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Hepatic resection offers a chance of a cure in selected patients with colorectal liver metastases ( CLM). To achieve adequate patient selection and curative surgery, (i) precise assessment of the extent of disease, (ii) sensitive criteria for chemotherapy effect, (iii) adequate decision making in surgical indication and (iv) an optimal surgical approach for pre-treated tumours are required. For assessment of the extent of the disease, contrast-enhanced computed tomography ( CT) and/or magnetic resonance imaging ( MRI) with gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid ( Gd- EOB-DTPA) is recommended depending on the local expertise and availability. Positron emission tomography ( PET) and PET/ CT may offer additive information in detecting extrahepatic disease. The RECIST criteria are a reasonable method to evaluate the effect of chemotherapy. However, they are imperfect in predicting a pathological response in the era of modern systemic therapy with biological agents. The assessment of radiographical morphological changes is a better surrogate of the pathological response and survival especially in the patients treated with bevacizumab. Resectability of CLM is dependent on both anatomic and oncological factors. To decrease the surgical risk, a sufficient volume of liver remnant with adequate blood perfusion and biliary drainage is required according to the degree of histopathological injury of the underlying liver. Portal vein embolization is sometimes required to decrease the surgical risk in a patient with small future liver remnant volume. As a complete radiological response does not signify a complete pathological response, liver resection should include all the site of a tumour detected prior to systemic treatment. [ABSTRACT FROM AUTHOR]

The article discusses the factors to consider when contemplating surgery to treat hepatic lesions. It emphasizes the importance for surgeons to have an understanding of the segmental and vascular anatomy of the liver. The diagnosis and treatment of cystic liver disease is tackled. It cites that the applicable diagnostic procedures for hepatic lesions include ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI).

Background: The objective of this research was to develop a digital system to archive the complete operative environment along with the assessment tools for analysis of this data, allowing prospective studies of operative performance, intraoperative errors, team performance, and communication. Ability to study this environment will yield new insights, allowing design of systems to avoid preventable errors that contribute to perioperative complications. Study design: A multitrack, synchronized, digital audio-visual recording system (RATE tool) was developed to monitor intraoperative performance, including software to synchronize data and allow assignment of independent observational scores. Cases were scored for technical performance, participants’ situational awareness (knowledge of critical information), and their comfort and satisfaction with the conduct of the procedure. Results: Laparoscopic cholecystectomy (n = 10) was studied. Technical performance of the RATE tool was excellent. The RATE tool allowed real time, multitrack data collection of all aspects of the operative environment, while permitting digital recording of the objective assessment data in a time synchronized and annotated fashion during the procedure. The mean technical performance score was 73% ± 28% of maximum (perfect) performance. Situational awareness varied widely among team members, with the attending surgeon typically the only team member having comprehensive knowledge of critical case information. Conclusions: The RATE tool allows prospective analysis of performance measures such as technical judgments, team performance, and communication patterns, offers the opportunity to conduct prospective intraoperative studies of human performance, and allows for postoperative discussion, review, and teaching. This study also suggests that gaps in situational awareness might be an underappreciated source of operative adverse events. Future uses of this system will aid teaching, failure or adverse event analysis, and intervention research. [Copyright &y& Elsevier]

Focal adhesion kinase (FAK) has been implicated in the regulation of cell migration. In addition, FAK expression is increased in a number of highly metastatic tumor cell lines. Therefore, we investigated the role of FAK in regulating migration of prostate carcinoma cell lines with increasing metastatic potential. We show that highly tumorigenic PC3 and DU145 cells exhibit intrinsic migratory capacity, while poorly tumorigenic LNCaP cells require a stimulus to migrate. Increased metastatic potential of PC3 and DU145 cells correlates with increased FAK expression, overall tyrosine phosphorylation and activity, as measured by autophosphorylation of tyrosine 397. However, in PC3 and DU145 cells, FAK autophosphorylation is adhesion dependent whereas a second site of tyrosine phosphorylation, tyrosine 861, a Src specific site, is uncoupled from adhesion-dependent signaling events. Finally, inhibiting the FAK/Src signal transduction pathway by over expressing FRNK (Focal adhesion kinase-Related Non-Kinase), an inhibitor of FAK activation, or treatment with PP2, a Src family kinase inhibitor, significantly inhibited migration of prostate carcinoma cell lines, demonstrating that tumor cell migration continues to be dependent on signals emanating from this pathway. Oncogene (2001) 20, 1152–1163. [ABSTRACT FROM AUTHOR]

Examines the effects of both the addition of Candida albicans to a peritonitis and abscess formation due to Escherichia coli and Bacteroides fragilis, and the deletion of various components of this system using directed antimicrobial therapy. Mortality in mixed infection; Recovery of abscesses when C. albicans is added to the bacterial inoculum.

