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Background Radiofrequency has been used as a tool for liver resection since 2002. A new laparoscopic device is reported in this article that assists liver resection laparoscopically. Methods From October 2006 to the present, patients suitable for liver resection were assessed carefully for laparoscopic resection with the laparoscopic Habib Sealer (LHS). Detailed data of patients resected laparoscopically with this device were collected prospectively and analyzed. Results In all, 28 patients underwent attempted laparoscopic liver resection. Four cases had to be converted to an open approach because of extensive adhesions from previous colonic operations. Twenty-four patients completed the procedure comprising tumorectomy (n = 7), multiple tumoretcomies (n = 5), segmentectomy (n = 3), and bisegmentectomies (n = 9). Vascular clamping of portal triads was not used. The mean resection time was 60 ± 23 min (mean ± SD), and blood loss was 48 ± 54 mL. None of the patients received any transfusion of blood or blood products perioperatively or postoperatively. Postoperatively, 1 patient developed severe exacerbation of asthma that required steroid therapy, and 1 other patient had a transient episode of liver failure that required supportive care. The mean duration of hospital stay was 5.6 ± 2 days (mean ± SD). At a short-term follow up, no recurrence was detected in patients with liver cancer. Conclusion Laparoscopic liver resection can be performed safely with this new laparoscopic liver resection device with a significantly low risk of intraoperative bleeding or postoperative complications.

Edited by John H Scholefield, Herand Abcarian, Axel Grothey, Tim Maughan. Oxford: Blackwell Publishing, 2006, £69.50, pp 296. ISBN 9781405127066. Colorectal adenocarcinoma (colorectal cancer; CRC) is the third most common type of cancer and the fourth most frequent cause of death due to cancer worldwide. Almost 1 million new cases of CRC occur annually, amounting to 492 000 related deaths. In developed countries, it is the second most common type of tumour, with a lifetime risk of …

Background Although previously examined, the potential relationship between preoperative biliary drainage (PBD), intraoperative bile culture (IBC), and postoperative morbidity and mortality rate for pancreatic surgery remains unclear. Methods Two hundred twenty patients underwent operation for either benign pancreatic disease or malignant periampullary and pancreatic neoplasms, consisting of pylorus-preserving proximal pancreatoduodenectomy (n = 180), biliary bypass (n = 31), and total pancreatectomy (n = 9). An intraoperative bile specimen was prospectively collected immediately after division of the bile duct and sent for bacteriologic evaluation for both aerobic and anaerobic microorganisms. Morbidity and mortality rates were evaluated. Results Of 220 patients evaluated, 113 patients (51.4%) had a positive IBC. Factors associated with a positive IBC were age >70 years (odds ratio [OR], 5.9;95% confidence interval, [CI]: 1.6-22.1; P = .007), history of coronary artery disease (OR, 0.08; 95% CI, 0.01-0.5; P = .007), diagnosis of neoplasia (OR, 0.3; 95% CI, 0.1-0.9; P =. 03), and PBD (OR, 0.1; 95% CI, 0.06-0.2; P = .0001). Infectious complications (OR, 1.8; 95% CI, 1-3; P = .03), and wound infection (OR, 2.8; 95% CI,1.4-5.3; P = .002) were greater in patients with positive IBC. Conclusions PBD predisposes to a positive IBC. Patients with a positive IBC have a clinically important increased risk of developing both infectious complications and wound infection after pancreatic surgery.

We report the case of a 73-year-old woman who presented with a soft tissue tumor located between the scapula and the rib cage. Magnetic resonance imaging showed an inhomogeneous tumor on the right dorsolateral thoracic wall that measured 7 × 4 × 7 cm with contrast enhancement. The findings were suggestive of partial infiltration of intercostal muscles and were suspicious of a malignant tumor. After local excision at a district hospital had failed to render definitive diagnosis, the patient underwent complete resection of the tumor at our institution. Histology from the specimen was consistent with elastofibroma dorsi with free resection margins.

AIM: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed. METHODS: A systematic review of the literature was performed using the Medline, Embase, PubMed, and Cochrane databases to identify all studies published up to 2013 that compared laparoscopic and open liver [laparoscopic hepatic resection (LLR) vs open liver resection (OLR)] and pancreatic [laparoscopic pancreatic resection (LPR) vs open pancreatic resection] resection. The last search was conducted on October 30, 2013. RESULTS: Four studies reported that LLR was associated with lower ward stay cost than OLR (2972 USD vs 5291 USD). The costs related to equipment (3345 USD vs 2207 USD) and theatre (14538 vs 11406) were reported higher for LLR. The total cost was lower in patients managed by LLR (19269 USD) compared to OLR (23419 USD). Four studies reported that LPR was associated with lower ward stay cost than OLR (6755 vs 9826 USD). The costs related to equipment (2496 USD vs 1630 USD) and theatre (5563 vs 4444) were reported higher for LPR. The total cost was lower in the LPR (8825 USD) compared to OLR (13380 USD). CONCLUSION: This systematic review support the economic advantage of laparoscopic over open approach to liver and pancreatic resection.

