Development of a Deep Learning System for Intra-Operative Identification of Cancer Metastases.

OBJECTIVE: The aim of this study was to develop and test a prototype of a deep learning surgical guidance system (CASL) that can intra-operative identify peritoneal surface metastases on routine laparoscopy images. BACKGROUND: For a number of cancer patients, operative resection with curative intent can end up in early recurrence of the cancer. Surgeons misidentifying visible peritoneal surface metastases is likely a common reason. METHODS: CASL was developed and tested using staging laparoscopy images recorded from 132 patients with histologically-confirmed adenocarcinoma involving the gastrointestinal tract. The data included images depicting 4287 visible peritoneal surface lesions and 3650 image patches of 365 biopsied peritoneal surface lesions. The prototype's diagnostic performance was compared to results from a national survey evaluating 111 oncologic surgeons in a simulated clinical environment. RESULTS: In a simulated environment, surgeons' accuracy of correctly recommending a biopsy for metastases while omitting a biopsy for benign lesions was only 52%. In this environment, the prototype of a deep learning surgical guidance system demonstrated improved performance in identifying peritoneal surface metastases compared to oncologic surgeons with an area under the receiver operating characteristic curve of 0.69 (oncologic surgeon) versus 0.78 (CASL) versus 0.79 (human-computer combined). A proposed model would have improved the identification of metastases by 5% while reducing the number of unnecessary biopsies by 28% compared to current standard practice. CONCLUSIONS: Our findings demonstrate a pathway for an artificial intelligence system for intra-operative identification of peritoneal surface metastases, but still requires additional development and future validation in a multi-institutional clinical setting.

Association Between Preoperative Angioembolization and Bleeding Complications in Patients With Benign Liver Tumors: Analysis of a National Database.

INTRODUCTION: The role of angioembolization (AE) in patients with benign liver diseases is an area of active research. This study aims to assess any difference in liver resection outcomes in patients with benign tumors dependent on utilization of preoperative AE. METHODS: A retrospective cohort study of patients undergoing elective liver resections for benign liver tumors was performed using the National Surgical Quality Improvement Program database (2014-2019). Only tumors of 5 cm in size or more were included in the analysis. We categorized the patients based on preoperative AE (AE + versus AE -). The primary outcome measured included bleeding complications within 72 h. The secondary outcomes were to determine predictors of bleeding. RESULTS: After propensity score matching, there were 103 patients in both groups. There was no difference in intraoperative or postoperative blood transfusions within 72 h of surgery (14.6% versus 12.6%; P = 0.68), reoperation (1.9% versus 1.9%; P = 1), or mortality (1.0% versus 0.0%; P = 1) between the two groups. Multivariate regression analysis revealed an open surgical approach (odds ratio [OR]: 4.59 confidence interval [CI]: 2.94-7.16), use of Pringle maneuver (OR: 1.7, CI: 1.26-2.310), preoperative anemia (OR: 2.79, CI: 2.05-3.80), and preoperative hypoalbuminemia (OR: 1.53 [1.14-2.05]) were associated with the need for intraoperative or postoperative blood transfusions within 72 h of surgery. CONCLUSIONS: Preoperative AE was not associated with reducing intraoperative or postoperative bleeding complications or blood transfusions within 72 h after surgery.

Long-Wave Infrared Imaging for Intraoperative Cancer Detection-What is the True Temperature of a Cancer?

BACKGROUND: During cancer operations, the cancer itself is often hard to delineate-buried beneath healthy tissue and lacking discernable differences from the surrounding healthy organ. Long-wave infrared, or thermal, imaging poses a unique solution to this problem, allowing for the real-time label-free visualization of temperature deviations within the depth of tissues. The current study evaluated this technology for intraoperative cancer detection. METHODS: In this diagnostic study, patients with gastrointestinal, hepatobiliary, and renal cancers underwent long-wave infrared imaging of the malignancy during routine operations. RESULTS: It was found that 74% were clearly identifiable as hypothermic anomalies. The average temperature difference was 2.4°C (range 0.7 to 5.0) relative to the surrounding tissue. Cancers as deep as 3.3 cm from the surgical surface were visualized. Yet, 79% of the images had clinically relevant false positive signals [median 3 per image (range 0 to 10)] establishing an accuracy of 47%. Analysis suggests that the degree of temperature difference was primarily determined by features within the cancer and not peritumoral changes in the surrounding tissue. CONCLUSION: These findings provide important information on the unexpected hypothermal properties of intra-abdominal cancers, directions for future use of intraoperative long-wave infrared imaging, and new knowledge about the in vivo thermal energy expenditure of cancers and peritumoral tissue.