Efficacy of single-shot opioid spinal analgesia after pancreatoduodenectomy remains understudied and lacks comparison to standard continuous thoracic epidural analgesia (TEA). Pancreatoduodenectomy patients who underwent TEA or opioid spinal for postoperative pain management from 2015 to 2020 were included in this observational cohort study. Primary outcome was patient-reported mean daily pain scores. Secondary outcomes included postoperative morphine milligram equivalents (MMEs) and length of stay (LOS). Multivariable linear regression models were constructed to compare risk-adjusted outcomes. 180 patients were included: 56 TEA and 124 opioid spinal. Compared to epidural patients, opioid spinal patients were more likely to be older (67.0 vs. 64.6, p=0.045), have greater BMI (26.5 vs. 24.4, p=0.02), and less likely to be smokers (19.4% vs. 41.1%, p=0.002). Opioid spinal, compared to TEA, was associated with lower intraoperative MMEs (0.25 vs. 22.7, p<0.001) and postoperative daily MMEs (7.9 vs. 10.3, p=0.03) on univariate analysis. However, after multivariable adjustment, there was no difference in average pain scores across the postoperative period (spinal vs. epidural: 4.18 vs. 4.14, p=0.93), daily MMEs (p=0.50), or LOS (p=0.23). There was no significant difference in postoperative pain scores, opioid use, or LOS between patients managed with TEA or opioid spinal after pancreatoduodenectomy. [ABSTRACT FROM AUTHOR]

Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (±9.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23% vs 27% vs 36%, respectively, P = 0.445) and similar 5-year OS (21% vs 24% vs 33%, respectively, P = 0.287). Thirty-five (24%) patients were bridged to transplantation with TACE and/or RFA. The 5-year OS was significantly improved in patients bridged to transplantation (P < 0.001). Survival does not differ between patients with solitary HCC ≤ 3 cm treated with TACE or RFA. Patients who were bridged to transplantation had significantly greater OS compared with patients who were not transplanted. [ABSTRACT FROM AUTHOR]

Abstract Background Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored. Methods All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods. Results A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76). Conclusions Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies. [ABSTRACT FROM AUTHOR]

Background: Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. Methods: All patients ≥18 years in the 2014–15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3–6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. Results: A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001). Conclusions: Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population. [ABSTRACT FROM AUTHOR]

Background: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.Methods: Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.Results: Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262).Conclusion: Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to determine whether bacterial contamination of islets affects graft success after total pancreatectomy with islet autotransplantation ( TPIAT). Background Factors associated with insulin independence after TPIAT are inconclusive. Although bacterial contamination does not preclude transplantation, the impact of bacterial contamination on graft success is unknown. Methods Patients who received TPIAT at the University of Virginia between January 2007 and January 2016 were reviewed. Patient charts were reviewed for bacterial contamination and patients were prospectively contacted to assess rates of insulin independence. Results There was no significant difference in demographic or perioperative data between patients who achieved insulin independence and those who did not. However, six of 27 patients analyzed (22.2%) grew bacterial contaminants from culture of the final islet preparations. These patients had significantly lower islet yield and C-peptide at most recent follow-up ( P<.05), and none of these patients achieved insulin independence. Conclusions Islet transplant solutions are often culture positive, likely secondary to preprocurement pancreatic manipulation and introduction of enteric flora. Although autotransplantation of culture-positive islets is safe, it is associated with higher rates of graft failure and poor islet yield. Consideration should be given to identify patients who may develop refractory chronic pancreatitis and offer early operative management to prevent bacterial colonization. [ABSTRACT FROM AUTHOR]

Background Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. Materials and methods Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. Results Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm ( n = 229, 44%), primary hepatic neoplasm ( n = 108, 21%), primary extra-hepatic biliary neoplasm ( n = 23, 4%), and nonmalignant indications ( n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). Conclusions Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection. [ABSTRACT FROM AUTHOR]

Background: Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.Methods: This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.Results: Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001).Conclusions: Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality. [ABSTRACT FROM AUTHOR]

