Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective.

BACKGROUND: Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. METHOD: Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. RESULTS: In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. CONCLUSION: HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

Primary hepatic solitary fibrous tumor with histologically benign and malignant areas.

Extrapleural solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm, presenting most commonly in the intrathoracic sites but which has been reported at numerous extrathoracic locations. The majority of intra-thoracic SFTs are benign, but 10%-15% behave aggressively. We report a case of primary hepatic SFT with histologically benign and malignant areas. A 65-year-old man underwent an abdominal CT scan following a cerebrovascular accident, which demonstrated a sharply demarcated large liver mass with a heterogenous enhancing area and occupying most of the left lobe of the liver. Histological examination following a hemihepatectomy showed an SFT with morphological patterns ranging from benign to malignant areas, including pleomorphism, increased cellularity, herringbone pattern, necrosis and a raised mitotic count. On review of the literature, only an occasional case report with malignant areas in a hepatic SFT was identified. This case highlights that SFT should be included in the differential diagnosis of a hepatic spindle cell lesion, and that on rare occasions, malignant areas can occur in this already uncommon neoplasm.

An unusual complication of PEG feeding after pancreatico-gastrostomy.

CONTEXT: We describe a late complication of the pancreatico-gastrostomy (PG) anastomosis following pancreatico-duodenectomy (PD). CASE REPORT: A percutaneous endoscopic gastrostomy (PEG) feeding tube was inserted many months post-operatively. In this patient activated pancreatic enzymes eroded the gastrostomy tract, resulting in pain, recurrent infection and eventual removal of the gastrostomy tube. CONCLUSIONS: Where surgical insertion of a feeding jejunostomy is not viable or deemed too high risk after Whipple or PPPD, we recommend careful consideration of PEG tube insertion in patients with PG reconstruction. If a PEG is used the prophylactic use of Lanreotide is recommended.

Well Differentiated Liposarcoma Presenting as a Duodenal Polyp: A Case Report and Review of the Literature.

Liposarcoma is the most common malignant soft tissue tumour in adults occurring predominantly in the retroperitoneum and extremities but very rarely within the gastrointestinal tract. We report on a 77-year-old gentleman who presented with a history of melaena and anaemia. On oesophagogastric duodenoscopy a duodenal polyp was identified. Surgical excision was performed and on histology, the duodenal polyp revealed a primary duodenal well differentiated liposarcoma. A literature review confirmed the rarity of primary duodenal liposarcomas, with only four cases previously reported.

The usefulness of P-POSSUM score in patients undergoing elective liver resection for benign disease, metastatic colorectal cancer and non-colorectal cancer.

BACKGROUND/AIMS: P-POSSUM predicts operative risk and mortality, although few reports describe its use in elective liver resection. We analysed P-POSSUM scores in patients undergoing resection for colorectal liver metastases, non-colorectal cancer and benign liver dis-ease. METHODOLOGY: Data for 664 elective liver resections were included between 1998 and 2009; 480 for colorectal metastases; 96 for benign and 88 for non-colorectal disease. Peri-operative management was standardised according to unit protocol. RESULTS: P-POSSUM predicted mortality was 3.73%, 6.27% and 9.99% for benign, colorectal and non-colorectal can-cer patients. 60-day mortality was 1.04%, 1.88% and 6.81%, p<0.001. There was correlation between predicted and actual mortality in non-colorectal patients, p=0.029 and weak correlation between physiological score and mortality in each group. There were high-er physiological scores in patients with morbidity and higher predicted mortality in colorectal patients experiencing morbidity, p=0.014. There was correlation be-tween observed and expected operative mortality in benign and non-colorectal patients. Long-term survival was unaffected by various aspects of the P-POSSUM system. CONCLUSIONS: Predicted mortality is over estimated in patients undergoing liver resection. Pre-operative,physiological score and predicted mortality may have a role predicting morbidity. P-POSSUM is ineffective in predicting prognosis following colorectal cancer metastases resection, although may be used to stratify risk in high risk cancer patients.

Delayed bile leak with avastin after liver resection for metastatic colorectal cancer.

Chemotherapy for metastatic colorectal cancer is constantly advancing. Its use in the adjuvant and neoadjuvant setting is also increasing. However, while long-term survival is improving, clinicians must be aware of the possible adverse events that can occur when treating with adjuvant chemotherapy and liver resection. We present a case of a life-threatening delayed bile leak following a liver resection for metastatic colorectal cancer in association with adjuvant treatment with bevacizumab. A 53-year-old man was treated with neoadjuvant bevacizumab followed by liver resection for metastatic colorectal cancer. He made an uneventful recovery. Forty-three days post-surgery he received bevacizumab and developed acute life-threatening bile leaks from the cut surface of the liver. He spent a total of 65 days in hospital, and required ERCP repeatedly and eventually had a repeat liver resection to resolve the bile leak. This case reports a possible association between bevacizumab and a life threatening delayed bile leak following liver resection.

Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial.

BACKGROUND: The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. OBJECTIVE: We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. METHODS: The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. RESULTS: Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of -£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. CONCLUSIONS: ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.

Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer?

Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 µmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.

Left hepatic trisectionectomy for hepatobiliary malignancies: Its' role and outcomes. A retrospective cohort study.

BACKGROUND: Left hepatic trisectionectomy (LHT) is a complex hepatic resection; its' role and outcomes in hepatobiliary malignancies remains unclear. MATERIALS AND METHODS: All patients undergoing LHT at the tertiary HPB referral unit at RSCH, Guildford, UK from September 1996 to October 2015 were included. Data were collected from a prospectively maintained database. RESULTS: Twenty-eight patients underwent LHT. The M:F ratio was 1.8:1. Median age was 60 years (range 43-76 years). Diagnoses included colorectal liver metastases (CRLM; n = 20); cholangiocarcinoma (CCA; n = 4); and other (neuroendocrine tumour metastases (NET; n = 3) and breast metastases (n = 1)). Median duration of surgery was 270 min (range 210-585 min). Median blood loss was 750 ml (300-2400 ml) with a perioperative transfusion rate of 21% (n = 6/28). The rate of all post-operative complications was 21% for all patients, and given the extensive resection performed four patients (14%) developed varying degrees of hepatic insufficiency. One patient with cholangiocarcinoma developed severe hepatic insufficiency, which was fatal within 90 days of surgery. 1 and 3-year survivals were 92% and 68% respectively. CONCLUSION: This study supports LHT in patients with significant tumour burden. Despite extensive resection, our favourable morbidity and mortality rates show this is a safe and beneficial procedure for patients with all hepatobiliary malignancies. Given the nature of resection the incidence of post-operative hepatic insufficiency is higher than less extensive hepatic resections.

Acute necrotising pancreatitis - early management in the district general hospital and tertiary hepato-pancreatico-biliary unit.

Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.

Debulking hepatectomy for an unusual case of a grade 1 stage 1 granulosa cell tumour of the ovary with late metastases.

Granulosa cell tumours of the ovary are rare. They are considered low-grade malignant cancers and infrequently metastasise to the liver. We present our experience of a case with a grade 1, stage 1 granulosa cell tumour of the ovary that systemically recurred 15 years following surgical resection. The patient went on to have a debulking hepatic resection 21 years following initial surgery despite a 6-year-long palliative diagnosis.

A rare case of a retroperitoneal enterogenous cyst with in-situ adenocarcinoma.

BACKGROUND: Retroperitoneal enterogenous cysts are uncommon and adenocarcinoma within such cysts is a rare complication. CASE PRESENTATION: We present the third described case of a retroperitoneal enterogenous cyst with adenocarcinomatous changes and only the second reported case whereby the cyst was not arising from any anatomical structure. CONCLUSION: This case demonstrates the difficulties in making a diagnosis as well as the importance of a multi-disciplinary approach, and raises further questions regarding post-operative treatment with chemotherapy.

The value of intraoperative ultrasound and preoperative imaging, individually and in combination, in liver resection for metastatic colorectal cancer.

INTRODUCTION: Liver resection is proved to offer potential long-term survival for colorectal liver metastases (CRLM). Accurate radiological assessment is vital to enable an appropriate surgical approach. The role of intraoperative ultrasound (IOUS) has been controversial. This study was designed to analyse the accuracy of IOUS compared with that of preoperative imaging (POI) in these patients. MATERIALS AND METHODS: A prospective analysis of 51 consecutive patients who underwent liver resection for CRLM was undertaken. The accuracy of POI and IOUS were correlated and compared with histopathological analysis. Statistical analyses included t-tests, to compare continuous variables, and chi-square and Fisher's exact tests to compare categorical variables. p<0.05 was considered significant RESULTS: POI correlated with histology in 35 patients (68.6%). The sensitivity and specificity were 82.4% and 86.3% respectively. IOUS correlated with histology in 31 (60.8%) patients. The sensitivity and specificity were 84.3% and 76.5% respectively. There was no difference in accuracy between modalities. The accuracy of POI combined with IOUS correlated with histology in 40 patients (78.4%). The sensitivity and specificity were 88.2% and 84.3% respectively. The accuracy of combined modalities was significantly greater than IOUS or POI alone. CONCLUSIONS: POI combined with IOUS may significantly increase the diagnostic accuracy of patients undergoing liver resection for CRLM.

