Alexsander K. Bressan

Time-to-Surgery and Survival Outcomes in Resectable Colorectal Liver Metastases: A Multi-Institutional Evaluation

BACKGROUNDnResection of colorectal liver metastases (CRLM) is associated with improved survival; however, the impact of time to resection on survival is unknown. The current multi-institutional study sought to evaluate the influence of time from diagnosis (Dx) to resection (Rx) on survival outcomes among patients with resectable, metachronous CRLM and to compare practice patterns across hospitals.nnnSTUDY DESIGNnMedical records of patients with ≤4 metachronous CRLM treated with surgery were reviewed and analyzed retrospectively. Time from Dx to Rx was analyzed as a continuous variable and also dichotomized into 2 groups (group 1: Dx to Rx <3 months and group 2: Dx to Rx ≥3 months) for additional analysis. Survival time distributions after resection were estimated using the Kaplan-Meier method. Between-group univariate comparisons were based on the log-rank test and multivariable analysis was done using Cox proportional hazards model.nnnRESULTSnFrom 2000 to 2010, six hundred and twenty-six patients were identified. Type of initial referral (p < 0.0001) and use of neoadjuvant (pxa0= 0.04) and/or adjuvant (p < 0.0001) chemotherapy were significantly different among hospitals. Patients treated with neoadjuvant chemotherapy (nxa0= 108) and those with unresectable disease at laparotomy (nxa0= 5) were excluded from final evaluation. Median overall survival and recurrence-free survival were 74 months (range 63.8 to 84.2 months) and 29 months (range 23.9 to 34.1 months), respectively. For the entire cohort, longer time from Dx to Rx was independently associated with shorter overall survival (hazard ratioxa0= 1.12; 95% CI, 1.06-1.18; p < 0.0001), but not recurrence-free survival. Median overall survival for group 1 was 76 months (range 62.0 to 89.2 months) vs 58 months (range 34.3 to 81.7 months) in group 2 (pxa0= 0.10). Among patients with available data pertaining to adjuvant chemotherapy (Nxa0= 457; 318 treated and 139 untreated), overall survival (87 months [range 71.2 to 102.8 months] vs 48 months [range 25.3 to 70.7 months]; p <0.0001), and recurrence-free survival (33 months [range 25.3 to 40.7 months] vs 22 months [range 14.5 to 29.5 months]; pxa0= 0.05) were improved significantly.nnnCONCLUSIONSnIn select patients undergoing initial resection for CRLM, longer time from Dx to Rx is independently associated with worse overall survival. In addition, despite uniform disease characteristics, practice patterns related to definitely resectable CRLM vary significantly across hospitals.

The adequacy of Hepato‐Pancreato‐Biliary training: how closely do perceptions of fellows and programme directors align?

BACKGROUNDnHepatopancreatobiliary fellowship programmes have recently undergone significant changes with regards to training standards, case-volume thresholds and multimodality educational platforms. The goals of this study were to compare the perspectives of fellows and programme directors (PDs) on perceptions of readiness to enter practice and identify core Hepato-Pancreato-Biliary (HPB) procedures that require increased emphasis during training.nnnMETHODSnThis survey targeted PDs and trainees participating in the Fellowship Council/AHPBA pathway. Data related to demographics, education and career plans were collected. Analysis of PD and fellow opinions regarding their confidence to perform core HPB procedures was completed.nnnRESULTSnThe response rate was 88% for both fellows (21/24) and PDs (23/26). There was good agreement between PDs and fellows in the perception of case volumes. Select differences where PDs ranked higher perceptions included major hepatectomies (PDs: 87% versus fellows: 57%, P = 0.04), pancreaticoduodenectomies (100% versus 81%, P = 0.04) and laparoscopic distal pancreatectomies (78% versus 43%, P = 0.03). Good or excellent case volumes translated into increased fellow readiness, except for some pancreatitis procedures, laparoscopic distal pancreatectomies and potentially major hepatectomies.nnnCONCLUSIONSnThis study provides insight into content domains that may require additional attention to achieve an appropriate level of proficiency and confidence upon completion of training.

