Tony Pang

OUTCOMES OF LAPAROSCOPIC ADRENALECTOMY FOR HYPERLADOSTERONISM

Background:  Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone‐producing adenoma. The aim of this study was to investigate the long‐term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism.

Minimally invasive parathyroidectomy using the lateral focused mini-incision technique without intraoperative parathyroid hormone monitoring

Minimally invasive parathyroidectomy (MIP) involves scan‐directed removal of a single adenoma through a 2·0‐cm mini‐incision without intraoperative monitoring. The aim of this study was to analyse the outcomes of MIP using such a simplified technique.

Surgical management of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the second most common cause of death from cancer worldwide. Standard potentially curative treatments are either resection or transplantation. The aim of this paper is to provide an overview of the surgical management of HCC, as well as highlight current issues in hepatic resection and transplantation. In summary, due to the relationship between HCC and chronic liver disease, the management of HCC depends both on tumour-related and hepatic function-related considerations. As such, HCC is currently managed largely through non-surgical means as the criteria, in relation to the above considerations, for surgical management is still largely restrictive. For early stage tumours, both resection and transplantation offer fairly good survival outcomes (5 years overall survival of around 50%). Selection therefore would depend on the level of hepatic function derangement, organ availability and local expertise. Patients with intermediate stage cancers have limited options, with resection being the only potential for cure. Otherwise, locoregional therapy with transarterial chemoembolization or radiofrequency ablation are viable options. Current issues in resection and transplantation are also briefly discussed such as laparoscopic resection, ablation vs resection, anatomical vs non-anatomical resection, transplantation vs resection, living donor liver transplantation and salvage liver transplantation.

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.

Frozen section of the pancreatic neck margin in pancreatoduodenectomy for pancreatic adenocarcinoma is of limited utility

Summary The use of frozen section to assess resection margins intraoperatively during pancreaticoduodenectomy facilitates further resection. However, it is unclear whether this actually improves patient survival. We reviewed the overall survival and resection margin status in consecutive pancreaticoduodenectomies performed for carcinoma. An R1 resection was defined as an incomplete excision (⩽1 mm margin); R0(p) resection as complete excision without re-resection and R0(s) resection as an initially positive neck margin which was converted to R0 resection after re-resection. Between 2007 and 2012, 116 pancreatoduodenectomies were performed for adenocarcinoma; 101 (87%) underwent frozen section of the neck margin which was positive in 19 (19%). Sixteen of these patients had negative neck margins after re-excision but only seven patients had no other involved margins [true R0(s) resections]. Median survival for the R0(p), R0(s) and R1 groups were 29, 16, 23 months, respectively (p = 0.049; R0(p) versus R0(s) p = 0.040). Intra-operative frozen section increased the overall R0 rate by 7% but this did not improve survival. Our findings question the clinical benefit of intraoperative margin assessment, particularly if re-excision cannot be performed easily and safely.

Re: Index cholecystectomy in grade II and III acute calculous cholecystitis is feasible and safe.

We read with interest the article by Kamalapurkar et al. extolling the benefits of index cholecystectomy in patients with grade II or III acute calculous cholecystitis. This retrospective study graded the severity of cholecystitis according to the Tokyo Guidelines definition in 229 consecutive patients. Eighty-eight per cent of patients with either grade II or grade III cholecystitis underwent operative intervention during the index admission, and the procedure was completed laparoscopically in 98 and 76%, respectively. However, 27% of patients with grade III cholecystitis had to be converted to an open operation and there was a 9% bile leak rate in this group. The authors alluded to the difficulty of determining operative findings in a retrospective study and concluded that classifying patients with grade II cholecystitis was not reliable. How many of their patients had detailed operative findings recorded in the notes, and did these findings correlate with the grading assigned? This would be helpful to determine whether some of the patients in the ‘grade II’ category were operated on for uncomplicated biliary colic rather than acute cholecystitis. The high conversion rate and subsequent post-operative bile leak rate in this study demonstrates the operative difficulties when dealing with genuine severe acute cholecystitis. The conclusion by Kamalapurkar et al. that emergency cholecystectomy in the setting of severe cholecystitis is safe and technically feasible is not warranted given the data presented. Instead more accurate preoperative assessment tools to triage patients with likely difficult operative pathology are needed. We implore surgeons to systematically document the operative findings during cholecystectomy, ideally using a grading system. This will allow scientific validation of preoperative assessment tools such as the Tokyo Guidelines that might triage patients for safe emergency cholecystectomy.

