Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital.

BACKGROUND: We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle. METHODS: This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype. RESULTS: The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries. CONCLUSION: Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.

Defining Standards for Hepatopancreatobiliary Cancer Surgery in Ontario, Canada: A Population-Based Cohort Study of Clinical Outcomes.

BACKGROUND: In 2006, Cancer Care Ontario created Surgical Oncology Standards for the delivery of hepatopancreatobiliary (HPB) surgery including hepatectomy and pancreaticoduodenectomy (PD). Our objective was to identify the impact of standardization on outcomes after HPB surgery in Ontario, Canada. STUDY DESIGN: This study was a population-level analysis of patients undergoing hepatectomy or PD (2003 to 2019). Logistic regression models were used to compare 30- and 90-day mortality and length of stay (LOS) before (2003 to 2006), during (2007 to 2011), and after (2012 to 2019) standardization. Interrupted time series models were used to co-analyze secular trends. RESULTS: A total of 7,904 hepatectomies and 5,238 PDs were performed. More than 80% of all cases were performed at a designated center (DC) before standardization. This increased to >98% in the poststandardization era. Median volumes at DCs increased from 55 to 67 hepatectomies/year and from 22 to 50 PDs/year over time. In addition, 30-day mortality after hepatectomy was 2.6% before standardization and 2.3% after standardization (p = 0.9); 30-day mortality after PD was 3.6% before standardization and 2.4% after standardization (p = 0.1). Multivariable analyses revealed a significant difference in 90-day mortality following PD poststandardization (4.3% vs 6.3%; adjusted odds ratio, 0.7; p = 0.03). Median LOS was shorter for hepatectomy (6 days vs 8 days) and PD (9 days vs 14 days; p < 0.0001) after standardization. Immediate and late effects on mortality and LOS were likely attributable to secular trends, which predated standardization. CONCLUSIONS: Standardization was associated with a higher volume of hepatectomy and PDs with further concentration of care at DCs. Pre-existing quality initiatives may have attenuated the effect of standardization on quality outcomes. Our data highlight the merits of a multifaceted provincial system for enabling consistent access to high quality HPB care throughout a region of 15 million people over a 16-year period.

Closed incision negative pressure wound therapy following pancreaticoduodenectomy for prevention of surgical site infections in high-risk patients.

BACKGROUND: Surgical site infection (SSI) is one of the most common sources of morbidity after pancreaticoduodenectomy. Surgical site infections are associated with readmissions, prolonged length of stay, delayed initiation of adjuvant chemotherapy and negative effects on quality of life. Incisional vacuum-assisted closure (iVAC) devices applied on closed incisions may reduce SSI rates. The objective of this retrospective review is to evaluate the impact of iVAC on SSI rate after pancreaticoduodenectomy. METHODS: A cohort of patients undergoing pancreaticoduodenectomy at a single institution who had at least 1 risk factor for SSI and who received an iVAC were compared with a historical cohort of high-risk patients who received conventional dressings after pancreaticoduodenectomy. The primary outcome was incidence of SSI within 30 days, abstracted from chart review. Secondary outcomes were 30-day readmission, 90-day mortality, rate of postoperative pancreatic fistula and rate of delayed gastric emptying. RESULTS: In total, 175 patients were included, of whom 61 received an iVAC. The incidence of SSI was 13% (8 of 61 patients) and 16% (18 of 114 patients) in the iVAC and conventional dressing groups, respectively (odds ratio 0.81, 95% confidence interval 0.33-1.98). Preoperative biliary drainage was the most frequent SSI risk factor. Binary logistic regression using SSI as the outcome demonstrated no significant association with iVAC use when adjusted for SSI risk factors. There were no differences in rates of postoperative pancreatic fistula, delayed gastric emptying or 90-day mortality. CONCLUSION: This report describes the outcomes of the integration of iVAC devices into routine clinical practice at a high-volume institution. Application of this device after pancreaticoduodenectomy for patients at elevated risk of SSI was not associated with a reduction in the rate of SSIs.

Use of artificial intelligence for decision-support to avoid high-risk behaviors during laparoscopic cholecystectomy.

