Adeel S. Khan

Neoadjuvant Therapy of Pancreatic Cancer: The Emerging Paradigm?

Pancreatic cancer remains one of the deadliest cancers due to difficulty in early diagnosis and its high resistance to chemotherapy and radiation. It is now clear that even patients with potentially resectable disease require multimodality treatment including chemotherapy and/or radiation to improve resectability and reduce recurrence. Tremendous efforts are currently being invested in refining preoperative staging to identify optimal surgical candidates, and also in developing various neoadjuvant or adjuvant regimens to improve surgical outcome. Although at present no studies have been done to directly compare the benefit of neoadjuvant versus adjuvant approaches, accumulating evidence suggests that the neoadjuvant approach is probably beneficial for a subset of the patient population, particularly those with borderline resectable disease in which complete surgical resection is almost certainly unachievable. In this article, we review the literature and rationales of neoadjuvant chemotherapy and chemoradiation, as well as their potential limitations and caveats. We also review the pathological findings following neoadjuvant therapies, and potential surgical complications that may be associated with neoadjuvant therapies.

Current surgical treatment strategies for hepatocellular carcinoma in North America

Hepatocellular carcinoma (HCC) is an aggressive tumor that often occurs in the setting of chronic liver disease. Many patients do not initially manifest any symptoms of HCC and present late when cure with surgical resection or transplantation is no longer possible. For this reason, patients at high risk for developing HCC are subjected to frequent screening processes. The surgical management of HCC is complex and requires an inter-disciplinary approach. Hepatic resection is the treatment of choice for HCC in patients without cirrhosis and is indicated in some patients with early cirrhosis (Child-Pugh A). Liver transplantation has emerged in the past decade as the standard of care for patients with cirrhosis and HCC meeting Milan criteria and in select patients with HCC beyond Milan criteria. Loco-regional therapy with transarterial chemoembolization, transarterial embolization, radiofrequency ablation and other similar local treatments can be used as neo-adjuvant therapy to downstage HCC to within Milan criteria or as a bridge to transplantation in patients on transplant wait list.

A Technique of Gastrojejunostomy to Reduce Delayed Gastric Emptying after Pancreatoduodenectomy

Delayed gastric emptying (DGE) through a gastroenterostomy is a clinical problem that affects many patients who have a standard Whipple procedure. A new method, which is associated with a low rate of DGE, is described.

Malpositioned transjugular intrahepatic portosystemic shunt in the common hepatic duct leading to biliary obstruction and liver transplantation.

For more than 20 years, placement of a transjugular intrahepatic portosystemic shunt (TIPS) has been a first-line treatment option for portal hypertension in patients with decompensated cirrhosis. It has been used in the management of complications such as variceal bleeding and refractory ascites. The most commonly reported complications of TIPS include hepatic encephalopathy (10%-49%), shunt stenosis or occlusion (13%-15% with covered stents and 18%78% with bare stents), sepsis (2%-10%), and stent migration to the portal vein or the right atrium (8%20%). Biliary complications from TIPS are considered rare, and only a few cases have been described. We report an unusual complication: the misplacement of a TIPS into the common hepatic duct (CHD).

What Did We Really Learn From the Collaborative? Is It In Our Best Interest to Use “Every Organ Every Time” in Kidney Transplantation?

The Organ Donation Breakthrough Collaborative (ODBC) was formed in 2003 in response to a widening gap between the number of available organs and the number of patients wait listed for transplantation, as well as recognition of a potential to avail a large pool of donor organs. It made an immediate impact by increasing the number of donations and of organs procured. As the bulk of the organs came from an expanded donor pool, the impact on organ use varied somewhat. The discard rates for kidneys, a life-sustaining organ, increased significantly. A substantial effort to decrease organ discards has raised questions over whether “every organ every time” is in the best interest of kidney transplantation. This article is based on currently available data and reviews the circumstances that led to the formation of the ODBC and its short- and long-term impact on kidney transplantation. We question whether this is the right direction for the current situation and discuss whether there might be other potential avenues to pursue in bridging this divide.

Clinical decision making in the management of pancreatic cystic neoplasms

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

Assessment and optimization of liver volume before major hepatic resection: current guidelines and a narrative review

Post hepatectomy liver failure (PHLF) remains a significant cause of morbidity and mortality after major liver resection. Although the etiology of PHLF is multifactorial, an inadequate functional liver remnant (FLR) is felt to be the most important modifiable predictor of PHLF. Pre-operative evaluation of FLR function and volume is of paramount importance before proceeding with any major liver resection. Patients with inadequate or borderline FLR volume must be considered for volume optimization strategies such as portal vein embolization (PVE), two stage hepatectomy with portal vein ligation (PVL), Yttrium-90 radioembolization, and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This paper provides an overview of assessing FLR volume and function, and discusses indications and outcomes of commonly used volume optimization strategies.

Determination and Optimization of Liver Function and Volume for Extended Hepatectomy

Post-hepatectomy liver failure (PHLF) is a major source of morbidity and mortality after major liver resections and appears to be related to the quality and volume of the future liver remnant (FLR). Assessment of liver quality and calculation of FLR using 3-D cross-sectional imaging modalities are essential before proceeding with any major live resection. Volume optimization strategies must be considered in all patients at high risk for PHLF. This chapter discusses the indications and details of the commonly used strategies of hepatic volume optimization. A proposed treatment algorithm is also included.

Flange Gastroenterostomy: In reply to Xu and Jia

fistula, and organ space infection. This might have been the authors’ motivation to invent this operation, although it was not stated in this study. However, the authors might have overlooked a randomized controlled trial that revealed that the rate of “primary” DGE, which occurred in the absence of other intra-abdominal complications, did not differ significantly between the antecolic and the retrocolic gastroenteric reconstruction methods.

Flange Gastroenterostomy: In Reply to Limongelli and Colleagues

Our coauthors and we thank the authors for their interest in our paper. Data were gathered prospectively and entered into ourWhipple database, which was used to study delayed gastric emptying (DGE). As in most prospective studies, there was not a continuous output of results, but a retrospective analysis of the results in the prospectively completed database. Next, the authors comment that the study might have been biased because a recent meta-analysis found that antecolic gastroenterostomy produced better outcomes with respect to DGE than retrocolic gastroenterostomy. But there seems to be some confusion here because if there was a bias, it would be against and not for the Flange technique, in which the anastomosis is placed in the retrocolic position. Also, the authors comment on the value of the International StudyGroupofPancreatic Surgery classification. Perhaps they noted that we used both the International Study Group of Pancreatic Surgery classification and the Modified Accordion Grading System to grade DGE and that, comparatively, the latter worked very well to grade DGE. The great advantage of the Modified Accordion Grading System is that the same system can be used to grade many complications well, not just DGE. The Modified Accordion Grading System permits an understanding of the severity of a DGE event in relation to a pancreatic fistula event or any other complication. Finally, Flange was developed by progressively introducing small variations in technique, as surgeons often do in the operating room, and observing their effect. The process is like developing a recipe. Flange is a recipe for obtaining a DGE rate of <10% after standard pancreaticoduodenectomy when the DGE rate is normally twice that in the hands of many pancreatic surgeons. Whether it is actually a good recipe will depend on whether the results can be reproduced by others. For success, the Flange recipe requires meticulous attention to the details of the method. We are unfamiliar with the phrase “knocking the fox,” but if others can report the same success that we observed with Flange, then perhaps the fox will get a big bump on his head.