Emma Johnston

A systematic review of two-stage hepatectomy in patients with initially unresectable colorectal liver metastases.

OBJECTIVES Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable using the two-stage hepatectomy (TSH) approach. This review was conducted with the aim of collating and evaluating published evidence for TSH in patients with initially unresectable CLM. METHODS Searches of the MEDLINE and EMBASE databases were undertaken to identify studies of TSH in patients with initially unresectable CLM. Studies were required to focus on the perioperative treatment regimen, operative strategy, morbidity, technical success and survival outcomes. RESULTS Ten observational studies were reviewed. A total of 459 patients with initially unresectable CLM were selected for the first stage of TSH. Preoperative chemotherapy was used in 88% of patients and achieved partial and stable response rates of 59% and 39%, respectively. Postoperative morbidity and mortality after the first stage of TSH were 17% and 0.5%, respectively. Portal vein embolization (PVE) was used in 76% of patients. Ultimately, 352 of the initial 459 (77%) patients underwent the second stage of TSH. Major liver resection was undertaken in 84% of patients; the negative margin (R0) resection rate was 75%. Postoperative morbidity and mortality after the second stage of TSH were 40% and 3%, respectively. Median overall survival was 37 months (range: 24-44 months) in patients who completed both stages of TSH. In patients who did not complete both stages of TSH, median survival was 16 months (range: 10-29 months). The 3-year disease-free survival rate was 20% (range: 6-27%). CONCLUSIONS Two-stage hepatectomy is safe and effective in selected patients with initially unresectable CLM. Further studies are required to better define patient selection criteria for TSH and the exact roles of PVE and preoperative and interval chemotherapy.

A Systematic Review of Clinical Response and Survival Outcomes of Downsizing Systemic Chemotherapy and Rescue Liver Surgery in Patients with Initially Unresectable Colorectal Liver Metastases

BackgroundSelected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable after systemic chemotherapy. We reviewed the evidence of downsizing systemic chemotherapy followed by rescue liver surgery in patients with initially unresectable CLM.MethodsLiterature search of databases (Medline and PubMed) to identify published studies of neoadjuvant chemotherapy followed by liver resection in patients with initially unresectable CLM was undertaken and focused on response rate of chemotherapy and survival outcomes.ResultsTen observational studies were reviewed. A total of 1,886 patients with initially unresectable CLM underwent systemic chemotherapy. An objective response was observed in 64% (range, 43–79%) of patients after systemic chemotherapy. Of these, 22.5% underwent macroscopically curative liver resection. Median overall survival was 45 (range, 36–60) months with 19% of patients alive and recurrence-free.ConclusionsCurrent evidence suggests that downsizing systematic chemotherapy followed by rescue liver resection is safe and effective for selected patients with initially unresectable CLM. Further studies are required to examine response rates and secondary resectability using new targeted molecular therapy-based regimens.Selected patients with unresectable colorectal liver metastases (CLM) may be rendered resectable after systemic chemotherapy. We reviewed the evidence of downsizing systemic chemotherapy followed by rescue liver surgery in patients with initially unresectable CLM. Literature search of databases (Medline and PubMed) to identify published studies of neoadjuvant chemotherapy followed by liver resection in patients with initially unresectable CLM was undertaken and focused on response rate of chemotherapy and survival outcomes. Ten observational studies were reviewed. A total of 1,886 patients with initially unresectable CLM underwent systemic chemotherapy. An objective response was observed in 64% (range, 43–79%) of patients after systemic chemotherapy. Of these, 22.5% underwent macroscopically curative liver resection. Median overall survival was 45 (range, 36–60) months with 19% of patients alive and recurrence-free. Current evidence suggests that downsizing systematic chemotherapy followed by rescue liver resection is safe and effective for selected patients with initially unresectable CLM. Further studies are required to examine response rates and secondary resectability using new targeted molecular therapy-based regimens.

Endoscopic necrosectomy of pancreatic necrosis: a systematic review

AimTo review the current status of the novel technique of endoscopic necrosectomy in the management of pancreatic necrosis after acute pancreatitis.MethodsStudies were identified by searching Medline, PubMed and Embase databases for articles from January 1990 to December 2009 using the keywords “acute pancreatitis”, “pancreatic necrosis” and “endoscopy”. Additional papers were identified by a manual search of the references from the key articles. Case series of fewer than five patients and case reports were excluded.ResultsIndications, techniques and outcomes of endoscopic necrosectomy were analysed. There were no randomised controlled trials identified. Ten case series were included in this analysis. There were a total of more than 1,100 endoscopic necrosectomy procedures in 260 patients with pancreatic necrosis. One hundred fifty-five were proven to be infected necrosis on culture. The overall mortality rate was 5%. The mean procedure-related morbidity rate was 27%. The rate of complete resolution of pancreatic necrosis with the endoscopic method alone was 76%.ConclusionsEndoscopic necrosectomy is a safe and effective treatment option in selected patients with pancreatic necrosis after acute pancreatitis. Future studies will be required to further define the selection criteria and the techniques for the endoscopic procedure.

