Daniel L. Chan

Systematic review of efficacy and outcomes of salvage liver transplantation after primary hepatic resection for hepatocellular carcinoma.

Upfront liver transplantation is the gold standard in the treatment of patients with hepatocellular carcinoma (HCC) and cirrhosis, but a shortage of donor organs negatively impacts on survival outcomes, with significant disease progression during long waiting lists. This systematic review evaluates the safety and efficacy of salvage liver transplantation (SLT) as treatment for recurrent HCC after initial hepatic resection.

Intraperitoneal chemotherapy in ovarian cancer: a review of tolerance and efficacy.

Purpose To review the two main approaches of intraperitoneal (IP) chemotherapy delivery in ovarian cancer: postoperative adjuvant IP chemotherapy after cytoreductive surgery (CRS) and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). Methods A literature search was conducted to identify studies that employed postoperative adjuvant IP chemotherapy after CRS or combined CRS and intraoperative HIPEC in patients with ovarian cancer. Data of interest included chemotherapy protocol, morbidity and mortality, and survival data. Results Three large randomized controlled trials comprising 707 patients with advanced ovarian cancer who received postoperative adjuvant IP chemotherapy were reviewed. Morbidity rate ranged from 56% to 94% in IP chemotherapy, and mortality rate ranged from 1% to 2%. Median disease-free survival ranged from 24 to 28 months, and overall survival ranged from 49 to 66 months. Planned chemotherapy completion rates ranged from 42% to 71%. Twenty-four nonrandomized studies that reported HIPEC comprised 1167 patients with both advanced and recurrent ovarian cancer. In patients with advanced ovarian cancer, mortality ranged from 0% to 5%, minor morbidity ranged from 16% to 90%, and major morbidity ranged from 0% to 40%. Median disease-free survival ranged from 13 to 56 months, and overall survival ranged from 14 to 64 months. Survival at 5 years ranged from 35% to 70%. In patients with recurrent ovarian cancer, the mortality rate ranged from 0% to 10%, minor morbidity ranged from 7% to 90%, and major morbidity ranged from 0% to 49%. Median disease-free survival ranged from 13 to 24 months and overall survival from 23 to 49 months. Survival at 5 years ranged from 12% to 54%. Conclusion There is level-one evidence suggesting the benefit of postoperative adjuvant intraperitoneal chemotherapy for patients with advanced ovarian cancer after cytoreductive surgery, albeit catheter-related complications resulted after treatment discontinuation. Studies report the use of HIPEC predominantly in the setting of recurrent disease and have demonstrated encouraging results, which merits further investigation in future clinical trials.

Clinical efficacy and predictors of outcomes of repeat hepatectomy for recurrent hepatocellular carcinoma – A systematic review

BACKGROUND Primary hepatectomy is an accepted treatment for primary hepatocellular carcinoma (HCC) with good long-term survival, but high rates of recurrence. This review aims to evaluate the safety and efficacy of repeat hepatectomy for recurrent HCC after initial hepatectomy. METHODS Electronic searches identified 22 eligible studies comprising of 1125 patients for systematic review. Studies with >10 patients, adopting repeat hepatectomy treatment for recurrent HCC initially treated with hepatectomy were selected for inclusion. A predetermined set of data comprising demographic details, morbidity and mortality indices and survival outcomes were collected for every study and tabulated. RESULTS Majority of patients selected for repeat hepatectomy had Child-Pugh A (median 94%, range 40-100). Intrahepatic recurrence occurred at a median of 22.4 (range 12-48) months in this patient cohort with single nodule recurrences comprising of 70% of cases. The median mortality rate was 0% (range 0-6%). Prolonged ascites was observed in a median of 4% (range 0-32%), bleeding in 1% (range 0-9%), bile leak in 1% (range 0-6%) and liver failure in 1% (range 0-2%). The median disease-free survival was 15 (range 7-32) months and median overall survival was 52 (range 22-66) months. Median 3-year and 5-year survival was 69% (range 41-88%) and 52% (range 22-83%) respectively. Recurrences occurring 12-18 months after initial hepatectomy was consistently associated with improved survival. CONCLUSION Synthesized data from observational studies of repeat hepatectomy suggests that this treatment approach for recurrent HCC is safe and achieves long-term survival. Standardization of criteria for repeat hepatectomy and a randomized trial are warranted.

