Mohammad H. Jamal

Portal vein embolization stimulates tumour growth in patients with colorectal cancer liver metastases

OBJECTIVES Portal vein embolization (PVE) can facilitate the resection of previously unresectable colorectal cancer (CRC) liver metastases. Bevacizumab is being used increasingly in the treatment of metastatic CRC, although data regarding its effect on post-embolization liver regeneration and tumour growth are conflicting. The objective of this observational study was to assess the impact of pre-embolization bevacizumab on liver hypertrophy and tumour growth. METHODS Computed tomography scans before and 4 weeks after PVE were evaluated in patients who received perioperative chemotherapy with or without bevacizumab. Scans were compared with scans obtained in a control group in which no PVE was administered. Future liver remnant (FLR), total liver volume (TLV) and total tumour volume (TTV) were measured. Bevacizumab was discontinued ≥ 4 weeks before PVE. RESULTS A total of 109 patients and 11 control patients were included. Portal vein embolization induced a significant increase in TTV: the right lobe increased by 33.4% in PVE subjects but decreased by 34.8% in control subjects (P < 0.001), and the left lobe increased by 49.9% in PVE subjects and decreased by 33.2% in controls (P= 0.022). A total of 52.8% of the study group received bevacizumab and 47.2% did not. There was no statistical difference between the two chemotherapy groups in terms of tumour growth. Median FLR after PVE was similar in both groups (28.8% vs. 28.7%; P= 0.825). CONCLUSIONS Adequate liver regeneration was achieved in patients who underwent PVE. However, significant tumour progression was also observed post-embolization.

Systematic review and meta-analysis of the effect of North American working hours restrictions on mortality and morbidity in surgical patients

Short duty hours, imposed by the Accreditation Council of Graduate Medical Education (ACGME) regulations, have been claimed to be associated with loss of continuity of care among surgical patients, leading to a potentially increased risk of adverse surgical outcomes. This systematic review and meta‐analysis assessed the strength of associations between duty hour restrictions and morbidity and mortality of various surgical procedures.

Predictors of response to radio‐embolization (TheraSphere®) treatment of neuroendocrine liver metastasis

BACKGROUND Neuroendocrine tumours (NET) frequently metastasize to the liver. NET liver metastasis has been shown to respond to Yttrium-90 microspheres therapy. The aims of the present study were to define factors that predict the response to radio-embolization in patients with NET liver metastases. METHODS From January 2006 until March 2009, all patients with NET liver metastasis that received radio-embolization using TheraSphere® (glass microspheres) were reviewed. The response was determined by a change in the percentage of necrosis (ΔN%) after the first radio-embolization based on the modified RECIST criteria (mRECIST) criteria. The following confounding variables were measured: age, gender, size of the lesions, liver involvement, World Health Organization (WHO) classification, the presence of extra-hepatic metastasis, octereotide treatment and previous operative [surgery and (RFA)] and non-operative treatments (chemo-embolization and bland-embolization). RESULTS In all, 25 patients were identified, with a median follow-up of 21.7 months. The median age was 64.6 years, 28% had extra-hepatic metastasis and 56% were WHO stage 2. Post-treatment, the mean ΔN% was 48.4%. Previous surgical therapy was a significant predictor of the response with a response rate of 66.7 ΔN% vs. 31.5 ΔN% (P= 0.02). Bilateral liver disease, a high percentage of liver involvement and large metastatic lesions were inversely related to the degree of tumour response although did not reach statistical significance. CONCLUSION Radio-embolization increased the necrosis of NET liver metastasis mainly in patients with less bulky disease. This may imply that surgical therapy before radio-embolization would increase the response rates.

Effects of the reduction of surgical residents' work hours and implications for surgical residency programs: a narrative review

BackgroundThe widespread implementation of resident work hour restrictions has led to significant alterations in surgical training and the postgraduate educational experience. We evaluated the experience of surgical residency programs as reflected in the literature from 2008 onward in order to summarize current challenges and identify key areas in need of further research.MethodsWe searched MEDLINE and EMBASE for English-language articles published from January 2008 to December 2011 related to work hour restrictions in surgical residency programs, including those pertaining to personal well-being, education and training, patient care, and faculty experiences.ResultsWe retrieved 240 unique abstracts and included 24 studies in the current review. Of the 10 studies examining effects on operating room experience, 4 reported negative or mixed outcomes and 6 reported neutral outcomes, although non-compliance was demonstrated in 2 of these studies. Effects on surgical faculty perceptions were consistently reported as negative, while the effect on patient outcomes and professionalism were found to be neutral and unchanged.ConclusionsFurther studies are needed to characterize operative experience at varying levels of training, particularly in the context of strict adherence to new work hours. Research that examines the effect of the work hour limitations on professionalism and non-operative educational activities, such as reading and simulation-based training, as well as sign-over practices, would also be of benefit.