In general, ‘poorly’ differentiated tumours have a worse prognosis when compared to more ‘well’ differentiated ones. Therefore, the use of a biological agent that could promote differentiation might have a therapeutic advantage. CCAAT enhancer binding protein alpha (C/EBPα) is a transcription factor known to be involved in the regulation of cell differentiation in a number of tissue types. Loss of C/EBPα expression, for example, causes abnormal levels of biliary transcription factors, impaired hepatocyte maturation and liver fibrosis. In contrast C/EBPα overexpression inhibits the development of hepatocellular carcinoma, restores myeloid differentiation and prevents hyperproliferation of hematopoietic cells in acute myeloid leukemia. In this study, we tested the effect of stimulation of C/EBPα expression by a specific small activating RNA (saRNA) on a panel of cell lines representing both well-differentiated and poorly-differentiated cancer cell types. The C/EBPα-saRNA inhibited proliferation of poorly differentiated small cell lung cancer and pancreatic cancer cell lines compared to treatment with scrambled double-stranded RNA controls. However C/EBPα-saRNA was not as effective in suppressing proliferation in well-differentiated insulinoma and breast cancer (MCF7) cell lines. Comparison of endogenous levels of C/EBPα, using qPCR and Western blots, showed that undifferentiated tumour cell lines expressed lower levels of C/EBPα when compared to the well-differentiated tumor types. Gene expression analysis in tumours from xenografts and cirrhotic DEN treated HCC rats, demonstrated that saRNA mediated stimulation of C/EBPα expression, could suppress the steady-state transcript levels for KLF4, OCT3, SOX2, C-Myc and C-Kit. The inhibited expression of these transcription factors correlated with greater expression of differentiation markers and reduced epithelial mesenchymal transition by the C/EBPα saRNA treated cells. Our results suggest that saRNA mediated stimulation of C/EBPα, could be of potential therapeutic value, especially in poorly differentiated cancers. Furthermore, intracellular expression levels of C/EBPα could be an important prognostic factor for predicting the therapeutic response in poor or un-differentiated tumors. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B225. Citation Format: K W. Huang, Vikash Reebye, Paul J. Mintz, Pal Saetrom, Piotr Swiderski, L Peng, C Liu, X X. Liu, Steen Lindkaer Jensen, Dimitris Zacharoulis, Nikos Kostomitsopoulos, Noriyaki Kasahara, Joanna Nicholls, Long R. Jiao, Madhava Pai, Duncan Spalding, Farzin Farzaneh, Malkhaz Mizandari, Tina Chikovani, Mohammed Emara, Abdelali Haoudi, Don Tomalia, John J. Rossi, Nagy A. Habib. Short activating RNA (saRNA) targeting C/EBPA significantly inhibits cell proliferation of undifferentiated cancer cells. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B225.

Introduction The five year survival for pancreatic ductal adenocarcinoma (PDAC) is less than 5% in spite of the advances in management of cancers in the last few decades. Even though surgical resection remains the only potentially curative treatment for PDAC, only 10–20% of patients are candidates for pancreatic resection with almost 50% of patients having distant spread of tumour and approximately one-third manifesting locally advanced disease. Kahaleh and colleagues have demonstrated that EUS guided RF ablation (EUS-RFA) of the pancreatic head using Habib EUS-RFA catheter (Emcision Ltd, UK) was well tolerated in 5 Yucatan pigs and with minimal pancreatitis (1). The aim of this report is to outline the feasibility, safety, complications and early results of EUS-RFA using Habib catheter in patients with inoperable PDAC. Methods Seven patients underwent EUS-RFA of PDAC. A novel monopolar radiofrequency (RF) catheter (1.2 mm Habib EUS-RFA catheter, Emcision Ltd, London) was placed through a 19 or 22 gauge fine needle aspiration (FNA) needle after FNA was performed. Results Seven patients had EUS-RFA of PDAC with a median age of 69 (range 50 – 77) years. There were 3 female and 4 male patients. Five patients had PDAC in the head of pancreas whilst two had in the body of pancreas. RF was applied at 5 watts, 10 watts and 15 watts in an incremental manner in 1, 3 and 3 patients respectively. The median number of applications were 3 (range 2 – 4) and each application was 90 seconds. The EUS-RFA was completed in all patients. The mean size was 35.2mm and the post procedure imaging in 3–6 months showed decrease in size of the lesion in two patients, whilst the lesions were unchanged in the rest of the patients. There were no early complications like injury or perforation of duodenal or gastric wall, bleeding or severe pancreatitis. All patients stayed overnight after the procedure for observation and four were discharged next day and there were no readmissions post procedure due to pain. One patient had mild pancreatitis which settled with conservative management and was discharged 3 days post procedure. Conclusion EUS- RFA of PDAC with a novel monopolar RF probe was well tolerated in 7 patients. The initial results suggest that the procedure is technically relatively easy and safe Disclosure of Interest M. Pai: None Declared, J. Yang: None Declared, X. Zhang: None Declared, Z. Jin: None Declared, D. Wang: None Declared, H. Senturk: None Declared, S. Lakhtakia: None Declared, D. N. Reddy: None Declared, M. Kahaleh: None Declared, N. Habib Shareholder of: EMcision Limited, London, United Kingdom, Conflict with: Director, EMcision Limited, London, United Kingdom, W. Brugge: None Declared. Reference Gaidhane M et.al . Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) of the Pancreas in a Porcine Model. Gastroenterol Res Pract. 2012; 431451.

