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Introduction: New Zealand has a population of only 5.5 million meaning that for many surgical procedures the country qualifies as a "low-volume center." However, the health system is well developed and required to provide complex surgical procedures that benchmark internationally against comparable countries. This investigation was undertaken to review regional variation and volumes of complex resection and palliative upper gastrointestinal (UGI) surgical procedures within New Zealand., Methods: Data pertaining to patients undergoing complex resectional UGI procedures (esophagectomy, gastrectomy, pancreatectomy, and hepatectomies) and palliative UGI procedures (esophageal stenting, enteroenterostomy, biliary enteric anastomosis, and liver ablation) in a New Zealand hospital between January 1, 2000 and December 31, 2019 were obtained from the National Minimum Dataset., Results: New Zealand is a low-volume center for UGI surgery (229 hepatectomies, 250 gastrectomies, 126 pancreatectomies, and 74 esophagectomies annually). Over 80% of patients undergoing hepatic resection/ablation, gastrectomy, esophagectomy, and pancreatectomy are treated in one of the six national cancer centers (Auckland, Waikato, Mid-Central, Capital Coast, Canterbury, or Southern). There is evidence of the decreasing frequency of these procedures in small centers with increasing frequency in large centers suggesting that some regionalization is occurring. Palliative procedures were more widely performed. Indigenous Māori were less likely to be treated in a nationally designated cancer center than non-Māori., Conclusions: The challenge for New Zealand and similarly sized countries is to develop and implement a system that optimizes the skills and pathways that come from a frequent performance of complex surgery while maintaining system resilience and ensuring equitable access for all patients., (© 2024 The Authors. World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Laparoscopic surgery is the gold standard treatment of symptomatic gallstones. For some, it is also the treatment of choice for choledocholithiasis. Certain special and rare circumstances regarding the number, size and location of bile duct stones or altered bile duct anatomy (embryonic or acquired), can be challenging to resolve with usual laparoscopic techniques. For these situations, we describe 10 surgical strategies that are relatively simple and inexpensive to apply, making them appropriate to be used in most surgical centers., (Copyright © 2020 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Postoperative infectious complications after a pancreaticoduodenectomy remain a significant cause of morbidity. Studies have demonstrated that a preoperative biliary stent increases the risk of postoperative infectious complications. Few studies have investigated the specific preoperative biliary stent bacterial sensitivities to preoperative antibiotics and the effect on infectious complications. The goal of this study was to investigate if the presence of a preoperative biliary stent increases the risk of postoperative infectious complications in patients undergoing a pancreaticoduodenectomy. Additionally, we aimed to investigate biliary stent culture sensitivities to preoperative antibiotics and determine if those sensitivities impacted postoperative infectious complications after a pancreaticoduodenectomy., Methods: A retrospective chart review of patients who had undergone a pancreaticoduodenectomy at a single institution tertiary care center from 2007 to 2018 was performed. Perioperative variables including microbiology cultures from biliary stents were collected and analyzed., Results: A total of 244 patients underwent a pancreaticoduodenectomy. A preoperative biliary stent was present in 45 (18%) patients. Infectious complications occurred in 25% of those patients with a preoperative biliary stent, and 19% of those without (P = .37). Of those patients with a stent that was cultured intraoperatively, 92% grew bacteria and 61% of those were resistant to the preoperative antibiotics administered. Of the patients with a preoperative biliary stent and bacteria resistant to the preoperative antibiotics, 17% developed a postoperative infectious complication, compared with 20% if the bacteria cultured was susceptible to the preoperative antibiotics (P = .64)., Conclusion: Infectious complications after pancreaticoduodenectomy are a significant cause of morbidity. Stent bacterial sensitivities to preoperative antibiotics did not reduce the postoperative infectious complications in the preoperative biliary stent group suggesting a multifactorial cause of infections., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background & Aims: Mutations in ABCB11 can cause deficiency of the bile salt export pump (BSEP), leading to cholestasis and end-stage liver disease. Owing to the rarity of the disease, the associations between genotype and natural history, or outcomes following surgical biliary diversion (SBD), remain elusive. We aimed to determine these associations by assembling the largest genetically defined cohort of patients with severe BSEP deficiency to date., Methods: This multicentre, retrospective cohort study included 264 patients with homozygous or compound heterozygous pathological ABCB11 mutations. Patients were categorized according to genotypic severity (BSEP1, BSEP2, BSEP3). The predicted residual BSEP transport function decreased with each category., Results: Genotype severity was strongly associated with native liver survival (NLS, BSEP1 median 20.4 years; BSEP2, 7.0 years; BSEP3, 3.5 years; p <0.001). At 15 years of age, the proportion of patients with hepatocellular carcinoma was 4% in BSEP1, 7% in BSEP2 and 34% in BSEP3 (p = 0.001). SBD was associated with significantly increased NLS (hazard ratio 0.50; 95% CI 0.27-0.94: p = 0.03) in BSEP1 and BSEP2. A serum bile acid concentration below 102 μmol/L or a decrease of at least 75%, each shortly after SBD, reliably predicted NLS of ≥15 years following SBD (each p <0.001)., Conclusions: The genotype of severe BSEP deficiency strongly predicts long-term NLS, the risk of developing hepatocellular carcinoma, and the chance that SBD will increase NLS. Serum bile acid parameters shortly after SBD can predict long-term NLS., Lay Summary: This study presents data from the largest genetically defined cohort of patients with severe bile salt export pump deficiency to date. The genotype of patients with severe bile salt export pump deficiency is associated with clinical outcomes and the success of therapeutic interventions. Therefore, genotypic data should be used to guide personalized clinical care throughout childhood and adulthood in patients with this disease., Competing Interests: Conflicts of interest Daan B.E. van Wessel: [nothing to disclose], Richard J. Thompson [consultancy for Shire, Albireo, Mirum, Horizon Pharmaceuticals, Sana Biotechnology, GenerationBio, Retrophin and Qing Bile Therapeutics], Emmanuel M. Gonzales [Consultant for CTRS and Mirum Pharmaceuticals], Irena Jankowska [nothing to disclose], Tassos Grammatikopoulos [nothing to disclose], Agustina Kadaristiana [nothing to disclose], Patryk Lipiński [nothing to disclose], Piotr Czubkowski [nothing to disclose], Nathalie Rock [nothing to disclose] Emmanuel Jacquemin [nothing to disclose], Anne Spraul [nothing to disclose], Etienne M. Sokal [founder and CSMO of Promethera Biosciences], Mohammad Shagrani [nothing to disclose], Dieter Broering [nothing to disclose], Talal Algoufi [nothing to disclose], Nejat Mazhar [nothing to disclose], Emanuele Nicastro [nothing to disclose] Deirdre Kelly [Consultant for Albireo], Gabriela Nebbia [nothing to disclose], Henrik Arnell [consultant for Albireo and Mirum Pharmaceuticals], Björn Fischler [has attended one advisory board meeting with Albireo in 2016], Jan Hulscher [nothing to disclose], Daniele Serranti [nothing to disclose], Cigdem Arikan [nothing to disclose], Esra Polat [nothing to disclose], Dominique Debray [consultant for Alexion pharmaceuticals], Florence Lacaille [nothing to disclose], Cristina Goncalves [nothing to disclose], Loreto Hierro [nothing to disclose], Gema Muñoz Bartolo [nothing to disclose], Yael Mozer-Glassberg [nothing to disclose], Amer Azaz [nothing to disclose], Jernej Brecelj [nothing to disclose], Antal Dezsőfi [nothing to disclose], Pier Luigi Calvo [nothing to disclose], Enke Grabhorn [nothing to disclose], Ekkehard Sturm [nothing to disclose] Wendy van der Woerd [nothing to disclose], Binita Kamath [consultant for Mirum Pharmaceuticals, Shire and DCI], Jian-She Wang [nothing to disclose], Liting Li [nothing to disclose], Özlem Durmaz [nothing to disclose], Zerrin Onal [nothing to disclose], Ton Bunt [nothing to disclose], Bettina Hansen [consultant for Mirum Pharmaceuticals, Albireo AB, Chemomab, Calliditas, Intercept, Cyma Bay, unrestricted grants from Cyma bay, Intercept, Mirum and Albireo], Henkjan J. Verkade [Consultant for Danone/Nutricia Research, Ausnutria BV, Albireo AB, GMP+Orphan, Mirum Pharmaceuticals, Intercept and Vivet]. Please refer to the accompanying ICMJE disclosure forms for further details., (Copyright © 2020 European Association for the Study of the Liver. All rights reserved.)