Acute care and emergency general surgery in patients with chronic liver disease: how can we optimize perioperative care? A review of the literature

The increasing prevalence of advanced cirrhosis among operative candidates poses a major challenge for the acute care surgeon. The severity of hepatic dysfunction, degree of portal hypertension, emergency of surgery, and severity of patients’ comorbidities constitute predictors of postoperative mortality. Comprehensive history taking, physical examination, and thorough review of laboratory and imaging examinations typically elucidate clinical evidence of hepatic dysfunction, portal hypertension, and/or their complications. Utilization of specific scoring systems (Child-Pugh and MELD) adds objectivity to stratifying the severity of hepatic dysfunction. Hypovolemia and coagulopathy often represent major preoperative concerns. Resuscitation mandates judicious use of intravenous fluids and blood products. As a general rule, the most expeditious and least invasive operative procedure should be planned. Laparoscopic approaches, advanced energy devices, mechanical staplers, and topical hemostatics should be considered whenever applicable to improve safety. Precise operative technique must acknowledge common distortions in hepatic anatomy, as well as the risk of massive hemorrhage from porto-systemic collaterals. Preventive measures, as well as both clinical and laboratory vigilance, for postoperative hepatic and renal decompensation are essential.

Completion pancreatectomy in the acute management of pancreatic fistula after pancreaticoduodenectomy: a systematic review and qualitative synthesis of the literature

BACKGROUNDnPancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula.nnnMETHODSnA systematic search of PubMed and EMBASE for all studies reporting clinical outcomes for CP in the acute treatment of pancreatic fistula following PD from January 1975 until May 2016.nnnRESULTSnEleven patient-series with a total of 5566 PD and 151 (3%) emergency CP were included. Median time from PD to CP ranged from 6 to 17 days (7 studies), and mean operative time and blood loss - reported in only two studies - were 197xa0min and 2173xa0mL respectively. Re-laparotomy following CP was required in 35% of patients. Median hospital length-of-stay varied from 21 to 64 days, and postoperative mortality was 42%.nnnCONCLUSIONSnEmergency surgery for postoperative pancreatic fistula should only be considered after expert consultation. CP carries a high risk of mortality, and it is most commonly recommended for a selected subgroup of patients with locally complicated fistula.

Assessing resectability of colorectal liver metastases: How do different subspecialties interpret the same data?

BACKGROUNDnMultimodal treatment of colorectal liver metastases (CRLMs) relies on precise upfront assessment of resectability. Variability in the definition of resectable disease and the importance of early consultation by a liver surgeon have been reported. In this pilot study we investigated the initial resectability assessment and patterns of referral of patients with CRLMs.nnnMETHODSnSurgeons and medical oncologists involved in the management of colorectal cancer at 2 academic institutions and affiliated community hospitals were surveyed. Opinions were sought regarding resectability of CRLMs and the type of initial specialty referral (hepatobiliary surgery, medical oncology, palliative care or other) in 6 clinical cases derived from actual cases of successfully performed 1- or 2-stage resection/ablation of hepatic disease. Case scenarios were selected to illustrate critical aspects of assessment of resectability, best therapeutic approaches and specialty referral. Standard statistical analyses were performed.nnnRESULTSnOf the 75 surgeons contacted, 64 responded (response rate 85%; 372 resectability assessments completed). Hepatic metastases were more often considered resectable by hepatobiliary surgeons than all other respondents (92% v. 57%, p < 0.001). Upfront systemic therapy was most commonly prioritized by surgical oncologists (p = 0.01). Hepatobiliary referral was still considered in 73% of unresectable assessments by colorectal surgeons, 59% of those by general surgeons, 57% of those by medical oncologists and 33% of those by surgical oncologists (p = 0.1).nnnCONCLUSIONnAssessment of resectability varied significantly between specialties, and resectability was often underestimated by nonhepatobiliary surgeons. Hepatobiliary referral was not considered in a substantial proportion of cases erroneously deemed unresectable. These disparities result largely from an imprecise understanding of modern surgical indications for resection of CRLMs.

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial

Introduction Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. Methods and analysis This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. Ethics and dissemination This study has been approved by the institution’s research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. Trial registration number NCT03050502.

Management of the Primary Colorectal Cancer and Synchronous Liver Metastases

In the last two decades, advances in liver surgery and systemic therapy have increased the scope and complexity of curative treatment of metastatic colorectal cancer. Synchronous liver metastasis represents a particularly challenging scenario where resection of the primary cancer and liver disease should be contemplated while still offering systemic therapy. Different treatment sequences have been proposed aiming to optimize long-term survival and decrease cumulative treatment-related morbidity. Safety and feasibility of colorectal-first, combined, and liver-first approaches have been demonstrated in selected subgroups of patients, but comparative analyses are undermined by the retrospective design and heterogeneity of available studies. The concept of a unifying ideal therapeutic approach does not seem realistic, and understanding the distinct principles of different strategies is paramount when planning surgical management of synchronous colorectal liver metastases. The role of systemic therapy before liver resection still requires better characterization.