Are the screening guidelines for branch duct intraductal papillary mucinous neoplasms cost-effective in an Australian setting?

BACKGROUNDS: Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreatic ductal system. These incidental cystic lesions are increasingly found on radiological imaging and screened for malignant transformation. The Fukuoka consensus guidelines recommend screening with computed tomography, magnetic resonance imaging or endoscopic ultrasound. Branch duct IPMN (BD-IPMN) have significantly lower malignancy and mortality rates compared to main duct IPMN. Our aim was to assess the cost-effectiveness of guideline's recommendations for BD-IPMN screening of cysts between 2 and 3 cm in an Australian context. METHODS: Markov model decision analysis was used to calculate the incremental cost-effectiveness ratio (ICER) of screening. The ICER was compared to a willingness to pay (WTP) threshold of $50 000. We performed scenario analysis to examine the effect of cyst size and non-linearity of malignancy rate on ICER. Probabilistic sensitivity analyses (PSA) were performed on our input parameters. RESULTS: Screening resulted in 586 quality adjusted life years gained and a net present value of $20 379 939, resulting in a base-case ICER of $34 758. After scenario analysis for non-linearity of malignancy rate the ICER increases to $64 555, which is above the WTP threshold. PSA indicates that ICER is most susceptible to the pre-test malignancy rate. CONCLUSION: This cost analysis demonstrates that screening of 2-3 cm BD-IPMN according to current guidelines is unlikely to be cost-effective in an Australian context. To determine the true ICER, a cost analysis on real-world data is required.

Acinar cystic transformation of the pancreas causing progressive main pancreatic duct dilation: a diagnostic dilemma.

Acinar cystic transformation (ACT) of the pancreas is a rare benign lesion. We describe a case of ACT with progressive main pancreatic duct dilation concerning for malignancy, not previously described. We discuss the difficulties associated with imaging and biopsy in differentiating this pathology from other cystic lesions, including intraductal mucinous papillary neoplasms.

Elective Laparoscopic Cholecystectomy as an Entrustable Professional Activity (EPA) for General Surgical Trainees in Australia.

INTRODUCTION: To evaluate the operation time and surgical outcomes of elective laparoscopic cholecystectomy performed by surgical trainees at different levels of training at Eastern health and hence, to establish the efficacy and safety of elective laparoscopic cholecystectomy as an Entrustable Professional Activity for surgical trainees in general surgery. OBJECTIVE: Elective laparoscopic cholecystectomies performed at our institution between January 2018 and January 2019 were included. Analyses were divided among three groups - consultants (C), fellows (F) and registrars (R). Standard technique with critical view of safety was used. RESULTS: A total of 592 patients was included, with a mean age of 54 ± 63 years old. The average operation time was 84 ± 51 minutes. Surgical education and training (SET) 2 trainees took significantly longer when compared to their SET3 and above counterparts as a primary operator (SET2: 131 ± 32 min, Reference; SET3: 78 ± 21 min, p = 0.003; SET4: 80 ± 33 min, p = 0.004; SET5: 77 ± 28 min, p = 0.003; F: 93 ± 77 min, p = 0.036; C: 85 ± 59 min; p = 0.007). Consultant primary operators took an average of 15 minutes longer to complete the operation when assisted by a SET trainee compared to the non-SET registrars (p = 0.03). The overall complication rate was 3.2% and was not significantly different among all three groups (p = 0.17). No death was recorded during the study period. The readmission and return to theatre rates were 7.8% and 0.8% respectively and were not significantly different among the groups (p-values = 0.61 and 0.69). All conversion to open were performed by the consultant primary operator. CONCLUSIONS: Elective laparoscopic cholecystectomy can be safely performed by surgical trainees at all SET levels when under appropriate supervision, although junior surgical trainees that is SET 2 took longer to complete the procedure. This operation seems to have a steep, but relatively short, learning curve and it may be broken down into various components. These components, with the addition of time, may be suitable as an Entrustable Professional Activity tool for assessing the competency of early SET trainees.

Effect of Roux-en-Y gastric bypass on Barrett's esophagus: a systematic review.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has been recommended as the bariatric procedure of choice for morbidly obese patients with Barrett's esophagus (BE). OBJECTIVES: To systematically review the effect of RYGB on BE. SETTING: University hospital, Melbourne, Australia. METHODS: A systematic review was performed. Studies were included of patients who had BE who underwent RYGB and had minimum 1 follow-up gastroscopy postoperatively. English language full-text articles were included, with case reports excluded. Endoscopic assessment methods of BE were compared to the American College of Gastroenterology (ACG) clinical guideline recommendations. A novel methodological quality assessment tool to assess risk of bias was developed. For each study, potential confounders for the effect of RYGB on BE were analyzed. RESULTS: Of 28 articles, 5 publications met inclusion criteria. Quality assessment did not demonstrate any high-quality publications. Of 63 patients, no cases showed progression of BE. Overall, regression rates of BE assessed at the postoperative endoscopy varied from 36%-62%. There was a lack of consensus between authors on definition of regression and short- versus long-segment BE. Eighty percent of patients with dysplasia had regression of dysplasia. Both studies that provided all required endoscopic information had poor compliance with ACG recommendations. Potential confounding factors for the effect of RYGB on BE included preoperative risk factors, selection bias based on length of BE, type of RYGB (resectional or nonresectional), concomitant hiatus hernia repair, postoperative use of proton pump inhibitor, and amount of weight loss. CONCLUSION: RYGB has been shown to be associated with regression of BE and dysplasia in some patients, with no cases of progression after short-term postoperative endoscopic assessment. A clearer definition of regression of BE and following ACG recommendations is necessary to allow standardized reporting and comparison of future results. Long-term, larger, multicenter high-quality studies, including assessment of all potential contributing factors for BE regression, are required.

