIMTs. METHODS: A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Scopus), JSTOR, Cochrane CENTRAL (Cochrane Library), and the databases included in the Web of Science for studies published between 1940 and 2023 on HIMTs, including its reported synonyms. Case series or cohort studies that reported on the management and outcomes of at least four patients with histologically confirmed HIMTs were included in the analysis. RESULTS: After screening 4553 publications, 22 articles including a total of 440 patients with confirmed HIMTs were eligible for inclusion. The average age was 53.4 years (range 42.0-65.0) with a male to female ratio of 1.7:1. Abdominal pain, discomfort, fever, and loss of weight were the most common presenting symptoms. Surgical resection is the standard of care for HIMTs and is associated with low mortality of 3.4% and low disease recurrence. CONCLUSION: HIMT is a disease more often affecting middle-aged males. The lesions are typically solitary with low recurrence after treatment. The relative roles of surgical versus medical treatment remain unclear. Differences in clinical presentation, histopathology, and treatment of HIMTs compared to inflammatory myofibroblastic tumour (IMT) at extrahepatic sites could challenge the current view of IMT as a single pathological entity.

Outcomes of jaundice in advanced hepatocellular carcinoma - a sub-Saharan perspective.

BACKGROUND: Jaundice is a marker of advanced disease and poor outcomes in hepatocellular carcinoma (HCC). The aim of this study was to describe and analyse the management and outcomes of jaundiced HCC patients at a large academic referral centre in sub-Saharan Africa (SSA). METHODS: Treatment-naïve adult HCC patients who presented with jaundice between 1990 and 2023 were analysed. RESULTS: During the inclusion period, 676 HCC patients were treated at Groote Schuur Hospital. The mean age of the 126 (18.6%) who were jaundiced was 48.8 (± 13.2) years. Eighty-nine (70.6%) were male. Ninety-four (74.6%) patients with jaundice secondary to diffuse tumour infiltration had best supportive care (BSC) only. Thirty-two had obstructive jaundice (OJ); four were excluded because of missing hospital records. In 28 of these patients, 16 underwent biliary drainage (BD) and 12 received BSC only. The mean overall survival (OS) of the 126 patients was 100.5 (± 242.3) days. The patients with diffuse tumour infiltration had an OS of 105.9 (± 273.3) days. The patients with OJ survived 86.5 (± 135.0) days. There was no significant difference in OS between the three patient groups (p = 0.941). In the OJ group, patients who underwent BD survived longer than the BSC group (117.9 ± 166.4 vs. 29.2 ± 34.7 days, p = 0.015).

Does the textbook outcome in pancreatic surgery score after pancreaticoduodenectomy for ampullary carcinoma have prognostic value?

BACKGROUND: The value of the textbook outcome in pancreatic surgery (TOPS) score, a composite measure of surgical performance for quality assurance, was evaluated in a South African tertiary hospital cohort of pancreaticoduodenectomies (PD) performed for adenocarcinoma of the ampulla of Vater (AAV). METHODS: A review of all patients undergoing a PD for AAV at a single centre between January 1999 and December 2023 was performed. Demographic, operative, pathological and postoperative variables were recorded. Ten clinical and histological variables were used to construct a TOPS score. These included an R0 resection, no postoperative pancreatic fistula (POPF), no bile leak, no post-pancreatectomy haemorrhage, no delayed gastric emptying, no major postoperative complications (< Gr 3 Clavien-Dindo), no readmission to ICU, length of stay ≤ 10 days, no 30-day readmission or intervention and no 30-day mortality. A textbook outcome (TO) was defined as the fulfilment of all 10 variables. In patients in whom TO was not achieved, the reasons for failure were identified. In addition, the number of patients who had major complications and died were categorised as failure to rescue (FTR). RESULTS: A positive TOPS score was achieved in 27 of 79 (34.2%) patients undergoing a PD. Overall five-year survival after PD was 33.9%. TOPS conferred a significant 1-year survival benefit, 88.9% vs 66.7% (OR 4.12, 95% CI 1.08-15.67, p = 0.038). There was no significant difference in 5-year survival between TOPS and non-TOPS patients, 40.0% vs 32.4% (OR 1.39, 95% CI 0.48-3.99, p = 0.54). A POPF occurred in 31.6% patients, resulting in a significantly longer hospital admission, 17 vs 10 days (95% CI 2.66-11.34, p = 0.0019). Twenty-one (26.6%) patients developed a major complication, five of whom died (FTR = 6.3%). CONCLUSION: This study confirmed the value of TOPS as a useful measurement to assess hospital quality metrics and short-term survival after PD for AAV. One quarter of patients developed a major complication with a 6.3% FTR.