Pancreatic head resection and reconstruction is technically challenging. Eight patients underwent pancreaticoduodenectomy for either ductal adenocarcinoma (n = 7) or neuroendocrine tumor (n = 1) in the head of the pancreas with a dilated pancreatic duct. The pancreatic stump could not be mobilized to form a standard pancreaticogastrostomy or a pancreaticojejunostomy following resection because of a complete fixation to the splenic vein (n = 2), common hepatic artery (n = 1), or mesentery (n = 3) or inadequate length of the pancreatic remnant (n = 2). After laying open the pancreatic duct along the pancreatic transection margin in the ventral aspect of the pancreas, a longitudinal ventral pancreaticojejunostomy was performed using polydioxanone 3/0 sutures. The average time taken to create this pancreatic anastomosis was less than 10 minutes. This longitudinal ventral pancreatic anastomosis is quick, easy to perform, and a safe alternative method for pancreatic reconstruction after pancreaticoduodenectomy.

Objective To determine whether interventional radiology (IR) or laparotomy (LAP) is the best management of delayed postoperative hemorrhage (DPH) after pancreaticoduodenectomy. Data Source We undertook an electronic search of MEDLINE and selected for analysis only original articles published between January 1, 1990, and December 31, 2007. Study Selection Two of us independently selected studies reporting on clinical presentation and incidence of postoperative DPH and the following outcomes: complete hemostasis, morbidity, and mortality. Data Extraction Two of us independently performed data extraction. Data were entered and analyzed by means of dedicated software from The Cochrane Collaboration. A random-effects meta-analytical technique was used for analysis. Data Synthesis One hundred sixty-three cases of DPH after pancreaticoduodenectomy were identified from the literature. The incidence of DPH after pancreaticoduodenectomy was 3.9%. Seventy-seven patients (47.2%) underwent LAP; 73 (44.8%), IR; and 13 (8%), conservative treatment. On meta-analysis comparing LAP vs IR for DPH, no significant difference was found between the 2 treatment options for complete hemostasis (73% vs 76%; P = .23), mortality (43% vs 20%; P = .14), or morbidity (77% vs 35%; P = .06). Conclusions This meta-analysis, although based on data from small case series, is unable to demonstrate any significant difference between LAP and IR in the management of DPH after pancreaticoduodenectomy. The management of this life-threatening complication is difficult, and the appropriate treatment pathway ultimately will be decided by the clinical status of the patient and the institution preference.

Background. Intraoperative blood loss has been shown to be an important factor correlating with morbidity and mortality in liver surgery. In spite of the technological advances in hepatic parenchymal transection devices, bleeding remains the single most important complication of liver surgery. The role of radiofrequency (RF) in liver surgery has been expanded from tumour ablation to major hepatic resections in the last decade. Habib™ 4X, a new bipolar RF device designed specifically for liver resection is described here. Methods. Habib™ 4X is a bipolar, handheld, disposable RF device and consists of two pairs of opposing electrodes which is introduced perpendicularly into the liver, along the intended transection line. It produces controlled RF energy between the electrodes and the heat produced seals even major biliary and blood vessels and enables resection of the liver parenchyma with a scalpel without blood loss or biliary leak. Results. Three hundred and eleven patients underwent 384 liver resections from January 2002 to October 2007 with this device. There were 109 major resections and none of the patients had vascular inflow occlusion (Pringle's manoeuvre). Mean intraoperative blood loss was 305ml (range 0–4300) ml, with less than 5% (n=18) rate of transfusion. Conclusion. Habib™ 4X is an additional device for hepatobiliary surgeons to perform liver resections with minimal blood loss and low morbidity and mortality rates.