The impact of venous thromboembolism (VTE) after hepatectomy on patient morbidity, mortality, and resource usage remains poorly defined. Better understanding of thromboembolic complications is needed to improve perioperative management and overall outcomes. About 3973 patients underwent hepatectomy within NSQIP between 2005 and 2008. Patient characteristics, operative features, and postoperative correlates of VTE were compared with identify risk factors for VTE and to assess its overall impact on postoperative outcomes. Overall incidence of postoperative VTE was 2.4 per cent. Risk factors for postoperative VTE included older age, male gender, compromised functional status, degree of intraoperative blood transfusion, preoperative albumin level (all P < 0.05), and extent of hepatectomy (P = 0.004). Importantly, major postoperative complications, including acute renal failure, pneumonia, sepsis, septic shock, reintubation, prolonged ventilation, cardiac arrest, and reoperation were all associated with higher rates of VTE (all P < 0.05). Operative mortality was increased among patients with VTE (6.5% vs 2.4%, P = 0.03), and patients with VTE had a 2-fold increase in hospital length of stay (12.0 vs 6.0 days, P < 0.001). Postoperative VTE remains a significant source of morbidity, mortality, and increased resource usage after hepatectomy in the United States. Routine aggressive VTE prophylaxis measures are imperative to avoid development of VTE among patients requiring hepatectomy. [ABSTRACT FROM AUTHOR]

Background Population-based studies historically report underutilization of a resection in patients with colorectal metastases to the liver. Recent data suggest limitations of the methods in the historical analysis. The present study examines trends in a hepatic resection and survival among Medicare recipients with hepatic metastases. Methods Medicare recipients with incident colorectal cancer diagnosed between 1991 and 2009 were identified in the SEER(Surveillance, Epidemiology and End Results)-Medicare dataset. Patients were stratified into historical (1991-2001) and current (2002-2009) cohorts. Analyses compared treatment, peri-operative outcomes and survival. Results Of 31 574 patients with metastatic colorectal cancer to the liver, 14 859 were in the current cohort treated after 2002 and 16 715 comprised the historical control group. The overall proportion treated with a hepatic resection increased significantly during the study period ( P < 0.001) with pre/post change from 6.5% pre-2002 to 7.5% currently ( P < 0.001). Over time, haemorrhagic and infectious complications declined (both P ≤ 0.047), but 30-day mortality was similar (3.5% versus 3.9%, P = 0.660). After adjusting for predictors of survival, the use of a hepatic resection [ hazard ratio (HR) = 0.40, 95% confidence interval (CI): 0.38-0.42, P < 0.001] and treatment after 2002 ( HR = 0.88, 95% CI: 0.86-0.90, P < 0.001) were associated with a reduced risk of death. Conclusions Case identification using International Classification of Diseases, 9th Revision (ICD-9) codes is imperfect; however, comparison of trends over time suggests an improvement in multimodality therapy and survival in patients with colorectal metastases to the liver. [ABSTRACT FROM AUTHOR]

IgG4-associated cholangitis can mimic hilar cholangiocarcinoma. Previously reported patients with IgG4-associated cholangitis mimicking cholangiocarcinoma had elevated serum IgG4 levels and long-segment biliary strictures. However, in the absence of other diagnostic criteria for malignancy, IgG4-associated cholangitis should remain a consideration among patients with normal serum IgG4 and a hilar mass suspicious for cholangiocarcinoma. The presence of a hilar mass and a malignant-appearing biliary stricture in two patients with normal serum IgG4 prompted further evaluation and subsequent concomitant liver and bile duct resection and reconstruction. The diagnosis of IgG4-associated cholangitis was established during the pathologic evaluation of the resected specimens. IgG4-associated cholangitis is a known imitator of hilar cholangiocarcinoma and should be considered in the differential diagnosis even among serologically IgG4-negative patients with a hilar mass prior to operative resection. [ABSTRACT FROM AUTHOR]

Background The utilization of post-operative clinical pathways leads to shorter hospital stays and decreased healthcare costs. This study evaluated patient outcomes after implementation of a 6-day discharge pathway after a pancreaticoduodenectomy. Methods A post-operative clinical pathway was developed and implemented for patients undergoing a pancreaticoduodenectomy at the present institution aimed at discharge by post-operative day six. Patient charts were retrospectively reviewed to determine the rates of adherence to the pathway at each step, readmission and post-operative complications. Results In total, 113 consecutive patients underwent a pancreaticoduodenectomy, receiving post-operative care under the clinical pathway guidelines. The median length of stay was 7 days (mode 6 days); 41% of patients were discharged by post-operative day six, 62% by day seven and 79% by day eight. In univariate analysis, delayed gastric emptying was associated with a delayed discharge after post-operative day six ( P = 0.002). There were no post-operative deaths and 16% of patients required readmission within 30 days of discharge. In univariate analysis, obesity was the only variable associated with an increased rate of readmission ( P < 0.001). Discussion Clinical pathway utilization after a pancreaticoduodenectomy allows a high percentage of patients to be discharged within a week and is associated with a low rate of readmission. Clinical pathway implementation allows for safe and efficient patient care. [ABSTRACT FROM AUTHOR]

Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases performed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants. [ABSTRACT FROM AUTHOR]

The article discusses cases of heparin-induced thrombocytopenia (HIT) complicated by bilateral adrenal hemorrhage (BAH). HIT is a common complication of heparin treatment, resulting in paradoxical venous and arterial thromboses. BAH could result as a secondary complication of adrenal vein thrombosis. Heparin treatment should be discontinued and thrombin inhibitor should be initiated in the presence of prothrombotic complications.

Background and aim: Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution. Methods: Our prospectively established pancreaticobiliary database was retrospectively analyzed to retrieve all patients with malignant biliary stricture who underwent PCMS placement and subsequently went for curative surgical attempt at our institution. Cancer type and staging, adverse events related to stent placement or surgery, type of surgery performed, time between stenting and surgery, length of postoperative hospitalization, and postoperative follow-up were recorded. Results: 27 patients (21 men; median age 66 years, range 39-82 years) received PCMS. Indications for placement included biliary stricture related to pancreatic cancer ( n = 23) or other malignancies ( n = 4). Median time between stenting and surgery was 32 days (range 6-569 days). Median time of hospitalization post surgery was 7 days (1-40 days). All patients underwent exploratory laparoscopy, followed in 9 (33.3%) by Whipple procedure with uneventful removal of the PCMS. Eighteen patients (66.6%) had their attempted curative resection terminated early due to intraoperative evidence of metastatic spread, with 8 (30%) patients undergoing peritoneal or liver metastasis biopsy. PCMS were left in place in those 18 patients. Complications related to PCMS in the bridge-to-surgery period included migration ( n = 2, 7.4%) and tissue overgrowth ( n = 1, 3.4%), all of them managed by endoscopic removal and replacement with PCMS. Median follow-up post surgery was 210 days (range 9-1,642 days). Conclusion: PCMS are an appropriate BTS option. For resectable patients, PCMS results in biliary drainage and allows for neoadjuvant treatment without portending subsequent curative resection (Whipple). For unresectable patients, long-term biliary drainage is provided by PCMS. [ABSTRACT FROM AUTHOR]

Staging of hepatocellular carcinoma (HCC) is complex and relies on multiple factors including tumor extent and hepatic function. No single staging system is applicable to all patients with HCC. The staging of the American Joint Committee on Cancer / International Union for Cancer Control should be used to predict outcome following resection or liver transplantation. The Barcelona Clinic Liver Cancer scheme is appropriate in patients with advanced HCC not candidate for surgery. Dual phase computed tomography or magnetic resonance imaging can be used for pretreatment assessment of tumor extent but the accuracy of these methods remains poor to characterize <1 cm lesions. Assessment of tumor response should not rely only on tumor size and new imaging methods are available to evaluate response to therapy in HCC patients. Liver volumetry is part of the preoperative assessment of patients with HCC candidate for resection as it reflects liver function. Preoperative portal vein embolization is indicated in patients with small future liver remnant (≤ 20% in normal liver; ≥ 40% in fibrotic or cirrhotic liver). Tumor size is not a contraindication to liver resection. Liver resection can be proposed in selected patients with multifocal HCC. Besides tumor extent, surgical resection of HCC may be performed in selected patients with chronic liver disease. [ABSTRACT FROM AUTHOR]