Pancreaticoduodenectomy for distal cholangiocarcinoma at a South African centre.

BACKGROUND: Surgical resection of distal cholangiocarcinoma (dCCA) offers the only chance for cure and long-term survival. The current literature provides limited data regarding the surgical management and long-term outcomes of dCCA. This study aims to describe the presentation, management, and outcomes of dCCA at a large academic referral centre in South Africa. METHODS: A retrospective study was performed of all patients who underwent curative-intended surgery for dCCA at Groote Schuur Hospital from 2000 to 2020. RESULTS: Over 21 years, 25 patients underwent pancreaticoduodenectomy (PD) for dCCA. Most patients were male (68%), and the mean age was 56.8 years. Of the patients, 22 (84%) underwent preoperative biliary drainage (PBD). There were 29 recorded complications in 25 patients; postoperative pancreatic fistula (POPF) and surgical site infection (SSI) each occurred in 24% of the cohort. The mean hospital stay was 17.2 days without perioperative mortality. With none lost to follow-up, the 1, 3, 5, 10, and 20-year survival rates were 84%, 24%, 16%, 12%, and 4%, respectively. Only T3 status was associated with significantly lower overall survival (OS). Age, albumin levels, PBD, margin status (R0 vs. R1), and nodal status (N0 vs. N1/N2) did not influence OS. CONCLUSION: This is the first study detailing the management and outcomes of dCCA from sub-Saharan Africa (SSA). Despite the complete resection of dCCA, the prognosis is poor, and the long-term survival rate in our study is equivalent to that reported in the literature. T3 disease is an important prognostic factor and is associated with poor OS. Surprisingly, nodal disease and margin status did not affect OS in the cohort of patients.

Liver resection for hepatocellular and fibrolamellar carcinoma in a South African tertiary referral centre - an observational cohort analysis.

BACKGROUND: More than 80% of global hepatocellular carcinomas (HCC) occur in sub-Saharan Africa (SSA) and South- East Asia. Compared with the rest of the world, HCC in SSA has the lowest resection and survival rates. This study assessed outcome following liver resection for HCC and fibrolamellar carcinoma (FLC) at a tertiary referral centre in South Africa. METHODS: A retrospective analysis was done of all liver resections for HCC and FLC at Groote Schuur Hospital and the University of Cape Town Private Academic Hospital between January 1990 and December 2021. Three groups were compared, (i) HCC occurring in normal livers, (ii) HCC occurring in cirrhotic livers, and (iii) fibrolamellar carcinoma. Postoperative complications were classified as per the expanded accordion severity grading system. Median overall survival (OS) and 95% confidence intervals (CI) were calculated. RESULTS: Forty-eight patients were included in the study, 25 for HCC in non-cirrhotic livers, 15 in cirrhotic livers and eight for FLC. Thirty-six patients (75%) underwent a major resection. No mortality occurred but 16 patients (33%) developed grade 1 to 4 complications postoperatively. Thirty-three patients (69%) developed recurrence of HCC following their initial resection of whom 29 (60%) ultimately died. Median overall survival (OS) for the total cohort after surgery was 57.2 months, 95% CI (29.7-84.6), 64.2 months (29.7-84.6), 61.9 months (28.1-95.6), and 31.7 months (1.5-61.8) for patients with HCC in non-cirrhotic livers, FLC and HCC in cirrhotic livers respectively. CONCLUSION: Liver resection for HCC and FLC was safe with no mortality, but one-third of patients had associated postoperative morbidity. The high long-term recurrence rate remains a major obstacle in achieving better survival results after resection.