Background: CA19-9 elevation has shown to be associated with poor prognosis in extrahepatic cholangiocarcinoma (ECCA). However, the role of CA19-9 in staging of ECCA has not been evaluated. We hypothesized that CA19-9 elevation is a marker of aggressive biology in ECCA and that inclusion of CA19-9 in the staging system may improve overall survival (OS) discrimination., Methods: Patients with ECCA whose CA19-9 levels, irrespective of surgical status, were reported to the National Cancer Database (2004-2015) were included. The patients were classified based on their CA19-9 levels and a new staging system was proposed. Net reclassification improvement (NRI) model was used to assess the predictive improvement in the proposed survival model as compared to AJCC-TNM staging., Results: Of the 2100 patients included in the study, 626 (32%) and 1474 (68%) had normal and elevated CA19-9 levels (>38 U/ml), respectively. Median OS was lower among patients with elevated CA19-9 level compared to those with CA19-9 level ≤38 U/ml (8.5 vs 16 months, p < 0.01). On multivariate analysis, CA19-9 elevation independently predicted poor prognosis [HR:1.72 (1.46-2.02); p < 0.01] with similar impact as node-positivity, positive resection margins and non-receipt of chemotherapy. We developed a new staging system by incorporating CA19-9 into the 7th edition AJCC TNM staging system. NRI of 46% (95%CI: 39-57%) indicates that the new staging system is substantially effective at re-classifying events at 12 months as compared to AJCC 7th edition., Conclusion: Elevated CA19-9 was found to be an independent risk factor for mortality in ECCA and its inclusion in the proposed staging system improved OS discrimination., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: The aim of the study was to prospectively investigate the long-term effects of gallbladder-preserving cholecystolithotomy in a selected population of Chinese patients., Methods: Between January 2007 and December 2016, all gallstone patients who met the criteria for gallbladder-preserving cholecystolithotomy in our hospital were included in the study and followed prospectively. The primary endpoint was the time of recurrence of cholecystolithiasis, and the secondary endpoint was the end of the study. The data were collected in half-year intervals., Results: We surveyed 81 male patients and 135 female patients. Most patients (176/216) had only 1 gallstone in the gallbladder. All patients underwent gallbladder-preserving cholecystolithotomy successfully. After the operation, 200 of the 216 patients were symptom free. There was no difference in the percentage of gallbladder emptying (the gallbladder emptying index) between the time prior to the operation and 6 months after gallbladder-preserving cholecystolithotomy (0.47 ± 0.18 vs 0.49 ± 0.18, P = .837). Twenty patients (9.3%) developed recurrent gallstones during the follow-up period. There was no difference in stone recurrence between patients who were treated with ursodeoxycholic acid for 6 months postoperatively and those treated with ursodeoxycholic acid for 12 months (P = .589). Most instances of recurrence occurred within 2 years of gallbladder-preserving cholecystolithotomy. Overall, the recurrence rates at 6, 12, and 24 months were 2.3%, 3.7%, and 7.6%, respectively., Conclusion: Gallbladder-preserving cholecystolithotomy is a safe and effective operative procedure for selected Chinese patients. The function of the gallbladder can be maintained after gallbladder-preserving cholecystolithotomy. The recurrence of cholelithiasis is infrequent in this Chinese population with a mean follow-up of 59 (range 8 to 120) months, and most patients with recurrent gallbladder stones experience no symptoms or only minor symptoms., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: There is a paucity of literature assessing the impact of endoscopic retrograde cholangiopancreatography (ERCP) availability at hospitals and the management of acute biliary pancreatitis (ABP). Thus, we sought to evaluate the impact of ERCP availability on the clinical outcomes of ABP., Methods: The Nationwide Inpatient Sample (2004-2013) was reviewed to identify adult inpatients (≥18 years) with ABP. Clinical outcomes (mortality, severe acute pancreatitis, and health care resource utilization) between hospitals that perform ERCP versus hospitals that do not perform ERCP were compared using multivariate and propensity score-matched analyses., Results: A majority of the non-ERCP hospitals were rural (73%) in location. Multivariate analysis demonstrated that the lack of ERCP availability was independently associated with increased mortality from ABP (odds ratio, 1.83; 95% confidence interval, 1.16-2.88). A propensity score-matched cohort analysis confirmed a significant increase in mortality from ABP in non-ERCP hospitals (1.1% vs 0.53%; odds ratio, 2.08; 95% confidence interval, 1.05-4.15, P = 0.037) compared with ERCP hospitals., Conclusions: This national survey reveals increased mortality for patients with ABP admitted to hospitals lacking ERCP services. While there is a need to increase ERCP availability in rural areas, optimizing strategies for early transfer of patients with ABP to hospitals with ERCP availability can potentially offset these limitations.

Background: Site-specific outcomes of resection for periampullary cancer have not been analyzed on a large, registry-based scale., Methods: We assessed data on periampullary cancers from the SEER database. Site- and stage-specific outcomes were analyzed. Resection was compared to no resection., Results: Resection was the main therapy in stages 1 and 2 (resection vs. no resection, 8644 vs. 7208 patients), was less frequent in stage 3 (1248 vs. 2783 patients) and was rarely-but still-used in stage 4 disease (541 vs. 11,212 patients). Pancreatic head (75.7%), 11.4% distal bile duct, 7.7% ampullary, and 5.3% duodenal cancers. Cancer subtype-independent median survival was 22.0 (resection) vs. 7.0 months (no resection) in stages 1 and 2, 21.0 vs. 8.0 months in stage 3, and 10.0 vs. 3.0 months in stage 4. Subtype-dependent median survival (resection vs. no resection) was 18.0 vs. 5.0 months in pancreatic head, 19.0 vs 4.0 months in distal bile duct, 41.0 vs 7.0 months in ampullary, and 38.0 vs 4.0 months in duodenal adenocarcinoma. On multivariable analysis, patient comorbidities, marital and insurance status, and income all influenced the decision to undergo resection., Conclusions: Surgery is still underutilized in the treatment of periampullary cancers. Patients with cancers originating from the duodenum or the ampulla of Vater benefit most from resectional surgery.

