Educational quality of Robotic Whipple videos on YouTube.

BACKGROUND: Videos on Robotic pancreaticoduodenectomy (RPD) may be watched by surgeons learning RPD. This study sought to appraise the educational quality of RPD videos on YouTube. METHODS: One-hundred videos showing RPD or 'Robotic Whipple' were assessed using validated scales (LAP-VEGaS & Consensus Statement Score (CSS)). The association between the scores and the video characteristics (e.g. order of appearance, provider type etc) was assessed. The minimum number of videos required to cumulatively cover the entire LAP-VEGaS and CSS was also noted. RESULTS: The videos were of variable quality; median LAP-VEGaS = 0.67 (0.17-0.94), median CSS = 0.45 (0.29-0.53). There was no association between the educational quality of the videos and their order of appearance, view counts, provider type, length or country of origin. Videos lacked information such as patient consent (100%), potential pitfalls (97%) or surgeon credentials (84%). The first 29 videos cumulatively met all the criteria of CSS and LAP-VEGaS scores except for reporting consent. CONCLUSION: YouTube videos on RPD are of variable quality, without any recognised predictors of quality, and miss important safety information. An impractical number of videos need to be watched to cumulatively fulfil educational criteria. There is a need for high-quality, peer-reviewed videos that adhere to educational principles.

A multicentre, prospective, randomized, controlled trial comparing EVARREST™ fibrin sealant patch to standard of care in controlling bleeding following elective hepatectomy: anatomic versus non-anatomic resection.

BACKGROUND: This multicentre, randomized clinical trial assessed the safety and effectiveness of the EVARREST™ Fibrin Sealant Patch (FP) in treating parenchymal bleeding following anatomic and non-anatomic liver resections. METHODS: One hundred and two patients were stratified according to the type of hepatic resection (anatomic/non-anatomic), and randomized (1:1) after identification of an appropriate bleeding site, to FP vs Standard of Care (SoC, manual compression ± topical haemostat). The primary endpoint was haemostasis at 4 min from bleeding site identification with no re-bleeding requiring re-treatment. RESULTS: The FP was superior in achieving haemostasis at 4 min (96%, 48/50) to SoC (46%, 24/52; p < 0.001). Stratification for resection type showed treatment differences for primary endpoint for anatomic (24/25 FP vs 13/23 SoC; p = 0.001) and non-anatomic liver resections (24/25FP vs 11/29 SoC; p < 0.001). Adverse events related to the study procedure were reported in 40/50 patients (80%) in the FP group and 43/52 patients (83%) in the SoC group. One (2%) adverse event (infected intra-abdominal fluid collection) was possibly related to study treatment. CONCLUSION: This clinical trial confirms that the FP is safe and highly effective in controlling parenchymal bleeding following hepatectomy regardless of the type of resection. ClinicalTrials.gov NCT01993888.

Spontaneous hepatic haemorrhage: a review of pathogenesis, aetiology and treatment.

BACKGROUND: A spontaneous hepatic haemorrhage (SHH) is a rare condition that presents acutely to both hepatobiliary and general surgeons. Management of the condition is challenging because of the emergent presentation requiring immediate intervention, the presence of underlying chronic liver disease and the multiple potential underlying aetiological conditions. METHODS: A literature search on a spontaneous hepatic haemorrhage was instituted on Medline (1966-2014), Cochrane Register of Controlled Trials, EMBASE (1947-2014), PubMed, Web of Science and Google Scholar. The specific topics of interest were causes - including rare causes, pathophysiological mechanisms and management options. A narrative review was planned from the outset. RESULTS: After 1546 abstracts were reviewed, 74 studies were chosen for inclusion. Hepatocellular carcinoma (HCC) is the commonest cause of a spontaneous haemorrhage with 10% of HCC presenting with bleeding. Other causes are benign hepatic lesions (hemangioma, adenoma, focal nodular hyperplasia, nodular regenerative hyperplasia, biliary cystadenoma and angiomyelolipoma), malignant hepatic tumours (angiosarcoma, haemangioendothelioma, hepatoblastoma and rhabdoid sarcoma), peliosis hepatis, amyloid, systemic lupus erythematosis, polyarteritis nodosa, HELLP syndrome and acute fatty liver of pregnancy. Treatment practice emphasizes arterial embolization to obtain haemostasis with a hepatectomy reserved for tumour-bearing patients after staging and assessment of liver function. CONCLUSION: A spontaneous hepatic haemorrhage is an acute presentation of a spectrum of conditions that requires early diagnosis and multidisciplinary management.