Single-Port Laparoscopic Repair of Perforated Duodenal Ulcers.

BACKGROUND: Laparoscopic single-port surgery has widely been introduced for the treatment of various abdominal conditions. But controversies still exist regarding its potential advantages and risks, especially for emergency surgery. The aim of this study was to evaluate the results of a single-port laparoscopic repair using straight laparoscopic instruments for the treatment of perforated duodenal ulcers. METHODS: A prospective consecutive case series was conducted including all patients with a perforated duodenal ulcer who underwent a laparoscopic single-port repair at a single institution from January 2012 to June 2018. The operation was performed through a single port using conventional straight laparoscopic instruments and intra-corporeal knot tying techniques. RESULTS: Out of 75 patients, simple closure of the perforation without omental patch was accomplished in 96% of cases. Conversion to an open operation was required in one patient (1.3%) due to a posterior duodenal perforation, and additional trocar placement was needed in another patient (1.3%). The mean incision length was 2.0 ± 0.2 cm. The mean operation time was 63.0 ± 26.6 min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8 days. Mean duration of analgesic use was 2.8 ± 0.8 days. The rate of postoperative complications was 2.7%, including two patients with wound infections. There were no instances of intestinal leak or abscess. The postoperative hospital stay was 5.7 ± 1.2 days. CONCLUSION: Laparoscopic single-port repair using conventional straight laparoscopic instruments with intra-corporeal knot tying technique was safe and feasible for patients with perforated duodenal ulcers with low risk factors. This method offers results comparable to those expected with the standard multiport laparoscopic approach with the addition of improved cosmetic outcomes.

Can We Accurately Identify Peritoneal Metastases Based on Their Appearance? An Assessment of the Current Practice of Intraoperative Gastrointestinal Cancer Staging.

BACKGROUND: Peritoneal lesions are common findings during operative abdominal cancer staging. The decision to perform biopsy is made subjectively by the surgeon, a practice the authors hypothesized to be imprecise. This study aimed to describe optical characteristics differentiating benign peritoneal lesions from peritoneal metastases. METHODS: The study evaluated laparoscopic images of 87 consecutive peritoneal lesions biopsied during staging laparoscopies for gastrointestinal malignancies from 2014 to 2017. A blinded survey assessing these lesions was completed by 10 oncologic surgeons. Three senior investigators categorized optical features of the lesions. Computer-aided digital image processing and machine learning was used to classify the lesions. RESULTS: Of the 87 lesions, 28 (32%) were metastases. On expert survey, surgeons on the average misidentified 36 ± 19% of metastases. Multivariate analysis identified degree of nodularity, border transition, and degree of transparency as independent predictors of metastases (each p < 0.03), with an area under the receiver operating characteristics curve (AUC) of 0.82 (95% confidence interval [CI], 0.72-0.91). Image processing demonstrated no difference using image color segmentation, but showed a difference in gradient magnitude between benign and metastatic lesions (AUC, 0.66; 95% CI 0.54-0.78; p = 0.02). Machine learning using a neural network with a tenfold cross-validation obtained an AUC of only 0.47. CONCLUSIONS: To date, neither experienced oncologic surgeons nor computerized image analysis can differentiate peritoneal metastases from benign peritoneal lesions with an accuracy that is clinically acceptable. Although certain features correlate with the presence of metastases, a substantial overlap in optical appearance exists between benign and metastatic peritoneal lesions. Therefore, this study suggested the need to perform biopsy for all peritoneal lesions during operative staging, or at least to lower the threshold significantly.

Laparoscopic narrow band imaging for detection of occult cancer metastases: a randomized feasibility trial.

