Charles Henry Caldow Pilgrim

Microwave ablation for hepatic malignancies: a multiinstitutional analysis.

Objective:This study hypothesized that tumor size, number of tumors, surgical approach, and tumor histology significantly affected microwave ablation (MWA) success and recurrence-free survival. Background:Although many hepatobiliary centers have adopted MWA, the factors that influence local control are not well described. Methods:Consecutive patients with hepatic malignancy treated by MWA were included from 4 high-volume institutions (2003–2011) and grouped by histology: hepatocellular carcinoma (HCC), colorectal liver metastases, neuroendocrine liver metastases, and other cancers. Independent significance of outcome variables was established with logistic regression and Cox proportional hazards models. Results:Four hundred fifty patients were treated with 473 procedures (139 HCC, 198 colorectal liver metastases, 61 neuroendocrine liver metastases, and 75 other) for a total of 875 tumors. Median follow-up was 18 months. Concurrent hepatectomy was performed in 178 patients (38%), and when performed was associated with greater morbidity. Complete ablation was confirmed for 839 of 865 tumors (97.0%) on follow-up cross-sectional imaging (10 were unevaluable). A surgical approach (open, laparoscopic, or percutaneous) had no significant impact on complication rates, recurrence, or survival. The local recurrence rate was 6.0% overall and was highest for HCC (10.1%, P = 0.045) and percutaneously treated lesions (14.1%, P = 0.014). In adjusted models, tumor size 3 cm or more predicted poorer recurrence-free survival (hazard ratio: 1.60, 95% CI: 1.02–2.50, P = 0.039). Conclusions:In this large data set, patients with 3 cm or more tumors showed a propensity for early recurrence, regardless of histology. Higher rates of local recurrence were noted in HCC patients, which may reflect underlying liver disease. There were no significant differences in morbidity or survival based on the surgical approach; however, local recurrence rates were highest for percutaneously ablated tumors.

Arterial resection at the time of pancreatectomy for cancer

BACKGROUND Tumor-induced arterial abutment/encasement has been traditionally a contraindication to surgery in patients with localized pancreatic cancer (PC). One recent meta-analysis reported greater mortality rates in this setting. We report herein a series of planned arterial resections in carefully selected patients who responded favorably to combined modality therapy for localized PC. METHODS We reviewed all patients with PC and arterial encasement treated between May 2011 and September 2013; all patients received an extensive course of neoadjuvant therapy before surgery. RESULTS Of 15 patients taken to surgery, 2 had peritoneal disease at laparoscopy, and therefore, laparotomy was not performed. Pancreatectomy (pancreaticoduodenectomy, 3; distal, 8; central pancreatectomy, 1; total, 1) was performed in the remaining 13, 10 of whom required arterial resection. The most common operation was an Appleby procedure. Of 10 patients who underwent combined pancreatectomy and arterial resection, their median age was 62 years (range, 33-75), median operative time was 7.5 hours, and median blood loss was 725 mL. Complications occurred in 3 of 15 patients with no perioperative mortality. Median duration of hospital stay was 9 days (range, 5-19). An R0 resection was achieved in 11 (85%) of 13 patients. At a median follow-up of 21 months, 8 of these 13 resected patients (62%) are alive without disease. CONCLUSION Planned arterial resection at the time of pancreatectomy can be performed with acceptable morbidity and mortality; patient selection and induction therapy are likely critically important variables that seem to impact patient outcome. Those patients with stable or responding disease after induction therapy represent the subset of patients with potentially favorable tumor biology in whom extended resections may enhance survival duration.