Introduction: We performed a study of the top 100 most cited articles in the five general surgery journals with the highest impact according to Journal Citation Report., Methods: We selected the five journals with the highest impact in 2015: Annals of Surgery, British Journal of Surgery, JAMA Surgery, Surgery, and Journal of the American College of Surgeons. In January 2017, using the Web of Science application, we performed a search of all articles published by these journals and identified the 100 most cited articles (top 100). We evaluated the number of citations, year of publication, type of article, country and hospital of the article, area of interest and number of authors., Results: The median number of citations per top 100 paper was 490. Twenty percent of the top 100 papers have been published since 2000. Overall, 70% are original papers, 8% randomized control trials, 11% reviews, 1% meta-analyses and 11% other subtypes. There are 13% proceedings papers. Sixty-one percent are from the US. The most frequently discussed topic is hepato-pancreato-biliary surgery (33%)., Conclusions: The top 100 most cited articles tend to be original articles describing studies carried out in the US, reporting significant surgical breakthroughs. Hepato-pancreato-biliary surgery is the most common subject area. Annals of Surgery had twice as many citations as the other journals studied. The archetypal article of the Top15 most cited is an original paper published in the twentieth century, with an average of 2000 citations., (Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background/aims: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP., Patients and Methods: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded., Results: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66-12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13-1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36-15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56-6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10-8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00-0.08) on multivariate analysis., Conclusion: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones., Competing Interests: None

This study aimed to assess the clinical value of transprepancreatic septotomy indwelling guide wire or pancreatic duct stent in intractable endoscopic retrograde cholangiopancreatography (ERCP) for bile duct cannulation.Of the 2107 patients treated by ERCP, a total of 81 cases with difficult bile duct cannulation underwent transprebiliopancreatic septotomy (referred to as the septotomy group, 37 cases) and transprepancreatic septotomy with pancreatic duct stent (modified septotomy group, 44 cases). Success rates of cannulation and postoperative complications for both methods were compared.Among them, 77 cases were successfully administered bile duct cannulation. The success rates of the septotomy and modified septotomy groups were 91.89% and 97.73%, respectively, with no significant difference (P = .489). Of the 77 patients, 12 cases had complications. The septotomy group included 7 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases; while in the modified septotomy group, there were 1 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases. The occurrence rate of acute pancreatitis in the modified septotomy group was lower than that of the septotomy group (2.33% vs 20.59%) with a significant difference (P = .026).These findings indicate that transprepancreatic septotomy with pancreatic duct stent seems to be a safe and feasible operation with reducing complication rates., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Summary: Over the last 3 decades, expansion in the scope and complexity of hepatopancreatobiliary (HPB) surgery has resulted in significant improvements in postoperative outcomes. As a result, the importance of dedicated fellowship training for HPB surgery is now well established, and the definition of formal program requirements has been actively pursued by a collaboration of the 3 distinct accrediting bodies within North America. While major advances have been made in defining minimum case volume requirements, qualitative assessment of the operative experience remains challenging. Our research collaborative (HPB Manpower and Education Study Group) has previously explored the perceived case volume adequacy of core HPB procedures within fellowship programs. We conducted a 1-year follow-up survey targeting the same cohort to investigate the association between operative case volumes and comfort performing HPB procedures within initial independent practice.

Background: The detection of celiac disease (CD) is suboptimal., Aims: We hypothesized that misdiagnosis is leading to diagnostic delays, and examine this assertion by determining if patients have increased risk of abdominal surgery before CD diagnosis., Methods: Through biopsy reports from Sweden's 28 pathology departments we identified all individuals with CD (Marsh stage 3; n=29,096). Using hospital-based data on inpatient and outpatient surgery recorded in the Swedish Patient Register, we compared abdominal surgery (appendectomy, laparotomy, biliary tract surgery, and uterine surgery) with that in 144,522 controls matched for age, sex, county and calendar year. Conditional logistic regression estimated odds ratios (ORs)., Results: 4064 (14.0%) individuals with CD and 15,760 (10.9%) controls had a record of earlier abdominal surgery (OR=1.36, 95% CI=1.31-1.42). Risk estimates were highest in the first year after surgery (OR=2.00; 95% CI=1.79-2.22). Appendectomy, laparotomy, biliary tract surgery, and uterine surgery were all associated with having a later CD diagnosis. Of note, abdominal surgery was also more common after CD diagnosis (hazard ratio=1.34; 95% CI=1.29-1.39)., Conclusions: There is an increased risk of abdominal surgery both before and after CD diagnosis. Surgical complications associated with CD may best explain these outcomes. Medical nihilism and lack of CD awareness may be contributing to outcomes., (Copyright © 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The rupture of hydatid cyst of the liver into the biliary tracts through a large fistula is one of the most difficult complications to treat. The techniques are various and each has its own morbidity. Internal transfistulary drainage is a surgical method of treatment of hydatid cysts of the liver opening in the biliary tract., Aims: The aim of this study was to identify the risk factors of specific postoperative complications of this surgical technique Methods: During the period's study, 823 patients with liver hydatid cyst were operated. 86 (11 %) of them were opened in the bile ducts through a large fistula. 50 patients (58 %) had internal transfistulary drainage., Results: The sex ratio was 1.6. The population was young with an average age of 40.8 years. The most frequent clinical feature of the opening in the biliary tract was acute cholangitis (42 %). The most common location of hydatid cyst was at the hepatic dome. The pericyst was flexible in only 62 % of cases. Thick pericysts were made flexible in 20% of cases and partly resection of protruding dome was made in 36 % of cases. Specific morbidity rate was 16% with no mortality. The uni and multivariate analysis had identified as risk factors for specific complications: the thick pericyst (P = 0.04), a size of the residual cavity ≥ 9cm; non visualization of the residual cavity on the post operative cholangiography was of borderline statistical significance (P = 0.049)., Conclusion: The internal transfistulary drainage is an easy and reliable surgical technique, its morbidity is low. It's indicated in the cases of large fistula with a thin pericyst and a diameter of the residual cavity less than 09 cm. Making thick pericyst flexible is a false security for the indication of internal transfistulary drainage and the non visualization of the residual cavity on the post operative cholangiography impose more frequent control for these patients since they are at risk of complications.

Background: The routine use of preoperative biliary drainage before pancreaticoduodenectomy (PD) remains controversial. This observational retrospective study compared stented and non-stented patients undergoing PD to assess any differences in post-operative morbidity and mortality., Methods: A total of 180 consecutive patients who underwent PD and had intra-operative bile cultures performed between January 2010 and February 2013 were retrospectively identified. All patients received peri-operative intravenous antibiotic prophylaxis, primarily cefazolin., Results: Overall incidence of post-operative surgical complications was 52.3 %, with no difference between stented and non-stented patients (53.4 % vs. 51.1 %; p = 0.875). However, stented patients had a significantly higher incidence of deep incisional surgical site infections (SSIs) (p = 0.038). In multivariate analysis, biliary stenting was confirmed as a risk factor for deep incisional SSIs (p = 0.044). Significant associations were also observed for cardiac disease (p = 0.010) and BMI ≥25 kg/m(2) (p = 0.045). Enterococcus spp. were the most frequent bacterial isolates in bile (74.5 %) and in drain fluid (69.1 %). In antimicrobial susceptibilty testing, all Enterococci isolates were cefazolin-resistant., Conclusion: Given the increased risk of deep incisional SSIs, preoperative biliary stenting in patients underging PD should be used only in selected patients. In stented patients, an antibiotic with anti-enterococcal activity should be chosen for PD prophylaxis.

