Post-hepatectomy liver failure: A timeline centered review.

BACKGROUND: Post-hepatectomy liver failure (PHLF) is a leading cause of postoperative mortality after liver surgery. Due to its significant impact, it is imperative to understand the risk stratification and preventative strategies for PHLF. The main objective of this review is to highlight the role of these strategies in a timeline centered way around curative resection. DATA SOURCES: This review includes studies on both humans and animals, where they addressed PHLF. A literature search was conducted across the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Knowledge electronic databases for English language studies published between July 1997 and June 2020. Studies presented in other languages were equally considered. The quality of included publications was assessed using Downs and Black's checklist. The results were presented in qualitative summaries owing to the lack of studies qualifying for quantitative analysis. RESULTS: This systematic review with 245 studies, provides insight into the current prediction, prevention, diagnosis, and management options for PHLF. This review highlighted that liver volume manipulation is the most frequently studied preventive measure against PHLF in clinical practice, with modest improvement in the treatment strategies over the past decade. CONCLUSIONS: Remnant liver volume manipulation is the most consistent preventive measure against PHLF.

The dilemma of the disappearing colorectal liver metastases: defining international trends in management.

OBJECTIVE: This survey sought to appraise the degree of consistency in the management of disappeared colorectal liver metastases (dCRLM) among liver surgeons in different countries. BACKGROUND: Colorectal liver metastases (CRLM) account for half of the deaths secondary to colorectal cancer. Due to the high utilization of chemotherapy before surgery, some or all CRLM can disappear (dCRLM) but management of dCRLMs remains unclear. METHODS: Seven simulated scenarios of dCRLM were presented to experienced liver surgeons using an online platform. Treatment decisions were submitted and analysed using the multi-rater kappa method. The effect of the experience, complexity of scenarios, and location and number of dCRLM on treatment decision were analysed. RESULTS: Sixty-seven liver surgeons from 25 countries completed the survey. There was no agreement about the therapeutic strategies of dCRLM in all scenarios (kappa 0.12, IQR 0.20-0.32). In scenarios with lower difficulty scores, surgeons tended to offer surgical resection for dCRLM alongside the visible CRLM (vCRLM), however, with poor agreement (kappa 0.32, IQR 0.19-0.51). No agreement was seen for clinical scenario in which all CRLM lesions disappeared (kappa 0.20). CONCLUSION: There are clear inconsistencies in the management decisions of dCRLM. Better evidence is required to define optimal management strategies.

Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis.

BACKGROUND: Compare outcomes of early laparoscopic cholecystectomy (ELC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC). METHODS: English-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay. RESULTS: Out of 1347 records, 14 studies were included. 205,361 (94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Mortality was higher in PTGBD; HR, 95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs PTGBD group (8.7%) in patients admitted to ICU; P-value = 0.011. Patients who had ELC were at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99]. CONCLUSION: ELC may be a preferred treatment option over PTGBD in AC. However, patient and disease specific factors should be considered to avoid unfavourable outcomes with ELC.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary.

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

The effect of divided attention on novices and experts in laparoscopic task performance.

BACKGROUND: Attention is important for the skilful execution of surgery. The surgeon's attention during surgery is divided between surgery and outside distractions. The effect of this divided attention has not been well studied previously. We aimed to compare the effect of dividing attention of novices and experts on a laparoscopic task performance. METHODS: Following ethical approval, 25 novices and 9 expert surgeons performed a standardised peg transfer task in a laboratory setup under three randomly assigned conditions: silent as control condition and two standardised auditory distracting tasks requiring response (easy and difficult) as study conditions. Human reliability assessment was used for surgical task analysis. Primary outcome measures were correct auditory responses, task time, number of surgical errors and instrument movements. Secondary outcome measures included error rate, error probability and hand specific differences. Non-parametric statistics were used for data analysis. RESULTS: 21109 movements and 9036 total errors were analysed. Novices had increased mean task completion time (seconds) (171 ± 44SD vs. 149 ± 34, p < 0.05), number of total movements (227 ± 27 vs. 213 ± 26, p < 0.05) and number of errors (127 ± 51 vs. 96 ± 28, p < 0.05) during difficult study conditions compared to control. The correct responses to auditory stimuli were less frequent in experts (68 %) compared to novices (80 %). There was a positive correlation between error rate and error probability in novices (r (2) = 0.533, p < 0.05) but not in experts (r (2) = 0.346, p > 0.05). CONCLUSION: Divided attention conditions in theatre environment require careful consideration during surgical training as the junior surgeons are less able to focus their attention during these conditions.

Management of Splanchnic Vein Thrombosis in Patients With Acute Pancreatitis: An International Survey of Current Practice.

OBJECTIVES: Splanchnic venous thrombosis (SpVT) is a complication of acute pancreatitis (AP). There is scarce literature on the prevalence and treatment of SpVT in AP. The aim of this international survey was to document current approaches to the management of SpVT in patients with AP. METHODS: An online survey was designed by a group of international experts in the management of AP. Twenty-eight questions covered the level of experience of the respondents, disease demographics, and management of SpVT. RESULTS: There were 224 respondents from 25 countries. Most respondents (92.4%, n = 207) were from tertiary hospitals and predominantly consultants (attendings, 86.6%, n = 194). More than half of the respondents (57.2%, n = 106) "routinely" prescribed prophylactic anticoagulation for AP. Less than half of the respondents (44.3%, n = 82) "routinely" prescribed therapeutic anticoagulation for SpVT. A clinical trial was considered justified by most respondents (85.4%, n = 157) and 73.2% (n = 134) would be willing to enroll their patients. CONCLUSIONS: The approach to anticoagulation in the treatment of patients with SpVT complicating AP was highly variable. Respondents indicate that a position of equipoise exists to justify randomized evaluation.

Management of pancreaticojejunal strictures after pancreaticoduodenectomy: clinical experience and review of literature.

BACKGROUND: Symptomatic pancreaticojejunal anastomotic stricture (PJS) is a rare complication following pancreaticoduodenectomy. The incidence, presentation and management of this condition are infrequently reported in the literature. Revision surgery is thought to be an effective treatment. Recent literature shows some success from endoscopic management. METHODS: The patients treated for symptomatic PJS from January 2005 to June 2014 were identified. Their clinical presentation and management was retrospectively reviewed. Patients were followed up in clinic or by telephonic interviews to assess their symptoms. RESULTS: Three patients (two females and one male) had symptomatic PJS out of 314 who underwent pancreaticoduodenectomy (0.9%). Main presentating symptom was intermittent abdominal pain. The diagnosis was confirmed by computed tomography scan and/or magnetic resonance cholangiopancreatography. One patient underwent a failed endoscopic retrograde cholangiopancreatography attempt to dilate the stricture. A redo-pancreaticojejunostomy was performed in all patients. At a mean follow-up of 8 months, two patients had complete resolution of symptoms and one patient had partial benefit. Five out of seven case series in literature support surgical management. CONCLUSION: Symptomatic PJS can be successfully treated with redo-pancreaticojejunostomy, with good medium-term outcomes. Although endoscopic intervention has been described, review of the literature shows that success rates are low and the long-term results are unknown.