Michael Hollands

Recurrence of hydatid disease.

Surgical management of hepatic hydatid disease has been associated with an overall local recurrence rate of approximately 10%. Local recurrence is rarely seen following complete resection of an intact cyst and is usually the result of spillage of live parasites or leaving a residual cyst wall containing germinal epithelium, daughter cysts, or protoscolices during surgery. Recurrence is frequently asymptomatic, so the diagnosis depends on dedicated follow-up of treated patients with serology and either ultrasonography or computed tomography. The management of locally recurrent disease should include administration of albendazole followed by the appropriate application of interventional radiotherapy or operation. As with the treatment of primary disease, the preservation of liver function and minimizing the risk to the patient remain the guiding principles of therapy of local recurrence. Human infection with Echinococcus granulosus typically results in a slowly growing parasitic cystic disease most frequently seen in the liver. The cysts may be asymptomatic for many years, and occasionally spontaneous regression has been noted. More commonly the disease is slowly progressive, and symptoms and complications eventually arise. Symptoms include pain from expansion or rupture, fever from pyogenic infection due to intrabiliary rupture and jaundice, or anaphylaxis from intrabiliary or extrahepatic rupture. The goals of therapy are to treat associated complications, eliminate local disease, and avoid recurrence while minimizing morbidity and mortality of the treatment itself. Over the past 30 years surgical intervention has been the conventional treatment [1–9]; however, the introduction of modern medical therapy with albendazole [10–14] and radiologic intervention employing percutaneous aspiration and scolicidal injection (PAIR) [15–20] have provided new therapeutic options. The number of therapies now available is testimony to the fact that none is ideal in every clinical situation, and there is a need to tailor treatment to the individual patient. The identification of recurrent disease in the liver or in extrahepatic locations is an important criterion of treatment efficacy. Recurrent disease may present with major complications including pyogenic infection, intrabiliary rupture, or anaphylaxis; however, it is usually initially asymptomatic, and therefore regular long-term follow-up should be routine after primary treatment. The various therapies for primary disease have been discussed elsewhere in this issue. The purpose of this paper is to offer an approach to the patient with recurrent hepatic hydatid disease. Recurrent Hepatic Hydatid Disease Recurrent disease is defined as the appearance of new active cysts after therapy of intrahepatic or extrahepatic disease. The failure to achieve permanent control of the primarily treated cyst is considered local recurrence. It occurs after surgical or radiologic intervention and manifests as reappearance of live cysts at the site of a previously treated cyst or the appearance of new extrahepatic disease resulting from procedure-related spillage. The development of new cysts remote within the liver or at remote extrahepatic locations, such as lung or bone, may not imply failure of the primary procedure but may simply reflect the manifestation of disseminated disease. The reason for local recurrence is failure to remove or kill all viable cysts and protoscolices at the time of the original operation. This virtually never occurs when the complete unopened cyst is resected [21–23]; however, with more conservative procedures, such as evacuation and partial cystectomy, there is a possibility of leaving viable material behind, especially in long-standing cysts where there may be penetration, or “budding,” through the pericyst into surrounding liver. It is important, therefore, to be meticulous when carrying out conservative surgery to avoid intraperitoneal spillage and to remove all cyst contents mechanically and through irrigation, including any cyst material that has penetrated the original pericyst. Despite numerous case series reported in the surgical literature, it is difficult to compare the effectiveness of the various treatment options regarding recurrence rates. There are no prospective trials of surgical therapy based on pretreatment selection criteria, and retrospective reviews are impossible to assess and compare because of case mix issues. Overall, the recurrence rate appears to