E. Baker

Robotic pancreaticoduodenectomy: comparison of complications and cost to the open approach

Robotic pancreaticoduodenectomy (RP) has shown some advantages over open pancreaticoduodenectomy (OP) but no data has been published providing a cost comparison.

Multimodality treatment of intrahepatic cholangiocarcinoma: A review

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary hepatic cancer in the United States. Currently, curative treatment involves aggressive surgery. Chemotherapy and radiation treatments have been used for unresectable tumors with some success. Optimizing the use of current and developing novel multimodality treatment for iCCA is essential to improving outcomes. J. Surg. Oncol. 2016;113:62–83.

High-Frequency Irreversible Electroporation: Safety and Efficacy of Next-Generation Irreversible Electroporation Adjacent to Critical Hepatic Structures:

Irreversible electroporation (IRE) is a nonthermal ablation modality employed to induce in situ tissue-cell death. This study sought to evaluate the efficacy of a novel high-frequency IRE (H-FIRE) system to perform hepatic ablations across, or adjacent to, critical vascular and biliary structures. Using ultrasound guidance H-FIRE electrodes were placed across, or adjacent to, portal pedicels, hepatic veins, or the gall bladder in a porcine model. H-FIRE pulses were delivered (2250 V, 2-5-2 pulse configuration) in the absence of cardiac synchronization or intraoperative paralytics. Six hours after H-FIRE the liver was resected and analyzed. Nine ablations were performed in 3 separate experimental groups (major vessels straddled by electrodes, electrodes placed adjacent to major vessels, electrodes placed adjacent to gall bladder). Average ablation time was 290 ± 63 seconds. No electrocardiogram abnormalities or changes in vital signs were observed during H-FIRE. At necropsy, no vascular damage, coagulated-thermally desiccated blood vessels, or perforated biliary structures were noted. Histologically, H-FIRE demonstrated effective tissue ablation and uniform induction of apoptotic cell death in the parenchyma independent of vascular or biliary structure location. Detailed microscopic analysis revealed minor endothelial damage within areas subjected to H-FIRE, particularly in regions proximal to electrode insertion. These data indicate H-FIRE is a novel means to perform rapid, reproducible IRE in liver tissue while preserving gross vascular/biliary architecture. These characteristics raise the potential for long-term survival studies to test the viability of this technology toward clinical use to target tumors not amenable to thermal ablation or resection.

Qualities and characteristics of successfully matched North American HPB surgery fellowship candidates

BACKGROUND Hepato-pancreato-biliary (HPB) fellowships in North America are difficult to secure with an acceptance rate of 1 in 3 applicants. Desirable characteristics in an HPB surgery applicant have not been previously reported. This study examines the perceptions of trainees and HPB program directors with regards to positive attributes in applicants for HPB fellowships. METHODS Parallel surveys were distributed by email with a web-link to current and recent HPB fellows in North America (from the past 5 years) with questions addressing the following domains: surgical training, research experience, and mentorship. A similar survey was distributed to HPB fellowship program directors in North America requesting their opinion as to the importance of these characteristics in potential applicants. RESULTS 32 of 60 of surveyed fellows and 21 of 38 of surveyed program directors responded between November 2014-February 2015. Fellows overall came from fairly diverse backgrounds (13/32 were overseas medical graduates) about one third of respondents having had some prior research experience. Program directors gave priority to the applicants interview, curriculum vitae, and their recommendation letters (in order of importance). Both the surveyed fellows and program directors felt that the characteristics most important in a successful HPB fellowship candidate include interpersonal skills, perceived operative skills, and perceived fund of knowledge. CONCLUSION Results of this survey provide useful and practical information for trainees considering applying to an HPB fellowship program.

