Exploring pre-surgery donor-specific antibodies in the context of organ shortage in liver transplant.

BACKGROUND: There is a growing disparity between the number of liver transplant (LT) candidates and availability of suitable liver allografts. Antibody-mediated rejection (AMR), secondary to positive donor-specific antibodies (DSA), remains a concern in liver transplantation. This study aimed to correlate expression of DSA on pre-transplant screening and outcomes of LT, specifically development of AMR in liver allografts and liver function profile in the post-operative period. METHODS: Data of consecutive patients undergoing orthotopic LT (OLT) at the South Australian Liver Transplant Unit was analysed. All patients underwent DSA testing pre-transplant. RESULTS: Within a cohort of 96 patients, over a post-OLT median follow-up of 849 days, only 2 patients (2%) developed AMR. While both patients had a positive DSA test preoperatively, overall DSA positivity was noted in 31% patients, with a specificity for prediction of AMR of 0.708. No significant association was noted between AMR (p = 0.092), T cell-mediated rejection/TCMR (p = 0.797) or late hepatic artery thrombosis/LHAT (p = 0.521). There was no significant interaction effect between DSA positivity and serum bilirubin or transaminases over a period of 100 days. CONCLUSION: AMR following LT is uncommon. A positive DSA pre-transplant does not imply a definite risk of AMR. Also, there does not exist a significant interaction in time between DSA expression and serum bilirubin or transaminase levels. Until there emerges evidence to the contrary, it appears reasonable to consider DSA-positive donors within the broad context of marginal donors in the context of a worldwide shortage of LT donor allografts.

Oestrogen hormone receptors in focal nodular hyperplasia.

BACKGROUND: The role of hormones in focal nodular hyperplasia (FNH) has been investigated with conflicting results. OBJECTIVE: The aim of this study was to evaluate oestrogen and progesterone receptor immunohistochemical expression in FNH and surrounding normal liver (control material). METHODS: Biopsy materials from FNH and control tissue were investigated using an immunostainer. Receptor expression was graded as the proportion score (percentage of nuclear staining) and oestrogen receptor intensity score. RESULTS: Study material included tissue from 11 resected FNH lesions and two core biopsies in 13 patients (two male). Twelve samples showed oestrogen receptor expression. The percentage of nuclear oestrogen receptor staining was <33% in eight FNH biopsies, 34-66% in two FNH biopsies, and >67% in both core biopsies. The better staining in core biopsies relates to limitations of the staining technique imposed by the fibrous nature of larger resected FNH. Control samples from surrounding tissue were available for nine of the resected specimens and all showed oestrogen receptor expression. Progesterone receptor expression was negligible in FNH and control samples. CONCLUSIONS: By contrast with previous studies, the majority of FNH and surrounding liver in this cohort demonstrated oestrogen receptor nuclear staining. The implications of this for continued oral contraceptive use in women of reproductive age with FNH remain uncertain given the lack of consistent reported growth response to oestrogen stimulation or withdrawal.

Elevation of the tumor marker CA19-9 in a pancreatic cancer survivor with benign prostatic hyperplasia: A clinical case report.

Serum carbohydrate antigen 19-9 (CA19-9) is used for recurrence surveillance in patients with resected pancreatic ductal adenocarcinoma (PDAC). This report describes the association of increasing CA19-9 in a male PDAC survivor with presence of prostatic hyperplasia. Unexplained elevation of CA19-9 in male PDAC survivors might be attributable to benign prostatic conditions.

Monitoring quality of care in hepatocellular carcinoma: A modified Delphi consensus.

Although there are several established international guidelines on the management of hepatocellular carcinoma (HCC), there is limited information detailing specific indicators of good quality care. The aim of this study was to develop a core set of quality indicators (QIs) to underpin the management of HCC. We undertook a modified, two-round, Delphi consensus study comprising a working group and experts involved in the management of HCC as well as consumer representatives. QIs were derived from an extensive review of the literature. The role of the participants was to identify the most important and measurable QIs for inclusion in an HCC clinical quality registry. From an initial 94 QIs, 40 were proposed to the participants. Of these, 23 QIs ultimately met the inclusion criteria and were included in the final set. This included (a) nine related to the initial diagnosis and staging, including timing to diagnosis, required baseline clinical and laboratory assessments, prior surveillance for HCC, diagnostic imaging and pathology, tumor staging, and multidisciplinary care; (b) thirteen related to treatment and management, including role of antiviral therapy, timing to treatment, localized ablation and locoregional therapy, surgery, transplantation, systemic therapy, method of response assessment, and supportive care; and (c) one outcome assessment related to surgical mortality. Conclusion: We identified a core set of nationally agreed measurable QIs for the diagnosis, staging, and management of HCC. The adherence to these best practice QIs may lead to system-level improvement in quality of care and, ultimately, improvement in patient outcomes, including survival.

Learning curve for laparoscopic repair of very large hiatal hernia.

BACKGROUND: Laparoscopic repair of a large hiatal hernia is technically challenging. A significant learning curve likely exists that has not been studied to date. METHODS: Since 1992, the authors have prospectively collected data for all patients undergoing laparoscopic repair of a very large hiatal hernia (50% or more of the stomach within the chest). Follow-up evaluation was performed after 3 months, then yearly. Visual analog scores were used to assess heartburn and dysphagia. Patients were grouped according to institutional and individual surgeons' experience to determine the impact of any learning curve. The outcome for procedures performed by consultant surgeons was compared with that for trainees. RESULTS: From 1992 to 2008, 415 patients with a 1-year minimum follow-up period were studied. Institutional and individual experience had a significant influence on operation time, conversion to open surgery, and length of hospital stay. However, except for heartburn scores during a 3-month follow-up evaluation of institutional experience (p=0.03), clinical outcomes were not influenced by either an institutional or individual learning curve. Furthermore, in general terms, whether the procedure was performed by a consultant or a supervised trainee had little effect on outcome. CONCLUSIONS: Institutional and individual learning curves had no significant influence on clinical outcomes, although improved experience was reflected in improved operation time, conversion rate, and hospital stay. These outcomes improved over the first 50 institutional cases, and the outcomes for individual surgeons improved for up to 40 cases.

