Richard Bryant

Treating Diabetes in the Morbidly Obese by Laparoscopic Gastric Banding

Background: Remission of diabetes following Roux-en-Y gastric bypass has been postulated to occur partly by bypass of the foregut. Laparoscopic adjustable gastric banding (LAGB) also reduces food intake but does not bypass the foregut, and its effects on diabetes have yet to be elucidated. Methods: Patients with diabetes or a history of diabetes and >6 months follow-up after LAGB were studied. Follow-up was conducted separately by a surgeon with regard to weight loss and potential morbidity and by a physician with regard to diabetic control. Results: 14 patients had had gestational diabetes, and diabetes was controlled by diet in 25, oral hypoglycemics in 38 and insulin in 11 patients. Reduction in body mass index (BMI) and percentage of excess weight loss (%EWL) were similar in these 4 subgroups, with a median reduction in BMI of 11.7 kg/m2 and %EWL of 51.1% at 24 months. 26 of 38 patients controlled with oral hypoglycemic medication and 6 of 11 insulin-dependent diabetics had all medication stopped at a median of 6.5 months following LAGB. Univariate and multivariate analyses identified %EWL ≥ 30.6% at 6 months as the only significant predictor of remission of diabetes. Conclusion:Two-thirds of the diabetic patients have had remission of diabetes following LAGB. LAGB is an effective treatment for diabetes in obese patients.

Long-term survival in laparoscopic vs open resection for colorectal liver metastases: inverse probability of treatment weighting using propensity scores

BACKGROUND This study compares long-term outcomes between intention-to-treat laparoscopic and open approaches to colorectal liver metastases (CLM), using inverse probability of treatment weighting (IPTW) based on propensity scores to control for selection bias. METHOD Patients undergoing liver resection for CLM by 5 surgeons at 3 institutions from 2000 to early 2014 were analysed. IPTW based on propensity scores were generated and used to assess the marginal treatment effect of the laparoscopic approach via a weighted Cox proportional hazards model. RESULTS A total of 298 operations were performed in 256 patients. 7 patients with planned two-stage resections were excluded leaving 284 operations in 249 patients for analysis. After IPTW, the population was well balanced. With a median follow up of 36 months, 5-year overall survival (OS) and recurrence-free survival (RFS) for the cohort were 59% and 38%. 146 laparoscopic procedures were performed in 140 patients, with weighted 5-year OS and RFS of 54% and 36% respectively. In the open group, 138 procedures were performed in 122 patients, with a weighted 5-year OS and RFS of 63% and 38% respectively. There was no significant difference between the two groups in terms of OS or RFS. CONCLUSION In the Brisbane experience, after accounting for bias in treatment assignment, long term survival after LLR for CLM is equivalent to outcomes in open surgery.

Intercostal and transthoracic trocars enable easier laparoscopic resection of dome liver lesions

BACKGROUND Dome liver lesions (those in segments VII or VIII) pose a challenge to standard laparoscopic resection. The use of additional intercostal and transthoracic trocars (ITTs) potentially facilitates resection over standard subcostal laparoscopic (SSL) techniques. METHODS A retrospective review of a prospectively collected liver resection database was performed, selecting all minor resections of segments VII and VIII using the ITT and SSL approaches. The techniques of intercostal transdiaphragmatic access are described and the surgical outcomes of the two groups compared. RESULTS A total of 19 patients were analysed. The ITT group included 8 patients and the SSL group included 11. The groups were comparable in median lesion size (20 mm in the ITT group and 26 mm in the SSL group). Blood loss, operative times, morbidity and conversion rates were similar. There was no lung injury or postoperative clinical pneumothorax in any patient undergoing transdiaphragmatic access. Median hospital stay was significantly shorter in the ITT group (2 days) than in the SSL group (6 days) (P = 0.032). CONCLUSIONS The ITT approach is safe, effective and complementary to standard laparoscopic techniques for the resection of small tumours in segments VII and VIII.