The role of endoscopic retrograde cholangiopancreatography in the treatment of hepatic cystic Echinococcus in a high HIV prevalence population: a retrospective cohort study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a useful, minimally invasive intervention in managing complicated hepatic cystic echinococcosis (HCE). This study aims to assess the use of ERCP in a South African HCE cohort with and without human immunodeficiency virus (HIV) co-infection. METHODS: An analysis was performed of patients with HCE who were assessed for surgery and underwent ERCP at a tertiary hospital in South Africa between 2011 and 2023. Demographics, clinical data, imaging characteristics, operative management, and postoperative complications were compared between HIV-negative (HIV-) and HIV-positive (HIV+) cohorts. RESULTS: Of the 91 patients assessed, 45 (mean age 34.6 years, 73.3% females, 23 HIV+) required ERCP. HIV status did not significantly affect cyst characteristics or surgical outcomes. HIV+ patients had a higher incidence of intraoperative bile leaks (p = 0.025). There were 18 patients who underwent preoperative ERCPs, mainly for biliary-cyst complications primarily causing obstructive jaundice. A total of 40 patients required postoperative ERCPs, mainly for bile leaks. There were no ERCP-related mortalities and only one case of pancreatitis. ERCP success rates were comparable in both cohorts, with an overall success rate of 86.7%. CONCLUSION: HIV co-infection did not significantly impact the clinical course or outcomes of cystic echinococcosis (CE) patients undergoing ERCP. Perioperative ERCP proved effective in managing biliary complications of HCE as well as postoperative complications, regardless of HIV status. This study underscores the importance of endoscopic interventions in the comprehensive management of CE.

Effect of preoperative biliary drainage on intraoperative biliary cultures and surgical outcomes after pancreatic resection.

BACKGROUND: Prolonged obstructive jaundice (OJ), associated with resectable pancreatic pathology, has many deleterious effects that are potentially rectifiable by preoperative biliary drainage (POBD) at the cost of increased postoperative infective complications. The aim of this study is to assess the impact of POBD on intraoperative biliary cultures (IBCs) and surgical outcomes in patients undergoing pancreatic resection. METHODS: Data from patients at Groote Schuur Hospital, Cape Town, between October 2008 and May 2019 were analysed. Demographic, clinical, and outcome variables were evaluated, including perioperative morbidity, mortality, and 5-year survival. RESULTS: Among 128 patients, 69.5% underwent POBD. The overall perioperative mortality in this study was 8.8%. The POBD group had a significantly lower perioperative mortality rate compared to the non-drainage group (5.6% vs. 25.6%). POBD patients had a higher incidence of surgical site infections (55.1% vs. 23.1%), polymicrobial growth from IBCs and were more likely to culture resistant organisms. Five-year survival was similar in the two groups. CONCLUSION: POBD was associated with a high incidence of resistant organisms on the IBCs, a high incidence of surgical site infections and a high correlation between cultures from the surgical site infection and the IBCs.

Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding.

BACKGROUND: This study investigated the value of prognostic scores to predict 90-day, 1-, 3- and 5-year survival after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding who failed endoscopic intervention. METHODS: The Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease Sodium (MELDNa), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Child-Pugh (C-P) grades and scores were calculated using Kaplan-Meier curves and Cox proportional hazards models in sTIPS patients treated between August 1991 and November 2020. RESULTS: Thirty-four patients (29 men, 5 women), mean age 52 years, SD ± 11.6 underwent sTIPS which controlled bleeding in 32 (94%) patients. Ten (29.4%) patients died in hospital at a median of 4.8 (range 1-10) days. On bivariate analysis, C-P score ≥ 10 (p = 0.017), high C-P grade (p = 0.048), MELD ≥ 15 (p = 0.010), MELD-Na score ≥ 22 (p < 0.001) and APACHE II score ≥ 15 (p < 0.001) predicted 90-day mortality. Individual clinical characteristics associated with 90-day mortality were grade 3 ascites (p = 0.029), > 10 units of blood transfused (p = 0.004), balloon tube placement (p < 0.001), endotracheal intubation (< 0.001) and inotrope support (p < 0.001). The overall 90-day, 1-, 3- and 5-year survival rates were 67.6%, 55.9%, 26.5% and 20.6% respectively. Nine patients (26.5%) were alive at a median of two years (range 1-18 years) post-TIPS. Patients with C-P grade A, C-P score < 10, MELD score < 15, MELD-Na score < 22 and APACHE II score < 15 had significantly better 90-day, 1-, 3- and 5-year survival rates. CONCLUSION: Although sTIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy, in-hospital mortality was 29% and less than one quarter were alive after five years. The selected cut-off values for the nominated scoring systems accurately predicted 90-day mortality and long-term survival.