Modern perspectives on factors predisposing to the development of gallbladder cancer

BACKGROUND Gallbladder cancer (GBC) is a rare malignancy, yet certain groups are at higher risk. Knowledge of predisposing factors may facilitate earlier diagnosis by enabling targeted investigations into otherwise non-specific presenting signs and symptoms. Detecting GBC in its initial stages offers patients their best chance of cure. METHODS PubMed was searched for recent articles (2008-2012) on the topic of risk factors for GBC. Of 1490 initial entries, 32 manuscripts reporting on risk factors for GBC were included in this review. RESULTS New molecular perspectives on cholesterol cycling, hormonal factors and bacterial infection provide fresh insights into the established risk factors of gallstones, female gender and geographic locality. The significance of polyps in predisposing to GBC is probably overstated given the known dysplasia-carcinoma and adenoma-carcinoma sequences active in this disease. Bacteria such as Salmonella species may contribute to regional variations in disease prevalence and might represent powerful targets of therapy to reduce incidences in high-risk areas. Traditional risk factors such as porcelain gallbladder, Mirizzis syndrome and bile reflux remain important as predisposing factors. CONCLUSIONS Subcentimetre gallbladder polyps rarely become cancerous. Because gallbladder wall thickening is often the first sign of malignancy, all gallbladder imaging should be scrutinized carefully for this feature.

Neutrophil-to-lymphocyte ratio as a predictor of outcomes for patients with hepatocellular carcinoma: A Western perspective

Neutrophil‐to‐lymphocyte ratio (NLR) is simple, inexpensive, and has been proposed to be predictive in hepatocellular carcinoma (HCC) in Europe and Asia. We aimed to evaluate whether NLR at presentation in a Western center provides any prognostic value compared to other common prognostic scores.

Optimal Management of the Splenic Vein at the Time of Venous Resection for Pancreatic Cancer: Importance of the Inferior Mesenteric Vein

BackgroundResection of the superior mesenteric vein (SMV)-portal vein (PV)-splenic vein (SV) confluence during pancreatectomy for pancreatic cancer requires management of the SV.DiscussionSimple SV ligation can result in sinistral portal hypertension if the inferior mesenteric vein (IMV) enters the confluence and is thereby resected, or if the IMV is insufficient to drain the SV. We describe herein three patients whose clinical course confirms the importance of the IMV decompressing the SV to avoid sinistral hypertension.

Recent advances in systemic therapies and radiotherapy for gallbladder cancer

Adjuvant treatment is not routine following resection for gallbladder cancer as most regimens have low response rates. In the palliative setting, recent advances have been made regarding combination chemotherapies and both gemcitabine/cisplatin and gemcitabine/oxaliplatin appear to be superior to single-agent 5FU, which has very little efficacy in this disease. There are isolated reports of dramatic responses to targeted monoclonal agents. The role of radiotherapy has recently been revisited, however, its effectiveness when patients are adequately surgically treated remains to be demonstrated.

Key Factors Influencing Prognosis in Relation to Gallbladder Cancer

IntroductionThe 5-year survival of patients with gallbladder cancer remains low. However, patients can be stratified into prognostic categories based on established factors such as T, N, and R status. New concepts regarding prognostic significance of lymph node disease, the importance of residual gallbladder fossa disease, and the gravity of presentation with jaundice are reviewed. In addition, a number of new prognostic factors proposed in recent years are considered.MethodsPubMed was searched for “gallbladder cancer” with builder “date-completion” 2008 to present. A total of 1,490 articles were screened from which 168 were retrieved. From this, 40 articles specifically related to prognosis form the basis for this review.DiscussionKey factors of prognostic significance remain T and N stage and R0 resection. Residual disease either in the gallbladder fossa, lymph nodes, or cystic duct margin dictates hepatectomy, lymphadenectomy and bile duct resection, respectively. Adequate lymphadenectomy requires removal of six nodes, and hepatectomy must be sufficient to achieve R0. Subtleties regarding lymph node ratio, significance of pathological features such as dedifferentiation, and budding may hold value for stratifying patients with early stage disease, but require further investigation.