BACKGROUND: Selection of cancer treatment fundamentally relies on staging of the underlying malignancy. The aim of this study was to evaluate the feasibility and effectiveness of laparoscopic narrow band imaging (NBI) for operative staging and detection of occult peritoneal cancer metastases. METHODS: A randomized, controlled feasibility trial with crossover design evaluating adult patients with gastrointestinal or gynecologic malignancies who have a clinical indication for diagnostic laparoscopy was conducted. Twenty-three patients were randomized to white-light followed by NBI laparoscopy (n = 11) or NBI followed by white-light laparoscopy (n = 12) using the Olympus Evis Exera II system. Three patients were excluded from analysis. RESULTS: In all 20 study patients, the abdominal cavity was sufficiently illuminated. An enhanced contrast of microvasculature and organ surface pattern was appreciated. Eight of the 20 patients (40%) were found to have metastases of the peritoneal surface. While NBI did not show any additional peritoneal lesions, 2 of the 63 suspicious-appearing nodules seen on white-light imaging were not visible on NBI (p = 0.50). The median diameter of all the nodules identified was 2 mm (range 1-50 mm) and was identical with each method. CONCLUSIONS: The information from this feasibility study demonstrated that NBI provides adequate illumination of the abdominal cavity and a unique contrast that enhances microvasculature and architectural surface pattern. The results suggest that NBI laparoscopy is not superior in detecting peritoneal metastases compared to standard white-light laparoscopy, but might provide a technology that could be applied for other abdominal pathologies.

From shadow to light: visualization of extrahepatic bile ducts using image-enhanced laparoscopy.

BACKGROUND: Correct recognition of the extrahepatic bile ducts is thought to be crucial to reduce the risk of bile duct injuries during various laparoscopic procedures. Image-enhanced laparoscopy techniques, utilizing various optical modalities other than white light, may help in detecting structures "hidden" underneath connective tissue. METHODS: A systematic literature search was conducted of studies describing image-enhanced laparoscopy techniques for visualization of the extrahepatic bile ducts. RESULTS: In all, 29 articles met inclusion criteria. They describe various techniques in the animal or human setting, including autofluorescence imaging, drug-enhanced fluorescence imaging, infrared thermography, and spectral imaging. This review describes these various techniques and their results. CONCLUSION: Image-enhanced laparoscopy techniques for real-time visualization of extrahepatic bile ducts are still in its infancy. Out of the techniques currently described, indocyanine green-enhanced near-infrared fluorescence laparoscopy has the most mature results, but other techniques also appear promising. It can be expected that in the future, image-enhanced laparoscopy might become a routine adjunct to any white-light laparoscopic operation near the hepatic hilum.

Does Preoperative Weight Loss Affect Outcomes After Major Liver Resection? Analysis of a National Database.

Introduction: The association between unintentional weight loss (WL) and outcomes after major hepatectomy for malignancy remains unclear.Methods: This retrospective cohort study reviewed the 2014-2019 NSQIP database of all patients who underwent major liver resections. The patients were categorized into two groups based on their history of weight loss. The primary outcome measure was the 30-day mortality. The secondary outcome was 30-day in-hospital complications.Results: In total, 384 patients had a history of preoperative weight loss. Preoperative WL was an independent predictor of septic shock (OR, 2.44; CI: 1.61, 3.69), bile leak (OR: 1.96; CI: 1.51, 2.55), and grade C liver failure (OR: 2.57; CI: 1.64, 4.01). However, preoperative WL was not a significant predictor of perioperative mortality (OR: 1.38; CI: 0.82, 2.32).Conclusion: The study found higher morbidity rates in patients undergoing liver resection with a history of weight loss. Further validation with prospective weight monitoring is needed to validate as a prognostic marker in patients undergoing hepatectomy. In addition, weight changes can help guide multidisciplinary decision-making in treating patients undergoing hepatectomy.

Can Surgeons Reliably Identify Non-cirrhotic Liver Disease During Laparoscopic Bariatric Surgery?

