Chakri Panjala

Impact of Neoadjuvant Chemoradiation on the Tumor Burden Before Liver Transplantation for Unresectable Cholangiocarcinoma

The very early experience with liver transplantation (LT) for cholangiocarcinoma (CC) was dismal because of the poor survival outcomes and the high recurrence rates. However, LT for CC in conjunction with neoadjuvant chemoradiation recently has shown encouraging results, although the data are extremely limited. At our institution between 2001 and 2008, 22 CC patients underwent protocol orthotopic LT at a median age of 45 years (range = 24‐63 years). At a median follow‐up of 601.5 days (range = 111‐1388 days), the median survival time of the cohort was 3.3 years. The 1‐, 2‐, and 3‐year Kaplan‐Meier survival probabilities were 90%, 70%, and 63%, respectively, whereas the historical 5‐year survival rates were 0% to 18% for intrahepatic CC and 23% to 26% for extrahepatic CC when patients underwent transplantation without neoadjuvant therapy. These encouraging survival rates for patients with this type of tumor, which is difficult to diagnose and treat, are no less significant when they are compared to the national 1‐ and 3‐year survival rates (86% and 68%, respectively) of patients undergoing deceased donor LT for malignant neoplasms of the liver (as reported by the United Network for Organ Sharing). In our series, disease recurrence was significantly associated with a larger residual tumor [6.3 versus 2.0 cm (mean values), P = 0.008] and with a shorter waiting time for LT after the chemoradiation protocol [18 versus 56 days (mean values), P = 0.04]. Our LT protocol for CC was found to be promising for patients with truly extrahepatic CC and for patients within stages I to IIB of the American Joint Committee on Cancer Staging system (100% survival at a median follow‐up of 2.2 years), but the results were notably poor for patients with stage III extrahepatic CC (median survival = 1.2 years). These observations highlight the need for accurate preoperative staging of CC for ideal LT recipient selection and the importance of a low tumor burden and a longer wait after neoadjuvant therapy. More effective chemoradiation regimens for reducing the tumor burden and the appropriate timing of LT after neoadjuvant chemoradiation require further research. Liver Transpl, 2012.

Quality in colonoscopy reporting: An assessment of compliance and performance improvement

BACKGROUND An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined. AIMS To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention. METHODS 300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance. RESULTS Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16). CONCLUSION This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.