Does HIV co-infection promote Echinococcus dissemination?

SUMMARY: The influence of human immunodeficiency virus (HIV) on the severity of hepatic cystic echinococcosis (CE) is uncertain. HIV-modulated immune suppression may increase the risk of contracting CE with less self-limiting disease, more rapid progression, and a higher likelihood of complications. A 30-year-old male with concurrent, untreated HIV underwent surgery for two large, complicated hepatic CE cysts, which were replacing the right hemiliver, and innumerable peritoneal daughter cysts. At operation, 30 kg of cystic material was removed from the liver and peritoneal cavity. Despite postoperative complications, including cardiac arrest, respiratory failure, and a bile leak, the patient made a full recovery.

Factors influencing in-hospital mortality for salvage percutaneous transjugular intrahepatic portosystemic shunting in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention.

BACKGROUND: Endoscopic therapy is the first-line treatment of choice for control of acute variceal bleeding (AVB). In high-risk patients with persistent AVB despite pharmacological treatment and endoscopic intervention, percutaneous transjugular intrahepatic portosystemic shunting (TIPS) provides a minimally invasive salvage method to reduce portal pressure and control bleeding. OBJECTIVES: To evaluate factors influencing in-hospital mortality after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding despite medical treatment and endoscopic intervention. METHODS: Clinical and laboratory data were analysed in all patients treated with sTIPS following failed endoscopic therapy for AVB between August 1991 and November 2020. Factors associated with and predictors of death were determined using bivariate analysis and univariate logistic regression analysis. RESULTS: Thirty-four patients (29 men, 5 women), mean age 52 years (range 31 - 80), received sTIPS for uncontrolled (n=11) or refractory (n=23) AVB. The causes of portal hypertension were alcohol-related (n=24) and non-alcohol-related cirrhosis. Salvage TIPS controlled bleeding in 32 patients, with recurrence in 1. Ten patients died in hospital (mean 4.8 days, range 1 - 10) of liver failure (n=4), multiorgan failure (n=3), alcoholic cardiomyopathy (n=2) and uncontrolled gastric variceal bleeding (n=1). On bivariate analysis, factors associated with death were Child-Pugh (C-P) score ≥10 (p=0.006), sodium Model for End-stage Liver Disease (MELD-Na) score ≥22 (p<0.001), ≥8 units of blood transfused (p<0.001), Sengstaken-Blakemore balloon tube placement (p<0.001), endotracheal intubation (p<0.001), inotropic support (p<0.001) and endoscopically uncontrolled bleeding (p<0.001). Univariate logistic regression analysis showed that the most significant predictors of mortality were inotrope dependency (odds ratio (OR) 134; p<0.001), endotracheal intubation (OR 99; p<0.001), endoscopically uncontrolled bleeding (OR 28; p=0.001), grade 3 ascites (OR 20.9; p=0.012) and C-P grade C (OR 8.8; p=0.011). CONCLUSION: Salvage TIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy with 29% in-hospital mortality. The most significant predictors of mortality were C-P grade C, grade 3 ascites, inotrope requirement, endotracheal intubation and endoscopically uncontrolled bleeding.

Mentorship during undergraduate surgical training: comparing perceptions of medical students and faculty at two institutions in South Africa and Sweden.