Background & Aims: Pyogenic liver abscess (PLA) is a rare and severe extraintestinal complication in patients with inflammatory bowel disease (IBD). However, the incidence of PLA in patients with IBD remains unknown., Methods: A nationwide cohort study was conducted by analysing data from the National Health Insurance Research Database in Taiwan. Patients with IBD (N = 11 504) from 2000 to 2010 and control participants without IBD (N = 46 016) were included in this study. We analysed the risks of PLA by using competing-risks (death) regression models., Results: The incidence of PLA was higher in the IBD cohort than in the control cohort (6.72 vs 4.06 per 10 000 person-years), with an adjusted subhazard ratio (SHR) of 1.46 (95% confidence interval [CI], 1.01-2.12). Patients with IBD who required two or more hospitalizations per year and underwent laparotomy had an increased risk of PLA. Patients with ulcerative colitis were more likely to develop PLA than were those with Crohn's disease (incidence, 8.56 vs 5.45 per 10 000 person-years; adjusted SHR, 1.65 vs 1.32). Among the IBD cohort, age and gender did not affect PLA risk. Patients with diabetes mellitus or percutaneous aspiration of the gallbladder and biliary tract and who underwent endoscopic insertion of a biliary drainage tube exhibited a significantly increased risk of PLA., Conclusions: Patients with IBD exhibited an increased risk of developing PLA, particularly those with ulcerative colitis. Knowledge of the expected frequency and potential risk for this severe extraintestinal infection may minimize the serious consequences., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Aim: To summarize the covered or uncovered SEMS for treatment of unresectable malignant distal biliary obstruction, comparing the stent patency, patient survival, and incidence of adverse events between the two SEMSs., Methods: The meta-analysis search was performed independently by two of the authors, using MEDLINE, EMBASE, OVID, and Cochrane databases on all studies between 2010 and 2015. Pooled effect was calculated using either the fixed or the random effects model., Results: Statistics shows that there is no difference between SEMSs in the hazard ratio for patient survival (HR 1.04; 95% CI, 0.92-1.17; P = 0.55) and stent patency (HR 0.87, 95% CI: 0.58 to 1.30, P = 0.5). However, incidence of adverse events (OR: 0.74, 95% CI: 0.57 to 0.97, P = 0.03) showed significant different results in the covered SEMS, with dysfunctions events (OR: 0.75, 95% CI: 0.56 to 1.00, P = 0.05) playing a more important role than complications (OR: 0.87, 95% CI: 0.58 to 1.30, P = 0.50)., Conclusions: Covered SEMS group had lower incidence of adverse events. There is no significant difference in dysfunctions, but covered SEMS trends to be better, with no difference in stent patency, patient survival, and complications.

Background: Studies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our objective was to determine if RVUs adequately reflect increased surgeon effort required to treat emergent versus elective patients receiving similar procedures., Methods: A retrospective analysis using The American College of Surgeons' National Surgical Quality Improvement Program 2011 data set was conducted. The control group consisted of patients undergoing elective colectomy, hernia repair, or biliary procedures as identified by Current Procedural Terminology. Comparison was made to emergent cases after being stratified to laparoscopic or open technique. Generalized linear models and logistic regression were used to assess specific outcomes, controlling for demographics and comorbidities of interest. The RVUs, operative time, and length of stay (LOS) were primary variables, with major/minor complications, mortality, and readmissions being evaluated as the relevant outcomes., Results: A total of 442,149 patients in the National Surgical Quality Improvement Program underwent one of the operative procedures of interest; 27,636 biliary (91% laparoscopic; 8.5% open), 28,722 colorectal (40.3% laparoscopic, 59.7% open), and 31,090 hernia (26.6% laparoscopic, 73.4% open) operations. Emergent procedures were found to have average RVU values that were identical to their elective case counterparts. Complication rates were higher and LOS were increased in emergent cases. Odds ratios for complications and readmissions in emergent cases were twice those of elective procedures. Mortality was skewed toward emergent cases., Conclusion: Our data indicate that the emergent operative management for various procedures is similarly valued despite increased LOS, more complications, higher mortality risk, and subsequently increased physician attention. Our findings suggest that the RVU system for acute care surgeons may need to be reevaluated to better capture the additional work involved in emergent patient care.

Background: Historically, emergency gallbladder surgery in elderly patients has been associated with high rates of morbidity and mortality. Recent studies have described much lower complication rates that may still overestimate morbidity. The purpose of this study was to determine the true population morbidity and mortality rates after gallbladder surgery in the elderly., Methods: All elderly patients (defined as age 65 years or older) admitted to the hospital with a principle diagnosis related to benign gallbladder disease in the Province of Manitoba from January 1, 1995 to December 31, 2008 were identified by using administrative claims data. Outcomes after emergency gallbladder surgery, including complication rates and their predictors, were compared with outcomes after elective surgery and after nonoperative treatment for gallbladder-related hospital admissions., Results: A total of 9,936 patients were included: 2,355 had emergency or urgent surgery and 4,901 had elective procedures, whereas 2,680 patients were treated without surgery. Emergency gallbladder surgery was associated with a mortality rate of 0.7 %, compared with 1.6 % for elective cases and 5.6 % for patients treated nonoperatively. Complication rates were 16.2, 17.7, and 25 % respectively. Independent predictors of 30-day mortality were age, male gender, increasing comorbidity, surgeon experience, and surgical treatment., Conclusions: Emergency gallbladder surgery in the elderly was not associated with higher mortality or complication rate compared with the elective setting. Elderly patients with gallbladder-related emergencies should be offered urgent surgery when feasible.

Background: The use of surgical robots has slowly gained an increasing presence in the realm of hepatobiliary and pancreatic (HPB) surgery. With additional experience, anecdotal evidence has been useful in guiding patient selection for complex robotic procedures. In the following analysis, we reviewed our case series and looked for predictors of conversion in robotic HPB surgery., Methods: We retrospectively reviewed all patients who underwent robotic HPB procedures by a single surgeon at two institutions during March 2006-June 2012. Patient demographics, operative data, procedure type and conversion information were recorded. Trends were analysed for indications for conversion. A subset analysis of robotic-assisted laparoscopic distal pancreatomy was performed and compared with laparoscopic and open distal pancreatectomy during the same time period by the same surgeon., Results: During this time period, 77 patients underwent robotic hepatobiliary and pancreatic procedures. All procedures were performed by a single surgeon (J.M.) and included 38 males (49%) and 39 females (51%). Median age was 59 and the majority of patients were ASA class III. There were 24 conversions, which decreased in frequency from 2009 (7) to 2011 (3). Reasons for conversion included significant obesity and technical difficulty. Patients with conversions had more intraoperative blood loss (966 vs 176 ml), more frequently received transfusion (29% vs 2%) and were more likely to have postoperative intensive care. Overall length of stay was longer following conversion (8.3 vs 5.6 days)., Conclusions: Robotic-assisted hepatobiliary and pancreatic procedures are often extremely complex, with a significant learning curve. Recognizing factors that prohibit successful completion of a robotic-assisted surgical procedure is key for patient safety. Careful patient selection in the appropriate settings facilitates the maximal benefit of robotic-assisted complex HPB surgery., (Copyright © 2013 John Wiley & Sons, Ltd.)

