K. Menon

Redefining resection margin status in pancreatic cancer

Curative resection is crucial to survival in pancreatic cancer; however, despite optimization and standardization of surgical procedures, this is not always achieved. This review highlights that the rates of microscopic margin involvement (R1) vary markedly between studies and, although resection margin status is believed to be a key prognostic factor, the rates of margin involvement and local tumour recurrence or overall survival of pancreatic cancer patients are often incongruent. Recent studies indicate that the discrepancy between margin status and clinical outcome is caused by frequent underreporting of microscopic margin involvement. Lack of standardization of pathological examination, confusing nomenclature and controversy regarding the definition of microscopic margin involvement have resulted in the wide variation of reported R1 rates that precludes meaningful comparison of data and clinicopathological correlation.

Serum C-reactive protein concentration and the prognosis of ductal adenocarcinoma of the head of pancreas

BACKGROUNDnThe prognostic role of serum C-reactive protein in pancreatic cancer has received increasing attention; however the confounding effects of biliary obstruction have not been addressed in previous studies. We sought to determine the prognostic importance of serum CRP prior to biliary intervention in the prognosis of pancreatic adenocarcinoma.nnnMETHODSnA retrospective case note review of patients diagnosed with pancreatic cancer between 2001 and 2006. Clinical, radiological and biochemical criteria were correlated with overall survival. Patients were divided into: Group 1 who underwent potentially curative resection, and Group 2 with advanced unresectable disease managed non-surgically.nnnRESULTSnIn total, 199 patients were included (58 resected). The proportion of patients with biliary obstruction was equal in both groups. Serum CRP and serum bilirubin concentration at presentation were significantly higher among patients in Group 2 compared to Group 1 (P values). On multivariate analysis, advancing age (P=0.012) and raised serum CRP concentration were independently associated with overall survival only in Group 2 patients (P=0.027, 95% CI 0.31-0.93). This association was independent of biliary tract obstruction.nnnCONCLUSIONnRaised serum C-reactive protein concentration at the time of presentation of advanced pancreatic cancer carries a poor prognosis independent of biliary tract obstruction.

The risk of gallbladder cancer from polyps in a large multiethnic series

BACKGROUNDnThe aim of this study is assess whether patients with Indian ethnic background are at an increased risk of developing gallbladder cancer (GBC) if they have been diagnosed with ultrasonic abnormalities of the gallbladder.nnnMETHODSnBetween January 1998 and July 2006, 137,655 abdominal ultrasound examinations were performed in Leeds Teaching Hospitals NHS Trust. After the exclusion of repeat scans and those performed for renal or pelvic disease, 71,431 reports were included in this analysis. Patients in whom the diagnosis of GBC has been made without histology have been identified from the database of Northern and Yorkshire Cancer Registry and the presence of GBC was correlated with ultrasonic gallbladder abnormalities.nnnRESULTSnGallbladder polyps (GBP) were detected in 3.3% of patients and these were larger than 10 mm in 0.1% of the cases. Age above 60 years, Indian ethnic background, single GBP larger than 10mm, the presence of gallstones, severe gallbladder wall thickening and irregular thickening were independently associated with the higher odds of developing GBC. The prevalence of malignancy in those with GBP was significantly higher among patients with Indian ethnic background compared to Caucasian patients, 5.5% versus 0.08%, p<0.001.nnnCONCLUSIONSnThe presence of GBP, irrelevant of size, amongst patients of Indian ethnic decent, is an indication for further investigation and/or cholecystectomy.

Acceptable Outcome After Kidney Transplantation Using Expanded Criteria Donor Grafts

Introduction. With the worldwide shortage of donors, extra lengths are ongoing to enlarge the donor pool. One means has been a greater use of “expanded criteria donor” (ECD) grafts. A major concern regarding ECD kidneys is poor long-term graft survival. The aims of this study were to determine whether ECD grafts, as defined by the United Network for Organ Sharing, had a negative impact on graft survival and to identify the principle donor and recipient factors that influenced graft survival in our patient cohort. Methods. We analyzed all deceased donor renal transplants in our unit from January 1995 to October 2005, in total 1053 transplants. Results. ECD grafts (United Network for Organ Sharing criteria) demonstrated higher rates of delayed graft function and higher early mean creatinine levels. However, there was no significant difference in 5-year graft survival. Multivariate analysis of our patient group identified donor hypertension and ischemic heart disease (IHD) as independent predictors of poor graft survival. Recipient age was significant on univariate but not on multivariate analysis. However, although younger recipients maintained acceptable 5-year graft survival despite donor hypertension, IHD, or a combination of both, these factors significantly reduced graft survival in older recipients. Conclusion. Although ECD grafts had slightly worse function, 5-year survival was comparable with standard grafts in all recipients. Donor hypertension, IHD, or a combination of both significantly reduced graft survival in older recipients, not evident in younger patients. We discuss the possible factors for improved outcome with ECD grafts in our patients and the implications of our patient analysis.