Should bariatric surgery be offered for hepatocellular adenomas in obese patients?

BACKGROUND: Obesity and metabolic syndrome are increasingly recognized as risk factors for development of hepatocellular adenoma (HCA). The implications of weight loss on HCA regression has not been previously reviewed. OBJECTIVES: To analyze the effects of surgical and nonsurgical weight loss on HCA. SETTING: University Tertiary Hospital. METHODS: Literature review of full-text articles from PubMed and Scopus on patients with HCA who underwent surgical or nonsurgical weight loss was performed. Only English language articles were included and editorial comments were excluded. Wilcoxon signed rank test was used for paired data analysis. Spearman correlation was used for correlation between percent excess weight loss (%EWL) and number and size of HCA lesions. RESULTS: Out of 4 studies, 7 patients were included in this review, all of whom were female. The median preintervention body mass index was 41 kg/m2 compared with the postintervention body mass index of 28 kg/m2 (P = .002). The %EWL following intervention positively correlated to reduction in number of HCA lesions (%) postintervention, with a Spearman correlation of .78 (P = .04). Similarly, %EWL postintervention was positively correlated, though not statistically significant, to reduction in lesion size (%), with a Spearman correlation of .46 (P = .29). All patients who were candidates for liver resection preintervention based on lesion size > 5 cm avoided liver resection postintervention following surgical and nonsurgical weight loss. CONCLUSIONS: Effective long-term weight loss by surgical and nonsurgical methods result in regression of HCAs. Weight loss could avoid major liver resections or decrease the morbidity associated with liver surgery. Bariatric surgery should be considered as an option for management of surgically challenging HCAs in carefully selected obese patients. Multicenter long-term trials, while adjusting for cofounding factors, are required to determine the effects of surgical compared with nonsurgical weight loss on maintenance of HCA regression.

Use of indocyanine green fluorescence compared to radioisotope for sentinel lymph node biopsy in early-stage breast cancer: systematic review and meta-analysis.

BACKGROUND: In early-stage breast cancer, indocyanine green (ICG)-fluorescence based sentinel lymph node (SLN) detection is being considered. This is a meta-analysis of SLN detection rates and sensitivity of ICG-fluorescence compared to radioisotope (RI), to evaluate its clinical applicability. DATA SOURCES: Systematic review of full-text articles from PubMed and Scopus, of women with early breast cancer who underwent SLN mapping using ICG and RI concurrently was performed. The meta-analysis was performed using the Mantel-Haenszel method. RESULTS: 2301 patients from 19 studies were included. No significant difference was observed between ICG and RI for SLN detection (OR0.90,95%CI0.66-1.24) or sensitivity (OR1.23,95%CI0.73-2.05) with heterogeneity between studies (I2 = 58%,P = 0.003). Sensitivity of dual mapping (ICG + RI) was significantly better compared to single mapping with RI (OR3.69,95%CI1.79-7.62) or ICG (OR3.32,95%CI1.52-7.24) alone with no heterogeneity between studies (I2 = 0%,P = 0.004). CONCLUSION: ICG-fluorescence could complement RI method or provide alternative in centers with poor accessibility to RI lymphoscintigraphy.

Predicting conversion from laparoscopic to open cholecystectomy presented as a probability nomogram based on preoperative patient risk factors.

BACKGROUND: We aim to develop a risk stratification tool to preoperatively predict conversion (CONV) from a laparoscopic to open cholecystectomy. METHODS: Multiple risk factors were analyzed with multivariate logistic regression and presented as probability nomograms. RESULTS: Of 732 patients, 47 (6.4%) required CONV. Among 40 preoperative risk factors evaluated, 5 variables were found to have significant association with CONV: 2 clinical variables, previous upper abdominal surgery (odds ratio [OR] 95.2) and obesity defined as body mass index greater than 30 kg/m(2) (OR 12.3), and 3 ultrasound parameters, visible choledocholithiasis (OR 19.8), impacted stone at the neck of the gallbladder (OR 5.9), and gallbladder wall width in millimeters (OR 2.1). Nomograms based on this multivariate model demonstrate the individual preoperative probability of CONV. Internal validation using receiver operator curve analysis showed an area under the curve of .97. CONCLUSION: Four probability nomograms were developed as a practical individual risk stratification tool to predict probability of CONV.

Brain tumour-associated status epilepticus.

We have reviewed the scant literature on status epilepticus in patients with brain tumours. Patients with brain tumour-associated epilepsy (TAE) appear less likely to develop status epilepticus (TASE) than patients with epilepsy in the general population (EGP) are to develop status epilepticus (SEGP). TASE is associated with lesions in similar locations as TAE; in particular, the frontal lobes. However, in contrast to TAE, where seizures commence early in the course of the disease or at presentation, TASE is more likely to occur later in the disease course and herald tumour progression. In marked contrast to TAE, where epilepsy risk is inversely proportional to Word Health Organization tumour grade, TASE risk appears to be directly proportional to tumour grade (high grade gliomas appear singularly predisposed). Whilst anti-epileptic drug (AED) resistance is more common in TAE than EGP (with resistance directly proportional to tumour grade and frontal location), TASE appears paradoxically more responsive to simple AED regimes than either TAE or SEGP. Although some results suggest that mortality may be higher with TASE than with SEGP, it is likely that (as with SEGP) the major determinant of mortality is the underlying disease process. Because all such data have been derived from retrospective studies, because TASE and SEGP are less common than TAE and EGP, and because TASE and SEGP classification has often been inconsistent, findings can only be considered preliminary: multi-centre, prospective studies are required. Whilst preliminary, our review suggests that TASE has a distinct clinical profile compared to TAE and SEGP.