Re-resection for gallbladder carcinoma incidentally discovered after cholecystectomy is routinely advocated. However, the incidence of finding additional disease at the time of re-resection remains poorly defined. Between 1984 and 2006, 115 patients underwent re-resection at six major hepatobiliary centers for gallbladder carcinoma incidentally discovered during cholecystectomy. Data on clinicopathologic factors, operative details, TNM tumor stage, and outcome were collected and analyzed. Data on the incidence and location of residual/additional carcinoma discovered at the time of re-resection were also recorded. On pathologic analysis, T stage was T1 7.8%, T2 67.0%, and T3 25.2%. The median time from cholecystectomy to re-resection was 52 days. At the time of re-resection, hepatic surgery most often consisted of formal segmentectomy (64.9%). Patients underwent lymphadenectomy (LND) (50.5%) or LND + common bile duct resection (43.3%). The median number of lymph nodes harvested was 3 and did not differ between LND alone (n = 3) vs LND + common duct resection (n = 3) (P = 0.35). Pathology from the re-resection specimen noted residual/additional disease in 46.4% of patients. Of those patients staged as T1, T2, or T3, 0, 10.4, and 36.4%, respectively, had residual disease within the liver (P = 0.01). T stage was also associated with the risk of metastasis to locoregional lymph nodes (lymph node metastasis: T1 12.5%; T2 31.3%, T3 45.5%; P = 0.04). Cystic duct margin status predicted residual disease in the common bile duct (negative cystic duct, 4.3% vs positive cystic duct, 42.1%) (P = 0.01). Aggressive re-resection for incidental gallbladder carcinoma is warranted as the majority of patients have residual disease. Although common duct resection does not yield a greater lymph node count, it should be performed at the time of re-resection for patients with positive cystic duct margins because over one-third will have residual disease in the common bile duct. [ABSTRACT FROM AUTHOR]

Purpose: After adopting a night float system, the residency program at the University of Virginia Health System Department of Surgery initiated a daily morning report (MR). The conference was originated to sign out new admissions and consults from the previous day to the services that would assume care. Although initially oriented toward transfer of patient information, MR is also hypothesized to serve as a competency-based resident education tool. Methods: An anonymous survey was distributed to on-service residents (n = 25). Questions were asked on a 5-point Likert scale. Respondents also ranked the weekly conferences, including MR, in terms of educational benefit derived. Results: Most residents agreed that MR is an efficient method to sign-out patient care [84% stongly agree (SA) or agree (A)] and that it provides an excellent educational experience (88% SA or A). They agreed that it is presented in an evidence-based format (88% SA or A). Regarding the core competencies, residents all asserted that MR addresses “patient care” (100% SA or A) and “medical knowledge” (100% SA or A). Most agreed that it addresses “professionalism” (60% SA or A), “interpersonal skills and communication” (76% SA or A), and “practice-based learning and improvement” (92% SA or A). The 4 most important components identified with respect to continuing to improve both patient care and resident education were the presence of the on-call attending, a review of relevant radiology, provision of follow-up on select cases, and critical review of the literature. On average, MR was seen as the most educational conference, with 52% of residents ranking it first. Conclusions: Although MR is ubiquitous in most primary care residency programs, such a conference has not typically been held on surgical services. The MR was developed at the University of Virginia Health System Department of Surgery as a necessity for patient sign-out. As this conference has continued to evolve, it has become an excellent tool for resident education. It now serves the purpose of enhancing patient care and medical education and of providing evidence of learning and assessment of the general competencies. The MR provides an example for program directors of how to tailor existing resident work sessions or conferences to meet Accreditation Council for Graduate Medical Education (ACGME) competency requirements. [Copyright &y& Elsevier]

OBJECTIVE: Endoscopic treatment of ampullary lesions has been well described, though it remains uncertain if specific features predict malignancy, and whether identifiable factors are associated with successful endoscopic resection of benign lesions.METHODS: Fifty-six consecutive patients undergoing endoscopic evaluation of ampullary neoplasia between March 2000 and May 2004 were included in the study. Clinical presentation, underlying medical conditions, endoscopic treatment, endoscopic ultrasound (EUS) to define extent of local involvement, pathology results, and outcome were documented. Data elements for analysis included EUS findings, lesion lifting with submucosal injection, age, gender, tumor size, and endoscopic intervention. Analyses were performed to determine the ability to predict malignancy and the ability to extirpate benign lesions.RESULTS: Thirty-one males and 25 females were included; mean age was 62 yr. Final diagnoses included 29 adenomas, 20 adenocarcinomas, 4 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Thirty of 35 patients with benign lesions had extirpation with a mean of two endoscopic procedures. Complications of endoscopic resection included cholangitis (), bleeding (), and pancreatitis (). The presence of malignancy was associated by multivariate analysis with the inability to obtain a cleavage plane with saline injection. Univariate analysis also identified EUS T stage as a predictor of malignancy. In benign lesions, none of the analyzed variables predicted successful endoscopic resection.CONCLUSION: In ampullary lesions, failure to achieve a cleavage plane with submucosal injection is the strongest predictor of malignancy followed by EUS T stage. Endoscopic treatment of benign ampullary neoplasia is effective; no factor was predictive of successful extirpation.(Am J Gastroenterol 2004;99:1–5) [ABSTRACT FROM AUTHOR]