Systematic review of actual 10‐year survival following resection for hepatocellular carcinoma

BACKGROUND Hepatic resection is a potentially curative therapy for hepatocellular carcinoma (HCC), but recurrence of disease is very common. Few studies have reported 10-year actual survival rates following hepatic resection; instead, most have used actuarial measures based on the Kaplan-Meier method. This systematic review aims to document 10-year actual survival rates and to identify factors significant in determining prognosis. METHODS A comprehensive search was undertaken of MEDLINE and EMBASE. Only studies reporting the absolute number of patients alive at 10 years after first resection for HCC were included; these figures were used to calculate the actual 10-year survival rate. A qualitative review and analysis of the prognostic factors identified in the included studies were performed. RESULTS Fourteen studies, all of which were retrospective case series, including data on 4197 patients with HCC were analysed. Ten years following resection, 303 of these patients were alive. The 10-year actual survival rate was 7.2%, whereas the actuarial survival quoted from the same studies was 26.8%. Positive prognostic factors included better hepatic function, a wider surgical margin and the absence of satellite lesions. CONCLUSIONS The actual long-term survival rate after resection of HCC is significantly inferior to reported actuarial survival rates. The Kaplan-Meier method of actuarial survival analysis tends to overestimate survival outcomes as a result of censorship of data and subgroup analysis.

Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe: Cholecystectomy for severe cholecystitis

According to the Tokyo Guidelines, recommendation on management of moderate and severe cholecystitis are cholecystostomy in severe cases and either cholecystostomy or emergency cholecystectomy in moderate cases depending on surgical experience. The rationale for this is that percutaneous cholecystostomy is a short procedure while laparoscopic cholecystectomy may be associated with a larger physiological insult. The aim of this study was to determine the safety and efficacy of cholecystectomy in moderate and severe acute calculous cholecystitis (ACC) at our institution.

Re: Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe.

We read with interest the article by Kamalapurkar et al. extolling the benefits of index cholecystectomy in patients with grade II or III acute calculous cholecystitis. This retrospective study graded the severity of cholecystitis according to the Tokyo Guidelines definition in 229 consecutive patients. Eighty-eight per cent of patients with either grade II or grade III cholecystitis underwent operative intervention during the index admission, and the procedure was completed laparoscopically in 98 and 76%, respectively. However, 27% of patients with grade III cholecystitis had to be converted to an open operation and there was a 9% bile leak rate in this group. The authors alluded to the difficulty of determining operative findings in a retrospective study and concluded that classifying patients with grade II cholecystitis was not reliable. How many of their patients had detailed operative findings recorded in the notes, and did these findings correlate with the grading assigned? This would be helpful to determine whether some of the patients in the ‘grade II’ category were operated on for uncomplicated biliary colic rather than acute cholecystitis. The high conversion rate and subsequent post-operative bile leak rate in this study demonstrates the operative difficulties when dealing with genuine severe acute cholecystitis. The conclusion by Kamalapurkar et al. that emergency cholecystectomy in the setting of severe cholecystitis is safe and technically feasible is not warranted given the data presented. Instead more accurate preoperative assessment tools to triage patients with likely difficult operative pathology are needed. We implore surgeons to systematically document the operative findings during cholecystectomy, ideally using a grading system. This will allow scientific validation of preoperative assessment tools such as the Tokyo Guidelines that might triage patients for safe emergency cholecystectomy.

Hepatic resection for metastatic melanoma: a systematic review.

Melanoma metastatic to the liver has a very poor prognosis, and has traditionally been treated using systemic chemotherapy with limited efficacy. Surgery is increasingly being explored as a therapeutic option for melanoma liver metastases, with varying levels of success. A systematic review was undertaken to explore the short-term and long-term outcomes associated with hepatectomy for melanoma metastases, in addition to identifying prognostic factors favouring increased survival. All eligible studies were identified through an electronic search of Medline and Embase (January 1990–March 2013). Each study was independently analysed by two reviewers, with relevant data extracted and tabulated according to predetermined criteria. Thirteen studies were selected that fulfilled the selection criteria, with a total of 551 patients undergoing hepatic resection for melanoma metastases. Metastases to the liver occurred at a median interval of 54 months. The median perioperative morbidity and mortality were 10% (range 0–28.6%) and 0% (range 0–7.1%), respectively. The median overall survival for operative patients was 24 months, with median survival being greater in the R0 resection group (25 months; range 9.5–65.6 months) compared with the R1/2 resection group (16 months; range 11.7–29 months). Overall median 1-, 3- and 5-year survival rates were 70% (range 39–100%), 36% (range 10.2–53%) and 24% (range 3–53%), respectively. Positive prognostic factors may include single hepatic metastases, a longer time to development of hepatic metastases and R0 resection. Hepatic resection for metastatic melanoma might confer a distinct survival benefit in a select group of patients, although disease recurrence is the norm.

