Richard Mimeault

Systematic review and meta-analysis of liver resection for metastatic melanoma

The multidisciplinary management of metastatic melanoma now occasionally includes major hepatic resection. The objective of this work was to conduct a systematic review of the literature on liver resection for metastatic melanoma.

Evaluating agreement regarding the resectability of colorectal liver metastases: a national case-based survey of hepatic surgeons.

BACKGROUND The resectability of colorectal liver metastases is in part largely based on the surgeons assessment of cross-sectional imaging. This process, while guided by principles, is subjective. The objective of the present study was to assess agreement between hepatic surgeons regarding the resectability of colorectal liver metastases. METHODS Forty-six hepatic surgeons across Canada were invited. A patient with biologically favourable disease was presented after having received neoadjuvant chemotherapy. The scenario was matched with 10 different scrollable abdominal CT scans representing a maximum response after six cycles of chemotherapy. Surgeons were asked to offer an opinion on resectability of liver metastases, and whether they would use adjunct modalities to hepatic resection. RESULTS Twenty-six surgeons participated. Twenty responses were complete. The median number of scenarios deemed resectable was 6/10 (range 3-8). Two control scenarios demonstrated perfect agreement. Agreement on resectability was poor for 4/8 test scenarios, of which one scenario demonstrated complete disagreement. Among resectable cases, the pattern of use of adjunct modalities was variable. A median ratio of 0.87 adjunct modality per resectable scenario per surgeon was used (range 0.25-1.75). CONCLUSION A significant lack of agreement was identified among surgeons on the resectability and use of adjunct modalities in the treatment of colorectal liver metastases.

Clinical and pathological features of intraductal papillary neoplasm of the biliary tract and gallbladder

BACKGROUND Intraductal papillary neoplasms of the biliary tract (IPNB) and intracholecystic papillary neoplasms (ICPN) are rare tumours characterized by intraluminal papillary growth that can be associated with invasive carcinoma. Their natural history remains poorly understood. This study examines clinicopathological features and outcomes. METHODS Patients who underwent surgery for IPNB/ICPN (2008-2014) were identified. Descriptive statistics and survival data were generated. RESULTS Of 23 patients with IPNB/ICPN, 10 were male, and the mean age was 68 years. The most common presentations were abdominal pain (n = 10) and jaundice (n = 9). Tumour locations were: intrahepatic (n = 5), hilar (n = 3), the extrahepatic bile duct (n = 8) and the gallbladder (n = 7). Invasive cancer was found in 20/23 patients. Epithelial subtypes included pancreatobiliary (n = 15), intestinal (n = 7) and gastric (n = 1). The median follow-up was 30 months. The 5-year overall (OS) and disease-free survivals (DFS) were 51% and 57%, respectively. Decreased OS (P = 0.09) and DFS (P = 0.05) were seen in patients with tumours expressing MUC1 on immunohistochemistry (IHC). CONCLUSION IPNB/ICPN are rare precursor lesions that can affect the entire biliary epithelium. At pathology, the majority of patients have invasive carcinoma, thus warranting a radical resection. Patients with tumours expressing MUC1 appear to have worse OS and DFSs.

The management of hepatobiliary cystadenomas: lessons learned

BACKGROUND Mucinous cystic neoplasms of the liver (hepatobiliary cystadenomas) are rare neoplastic lesions. Such cysts are often incorrectly diagnosed and managed, and carry a risk of malignancy. The objective of this study was to review the surgical experience with these lesions over 15 years. METHODS A retrospective chart review identified consecutive patients undergoing surgery for liver cystadenomas from 1997-2011. Clinical data were collected and summarized. RESULTS Thirteen patients (mean age 51 years, 12/13 females) with cysts 4.6-18.1 cm were identified. Most cysts were located in the left lobe/centrally (11/12) and had septations (8/13). Mural nodularity was infrequent (3/13). Nine patients had liver resection/enucleation, whereas four had unroofing. Frozen section analysis had a high false-negative rate (4/6). All patients had cystadenomas, of which two had foci of invasive carcinoma (cystadenocarcinoma) within mural nodules. There was no 90-day mortality. All but one patient (myocardial infarction) were alive at a median follow-up of 23.1 months. No patient with unroofing has developed malignancy to date. CONCLUSIONS Non-invasive hepatobiliary cystadenomas present as large central/left-sided cysts in young or middle-aged women. Associated malignancy was relatively uncommon and found within mural nodules. Intra-operative frozen section analysis was ineffective at ruling out cystadenomas. Complete excision is recommended, but close follow-up might be considered in patients with a prohibitive technical or medical risk, in the absence of nodularity on high-quality imaging.

Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections

Background. Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under‐reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations. Methods. Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5 cm H2O). The target phlebotomy volume was 7–10 mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010–2014) of major resections was included for comparison. Results. A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2 mg/kg (4.7–10.2), yielding a median drop in central venous pressure of 3 cm H2O (0–15). Median blood loss was 400 vs 700 mL (P = .0016), and the perioperative transfusion rate was 8.1% vs 32% (P = .0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end‐organ ischemic complications. Conclusion. Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.

Paraduodenal pancreatitis as an uncommon cause of gastric outlet obstruction: A case report and review of the literature

Highlights • Paraduodenal pancreatitis is a rare form of focal chronic or recurrent pancreatitis that can present as gastric outlet obstruction.• Endoscopic ultrasound and fine needle aspiration biopsy provides the best diagnostic modality.• Key histopathologic features include Brunner gland hyperplasia, myofibroblastic proliferation, spindle cells and foamy cells.• Cross-sectional imaging demonstrates a fibrotic, sheet-like mass with cystic change between the duodenal wall and pancreatic head.• The optimal treatment for refractory symptoms is pancreaticoduodenectomy.

Technique for salvage ERCP with gastric bypass anatomy and severe intra-abdominal adhesions.

BACKGROUND Choledocholithiasis is a complex problem in patients with Roux-en-Y gastric bypass anatomy. Several techniques of biliary clearance have been described, but these can be limited by intra-abdominal adhesions. PATIENT AND METHODS A 36-French surgical gastrostomy was created and was allowed to mature for 10 weeks. It was exchanged for a 15-mm laparoscopic surgery trocar under fluoroscopic guidance. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out using the trocar as a stable access point. Complete biliary clearance was achieved in one sitting using sphincterotomy, large-diameter biliary orifice balloon dilation, and balloon/basket sweeps. RESULTS Total endoscopy time was 120 minutes. There were no complications associated with the procedure. The postprocedure length of stay was 2 days. The total bilirubin level at discharge was 1.2 mg/dL (20 μmol/L). CONCLUSIONS In patients with gastric bypass anatomy and severe adhesions, successful salvage therapeutic ERCP can be achieved using a gastrostomy tract and a large-bore laparoscopy trocar for access to the defunctioned stomach.