Val Usatoff

Posthepatectomy liver failure: A definition and grading by the International Study Group of Liver Surgery (ISGLS)

BACKGROUNDnPosthepatectomy liver failure is a feared complication after hepatic resection and a major cause of perioperative mortality. There is currently no standardized definition of posthepatectomy liver failure that allows valid comparison of results from different studies and institutions. The aim of the current article was to propose a definition and grading of severity of posthepatectomy liver failure.nnnMETHODSnA literature search on posthepatectomy liver failure after hepatic resection was conducted. Based on the normal course of biochemical liver function tests after hepatic resection, a simple and easily applicable definition of posthepatectomy liver failure was developed by the International Study Group of Liver Surgery. Furthermore, a grading of severity is proposed based on the impact on patients clinical management.nnnRESULTSnNo uniform definition of posthepatectomy liver failure has been established in the literature addressing hepatic surgery. Considering the normal postoperative course of serum bilirubin concentration and International Normalized Ratio, we propose defining posthepatectomy liver failure as the impaired ability of the liver to maintain its synthetic, excretory, and detoxifying functions, which are characterized by an increased international normalized ratio and concomitant hyperbilirubinemia (according to the normal limits of the local laboratory) on or after postoperative day 5. The severity of posthepatectomy liver failure should be graded based on its impact on clinical management. Grade A posthepatectomy liver failure requires no change of the patients clinical management. The clinical management of patients with grade B posthepatectomy liver failure deviates from the regular course but does not require invasive therapy. The need for invasive treatment defines grade C posthepatectomy liver failure.nnnCONCLUSIONnThe current definition of posthepatectomy liver failure is simple and easily applicable in clinical routine. This definition can be used in future studies to allow objective and accurate comparisons of operative interventions in the field of hepatic surgery.

Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery

BACKGROUNDnDespite the potentially severe impact of bile leakage on patients perioperative and long-term outcome, a commonly used definition of this complication after hepatobiliary and pancreatic operations has not yet been established. The aim of the present article is to propose a uniform definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy.nnnMETHODSnAn international study group of hepatobiliary and pancreatic surgeons was convened. A consensus definition of bile leakage after hepatobiliary and pancreatic operative therapy was developed based on the postoperative course of bilirubin concentrations in patients serum and drain fluid.nnnRESULTSnAfter evaluation of the postoperative course of bilirubin levels in the drain fluid of patients who underwent hepatobiliary and pancreatic operations, bile leakage was defined as bilirubin concentration in the drain fluid at least 3 times the serum bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis. Using this criterion severity of bile leakage was classified according to its impact on patients clinical management. Grade A bile leakage causes no change in patients clinical management. A Grade B bile leakage requires active therapeutic intervention but is manageable without relaparotomy, whereas in Grade C, bile leakage relaparotomy is required.nnnCONCLUSIONnWe propose a simple definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy. The application of the present proposal will enable a standardized comparison of the results of different clinical trials and may facilitate an objective evaluation of diagnostic and therapeutic modalities in the field of hepatobiliary and pancreatic operative therapy.

Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS)

BACKGROUNDnA standardized definition of post-hepatectomy haemorrhage (PHH) has not yet been established.nnnMETHODSnAn international study group of hepatobiliary surgeons from high-volume centres was convened and a definition of PHH was developed together with a grading of severity considering the impact on patients clinical management.nnnRESULTSnThe definition of PHH varies strongly within the hepatic surgery literature. PHH is defined as a drop in haemoglobin level > 3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding. Evidence of intra-abdominal bleeding should be obtained by imaging or blood loss via the abdominal drains if present. Transfusion of up to two units of PRBC is considered as being Grade A PHH. Grade B PHH requires transfusion of more than two units of PRBC, whereas the need for invasive re-intervention such as embolization and/ or re-laparotomy defines Grade C PHH.nnnCONCLUSIONnThe proposed definition and grading of severity of PHH enables valid comparisons of results from different studies. It is easily applicable in clinical routine and should be applied in future trials to standardize reporting of complications.

A review of the surgical strategies for the management of gallbladder carcinoma based on T stage and growth type of the tumour

AIMSnSurgery for gallbladder carcinoma is a technically challenging exercise. The extent of resection varies based on a number of factors, and controversy exists regarding what constitutes an acceptable resection. A review of current recommendations and practice was undertaken.nnnMETHODSnA comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of gallbladder cancer and surgery. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.nnnOBSERVATIONSnThe extent of hepatic resection and lymph node dissection required varies in particular with T stage. Growth pattern and anatomical location of the tumour within the gallbladder also influence surgical management.nnnCONCLUSIONSnDiscrepancy exists between the Eastern and Western literature in terms of what constitutes an acceptable limit of resection, and these issues are discussed.

Laparoscopic hepatectomy is a safe procedure for cancer patients

BACKGROUNDnUtilizing laparoscopy for major surgeries such as hepatectomy is a relatively new concept. Initially, benign pathologies dominated indications for resection. Our experience in an Australian setting with primarily malignant diagnoses is described.nnnMETHODSnA review of patients profiles, pathology, surgery and outcome was performed on 35 patients between December 2005 and August 2008. Data were collected and analysed retrospectively from medical records on a pre-designed datasheet.nnnRESULTSnCommonest indication for resection was colorectal metastasis (54%), 71% of all resections were for malignancy. Average operating time was 2 h 31 min (range 30 min-7 h, 15 min). Major morbidity consisted of one bile leak, two subphrenic abscesses and one pulmonary embolus. There were no deaths. Conversion to open was required in 20% and two patients required intra-operative blood transfusions. Average length of stay overall was 6.1 days (range 1-27), but as low as 2 days for some left lateral sectionectomies. Cessation of parenteral analgesia, return to normal diet and full mobility were achieved on average at 2.4, 2.3 and 2.8 days. Significant post-operative liver dysfunction was seen in two patients, which returned to normal by discharge. One patient died of disease progression 4 months after surgery. There were two involved margins in 35 patients (6%).nnnCONCLUSIONSnLaparoscopic hepatectomy is a developing and safe technique in a select group of patients including those with malignancies, resulting in short hospital stays, rapid return to normal diet, full mobility and minimal morbidity with acceptable oncological parameters. This study is not comparative in nature, but provides evidence to support further investigation and establishment of this new technique for liver resection.

Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma

AIMSnGallbladder carcinoma usually presents late with advanced disease. It develops in an anatomically complex area. Consideration is given to resection of relevant local structures with respect to outcome.nnnMETHODSnA comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of gallbladder cancer and surgery. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma.nnnOBSERVATIONSnHepatic resection is advocated and tailored to pathological T stage. Lymph node dissection and bile duct resection, as well as en bloc resection of other viscera, remain areas of controversy.nnnCONCLUSIONSnEastern and Western practice standards of care differ, but hepatic resection with some lymph node dissection is present in both approaches. Philosophy regarding aggression with respect to en bloc resection of adjacent organs and actual extent of lymphatic resection remains disparate.

mRNA gene expression correlates with histologically diagnosed chemotherapy-induced hepatic injury

INTRODUCTIONnChemotherapy-induced hepatic injuries (CIHI) are an increasing problem facing hepatic surgeons. It may be possible to predict the risk of developing CIHI by analysis of genes involved in the metabolism of chemotherapeutics, previously established as associated with other forms of toxicity.nnnMETHODSnQuantitative reverse transcriptase-polymerase chain reaction methodology (q-RT-PCR) was employed to quantify mRNA expression of nucleotide excision repair genes ERCC1 and ERCC2, relevant in the neutralization of damage induced by oxaliplatin, and genes encoding enzymes relevant to 5-flurouracil metabolism, [thymidylate synthase (TS), thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD)] in 233 hepatic resection samples. mRNA expression was correlated with a histopathological injury scored via previously validated methods in relation to steatosis, steatohepatitis and sinusoidal obstruction syndrome.nnnRESULTSnLow-level DPD mRNA expression was associated with steatosis [odds ratio (OR) = 3.95, 95% confidence interval (CI) = 1.53-10.19, P < 0.003], especially when stratified by just those patients exposed to chemotherapy (OR = 4.48, 95% CI = 1.31-15.30 P < 0.02). Low expression of ERCC2 was associated with sinusoidal injury (P < 0.001). There were no further associations between injury patterns and target genes investigated.nnnCONCLUSIONSnPredisposition to the development of CIHI may be predictable based upon individual patient expression of genes encoding enzymes related to the metabolism of chemotherapeutics.

Role of laparoscopy in blunt liver trauma.

Although much has been written about the role of laparoscopy in the acute setting for victims of blunt and penetrating trauma, little has been published on delayed laparoscopy relating specifically to complications of conservative management of liver trauma. There has been a shift towards managing liver trauma conservatively, with haemodynamic instability being the key indication for emergency laparotomy, rather than computed tomography findings. However, as a side‐effect of more liver injuries being treated non‐operatively, bile leak from a disrupted biliary tree presenting later in admission has appeared as a new problem to manage. We describe in this article three cases that have been managed by laparoscopy and drainage alone, outlining the advantages of this technique and defining a new role for delayed laparoscopy in blunt liver trauma.

Correlations between histopathological diagnosis of chemotherapy-induced hepatic injury, clinical features, and perioperative morbidity.

BACKGROUNDnChemotherapy has in some series been linked with increased morbidity after a hepatectomy. Hepatic injuries may result from the treatment with chemotherapy, but can also be secondary to co-morbid diseases. The aim of the present study was to draw correlations between clinical features, treatment with chemotherapy and injury phenotypes and assess the impact of each upon perioperative morbidity.nnnPATIENTS AND METHODSnRetrospective samples (n= 232) were scored grading steatosis, steatohepatitis and sinusoidal injury (SI). Clinical data were retrieved from medical records. Correlations were drawn between injury, clinical features and perioperative morbidity.nnnRESULTSnInjury rates were 18%, 4% and 19% for steatosis, steatohepatitis and SI, respectively. High-grade steatosis was more common in patients with diabetes [odds ratio (OR) = 3.33, P= 0.01] and patients with a higher weight (OR/kg = 1.04, P= 0.02). Steatohepatitis was increased with metabolic syndrome (OR = 5.88, P= 0.02). Chemotherapy overall demonstrated a trend towards an approximately doubled risk of high-grade steatosis and steatohepatitis although not affecting SI. However, pre-operative chemotherapy was associated with an increased SI (OR = 2.18, P= 0.05). Operative morbidity was not increased with chemotherapy, but was increased with steatosis (OR = 2.38, P= 0.02).nnnCONCLUSIONSnDiabetes and higher weight significantly increased the risk of steatosis, whereas metabolic syndrome significantly increased risk of steatohepatitis. The presence of high-grade steatosis increases perioperative morbidity, not administration of chemotherapy per se.

Surgical outcomes for duodenal adenoma and adenocarcinoma: a multicentre study in Australia and the United Kingdom.

Pancreaticoduodenectomy is often required in patients with duodenal adenoma and adenocarcinoma and these patients generally have soft pancreatic texture and small pancreatic ducts, the two most significant factors associated with post‐operative pancreatic fistula (POPF). The aims of the study were to evaluate the rate of POPF and long‐term outcomes for patients with duodenal adenoma and adenocarcinoma who underwent curative resection.