Brian K. P. Goh

Evaluation of the Sendai and 2012 International Consensus Guidelines based on cross-sectional imaging findings performed for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically treated patients

BACKGROUNDnThe Sendai Consensus Guidelines (SCG) were formulated in 2006 to guide the management of mucinous cystic lesions of the pancreas (CLPs) and were updated in 2012 (International Consensus Guidelines, ICG 2012). This study aims to evaluate the clinical utility of the ICG 2012 with the SCG based on initial cross-sectional imaging findings.nnnMETHODSnOne hundred fourteen patients with mucinous CLPs were reviewed and classified according to the ICG 2012 as high risk (HR(ICG2012)), worrisome (W(ICG2012)), and low risk (LR(ICG2012)), and according to the SCG as high risk (HR(SCG)) and low risk (LR(SCG)).nnnRESULTSnOn univariate analysis, the presence of symptoms, obstructive jaundice, elevated serum carcinoembryonic antigen (CEA)/carbohydrate antigen (CA)19-9, solid component, main pancreatic duct ≥ 10 mm, and main pancreatic duct ≥ 5 mm was associated with high grade dysplasia/invasive carcinoma in all mucinous CLPs. Increasing number of HR(SCG) or HR(ICG2012) features was associated with a significantly increased likelihood of malignancy. The positive predictive value of HR(SCG) and HR(ICG2012) for high grade dysplasia/invasive carcinoma was 46% and 62.5% respectively. The negative predictive value of both LR(SCG) and LR(ICG2012) was 100%.nnnCONCLUSIONnBoth the guidelines were useful in the initial cross-sectional imaging evaluation of mucinous CLPs. The ICG 2012 guidelines were superior to the SCG guidelines.

A Systematic Review and Meta-Analysis Comparing Laparoscopic Versus Open Gastric Resections for Gastrointestinal Stromal Tumors of the Stomach

