Significance of predicted future liver remnant volume on liver failure risk after major hepatectomy: a case matched comparative study.

Introduction: Future liver remnant volume (FLRV), a risk factor for liver failure (PHLF) after major hepatectomy (MH), is not routinely measured. This study aimed to evaluate the association between FLRV and PHLF. Patients and methods: All patients undergoing MH (4 + segments) between 2011 and 2018 were identified from a prospectively maintained single-centre database. Perioperative data were collected for patients with PHLF, who were matched (1:2) with non-PHLF controls. FLRV and FLRV% (i.e., % of total liver volume) were calculated retrospectively from preoperative CT scans using Synapse-3D software, and compared between the PHLF and matched control groups. Results: Of 711 patients undergoing MH, PHLF occurred in 27 (3.8%), of whom 24 had preoperative CT scans available. These patients were matched to 48 non-PHLF controls, 98% of whom were classified as being at high risk of PHLF on preoperative risk scoring. FLRV% was significantly lower in the PHLF group, compared to matched controls (median: 28.7 vs. 35.2%, p = 0.010), with FLRV% < 30% in 58% and 29% of patients, respectively. Assessment of the ability of FLRV% to differentiate between PHLF and matched controls returned an area under the ROC curve of 0.69, and an optimal cut-off value of FLRV% < 31.5%, which yielded 79% sensitivity and 67% specificity. Conclusions: FLRV% is significantly predictive of PHLF after MH, with over half of patients with PHLF having FLRV% < 30%. In light of this, we propose that all patients should undergo risk stratification prior to MH, with the high risk patients additionally being assessed with CT volumetry.

Impact of Frailty on Short-Term Outcomes After Laparoscopic and Open Hepatectomy.

BACKGROUND: Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on post-operative outcomes after LH and OH. PATIENTS AND METHODS: Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail. RESULTS: Of 1826 patients, 34.7% (N = 634) were frail and 18.6% (N = 340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p < 0.001) and post-operative complications (36.3% vs. 26.1%, p < 0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients. CONCLUSIONS: Frailty is independently associated with inferior post-operative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.

Survival Advantage of Upfront Surgery for Pancreatic Head Cancer Without Preoperative Biliary Drainage.

INTRODUCTION: Level 1 evidence from randomized trials demonstrates less complication when jaundiced patients with resectable pancreatic cancer proceed directly to surgery, rather than undergo preoperative biliary drainage (PBD) first. Although "fast track" surgery significantly increases the resectability rate, it is unknown whether this translates into a survival benefit. This study evaluated the effect of upfront surgery on long-term survival using an intention-to-treat (ITT) analysis. METHODS: Patients were identified from a prospectively maintained database, stratified according to whether or not they underwent PBD. RESULTS: Among 157 patients, 84 (54%) underwent PBD. Of these, 73% underwent surgery, compared to 100% of those without PBD (p<0.001). Reasons for not undergoing surgery were progression of cancer (N=11), progressive frailty (N=5), or PBD-related complication (N=7). In those who underwent surgery, PBD was associated with a longer time from diagnosis to surgery (median: 59 vs. 14 days, p<0.001), and a higher rate of unresectable cancer at surgery (26% vs. 3%, p<0.001). On an ITT basis, patients treated with PBD had significantly shorter survival, at a median of 15 vs. 19 months (HR: 1.59, 95% CI: 1.07-2.37, p=0.023). However, for the subset of patients who underwent resection, survival was similar in the two groups (HR: 1.07, 95% CI: 0.66-1.73, p=0.773). CONCLUSIONS: A reduced time to surgery with avoidance of PBD offers survival benefit. This is only appreciated on ITT analysis, which includes patients who are initially considered candidates for surgery, but ultimately do not undergo surgery. Considering this 'hidden' cohort of patients is important when considering optimal pathways for the treatment of resectable pancreatic cancer.

Jejunojejunal Intussusception as the Initial Presentation of Non-Hodgkin's B-Cell Lymphoma in an Adult Patient: A Case Report and Review of the Literature.

Introduction. Intussusception is a rare cause of bowel obstruction in adults and is usually associated with an underlying pathology, benign, or malignant. This is a report of a case of jejunojejunal intussusception secondary to non-Hodgkin's B-cell lymphoma in an adult patient. Case Presentation. A 74-year-old male with no previous significant medical history presented with symptoms of acute intestinal obstruction. A CT scan of the abdomen and pelvis revealed 2 areas of jejunojejunal intussusception, which were surgically managed successfully. Histopathological examination of the specimen revealed the presence of high grade diffuse large B-cell-type non-Hodgkin's lymphoma, and the patient was referred to the oncology team for further management. Discussion. B-cell lymphoma is a rare but well-documented cause of intussusception in adults, with most cases being at the ileocolic region. We present a rare case of jejunojejunal intussusception as the initial presentation of non-Hodgkin's B-cell lymphoma in an adult patient.

Clinical significance of Src expression and activity in human neoplasia.

Src, a 60 kDa non-receptor tyrosine kinase, is the product of normal c-src of the human genome and member of the Src protein tyrosine kinases family (SFK). As described by Martin and Rous, a genetic recombination between c-src and the RSV oncogene of Rous sarcoma virus results in a modified Src protein, with increased intrinsic activity and transforming potential in animal and human tissues. Several in vitro and in vivo studies supported this theory providing insight in the signalling pathways involved. Accumulating evidence from studies on clinical samples supported the role of Src in the process of carcinogenesis and disease progression in several human malignancies. Some studies have further reinforced the significance of the kinase in malignacy by correlating its expression and/or activity with important clinicopathological parameters, such as tumour stage, histopathological grade, proliferative capacity and most importantly patient's survival. This review is a comprehensive report of the published evidence on the expression and clinical significance of Src in human malignancy, which constitutes the background of the current studies and clinical trials on the use of Src inhibitors as novel potent antineoplastic strategy.