Hepatic incidentaloma: the rule of tens.

OBJECTIVES: Hepatic incidentalomas (HI) are asymptomatic lesions detected incidentally during investigations for other pathologies. This prospective series outlines the management and outcomes of 121 HI managed over 7 years. METHODS: Data were recorded prospectively on 121 patients referred between 2003 and 2010 for assessment of HI out of 1081 patients referred for a hepatic resection. Patients were reviewed in multidisciplinary meetings and investigated with tumour markers and radiological investigations. HI were classified as hypo- or hypervascular depending on arterial phase CT scan findings. Univariate and multivariate analysis was performed to define predictive factors for malignancy. RESULTS: Forty HI were hypovascular, 35 were benign (18 cysts, 12 focal fatty sparing, 1 fetal lobulation and 4 solitary necrotic nodules) and 5 cholangiocarcinomas (all resected)]. Eighty-one HI were hypervascular, 72 were benign [40 focal nodular hyperplasia (FNH), 8 adenoma and 24 hemangiomas) and 9 cancers (5 HCC, 4 metastases: 7 resected). Male gender [relative risk (RR) 2.70, confidence interval (CI) 1.69-3.51], age >45 years (RR 3.15, CI 2.71-3.89), tumour diameter >4 cm (RR 3.35, CI 3.13-4.01) and late (8 min) enhancement on magnetic resonace imaging (MRI) (RR 4.15, CI 3.01-4.79) were predictive of malignancy. CONCLUSIONS: HI constitute 10% of practice volume. 10% of hyper and hypovascular incidental lesions are malignant. Most can be treated aggressively after diagnosis.

A phase III, randomized, controlled, superiority trial evaluating the fibrin pad versus standard of care in controlling parenchymal bleeding during elective hepatic surgery.

INTRODUCTION: Haemostasis after liver resection may be difficult to achieve as a result of the presence of challenging bleeding, the anatomic landscape of the liver and the quality of tissue making up the hepatic parenchyma. The fibrin pad (FP) is a topical absorbable haemostat designed to be effective in a variety of tissues and across multiple bleeding intensities. This is the first clinical trial to evaluate the hemostat's safety and effectiveness in controlling bleeding during elective hepatic resection. METHODS: This prospective, randomized, controlled superiority trial enrolled 104 subjects undergoing elective hepatectomy in 5 countries. After parenchymal transection, subjects with an appropriately defined target bleeding site (TBS) were stratified according to the type of hepatic parenchyma and immediately randomized 1:1: FP versus Standard of Care (SoC). SoC comprised manual compression with the use of an approved topical absorbable haemostat. The primary endpoint was haemostasis at 4 min from identification of the TBS, with no re-bleeding requiring re-treatment prior to abdominal closure. Results were stratified for both normal and abnormal (steatosis or cirrhosis) hepatic parenchyma. All subjects were followed for 60 days post-operatively. RESULTS: The intent-to-treat (ITT) analysis showed an overall treatment difference of 53.0% (P < 0.001), 82.5% (33/40 FP) versus 29.5% (13/44 SoC) in achieving haemostasis at 4 min with no re-bleeding requiring treatment up to wound closure. The per protocol analysis showed an overall treatment difference of 65.7% (P < 0.001), with 33/35 successes (94.3%) in the FP group and 12/42 in the SoC group (28.6%). The stratification results showed treatment differences between the normal parenchyma group, 63.6% (95.8% FP versus 32.3% SoC P < 0.001) and a larger difference of 72.7% in the abnormal parenchyma group (90.9% FP versus 18.2% SoC P = 0.0003). Post-operative intra-abdominal fluid collections were less frequent in the FP group (3.4% FP versus 13.3% SoC P = 0.059). There was no difference in the safety profile between the FP or SoC groups. CONCLUSIONS: The FP is safe and effective when used as an adjunct to achieve haemostasis during hepatic surgery. The success rate of achieving haemostasis with a FP remained high compared with the SOC group, especially in steatotic or cirrhotic liver tissue where the control success rates diminish. In addition, FP treatment of hepatic parenchymal surfaces may reduce the risk of post-operative biliary and fluid collections.

Robot-assisted general surgery in Aotearoa New Zealand.