Choledochal cysts are increasingly reported in adults. The presence of cyst-related complications alters its presentation and complicates the management. We reviewed our experience to find the clinical presentation, complications, and the management of choledochal cysts. The records of 132 patients with choledochal cysts presented to us between 2003 and 2010 maintained as a prospective database were analyzed for demography, clinical presentation, radiological investigation, management, and outcome. There were 12 children and 120 adults. Based on preoperative cholangiogram, 93 (71%) patients had Type I and 39 (29%) Type IVA cysts. The overall incidence of complicated choledochal cyst was 4 of 12 (33%) in children and 85 of 120 (71%) in adults. The most common complication was cystolithiasis (49%) followed by cholangitis (32%), acute pancreatitis (10%), hepatolithiasis (7%), malignancy (3%), portal hypertension (2%), and chronic pancreatitis (2%). Acute pancreatitis and cholangitis were managed conservatively. Endoscopic stenting was performed in patients with cholangitis and those requiring staged treatment as a result of portal hypertension. Overall 114 patients underwent cyst excision with Roux-en-y hepaticojejunostomy. The overall morbidity was 17.5 per cent (wound infection 13% and bilioenteric anastomotic leak 7%). There was one postoperative death resulting from cardiac failure. Three patients developed anastomotic stricture and underwent redo hepaticojejunostomy. Choledochal cysts in adults are often associated with complications. Complications are more common in adults compared with children. Acute pancreatitis, cholangitis and portal hypertension are managed conservatively and then followed up by definitive surgery. Cyst excision with Roux-en-Y hepaticojejunostomy is necessary to prevent the recurrence of complications.

Background: Complex hepatobiliary surgical procedures for benign and malignant conditions are regularly performed at tertiary academic referral centers with excellent outcomes, but whether similar surgical outcomes are achievable in community hospitals is not well documented., Methods: Eighty-four patients underwent complex hepatobiliary surgery between December 2004 and December 2008. Data were prospectively analyzed, including patient demographics, operative procedures, perioperative parameters, pathology, complications up to 30 days postoperatively, and long-term outcomes., Results: The most frequent procedures performed were isolated segmentectomy or segmentectomies (n = 41 [49%]). Major hepatic resections (n = 32 [38%]) included 25 lobectomies (30%) and 7 trisegmentectomies (8%). Nine patients (11%) had surgical complications, and the most common indications for surgery was metastatic carcinoma (n = 42 [50%])., Conclusions: Complex hepatobiliary surgery can be performed safely at a community-based teaching hospital with excellent outcomes. In the ongoing debate centering on mandatory referral and centralization of complex surgical procedures, tertiary community hospitals with well-determined outcomes should be included., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: We sought to examine biliary complications in adult right-lobe living donor liver transplantation (LDLT) with duct-to-duct anastomosis (RL-LDLT-DD), evaluating the efficacy of endoscopic retrograde cholangiography (ERC) in the diagnosis and management of biliary complications following LDLT., Methods: Ninety adult RL-LDLT-DD were performed from June 2004 to August 2007, including 21 (23.3%) cases of biliary complications., Results: The endoscopic retrograde cholangiopancreatiography (ERCP) findings were stricture only (n = 8), stricture plus leakage (n = 9), and leakage only (n = 4). In the overall 13 cases of leakage, nine patients recovered after treatment by stent or endoscopic nasobiliary drainage. The time to resolution was 3.0 +/- 1.3 months with 2.2 +/- 1.3 endoscopic examinations. All bile duct complications were treated by ERC first. Among 17 cases with stricture, seven cases were successfully treated by endoscopy and three cases by percutaneous transhepatic cholangiography plus stent (PTCS). In the other seven cases, the treatment was still ongoing in five cases and two subjects died during treatment. The mean time to stricture resolution 7.2 +/- 3.3 months with 3.9 +/- 1.4 endoscopic examinations. The results of 21 cases were 5/21 mortalities (23.8%), successful ERC treatment in 9/21; (42.9%), successful PTCS treatment in 3/21 (14.3%), and ongoing ERC treatment in 5/21, (23.8%), including one case with successful ERC treatment who died of lung infection postoperatively. During follow-up (13.1 +/- 9.9 months), there was no recurrence in the stricture or leak., Conclusions: When compared with the literature, RL-LDLT-DD without biliary drainage does not increase the incidence of biliary complications. From our study, ERC and PTC play a complementary roles in the treatment of bile duct complications.

Background: Most centers advocate orthotopic liver transplantation (OLT) for patients with primary sclerosing cholangitis (PSC) and cirrhosis. Management of PSC patients without cirrhosis remains controversial. We examined the results of extrahepatic biliary resection (EHBR) for PSC., Study Design: Between 1981 and 2006, 126 patients with PSC underwent EHBR (n = 77) or OLT (n = 49). Data on biliary drainage procedures, perioperative morbidity, and longterm survival were collected and analyzed., Results: Of 77 patients undergoing EHBR, mean preoperative bilirubin level was 5.6 mg/dL. Nine (11.7%) patients had cirrhosis. Most patients had preoperative biliary drainage (ERCP, 61.0%; PTC, 67.5%). At operation, 73 (94.8%) patients underwent EHBR, including hepatic duct bifurcation. Most patients also had insertion of bilateral transhepatic silicone elastomer biliary stents; 4 (5.2%) underwent EHBR with stent insertion plus hepatectomy. For EHBR patients, perioperative complication rate was 38.7% and 30-day mortality was 3.9%. Bilirubin levels significantly decreased postoperatively (mean drop 3.8 mg/dL; p < 0.01). At 3 years, 57.1% of patients had no PSC-related readmissions, and 16.2% had more than 3. At a median followup of 10.5 years, 5- and 10-year survival was 76.4% and 52.7%, respectively. Cholangiocarcinoma did not develop in any patients, and only seven required OLT. Factors associated with worse survival included postoperative bilirubin >or= 2 mg/dL and history of cirrhosis (both p < 0.001). In patients undergoing EHBR, noncirrhotic patients had significantly better longterm outcomes versus cirrhotic patients (10-year survival, 60.2% versus 12.0%; p < 0.001). In contrast, 10-year survival of OLT patients with cirrhosis was 57.0%., Conclusions: Noncirrhotic patients with PSC can be successfully managed with EHBR. EHBR for noncirrhotic patients is associated with low perioperative morbidity, few readmissions, no new cholangiocarcinomas, and 10-year survival > 60%. OLT should be reserved for patients with PSC and associated hepatic cirrhosis.

Operations on the liver and pancreas have fallen within the domain of the general surgeon and have been part of general surgery training. The more complex procedures involving these organs are limited in number in most general surgery residencies and do not afford an opportunity for vast experience. Moreover, fellowship programs in hepato-bilio-pancreatic (HPB) surgery and the development of laparoscopic techniques may have further limited the familiarity of general surgery residents with these operations. To determine the experience accrued by finishing general surgery residents, we accessed, through the Residency Review Committee of the Accreditation Council for Graduate Medical Education, the Resident Case Log System used by general surgery residents throughout their training to document operative cases. The number of operations on the gallbladder, bile ducts, pancreas, and liver was examined over the past 16 years (there were missing data for 3 years). Reference years 1995 and 2005 were compared to detect trends. Experience with laparoscopic cholecystectomy has steadily increased and averaged more than 100 cases in 2006. Experience in liver resection, distal pancreatectomy, and partial (Whipple) pancreatectomy has statistically improved from 1995 to 2005, but the numbers of cases are low, generally less than five per finishing resident. Experience in open common bile duct and choledocho-enteric anastomoses has statistically declined from 1995 to 2005, averaging less than four cases per finishing resident. The mode (most frequently performed number) for liver and pancreas resections was either 0 or 1. It is doubtful this experience in HPB surgery engenders confidence in many finishing residents. Attention should be focused on augmenting training in HPB surgery for general surgery residents perhaps through a combination of programmatic initiatives, ex vivo experiences, and minifellowships. Institutional initiatives might consist of defined HPB services with appropriate expertise, infrastructure, process, and outcome measures in which a resident-oriented, competency-based curriculum could be developed.