BACKGROUND: Having a mentor during undergraduate surgical training has been shown to positively influence medical students by increasing interest in surgery, improving confidence, and assisting in career planning. This study aimed to evaluate and compare medical student and faculty perceptions of mentorship during undergraduate surgical training and compare results between two teaching institutions in South Africa and Sweden. METHODS: An electronic, online questionnaire was anonymously distributed to medical students and general surgical faculty at the University of Cape Town (UCT), South Africa, and Karolinska Institutet (KI), Stockholm, Sweden. The questionnaire consisted of multiple choice, true or false, and five-point Likert scale questions, exploring perceptions of mentorship and role models, as well as rating the most important mentor characteristics. RESULTS: Approximately one third (34.2%) of students stated they had a mentor during their surgical training, with significant differences found between student cohorts (p < 0.001). The 'registrar' was most commonly reported as the best role model for medical students by faculty from both UCT (50.0%) and KI (69.4%), as well as UCT students (36.6%). Students rated the following mentor qualities significantly higher compared to faculty: student encouragement (p = 0.037), adequate supervision (p = 0.007), setting of fair expectations (p = 0.002), and teaching skills (p = 0.010). CONCLUSION: With significant differences existing in the perceptions of medical students and faculty regarding mentorship and role models during undergraduate surgical training in both South African and Swedish institutions, reconciling and harmonising these differences will be crucial in fostering constructive mentoring relationships.

Charles F M Saint - South Africa's original surgical pioneer.

Charles F M Saint, a 33-year-old graduate from the University of Durham, Newcastle upon Tyne, was appointed to establish the first department of surgery in South Africa (SA) at the University of Cape Town (UCT) in 1920. A mentee of the celebrated British surgeon, Prof. James Rutherford Morison, Saint's distinguished surgical pedigree and exceptional academic and clinical achievements underpinned his astute leadership and legendary ability to inspire, essential qualities necessary for the founding professor of SA surgery. Saint's imprimatur gave primacy to teaching and a priority to skilled, rigorous and fundamental undergraduate instruction, expounding the Morison-Saint philosophy, which made the department the seedbed of SA surgery. He was the first to introduce basic research programmes in clinical departments. During his tenure, Saint received wide international recognition and honours and when he retired in 1946, he had taught more than 1 300 students, trained 7 professors of surgery and over 40 specialist surgeons, instilling his distinctive brand of disciplined, caring surgery. In his 26 years at UCT and Groote Schur Hospital, Saint laid the foundations and built a department of surgery with a global reach and an enduring legacy at the southern tip of Africa.

Pancreas preserving duodenectomy for duodenal polyposis in familial adenomatous polyposis.

SUMMARY: Duodenal polyposis is common in familial adenomatous polyposis with a significant associated lifetime risk of cancer. Screening and regular surveillance is recommended, guided by the Spigelman stage. Pancreas preserving duodenectomy (PPD) is the preferred operation in patients needing removal of the whole duodenum. This presentation demonstrates the technique of PPD with particular emphasis on the resection and ampullary reconstruction. Initial early feeding tube placement through the cystic duct stump into the duodenum enables identification of the papilla and pancreatic duct as well as subsequent dissection. Separate trans-anastomotic pancreatic and biliary stents facilitate creation and patency of the pancreato-biliary anastomosis. The operation has similar outcomes compared to pancreaticoduodenectomy, however, the anatomical reconstruction allows for postoperative surveillance.

The consequences of major visceral vascular injuries on outcome in patients with pancreatic injuries: a case-matched analysis.

BACKGROUND: Major pancreatic injuries are complex to treat, especially when combined with vascular and other critical organ injuries. This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries. METHOD: A registered prospective database of 461 consecutive patients with pancreatic injuries was used to identify 68 patients with a Pancreatic Injury combined with a major visceral Vascular Injury (PIVI group) and were matched one-to-one by an independent blinded reviewer using a validated individual matching method to 68 similar Pancreatic Injury patients without a vascular injury (PI group). The two groups were compared using univariate and multivariate logistic regression analysis and outcome including complication rates, length of hospital stay and 90-day mortality rate was measured. RESULTS: The two groups were well matched according to surgical intervention. Mortality in the PIVI group was 41% (n = 28) compared to 13% (n = 9) in the PI alone group (p = 0.000, OR 4.5, CI 1.00-10.5). On univariate analysis the PIVI group was significantly more likely to (i) be shocked on admission, (ii) have a RTS < 7.8, (iii) require damage control laparotomy, (iv) require a blood transfusion, both in frequency and volume, (v) develop a major postoperative complication and (vi) die. On multivariate analysis, the need for damage control laparotomy was a significant variable (p = 0.015, OR 7.95, CI 1.50-42.0) for mortality. Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% (5/27) compared to an increased mortality of 56.1% (23/41) of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p = 0.0026). CONCLUSION: This study confirms that pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries and that the addition of a vascular injury with an increasing AAST grade of pancreatic injury exponentially compounds the mortality rate.

