Transfusion-free Strategies in Liver and Pancreatic Surgery: A Predictive Model of Blood Conservation for Transfusion Avoidance in Mainstream Populations.

OBJECTIVE: The objective of this study is to (1) describe the techniques and prove the feasibility of performing complex hepatobiliary and pancreatic surgery on a Jehovah Witness (JW) population.  (2) Describe a strategy that offsets surgical blood loss by the manipulation of circulating blood volume to create reserve whole blood upon anesthesia induction. BACKGROUND: Major liver and pancreatic resections often require operative transfusions. This limits surgical options for patients who do not accept major blood component transfusions. There is also growing recognition of the negative impact of allogenic blood transfusions. METHODS: A 23-year, single-center, retrospective review of JW patients undergoing liver and pancreatic resections was performed. We describe perioperative management and patient outcomes. Acute normovolemic hemodilution (ANH) is proposed as an important strategy for offsetting blood losses and preventing the need for blood transfusion. A quantitative mathematical formula is developed to provide guidance for its use. RESULTS: One hundred one major resections were analyzed (liver n=57, pancreas n=44). ANH was utilized in 72 patients (liver n=38, pancreas n=34) with median removal of 2 units that were returned for hemorrhage as needed or at the completion of operation. There were no perioperative mortalities. Morbidity classified as Clavien grade 3 or higher occurred in 7.0% of liver resection and 15.9% of pancreatic resection patients. CONCLUSIONS: Deliberate perioperative management makes transfusion-free liver and pancreatic resections feasible. Intraoperative whole blood removal with ANH specifically preserves red cell mass, platelets, and coagulation factors for timely reinfusion. Application of the described JW transfusion-free strategy to a broader general population could lessen blood utilization costs and morbidities.

A Preliminary Controlled Trial of Endoscopic Ultrasound-guided Fiducial Markers to Guide Pancreas Surgery.

OBJECTIVE: Endoscopic ultrasound (EUS) is routinely used for fiducial marker placement (FMP) to guide stereotactic radiation of pancreatic tumors, but EUS-FMP explicitly to guide surgery has not been studied in a prospective, controlled manner. Multipurpose EUS systems have been developed that facilitate simultaneous EUS-FMP at the time of biopsy. We aimed to evaluate the feasibility of EUS-FMP to guide pancreatic resection. METHODS: In this prospective trial, we enrolled patients with resectable pancreas masses undergoing tissue sampling and placed preloaded fiducials immediately after biopsy. Intraprocedure confirmation of carcinoma, neuroendocrine, and nonlymphomatous neoplasia by rapid on-site evaluation and lesion size <4 cm was required. The main outcomes were the feasibility and ease of preoperative placement and intraoperative detection of the markers using predefined Likert scales. RESULTS: In 20 patients, EUS-FMP was successful before planned surgery and placement was technically straightforward (Likert Scale: 9.1 ± 1.3; range: 1, most challenging to 10, most facile). Intraoperative detection was feasible and improved when compared with a pre-established comparator of 5 representing an equivalent lesion without a marker (Likert Scale: 7.8 ± 2.2; range: 1, most difficult to 10, most facile; P = 0.011). The mean tumor size on EUS was 1.7 ± 0.9 (range: 0.5 to 3.6) cm. CONCLUSION: EUS-FMP is feasible and safe for resectable pancreatic tumors before surgery and may assist in perioperative detection. Preloaded fiducials may be considered for placement at the time of initial referral for EUS-fine needle biopsy.