Objective: To determine the outcomes of Canadian children with biliary atresia., Study Design: Health records of infants born in Canada between January 1, 1985 and December 31, 1995 (ERA I) and between January 1, 1996 and December 31, 2002 (ERA II) who were diagnosed with biliary atresia at a university center were reviewed., Results: 349 patients were identified. Median patient age at time of the Kasai operation was 55 days. Median age at last follow-up was 70 months. The 4-year patient survival rate was 81% (ERA I = 74%; ERA II = 82%; P = not significant [NS]). Kaplan-Meier survival curves for patients undergoing the Kasai operation at age < or = 30, 31 to 90, and > 90 days showed 49%, 36%, and 23%, respectively, were alive with their native liver at 4 years (P < .0001). This difference continued through 10 years. The 2- and 4-year post-Kasai operation native liver survival rates were 47% and 35% for ERA I and 46% and 39% for ERA II (P = NS). A total of 210 patients (60%) underwent liver transplantation; the 4-year transplantation survival rate was 82% (ERA I = 83%, ERA II = 82%; P = NS)., Conclusions: This is the largest outcome series of North American children with biliary atresia at a time when liver transplantation was available. Results in each era were similar. Late referral remains problematic; policies to ensure timely diagnosis are required. Nevertheless, outcomes in Canada are comparable to those reported elsewhere.

Background/aims: Because dietary modifications have prolonged the life expectancy of patients with glycogen storage disease type Ia (GSD Ia), the incidence of hepatocellular adenoma (HCA) to carcinoma (HCC) transformation is increasing. The objective of this retrospective study is to assess the safety and effectiveness of HCA resection in GSD Ia patients., Methods: Clinicopathologic, peri-operative, and long-term data were reviewed from patients who underwent HCA resection. Comparisons were made with Fisher's exact, Mann-Whitney U, and log-rank tests; survival was estimated with Kaplan-Meier analysis., Results: From 1998 to 2006, 38 patients underwent HCA resection. Seven (22%) had GSD Ia. Post-operative mortality occurred in one GSD Ia patient. GSD Ia patients had greater morbidity (86% vs. 20%) and shorter time to adenoma progression (median 23 months vs. not yet reached) after partial hepatectomy compared to the general population (p<0.05). Six GSD Ia patients had no evidence of HCC and recovered after resection without long-term morbidity. Three GSD Ia patients underwent liver transplantation 77, 32, and 23 months after adenoma resection., Conclusions: Despite substantial morbidity, partial hepatectomy is feasible in GSD Ia patients and is an effective intermediate step in the prevention of HCC until definitive treatment with liver transplantation.

Background/aims: To study the impact of hepatitis B e antigen on tumor recurrence and patients' survival after curative resection of hepatocellular carcinoma., Methods: Two hundred and three patients with small hepatocellular carcinomas (3cm) who had undergone curative resection were divided into HBeAg-positive group and HBeAg-negative group. Clinicopathological factors and postoperative outcomes were compared between groups, and risk factors for survival and recurrence were studied., Results: The median follow-up time was 32.9months. Patients with negative HBeAg had higher 5-year overall survival rates (76% vs 53.9%, hazards ratio (HR): 2.363, 95% CI: 1.335-4.181, p=0.002) and 5-year disease-free survival rates (52.9% vs 37.4%, HR: 1.603, 95% CI: 1.00-2.561, p=0.046). There was no significant difference in operative morbidity and tumor factors between the two groups, but younger age, higher serum alanine aminotransferase levels, and more macronodular cirrhosis were found in the HBeAg-positive group. Multivariate analysis revealed that age >50years, HBeAg positivity and macronodular cirrhosis were independent factors for overall survival, and HBeAg positivity and multiple tumor nodules were independent factors for disease-free survival. Positive serum HBeAg was associated with a higher risk of early recurrence (within 1year)., Conclusions: HBeAg is associated with a higher risk of early recurrence and poorer survival in patients after curative resection of small HCC.

Objective: Several pre-cut procedures have been used in patients with inaccessible bile ducts. Trans-pancreatic sphincterotomy (TS) has been demonstrated to be a valid, but little used technique. We describe our experience with TS with a prospective analysis of its results., Patients and Methods: Twenty patients who underwent TS due to the impossibility of cannulating the biliary tract using routine methods between November 2004 and October 2005 were included. CT-25 sphincteromes (Cook) were used, introducing the tip into the common bile duct or pancreatic duct, performing the cut toward the bile duct, and sectioning the roof of the common bile duct., Results: We performed 298 ERCP, 176 sphincterotomies and 20 TS (11.3% of sphincterotomies). Cannulation was achieved in 90% of the patients overall and immediate cannulation was achieved in 85%. The percentage of complications was 15% and none were severe. There were no cases of post-ERCP pancreatitis or mortality due to complications., Conclusions: TS is an effective technique in gaining immediate access to the biliary tract in a high percentage of patients when access cannot be obtained using routine methods. The risk of complications in not higher than that of other pre-cut techniques.

Background: Both hospital and surgeon volume influence outcomes. With introduction of new technologies, some procedures are now performed less frequently. ERCP has replaced the need for common duct exploration (CDE) in most cases of choledocholithiasis. We explored the secular trends and outcomes of CDE and how they have changed relative to introduction of ERCP., Study Design: The National Hospital Discharge Survey database was analyzed for the years 1979 to 2001. Procedural frequency of ERCP and CDE was determined. Charlson and Elixhauser comorbidity indices were used to characterize patients' disease burden for the years 1993 to 2001. Length of stay, mortality, and complication rates for each procedure were determined., Results: At the beginning of the study period, an estimated 47,000 CDEs were performed annually. These declined to 7,700 per year as ERCP increased to 42,500 procedures per year at the end of the study period. CDE complication rates increased from 3.4% to 17.4% over the same period. Comorbidity analysis for the years 1993 to 2001 revealed that ERCP and CDE patients had equivalent disease burdens. Technical complication rates rose in parallel to the increased overall CDE complication rate., Conclusions: ERCP has replaced the need for most but not all CDE. With diminished CDE experience at a national level, the complication rate has markedly increased, at least in part from technical complications. Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CDE experience.

Context: Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear., Objective: To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries., Design, Setting, and Patients: Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury., Main Outcome Measure: Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics., Results: Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.88) for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon., Conclusions: The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.

Context: The Heart and Estrogen/progestin Replacement Study (HERS) was a randomized trial of estrogen plus progestin therapy after menopause., Objective: To examine the effect of long-term postmenopausal hormone therapy on common noncardiovascular disease outcomes., Design and Setting: Randomized, blinded, placebo-controlled trial of 4.1 years' duration (HERS) and subsequent open-label observational follow-up for 2.7 years (HERS II), carried out between 1993 and 2000 in outpatient and community settings at 20 US clinical centers., Participants: A total of 2763 postmenopausal women with coronary disease and average age of 67 years at enrollment in HERS; 2321 women (93% of those surviving) consented to follow-up in HERS II., Intervention: Participants were randomly assigned to receive 0.625 mg/d of conjugated estrogens plus 2.5 mg of medroxyprogesterone acetate (n = 1380) or placebo (n = 1383) during HERS; open-label hormone therapy was prescribed at personal physicians' discretion during HERS II. The proportions with at least 80% adherence to hormones declined from 81% (year 1) to 45% (year 6) in the hormone group and increased from 0% (year 1) to 8% (year 6) in the placebo group., Main Outcome Measures: Thromboembolic events, biliary tract surgery, cancer, fracture, and total mortality., Results: Comparing women assigned to hormone therapy with those assigned to placebo, the unadjusted intention-to-treat relative hazard (RH) for venous thromboembolism declined from 2.66 (95% confidence interval [CI], 1.41-5.04) during HERS to 1.40 (95% CI, 0.64-3.05) during HERS II (P for time trend =.08); it was 2.08 overall for the 6.8 years (95% CI, 1.28-3.40), and 3 of the 73 women with thromboembolism died within 30 days due to pulmonary embolism. The overall RH for biliary tract surgery was 1.48 (95% CI, 1.12-1.95); for any cancer, 1.19 (95% CI, 0.95-1.50); and for any fracture, 1.04 (95% CI, 0.87-1.25). There were 261 deaths among those assigned to hormone therapy and 239 among those assigned to placebo (RH, 1.10; 95% CI, 0.92-1.31). Adjusted and as-treated analyses did not alter our conclusions., Conclusions: Treatment for 6.8 years with estrogen plus progestin in older women with coronary disease increased the rates of venous thromboembolism and biliary tract surgery. Trends in other disease outcomes were not favorable and should be assessed in larger trials and in broader populations.