A prospective study of the impact of fluorodeoxyglucose positron emission tomography with concurrent non‐contrast CT scanning on the management of operable pancreatic and peri‐ampullary cancers

BACKGROUND The role of fluorodeoxyglucose (FDG) positron emission tomography (PET/CT) scanning in operable pancreas cancer is unclear. We, therefore, wanted to investigate the impact of PET/CT on management, by incorporating it into routine work-up. METHODS This was a single-institution prospective study. Patients with suspected and potentially operable pancreas, distal bile duct or ampullary carcinomas underwent PET/CT in addition to routine work-up. The frequency that PET/CT changed the treatment plan or prompted other investigations was determined. The distribution of standard uptake values (SUV) among primary tumours, and adjacent to biliary stents was characterised. RESULTS Fifty-six patients were recruited. The surgical plan was abandoned in 9 (16%; 95% CI: 6-26) patients as a result of PET/CT identified metastases. In four patients, metastases were missed and seven were inoperable at surgery, not predicted by PET/CT. Unexpected FDG uptake resulted in seven additional investigations, of which two were useful. Among primary pancreatic cancers, a median SUV was 4.9 (range 2-12.1). SUV was highest around the biliary stent in 17 out of 28 cases. PET/CT detected metastases in five patients whose primary pancreatic tumours demonstrated mild to moderate avidity (SUV < 5). CONCLUSIONS PET/CT in potentially operable pancreas cancer has limitations. However, as a result of its ability to detect metastases, PET/CT scanning is a useful tool in the selection of such patients for surgery.

GASTRIC BANDING AT THE ROYAL BRISBANE AND WOMEN’S HOSPITAL: TRIALS AND TRIBULATIONS OF A PUBLIC SERVICE

Background:  The Royal Brisbane and Women’s Hospital provides the only gastric banding service for the public to the state of Queensland. Our patients are potentially a different group from the previously reported Australian series with respect to weight, comorbidities and ease of follow up and we therefore present this series of public patient for comparison of medium‐term results.

Laparoscopic approach to a planned two‐stage hepatectomy for bilobar colorectal liver metastases

This report describes the technical aspects and outcomes of a laparoscopic approach in planned two‐stage liver resections for patients with bilobar colorectal cancer (CRC) liver‐only metastases.

Laparoscopic resection of hepatocellular carcinoma in patients with and without cirrhosis: the Brisbane experience

Dr. Nicholas A. O’Rourke (Right) and Dr. Daniel J. Kilburn (Left) are co-authors of this paper. Dr. O’Rourke is the Chairman of General Surgery and the Chief of HPB at the Royal Brisbane Hospital (RBH), Brisbane, Queensland, Australia. He is an immediate past President of ANZHPBA and current Secretary-General of the International Laparoscopic Liver Society (ILLS). Dr. Kilburn is a surgical resident at the RBH with a keen interest in laparoscopic HPB surgery. www.hrjournal.net

Subclassification of hepatocellular adenomas: practical considerations in the implementation of the Bordeaux criteria

Hepatocellular adenomas are benign liver lesions with a risk of rupture and malignant transformation. Various molecular subgroups have been identified which appear to have characteristic morphological and immunohistochemical features. We examined the morphology and immunohistochemical profile of a series of 121 HCA from 97 patients to identify the HCA subtypes present and determine the number at risk for malignant transformation according to the World Health Organization (WHO) criteria for hepatocellular adenomas. There were 34 HNF1α inactivated HCA (28%), 61 inflammatory HCA (50%), 15 β-catenin activated HCA (12%) and 11 unclassified adenomas (9%). This proportion of cases was similar to that seen in other series utilising molecular classification. The morphological features of the adenomas were suggestive but not definite indicators of the subtypes present. Morphological features that showed overlap between the subtypes included steatosis within the lesion, a ductular reaction and focal atypia, so that immunohistochemical typing was required for accurate classification. In conclusion, immunohistochemistry is a clinically useful surrogate for identifying underlying molecular changes in the HCA subtypes.

Laparoscopic pancreaticoduodenectomy in Brisbane, Australia: an initial experience.

The role of minimally invasive approach for pancreaticoduodenectomy has not yet been well defined in Australia. We present our early experience with laparoscopic pancreaticoduodenectomy (LPD) from Brisbane, Australia.