David W. Storey

Long term nutritional status and quality of life following major upper gastrointestinal surgery - a cross-sectional study.

BACKGROUND & AIMS Major upper gastrointestinal surgery results in permanent alterations to the gastrointestinal tract, and previously been shown to impair nutritional status. The aim of this study was to assess long term nutritional status and quality of life in people having had major upper gastrointestinal surgery, and the relationship between the two measures. METHODS People having had major upper gastrointestinal surgery greater than 6 months ago were recruited. Nutrition assessment included weight, anthropometry, Subjective Global Assessment, dietary intake and assessment of gastrointestinal symptoms; quality of life was assessed using the EORTC QLQ-C30 questionnaire. Associations between nutritional status, type of surgery and quality of life were analysed. RESULTS Thirty people were recruited with fourteen people showing a degree of malnutrition according to subjective global assessment. Total gastrectomy and oesophagectomy surgery resulted in significantly higher percent weight loss than those having undergone pancreaticoduodenectomy (p = 0.01). Subjective global assessment correlated with quality of life (p = 0.003). Subjective global assessment and gastrointestinal symptoms were both significant variables in explaining quality of life (p < 0.001). CONCLUSIONS Nutritional status in this group was significantly compromised, and impacted on quality of life. Individualised nutrition intervention to address malnutrition and gastrointestinal symptoms should be integrated into post surgery management.

Hepatic resection with vascular isolation and routine supraceliac aortic clamping

BACKGROUND Hepatic resection with total vascular isolation has been reported to reduce hemorrhage. Addition of supraceliac aortic clamping putatively avoids hemodynamic instability, but may increase morbidity. METHODS This technique was used in 99 major liver resections utilizing scalpel division and suture hemostasis. RESULTS Livers were normal in 86 patients, cirrhotic with no portal hypertension in 5, and cirrhotic with portal hypertension in 8. There was 1 death in 91 patients with no portal hypertension due to hepatic failure or bleeding esophageal varices. There were 59 hemihepatectomies and 40 segmentectomies. Median operating time was 145 and 110 minutes, respectively, and mean transfused blood was 4 and 0 units, respectively, with minimal morbidity. CONCLUSIONS Use of total hepatic vascular isolation with routine supraceliac aortic clamping is a safe and expedient method of hepatic resection that limits blood loss and maintains hemodynamic stability, but does not increase morbidity. However, the presence of portal hypertension precludes safe resection.

A PILOT STUDY OF PREOPERATIVE AND POSTOPERATIVE CHEMOTHERAPY IN PATIENTS WITH OPERABLE GASTRIC CANCER: AUSTRALASIAN GASTROINTESTINAL TRIALS GROUP STUDY 9601

Background:  With poor cure rates in gastric cancer using surgery alone, the safety, efficacy and feasibility of preoperative and postoperative chemotherapy was investigated.

Therapeutic considerations in obstructive jaundice due to hepatic artery aneurysm

Sir, The presentation of a 52-year-old woman with obstructive jaundice and an aneurysm of the common hepatic artery prompted analysis of the relative merits of surgery compared to interventional radiology in her case. The aneurysm was a true fusiform aneurysm of the common hepatic artery, presumed to be mycotic, as she had undergone a mitral valve replacement 2 years previously for bacterial endocarditis. Hepatic artery aneurysms may present as Quinkes triad of abdominal pain, haemobilia and obstructive jaundice 1. However 60–80% of patients present when the aneurysm ruptures. Jaundice may occur by external compression of or rupture into the biliary tree with thrombotic debris occluding the lumen. An endoluminal stent had relieved her jaundice. A selective angiogram demonstrated the aneurysm and showed occlusion of the right hepatic artery. Significant collateral circulation was present, indicating that hepatic artery occlusion could be tolerated without ischaemic hepatic injury. Ligation of the common hepatic artery with excision of the aneurysm and ligation of its branches was performed. The aneurysm had actually destroyed the left side of the common hepatic duct and frank rupture into the bile duct was only prevented by the thrombus within the lumen of the aneurysm. The aneurysm and the damaged hepatic duct and gallbladder (containing stones) were resected and an hepatodocho-jejunostomy reconstruction was performed. Hepatic arterial perfusion remained adequate and no arterial reconstruction was required. Once jaundice develops in the presence of hepatic artery aneurysm frank rupture may have already occurred or should be considered imminent. Embolization may prevent or control haemorrhage 2. However, as the bile duct may be extensively damaged and as the aneurysmal thrombosis may be infected, surgical treatment would appear to be the preferred definitive treatment rather than embolization. The development of jaundice in a case of hepatic artery aneurysm should prompt urgent surgical intervention. Although insertion of an endoluminal stent successfully relieved the biliary obstruction prior to this patients referral to our unit we would caution against stenting. The risk of a stent entering the aneurysm and precipitating major haemorrhage must be considerable. The biliary obstruction should be dealt with as part of the definitive excision of the aneurysm and repair of the damaged bile duct.