Synchronous association of small bowel stromal tumour with colonic adenocarcinoma.

Gastrointestinal stromal tumours (GIST) are rare mesenchymal tumours of the gastrointestinal tract (GIT) believed to arise from the interstitial cells of Cajal.1 Rare associations with other primary gastrointestinal neoplasms of different histology are reported in the published work.2 Common aetiology and carcinogenetic mechanisms are considered a possibility in their association, but have not yet been proved. GIST is commonly seen associated with adenocarcinoma of the stomach. There are only a few reports of synchronous occurrence of GIST of the small intestine and colorectal adenocarcinoma.3 We present a case of metastatic sigmoid colon adenocarcinoma with synchronous GIST of the jejunum. A 77-year-old woman presented with left iliac fossa pain of increasing severity. This was associated with intermittent fresh rectal bleeding of 2weeks duration. In addition, she reported intermittent constipation for 6months. On examination, she was haemodynamically normal with low-grade fever. Abdomen examination showed tenderness in the left iliac fossa and decreased bowel sounds. Per rectal examination was normal. Biochemical and haematological parameters were normal aside from increased white cell count. Computed tomography abdomen and pelvis showed free gas in the peritoneal cavity, wall thickening in the sigmoid colon and a small low-density lesion in segment VI of liver. At emergency laparotomy, a mass lesion in the sigmoid colon was noted with adherent terminal ileum and free pus. In the left lobe of the liver was an umbilicated lesion, and there was a jejunal polyp identified incidentally. A Hartmann’s procedure was carried out with en bloc resection of a segment of terminal ileum. The jejunal polyp was excised and a Trucut biopsy of the liver lesion was carried out. Histopathological examination of the colonic specimen showed moderately differentiated colonic adenocarcinoma involving the serosal surface with clear resection margins. Pericolic and apical nodes were involved and the liver lesion was a metastasis. The jejunal polyp showed spindle cells strongly positive for vimentin and c-Kit stain (Fig. 1) and negative for Desmin, S100. This was consistent with GIST. Mild nuclear pleomorphism was present, but no necrosis or mitotic figures were identified. A diagnosis of GIST of probable low malignant potential was made. Incidentally, the colorectal carcinoma cells also showed focally positive membranous staining for c-Kit stain (Fig. 2). Her postoperative course was uneventful but disappointingly, staging PET scan showed extensive multiple metastatic lesions in liver, abdominal lymph nodes and bone. The patient was referred for symptomatic palliative care. The term GIST was first coined by Mazur and Clark in 1983.3 Kindblom et al. identified the intestinal pacemaker cells called interstitial cells of Cajal, which are presumed to be the origin of these tumours.1 GIST are commonly identified in stomach and small intestine. A search of published work showed reports of GIST in association with other neoplasms, especially gastrointestinal malignancies. The association of GIST and adenocarcinoma is commonly seen in stomach.2 Synchronous occurrence of GIST and adenocarcinoma at two different sites in the GIT is rarely seen.

The Abdominal Reapproximation Anchor Device A Single Australian Tertiary Hospital Experience

Introduction. Achieving primary fascial closure after damage control laparostomy can be challenging. A number of devices are in use, with none having yet emerged as best practice. In July 2013, at Westmead Hospital, we started using the abdominal reapproximation anchor (ABRA; Canica Design, Almonte, Ontario, Canada) device. We report on our experience. Methods. A retrospective review of medical records for patients who had open abdomens managed with the ABRA device between July to December 2013 was done. Data extracted included age, sex, body mass index (BMI), reason for the open abdomen, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of laparostomies prior to ABRA placement, duration of placement, device complications, length of hospital and intensive care unit (ICU) stay, and outcomes. Results. Four cases of open abdomens managed using the ABRA device were identified, with 3 a consequence of intra-abdominal sepsis and 1 a consequence of penetrating trauma. Mean BMI was 33.5 kg/m2, APACHE II score was 14.5, duration with open abdomen prior to ABRA placement was 11.75 days, duration with ABRA in situ was 9 days, duration of hospital stay was 64.25 days, and ICU stay was 37.75 days. Three patients (75%) achieved fascial closure, and 1 achieved skin closure. No incidences of enterocutaneous fistulae occurred. Conclusion. The ABRA is a unique emerging alternative to aid in achieving fascial closure in patients managed with open abdomens. Our case series demonstrates that it can be used effectively in selected patients. Studies are needed to compare its efficacy with more traditional methods.