Assessing resectability of colorectal liver metastases: How do different subspecialties interpret the same data?

BACKGROUND: Multimodal treatment of colorectal liver metastases (CRLMs) relies on precise upfront assessment of resectability. Variability in the definition of resectable disease and the importance of early consultation by a liver surgeon have been reported. In this pilot study we investigated the initial resectability assessment and patterns of referral of patients with CRLMs. METHODS: Surgeons and medical oncologists involved in the management of colorectal cancer at 2 academic institutions and affiliated community hospitals were surveyed. Opinions were sought regarding resectability of CRLMs and the type of initial specialty referral (hepatobiliary surgery, medical oncology, palliative care or other) in 6 clinical cases derived from actual cases of successfully performed 1- or 2-stage resection/ablation of hepatic disease. Case scenarios were selected to illustrate critical aspects of assessment of resectability, best therapeutic approaches and specialty referral. Standard statistical analyses were performed. RESULTS: Of the 75 surgeons contacted, 64 responded (response rate 85%; 372 resectability assessments completed). Hepatic metastases were more often considered resectable by hepatobiliary surgeons than all other respondents (92% v. 57%, p < 0.001). Upfront systemic therapy was most commonly prioritized by surgical oncologists (p = 0.01). Hepatobiliary referral was still considered in 73% of "unresectable" assessments by colorectal surgeons, 59% of those by general surgeons, 57% of those by medical oncologists and 33% of those by surgical oncologists (p = 0.1). CONCLUSION: Assessment of resectability varied significantly between specialties, and resectability was often underestimated by nonhepatobiliary surgeons. Hepatobiliary referral was not considered in a substantial proportion of cases erroneously deemed unresectable. These disparities result largely from an imprecise understanding of modern surgical indications for resection of CRLMs.

CONTEXTE: Le traitement multimodal des métastases hépatiques du cancer colorectal (MHCR) repose sur une rigoureuse évaluation initiale de la résécabilité. On a fait état de l'imprécision de la définition de résécabilité et de l'importance de demander rapidement une consultation en chirurgie du foie. Au cours de cette étude, nous avons fait le point sur l'évaluation initiale de la résécabilité et sur les types de consultations demandées pour les patients présentant des MHCR. MÉTHODES: Nous avons interrogé les chirurgiens et oncologues médicaux responsables de la prise en charge du cancer colorectal dans 2 établissements universitaires et leurs hôpitaux communautaires affiliés. Nous leur avons demandé leur opinion sur la résécabilité des MHCR et le type de consultation demandée initialement (chirurgie hépatobiliaire, oncologie médicale, soins palliatifs ou autres) concernant 6 cas cliniques inspirés de cas réels de résection ou ablation réussie pour maladie hépatique de stade 1 ou 2. Ces scénarios de cas cliniques ont été choisis pour illustrer certains aspects cruciaux de l'évaluation de la résécabilité, des approches thérapeutiques optimales et des demandes de consultation. Des analyses statistiques standards ont été effectuées. RÉSULTATS: Parmi les 75 chirurgiens rejoints, 64 ont répondu (taux de réponse 85 %; 372 évaluations de résécabilité ont été effectuées). Les métastases hépatiques ont été plus souvent jugées résécables par les chirurgiens hépatobiliaires que par tous les autres répondants (92 % c. 57 %, p < 0,001). Un traitement systémique initial a le plus souvent été privilégié par les chirurgiens-oncologues (p = 0,01). Une consultation auprès de spécialistes hépatobiliaires était encore considérée comme nécessaire pour les cas jugés «â€¯non résécables ¼ dans une proportion de 73 % par les chirurgiens spécialistes du cancer colorectal, de 59 % par les chirurgiens généraux, de 57 % par les oncologues médicaux et de 33 % par les chirurgiens-oncologues (p = 0,1). CONCLUSION: L'évaluation de la résécabilité a significativement varié d'une spécialité à l'autre et la résécabilité a souvent été sous-estimée par les chirurgiens non spécialistes de voies hépatobiliaires. La consultation auprès des spécialistes hépatobiliaires n'a pas été envisagée pour une proportion substantielle de cas jugés à tort non résécables. Ces disparités se soldent en bonne partie d'une mécompréhension des indications actuelles de la chirurgie pour MHCR.

Sarcopenia and myosteatosis are accompanied by distinct biological profiles in patients with pancreatic and periampullary adenocarcinomas.