INTRODUCTION: Bile duct injuries (BDIs) are a significant source of morbidity among patients undergoing laparoscopic cholecystectomy (LC). GoNoGoNet is an artificial intelligence (AI) algorithm that has been developed and validated to identify safe ("Go") and dangerous ("No-Go") zones of dissection during LC, with the potential to prevent BDIs through real-time intraoperative decision-support. This study evaluates GoNoGoNet's ability to predict Go/No-Go zones during LCs with BDIs. METHODS AND PROCEDURES: Eleven LC videos with BDI (BDI group) were annotated by GoNoGoNet. All tool-tissue interactions, including the one that caused the BDI, were characterized in relation to the algorithm's predicted location of Go/No-Go zones. These were compared to another 11 LC videos with cholecystitis (control group) deemed to represent "safe cholecystectomy" by experts. The probability threshold of GoNoGoNet annotations were then modulated to determine its relationship to Go/No-Go predictions. Data is shown as % difference [99% confidence interval]. RESULTS: Compared to control, the BDI group showed significantly greater proportion of sharp dissection (+ 23.5% [20.0-27.0]), blunt dissection (+ 32.1% [27.2-37.0]), and total interactions (+ 33.6% [31.0-36.2]) outside of the Go zone. Among injury-causing interactions, 4 (36%) were in the No-Go zone, 2 (18%) were in the Go zone, and 5 (45%) were outside both zones, after maximizing the probability threshold of the Go algorithm. CONCLUSION: AI has potential to detect unsafe dissection and prevent BDIs through real-time intraoperative decision-support. More work is needed to determine how to optimize integration of this technology into the operating room workflow and adoption by end-users.

Comparing the Warshaw technique with vessel-preservation in laparoscopic spleen preserving distal pancreatectomy: is there a better approach?

BACKGROUND: Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection of the splenic vessels via the Warshaw Technique (WT) or via preservation of the splenic vessels (SVP). Our study aims to compare outcomes for the two methods of LSPDP. METHODS: We performed a retrospective chart review with intent-to-treat analysis of adults undergoing LSPDP at a single institution from 2009 to 2021. We compared demographic characteristics, operative parameters, oncologic pathology review, and postoperative outcomes. RESULTS: There were 102 consecutive cases of LSPDP (59 WT, 43 SVP) over 12 years. The rate of successful spleen preservation was not significantly different between the two groups (76.3%WT, 65.1%VSP,p = 0.27). Rates of conversion to laparotomy, postoperative complications including pancreatic fistulas and splenic infarcts and amount of intraoperative blood loss were similar between the groups. Median operative time was significantly shorter with the WT (141 vs. 177 min, p < 0.05). The median length of stay in hospital was not significantly different among the groups. CONCLUSION: Both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique may be more efficient with respect to the use of limited operative resources.

Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial.

OBJECTIVE: To determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer. DESIGN: Multicentre, open label, randomised controlled trial. SETTINGS: 12 hospitals in Quebec and Ontario, Canada, between 25 October 2011 and 31 December 2020. PARTICIPANTS: 614 adults (age ≥18 years) were eligible with pathologically confirmed invasive adenocarcinoma of the colon or rectum, no evidence of metastatic disease, a haemoglobin concentration of ≥8 g/dL, and were scheduled to undergo surgical resection. INTERVENTIONS: Random assignment to extended duration thromboprophylaxis using daily subcutaneous tinzaparin at 4500 IU, beginning at decision to operate and continuing for 56 days postoperatively, compared with in-patient postoperative thromboprophylaxis only. MAIN OUTCOME MEASURES: Primary outcome was disease-free survival at three years, defined as survival without locoregional recurrence, distant metastases, second primary (same cancer), second primary (other cancer), or death. Secondary outcomes included venous thromboembolism, postoperative major bleeding complications, and five year overall survival. Analyses were done in the intention-to-treat population. RESULTS: The trial stopped recruitment prematurely after the interim analysis for futility. The primary outcome occurred in 235 (77%) of 307 patients in the extended duration group and in 243 (79%) of 307 patients in the in-hospital thromboprophylaxis group (hazard ratio 1.1, 95% confidence interval 0.90 to 1.33; P=0.4). Postoperative venous thromboembolism occurred in five patients (2%) in the extended duration group and in four patients (1%) in the in-hospital thromboprophylaxis group (P=0.8). Major surgery related bleeding in the first postoperative week was reported in one person (<1%) in the extended duration and in six people (2%) in the in-hospital thromboprophylaxis group (P=0.1). No difference was noted for overall survival at five years in 272 (89%) patients in the extended duration group and 280 (91%) patients in the in-hospital thromboprophylaxis group (hazard ratio 1.12; 95% confidence interval 0.72 to 1.76; P=0.1). CONCLUSIONS: Extended duration to perioperative anticoagulation with tinzaparin did not improve disease-free survival or overall survival in patients with colorectal cancer undergoing surgical resection compared with in-patient postoperative thromboprophylaxis alone. The incidences of venous thromboembolism and postoperative major bleeding were low and similar between groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT01455831.