Simultaneous ventral hernia repair in bariatric surgery.

Obesity is a significant risk factor in abdominal hernia occurrence and recurrence. In patients having bariatric surgery, there are no clear guidelines as to whether repair should be done simultaneously, especially if procedures involve division or resection of part of the gastrointestinal tract.

Repeat cytoreductive surgery (CRS) for recurrent colorectal peritoneal metastases: Yes or no?

PURPOSE To clarify the role of repeat CRS for recurrent colorectal carcinoma (CRC) through: (i) Systematic review of the literature (ii) Analysis of survival outcomes in a prospective cohort. METHODS (i) Pubmed and MEDLINE from 1980 to July 2013 searched using terms: colorectal carcinoma, peritonectomy, cytoreductive surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), redo, repeat, and iterative. (ii) Kaplan-Meier Survival analysis of consecutive patients undergoing repeat CRS at St George Hospital between Jan 2000 and July 2013. RESULTS (i) The search strategy yielded 309 articles, 5 meeting inclusion criteria, reporting on 91 patients. Median overall survival from first CRS ranged from 39 to 57.6 months with 3-yr survival of 50%, and 5-year survival of 30%. Median survival from second CRS was 20-months with 1-yr survivals of 72% and 66% and 2-year survivals of 50% and 44%. (ii) Repeat CRS performed on 18 patients found median survival from first CRS was 59 months, with 1, 3, and 5-year survival of 100%, 52% and 26% respectively. Median survival from repeat CRS was 22.6 months with 1, 2, and 3-year survival of 94%, 48% and 12% respectively. CONCLUSION The current data on repeat CRS in CRC is relatively immature and more data is required before drawing clear conclusions. Patient selection should be on a case by case basis conducted through a MDT process with emphasis on surrogate markers for favourable outcomes.

Systematic review and meta-analysis of hepatic arterial infusion chemotherapy as bridging therapy for colorectal liver metastases.

BACKGROUND Hepatic arterial infusion chemotherapy (HAIC) has been shown to be beneficial in the management of unresectable colorectal liver metastases (CRLM). This systematic review evaluates the potential role of HAIC as a neoadjuvant downstaging therapy, prior to hepatic resection with curative intent for initially unresectable CRLM. METHODS A literature search was conducted using Pubmed, EMBASE and Medline databases from January 2000 to November 2013. Studies adopting HAIC as a neoadjuvant bridging therapy for hepatic resection for CRLM were included. RESULTS Eleven studies (n = 1514) were included. HAIC response rate was 50% and achieved conversion to surgery rate in 18% of patients. The median overall and 5-year survival for patients who underwent conversion to hepatectomy was 53 months and 49% compared to 16 months and 3% for patients who did not undergo surgery. Meta-analysis demonstrated strong association between hepatectomy and improved 5-year survival (RR 0.56, 95% CI = 0.48-0.65, Z = 7.26, p < 0.00001). CONCLUSION For patients presenting with unresectable CRLM, HAIC in conjunction with current systemic chemotherapy may allow some patients to undergo resection and potentially provide long-term survival.

