Victor T. W. Lee

Are preoperative blood neutrophil‐to‐lymphocyte and platelet‐to‐lymphocyte ratios useful in predicting malignancy in surgically‐treated mucin‐producing pancreatic cystic neoplasms?

The aim of this study was to determine if neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) were predictive of malignancy in mucin‐producing pancreatic cystic neoplasms (MpPCN).Introduction The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN). Methods One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively. Results High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories. Conclusions PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms. J. Surg. Oncol. 2015; 112:366–371.

Laparoscopic liver resection for posterosuperior and anterolateral lesions—a comparison experience in an Asian centre

BACKGROUND Minimally invasive surgery has been one of the recent developments in liver surgery, laparoscopic liver resection (LLR) was initially performed for benign lesions at easily accessible locations. As the surgical techniques, technology and experience improved over the past decades, LLR surgery had evolved to tackle malignant lesions, major resections and even in difficult locations without compromising safety and principles of oncology. It was also shown to be beneficial in cirrhotic patients. We describe our initial experience with LLR in a population with significant proportion having cirrhosis, emphasising our approach for lesions in the posterosuperior (PS) segments of the liver (segments 1, 4a, 7, and 8). METHODS A review of patients undergoing LLR in single institution from 2006 to 2015 was performed from a prospective surgical database. Clinicopathological, operative and perioperative parameters were analyzed to compare outcomes in patients who underwent LLR for PS vs. anterolateral lesions (AL). RESULTS LLR was performed in consecutive 197 patients, with a mean age of 60 years. The indications for resection were hepatocellular carcinoma (HCC) (n=105; 53%), colorectal cancer liver metastasis (n=31; 16%), other malignancies (n=19; 10%) and benign lesions (n=42; 21%). A significant proportion had liver cirrhosis (25.9%). More females underwent surgery in the AL group and indications for surgery were similar between both groups. Major liver resection was performed more frequently for the PS group than for the AL group (P<0.001) and significantly more PS resections was performed in our latter experience (P=0.02). The mean operative time and the conversion rate were significantly greater in the PS group than in the AL group (P≤0.001 and 0.03, respectively). However, the estimated blood loss (EBL), rate of blood transfusion and mean postoperative stay were similar in the two groups (P=0.04, 0.88 and 0.92, respectively). The overall 90-day morbidity and mortality rate was 21.3% and 0.5% respectively, with no differences between the two groups. Surrogates of difficulty such as operative time, blood loss, conversion and outcomes e.g., morbidity and mortality, were similar in patients who underwent PS resections with or without cirrhosis. CONCLUSIONS LLR in selected patients is technically feasible and safe including cirrhotic patients with lesions in the PS segments.

Mucosal Repair of Posterior Perforation of Duodenal Diverticulitis Using Roux Loop Duodenojejunostomy

Perforation of duodenal diverticulum is a rare occurrence but has a potentially fatal outcome. It is a difficult surgical problem because of delayed diagnosis and the attendant risk of duodenal fistula following primary repair. We present a case of posterior perforation of duodenal diverticulitis, diagnosed on computed tomography and successfully repaired with a Roux loop duodenojejunostomy. We also discuss the rare pathology, diagnosis and surgical options with special reference to this alternative form of mucosal repair.

Laparoscopic Liver Resection for Tumors in the Left Lateral Liver Section.