This study is a systematic review and meta-analysis that compares the short- and long-term outcomes of laparoscopic gastric resection (LR) versus open gastric resection (OR) for gastric gastrointestinal stromal tumors (GISTs). Comparative studies reporting the outcomes of LR and OR for GIST were reviewed. A total of 11 nonrandomized studies reviewed 765 patients: 381 LR and 384 OR. A higher proportion of high-risk tumors and gastrectomies were in the OR compared with LR (odds ratio, 3.348; 95xa0% CI, 1.248–8.983; pxa0=xa0.016) and (odds ratio, .169; 95xa0% CI, .090–.315; pxa0<xa0.001), respectively. Intraoperative blood loss was significantly lower in the LR group [weighted mean difference (WMD), −86.508xa0ml; 95xa0% CI, −141.184 to −31.831xa0ml; pxa0<xa0.002]. The LR group was associated with a significantly lower risk of minor complications (odds ratio, .517; 95xa0% CI, .277–.965; pxa0=xa0.038), a decreased postoperative hospital stay (WMD, −3.421xa0days; 95xa0% CI, −4.737 to −2.104xa0days; pxa0<xa0.001), a shorter time to first flatus (WMD, −1.395xa0days; 95xa0% CI, −1.655 to −1.135xa0days; pxa0<xa0.001), and shorter time for resumption of oral intake (WMD, −1.887xa0days; 95xa0% CI, −2.785 to −.989xa0days; pxa0<xa0.001). There was no statistically significant difference between the two groups with regard to operation time (WMD, 5.731xa0min; 95xa0% CI, −15.354–26.815xa0min; pxa0=xa0.594), rate of major complications (odds ratio, .631; 95xa0% CI, .202–1.969; pxa0=xa0.428), margin positivity (odds ratio, .501; 95xa0% CI, .157–1.603; pxa0=xa0.244), local recurrence rate (odds ratio, .629; 95xa0% CI, .208–1.903; pxa0=xa0.412), recurrence-free survival (RFS) (odds ratio, 1.28; 95xa0% CI, .705–2.325; pxa0=xa0.417), and overall survival (OS) (odds ratio, 1.879; 95xa0% CI, .591–5.979; pxa0=xa0.285). LR results in superior short-term postoperative outcomes without compromising oncological safety and long-term oncological outcomes compared with OR.BackgroundThis study is a systematic review and meta-analysis that compares the short- and long-term outcomes of laparoscopic gastric resection (LR) versus open gastric resection (OR) for gastric gastrointestinal stromal tumors (GISTs).MethodsComparative studies reporting the outcomes of LR and OR for GIST were reviewed.ResultsA total of 11 nonrandomized studies reviewed 765 patients: 381 LR and 384 OR. A higher proportion of high-risk tumors and gastrectomies were in the OR compared with LR (odds ratio, 3.348; 95xa0% CI, 1.248–8.983; pxa0=xa0.016) and (odds ratio, .169; 95xa0% CI, .090–.315; pxa0<xa0.001), respectively. Intraoperative blood loss was significantly lower in the LR group [weighted mean difference (WMD), −86.508xa0ml; 95xa0% CI, −141.184 to −31.831xa0ml; pxa0<xa0.002]. The LR group was associated with a significantly lower risk of minor complications (odds ratio, .517; 95xa0% CI, .277–.965; pxa0=xa0.038), a decreased postoperative hospital stay (WMD, −3.421xa0days; 95xa0% CI, −4.737 to −2.104xa0days; pxa0<xa0.001), a shorter time to first flatus (WMD, −1.395xa0days; 95xa0% CI, −1.655 to −1.135xa0days; pxa0<xa0.001), and shorter time for resumption of oral intake (WMD, −1.887xa0days; 95xa0% CI, −2.785 to −.989xa0days; pxa0<xa0.001). There was no statistically significant difference between the two groups with regard to operation time (WMD, 5.731xa0min; 95xa0% CI, −15.354–26.815xa0min; pxa0=xa0.594), rate of major complications (odds ratio, .631; 95xa0% CI, .202–1.969; pxa0=xa0.428), margin positivity (odds ratio, .501; 95xa0% CI, .157–1.603; pxa0=xa0.244), local recurrence rate (odds ratio, .629; 95xa0% CI, .208–1.903; pxa0=xa0.412), recurrence-free survival (RFS) (odds ratio, 1.28; 95xa0% CI, .705–2.325; pxa0=xa0.417), and overall survival (OS) (odds ratio, 1.879; 95xa0% CI, .591–5.979; pxa0=xa0.285).ConclusionsLR results in superior short-term postoperative outcomes without compromising oncological safety and long-term oncological outcomes compared with OR.

Utility of the Sendai Consensus Guidelines for Branch-Duct Intraductal Papillary Mucinous Neoplasms: A Systematic Review

IntroductionThe Sendai Consensus Guidelines (SCG) was formulated in 2006 to guide the management of intraductal papillary mucinous neoplasms (IPMN). The main area of controversy is the criteria for selection of branch duct (BD)-IPMN for resection. Although these guidelines have gained widespread acceptance, there is limited data to date supporting its use. This systematic review is performed to evaluate the utility of the Sendai Consensus Guidelines (SCG) for BD-IPMN.MethodsStudies evaluating the clinical utility of the SCG in surgically resected neoplasms were identified. The SCG were retrospectively applied to all resected neoplasms in these studies. BD-IPMNs which met the criteria for resection were termed SCG+ve and those for surveillance were termed SCG−ve.ResultsTwelve studies were included, of which, 9 were suitable for pooled analysis. There were 690 surgically resected BD-IPMNs, of which, 24xa0% were malignant. Five hundred one BD-IPMNs were classified as SCG+ve and 189 were SCG−ve. The positive predictive value (PPV) of SCG+ve neoplasms ranged from 11 to 52xa0% and the NPV of SCG−ve neoplasms ranged from 90 to 100xa0%. Overall, there were 150/501 (29.9xa0%) of malignant BD-IPMNs in the SCG+ve group and 171/189 (90xa0%) of benign BD-IPMNs in the SCG−ve group. Of the 18 reported malignant (11 invasive) BD-IPMNs in the SCG−ve group, 17 (including all 11 invasive) were from a single study. When the results from this single study were excluded, 170/171 (99xa0%) of SCG−ve BD-IPMNs were benign.ConclusionThe results of this review confirm the limitations of the SCG for BD-IPMN. The PPV of the SCG in predicting a malignant BD-IPMN was low and some malignant lesions may be missed based on these guidelines.