Induction chemotherapy via hepatic artery for gallbladder carcinoma.

The prognosis after surgery for carcinoma of the gallbladder remains poor. Treatment failure is frequently due to loco-regional recurrence in the adjacent liver and regional lymph nodes. We report a case of gallbladder carcinoma with proven involvement of the cystic duct node (Nevin stage IV). Pre-operative intra-arterial induction chemotherapy using two cycles of cisplatin, 5-fluorouracil, doxorubicin and mitomycin C was administered via the common hepatic artery. A radical cholecystectomy was performed 4 weeks later, and histological examination of the resected specimen showed a near total response, with no residual nodal disease. The patient remains well and free of disease 3 years later. Intra-arterial induction chemotherapy warrants further evaluation.

Parenteral Nutrition With Standard Solutions: Not the Best Solution for Everyone? A Retrospective Audit of 300 Patients

An observational retrospective study audited the incidence of adverse events in 300 consecutive inpatients receiving a single, premade total nutrient admixture. No patient experienced critically high triglycerides; 16% of patients had a metabolic adverse event, including raised bilirubin, urea, creatinine, or liver enzymes. Line sepsis occurred on 30 occasions representing 0.67 infections per 1000 catheter days. Mortality was significantly higher in dialysis, nonsurgical, and intensive care unit patients. The use of a standard formulation for all parenterally nourished patients does not lead to an unacceptable incidence or severity of metabolic complications; however, it did not meet the protein requirements of surgical or critically ill patients. (See Abstract Video, Supplemental Digital Content 1, http://links.lww.com/JIN/A62).

A comparison of the operative outcomes of D1 and D2 gastrectomy performed at a single Western center with multiple surgeons: a retrospective analysis with propensity score matching

BackgroundThere has been worldwide debate on lymphadenectomy for gastric cancer, with increasing consensus on performing an extended (D2) resection. There is a paucity of data in Australia. Our aim is to compare overall outcomes between a D1 and D2 lymphadenectomy for gastric cancer in a single specialist unit.MethodsWe performed a retrospective analysis on patients who underwent a curative primary gastric resection for gastric adenocarcinoma between January 1996 and April 2016, primary outcomes included overall survival (OS) and disease-free survival (DFS). Propensity score matching (PSM) analysis was used to balance covariates between D1/D1+ and D2 groups. Kaplan-Meier survival curves of D1/D1+ versus D2 were constructed and evaluated using the log-rank test with subgroup analyses for pathological node (pN) status. Multiple Cox proportional hazards model was used to determine predictors of overall survival.ResultsTwo hundred four patients underwent a gastrectomy, 54 had D1/D1+, and 150 had a D2 lymphadenectomy. After PSM, there were 39 patients in each group, the 10-year OS for D1/D1+ was 52.1 and 76.2% for D2 (p = 0.008), and 10-year DFS was 35% for D1 and 58.1% for D2 (p = 0.058). Subgroup analysis showed that node-negative (N0) patients had improved 5-year OS for D2 (90.9%), compared to D1/D1+ (76.4%) (p = 0.028). There was no difference in operative mortality between the groups (D1 vs D2: 2 vs 0%, p = 0.314), nor in post-operative complications (p = 0.227). Multiple Cox analysis showed advanced tumor stage (stages III and IV), and lymphadenectomy type (D1) and the presence of postoperative complications were independent predictors of poor overall survival.ConclusionsD2 lymphadenectomy with spleen and pancreas preservation can be performed safely on patients with gastric adenocarcinoma. Significant improvement in overall survival is observed in patients with N0 disease who underwent D2 lymphadenectomy without increasing operative morbidity or mortality. This paper supports the notion of a global consensus for a D2 lymphadenectomy, particularly in the Western context.

General surgery primary operator rates: a guide to achieving future competency

Competency in surgical training is a topic of much recent discussion, with concern regarding the adequacy of current training schemes to achieve competency. Most programmes use caseload and primary operator rates to assess trainee progression. Some trainees still lack technical competence even when recommended procedural numbers are met. It is possible that current measures of individuals capabilities used in surgical education are outdated.