Background: The laparoscopic approach is increasingly adopted for liver resections today especially for lesions located in the left lateral liver section. This study was conducted to determine the impact of the introduction of laparoscopic liver resection (LLR) as a surgical option for suspected small- to medium-sized (<8 cm) tumors located in the left lateral section (LLS). Methods: This is a retrospective review of 156 consecutive patients who underwent LLR or open liver resection (OLR) of tumors located in the LLS. The study was divided into 2 consecutive periods (period 1, January 2003 through September 2006, and period 2, October 2006 through April 2014); LLR was available as a surgical option only in the latter period. Comparisons made were LLR versus OLR, LLR versus OLR (in period 2 only), and resections performed in period 1 versus period 2. Results: Forty-two patients underwent LLR with 4 conversions. LLR was significantly associated with a longer median operative time [167.5 minutes (range, 60–525) vs 105 minutes (range, 40–235); P < .001], decreased need for the Pringle maneuver [n = 1 (2%) vs 22 (19%); P = .008], and shorter postoperative stay [n = 4 (range, 1–10) days vs 5 days (range, 2–47); P < .001] compared with open resection. Comparison of the 42 patients who underwent LLR with the 64 contemporaneous patients who underwent OLR demonstrated similar outcomes. Again, LLR was associated with a significantly longer operation, decreased need for the Pringle maneuver, and shorter hospital stay. Conclusions: LLR can be safely adopted to treat lesions in the LLS. The procedure is associated with a shorter postoperative stay and a decreased need for the Pringle maneuver, but longer operative time compared with that required for OLR.

Renal cell carcinoma of 4 cm or less: an appraisal of its clinical presentation and contemporary surgical management.

OBJECTIVE Greater availability and utilization of modern radiological imaging modalities have resulted in an increase in the incidental discovery of renal cell carcinoma. Such tumours tend to be smaller than their symptomatic counterparts and may potentially be adequately treated using nephron-sparing surgery. METHODS A retrospective review of all patients who were diagnosed with renal cell carcinoma of 4 cm or less between January 1990 and December 2001 was conducted to review clinical presentation, surgical management and survival. RESULTS The cohort comprised 102 patients who underwent surgery, of 402 patients diagnosed with renal cell carcinoma over the study period. Sixty-eight patients (67%) had tumours detected incidentally. Thirty patients (29%) were managed with partial nephrectomy and 72 (71%) with radical nephrectomy. The median tumour size was 3.0 cm (range, 1.5-4.0 cm). Overall, median follow-up was 60 months (range, 1-148 months). Overall 5-year survival for patients who underwent partial nephrectomy and radical nephrectomy was 96.6% and 85.8%, respectively. Cancer-specific 5-year survival was 100%. CONCLUSION A significant proportion of patients had incidental diagnosis of small renal cell carcinoma. Local control may be achieved with either radical or partial nephrectomy, with excellent survival expected.

Prospective study to determine early hypertrophy of the contra-lateral liver lobe after unilobar, Yttrium-90, selective internal radiation therapy in patients with hepatocellular carcinoma

Background: Liver resection is a major curative option in patients presenting with hepatocellular carcinoma. An inadequate functional liver remnant is a major limiting factor precluding liver resection. In recent years, hypertrophy of the functional liver remnant after selective internal radiation therapy hypertrophy has been observed, but the degree of hypertrophy in the early postselective internal radiation therapy period has not been well studied. Methods: We conducted a prospective study on patients undergoing unilobar, Yttrium‐90 selective internal radiation therapy for hepatocellular carcinoma to evaluate early hypertrophy at 4–6 weeks and 8–12 weeks after selective internal radiation therapy. Results: In the study, 24 eligible patients were recruited and had serial volumetric measurements performed. The median age was 66 years (38–75 years). All patients were either Child‐Pugh Class A or B, and 6/24 patients had documented, clinically relevant portal hypertension; 15 of the 24 patients were hepatitis B positive. At 4–6 weeks, modest hypertrophy was seen (median 3%; range −12 to 42%) and this increased at 8–12 weeks (median 9%; range −12 to 179%). No preprocedural factors predictive of hypertrophy were identified. Conclusion: Hypertrophy of the functional liver remnant after selective internal radiation therapy with Yttrium‐90 occurred in a subset of patients but was modest and unpredictable in the early stages. Selective internal radiation therapy cannot be recommended as a standard treatment modality to induce early hypertrophy for patients with hepatocellular carcinoma. (Surgery 2017;160:XXX‐XXX.)