Are the Sendai and Fukuoka Consensus Guidelines for Cystic Mucinous Neoplasms of the Pancreas Useful in the Initial Triage of all Suspected Pancreatic Cystic Neoplasms? A Single-Institution Experience with 317 Surgically-Treated Patients

The Sendai Consensus Guidelines (SCG) were formulated in 2006 and updated in Fukuoka in 2012 (FCG) to guide management of cystic mucinous neoplasms of the pancreas. This study aims to evaluate the clinical utility of the SCG and FCG in the initial triage of all suspected pancreatic cystic neoplasms. Overall, 317 surgically-treated patients with a suspected pancreatic cystic neoplasm were classified according to the SCG as high risk (HRSCG) and low risk (LRSCG), and according to the FCG as high risk (HRFCG), worrisome (WFCG), and low risk (LRFCG). Cystic lesions of the pancreas (CLP) were classified as potentially malignant/malignant or benign according to the final pathology. The presence of symptoms, proximal lesions with obstructive jaundice, elevated serum carcinoembryonic antigen/carbohydrate antigen 19-9 (CEA/CA 19-9), size ≥3xa0cm, presence of solid component, main pancreatic duct dilatation, thickened enhancing walls, and change in ductal caliber with distal atrophy were predictive of a potentially malignant/malignant CLP on univariate analyses. The positive predictive value (PPV) and negative predictive value (NPV) of HRSCG and HRICG2012 for a potentially malignant/malignant lesion was 67 and 88xa0%, and 88 and 92.5xa0%, respectively. There were no malignant lesions in both LR groups but some potentially malignant lesions such as cystic pancreatic neuroendocrine neoplasms with uncertain behavior were classified as LR. The updated FCG was superior to the SCG for the initial triage of all suspected pancreatic cystic neoplasms. CLP in the LRFCG group can be safely managed conservatively, and those in the HRFCG group should undergo resection.BackgroundThe Sendai Consensus Guidelines (SCG) were formulated in 2006 and updated in Fukuoka in 2012 (FCG) to guide management of cystic mucinous neoplasms of the pancreas. This study aims to evaluate the clinical utility of the SCG and FCG in the initial triage of all suspected pancreatic cystic neoplasms.Study DesignOverall, 317 surgically-treated patients with a suspected pancreatic cystic neoplasm were classified according to the SCG as high risk (HRSCG) and low risk (LRSCG), and according to the FCG as high risk (HRFCG), worrisome (WFCG), and low risk (LRFCG). Cystic lesions of the pancreas (CLP) were classified as potentially malignant/malignant or benign according to the final pathology.ResultsThe presence of symptoms, proximal lesions with obstructive jaundice, elevated serum carcinoembryonic antigen/carbohydrate antigen 19-9 (CEA/CA 19-9), size ≥3xa0cm, presence of solid component, main pancreatic duct dilatation, thickened enhancing walls, and change in ductal caliber with distal atrophy were predictive of a potentially malignant/malignant CLP on univariate analyses. The positive predictive value (PPV) and negative predictive value (NPV) of HRSCG and HRICG2012 for a potentially malignant/malignant lesion was 67 and 88xa0%, and 88 and 92.5xa0%, respectively. There were no malignant lesions in both LR groups but some potentially malignant lesions such as cystic pancreatic neuroendocrine neoplasms with uncertain behavior were classified as LR.ConclusionThe updated FCG was superior to the SCG for the initial triage of all suspected pancreatic cystic neoplasms. CLP in the LRFCG group can be safely managed conservatively, and those in the HRFCG group should undergo resection.