INTRODUCTION: Pancreatic and periampullary adenocarcinomas are associated with abnormal body composition visible on CT scans, including low muscle mass (sarcopenia) and low muscle radiodensity due to fat infiltration in muscle (myosteatosis). The biological and clinical correlates to these features are poorly understood. METHODS: Clinical characteristics and outcomes were studied in 123 patients who underwent pancreaticoduodenectomy for pancreatic or non-pancreatic periampullary adenocarcinoma and who had available preoperative CT scans. In a subgroup of patients with pancreatic cancer (n = 29), rectus abdominus muscle mRNA expression was determined by cDNA microarray and in another subgroup (n = 29) 1H-NMR spectroscopy and gas chromatography-mass spectrometry were used to characterize the serum metabolome. RESULTS: Muscle mass and radiodensity were not significantly correlated. Distinct groups were identified: sarcopenia (40.7%), myosteatosis (25.2%), both (11.4%). Fat distribution differed in these groups; sarcopenia associated with lower subcutaneous adipose tissue (P<0.0001) and myosteatosis associated with greater visceral adipose tissue (P<0.0001). Sarcopenia, myosteatosis and their combined presence associated with shorter survival, Log Rank P = 0.005, P = 0.06, and P = 0.002, respectively. In muscle, transcriptomic analysis suggested increased inflammation and decreased growth in sarcopenia and disrupted oxidative phosphorylation and lipid accumulation in myosteatosis. In the circulating metabolome, metabolites consistent with muscle catabolism associated with sarcopenia. Metabolites consistent with disordered carbohydrate metabolism were identified in both sarcopenia and myosteatosis. DISCUSSION: Muscle phenotypes differ clinically and biologically. Because these muscle phenotypes are linked to poor survival, it will be imperative to delineate their pathophysiologic mechanisms, including whether they are driven by variable tumor biology or host response.

Efficacy of a Dual-ring Wound Protector for Prevention of Surgical Site Infections After Pancreaticoduodenectomy in Patients With Intrabiliary Stents: A Randomized Clinical Trial.

OBJECTIVE: To evaluate the efficacy of a dual-ring wound protector for preventing incisional surgical site infection (SSI) among patients with preoperative biliary stents undergoing pancreaticoduodenectomy (PD). METHODS AND ANALYSIS: This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients with a biliary stent undergoing elective PD at 2 tertiary care institutions were included (February 2013 to May 2016). Patients were randomly assigned to receive a surgical dual-ring wound protector or no wound protector, and also the current standard of care. The main outcome measure was incisional SSI, as defined by the Centers for Disease Control and Prevention criteria, within 30 days of the index operation. RESULTS: A total of 107 patients were recruited (mean age 67.2 years; standard deviation 12.9; 65% male). No significant differences were identified between the intervention and control groups (age, sex, body mass index, preoperative comorbidities, American Society of Anesthesiologists class, prestent cholangitis). There was a significant reduction in the incidence of incisional SSI in the wound protector group (21.1% vs 44.0%; relative risk reduction 52%; P = 0.010). Patients with completed PD also displayed a decrease in incisional SSI with use of the wound protector compared with those palliated surgically (27.3% vs 48.7%; P = 0.04). Multivariate analysis did not identify any significant modifying factor relationships (estimated blood loss, duration of surgery, hospital site, etc.) (P > 0.05). CONCLUSION: Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during PD significantly reduces the risk of incisional SSI.

The adequacy of hepatopancreatobiliary training: How does operative exposure and perceived readiness in fellowship translate into subsequent practice?

SUMMARY: Over the last 3 decades, expansion in the scope and complexity of hepatopancreatobiliary (HPB) surgery has resulted in significant improvements in postoperative outcomes. As a result, the importance of dedicated fellowship training for HPB surgery is now well established, and the definition of formal program requirements has been actively pursued by a collaboration of the 3 distinct accrediting bodies within North America. While major advances have been made in defining minimum case volume requirements, qualitative assessment of the operative experience remains challenging. Our research collaborative (HPB Manpower and Education Study Group) has previously explored the perceived case volume adequacy of core HPB procedures within fellowship programs. We conducted a 1-year follow-up survey targeting the same cohort to investigate the association between operative case volumes and comfort performing HPB procedures within initial independent practice.

The management of hepatobiliary cystadenomas: lessons learned.

BACKGROUND: Mucinous cystic neoplasms of the liver (hepatobiliary cystadenomas) are rare neoplastic lesions. Such cysts are often incorrectly diagnosed and managed, and carry a risk of malignancy. The objective of this study was to review the surgical experience with these lesions over 15 years. METHODS: A retrospective chart review identified consecutive patients undergoing surgery for liver cystadenomas from 1997-2011. Clinical data were collected and summarized. RESULTS: Thirteen patients (mean age 51 years, 12/13 females) with cysts 4.6-18.1 cm were identified. Most cysts were located in the left lobe/centrally (11/12) and had septations (8/13). Mural nodularity was infrequent (3/13). Nine patients had liver resection/enucleation, whereas four had unroofing. Frozen section analysis had a high false-negative rate (4/6). All patients had cystadenomas, of which two had foci of invasive carcinoma (cystadenocarcinoma) within mural nodules. There was no 90-day mortality. All but one patient (myocardial infarction) were alive at a median follow-up of 23.1 months. No patient with unroofing has developed malignancy to date. CONCLUSIONS: Non-invasive hepatobiliary cystadenomas present as large central/left-sided cysts in young or middle-aged women. Associated malignancy was relatively uncommon and found within mural nodules. Intra-operative frozen section analysis was ineffective at ruling out cystadenomas. Complete excision is recommended, but close follow-up might be considered in patients with a prohibitive technical or medical risk, in the absence of nodularity on high-quality imaging.