Complicated gallstone disease: diagnosis and management of Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome (MS) is characterized by an obstruction of the proximal bile duct due to extrinsic compression by either an impacted stone in the gallbladder neck or local inflammatory changes. Although this is a rare syndrome in developed countries (0.7-1.4 %), preoperative diagnosis and careful surgical management are essential to avoid bilio-vascular injuries and misdiagnosed malignancy. METHODS: The purpose of this study was to review our experience in the diagnosis and management of MS, assess the role of laparoscopy and the risk of concomitant gallbladder carcinoma. This study took place in a large county hospital which serves indigent and undocumented immigrants without easy access to healthcare. Data were collected through a retrospective chart review of 4939 patients that underwent cholecystectomy over 6 years. Patient demographics, preoperative, intraoperative, postoperative data and outcomes were analyzed. RESULTS: MS was identified in 60 of 4939 patients (1.21 %) who underwent cholecystectomy. The mean age at presentation was 47 years, and 35 patients were females. The most common symptom at presentation was abdominal pain (100 %) followed by nausea/vomiting (87 %) and jaundice (43 %). Type I MS was diagnosed in 16 patients and 44 had type II MS. Preoperative diagnosis was achieved in 43 patients (71 %). Magnetic resonance cholangiopancreatography was the best diagnostic modality. Laparoscopic cholecystectomy was successful in 4 out of 16 patients with type I MS. Three patients (5.26 %) had simultaneous gallbladder cancer. Overall morbidity was 27 % and mortality was 0. Clavien grade ≥3 complications were seen in six patients (10 %). The mean length of follow-up was 2.3 months (range 0-5) for type I MS patients and 5.4 months (range 0-46) for type II patients. CONCLUSIONS: MS is rare, but preoperative diagnosis or intraoperative suspicion is important. Laparoscopic cholecystectomy may be possible in selected type I cases. Open cholecystectomy is the standard of care for type II MS.

Surgical transgastric debridement of walled off pancreatic necrosis: an option for patients with necrotizing pancreatitis.

BACKGROUND: Transgastric debridement of walled off pancreatic necrosis (WOPN) is a surgical treatment option for patients requiring pancreatic debridement for necrotizing pancreatitis. The reported experience with surgical transgastric pancreatic debridement is limited, however, the lower incidence of postoperative pancreatic fistulae with this procedure compared to other options warrants further evaluation of this technique. METHOD: Retrospective chart review. RESULTS: Twenty-two patients underwent transgastric debridement with a cystogastrostomy for clinically symptomatic WOPN from January 1, 2005 to July 31, 2013. Eight cases were performed laparoscopically and 14 were performed by an open approach. The mean patient age was 50.9 (50.9 ± 14.5) and the median American Society of Anesthesiologist score was 3. The most common etiology for pancreatitis was gallstones and the median time from attack of pancreatitis to definitive surgical management was 60 days (range 22-300 days). Median operative time was 182 min (range 85-327 min) with 100 cc (range 20-500 cc) of blood loss. In seven patients the necrosis was infected and in 15 patients the necrosis was sterile as determined by the intraoperative culture of the necrotic material. The overall significant morbidity (Clavien type 3 or greater) was 13.6 % and the mortality was 0 %. The incidence of postoperative pancreatic fistula was 0 %. 20 patients (90 %) were symptom free during a median follow-up of 12 months. CONCLUSION: In selected patients with clinically symptomatic WOPN, surgical transgastric pancreatic debridement appears to be a safe procedure with a low morbidity and mortality. The low incidence of postoperative pancreatic fistulae warrants further evaluation.

Multidisciplinary Treatment of Cystic Fibrosis-Related Recurrent Pyogenic Cholangitis (CF-RPC).

BACKGROUND: As the survival of cystic fibrosis patients improves due to better treatment of its pulmonary manifestations, the management of hepatobiliary complications becomes increasingly vital. While focal biliary cirrhosis is common, large duct manifestations are less frequently encountered. METHODS: We prospectively evaluated cases of large bile duct disease in a large adult cystic fibrosis practice at the Keck Hospital of the University of Southern California. RESULTS: Over a 5-year period, six patients presented with cholangiectasia, hepatolithiasis, and strictures. Their clinical presentation and course closely resembled recurrent pyogenic cholangitis (RPC). Treatment of cholangitis and strictures was primarily by endoscopic retrograde cholangiopancreatography, but major hepatobiliary surgery following pulmonary optimization was required in 33 %. CONCLUSION: In adult populations, CF-RPC may not be as unusual as previously reported and recognition allows optimal endoscopic, medical, and surgical management.

Blood Conservation Strategies and Liver Transplantation Transfusion-Free Techniques Derived from Jehovah's Witness Surgical Cohorts.