Contemporary damage control surgery outcomes: 80 patients with severe abdominal injuries in the right upper quadrant analyzed.

BACKGROUND: Damage control laparotomy (DCL) is a well-established surgical strategy in the management of the severely injured abdominal trauma patients. The selection of patients by intra-abdominal organs involvement for DCL remains controversial. The aim of this study was to assess the injury to the abdominal organs that causing severe metabolic failure, needing DCL. METHODS: Severely injured abdominal trauma patients with a complex pattern of injuries were reviewed over a 52-month period. They were divided into DCL and definitive repair (DR) group according to the operative strategy. Factors identifying patients who underwent a DCL were analyzed and evaluated. RESULTS: Twenty-five patients underwent a DCL, and 55 patients had DR. Two patients died before or during surgery. The number and severity of overall injuries were equally distributed in the two groups of patients. Patients who underwent a DCL presented more frequently hemodynamically unstable (p = 0.02), required more units of blood (p < 0.0001) and intubation to secure the airway (p < 0.0001). The onset of metabolic failure was more profound in these group of patients than DR group. The mean Basedeficit was - 7.0 and - 3.8, respectively, (p = 0.003). Abdominal vascular (p = 0.001) and major liver injuries (p = 0.006) were more frequently diagnosed in the DCL group. The mortality, complications (p < 0.0001), hospital (p < 0.0001), and ICU stay (p < 0.009) were also higher in patients with DCL. CONCLUSION: In severely injured with an intricate pattern of injuries, 31% of the patients required a DCL with 92% survival rate. Severe metabolic failure following significant liver and abdominal vascular injuries dictates the need for a DCL and improves outcome in the current era.

Resection of benign liver tumours: an analysis of 62 consecutive cases treated in an academic referral centre.

BACKGROUND: Benign tumours of the liver are increasingly diagnosed and constitute a substantial proportion of all hepatic tumours evaluated and resected at tertiary referral centres. This study assessed the safety and outcome after resection of benign liver tumours at a major referral centre. METHOD: All patients with symptomatic benign liver tumours who underwent resection were identified from a prospective departmental database of a total of 474 liver resections (LRs). Demographic data, operative management and morbidity and mortality using the Accordion classification were analysed. RESULTS: Sixty-two patients (56 women, 6 men, median age 45 years, range 17-82) underwent resection of symptomatic haemangiomata n=23 (37.1%), focal nodular hyperplasia n=19 (30.6%), biliary cystadenoma n=16 (25.8%) and hepatic adenomas n=4 (6.5%). A major resection was required in 25 patients, 14 patients had 4 segments resected, 11 had 3 segments and 37 patients had 2 or fewer segments resected. Median operating time was 169 minutes (range 80-410). Median blood loss was 300 ml (range 50-4500 ml) and an intra-operative blood transfusion was required in 6 patients. Median length of post-operative hospital stay was 7 days (range 4-32). Complications occurred in 11 patients (Accordion grades 1 n=1, 2 n=4, 3 n=1, 4 n=4, 6 n=1). Four patients required re-operation (bleeding n=2, bile leak n=1, small bowel obstruction n=1). An elderly patient died in hospital on day 16 following a postoperative cerebrovascular accident. CONCLUSION: Clinically relevant symptomatic benign liver tumours comprise a substantial proportion of LRs. Our data suggest that resections can be performed safely with minimal blood loss and transfusion requirements. We advocate selective resection according to established indications. Despite the low postoperative mortality rate, the risk of postoperative complications emphasizes the need for careful selection of patients for resection.

Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic Level 1 trauma centre.