Robot-assisted surgery refers to a surgeon controlling a robotic device that performs an operation. This viewpoint explores the current state of robot-assisted surgery in Aotearoa New Zealand using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California, United States), the only currently available robotic surgical system for general surgery in the country. We describe the contemporary progress in Aotearoa New Zealand compared to Australia and globally, and present emerging high-level evidence from randomised controlled trials regarding the utility of the robot-assisted approach for general surgery procedures. From the available evidence, we suggest that the value of robot-assisted general surgery in the public healthcare system arises from its emerging clinical benefits for complex procedures and its potential to engender equitable access and outcomes, particularly for Maori and Pacific peoples, improve education and training and contribute towards quality assurance and workforce development. Therefore, its implementation aligns with the New Zealand Health Strategy's long-term goals and priority areas to achieve pae ora, healthy futures for all.

Indigenous child health in New Zealand: some surgical issues.

New Zealand Maori make up nearly 15% of the population of New Zealand, and their population has increased significantly in the last 20 years. Because of this, the average age of Maori is only 22.7 years with 35% of Maori aged 15 years or less. In spite of this youthful profile, the Maori population has high health needs with trauma, ear disease, respiratory disease and infectious diseases as significant causes of hospitalisation and death. The role of surgery in the management of three potentially preventable but significant health issues affecting Maori children - trauma, cutaneous sepsis (cellulitis and superficial abscess) and obesity - is reviewed.

Frequency and cost of acute surgical admissions in over-anticoagulated patients: over-anticoagulation in the community.

BACKGROUND: Anticoagulation treatment in the community is common. This investigation was undertaken to determine the frequency of patient surgical admission with conditions associated with over-anticoagulation in the community and the surgical resource required to effectively and safely manage these patients acutely. METHODS: Hospital discharge data on individual patients admitted to Waitemata District Health Board hospitals between December 2014 and November 2015 inclusive were reviewed. Data were extracted on individual patients with relevant ICD-10 codes (D683, Y442, Y443). Individual records for patients admitted to general surgery were then reviewed and costing information related to admissions extracted. RESULTS: A total of 551 patients were admitted in a 12-month period (4.8 admissions/1000 warfarin users and 2.4 admissions/1000 dabigatran users) for conditions associated with over-anticoagulation, with 35 admitted to the general surgery service, of whom 29 were taking warfarin and six taking dabigatran. A total of 21 patients were admitted with haemorrhagic conditions, and 14 over-anticoagulated patients were admitted with general surgical conditions requiring treatment. All patients were managed by withholding anticoagulant medication, 12 required formal reversal, three required red cell transfusion and four haemostatic procedures. The average hospital stay was 4 days, with inpatient costs of NZ$3500. CONCLUSION: Management of patients admitted with over-anticoagulation in the community is a significant surgical workload; however, acute management is usually straightforward.

Gall bladder polyps in sclerosing cholangitis: does the 1-cm rule apply?

INTRODUCTION: Polyps of the gall bladder (PLG) are common findings in radiological investigations of the gall bladder and most are benign although carcinoma of the gall bladder can arise in PLG. In the general population PLG less than 1 cm in diameter are thought to have a low risk of malignancy and can be cautiously observed. METHODS: All patients undergoing surgical resection for gall bladder cancer were entered into a prospective database. Four patients with primary sclerosing cholangitis (PSC) presenting with gall bladder cancer in a PLG are studied. RESULTS: Four patients (two men; median age 46.5 years, range 37-71 years) presented with PLG and known histories of PSC. All patients were shown to have PLG of size between 7 mm x 8 mm and 25 mm x 14 mm on imaging with no radiological evidence of carcinoma. Tumour markers carcinoembryonic antigen and CA19-9 were within the normal range in all patients. All patients were managed with cholecystectomy. Two patients with T1 tumours remain alive and well at 2 and 4 years post-cholecystectomy. Of the remaining two patients with T2 tumours, one underwent re-resection of the liver bed and portal lymph nodes and remains alive and well at 12 months. The remaining patient developed an abdominal wall recurrence 12 months after cholecystectomy. She has also undergone resection with postoperative radiation therapy and remains well after 12 months of clinical follow up. CONCLUSION: Gall bladder polyps, which are common and are usually benign in the general population, are often malignant in PSC. Regardless of size, any PLG in a patient with PSC should be considered for cholecystectomy.

Primary Castleman's Disease of the Liver.

Castleman's disease is a rare lymphoproliferative disorder that may affect the liver as part of mutlicentric disease or, rarely, as unicentric hepatic disease. Primary hepatic disease is difficult to diagnose but demonstrates diffusion restriction on magnetic resonance scan and can be treated curatively with hepatic resection.

Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management.

AIM: To review the role of multidisciplinary management in treating sporadic duodenal adenomas (SDA). METHODS: SDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed. RESULTS: Twenty-eight patients (14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location (NA), 10 as ampullary location (A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection (2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection (EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo (range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection (distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum). CONCLUSION: SDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large (> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.

Quadrate lobe: a reliable landmark for bile duct anatomy during laparoscopic cholecystectomy.

BACKGROUND: This investigation was undertaken to determine whether the shape of the inferior surface quadrate lobe (segment IV) can assist in defining a safe starting point for dissection during laparoscopic cholecystectomy. METHODS: Patients undergoing laparoscopic cholecystectomy were prospectively audited. Intraoperative cholangiograms and photographs of the quadrate lobe were reviewed measuring the angle between the cystic duct and common bile duct and its relationship to quadrate shape. RESULTS: The results of 56 patients were included. The shape of the inferior surface of the quadrate lobe was rectangular in 35, pyramidal in 13 and square in eight patients. The median cystic/bile duct angle was 43°, 37° and 26° for square, rectangular and pyramidal quadrate shapes, respectively. The angle for pyramidal-shaped lobes was narrower than that for rectangular or square lobes (P < 0.05). Regression analysis showed an inverse relationship between the shape ratio and the cystic/bile duct angle (P = 0.015). CONCLUSION: This investigation confirms a relationship between the shape of the inferior surface of the quadrate lobe and the cystic/bile duct angle and suggests that the anatomy of the inferior surface of the quadrate lobe can be used to define an optimal starting point for dissection of the biliary cystic triangle.

Is routine placement of surgical drains necessary after elective hepatectomy? Results from a single institution.

Routine drainage is no longer used after many major abdominal procedures. However, the role of routine surgical drainage after hepatic resection is unclear. Of the two randomized trials published, one concluded drainage is unnecessary after hepatectomy, and another concluded it could be used after major resections only. Between January 1999 and December 2003, 211 elective hepatic resections were performed by two surgeons at Auckland Hospital. Drains were used routinely by one surgeon (n = 126), while another routinely did not drain (n = 85). Patients undergoing a biliary reconstruction were not included in this analysis. Patient and clinical data were recorded prospectively, and no outcome analyses were performed until 2004. The demographic features were similar between the drained and non-drained groups. There were no differences in length of hospital stay (no drain, 7 +/- 0.8 days; drain, 7 +/- 0.9 days: P = not significant [NS]), in mortality (no drain, 1.2%; drain, 1.6%: P = NS), biliary fistula (no drain, zero cases; drain, two cases: P = NS), or overall complication rate (no drain, 50.5%; drain, 54.7%: P = NS). Both groups had similar rates of postoperative collection (no drain, four patients [5%]; drain, five patients [4%]: P = NS), and there was no difference in the use of percutaneous drainage of collections between the groups (no drain, four patients [5%]; drain, two patients [2%]: P = NS). Multivariate analysis showed that intraoperative blood loss of 2000 ml or greater (relative risk [RR], 1.57; 95% confidence interval [CI], 1.39-1.75; P < 0.01), number of segments resected (RR, 1.4; 95% CI, 1.21-1.89; P < 0.01), and presence of steatosis/fibrosis or cirrhosis (RR, 1.6; 95% CI, 1.01-2.1; P < 0.05) to be predictive of postoperative complications. The presence of a surgical drain was not predictive of complications. Routine surgical drainage after elective hepatectomy is not necessary.

Henry Barrett: pioneer paediatric surgeon.

BACKGROUND: Henry Barrett worked as a general surgeon in New Plymouth, New Zealand between 1939 and 1978. In this time, he made significant contributions to the development of paediatric surgery in New Zealand. METHODS: Henry Barrett's archive and personal papers remain in the possession of his family. These described his pioneering operations first hand. RESULTS: In an 18-month period from 1947 to 1948, in New Plymouth small provincial hospital, Henry Barrett successfully completed the first primary repair of an oesophageal atresia with distal tracheoesophageal fistula in the Southern Hemisphere and the second and third successful ligations of patent ductus arteriosus in New Zealand. All three patients survived into adulthood. CONCLUSION: Henry Barrett pioneered the undertaking of two complex paediatric surgical procedures in New Zealand. These operations were performed without specialist paediatric support at a time when procedures for these conditions, particularly patent ductus arteriosus, were viewed with suspicion.