Synchronous Ventral Hernia Repair in Bariatric Patients

Dear Editor, We note with interest the article of Eid et al. [1] and correspondence in the journal recently on the topic issue of timing of ventral hernia in bariatric patients. We note that this correspondence recommends a range of options in managing these patients but provides little evidence to back up these recommendations. While the issue of ventral hernia is obviously complex, we are concerned that recommending non-standard treatments may lead to outcomes that expose patients to increased risks and repeated surgical procedures. The use of suture and absorbable mesh repairs have been shown to have high recurrence rates, and leaving hernias untreated will expose patients to the certain requirement for later surgery and the risks of small bowel obstruction associated with their rapid weight loss. With this consideration, we consider all patients undergoing bariatric procedures with ventral hernias as candidates for synchronous repair, unless they had massive abdominal wall defects or cutaneous redundancy, in which case they are usually offered sleeve gastrectomy followed by delayed abdominal wall reconstruction. This number is small. We have attempted to answer the question of whether patients having bariatric surgery can have simultaneous ventral hernia repair if it is felt that the defect is amenable to laparoscopic repair by studying our outcomes [2]. In our series of 45 patients undergoing synchronous bariatric surgery and ventral hernia repair, the results were similar to those of laparoscopic repair alone. Two patients developed infected seromas that responded to simple drainage, and there have been no mesh removals or clinical hernia recurrence to date. This fits with the results of a Cochrane review comparing open and laparoscopic techniques concluding that laparoscopic hernia repair infection rates were 3.14 % (range 0–6.06 %) [3]. While valid concerns exist about the potential complication rate of using permanent mesh in patients having bariatric surgery, the rate of complications appear reassuringly low. Surgeons can be comfortable making decisions based on data, and in this situation, these data suggest that patients presenting for bariatric surgery with concomitant hernia can be offered standard treatment with the expectation of standard outcomes. The outcomes of non-standardised techniques such as suture repair or using biologics are poorly known, and since these repairs are either more likely to fail or are more complex than usual laparoscopic repair methods, they are hard to recommend in the face of established safe and effective techniques. In the future, a multicentre study may be able to provide sufficient numbers for a case-control or randomised trial, but until this occurs, clinicians must incorporate current evidence through available case-series, experience and extrapolation from published trials of established techniques.

The injury profile and acute treatment costs of major trauma in older people in New South Wales

To Describe injury profile and costs of older person trauma in New South Wales; quantify variations with peer group costs; and identify predictors of higher costs.

Gastric outlet obstruction secondary to parastomal hernia: case report and literature review

The stomach can be involved in abdominal wall hernias, albeit rarely. Gastric outlet obstruction in this setting is an unusual clinical entity, most commonly seen with large inguinoscrotal hernias. There are only six reported cases in the literature. We present a case of gastric outlet obstruction in an 85-year-old female who presented with acute incarceration of a parastomal hernia. An 85-year-old female presented to the emergency department with acute incarceration of a known left-sided parastomal hernia. This was associated with severe pain localized to the hernia site and profuse vomiting. Her surgical history included total abdominal hysterectomy and pelvic radiotherapy for ovarian cancer, and a loop colostomy a decade prior for management of symptomatic radiation proctitis. The patient was tachycardic (120 bpm) and febrile (38.2 C) on arrival to the emergency department. On physical examination, an irreducible tender parastomal hernia was identified. Biochemical abnormalities included leucocytosis and acute renal impairment (white blood cell count 20.6 × 10/L, creatinine 180 μmol/L, urea 18 mmol/L). Abdominal computed tomography (CT) demonstrated a massively distended stomach (Fig. 1). The distal stomach was located within a large parastomal hernia. The decompressed duodenum and loop colostomy are seen traversing the fascial defect (Fig. 2). Nasogastric decompression drained 2.5 L of dark brown fluid with dramatic decrease in the size of the hernia and resolution of pain. The patient was resuscitated in the emergency department and taken to operating theatre. Laparoscopy revealed a partially reduced parastomal hernia containing omentum. The stomach had reduced, either with nasogastric decompression, anaesthetic induction or insufflation of the abdomen. Based on the size of the defect and uncertain hernia contents, a decision was made to convert to laparotomy. A 5 × 5 cm parastomal hernia defect was identified at laparotomy. Complete small bowel adhesiolysis was performed. The loop colostomy was defined and the efferent and afferent limbs disconnected with a linear stapler. The fascial defect was closed with interrupted nylon figure-of-eight sutures from the internal aspect. The residual colostomy was excised and a new Abcarian stoma created on the right side. The midline wound and colostomy excision site were closed in the usual fashion. The patient made an uneventful recovery. Oral intake was tolerated on post-operative day 1 with discharge home on day 6.

Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care

Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional ‘generalist’ general surgery approach or the ASU model.