Thinking Your Way Through a Difficult Laparoscopic Cholecystectomy: Technique for High-Quality Subtotal Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is a bailout strategy to prevent bile duct injury in difficult gallbladder cases. It is associated with acceptable morbidity that is readily managed with postoperative interventions. Here we share our techniques for LSC. We begin with landmarking, which includes the line of safety, a theoretical line the sulcus of Rouvière and the junction of the cystic and hilar plates. If the fundus can be grasped, then the gallbladder is dissected off the cystic plate using the top-around approach. The gallbladder is then amputated, creating a short cuff of proximal gallbladder. This cuff can be left patent (2A) or cinched close with an ENDOLOOP (Ethicon) if it is small, ideally less than 1 cm (1A). If the fundus cannot be grasped, then an inverted T incision is made on the anterior gallbladder wall. The longitudinal incision is extended toward the fundus, and the transverse incision is extended superiorly along the cystic plate edge. Two "bunny ears" are developed and ultimately resected to excise the anterior gallbladder wall at an oblique angle while leaving the posterior wall intact (2B). If the remaining cuff is small, then it can be sutured closed against the gallbladder back wall (1B). In the setting of extensive bowel adhesion to the anterior gallbladder, we perform a fundectomy, from which we extend two incisions along the cystic plate to open the gallbladder like a clamshell. Our paper describes and illustrates our St Joseph's Health Centre institutional LSC approach and subtype classification (1A, 1B, 2A, and 2B).

Administrative codes may have limited utility in diagnosing biliary colic in emergency department visits: A validation study.

Backgrounds/Aims: Biliary colic is a common cause of emergency department (ED) visits; however, the natural history of the disease and thus the indications for urgent or scheduled surgery remain unclear. Limitations of previous attempts to elucidate this natural history at a population level are based on the reliance on the identification of biliary colic via administrative codes in isolation. The purpose of our study was to validate the use of International Statistical Classification of Diseases and Related Health Problems codes, 10th Revision, Canadian modification (ICD-10-CA) from ED visits in adequately differentiating patients with biliary colic from those with other biliary diagnoses such as cholecystitis or common bile duct stones. Methods: We performed a retrospective validation study using administrative data from two large academic hospitals in Toronto. We assessed all the patients presenting to the ED between January 1, 2012 and December 31, 2018, assigned ICD-10-CA codes in keeping with uncomplicated biliary colic. The codes were compared to the individually abstracted charts to assess diagnostic agreement. Results: Among the 991 patient charts abstracted, 26.5% were misclassified, corresponding to a positive predictive value of 73% (95% confidence interval 73%-74%). The most frequent reasons for inaccurate diagnoses were a lack of gallstones (49.8%) and acute cholecystitis (27.8%). Conclusions: Our findings suggest that the use of ICD-10 codes as the sole means of identifying biliary colic to the exclusion of other biliary pathologies is prone to moderate inaccuracy. Previous investigations of biliary colic utilizing administrative codes for diagnosis may therefore be prone to unforeseen bias.

Chronic Liver Disease and Liver Cancer: What the Hepatologists, Oncologists, and Surgeons Want to Know from Radiologists.

Effective communication between radiologists and physicians involved in the management of patients with chronic liver disease is paramount to ensuring appropriate and advantageous incorporation of liver imaging findings into patient care. This review discusses the clinical benefits of innovations in radiology reporting, what information the various stakeholders wish to know from the radiologist, and how radiology can help to ensure the effective communication of findings.

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury.

BACKGROUND: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program. STUDY DESIGN: Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. RESULTS: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences. CONCLUSIONS: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

The inferior boundary of dissection as a novel landmark for safe laparoscopic cholecystectomy.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy over 30 years ago, rates of bile duct injury have remained elevated compared to the era of open cholecystectomy. We propose an anatomical landmark, the Inferior Boundary of Dissection, to help prevent dangerous dissection in the porta hepatis and provide clues as to when a critical view of safety may not be immediately achieved. METHODS: This landmarking approach is based on fundamentals of biliary anatomy and surface landmarks of the liver. RESULTS: The 'Boundary' extends from Rouviere's sulcus to the junction of the peritoneum and fat overlying the cystic and hilar plates, near the base of segment 4. This anatomic landmark represents the lower boundary for safe dissection, by outlining the location of the biliary pedicles. CONCLUSION: The two points of reference are reliable surface landmarks with predictable and consistent relationships to the biliary pedicles. It also serves as a line above which the gallbladder can be opened or mobilized in a 'top-around' approach, facilitating subtotal cholecystectomy when the hepatocystic triangle appears hostile due to inflammation. The landmark has been well-received in our region as a facile instrument for safe cholecystectomy and we advocate for its broader use.