Evaluation of the Fukuoka Consensus Guidelines for intraductal papillary mucinous neoplasms of the pancreas: Results from a systematic review of 1,382 surgically resected patients

BACKGROUNDnInternational consensus guidelines to guide management of intraductal papillary mucinous neoplasms (IPMN) were revised in Fukuoka and published in 2012. However, despite widespread acceptance of the Fukuoka Consensus Guidelines (FCG), the utility of these guidelines have not been well-validated. This systematic review was performed to evaluate the clinical utility of the FCG.nnnDESIGNnA computerized search of the PubMed and Scopus databases was performed to identify all studies evaluating the utility of the FCG in surgically resected IPMN. IPMN were stratified according to the FCG as high risk (HR), worrisome risk (WR), and low risk (LR). HR and WR IPMN were termed FCG+ve and LR IPMN were termed FCG-ve.nnnRESULTSnSeven studies analyzing 1,382 patients were included. There were 402 malignant neoplasms (29%), including 242 invasive IPMNs. There were 1,000 IPMN classified as FCG+ve. The FCG+ve group had a positive predictive value (PPV) ranging from 27 to 62% and the FCG-ve group had negative predictive value ranging from 82 to 100%. Pooled analysis demonstrated that there was 362 of 1,000 (36%) malignant FCG+ve IPMN and 342 of 382 (90%) benign FCG-ve IPMN. PPV of the HR group and the WR groups alone were 104 of 158 (66%) and 75 of 261 (29%), respectively. Forty of 382 (11%), including 22 (6%) invasive FCG-ve IPMN, were malignant. Twenty-six malignant including 18 invasive FCG-ve IPMN were reported from a single study. When the results from this study were excluded, there were only 14 of 241 malignant neoplasms (6%), including 4 of 241 (2%) invasive FCG-ve IPMN in the remaining 6 studies.nnnCONCLUSIONnThe FCG+ve criteria had a similarly low PPV compared with the 2006 consensus criteria. Stratification of IPMN into HR and WR groups resulted in a higher PPV in the HR group. Some malignant and even invasive IPMN may be missed by the FCG criteria.

Systematic review and meta-analysis of the spectrum and outcomes of different histologic subtypes of noninvasive and invasive intraductal papillary mucinous neoplasms.

BACKGROUNDnOur aim was to review the available evidence to determine the clinical importance of the histologic subtypes of noninvasive and invasive intraductal papillary mucinous neoplasms (IPMNs) on disease characteristics and overall survival.nnnMETHODSnWe reviewed systematically 14 comparative studies that reported clinicopathologic characteristics and survival of 1,617 patients with IPMN (900 noninvasive and 717 invasive).nnnRESULTSnThe pancreatobiliary subtype was associated with the greatest likelihood of tumor invasion (67.9%; odds ratio [OR], 2.87; 95% CI, 1.90-4.35), harboring an associated mural nodule (56.6%; OR, 2.92; 95% CI, 1.21-7.04), demonstrating tumor recurrence (46.3%; OR, 3.28; 95% CI, 1.41-7.66) and transformation to tubular adenocarcinoma (81.8%; OR, 92.96; 95% CI, 20.76-416.28) among all subtypes. The gastric subtype was associated with the least likelihood of tumor invasion (10.2%; OR, 0.18; 95% CI, 0.13-0.26), association with main duct IPMN (19.2%; OR, 0.12; 95% CI, 0.06-0.26), and tumor recurrence (9.4%; OR, 0.47; 95% CI, 0.26-0.83) among all subtypes. The intestinal subtype had the greatest likelihood of progressing to colloid carcinoma among all subtypes. Tubular adenocarcinoma was associated with an increased risk of vascular invasion (32.9%; OR, 4.86; 95% CI, 1.96-12.01), perineural invasion (54.5%; OR, 2.30; 95% CI, 1.22-4.34), nodal metastasis (52.4%; OR, 3.31; 95% CI, 1.79-6.14), and a positive margin status (17.3%; OR,xa08.45; 95% CI, 1.52-46.83). Tubular adenocarcinoma (hazard ratio [HR], 1.90; 95% CI, 1.36-2.67) had a poorer 5-year overall survival compared with colloid carcinoma and was similar to the survival observed in pancreatic ductal adenocarcinoma (HR, 2.00; 95% CI, 1.59-2.52).nnnCONCLUSIONnThe prognosis of IPMN depends on its pathologic subtype. Subtype identification should be considered an essential component in future guidelines for the management of IPMN.

Factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy: initial experience at a single institution.