Complications following liver resection for colorectal metastases do not impact on longterm outcome

BACKGROUND It has been suggested that adverse postoperative outcomes may have a negative impact on longterm survival in patients with colorectal liver metastases. OBJECTIVES This study was conducted to evaluate the prognostic impact of postoperative complications in patients submitted to a potentially curative resection of colorectal liver metastases. METHODS A retrospective analysis of outcomes in 199 patients submitted to hepatic resection with curative intent for metastatic colorectal cancer during 1999-2008 was conducted. RESULTS The overall complication rate was 38% (n = 75). Of all complications, 79% were minor (Grades I or II). There were five deaths (3%). The median length of follow-up was 39 months. Rates of 5-year overall and disease-free survival were 44% and 27%, respectively. Univariate analysis demonstrated that an elevated preoperative level of carcinoembryonic antigen (CEA), intraoperative blood loss of > 300 ml, multiple metastases, large (≥ 35 mm) metastases and resection margins of < 1 mm were associated with poor overall and disease-free survival. In addition, male sex and synchronous metastases were associated with poor disease-free survival. Postoperative complications did not have an impact on either survival measure. The multivariate model did not include complications as a predictive factor. CONCLUSIONS Postoperative complications were not found to influence overall or disease-free survival in the present series. The number and size of liver metastases were confirmed as significant prognostic factors.

Immunohistochemical validation of overexpressed genes identified by global expression microarrays in adrenocortical carcinoma reveals potential predictive and prognostic biomarkers.

BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The aim of this study was to identify novel protein signatures that would predict clinical outcomes in a large cohort of patients with ACC based on data from previous gene expression microarray studies. MATERIALS AND METHODS A tissue microarray was generated from the paraffin tissue blocks of 61 patients with clinical outcomes data. Selected protein biomarkers based on previous gene expression microarray profiling studies were selected, and immunohistochemistry staining was performed. Staining patterns were correlated with clinical outcomes, and a multivariate analysis was undertaken to identify potential biomarkers of prognosis. RESULTS Median overall survival was 45 months, with a 5-year overall survival rate of 44%. Median disease-free survival was 58 months, with a 5-year disease-free survival rate of 44%. The proliferation marker Ki-67 and DNA topoisomerase TOP2A were associated with significantly poorer overall and disease-free survival. The results also showed strong correlation between the transcriptional repressor EZH2 and TOP2A expression, suggesting a novel role for EZH2 as an additional marker of prognosis. In contrast, increased expression of the BARD1 protein, with its ubiquitin ligase function, was associated with significantly improved overall and disease-free survival, which has yet to be documented for ACC. CONCLUSION We present novel biomarkers that assist in determining prognosis for patients with ACC. Ki-67, TOP2A, and EZH2 were all significantly associated with poorer outcomes, whereas BARD1 was associated with improved overall survival. It is hoped that these biomarkers may help tailor additional therapy and be potential targets for directed therapy.

Endoscopic resection of large duodenal and papillary lateral spreading lesions is clinically and economically advantageous compared with surgery

Background and study aims Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools. Patients and methods Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared. Results A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %; P = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; P < 0.001), and was less costly than surgery (mean

Analysis of actual healthcare costs of early versus interval cholecystectomy in acute cholecystitis

 11 093 vs.