INTRODUCTION: Identification of liver disease during bariatric operations is an important task given the patients risk for occult fatty liver disease. Surgeon's accuracy of assessing for liver disease during an operation is poorly understood. The objective was to measure surgeons' performance on intra-operative visual assessment of the liver in a simulated environment. METHODS: Liver images from 100 patients who underwent laparoscopic bariatric surgery and pre-operative ultrasound elastography between July 2020 and July 2021 were retrospectively evaluated. The perception of 15 surgeons regarding the degree of hepatic steatosis and fibrosis was collected in a simulated clinical environment by survey and compared to results determined by ultrasonographic exam. RESULTS: The surgeons' ability to correctly identify the class of steatosis and fibrosis was poor (accuracy 61% and 59%, respectively) with a very weak correlation between the surgeon's predicted class and its true class (r = 0.17 and r = 0.12, respectively). When liver disease was present, surgeons completely missed its presence in 26% and 51% of steatosis and fibrosis, respectively. Digital image processing demonstrated that surgeons subjectively classified steatosis based on the "yellowness" of the liver and fibrosis based on texture of the liver, despite neither correlating with the true degree of liver disease. CONCLUSION: Laparoscopic visual assessment of the liver surface for identification of non-cirrhotic liver disease was found to be an inaccurate method during laparoscopic bariatric surgery. While validation studies are needed, the results suggest the clinical need for alternative approaches.

Evaluation of a polarization-enhanced laparoscopy prototype for improved intra-operative visualization of peritoneal metastases.

Despite careful staging, the accuracy for preoperative detection of small distant metastases remains poor, creating a clinical need for enhanced operative staging to detect occult peritoneal metastases. This study evaluates a polarization-enhanced laparoscopy (PEL) prototype and assesses its potential for label-free contrast enhancement of peritoneal metastases. This is a first-in-human feasibility study, including 10 adult patients who underwent standard staging laparoscopy (SSL) for gastrointestinal malignancy along with PEL. Image frames of all detectable peritoneal lesions underwent analysis. Using Monte Carlo simulations, contrast enhancement based on the color dependence of PEL (mPEL) was assessed. The prototype performed safely, yet with limitations in illumination, fogging of the distal window, and image co-registration. Sixty-five lesions (56 presumed benign and 9 presumed malignant) from 3 patients represented the study sample. While most lesions were visible under human examination of both SSL and PEL videos, more lesions were apparent using SSL. However, this was likely due to reduced illumination under PEL. When controlling for such effects through direct comparisons of integrated (WLL) vs differential (PEL) polarization laparoscopy images, we found that PEL imaging yielded an over twofold Weber contrast enhancement over WLL. Further, enhancements in the discrimination between malignant and benign lesions were achieved by exploiting the PEL color contrast to enhance sensitivity to tissue scattering, influenced primarily by collagen. In conclusion, PEL appears safe and easy to integrate into the operating room. When controlling for the degree of illumination, image analysis suggested a potential for mPEL to provide improved visualization of metastases.

Polarization enhanced laparoscope for improved visualization of tissue structural changes associated with peritoneal cancer metastasis.

A polarization enhanced laparoscopy (PEL) imaging system was developed to examine the feasibility of utilizing PEL to augment conventional white light laparoscopy (WLL) in the visualization of peritoneal cancer metastases. The system includes a modified tip to illuminate tissue with linearly polarized light and elements in the detection path enabling recording of corresponding images linearly co- and cross-polarized relative to the incident light. WLL and PEL images from optical tissue phantoms with features of distinct scattering cross-section confirm the enhanced sensitivity of PEL to such characteristics. Additional comparisons based on images acquired from collagen gels with different levels of fiber alignment highlight another source of PEL contrast. Finally, PEL and WLL images of ex vivo human tissue illustrate the potential of PEL to improve visualization of cancerous tissue surrounded by healthy peritoneum. Given the simplicity of the approach and its potential for seamless integration with current clinical practice, our results provide motivation for clinical translation.

Development of pancreatoduodenectomy in North America.