Outcomes of surgical resection and loco‐regional therapy in patients with stage 3A hepatocellular carcinoma: a retrospective review from the national cancer database

OBJECTIVES In advanced stages, hepatocellular carcinoma (HCC) is often associated with major vascular involvement (cava, portal vein). The aim of the present study was to analyse the role of surgical resection (SR) and loco-regional therapy (LRT) in these advanced stage patients to determine if there was a survival benefit. METHODS The study is a retrospective analysis from the Commission on Cancers National Cancer Data Base (NCDB) from 1998 to 2011. In total, 148,882 patients with liver cancer were identified, of which 126,984 had HCC. Of these, 64,264 patients (1998-2006) had 5-year survival data available and 8825 patients had Stage 3A disease based on AJCC classification. Of these patients, 884 had SR, 771 had LRT and 7170 patients had neither intervention. Kaplan-Meier curves and log-rank tests were used for statistical analysis. RESULTS Eight thousand eight hundred and twenty-five patients met analysis criteria. The mean age (years) in the SR, LRT and no intervention group were 62.5, 64.3 and 64.2, respectively. Most patients were males in all three groups (77.5%, 74.5% and 68.1%). The mean tumour size (cm) in the three groups was 9.8, 6.4 and 8.4, respectively. SR and LRT were primarily performed in major academic and comprehensive cancer programmes compared with community cancer programmes and other centres (SR: 93% versus 7%; LRT: 94.6% versus 5.4%). The median 5-year survival (months) was 26.6 in SR, 16.5 in LRT and 4.8 in the no intervention group (P < 0.0001). CONCLUSION A SR and LRT offer a survival benefit in select patients diagnosed with Stage 3A HCC.

Operative microwave ablation for hepatocellular carcinoma: a single center retrospective review of 219 patients

BACKGROUND Microwave ablation (MWA) of hepatocellular carcinoma (HCC) offers local regional treatment that can be safely and effectively performed, even in patients with advanced liver disease. We update results from our groups previous analysis of operative MWA for HCC. METHODS Retrospective review was performed of all patients who underwent operative MWA for HCC from 2007-2014. Patient demographics, operative characteristics and complications were recorded. Follow up imaging was reviewed to determine rates of complete ablation, local, regional and metastatic recurrence. RESULTS Two hundred and nineteen patients were included with a total of 340 tumors treated with operative MWA. Median tumor size was 3.2 cm (range, 1-6 cm). Cirrhosis was present in 89.5% of patients, 60.7% had hepatitis C, and 8.2% had hepatitis B. Thirty-five point nine percent were Child-Pugh class B/C. Ninety-six point eight percent of MWA procedures were performed laparoscopically. Four deaths occurred within 30 days (1.8%). Clavien-Dindo grade III complications occurred in 3.2% of patients. Complete ablation was identified in 97.1% of tumors, with local recurrence rates of 8.5% at 10.9 months median follow up (0-80 months). Regional recurrence occurred in 34.8% of patients at 10.9 months median follow up and metastatic recurrence was seen in 8.1% of patients. One year overall survival was 80.0% and 2-year survival was 61.5%. CONCLUSIONS We propose that laparoscopic MWA offers a low morbidity approach for treatment of HCC affording low rates of local recurrence even for patients with significant underlying liver dysfunction. This large series offers insight into outcomes of this modality as definitive treatment for patients with HCC.

Routine versus difficult cholecystectomy: using predictive analytics to assess patient outcomes

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program® (NSQIP) Surgical Risk. Calculator (SRC) estimates postoperative outcomes. The aim of this study was to develop and validate a specific predictive outcomes model for cholecystectomy procedures. METHODS Patients who underwent cholecystectomy between 2008 and 2016 and were deemed too high risk for acute care general surgery (GS) and had surgery performed by the Division of Hepatopancreatobiliary Surgery (HPB) were identified. Outcomes of the HPB cholecystectomies were matched against cholecystectomies performed by GS. New predictive models for postoperative outcomes were constructed. Area under the curve was used to assess predictive accuracy for both models and internal validation was performed using bootstrap logistic regression. RESULTS A total of 169/934 (18%) cholecystectomies were identified as too high risk for GS. These 169 patients were matched with 126 patients who had cholecystectomy performed by GS. For GS and HPB cholecystectomies, the proposed model demonstrated better discriminative ability compared to the SRC based on ROC curves (proposed model: 0.589-0.982; SRC: 0.570-0.836) for each of the predicted outcomes. CONCLUSION For patients undergoing cholecystectomy, customized models are superior for predicting individual perioperative risk and allow more accurate, patient-specific delivery of care.