Serum Macrophage Migration Inhibitory Factor Is an Early Marker of Pancreatic Necrosis in Acute Pancreatitis

Objective:To determine if 24-hour blood concentrations of macrophage migration inhibitory factor (MIF), soluble CD14, and CD163 receptors could predict complications associated with acute pancreatitis (AP). Summary Background Data:Soluble receptor proteins derived from the macrophage-monocyte lineage potentiate the inflammatory cytokine response early in AP. Understanding the temporal expression of these molecules could afford better measures for therapeutic intervention. Methods:Patients with AP (amylase >5 times normal) were recruited within 24-hour of onset of pain. Peripheral blood was analyzed for MIF, sCD163, and sCD14 levels and levels correlated with CRP, APACHE-II score, and clinical disease severity (Atlanta criteria); subclassified as multiorgan dysfunction (MOF), pancreatic necrosis (PN >30% on contrast CT), and death. Results:In total, 64 patients with AP (severe, 19: 8 had MOF alone, 7 both PN and MOF, 2 PN without MOF, and 2 single-organ failures with local septic complications) were recruited. Both sCD14 and MIF concentrations were elevated in patients with severe attacks (P = 0.004 and P < 0.001 respectively), and patients who developed MOF (P = 0.004 and P < 0.001). However, only serum MIF was significantly raised in patients who subsequently developed PN (median, 92.5 ng/mL; IQR, 26–181 vs. 31.1 ng/mL; IQR, 5–82, P < 0.001), independently of MOF (P = 0.01). Multivariate analysis demonstrated serum MIF as an independent predictor of PN (P = 0.01; OR = 2.73; 95% CI, 2.72–2.74). Conclusion:The prognostic utility of 24-hour plasma MIF concentration in predicting PN has major clinical and healthcare resource implications. Its mechanistic pathway may afford novel therapeutic interventions in clinical disease by using blocking agents to ameliorate the systemic manifestations of AP.

Non‐operative management of pyogenic liver abscess

BACKGROUNDnLiver abscess is a serious disease traditionally managed by open drainage. The advances in interventional radiology over the last two decades have allowed a change in approach to this condition. We have reviewed our experience in managing liver abscess over the last 7 years.nnnMETHODSnDetails of all patients admitted with liver abscess between 1995 and 2002 were prospectively entered onto our database. A review was performed to document the use of imaging and drainage techniques. Aetiology, morbidity, mortality and duration of hospital stay were recorded.nnnRESULTSnForty-two patients (median age 53 [22-85] years; M:F 18:24) were admitted with liver abscess (multiple abscess 20); 19 cases were of portal tract origin, 16 cases were of biliary tract origin and 7 cases were spontaneous. Forty-one patients were managed non-operatively, all received antibiotics (cephalosporins 76%, metronidazole 88%, quinolones 33%). Diagnosis was made on ultrasound scan (22) or CT (20). Five patients were managed with antibiotics alone. Fifteen patients were managed initially with percutaneous aspiration and five subsequently required percutaneous drainage. Twenty-one patients had primary percutaneous drainage, nine requiring a further procedure (aspiration 3, drainage 6). One patient underwent hepatic resection. Median hospital stay was 16 (6-35) days. There was one death, but no procedure-related morbidity.nnnDISCUSSIONnNon-operative management of solitary and multiple liver abscesses is safe and effective.

In-contiguity and non-anatomical extension of right hepatic trisectionectomy for liver metastases.

In some patients undergoing right hepatic trisectionectomy for metastases, extension of the resection beyond the falciform ligament is necessary to achieve tumour clearance. The aim of the present study was to assess the early and long‐term outcomes and hepatic function in patients who underwent extensive liver resection beyond right trisectionectomy.