Staged hepatectomy for bilobar colorectal hepatic metastases

OBJECTIVES This study describes the management of patients with bilobar colorectal liver metastases (CRLM). METHODS A retrospective collection of data on all patients with CRLM who were considered for staged resection (n= 85) from January 2003 to January 2011 was performed. Patients who underwent one hepatic resection were considered to have had a failed staged resection (FSR), whereas those who underwent a second or third hepatic resection to produce a cure were considered to have had a successful staged resection (SSR). Survival was calculated from the date of diagnosis of liver metastases. Complete follow-up and dates of death were obtained from the Government of Quebec population database. RESULTS Median survival was 46 months (range: 30-62 months) in the SSR group and 22 months (range: 19-29 months) in the FSR group. Rates of 5-year survival were 42% and 4% in the SSR and FSR groups, respectively. Fifteen of the 19 patients who remained alive at the last follow-up date belonged to the SSR group. CONCLUSIONS In patients in whom staged resection for bilobar CRLM is feasible, surgery would appear to offer benefit.

Unresectable pancreatic adenocarcinoma: do we know who survives?

BACKGROUND This study attempts to define clinical predictors of survival in patients with unresectable pancreatic adenocarcinoma (UPA). METHODS A retrospective study of 94 consecutive patients diagnosed with UPA from 2001 to 2006 was performed. Using data for these patients, a symptom score was devised through a forward stepwise Cox proportional hazards model based on four weighted criteria: weight loss of >10% of body weight; pain; jaundice, and smoking. The symptom score was subsequently validated in a distinct cohort of 32 patients diagnosed with UPA in 2007. RESULTS In the original cohort, the overall median survival was 9.0 months (95% confidence interval [CI] 7.6-10.4). This altered to 10.3 months (95% CI 6.1-14.5) in patients with locally advanced disease, and 6.6 months (95% CI 4.2-9.0) in patients with distant metastasis. Median survival was 14.6 months (95% CI 13.1-16.1) in patients with a low symptom (LS) score and 6.3 months (95% CI 4.1-8.5) in patients with a high symptom (HS) score. A total of 73% of LS score patients survived beyond 9 months, compared with only 38% of HS score patients (P<0.001). The discrimination of the LS score was greater than that of any conventional method, including imaging. The validation cohort confirmed the discriminative ability of the symptom score for survival. CONCLUSIONS A simple and clinically meaningful point-based symptom score can successfully predict survival in patients with UPA.

Complications of ureterovesical anastomosis in adult renal transplantation: Comparison of the Lich-Gregoire and the Taguchi techniques

BACKGROUND Our aim is to identify the incidence of urologic complications in adult renal transplantation comparing two different ureterovesical anastomosis techniques, the Taguchi (T) and Lich-Gregoire (LG). MATERIAL/METHODS Retrospective analysis of adult renal transplants performed at the MUHC between 2000-2009. Excluded: multi-organ transplants, re-do transplants, variant ureteric anastomosis and patients received grafts from UNOS ECD. 372 patients were analyzed. 209 patients (56%) in the T group and 163 patients (44%) in the LG group. Fishers exact test was used to compare the groups for urologic complications. A multivariate analysis was performed to identify factors associated with graft rejection and death. RESULTS 21 patients developed a urinary leak or stricture. A total of 13 patients (3.4%) developed ureteric strictures and 9 (2.4%) patients developed urinary leak with no difference in urinary leak or stricture between both groups (p=1). Hematuria requiring intervention developed in 55 patients. A higher incidence of complicated hematuria in the T group when compared to the LG group (37 vs. 18, p=0.079)). No differences in other ureteric complications between the 2 groups. Delayed graft function OR=3.4 (95% CI=1.8-6.3) and grafts from a deceased donors OR=2.2 (95% CI=1.1-4.5) are factors associated with graft loss. Factors associated with first episode of rejection include delayed graft function OR=2.4 (95% CI=1.3-4.4), and the development of ureteric stricture OR=3.9 (95% CI=1.8-8.7). CONCLUSIONS Both techniques can be used interchangeably for adult renal transplantation. T technique is associated with a greater risk of hematuria. Ureteric strictures are associated with a shorter time to first graft rejection.