PURPOSE: Pancreatoduodenectomy has been developed over more than 100 years, with contributions being made by many countries to the various aspects of the technique. METHODS: This review outlines the contributions of America toward the technical conduct of the procedure. RESULTS: There have been seven phases of the development and refinement of pancreatoduodenectomy from 1935 until now: Phase 1, development and feasibility (1935-1950); Phase 2, radicality of the procedure (1960-1975); Phase 3, total pancreatectomy (1960-1975); Phase 4, pylorus preservation (1975-1985); Phase 5, surgical experience trials (1980-2000); Phase 6, adjuvant treatments (1990 to now); and Phase 7, minimally invasive techniques (1995 to now). CONCLUSIONS: In conjunction with Japan, Germany, Italy, France, and many other countries, North America has contributed substantially to the development of the current, state-of-the-art performance of pancreatoduodenectomy and its evaluation.

The birth of pancreatic surgery: a tribute to Friedrich Wilhelm Wandesleben.

Friedrich Wilhelm Wandesleben (1800-1868), a small-town German physician, performed surgical drainage of a traumatic pancreatic pseudocyst in November 1841. This operation should be acknowledged as the world's first reported operation on the human pancreas. The surgeon, the operation, and its implications for future pancreatic operations are the subjects of this historical review.

Invasive intraductal papillary mucinous neoplasm: predictors of survival and role of adjuvant therapy.

BACKGROUND: Adjuvant treatment for pancreatic adenocarcinoma has been shown to improve survival. An increasingly recognized 'subtype' of pancreatic adenocarcinoma is invasive intraductal papillary mucinous neoplasm (IPMN). It is unclear whether adjuvant treatment for invasive IPMN improves survival. This study aimed to determine the impact of adjuvant treatment in invasive IPMN. METHODS: We conducted a retrospective analysis of merged clinical databases including 412 patients undergoing resection for IPMN at two academic institutions between 1989 and 2006. RESULTS: Of 412 patients with IPMN who underwent pancreatectomy, 98 had invasive carcinoma. Median survival in invasive IPMN was 32 months. Adjuvant treatment did not affect median survival in node-positive or node-negative invasive IPMN. Biopsy-proven recurrence of invasive IPMN occurred in 45 patients (46%). The median disease-free interval from resection to recurrence was 27 months. Treatment of recurrences with chemotherapy or radiation therapy was not associated with a difference in survival; however, a subgroup of patients with recurrence in the remnant pancreas who underwent re-resection appeared to have more favourable outcomes. CONCLUSIONS: An invasive component measuring >2 cm and lymph node involvement are associated with poorer prognosis. Adjuvant therapy in invasive IPMN appears to confer no survival benefit. In selected patients with recurrence of invasive IPMN in the remnant pancreas, re-resection should be considered.

Polycystic liver disease: a critical appraisal of hepatic resection, cyst fenestration, and liver transplantation.

OBJECTIVE: To identify operative morbidity, mortality, and long-term outcome after operative treatment for symptomatic polycystic liver disease (PLD) and develop a treatment algorithm for patients with PLD. BACKGROUND: PLD represents a challenging clinical problem that can result in massive hepatomegaly and various complications, leading to significant decline in health status and quality of life. The optimal surgical treatment for this disease is still evolving. METHODS: All patients who underwent hepatic resection, cyst fenestration, or liver transplantation for PLD from 1985 to 2006 were identified retrospectively. Long-term outcomes were evaluated by patient survey. Mean follow-up was 8 +/- 0.5 years. RESULTS: Of 141 patients (122 women; age: 51 +/- 1 years) with PLD, 117 had concomitant polycystic kidney disease. All patients suffered from symptomatic hepatomegaly with 85% being functionally impaired (Eastern Cooperative Oncology Group Performance Status: 1-3). Despite significant inferior vena cava or hepatic venous compression in 65%, hepatic function was commonly preserved. A total of 124 patients underwent partial hepatectomy with cyst fenestration, 10 underwent cyst fenestration alone, and 7 underwent liver transplantation for primary treatment of PLD. Overall operative morbidity and mortality was 58% and 4%, respectively, with major complications (Clavien grade: III-V) in 30%. Five- and 10-year survival was 90% and 78%, respectively. Eastern Cooperative Oncology Group Performance Status performance status normalized or improved in 75% of patients and 73% returned to work full-time. At follow-up, health survey scores were similar to the general population despite subsequent recurrence of symptoms in 73% of patients. CONCLUSION: Selective patients with massive hepatomegaly from PLD benefit from operative intervention. The type of operation performed is mainly dependent on the distribution of the cysts, coincident sectoral vascular patency and parenchymal preservation, and hepatic reserve. Hepatic resection can be performed with acceptable morbidity and mortality, prompt and durable relief of symptoms, and maintenance of liver function. Cyst fenestration and liver transplantation, though effective in selected patients, are less broadly applicable.