Suturing efficiency during hiatal repair for laparoscopic fundoplication.

BACKGROUND: An increasingly important part of general surgical training is the development of skills in advanced laparoscopic surgery. However, this aspect of laparoscopy is not always well taught, and there is scope for improving both training and the assessment of performance. Recently, the improved affordability and accessibility of digital video technology and supporting computer systems has enabled critical analysis of operative techniques in laparoscopic surgery to be carried out inexpensively. The aim of the present project was to develop a method for the objective analysis of a laparoscopic suturing task in the real clinical environment, so that surgeon-in-training performance could be objectively evaluated. METHODS: Eight videos of laparoscopic fundoplication procedures were used and the process of posterior hiatal repair was specifically analysed. The procedures were carried out by three operators, each with a different level of advanced laparoscopic experience. Two blinded assessors independently analysed the videos in 5-s intervals at two separate sittings. Analysis concentrated on the types of movements as well as their efficiency in progressing the task. RESULTS: The total time taken for the posterior hiatal repair varied between 165 and 350 s (mean 240), and the mean number of actions was 42 (range 25-55). The mean percentage of efficiency (actions deemed 'very efficient' and 'efficient'vs actions deemed fair or inefficient) was 44% overall. More experienced surgeons took less time to complete the hiatal repair and had a higher percentage of efficiency of actions than inexperienced surgeons. Inefficient or unnecessary movements could be identified; these were less common for the more experienced surgeons. CONCLUSION: Video deconstruction enabled critical analysis of hiatal suturing in advanced laparoscopic surgery, highlighting inefficient actions. This offers a method for objectively assessing technique using readily available equipment. The method could be used to provide constructive feedback to surgical trainees.

South Australian clinical registry for metastatic colorectal cancer.

INTRODUCTION: The aims of the South Australian Clinical Registry for Metastatic Colorectal Cancer are to record case outcomes according to site of recurrence and mode of clinical practice and to utilize the accumulated information for quality assurance activities. METHODS: All patients who had a diagnosis of synchronous or metachronous metastatic colorectal cancer (CRC) after 1 February 2006 were eligible to be included in the registry. Data on patient details, disease characteristics, investigations, histopathology and treatment were collected. Disease-specific survival data were assessed using Kaplan-Meier product moment estimates and the log-rank test of equality was used for comparisons. RESULTS: 1544 patients have been entered as of 22 March 2010. In addition, 54.7% of primary CRCs were in the rectosigmoid area, 92.9% of them adenocarcinomas. Also, 52.6% of patients received chemotherapy and 15% had radiotherapy. Two hundred five patients underwent liver resection, nine had radiofrequency ablation and seven had selective internal radiotherapy. The overall 3-year survival from time of diagnosis of metastatic CRC was 29.5%. There was no significant survival difference between patients with synchronous and metachronous metastatic CRC. Patients with lung- or liver-only metastases have significantly improved survival if they underwent surgical resection. DISCUSSION: The treatment of patients with metastatic CRC continues to progress with modern medical and surgical developments. Important insights into the current patterns of care and clinical outcomes for metastatic CRC are provided by these data. In addition, this registry provides a feasible and useful database for the evaluation of current treatments established as best evidence in this population.

Influence of resection margin on survival in hepatic resections for colorectal liver metastases.

BACKGROUND: Traditionally a 1-cm margin has been accepted as the gold standard for resection of colorectal liver metastases. Evidence is emerging that a lesser margin may provide equally acceptable outcomes, but a critical margin, below which recurrence is higher and survival poorer, has not been universally agreed. In a recent publication, we reported peri-operative morbidity and clear margin as the two independent prognostic factors. The aim of the current study was to further analyse the effect of the width of the surgical margin on patient survival to determine whether a margin of 1 mm is adequate. METHODS: Two hundred and sixty-one consecutive primary liver resections for colorectal metastases were analysed from 1992 to 2007. The resection margins were assessed by microscopic examination of paraffin sections. The initial analysis was performed on five groups according to the resection margins: involved margin, 0-1 mm, >1-<4 mm, 4-<10 mm and > or = 10 mm. Subsequent analysis was based on two groups: margin <1 mm and >1 mm. RESULTS: With a median follow-up of 4.7 years, the overall 5-year patient and disease-free survival were 38% and 22%, respectively. There was no significant difference in patient- or disease-free survival between the three groups with resection margins >1 mm. When a comparison was made between patients with resection margins < or = 1 mm and patients with resection margins >1 mm, there was a significant 5-year patient survival difference of 25% versus 43% (P < 0.04). However, the disease-free survival difference did not reach statistical significance (P = 0.14). CONCLUSIONS: In this cohort of patients, we have demonstrated that a resection margin of greater than 1 mm is associated with significantly improved 5-year overall survival, compared with involved margins or margins less than or equal to 1 mm. The possible beneficial effect of greater margins beyond 1 mm could not be demonstrated.

Acute ruptured esophageal duplication cyst.

A 32-year-old man presented acutely with a ruptured esophageal duplication cyst. This is a rare complication from an unusual congenital condition. The case describes his clinical presentation, radiological investigation and surgical management. The pathology of the excised specimen is described and a literature review concludes that complete surgical resection of an esophageal duplication is always recommended, even if the condition is asymptomatic. Conventionally this is achieved via a thoracotomy, however thoracoscopic-assisted excision may have a role.