A proposal for the ideal algorithm for the diagnosis, staging, and treatment of pancreas masses suspicious for pancreatic adenocarcinoma: Results of a working group of the Canadian Society for Endoscopic Ultrasound.

Numerous clinical pathways exist for patients presenting with a suspicious pancreatic mass. These range from direct surgical intervention following staging, with preoperative cross-sectional imaging, EUS with or without fine-needle aspiration or fine-needle core biopsy; neoadjuvant chemotherapy and/or radiation therapy; or palliation. Although international guidelines exist for pancreas cancer management, the ideal workup and treatment for a suspicious pancreas mass is unclear. During its annual meeting in September 2017 (The Forum for Canadian Endoscopic Ultrasonography), the Canadian Society of Endoscopic Ultrasound organized a working group of experienced endosonographers and hepatobiliary surgeons from across Canada to achieve this goal.

Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder

Background: Laparoscopic subtotal cholecystectomy (LSC) can be employed when extensive fibrosis or inflammation of the cystohepatic triangle prohibits safe dissection of the cystic duct and artery. The purpose of this study was to compare postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy (LC) or LSC. Methods: In this retrospective study, we compared the postoperative outcomes of patients with severe cholecystitis who underwent LC or LSC between July 2010 and July 2016 at St. Joseph's Health Centre, Toronto. We further stratified LSC cases on the basis of the extent of gallbladder (GB) dissection and GB remnant closure. Results: A total of 105 patients who underwent LC and 46 who underwent LSC were included in the study. There were 4 bile duct injuries in the LC group and 0 in the LSC group. Bile leaks (relative risk [RR] 3.4, 95% confidence interval [CI] 1.01­11.5) and subphrenic collections (RR 3.1, 95% CI 1.3­8.0) were more common in the LSC group. Overall postoperative morbidity did not differ significantly between the 2 groups. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) (RR 3.2, 95% CI 1.1­9.5) and biliary stent insertion (RR 4.6, 95% CI 1.2­17.5) were more common in the LSC group. Bile leaks appeared to be more prominent with open GB remnants but all cases of leak were successfully managed with ERCP and biliary stenting. Conclusion: LSC may mitigate the risk of bile duct injury when dissection into the cystohepatic triangle is unsafe. There were more bile leaks in patients who underwent LSC; however, they were readily managed with endoscopic stents. Long-term biliary fistulae were not observed. LSC should be considered early as a means of completing difficult cholecystectomies safely without the need for cholecystostomy tube or conversion to laparotomy.

Contexte: La cholécystectomie laparoscopique subtotale (CLS) peut être utilisée si une fibrose ou une inflammation étendue du triangle cystohépatique empêche l'ablation sécuritaire du canal et de l'artère cystiques. Cette étude avait pour but de comparer les résultats postopératoires chez des patients atteints de cholécystite grave ayant subi une cholécystectomie laparoscopique (CL) ou une CLS. Méthodes: Dans cette étude rétrospective, nous avons comparé les résultats postopératoires des patients atteints de cholécystite grave ayant subi une CL ou une CSL entre juillet 2010 et juillet 2016 au St. Joseph's Health Centre de Toronto. Nous avons ensuite stratifié les cas de CSL selon la proportion de la vésicule biliaire excisée et la suture du reliquat. Résultats: En tout, 105 patients ayant subi une CL et 46 une CLS ont été inclus dans l'étude. On a dénombré 4 lésions du canal cholédoque dans le groupe CL et 0 dans le groupe CLS. Les fuites biliaires (risque relatif [RR] 3,4, intervalle de confiance [IC] de 95 % 1,01­ 11,5) et les collections sous-diaphragmatiques (RR 3,1, IC de 95 % 1,3­8,0) ont été plus fréquentes dans le groupe CSL. Globalement, la morbidité postopératoire n'a pas été significativement différente entre les 2 groupes. La cholangiopancréatographie rétrograde endoscopique (CPRE) postopératoire (RR 3,2, IC de 95 % 1,1­9,5) et la pose d'une endoprothèse biliaire (RR 4,6, IC de 95 % 1,2­17,5) ont été plus fréquentes dans le groupe CLS. Les fuites biliaires ont semblé plus marquées en l'absence de suture des reliquats, mais tous les cas de fuite ont été traités avec succès par CPRE et endoprothèse biliaire. Conclusion: La CLS pourrait atténuer le risque de lésion du canal cholédoque lorsqu'il est contre-indiqué d'intervenir au niveau du triangle cystohépatique. On a observé plus de fuites biliaires chez les patients soumis à la CLS; par contre, ces fuites ont rapidement été corrigées à l'aide d'endoprothèses. Aucune fistule biliaire n'a été observée à long terme. La CLS devrait être envisagé sans tarder pour finaliser sécuritairement les cholécystectomies compliquées sans recourir au drain de cholécystostomie ou à conversion en laparotomie.