be less than 10%, with the likelihood of recurrence made lower when complete cyst excision is possible [21–23]. In the case of radical procedures, there is a trade-off between a low recurrence rate and increased mortality from the procedure. Correspondence to: B. Taylor, M.D., e-mail: bryce.taylor@uhn.on.ca Diagnosis of Recurrence A standardized protocol employing ultrasonography (US) or computed tomography (CT) with follow-up for at least 3 years is essential for the documentation of therapeutic efficacy in this disease [24, 25]. Recurrence may occur many years later, however, and longer follow-up is recommended when possible. The onset of recurrent disease is frequently asymptomatic; and clinical evaluation, even supplemented by serum liver tests and serologic tests, may not be diagnostic [26]. Blood titers may decrease slowly over months to years even with complete removal of disease [20, 27]. A positive serologic test during follow-up is therefore not necessarily diagnostic of recurrence, but a rising titer is. The preferred methods for identifying recurrent disease, in addition to clinical and serologic evaluation, are US and CT scanning [28–33]. Both modalities are sensitive and reasonably specific for diagnosing primary hydatid disease. The radiographic appearance of postoperative cysts may vary significantly and is frequently time-dependent. Unremoved, treated cysts typically show disappearance of the cyst fluid, overall shrinkage, and thickening and irregularity of the cyst wall [30, 31]. Small cyst-like structures are often identified at the site of surgical cyst evacuation. These structures must be followed on serial examination to differentiate postoperative changes from either persistent or new, live parasites. The difficulty of differentiating effectively treated cysts and locally recurrent disease has been well documented. Growth of the cyst appears to be the best imaging marker for significant locally recurrent disease. Critical to advancing our understanding of recurrent hydatid disease is adoption of a uniform staging, classification, and reporting system. A simple system, modeled after those suggested for primary disease [34–37], is shown in Table 1. Therapeutic Options for Recurrent Disease Not every patient with documented recurrent active hydatid disease needs to be treated. Unlike recurrent malignant disease, hydatid disease progresses slowly and is rarely life-threatening. Asymptomatic patients with serious co-morbid conditions or advanced age are best followed and treated only for complications. In fit patients, documented recurrence should be treated regardless of whether symptomatic. Complications such as infection or biliary obstruction should, if possible, be treated first, i.e., with drainage, endoscopic retrograde cholangiopant creatography (ERCP), and bile duct clearance. Intrahepatic Recurrence The treatment options are generally the same for recurrent disease as for primary disease. The fact that appropriate primary treatment has failed, however, suggests that more radical treatment may be indicated in the case of recurrence, and that is our general policy. In highly complex liver hydatids, where the cyst is centrally placed and involves major biliary pedicles (and intimate to major vessels), it is occasionally necessary to treat recurrent disease repeatedly when it is symptomatic, without ever achieving complete eradication. Excellent long-term palliation with good quality of life is possible and is preferable to mortality following overly enthusiastic attempts to achieve cure by radical excisions in every case. The treatment options are listed in Table 2.Surgical management of hepatic hydatid disease has been associated with an overall local recurrence rate of approximately 10%. Local recurrence is rarely seen following complete resection of an intact cyst and is usually the result of spillage of live parasites or leaving a residual cyst wall containing germinal epithelium, daughter cysts, or protoscolices during surgery. Recurrence is frequently asymptomatic, so the diagnosis depends on dedicated follow-up of treated patients with serology and either ultrasonography or computed tomography. The management of locally recurrent disease should include administration of albendazole followed by the appropriate application of interventional radiotherapy or operation. As with the treatment of primary disease, the preservation of liver function and minimizing the risk to the patient remain the guiding principles of therapy of local recurrence.

