Charles H.C. Pilgrim

A review of the surgical strategies for the management of gallbladder carcinoma based on T stage and growth type of the tumour

AIMSnSurgery for gallbladder carcinoma is a technically challenging exercise. The extent of resection varies based on a number of factors, and controversy exists regarding what constitutes an acceptable resection. A review of current recommendations and practice was undertaken.nnnMETHODSnA comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of gallbladder cancer and surgery. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.nnnOBSERVATIONSnThe extent of hepatic resection and lymph node dissection required varies in particular with T stage. Growth pattern and anatomical location of the tumour within the gallbladder also influence surgical management.nnnCONCLUSIONSnDiscrepancy exists between the Eastern and Western literature in terms of what constitutes an acceptable limit of resection, and these issues are discussed.

Laparoscopic hepatectomy is a safe procedure for cancer patients

BACKGROUNDnUtilizing laparoscopy for major surgeries such as hepatectomy is a relatively new concept. Initially, benign pathologies dominated indications for resection. Our experience in an Australian setting with primarily malignant diagnoses is described.nnnMETHODSnA review of patients profiles, pathology, surgery and outcome was performed on 35 patients between December 2005 and August 2008. Data were collected and analysed retrospectively from medical records on a pre-designed datasheet.nnnRESULTSnCommonest indication for resection was colorectal metastasis (54%), 71% of all resections were for malignancy. Average operating time was 2 h 31 min (range 30 min-7 h, 15 min). Major morbidity consisted of one bile leak, two subphrenic abscesses and one pulmonary embolus. There were no deaths. Conversion to open was required in 20% and two patients required intra-operative blood transfusions. Average length of stay overall was 6.1 days (range 1-27), but as low as 2 days for some left lateral sectionectomies. Cessation of parenteral analgesia, return to normal diet and full mobility were achieved on average at 2.4, 2.3 and 2.8 days. Significant post-operative liver dysfunction was seen in two patients, which returned to normal by discharge. One patient died of disease progression 4 months after surgery. There were two involved margins in 35 patients (6%).nnnCONCLUSIONSnLaparoscopic hepatectomy is a developing and safe technique in a select group of patients including those with malignancies, resulting in short hospital stays, rapid return to normal diet, full mobility and minimal morbidity with acceptable oncological parameters. This study is not comparative in nature, but provides evidence to support further investigation and establishment of this new technique for liver resection.

Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma

AIMSnGallbladder carcinoma usually presents late with advanced disease. It develops in an anatomically complex area. Consideration is given to resection of relevant local structures with respect to outcome.nnnMETHODSnA comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of gallbladder cancer and surgery. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.nnnOBSERVATIONSnHepatic resection is advocated and tailored to pathological T stage. Lymph node dissection and bile duct resection, as well as en bloc resection of other viscera, remain areas of controversy.nnnCONCLUSIONSnEastern and Western practice standards of care differ, but hepatic resection with some lymph node dissection is present in both approaches. Philosophy regarding aggression with respect to en bloc resection of adjacent organs and actual extent of lymphatic resection remains disparate.

The developing clinical problem of chemotherapy‐induced hepatic injury

Chemotherapy is being administered to an increasing number of patients with colorectal liver metastases (CRLM), whether they have resectable disease or not. Although this may be appropriate to downstage patients with unresectable disease, and offers theoretical advantages to those who have resectable disease, there is a price to be paid in the development of chemotherapy‐induced hepatic injuries (CIHI). These include chemotherapy‐associated fatty liver diseases and sinusoidal injuries. The main chemotherapeutic agents currently used in the adjuvant setting for colorectal carcinoma, and the neoadjuvant treatment of CRLM include 5‐flurouracil, oxaliplatin and irinotecan, and while there are non‐specific and overlapping injury profiles, oxaliplatin does appear to be primarily associated with sinusoidal injury and irinotecan with steatohepatitis. In this review, the rationale for administering chemotherapy to patients with CRLM is presented, and the problems this brings are outlined. The specific injury patterns will be detailed, as well as the data correlating specific chemotherapy regimens to these injury patterns. Finally, the clinical outcomes of patients with CRLM who undergo neoadjuvant chemotherapy followed by hepatic resection will be considered. The need for methods to identify patients at risk of CIHI and to recognize established CIHI prior to surgery will be emphasized.

mRNA gene expression correlates with histologically diagnosed chemotherapy-induced hepatic injury

INTRODUCTIONnChemotherapy-induced hepatic injuries (CIHI) are an increasing problem facing hepatic surgeons. It may be possible to predict the risk of developing CIHI by analysis of genes involved in the metabolism of chemotherapeutics, previously established as associated with other forms of toxicity.nnnMETHODSnQuantitative reverse transcriptase-polymerase chain reaction methodology (q-RT-PCR) was employed to quantify mRNA expression of nucleotide excision repair genes ERCC1 and ERCC2, relevant in the neutralization of damage induced by oxaliplatin, and genes encoding enzymes relevant to 5-flurouracil metabolism, [thymidylate synthase (TS), thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD)] in 233 hepatic resection samples. mRNA expression was correlated with a histopathological injury scored via previously validated methods in relation to steatosis, steatohepatitis and sinusoidal obstruction syndrome.nnnRESULTSnLow-level DPD mRNA expression was associated with steatosis [odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.53-10.19, P < 0.003], especially when stratified by just those patients exposed to chemotherapy (OR = 4.48, 95% CI = 1.31-15.30 P < 0.02). Low expression of ERCC2 was associated with sinusoidal injury (P < 0.001). There were no further associations between injury patterns and target genes investigated.nnnCONCLUSIONSnPredisposition to the development of CIHI may be predictable based upon individual patient expression of genes encoding enzymes related to the metabolism of chemotherapeutics.