Laparoscopic colectomy: trends in implementation in Canada and globally

Summary: Comparisons with other high-income countries suggest that Canada has been slower to adopt laparoscopic colectomy (LC). The Canadian Association of General Surgeons sought to evaluate the barriers to adoption of laparoscopic colon surgery and to propose potential intervention strategies to enhance the use of the procedure. Given the clinical benefits of laparoscopic surgery for patients, the increasing needs for surgical care and the desire of Canadian general surgeons to advance their specialty and enhance the care of their patients, it is an important priority to improve the utilization of LC.

Critical appraisal of predictive tools to assess the difficulty of laparoscopic liver resection: a systematic review.

BACKGROUND: Objective assessment of the difficulty of laparoscopic liver resection (LLR) preoperatively is key in improving its uptake. Difficulty scores are proposed but are not used routinely in practice. We identified and appraised predictive models to estimate LLR difficulty. METHODS: We systematically searched the literature for tools predicting LLR difficulty. Two independent reviewers selected studies, abstracted data and assessed methodology. We evaluated tools' quality and clinical relevance using the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) guidelines. RESULTS: From 1037 citations, we included 8 studies reporting on 4 predictive tools using data from 1995 to 2016 in Asia and Europe. In 4 development studies, tools were designed to predict difficulty as assigned by experts using a 10-level difficulty index, operative time, post-operative morbidity or intra-operative complications. Internal validation and performance metrics were reported in one development study. One tool was subjected to external validations in 4 studies (1 independent and geographic). Validations compared post-operative outcomes (operative time, blood loss, transfusion, major morbidity and conversion) between the risk categories. One study validated discrimination (AUROC 0.53). Calibration was not assessed. CONCLUSION: Existing tools cannot be used confidently to predict LLR difficulty. Consistent objective clinical outcomes to predict to define LLR difficulty should be established, and better-quality tools developed and validated in a wide array of populations and clinical settings, following best practices for predictive tools development and validation. This will improve risk stratification for future trials and uptake of LLR.

Patient blood management for liver resection: consensus statements using Delphi methodology.

BACKGROUND: Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS: An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS: The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS: PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

Synchronous colorectal liver metastases: a national survey of surgeon opinions on simultaneous resection and multidisciplinary cooperation.

BACKGROUND: The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We sought to better understand surgeon viewpoints on optimal referral patterns and the delivery of simultaneous resections. METHODS: A 40 question on-line survey was offered to members of the Canadian surgical community. Statistical analysis was descriptive. RESULTS: A total of 52 surgeons responded. Most colorectal surgeons (CRS) had access to and a good working relationship with regional hepatobiliary (HPB) surgeons (86%) and medical oncologists (100%). The majority (92%) believed there was a role for simultaneous resection of sCRLM, with 69% having first hand experience. Many CRS (62%) discussed all cases of known hepatic metastases with HPB prior to any resection. When a lesion was asymptomatic/minimally symptomatic, most CRS (92%) discussed them with medical oncology/HPB prior to resection (8%). Bilobar metastases (58%), patient comorbidities (35%), portal lymphadenopathy (35%), and patient age (15%) restricted CRS from obtaining HPB consultations. Many CRS (46%) did not believe that resecting hepatic metastases prior to the primary lesion might be beneficial. Most CRS (60%) reported they could not accurately predict hepatic resectability, with only 27% familiarity with evidence-based guidelines. Despite working in smaller hospitals with less access to HPB and less experience with simultaneous resections, non-CR general surgeons more commonly supported a 'liver-first' approach. CONCLUSIONS: There was general agreement between CRS and general surgeons on numerous topics, but additional education is required with regard to HPB surgical capabilities and to provide truly individualized patient-centered care.