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.

Ten-year survival after liver resection for colorectal metastases: systematic review and meta-analysis.

Background. Liver resection in metastatic colorectal cancer is proved to result in five-year survival of 25–40%. Several factors have been investigated to look for prognostic factors stratifications such as resection margins, node involvement in the primary disease, and interval between the primary disease and liver metastases. Methods. We searched MEDLINE and EMBASE for studies that reported ten-year survival. Metaanalysis was performed to analyse the effect of recognised prognostic factors on cure rate for colorectal metastases. The meta-analysis was performed according to Ottawa-Newcastle method of analysis for nonrandomised trials and according to the guidelines of the PRISMA. Results. Eleven studies were included in the analysis, which showed a ten-year survival rate of 12–36%. Factors that have favourable impact are clear resection margin, low level of CEA, single metastatic deposit, and node negative disease. The only factor that excluded patients from cure is the positive status of the resection margin. Conclusion. Predicted ten-year survival after liver resection for colorectal metastases varies from 12 to 36%. Only positive resection margins resulted in no 10-year survivors. No patient can be excluded from consideration for liver resection so long the result is negative margins.

World Health Assembly Resolution WHA68.15: “Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage”—Addressing the Public Health Gaps Arising from Lack of Safe, Affordable and Accessible Surgical and Anesthetic Services

Abstract On May 22 2015, the 68th World Health Assembly (WHA) adopted resolution WHA68.15, “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage (UHC).” For the first time, governments worldwide acknowledged and recognized surgery and anesthesia as key components of UHC and health systems strengthening. The resolution details and outlines the highest level of political commitments to address the public health gaps arising from lack of safe, affordable, and accessible surgical and anesthetic services in an integrated approach. This article reviews the background of resolution WHA68.15 and discusses how it can be of use to surgeons, anesthetists, advanced practice clinicians, nurses, and others caring for the surgical patients, especially in low- and middle-income countries.

Impact of the CUSA and Operative Ultrasound on Hepatic Resection

New technologies have been developed for liver surgery, and, like all new technologies, they have a glamour which makes them seem desirable. There is an understanding abroad that they make liver surgery easier and open up the field to those without special training. But there is no proof that the new devices are in any way cost-effective, and certainly no proof that liver surgery has become safer since their advent. Fifty consecutive elective liver resections have been studied, almost half performed with the aid of the ultrasonic dissector and aspirator and diagnostic intraoperative ultrasound. There was no mortality in the whole group, but a 24% morbidity. Operative diagnostic ultrasound was thought to allow more precise planning of surgery. Its use was not associated with any increase in operative time, nor was there any increase in postoperative morbidity. The ultrasonic dissector and aspirator improved technique, reflected in a lower blood loss for each case, in fewer transfusions required, in a shorter postoperative hospital stay and in an ability to achieve these benefits in older patients. Neither device could be said to offer an entree to instant liver surgery. The use of the two devices apparently offered savings measured by a fall in the median postoperative hospital stay of 4.5 days, by a saving of 700 mls in median blood requirement and by a fall in transfusion rate from 64% to 9%.

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.

A Leiomyoma of The Liver

A seventeen year old Turkish born male school student presented with a four year history of recurrent abdominal pain. The pain was epigastric in distribution and relieved by non-steroidal anti-inflammatory drugs. He had not lost weight and there were no other associated abdominal symptoms. On examination the liver edge was palpable 12 cm below the costal margin in the mid-clavicular line. There were no other findings on physical examination. Liver function tests were normal. There was no evidence of previous hepatitis B virus infection and CEA (carcinoembryonic antigen) and AFP (alpha fetoprotein) levels were normal. An ultrasound examination was performed which showed a hypoechoic poorly defined solid mass in the left lobe of the liver. A subsequent CT scan confirmed the presence of the mass which was enhanced by the injection of contrast medium. A provisional diagnosis of a haemangioma of the liver was made. A subsequent blood pool scan did not confirm this suspicion as there was reduced tracer accumulation in the region of the left lobe of the liver. It was decided to proceed to arteriography. This showed a vascular lesion strongly suggestive of a hepatoma (Figure 1). Venous phase pictures showed that the left branch of the portal vein had been occluded by the tumour (Figure 2). An inferior vena cavagram was then performed and this showed that the left hepatic vein was also occluded with only a thin stream of contrast seen. The hepatic vein also seemed to communicate directly with the portal venous system. Fine needle aspiration cytology of this lesion showed smooth muscle cells but there was no evidence of hepatocellular carcinoma. The origin of the cells may have been either stromal or from a smooth muscle tumour. A laparotomy was performed nine days after admission. Inspection and palpation of the gastrointestinal tract did not reveal a potential primary site. A large tumour was found in the left lobe of the liver with intense fibrous reaction around it. The tumour appeared to extend into the falciform ligament and apparently involved the root of the left hepatic vein. Further fine needle aspiration cytology was performed and once again smooth muscle cells were seen. Frozen section suggested that the