A matched-pair analysis of laparoscopic versus open pancreaticoduodenectomy: oncological outcomes using Leeds Pathology Protocol

BACKGROUNDnLaparoscopic pancreaticoduodenectomy (LPD) is a safe procedure. Oncological safety of LPD is still a matter for debate. This study aimed to compare the oncological outcomes, in terms of adequacy of resection and recurrence rate following LPD and open pancreaticoduodenectomy (OPD).nnnMETHODSnBetween November 2005 and April 2009, 12 LPDs (9 ampullary and 3 distal common bile duct tumors) were performed. A cohort of 12 OPDs were matched for age, gender, body mass index (BMI) and American Society of Anesthesiologists (ASA) score and tumor site.nnnRESULTSnMean tumor size LPD vs OPD (19.8 vs 19.2 mm, P=0.870). R0 resection was achieved in 9 LPD vs 8 OPD (P=1.000). The mean number of metastatic lymph nodes and total number resected for LPD vs OPD were 1.1 vs 2.1 (P=0.140) and 20.7 vs 18.5 (P=0.534) respectively. Clavien complications grade I/II (5 vs 8), III/IV (2 vs 6) and pancreatic leak (2 vs 1) were statistically not significant (LPD vs OPD). The mean high dependency unit (HDU) stay was longer in OPD (3.7 vs 1.4 days, P<0.001). There were 2 recurrences each in LPD and OPD (log-rank, P=0.983). Overall mortality for LPD vs OPD was 3 vs 6 (log-rank, P=0.283) and recurrence-related mortality was 2 vs 1. There was one death within 30 days in the OPD group secondary to severe sepsis and none in the LPD group.nnnCONCLUSIONSnCompared to open procedure, LPD achieved a similar rate of R0 resection, lymph node harvest and long-term recurrence for tumors less than 2 cm. Though technically challenging, LPD is safe and does not compromise oncological outcome.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

Objective: The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery. Background: The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the specialitys continued safe progression and dissemination. Methods: A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements. Results: Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee. Conclusion: The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts’ knowledge taking in consideration the relevant stakeholders’ opinions and complying with the international methodology standards.

Outcomes of Kidney Grafts Refused by One or More Centers and Subsequently Transplanted at a Single United Kingdom Center

INTRODUCTIONnThe rate-limiting factor in kidney transplantation is the shortage of donor organs with resulting steady increase in patients on the transplant waiting list. In our center we have seen an increase in the use of kidneys refused as unsuitable by one or more centers in the United Kingdom (UK). This study was performed to analyze the outcomes of transplantation from kidneys refused by one or more centers and subsequently transplanted by our institution.nnnMETHODSnWe performed a retrospective analysis using the UK Transplant database of donor grafts refused by one or more centers and subsequently transplanted by us from January 2000 to December 2005. We documented the reason for refusal, donor and recipient factors, incidence of graft rejection, and primary and delayed graft function. Graft function and patient survival at 3 years were compared with standard donor grafts.nnnRESULTSnFrom January 2000 to December 2005, we performed 623 renal transplantations, including 60 (9.6% from donors who were refused by one or more centers and 402 standard donor grafts. The main reasons for initial refusal included: elderly donor 25% (median age, 61 years), better HLA match required 33.3%, anatomical 5%, medical history of donor 6.6%, virology 4.8%, prolonged cold ischemia time 3.3% (median, 33.5 hours), and organ damage 1.6%. The 3-year median creatinine levels of donor grafts refused by multiple centers was 126 mumol/L compared with 135 mumol/L for standard grafts (P = .97). Three-year graft and patient survival rates were 86.6% and 96%, for grafts refused by multiple centers and 87% and 95%, for standard grafts, respectively. Upon multivariate analysis none of the above variables were significant predictors of 3-year failure of grafts refused by multiple centers.nnnCONCLUSIONSnNearly 10% of kidney transplants in our center were performed with grafts refused by one or more centers as unsuitable. The graft and patient survivals were similar to those of standard grafts. None of the factors for refusal of kidneys by other centers predicted graft failure at 3 years. There may be an element of subjective assessment and subsequently a cascade effect involved in refusal of some of these kidneys.