AbstractBackgroundLaparoscopic liver resection has been increasingly adopted worldwide as a result of the rapid advancement in surgical techniques and equipment. This study aims to determine the factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy (LMH) based on a single center multi-surgeon experience.nMethodsThis is a retrospective review of the first 147 consecutive LMH performed between 2006 and April 2014 at a single institution. Data on patient demographics, pathology results, perioperative outcomes, and operative results were collected. Factors associated with open conversion were analyzed via univariate analysis and a P value <.05 was considered statistically significant.nResultsLMH was performed for malignancy in 114 (77.6xa0%) patients of which hepatocellular carcinoma (nxa0=xa082) and colorectal metastases (nxa0=xa016) were the most common pathologies. Forty-one (27.9xa0%) patients had cirrhotic livers and 18 (15.7xa0%) had fibrotic livers. Fifty patients (44xa0%) had concomitant surgery in addition to LMH. Twenty (13.6xa0%) procedures required open conversion and the most common reason was for bleeding (nxa0=xa012). Twenty-five patients (17xa0%) experienced postoperative complications. Univariate analyses demonstrated that only individual surgeon volume (nxa0≤xa010 cases) [15 (24.2xa0%) vs 5 (5.9xa0%), Pxa0=xa0.001] and institution volume (nxa0≤xa025 cases) [8 (32xa0%) vs 12 (9.8xa0%), Pxa0=xa0.003] were factors associated with open conversion. Open conversion was significantly associated with increased intra-operative blood loss, increased intra-operative blood transfusion, increased postoperative morbidity, and longer postoperative stay.ConclusionsIndividual surgeon and institution volumes were important factors associated with open conversion after LMH. Open conversion after LMH resulted in poorer outcomes compared to procedures that were successfully completed laparoscopically.

Number of Nodules, Child-Pugh Status, Margin Positivity, and Microvascular Invasion, but not Tumor Size, are Prognostic Factors of Survival after Liver Resection for Multifocal Hepatocellular Carcinoma

BackgroundPresently, the role of liver resection (LR) for multifocal hepatocellular carcinoma (HCC) remains controversial. However, in many regions worldwide, LR remains the only treatment modality available to such patients which offers the possibility of long-term cure. The aim of this study is to determine the outcomes and prognostic factors of patients with multifocal HCC after LR.MethodsThis is a retrospective analysis of 110 patients who underwent potentially curative LR for pathologically proven multifocal HCC between 2000 and 2011.ResultsThe median age was 64 (range, 18–84)u2009years, and there were 88 males (80.0xa0%). Sixty-one patients underwent a major hepatectomy, and the overall postoperative mortality was 1.8xa0%. Sixty-eight patients had liver cirrhosis, of which, 58 were child’s A and 10 were child’s B. The 1- and 5-year overall survival (OS) was 82 and 44xa0%, respectively. The corresponding 1- and 5-year recurrence-free survival (RFS) was 57 and 19xa0%, respectively. Multivariate analysis demonstrated that the number of nodules (>3) and presence of microvascular invasion were associated with RFS. Number of nodules (>3), margin positivity, Child-Pugh status, and presence of microvascular invasion were independent prognostic factors of OS.ConclusionsLR followed by treatment of recurrences may result in reasonable long-term survival and should be considered in a selected group of patients with multifocal HCC. Number of nodules (>3), margin positivity, Child-Pugh status, and presence of microvascular invasion, but not tumor size, were independent negative predictors of OS. These findings have potential implications on the AJCC staging for multifocal HCC.

Systematic review and meta-analysis comparing the surgical outcomes of invasive intraductal papillary mucinous neoplasms and conventional pancreatic ductal adenocarcinoma.