Analysis of residual pancreatic bed necrosis using computed tomography following minimally invasive necrosectomy.

PURPOSE: In a unit practicing minimally invasive pancreatic necrosectomy (MIPN), our aim was to assess whether tomographic residual necrotic volume was an objective indicator for repeat necrosectomy. METHODS: Prospective study of acute pancreatitis admissions. Patients with infected pancreatic necrosis or deteriorating sepsis had MIPN. Outcome parameters included necrotic volumes, conversion rate, morbidity, and mortality. RESULTS: Thirty patients were admitted with acute pancreatitis of which 15 required organ support. Twenty-nine necrosectomy sessions were performed. Average time from admission to necrosectomy was 39.7 days with an internecrosectomy interval of 6 to 14 days. Mean reduction of necrosis volume was 89.5% and postnecrosectomy volumes were variable. Mean length of hospital and intensive care unit stay was 124.3 and 40.2 days, respectively. Complications included bleeding, pancreatic fistula, and gastric outlet obstruction. No in-hospital deaths or conversions occurred. CONCLUSION: Frequent MIPN achieves substantial pancreatic bed volume reduction with no conversions. Repetitive tomographic scanning is of limited use as an indicator for renecrosectomy.

Early and long-term outcomes of patients undergoing liver resection and diaphragm excision for advanced colorectal liver metastases.

INTRODUCTION: At present, liver resection offers the best long-term outcome and only chance for cure in patients with colorectal liver metastases. However, there are no large series that report the early and long-term outcomes of patients who require simultaneous diaphragm excision. This study was designed to investigate these patients. PATIENTS AND METHODS: A total of 285 consecutive liver resections were performed over a 10-year period. Of these, 258 had liver resections alone and 27 underwent liver resection and simultaneous diaphragm excision. Data were collected prospectively and analysed retrospectively. Pre-operative assessment was standardised. The outcomes between the two groups were compared. RESULTS: There was no difference in age, hospital stay or intra-operative blood loss. The diaphragm was histologically involved in four out of 27 resections. As a result, the cancer involved resection margin incidence was greater in the liver resection and diaphragm excision group (14.8% versus 3.9%; P = 0.12). The median tumour size was also different between the two groups (60 mm versus 30 mm; P = 0.001). The liver and diaphragm resection group had a greater peri-operative complication rate (44.4% versus 21.3%; P = 0.02) and mortality (7.4% versus 1.6%; P = 0.25). Overall and disease-free survival was significantly worse in the group who underwent simultaneous diaphragm excision and liver resection (P = 0.04 and P = 0.005, respectively). Diaphragm invasion was found to be an independent predictor of poor overall outcome (P = 0.02). CONCLUSIONS: Liver resection and simultaneous diaphragm excision have a greater incidence of peri-operative morbidity and mortality and a significantly worse long-term outcome compared with liver resection alone. However, these data suggest that liver resection in the presence of diaphragm invasion may still offer a favourable outcome compared with chemotherapy treatment alone. Therefore, we believe that diaphragm involvement by tumour should not be a contra-indication to hepatectomy.

Feeding patients following pancreaticoduodenectomy: a UK national survey.

INTRODUCTION: Providing nutrition for patients following pancreaticoduodenectomy (PD) is vital but can be challenging. Due to the lack of UK national guidelines for the provision of nutrition and nutritional pre-operative assessment regarding PD, a national survey was conducted. PATIENTS AND METHODS: A questionnaire was sent to the Department of Nutrition and Dietetics at each of the 31 specialist pancreatic centres listed with the Pancreatic Society of Great Britain and Ireland. Questions were asked regarding the nutritional assessment and treatment of patients undergoing classical PD and pylorus-preserving PD (PPPD) resections. RESULTS: Twenty-two centres responded to the questionnaire. With regard to PD and PPPD, 82% routinely feed patients following resection, 32% have a regimen for staring feeds, 18% carry out pre-operative nutritional assessment, five centres have funding for an hepatobiliary dietition, and only four centres have a specialist hepatobiliary dietition employed. There was no consensus regarding the type or route of feeding, and at least one centre reported using parenteral nutrition exclusively. CONCLUSIONS: Very few centres in the UK have funding for a hepatobiliary dietition. Hence pre-operative nutritional assessment in patients undergoing PD and PPPD does not receive much input. Although the importance of postoperative feeding in these patients is appreciated in all major units, there is no consensus with regards to feeding regimens. The authors hope this observational study will address these issues with this important message and stimulate further study in this area.