Pancreatic cancer and predictors of survival: comparing the CA 19-9/bilirubin ratio with the McGill Brisbane Symptom Score

INTRODUCTION Few tools predict survival from pancreatic cancer (PAC). The McGill Brisbane Symptom Score (MBSS) based on symptoms at presentation (weight loss, pain, jaundice and smoking) was recently validated. The present study compares the ability of four strategies to predict 9-month survival: MBSS, carbohydrate antigen 19-9 (CA 19-9) alone, CA19-9-to-bilirubin ratio and a combination of MBSS and the CA19-9-to-bilirubin ratio. METHODOLOGY A retrospective review of 133 patients diagnosed with PAC between 2005 and 2011 was performed. Survival was determined from the Quebec civil registry. Blood CA 19-9 and bilirubin values were collected (n = 52) at the time of diagnosis. Receiver-operating characteristic (ROC) curves were used to determine a cutoff for optimal test characteristics of CA 19-9 and CA19-9-to-total bilirubin ratio in predicting survival at 9 months. Predictive characteristics were then calculated for the four strategies. RESULTS Of the four strategies, the one with the greatest negative predictive value was the MBSS: negative predictive value (NPV) was 90.2% (76.9-97.3%) and the positive likelihood ratio (LR) was the greatest. The ability of CA 19-9 levels alone, at baseline, to predict survival was low. For the CA19-9-to-bilirubin ratio, the test characteristics improved but remained non-significant. The best performing strategy according to likelihood ratios was the combined MBSS and CA19-9 to the bilirubin ratio. CONCLUSION CA19-9 levels and the CA19-9-to-bilirubin ratio are poor predictors of survival for PAC, whereas the MBSS is a far better predictor, confirming its clinical value. By adding the CA19-9-to-bilirubin ratio to the MBSS the predictive characteristics improved.

Impact of the Sentinel Node Frozen Section Result on the Probability of Additional Nodal Metastases as Predicted by the MSKCC Nomogram in Breast Cancer

OBJECTIVE Sentinel lymph node frozen section is used to obviate the need for a second operation in breast cancer patients with involved nodes. However, the overall sensitivity, specificity and accuracy of sentinel lymph node frozen section are debated, and the impact of sentinel lymph node frozen section positivity on the risk of additional nodal metastases is not known and was the focus of this investigation. METHODS We used our hospital record system to identify 176 sentinel lymph node biopsies done out of 354 cases of Stage T1-3N0 breast cancers managed from 2005 to 2007 and evaluated the sentinel lymph node frozen section results against the predictions of additional nodal metastases based on the Memorial Sloan-Kettering Breast Cancer Nomogram which is a validated tool for this purpose. RESULTS Sentinel lymph node metastases size was an independent predictor of sentinel lymph node frozen section sensitivity and those with macrometastases had 15 times the odds (odds ratio, 15.4; 95% confidence interval, 3.4-69.1) of having a true-positive frozen section when compared with those with micrometastases. The breast cancer nomogram predicted that the latter patients have a very low probability of additional nodal metastases with a median probability at 10% (inter-quartile range, 7-14%). CONCLUSIONS A negative sentinel lymph node frozen section is also associated with a low probability of additional nodal metastases. Additional prognostic factors in the breast cancer nomogram are of little clinical impact because the most predictive factor in the nomogram is the method of detection.

47 Gallbladder and Biliary Disease in Bariatric Surgery Patients

The high prevalence of obesity and bariatric surgery resulting in rapid weight loss is known to be a risk factor for gallbladder and biliary diseases. The incidence of newly diagnosed gallstones after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) can be as high as 50 %, but they are mostly asymptomatic. There are multiple physiological changes that contribute to the formation of cholesterol stones and biliary dyskinesia. Three different strategies are suggested and developed to manage this condition. The most common approach, especially for laparoscopic weight loss surgeries, involves the prevention of formation of gallstones with oral bile salts. The rise of bariatric surgery, in particular LRYGB and the management of biliary diseases including choledocholithiasis, involves modification of the traditional ERCP technique. Surgically assisted ERCP has developed as an effective method in managing biliary diseases with patients after LRYGB.