Objective: To find out if our results for the treatment of extrahepatic bile duct cancer have improved we reviewed our latest patients as a comparison to a previously reported series from this department., Design: Retrospective study., Setting: Tertiary referral centre, Sweden., Subjects: 102 patients who presented with extrahepatic bile duct cancer 1979-1995., Main Outcome Measures: Morbidity, mortality, and short and long term survival., Results: 16 patients had various types of resection, which were radical in 14 according to the surgeon and in 10 according to the pathologist. One patient (6%) died in hospital, and 1 (44%) developed complications. 13 patients had other operations that did not involve resection, 23 had laparotomy alone, 61 had biliary drainage either by percutaneous transhepatic cholangiography (PTC) or endoscopy, and 10 had no active treatment. One patient of the 16 (6%) who had resections has survived for more than five years and another one is still alive after 40 months., Conclusion: Long term survival has not improved for patients with extrahepatic bile duct cancer in our hospital during the last decades.

Background: Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationship between hospital volume and mortality with this procedure across all US hospitals., Methods: Using information from the Medicare claims database, we performed a national cohort study of 7,229 Medicare patients more than 65 years old undergoing pancreaticoduodenectomy between 1992 and 1995. We divided the study population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (<1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate logistic regression to account for potentially confounding patient characteristics, we examined the association between institutional volume and in-hospital mortality, our primary outcome measure., Results: More than 50% of Medicare patients undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, respectively, vs. 4%, P<.001). Within the high-volume quartile, the 10 hospitals with the nation's highest volumes had lower mortality rates than the remaining high-volume centers (2.1% vs. 6.2%, P<.01). The strong association between institutional volume and mortality could not be attributed to patient case-mix differences or referral bias., Conclusions: Although volume-outcome relationships have been reported for many complex surgical procedures, hospital experience is particularly important with pancreaticoduodenectomy. Patients considering this procedure should be given the option of care at a high-volume referral center.

Controversy persists regarding the role of prophylactic gastrojejunostomy in patients with unresectable periampullary adenocarcinoma. In review of the retrospective series, presence of gastric outlet obstruction (GOO) has been claimed to be a bad prognostic sign. This prospective study aimed to clarify the necessity of routine prophylactic gastrojejunostomy in patients with unresectable periampullary adenocarcinoma. The incidence and prognostic significance of GOO were also evaluated. Sixty-six patients with unresectable periampullary adenocarcinoma were enrolled. They were divided into 2 groups to receive either a single biliary bypass or a double bypass (concomitant gastric and biliary bypasses) if they had GOO. The single bypass group was followed up to assess the incidence of GOO and subsequent need of a gastric bypass. Prognostic factors were evaluated by univariate and multivariate analyses. Forty-four (67%) of the overall 66 patients presented with GOO at the time of diagnosis. There was no statistical difference regarding the morbidity and mortality between the 2 groups, except longer (7 days) hospital stay in the double bypass group. Seven (31.8%) of the 22 patients in the single bypass group subsequently developed GOO an average of 6.2 +/- 1.0 months after their initial biliary bypass. By univariate analysis, significant prognostic factors for unresectable periampullary adenocarcinoma were: GOO (p = 0.0379), pancreatic head origin (p = 0. 0146 by univariate analysis), and distant metastasis (p < 0.0001). After multivariate analysis, only pancreatic head origin and distant metastasis remained significant independent factors of poor prognosis. In conclusion, gastrojejunostomy should be performed prophylactically in addition to a biliary bypass in patients with unresectable periampullary adenocarcinoma. The presence of GOO is not an independent factor of poor prognosis, but a reflection of the aggressive biologic behavior of pancreatic head adenocarcinoma.

After reviewing the literature on this subject, the authors examine the quality of life of geriatric patients after biliary tract surgery secondary to biliary tract carcinoma or non-neoplastic pathologies. From an analysis of the results the authors conclude that surgery is useful not only in non-neoplastic forms, but also in the event of carcinoma given that it is possible to improve the quality of life of these patients.

Reoperations of the biliary apparatus is a branch of biliary surgery still not well enough clarified and difficult to cope with. A total of 169 patients are subjected to operation and investigation in the clinic of abdominal surgery. In 71 of them reoperation is undertaken over the period 1952-1973, and in 97--in the period 1974 through 1993, representing 8.7 per cent of all biliary operations done for benign diseases of the biliary apparatus. In 95 per cent of cases the primary operation is related to cholelithiasis (ChL). One-hundred fifty-five cases (92.6 per cent) are reoperated once, nine (5.3 per cent)--twice, and four (0.7 per cent)--three, four and five times. What is more, 56 of the patients are operated in the clinic of abdominal surgery, and 112--elsewhere in surgical units and departments throughout the country. The severer clinical picture, prolonged postoperative period, increased operative risk and worsened prognosis in the latter group are underscored. The underlying causes necessitating secondary corrective intervention are analyzed--76 per cent are conditioned by ChL, and 24 per cent--by the primary operation. The indications for reoperation are classified in three groups: a) failure to remove or partially removed gallbladder, b) in case of preexisting primary, or secondary postoperative development of various forms of cholelithiasis, c) in surgery induced morbid conditions. A table is presented illustrating the character of secondary operations, performed in the series of 168 patients under study, namely: in 20 per cent the gallbladder is operated on, and in 80 per cent--the extrahepatic bile ducts. Postoperative morbidity is higher as compared to the one in primary operations and not infrequently it is conditioned by preexisting complications. Postoperative mortality rate amounts to 10 per cent.

From 1968 to 1983, 271 patients were treated for biliary atresia by a group of surgeons from the same pediatric surgical unit, in Paris, using procedures adapted to the local anatomy and all derived from the Kasai technique. Eighty children have survived more than 10 years since the surgery, without the need for liver transplantation during the 10-year period. However, three children died subsequently from complications of the liver disease. Thirteen others later underwent liver transplantation, which accounted for three additional deaths. Thus, of the 64 patients left for study, 38 had a good result with respect to serum bilirubin level, but 18 of them still have symptoms of portal hypertension. Among another group of 14 patients with serum bilirubin levels between 18 and 36 mumol/L, 11 are leading a near-normal life. The mean follow-up period for this study is 14 years; the oldest patient is aged 24 years. One patient, already the mother of a normal son, is awaiting her second baby; she was treated by portocholecystostomy at 2 months of age. As a rule, liver transplantation should not be considered an alternative to the Kasai operation as initial treatment of biliary atresia. It may be the only form of treatment for survivors without jaundice, if survival becomes compromised by complications owing to portal hypertension or pulmonary shunts.