Operative mortality, blood loss and the use of Pringle manoeuvres in 526 consecutive liver resections.

INTRODUCTION: Centres with high volumes of high-risk surgery have significantly better outcomes than low-volume centres for pancreatic resection, oesophagectomy and pelvic exenteration. However, this has not to date been conclusively demonstrated for hepatic resection. With increased experience, operative practice can change. The use of the Pringle manoeuvre reduced substantially over a 12-year period in a single centre as it was felt anecdotally that its use increased the incidence of hepatic insufficiency and operative mortality. This study was designed to review 12 years of experience in a single hepatobiliary centre. PATIENTS AND METHODS: Data regarding 526 consecutive liver resections were prospectively recorded and retrospectively analysed in a high-volume referral unit over a 12-year period. Patients' demographics, operative mortality and morbidity were analysed on an annual basis. RESULTS: Overall peri-operative mortality was 1.9%. Operative mortality in the first 6 years compared to the latter 6 years was 4.1% and 1.2%, respectively (P = 0.13). The morbidity rate was 26.8% and 20.3% in the first and second halves of the study, respectively (P = 0.15). With increased experience, intra-operative blood loss and patients receiving blood transfusions decreased (P = 0.047 and 0.03, respectively) while the number of intra-operative Pringle manoeuvres also decreased (P < 0.0001). Hospital stay decreased significantly over the 12 years (P = 0.049). CONCLUSIONS: High-volume centres are the safest environment for hepatic resection. With increased experience, it may be possible to reduce the intra-operative use of the Pringle manoeuvre without increasing the intra-operative blood loss. This may be associated with a decrease in hepatic insufficiency and peri-operative mortality.

Early postoperative outcomes following hepatic resection for benign liver disease in 79 consecutive patients.

BACKGROUND: Liver resection is an accepted treatment modality for malignant disease of the liver. However, because of its potential morbidity and mortality, the practice of liver resection in benign disease is more controversial. This study was designed to assess the early outcomes of 79 consecutive liver resections for benign disease over a 12-year period and compare these with early outcomes of 390 consecutive liver resections for metastatic colorectal cancer (MCRC) during the same period. METHODS: Consecutive liver resections were carried out in a single hepatopancreatobiliary (HPB) centre between 1996 and 2008. Patient demographics and early outcomes were recorded. Statistical analyses were performed using spss (Version 15). P < 0.05 was considered to be significant. RESULTS: There was no difference in median age between the benign group vs. the MCRC group (P = 0.181). However, there was a significant trend towards a lower ASA grade in the benign group (P < 0.001). There was no difference in median blood loss (P = 0.139) or hospital stay (P = 0.262). Morbidity rates were 8.9% in the benign group and 20.5% in the MCRC group (P = 0.002). The rate of serious complications was 1.3% in the benign group compared with 4.4% in the MCRC group (P = 0.041). There were no postoperative deaths in the benign group and eight (2%) in the MCRC group (P = 0.004). CONCLUSIONS: Liver resection for benign liver tumours can be undertaken with a mortality rate approaching zero and minimal morbidity in specialist HPB units.

A safe, effective, and cheap method of achieving pancreatic rest in patients with chronic pancreatitis with refractory symptoms and malnutrition.

OBJECTIVES: Chronic pancreatitis (CP) is common. It is associated with a substantial morbidity, including malnutrition, malabsorption, pseudocysts, metabolic disturbances, and intractable abdominal pain. Approximately 5% of patients with CP are refractory to nutritional support and opiate analgesia, making management challenging.Pancreatic rest can provide symptomatic relief. However, achieving simultaneous pancreatic rest and adequate nutritional support in these patients is difficult. We describe a technique for providing nutritional support and pancreatic rest in patients with intractable symptomatic CP. METHODS: Three patients with symptomatic CP refractory to standard treatment were included in the study. All 3 patients had masses associated with the pancreas. Symptom relief and adequate nutritional support were achieved by inserting a long-term nasojejunal (NJ) tube (Flocare Bengmark, Nutricia Clinical Care, United Kingdom) under ambulatory endoscopic guidance. Data were recorded prospectively. RESULTS: Long-term NJ tube feeding achieved pancreatic rest and significant symptomatic relief while delivering adequate nutritional support. Pseudocyst size decreased substantially in 2 patients. The third patient was found to have pancreatic carcinoma after pancreaticoduodenectomy. CONCLUSIONS: In patients with symptomatic CP refractory to standard nutritional support and opiate analgesia, long-term NJ tube feeding can be a cheap, well-tolerated, safe, and effective method of providing adequate nutritional support and substantially relieving intractable symptoms.