Intraductal papillary mucinous neoplasm of the biliary tract: a real disease?

BACKGROUND: Despite increasing numbers of reports, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is not yet recognized as a unique neoplasm. The aim of the present study was to define the presence of BT-IPMN in a large series of resected biliary neoplasms. METHODS: From May 1994 to December 2006, BT-IPMN cases were identified by reviewing pathology specimens of all resected cholangiocarcinomas and other biliary neoplasms when cystic, papillary or mucinous features were cited in pathology reports. RESULTS: BT-IPMN was identified in 23 out of 253 (9%) specimens using the strict histopathological criteria of IPMN. The most common presenting symptom was abdominal discomfort which was present in 15 patients (65%). Only one of the original operative pathology reports used the term IPMN; 16 (70%) used the terms cystic, mucinous and/or papillary. BT-IPMN was isolated to non-hilar extra-hepatic ducts in 12 (52%), intra-hepatic ducts in 6 (26%) and hilar extra-hepatic ducts in 5 patients (22%). Carcinoma was found in association with BT-IPMN in 19 patients (83%); 5-year survival was 38% after resection. CONCLUSION: BT-IPMN occurs throughout the intra- and extra-hepatic biliary system and can be identified readily as a unique neoplasm. Broader acceptance of BT-IPMN as a unique neoplasm may lead to a better understanding of the pathogenesis of biliary malignancies.

Two-photon images reveal unique texture features for label-free identification of ovarian cancer peritoneal metastases.

For cancer patients, treatment selection fundamentally relies on staging, with "under-staging" considered a common problem. Imaging modalities that can complement conventional white-light laparoscopy are needed to detect more accurately small metastatic lesions in patients undergoing operative cancer care. Biopsies from healthy parietal peritoneum and ovarian peritoneal metastases obtained from 8 patients were imaged employing a two-photon laser scanning microscope to generate collagen-second harmonic generation (SHG) and fluorescence images at 755 nm and 900 nm excitation and 460 ± 20 nm and 525 ± 25 nm emission. Forty-one images were analyzed by automated image processing algorithms and statistical textural analysis techniques, namely gray level co-occurrence matrices. Two textural features (contrast and correlation) were employed to describe the spatial intensity variations within the captured images and outcomes were used for discriminant analysis. We found that healthy tissues displayed large variations in contrast and correlation features as a function of distance, corresponding to repetitive, increased local intensity fluctuations. Metastatic tissue images exhibited decreased contrast and correlation related values, representing more uniform intensity patterns and smaller fibers, indicating the destruction of the healthy stroma by the cancerous infiltration. The textural outcomes resulted in high classification accuracy as evaluated quantitatively by discriminant analysis.

Surgical treatment of alcohol-associated chronic pancreatitis: the challenges and pitfalls.

Long-term excessive alcohol consumption is the most common risk factor for the development of chronic pancreatitis. Management of patients with alcohol-associated chronic pancreatitis can be complicated by problems associated with dependency, psychosocial burden, and physical changes like malnutrition and hepatic insufficiency. The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (LPJ, n = 184), pancreatoduodenectomy (PD, n = 97), or distal pancreatectomy (DP, n = 91) for chronic pancreatitis were retrospectively analyzed. Long-term outcome was assessed by patient survey with a median follow up of 5.5 +/- 0.2 years. Of 372 patients, 171 underwent surgery for alcohol-associated chronic pancreatitis. According to patient questioning, the prevalence of alcohol cessation before surgery in the 171 patients was 81 per cent. Operative morbidity in the 171 patients was 20 per cent, 50 per cent, and 26 per cent after LPJ, PD, and DP, respectively, with an overall perioperative mortality rate of 2 per cent. None of the patients developed delirium tremens using an alcohol withdrawal protocol. Continued alcohol abuse before surgery did not affect perioperative morbidity (P > 0.05). Follow up was available for a total of 229 patients, of which 39 per cent with alcohol-associated chronic pancreatitis had died compared with 16 per cent in the nonalcohol group (P < 0.001). Of the remaining 171 patients, 45 per cent with alcohol-associated chronic pancreatitis had good pain control compared with 49 per cent of the remainder (P > 0.05). Continuation of alcohol abuse after operation did not affect success for pain control at follow up (P > 0.05). Surgical treatment of alcohol-associated chronic pancreatitis can be performed with similar morbidity and mortality compared with other forms of chronic pancreatitis. Alcohol cessation is preferred but not mandated to achieve good operative long-term outcome. Caution needs to be taken to prevent postoperative alcohol withdrawal. Long-term follow up with psychosocial support and management of co-existing addictions is important.