BACKGROUND: This study evaluated factors influencing mortality in a large cohort of patients who sustained pancreatic injuries and underwent DCS. METHODS: A prospective database of consecutive patients with pancreatic injuries treated at a Level 1 academic trauma centre was reviewed to identify those who underwent DCS between 1995 and 2014. RESULTS: Seventy-nine (71 men, median age: 26 years, range 16-73 years, gunshot wounds = 62, blunt = 14, stab = 3) patients with pancreatic injuries (35 proximal, 44 distal) had DCS. Fifty-nine (74.7 %) patients had AAST grade 3, 4 or 5 pancreatic injuries. The 79 patients had a total of 327 associated injuries (mean: 3 per patient, range 0-6) and underwent a total of 187 (range 1-7) operations. Vascular injuries (60/327, 18.3 %) occurred in 41 patients. Twenty-seven (34.2 %) patients died without having a second operation. The remaining 52 patients had two or more laparotomies (range 2-7). Overall 28 (35 %) patients underwent a pancreatic resection either during DCS (n = 18) or subsequently as a secondary procedure (n = 10) including a Whipple (n = 6) when stable. Overall 43 (54.4 %) patients died. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.01) and combined vascular and total number of associated organs injured (p < 0.04). CONCLUSIONS: Despite the magnitude of their combined injuries and the degree of physiological insult, DCS salvaged 45 % of critically injured patients who later underwent definitive pancreatic surgery. Mortality correlated with associated vascular injuries overall, major visceral venous injuries and the combination of vascular plus the total number of associated organs injured.

Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries.

BACKGROUND: This single-centre study evaluated the efficacy of damage control surgery and delayed pancreatoduodenectomy and reconstruction in patients who had combined severe pancreatic head and visceral venous injuries. METHODS: Prospectively recorded data of patients who underwent an initial damage control laparotomy and a subsequent pancreatoduodenectomy for severe pancreatic injuries were evaluated to assess optimal operative sequencing. RESULTS: During the 20-year study period, 312 patients were treated for pancreatic injuries of whom 14 underwent a pancreatoduodenectomy. Six (five men, one woman, median age 20, range 16-39 years) of the 14 patients were in extremis with exsanguinating venous bleeding and non-reconstructable AAST grade 5 pancreatoduodenal injuries and underwent a damage control laparotomy followed by delayed pancreatoduodenectomy and reconstruction when stable. During the initial DCS, the blood loss compared to the subsequent laparotomy and definitive procedure was 5456 ml, range 2318-7665 vs 1250 ml, range 850-3600 ml (p < 0.01). The mean total fluid administered in the operating room was 11,150 ml, range 8450-13,320 vs 6850 ml, range 3350-9020 ml (p < 0.01). The mean operating room time was 113 min, range 90-140 vs 335 min, range 260-395 min (p < 0.01). During the second laparotomy five patients had a pylorus-preserving pancreatoduodenectomy and one a standard Whipple resection. Four of the six patients survived. Two patients died in hospital, one of MOF and coagulopathy and the other of intra-abdominal sepsis and multi-organ failure. Median duration of intensive care was 6 days, (range 1-20 days) and median duration of hospital stay was 29 days, (range 1-94 days). CONCLUSION: Damage control laparotomy and delayed secondary pancreatoduodenectomy is a live-saving procedure in the small cohort of patients who have dire pancreatic and vascular injuries. When used appropriately, the staged resection and reconstruction allows survival in a previously unsalvageable group of patients who have severe physiological derangement.

Instilling a culture of safety for laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) is the preferred and most widely used method for removal of the gallbladder in patients with symptomatic cholelithiasis. Modern laparoscopic equipment provides better illumination and definition with the most recent generation processors and cameras offering the possibility of 3D visualization. The minimal access approach results in smaller wounds, less postoperative pain, faster recovery, shorter hospital stay and ultimately a better cosmetic result.1 The major disadvantage of LC, however, is the biliary complications associated with the procedure, the most serious of which is a major bile duct injury (BDI).2 Although the technique was introduced more than two decades ago, the incidence of BDIs has not decreased and still occurs in 0.4% of operations, a figure twice as high as recorded during the era of open cholecystectomy.3 A recent Swedish population-based study reporting a BDI rate of 1.5% suggests that the rates in the literature may be an underestimation, or more alarmingly, that BDI rates are increasing.