Role of laparoscopy in blunt liver trauma.

Although much has been written about the role of laparoscopy in the acute setting for victims of blunt and penetrating trauma, little has been published on delayed laparoscopy relating specifically to complications of conservative management of liver trauma. There has been a shift towards managing liver trauma conservatively, with haemodynamic instability being the key indication for emergency laparotomy, rather than computed tomography findings. However, as a side‐effect of more liver injuries being treated non‐operatively, bile leak from a disrupted biliary tree presenting later in admission has appeared as a new problem to manage. We describe in this article three cases that have been managed by laparoscopy and drainage alone, outlining the advantages of this technique and defining a new role for delayed laparoscopy in blunt liver trauma.

Correlations between histopathological diagnosis of chemotherapy-induced hepatic injury, clinical features, and perioperative morbidity.

BACKGROUNDnChemotherapy has in some series been linked with increased morbidity after a hepatectomy. Hepatic injuries may result from the treatment with chemotherapy, but can also be secondary to co-morbid diseases. The aim of the present study was to draw correlations between clinical features, treatment with chemotherapy and injury phenotypes and assess the impact of each upon perioperative morbidity.nnnPATIENTS AND METHODSnRetrospective samples (n= 232) were scored grading steatosis, steatohepatitis and sinusoidal injury (SI). Clinical data were retrieved from medical records. Correlations were drawn between injury, clinical features and perioperative morbidity.nnnRESULTSnInjury rates were 18%, 4% and 19% for steatosis, steatohepatitis and SI, respectively. High-grade steatosis was more common in patients with diabetes [odds ratio (OR) = 3.33, P= 0.01] and patients with a higher weight (OR/kg = 1.04, P= 0.02). Steatohepatitis was increased with metabolic syndrome (OR = 5.88, P= 0.02). Chemotherapy overall demonstrated a trend towards an approximately doubled risk of high-grade steatosis and steatohepatitis although not affecting SI. However, pre-operative chemotherapy was associated with an increased SI (OR = 2.18, P= 0.05). Operative morbidity was not increased with chemotherapy, but was increased with steatosis (OR = 2.38, P= 0.02).nnnCONCLUSIONSnDiabetes and higher weight significantly increased the risk of steatosis, whereas metabolic syndrome significantly increased risk of steatohepatitis. The presence of high-grade steatosis increases perioperative morbidity, not administration of chemotherapy per se.

Management of haemodynamically stable patients with penetrating abdominal stab injuries: review of practice at an Australian major trauma centre

AbstractIntroductionThe management of haemodynamically stable patients who present following a penetrating abdominal injury (PAI) remains variable between mandatory surgical exploration and more selective non-operative approaches. The primary aim of this study was to assess compliance with an algorithm guiding selective non-operative management of haemodynamically stable patients with PAI. The secondary aim was to examine the association between compliance and unnecessary laparotomies.nMethodsThis was a retrospective cohort study involving all patients with PAI that presented to a major trauma centre from January 2007 to December 2011. Data were extracted from the trauma registry and patients’ electronic medical records.ResultsnThere were 189 patients included in the study, of which 79 (41.8xa0%) patients complied with the algorithm. The laparotomy rate in the setting of algorithm compliance was significantly lower than algorithm non-compliance (12.7 vs. 68.2xa0%; pxa0<xa00.01) as were unnecessary laparotomy rates (0 vs. 33.3xa0%; pxa0=xa00.03).ConclusionAmong haemodynamically stable patients presenting with PAI, compliance with an algorithm guiding selective non-operative management was low, but associated with lower laparotomy and lower unnecessary laparotomy rates. Improved compliance with algorithms directed towards selective non-operative management of PAI should be encouraged with stringent vigilance towards patient safety.

Surgical outcomes for duodenal adenoma and adenocarcinoma: a multicentre study in Australia and the United Kingdom.

Pancreaticoduodenectomy is often required in patients with duodenal adenoma and adenocarcinoma and these patients generally have soft pancreatic texture and small pancreatic ducts, the two most significant factors associated with post‐operative pancreatic fistula (POPF). The aims of the study were to evaluate the rate of POPF and long‐term outcomes for patients with duodenal adenoma and adenocarcinoma who underwent curative resection.

Gallbladder Carcinoma as a Long-Term Complication of Cholecystojejunostomy

IntroductionDevelopment of gallbladder cancer following cholecystojejunostomy has not previously been described.MethodsA case of a patient who developed gallbladder cancer 22xa0years following cholecystojejunostomy is presented, and a literature review of known complications of cholecysto-enteric anastomosis was performed.DiscussionCholangitis is the commonest reported complication, known to predispose the biliary epithelium to malignant change, but has not been described until now as being carcinogenic for the gallbladder. Gallbladder carcinoma may be a rare long-term complication of cholecystojejunostomy.