Biliary apparatus cancer is a rare condition characterized by low operability percentage. This is a comparative study of two series of patients, operated during the periods 1952-1979 and 1980-1994. In the first observation period (28 years) 119 patients are operated, and in the second 13-year period a total of 206 patients are subjected to operative and endoscopic treatment. One-hundred five patients present gallbladder carcinoma. The age, gender and clinical patterns characterizing the contingent being examined do not show noteworthy changes with time. Over the past few years, a variety of palliative operations are used, with the proportion of cases subjected to radical operation showing no increase. Carcinoma of bile ducts is diagnosed in 98 patients. During the second observation period, the number of women and patients in advanced and senile age augment. The diagnosis is delayed; thanks to puncture biopsy with cytological study, histological verification shows a three-fold increase. The number of radical operations is slightly increased while the percentage of explorative laparotomies is noticeably diminished. Carcinoma of papilla Vateri has optimal outlooks for surgical treatment. In the latter case too the number of women and patients above 60 years of age shows an increase. Radical intervention is resorted to in fourteen out of 33 patients.

T tubes are commonly used to splint biliary anastomoses after liver transplantation. Although several advantages are claimed for this approach, there is undoubtedly some iatrogenic morbidity associated with the use of T tubes in this situation. We have evaluated 120 consecutive biliary reconstructions after liver transplant, the majority of which were unsplinted end to end bile duct anastomoses. We have shown that biliary leakage and stricture rates are not significantly affected by T tubes. We have also shown that endoscopic retrograde cholangiopancreatography and percutaneous cholangiography are reliable posttransplant methods for cholangiography and stricture dilatation. Routine T tube splintage of post-liver transplant biliary anastomoses is unjustified.

Of 7000 patients operated on biliary ducts in 622 the recovering and reconstructive interventions were conducted. Late follow-up result was studied in 313 (51%) patients. Good result was noted in 179 (57.7%) patients, fair--in 99 (32.2%), poor--in 35 (10.1%) in terms from 3 months till 17 years. In patients operated on for the "forgotten" biliary ducts concrements, frequently combined with stenosis of common biliary duct terminal portion, most frequently good and fair result was noted. Late follow-up result of reconstructive operations using external transhepatic carcass drainage was significantly better than after application of other methods of correction for high stricture and injury of biliary ducts.

The extrahepatic biliary tree traumatisms are rare and hard to diagnose; 15 of 864 patients with surgery treatment for abdominal trauma for over 19 years (1974-1992) were studied retrospectively. Twelve blunt abdominal traumas (9 traffic accident and 3 falls down) and 3 open traumas (stabbing in two and gunshot wounds in one case). Eleven had gallbladder injury, two gallbladder and biliary duct and two exclusively biliary duct. Only one case was an isolated lesion, in the rest of cases, intra or extra abdominal lesions, occasionally both, were seen. The diagnostic method, associated lesions, morbi-mortality are reviewed. Surgical treatment was cholecystectomy for gallbladder injury and direct suture with T-tube (Kehr) for biliary duct injury.

Hepatobiliary scintigraphy with analogs of iminodiacetic acid (IDA) has become one of the primary tools in the diagnosis of biliary tract diseases, especially in the evaluation of surgical results and detection of complications that may arise from biliary operative procedures. We have performed cholescintigraphy in 19 patients. Of them, 9 underwent choledochojejunostomy with Roux-en-Y reconstruction for recurrent choledocholithiasis, 1 underwent right hepatic resection for metastasis extirpation, 8 were post cholecystectomy patients effected with upper abdominal pain located either in the epigastric region or right upper quadrant referable to post cholecystectomy syndrome and the last exhibited chronic pancreatitis ans suspicious sphincter of Oddi stenosis. The scintigraphy data were compared with the information yielded by sonography, intravenous cholangiogram (IVC) and, when possible, by endoscopic retrograde cholangiopancreatography (ERCP). Scans were considered pathologic when one or more of the following criteria were present: a) delayed biliary to bowel transit (greater than 1 hr), b) abnormal time-activity dynamic, c) no intestinal activity (obstruction), d) apparent ductal dilatation. In the group of biliary-enteric anastomosed patients, cholescintigraphic findings have shown 3 normal cases, 3 cases of biliary-intestinal obstruction confirmed by surgery, and 3 with abnormal activity retention in the jejunum loop due, in 2 patients, to hypokinesia since the quick emptying following the administration of 10 mg i.v. of metoclopramide, while in the other one, the surgery reexploration exhibited the presence of adhesions producing intestinal stricture. in the last patient of this group, the cholescintigraphy was performed to detect possible biliary leaks. In the post cholecystectomy patients, the cholescintigraphy exhibited in 3 cases dilated common duct with functional patency since the normal biliary-bowel transit time (less than 1 hr); this was confirmed by sonogram and IVC.(ABSTRACT TRUNCATED AT 250 WORDS)

The experience with simultaneous performance of the operations on the bile ducts and other organs in 802 patients, including 109 who underwent simultaneous operations on 2 or several organs for pathogenetically unrelated diseases (lethality--1.9%), 662--combined interventions on the anatomically and functionally connected organs for main disease and its complications (lethality 29%), is summarized. Simultaneous performance of the operations ensures the effective and radical surgical treatment.

Based on an analysis of 284 observations amounting to 1.8% of the total number of operations on organs of the abdominal cavity the authors give more exact indications to early relaparotomy and to more optimal methods to eliminate complications appearing after primary operations. They recommend wider use of additional methods of diagnosis of postoperative complications which will result in less lethality after relaparotomies.

The normal and pathological US features of different types of bilioenterostomy (hepaticojejunostomy, choledochoduodenostomy, polyductal bilioenteric anastomosis) are described, as observed in a prospective study of 27 patients, for a total number of 35 (18 normal and 17 abnormal) examinations. For 20 patients with hepaticojejunostomy, the bilioenteric anastomosis was identified on 13/13 normal examinations and 10/12 pathological examinations. For 2 patients with choledochoduodenostomy, the bilioenteric anastomosis was identified on 2/2 examinations. For 5 patients with polyductal bilioenteric anastomosis (each patient having 2 or 3 anastomoses), all surgical anastomoses were separately identified on 6/8 examinations; as for the remaining 2 patients, 2/3 and 1/3 anastomoses were seen. An abnormal condition was correctly recognized in all the 11 patients with local disease (lithiasis and benign biliary stricture, 2 patients; benign biliary stricture, 5 patients; primary cholangiocarcinoma, 1 patient; recurrent malignancy, 3 patients); in 1 patient, parenchymal and biliary abnormalities due to vascular obstruction were misinterpreted as a result of benign stricture. US can demonstrate the surgical anastomoses between the resected common bile duct or second order intrahepatic ducts and the jejunal loop, with typical features according to the type of surgery performed. Knowledge of such normal appearances after bilioenteric surgery is mandatory in order to detect and correctly evaluate such possible abnormalities at this site as lithiasis and benign or malignant strictures.

109 patients older than seventy years of age and operated of gallstone disease in our service during a period of 4.5 years are presented. The average age of the series was 78.8 years, with a male/female (M/F) ratio of 1/1.6. 77% of the patients were admitted on an emergency basis due to a complication derived from the gallstone disease they were suffering. Only 39.8% of the patients were previously diagnosed of gallstone disease at the time of admission and 10% presented an associated surgical condition which was treated simultaneously. Overall morbidity of the series was 36%, with a mortality of 2 cases (1.9%).