Red blood cell and component transfusions are a frequent and widely accepted accompaniment of surgical procedures. Although the risk of specific disease transmission via allogeneic blood transfusions (ABT) is very low, the occurrence of transfusion related immune modulation (TRIM) still remains a ubiquitous concern. Recent studies have shown that ABT are linked to increased morbidity and mortality across various specialties, with negative outcomes directly correlated to number of transfusions. Blood conservation methods are therefore necessary to reduce ABT. Acute normo-volemic hemodilution (ANH) along with pre-operative blood augmentation and intraoperative cell salvage are blood conservation techniques utilized in tertiary and even quaternary (transplantation) surgery in Jehovah's Witnesses with excellent outcomes. The many hematologic complications such as anemia, thrombocytopenia and coagulopathies that occur with liver transplantation present a significant barrier when trying to avoid ABT. Despite this, living donor liver transplantation (LDLT) has been successfully performed in a transfusion-free environment, providing valuable insight into the possibilities of limiting ABT and its associated risks in all patients.

The influence of frailty on perioperative outcomes in patients undergoing surgical resection of liver metastases: a nationwide readmissions database study.

Background: Liver metastases arise frequently from primary colorectal, pancreatic, and breast cancers. Research has highlighted the patient's frailty status as an important predictor of outcomes, but the literature evaluating the role of frailty in patients with secondary metastatic disease of the liver remains limited. Using predictive analytics, we evaluated the role of frailty in patients who underwent hepatectomy for liver metastases. Methods: We used the Nationwide Readmissions Database from 2016-2017 to identify patients who underwent resection of a secondary malignant neoplasm of the liver. Patient frailty was evaluated using the Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining diagnosis indicator. Propensity score matching was performed and Mann-Whitney U testing was used to analyze complication rates. Receiver operating characteristic (ROC) curves were created following creation of logistic regression models for predicting discharge disposition. Results: Frail patients reported significantly higher rates of nonroutine discharges, longer inpatient stays, greater costs, higher rates of acute infection, posthemorrhagic anemia, urinary tract infection (UTI), deep vein thrombosis (DVT), wound dehiscence and readmission, and greater mortality (P<0.05). Predictive models for patient discharge disposition, DVT and UTI demonstrated that the use of frailty status and age improved the area under the ROC curves significantly compared to models using age alone. Conclusions: Frailty was found to be significantly correlated with higher rates of medical complications during inpatient stay following hepatectomy in patients with liver metastasis. The inclusion of patient frailty status in predictive models improved their predictive capacity compared to those using age alone.

A Potential Role for Robotic Cholecystectomy in Patients with Advanced Liver Disease: Analysis of the NSQIP Database.

Robotic surgery has been widely adopted by many specialties, including hepatobiliary surgery. However, robotic procedures generally require longer operative times and are costlier than their laparoscopic counterparts. The role for robotic cholecystectomy (RC), particularly in patients with advanced liver disease, has not been established. A retrospective analysis of the NSQIP database was performed, focusing on patients with chronic liver disease who underwent cholecystectomy. Patients were categorized based on their model for end-stage liver disease (MELD) score and the type of surgical procedure: open, laparoscopic, or RC. Rates of a variety of postoperative complications including length of stay (LOS) were analyzed. In patients with a MELD score of 21 to 30, open cholecystectomy was associated with a long hospital LOS (3 vs 1 vs 1; P -0.01). RC was equivalent to laparoscopic cholecystectomy in terms of perioperative mortality for higher MELD score patients but was associated with lower conversion rates and overall LOS. This data suggests that RC should be considered in patients with advanced liver disease needing cholecystectomy.

Clear Cell Variant of Solid Pseudopapillary Neoplasm of the Pancreas: A Report of a Rare Variant and Review of the Literature.

The clear cell variant of solid pseudopapillary neoplasm (ccSPN) of the pancreas was first described in 2006. In this article, we report a case of this rare variant and review the few published reports. Both the current and previous reports show that ccSPN has several morphologic differences from conventional SPN, including clear vacuoles, fewer pseudopapillary formations, more solid/diffuse architecture, less hemorrhage, and fewer cholesterol clefts. Some of these features peculiar to ccSPN, such as solid/diffuse architecture, have been proposed to suggest aggressive behavior, though reports of ccSPN are rare and often have limited clinical follow-up. ccSPN also appears to occur more frequently in males than conventional SPNs. These clinical and pathologic features lead to unique set of differential diagnostic considerations for ccSPN, including metastatic renal cell carcinoma, perivascular epithelial cell tumor, and clear cell variants of other carcinomas. These unique features, atypical differential, and uncertain prognostic ramifications all make ccSPN an important variant to be aware of and report.