Jaundice associated pruritis: a review of pathophysiology and treatment.

To review the underlying pathophysiology and currently available treatments for pruritis associated with jaundice. English language literature was reviewed using MEDLINE, PubMed, EMBASE and clinicaltrials.gov for papers and trails addressing the pathophysiology and potential treatments for pruritis associated with jaundice. Recent advances in the understanding of the peripheral anatomy of itch transmission have defined a histamine stimulated pathway and a cowhage stimulated pathway with sensation conveyed centrally via the contralateral spinothalamic tract. Centrally, cowhage and histamine stimulated neurons terminate widely within the thalamus and sensorimotor cortex. The causative factors for itch in jaundice have not been clarified although endogenous opioids, serotonin, steroid and lysophosphatidic acid all play a role. Current guidelines for the treatment of itching in jaundice recommend initial management with biliary drainage where possible and medical management with ursodeoxycholic acid, followed by cholestyramine, rifampicin, naltrexone and sertraline. Other than biliary drainage no single treatment has proved universally effective. Pruritis associated with jaundice is a common but poorly understood condition for which biliary drainage is the most effective therapy. Pharmacological therapy has advanced but remains variably effective.

Inflammatory pseudotumor of the liver: demographics, diagnosis, and the case for nonoperative management.

BACKGROUND: Inflammatory pseudotumor of the liver (IPL) is an unusual tumor-like condition that is becoming recognized as an important differential diagnosis in the patient presenting with liver masses. This report describes six cases of IPL. STUDY DESIGN: Clinical, diagnostic, pathologic, and followup data were collected prospectively on six patients presenting to a specialist hepatobiliary unit. RESULTS: Six patients with IPL presented over a 2-year period. Median age was 35 years (range 2 to 79 years) and five patients were men. Three patients were Polynesian (Tongan and Samoan) and one was New Zealand Maori. Five patients presented with nonspecific symptoms (fever, arthralgia, myalgia) and IPL was an incidental finding in one patient. At presentation, four patients had elevated white cell counts, and five patients had abnormal liver function tests with elevations in alkaline phosphotase and gamma-glutamyl transferase the most commonly seen. Carcinogenic embryonic antigen and alpha fetoprotein were normal in all patients, although one was a known hepatitis B carrier. In all cases of IPL, diagnosis was made on core biopsy of the liver lesions and all patients were managed nonoperatively with complete resolution of the tumors. Two patients had marked reduction in systemic symptoms (fever and pain) from a short course of oral steroids. CONCLUSIONS: IPL appears to be a relatively common problem in Maori and Polynesians. Recognition and differentiation of this condition from malignant liver lesions are important to avoid unnecessary surgery.

Laparoscopic staging of upper gastrointestinal malignancy.

BACKGROUND: Laparoscopic staging (LS) of upper gastrointestinal malignancy has decreased the number of non-curative laparotomies. However, as radiological techniques have improved the value of this invasive staging technique has decreased, with some units either being more selective or abandoning it altogether for certain tumour types. The aim of the present study is to prospectively evaluate the additional utility of LS of upper gastrointestinal malignancy after radiological staging with modern techniques. METHODS: One hundred and six consecutive patients assessed as having potentially curable upper gastrointestinal malignancy after radiological staging underwent LS between April 1999 and June 2001. Laparoscopic findings, outcome at laparotomy and complications were prospectively recorded. RESULTS: Laparoscopic staging detected incurable disease in 28 of the 106 patients (26%). The negative likelihood ratio was 0.36 (95% CI 0.24-0.53). Twenty-seven patients were considered incurable because of findings at laparoscopy and one on the findings of laparoscopic ultrasound. Ten patients underwent open palliative procedures and seven had non-therapeutic laparotomies giving a non-curative laparotomy rate of 16%. LS was most useful for primary liver and biliary tract tumours and was least useful for colorectal liver metastases. The most frequent findings denoting incurability were the presence of liver disease (12 cases) and peritoneal metastases (nine cases). Complications occurred in three patients with one death being attributable in part to the laparoscopy. CONCLUSIONS: Laparoscopy was useful in decreasing the number of non-therapeutic laparotomies, but laparoscopic ultrasound gave little additional benefit. The utility of LS was dependent on tumour type and in particular was of marginal benefit for colorectal liver metastases. LS remains a useful staging tool but should be applied selectively.