ObjectiveThe aim of this study was to summarize the current literature comparing the surgical outcomes of invasive intraductal papillary mucinous neoplasms (IPMNINV) and conventional pancreatic ductal adenocarcinomas (PDAC) in order to determine the differences in disease characteristics and prognosis.MethodsSystematic review of the literature yielded 12 comparative studies reporting the clinicopathological characteristics and overall survival (OS) of 1,450 patients with IPMNINV with 19,304 patients with conventional PDAC.ResultsIPMNINV had a significantly lower likelihood of tumors extending beyond the pancreas [27.6 vs. 94.3xa0%; T4 vs. T1: odds ratio (OR) 0.111, 95xa0% confidence intervals (CI) 0.057–0.214], nodal metastasis (45.4 vs. 62.9xa0%: OR 0.507, 95xa0% CI 0.347–0.741), positive margin (14.2 vs. 28.3xa0%; OR 0.438, 95xa0% CI 0.322–0.596), perineural invasion (49.2 vs. 76.5xa0%; OR 0.304, 95xa0% CI 0.106–0.877) and vascular invasion (25.2 vs. 45.7xa0% OR 0.417, 95xa0% CI 0.177–0.980) when compared with PDAC. The 5-year OS of IPMNINV was significantly better than PDAC [31.4 vs. 12.4xa0%: hazard ratio (HR) 0.659, 95xa0% CI 0.574–0.756]. The tubular subtype had a poorer 5-year OS and demonstrated significantly more aggressive features such as nodal metastases, vascular invasion, and perineural invasion compared with the colloid subtype.ConclusionIPMNINV were significantly more likely to present at an earlier stage and were less likely to demonstrate nodal involvement, perineural invasion and vascular invasion. When controlled for stage, IPMNINV had an improved OS when compared with PDAC in the early stages.The aim of this study was to summarize the current literature comparing the surgical outcomes of invasive intraductal papillary mucinous neoplasms (IPMNINV) and conventional pancreatic ductal adenocarcinomas (PDAC) in order to determine the differences in disease characteristics and prognosis. Systematic review of the literature yielded 12 comparative studies reporting the clinicopathological characteristics and overall survival (OS) of 1,450 patients with IPMNINV with 19,304 patients with conventional PDAC. IPMNINV had a significantly lower likelihood of tumors extending beyond the pancreas [27.6 vs. 94.3xa0%; T4 vs. T1: odds ratio (OR) 0.111, 95xa0% confidence intervals (CI) 0.057–0.214], nodal metastasis (45.4 vs. 62.9xa0%: OR 0.507, 95xa0% CI 0.347–0.741), positive margin (14.2 vs. 28.3xa0%; OR 0.438, 95xa0% CI 0.322–0.596), perineural invasion (49.2 vs. 76.5xa0%; OR 0.304, 95xa0% CI 0.106–0.877) and vascular invasion (25.2 vs. 45.7xa0% OR 0.417, 95xa0% CI 0.177–0.980) when compared with PDAC. The 5-year OS of IPMNINV was significantly better than PDAC [31.4 vs. 12.4xa0%: hazard ratio (HR) 0.659, 95xa0% CI 0.574–0.756]. The tubular subtype had a poorer 5-year OS and demonstrated significantly more aggressive features such as nodal metastases, vascular invasion, and perineural invasion compared with the colloid subtype. IPMNINV were significantly more likely to present at an earlier stage and were less likely to demonstrate nodal involvement, perineural invasion and vascular invasion. When controlled for stage, IPMNINV had an improved OS when compared with PDAC in the early stages.

Importance of tumor size as a prognostic factor after partial liver resection for solitary hepatocellular carcinoma: Implications on the current AJCC staging system

Background n nPresently, the impact of tumors size as a prognostic factor after curative liver resection (LR) for solitary hepatocellular carcinoma (HCC) remains controversial. This study was performed to determine the prognostic factors of patients undergoing LR for solitary HCC with special emphasis on the importance of tumor size. n n n nMethods n nBetween 2000 and 2013, 560 patients underwent curative LR for solitary primary HCC which met the study criteria. n n n nResults n nOne-hundred and seventy-eight patients underwent major hepatectomies and the overall in-hospital mortality was 2.0%. There were 282 patients (50.4%) with liver cirrhosis. The 5-year overall survival (OS) was 64% and recurrence free survival (RFS) was 50%, respectively. Multivariate analyses demonstrated that cirrhosis, microvascular invasion and size were independent predictors of RFS and cirrhosis, microvascular invasion and age were independent prognostic factors of OS. Subset analysis demonstrated that tumor size was a prognostic factor for solitary HCC with microvascular invasion (AJCC T2) but not solitary HCC without microvascular invasion (AJCC T1). n n n nConclusions n nSize, microvascular invasion, and cirrhosis are independent prognostic factors of RFS for solitary HCC after LR. Tumor size is an important prognostic factor in T2 but not T1 solitary tumors. These findings suggest that the current AJCC TNM staging system may need to be revised. J. Surg. Oncol.