Search

Background: Alagille syndrome is a multi-system developmental disorder associated with paucity of interlobular bile ducts and cholestasis, rarely associated with hepatocellular carcinoma. Associated syndromic co-morbidities may complicate surgical management. As such, we herein review the modern management of a large hepatocellular carcinoma in an adult patient with Alagille syndrome and review the literature of adult Alagille patients with hepatocellular carcinoma.Case Presentation: A 29-year-old woman with a history of Alagille syndrome was referred with biopsy-proven 12 × 8 cm hepatocellular carcinoma replacing her right liver. Biopsy of the contralateral liver demonstrated findings consistent with Alagille syndrome, but no underlying cirrhosis. CT volumetrics demonstrated a future liver remnant of 40%. Extensive hematologic and cardiac work-up was performed pre-operatively, given the syndrome's associated bleeding dyscrasias and cardiac abnormalities. The patient underwent a margin-negative right hepatectomy using the "hanging" technique through a thoracoabdominal approach. The patient developed a transient hyperbilirubinemia but no hepatic insufficiency and did well post-operatively.Conclusion: Since Alagille syndrome affects multiple organ systems, preoperative evaluation of cardiac, hematologic, and hepatic function should be considered. This case illustrates the peri-operative management of an Alagille patient, and highlights several key technical points that contributed to a successful resection. [ABSTRACT FROM AUTHOR]

Background: We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. Methods: A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. Results: Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333–$39,273] vs. no ADRD: $27,101 [IQR $13,433–$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25–1.40), extended length‐of‐stay (OR 1.26, 95% CI 1.21–1.32), 90‐day readmission (OR 1.37, 95% CI 1.31–1.43), and 90‐day mortality (OR 1.76, 95% CI 1.66–1.86) (all p < 0.001). Conclusion: Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non‐home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision‐making about surgery among the growing number of older patients with cognitive deficits. [ABSTRACT FROM AUTHOR]

Early postoperative mortality risk prediction is crucial for clinical management of gastric cancer. This study aims to predict 90-day mortality in gastric cancer patients undergoing gastrectomy using automated machine learning (AutoML), optimize models for preoperative prediction, and identify factors influential in prediction. National Cancer Database was used to identify stage I–III gastric cancer patients undergoing gastrectomy between 2004 and 2016. 26 features were used to train predictive models using H2O.ai AutoML. Performance on validation cohort was measured. In 39,108 patients, 90-day mortality rate was 8.8%. The highest performing model was an ensemble (AUC = 0.77); older age, nodal ratio, and length of inpatient stay (LOS) following surgery were most influential for prediction. Removing the latter two parameters decreased model performance (AUC 0.71). For optimizing models for preoperative use, models were developed to first predict node ratio or LOS, and these predicted values were inputted for 90-day mortality prediction (AUC of 0.73–0.74). AutoML performed well in predicting 90-day mortality in a larger cohort of gastric cancer patients that underwent gastrectomy. These models can be implemented preoperatively to inform prognostication and patient selection for surgery. Our study supports broader evaluation and application of AutoML to guide surgical oncologic care. [ABSTRACT FROM AUTHOR]

Background: In patients with newly diagnosed pancreatic cancer, the classification of indeterminate liver lesions is an unanswered clinical dilemma as misclassification of these lesions can impact the assignment of clinical stage and subsequent treatment planning. Our objective was to design a standardized classification system to more accurately define the risk of malignancy in indeterminate liver lesions.Methods: In this retrospective study, patients with localized, non-metastatic pancreatic cancer were identified and pre-treatment computed tomography (CT) scans were evaluated for the presence or absence of liver lesions. Liver lesions were defined as definitely benign (1) or indeterminate (2). Indeterminate lesions were further sub-classified as either indeterminate probably benign (2B) or indeterminate possibly malignant (2M). The index liver lesion was evaluated on follow-up imaging for stability or unequivocal disease progression.Results: From 2008 to 2015, 304 patients with localized, non-metastatic pancreatic cancer were identified and 125 (41%) patients had liver lesions. Of the 125 patients, the liver lesions in 35 (28%) were classified as definitely benign and in 90 (72%) patients they were classified as indeterminate. The 90 patients with indeterminate lesions included 80 (89%) classified as indeterminate probably benign (2B) and 10 (11%) classified as indeterminate possibly malignant (2M). After a median follow-up of 56 weeks, no patient with a definitely benign lesion had metastatic disease progression of the index lesion. Of the 90 patients with indeterminate liver lesions, the index lesion progressed to unequivocal liver metastasis in 8 (9%) patients; 5 (6%) of the 80 lesions classified as indeterminate probably benign (2B), and 3 (30%) of the ten lesions classified as indeterminate possibly malignant (2M). The sensitivity of the classification system was 38% and the specificity was 91%. The positive predictive value was 30% and the negative predictive value was 94%.Conclusions: A significant proportion of patients with localized pancreatic cancer will have liver lesions identified at the time of diagnosis and most of these lesions will have indeterminate characteristics. A classification system which further stratifies indeterminate liver lesions by malignant potential can assist clinicians in determining optimal treatment plan and is associated with a high negative predictive value. [ABSTRACT FROM AUTHOR]