Porcelain Gallbladder: Is Observation a Safe Option in Select Populations?

BACKGROUND: Management of gallbladder wall calcifications has been controversial for many decades. Although the traditionally perceived strong association with gallbladder cancer mandated prophylactic cholecystectomy, newer evidence suggests a much lesser association and might indicate an observational approach. STUDY DESIGN: A retrospective cohort study of 113 patients with gallbladder wall calcifications diagnosed between 2004 and 2016 at a single institution was conducted. Radiographic re-review identified patients with definitive (n = 70) and highly probable (n = 43) gallbladder wall calcifications. Patients were categorized according to their designated treatment plan. RESULTS: In the observation group (n = 90), delayed cholecystectomy for gallbladder-related symptoms was necessary in 4 patients (4%). None of the patients in this group were diagnosed with a gallbladder malignancy during a mean of 3.2 ± 3.2 years follow-up. In the operative group (n = 23), peri-operative complications occurred in 13%, and gallbladder malignancy was found in 2 patients. In comparison, although patients in the observation group were older and had more comorbidities, the rate of adverse events was not significantly different (4% vs 13%; p = 0.15) with an overall low risk for potentially life-threatening complications to the patient when observed clinically. CONCLUSIONS: For management of gallbladder wall calcifications, observation appears to provide no significant difference in adverse events, including the risk of gallbladder malignancy developing, compared with an operative approach. Although there is a need for intervention in the presence of symptoms and findings suggestive of malignancy, prophylactic cholecystectomy should be avoided in patients with limited life expectancy and significant comorbidities.

Operative management of chronic pancreatitis: longterm results in 372 patients.

BACKGROUND: Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or for the presence of complications of the disease. This study evaluates a single-center experience with operative management of chronic pancreatitis. STUDY DESIGN: The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (n = 184), pancreaticoduodenectomy (n = 97), or distal pancreatectomy (n = 91) for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Longterm outcomes were assessed by patient survey, with a median followup of 5.5 +/- 0.2 years. RESULTS: Primary indication for operative treatment included intractable pain (n = 215), pancreatic duct disruption (n = 109), inflammatory mass (n = 42), or biliary obstruction (n = 6). Perioperative morbidity was 22%, 51%, and 29% after lateral pancreaticojejunostomy, pancreaticoduodenectomy, and distal pancreatectomy, respectively, with a perioperative mortality rate of 1%. Two hundred twenty-eight patients were available for longterm followup. Fifty-eight patients (25%) died in the followup period. Twenty-four percent of the remaining 170 patients were pain free, and 25% had good pain control after the procedure. On multivariate analysis, risk factors for poor pain control were pancreaticoduodenectomy (p < 0.01), preoperative narcotic dependence (p < 0.02), earlier abdominal operations (p < 0.02), and an absent history of gallstone pancreatitis (p < 0.05). Sixty-two percent returned to work. Quality of life assessed by SF-36 version 2 questionnaire showed norm-based scores between the 35th and 46th percentile and slightly below, but not substantially different from, a general population. New onset of endocrine and exocrine insufficiency was present in 35% and 29% of patients, respectively. CONCLUSIONS: Operative management of chronic pancreatitis can be performed with low mortality and acceptable morbidity. Surgical treatment can provide good pain control, return patients to work, and achieve a satisfactory quality of life in the majority of patients. Longterm mortality is high in a subset of patients.