An Often Overlooked Diagnosis: Imaging Features of Gallbladder Cancer

Up to 50% of patients with gallbladder carcinoma (GBCA) do not have the diagnosis identified on initial imaging and erroneously proceed to simple cholecystectomy as the first surgical procedure. A more careful consideration of the imaging findings should allow a higher number of patients to be identified preoperatively, and should subsequently translate to more patients being referred for appropriate preoperative workup and definitive oncological management. Patients with T3 GBCA should be readily diagnosed even with simple transabdominal ultrasonography (US), as these lesions, by definition, invade into the liver, and although T2 lesions might be more subtle, many of these lesions should also be identifiable to the astute eye if attention is paid to some fundamental details of the imaging characteristics. Of particular note is the nature of gallbladder wall thickening, which is described in this review. T1b lesions will no doubt continue to pose a diagnostic problem; fortunately, no detriment to long-term outcomes has been displayed after re-resection for a postoperative diagnosis for this stage of disease. Preoperative assessment of depth of invasion, although a critical determinant to guide extent of liver resection required for an R0 resection, is particularly difficult in GBCA, given the lack of a submucosa, and also the peculiarity of the normal extension of an epithelial lining into the muscular layer at times (as manifest by Rokitansky-Aschoff sinuses). Certain CT features can be useful in this regard, and any patient with US characteristics that are suspicious for malignancy should proceed to additional investigation rather than to cholecystectomy in the first instance.

Mesocaval Shunting: A Novel Technique to Facilitate Venous Resection and Reconstruction and Enhance Exposure of the Superior Mesenteric and Celiac Arteries during Pancreaticoduodenectomy

Adequate exposure of the superior mesenteric artery (SMA) is necessary to facilitate a negative SMA margin, which represents the most critical oncologic step during pancreaticoduodenectomy for pancreatic cancer. For tumors inseparable from the superior mesenteric vein (SMV), or the SMV-portal vein (PV) confluence, which clearly require venous resection and reconstruction, SMA exposure and dissection is traditionally accomplished by 1 of 2 techniques. First, the SMA can be exposed medial to the SMV if the SMV-PV confluence is encased at the splenic vein (SV) confluence, and the SV can be divided, which widely exposes the SMA, as originally described by Fortner. However, if the inferior mesenteric vein (IMV) enters the SMV (rather than the SV), SV ligation may predispose to sinistral portal hypertension and gastrointestinal hemorrhage because retrograde decompression via the IMV is not possible. We have described the use of distal splenorenal shunting in such situations to allow SV decompression. If the SMV segment to be resected is distal to the splenic-portal junction, the SV does not need to be divided; however, this prevents easy access to the proximal SMA from this anterior approach and also prevents the PV from achieving increased length (for a primary anastomosis to the SMV). For these 2 reasons, some surgeons routinely divide the SV when performing segmental venous resection and reconstruction. However, preservation of the splenic-portal junction, if possible, is important because it essentially eliminates the risk of PV thrombosis or stenosis, which can occur after SMV-PV resection or reconstruction when the SV is divided. Alternatively, when resecting

Duplicate pancreas meets gastric duplication cyst: A tale of two anomalies

INTRODUCTION Congenital anomalies are a rare cause of pancreatitis in adults. Gastric duplications are the least common duplication of the gastrointestinal tract and are even more uncommon in the setting of a duplicate pancreas. PRESENTATION OF CASE This manuscript contains a case report and review of the literature of an adult who presented with recurrent pancreatitis and was found to have a gastric duplication cyst that communicated with a duplicate pancreas. The study aim is to alert practitioners to the duplicate anomaly and recommend appropriate therapy. DISCUSSION Combined gastric and pancreatic duplications usually occur in young females with nonspecific, recurrent abdominal pain. This combined duplication can result in pancreatitis when the gastric duplication is contiguous with the stomach. Heightened awareness of the condition, appropriate diagnostics with accurate interpretation and a minimalist approach to resection are warranted. CONCLUSION Recurrent abdominal pain and pancreatitis in young adults devoid of risk factors should lead to consideration of congenital anomalies. Not all cysts near the pancreas and stomach are pseudocysts. ECRP and abdominal CT/MRI provide critical diagnostic information. This dual anomaly is best treated by simple excision of the gastric duplication and heterotopic pancreas.