Developing and validating a center-specific preoperative prediction calculator for risk of outcomes following major hepatectomy procedures

BACKGROUND The American College of Surgeons NSQIP® Surgical Risk Calculator (SRC) was developed to estimate postoperative outcomes. Our goal was to develop and validate an institution-specific risk calculator for patients undergoing major hepatectomy at Carolinas Medical Center (CMC). METHODS Outcomes generated by the SRC were recorded for 139 major hepatectomies performed at CMC (2008-2016). Novel predictive models for seven postoperative outcomes were constructed and probabilities calculated. Brier score and area under the curve (AUC) were employed to assess accuracy. Internal validation was performed using bootstrap logistic regression. Logistic regression models were constructed using bivariate and multivariate analyses. RESULTS Brier scores showed no significant difference in the predictive ability of the SRC and CMC model. Significant differences in the discriminative ability of the models were identified at the individual level. Both models closely predicted 30-day mortality (SRC AUC: 0.867; CMC AUC: 0.815). The CMC model was a stronger predictor of individual postoperative risk for six of seven outcomes (SRC AUC: 0.531-0.867; CMC AUC: 0.753-0.970). CONCLUSION Institution-specific models provide superior outcome predictions of perioperative risk for patients undergoing major hepatectomy. If properly developed and validated, institution-specific models can be used to deliver more accurate, patient-specific care.

Robotic-assisted completion Cholecystectomy: a safe and effective minimally invasive approach to a challenging surgical scenario

Average LOS 1.1 days TP20-02 ROBOTIC-ASSISTED COMPLETION CHOLECYSTECTOMY: A SAFE AND EFFECTIVE MINIMALLY INVASIVE APPROACH TO A CHALLENGING SURGICAL SCENARIO W. Lyman, M. Passeri, A. Sastry, D. Iannitti, D. Vrochides, E. Baker and J. Martinie Department of General Surgery, and Division of HPB Surgery, Carolinas Medical Center, United States Background: Subtotal cholecystectomy remains a viable and safe option when intraoperative conditions preclude visualization of the Critical View of Safety. 1.8% of these patients eventually require a reoperation. Traditionally, completion cholecystectomy following subtotal cholecystectomy required an open approach. In this study, we present our institutional experience with 16 robotic-assisted completion cholecystectomies following previous subtotal cholecystectomy. Methods: Operating room logs were reviewed from 20102017 to identify all robotic cholecystectomies performed at our institution. Review of all operative reports identified 16 completion cholecystectomies following a previous subtotal cholecystectomy. All additional variables including demographics, operative variables, and postoperative outcomes were collected from EMR records. Results: Median time from previous subtotal cholecystectomy to robotic completion cholecystectomy was 84 months (7 years). 58.3% of patients previously underwent an open subtotal cholecystectomy. The remaining patients underwent a laparoscopic subtotal cholecystectomy. Additional demographics and outcomes can be seen in Table 1. One patient required oral antibiotics for incisional site erythema. No patients required a conversion to an open procedure and average length of stay was 1.1 days. Conclusions: Although traditionally performed with an open approach, we have had success in recent years at our institution with a robotic-assisted approach to completion

A Complete Pathological Response to Pembrolizumab following ex vivo Liver Resection in a Patient with Colorectal Liver Metastases

Advances in the systemic treatment of stage IV colorectal cancer with liver metastases has offered improved survival rates for patients who otherwise face a dismal prognosis. However, a pathologically complete response (PCR) to chemotherapy for colorectal liver metastases is still rare, and its significance is not fully understood. In this case report, we describe a patient who achieved PCR after neoadjuvant immunotherapy with pembrolizumab and a left hepatectomy using an ex vivo resection technique.