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Whats Hot and Whats not in Hepatobiliary Surgery

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Whats Hot and Whats not in Hepatobiliary Surgery Powered By Docstoc
					What's Hot and What's not in
 Hepatobiliary Surgery?

          Dr. Subash Gupta
   Gyan Burman Liver Surgery Unit
      Sir Ganga Ram Hospital
             New Delhi
• Looked at five journals
  –   Annals of surgery
  –   Journal of American College of Surgeons
  –   British journal of surgery
  –   HPB surgery
  –   World journal of surgery
• Discuss mainly Annals of Surgery articles
  in last one year
              Papers selected
•   Improved mortality after liver resection
•   Liver Transplantation for HCC
•   Radiofrequency ablation for liver tumours
•   LDLT without blood products
•   Bioartificial liver support
•   Non heart beating liver donation
• FDG-PET staging for colorectal liver
  metastasis
• 3-D virtual cholangioscopy
• Delayed cholecystectomy after pancreatitis
• Extended hepatectomy
• LDLT for cholangiocarcinoma
Arch Surg. 2003 Nov; 138(11): 1198-206;
discussion 1206. One thousand fifty-six
hepatectomies without mortality in 8
years.
Imamura H, Seyama Y, Kokudo N, Maema A, Sugawara Y, Sano
K, Takayama T, Makuuchi M.
Division of Hepato-Biliary-Pancreatic Surgery and Artificial Organ and
Transplantation, Department of Surgery, Graduate School of Medicine,
University of Tokyo, Tokyo, Japan.

 CONCLUSIONS: Liver resection can be performed without mortality provided that it is carried out
in a high-volume medical center by well-trained hepatobiliary surgeons paying meticulous attention
to the balance between the liver functional reserve and the volume of liver to be
removed.
                Comments
• High volume hepatobiliary centre
• 532 hepatocellular cancers
  – 80% are cirrhotic
• Only a small percentage were colorectal
  metastasis
• Liver functional reserve and liver remnant
  volume
   How has this been achieved?
• Torzilli Arch Surg, 1999, no mortality after
  107 consecutive resections,
  – Ascites, serum bilirubin, ICG 15 <14%
• Precise delineation of vascular relations
  using CT angiography and volumetry
• Assessment of liver reserve
  – Child-Pugh scoring, Class B and above
  – ICG clearance at 15 minutes, retention > 14%
    bad risk
  – 99m-Tc-galactosyl human serum albumin
        – Functional scintigraphy

      Needs validation by comparing with outcome
      So far it has only been compared with CP grade
•   Low CVP. Vascular inflow occlusion,
    Ischaemic preconditioning Clavien Ann Surg
    2003
•   CUSA, harmonic scalpel (laparoscopic
    resection), bipolar drip diathermy, Argon
    beam coagulator
 Annals of Surgery. 240(3):451-461, September 2004.
  Japanese Study Group on Organ Transplantation


Living Donor Liver Transplantation for Adult Patients
With Hepatocellular Carcinoma: Experience in Japan

Results: Currently, 236 (74.7%) of the patients are living.
One- and 3-year patient survivals were 78.1% and 69.0%,
respectively.
Conclusion: LDLTx can achieve acceptable survival in
HCC patients, even when liver function is markedly
impaired, or HCC is uncontrollable by conventional
antitumor treatments.
               Comments I
• Milan criteria, 3 nodules, single nodule < 5
  cm in size
• 316 patients with HCC
  – Milan criteria, disease free survival 79%
  – Beyond Milan, disease free survival 52%
• LRLT: no issue of better utilization of
  scarce cadaveric donor livers!
• Priority for HCC in new MELD scoring
               Comments II
• Fan ST, BJS, leading article
  – Donor safety
  – Right lobe grafts results 64% vs. 74% three
    year survival
  – May require cadaveric graft for
    retransplantation
• Resection and salvage transplantation
  – Rather than primary OLtx
Annals of Surgery. 240(5):900-909, November 2004
Mazzaferro, Milan Group


Radiofrequency Ablation of Small Hepatocellular Carcinoma in
Cirrhotic Patients Awaiting Liver Transplantation: A Prospective
Study


  Conclusions: RFA is a safe and effective treatment of small HCC
  in cirrhotics awaiting OLT, although tumor size (>3 cm) and time
  from treatment (>1 year) predict a high risk of tumor persistence
  in the targeted nodule. RFA should not be considered an
  independent therapy for HCC.
Annals of Surgery. 240(1):102-107, July 2004.,
Vivarelli, Marco et al
Department of Surgery and Transplantation, University of Bologna and Verona,
Verona, Italy.

Surgical Resection Versus Percutaneous Radiofrequency Ablation in the
Treatment of Hepatocellular Carcinoma on Cirrhotic Liver.


   One- and 3-year survival were 78 and 33%; 1- and 3-year disease-free
   survival were 60 and 20%. Overall and disease-free survival were
   significantly higher in group A (P = 0.002 and 0.001). The advantage
   of surgery was more evident for Child-Pugh class A patients and for
   single tumors of more than 3 cm in diameter. Results were similar in 2
   groups for Child-Pugh class B patients

   Conclusions: RFA has still to be confirmed as an alternative to surgery
   for potentially-resectable HCCs.
• Is RFA stand alone treatment for HCC?
• Complete response rate only 55% (63% for <3
  cm)
• > 3 cm in size and > 1 year wait for OLTx
   – High rate of recurrence in explanted liver
• Child’s B group, RFA and surgical resection
  similar survival, therefore they should be
  transplanted
• Not an independent therapy for HCC!
   Live Donor Liver Transplantation Without Blood Products:
    Strategies Developed for Jehovah's Witnesses Offer Broad
                           Application



Jabbour, Nicolas et al,
Departments of Surgery and Medicine, Keck School of Medicine, University
of Southern California; and USC University Hospital, Transfusion Free
Medicine and Surgery, Los Angeles, CA.




All transfusion-free patients underwent preoperative blood
augmentation with erythropoietin, intraoperative cell
salvage, and acute normovolemic hemodilution. These
techniques were used in only 7%, 80%, and 10%,
respectively, in transfusion-eligible patients.
• Any surgery in Jehovah’s witnessess is
  fraught with worry
• 38 patients were operated without blood
  products
• Erythropoietin
• Acute normovolemic haemodilution
• Meticulous surgical technique
• Cell saver
Annals of Surgery. 239(5):660-670, May 2004.
Demetriou, Achilles
Prospective, Randomized, Multicenter, Controlled Trial of a Bioartificial
Liver in Treating Acute Liver Failure


    Results: For the entire patient population, survival at 30 days was 71%
    for BAL versus 62% for control (P = 0.26). After exclusion of primary
    nonfunction patients, survival was 73% for BAL versus 59% for
    control (n = 147; P = 0.12). When survival was analyzed accounting
    for confounding factors, in the entire patient population, there was no
    difference between the 2 groups (risk ratio = 0.67; P = 0.13). However,
    survival in fulminant/subfulminant hepatic failure patients was
    significantly higher in the BAL compared with the control group (risk
    ratio = 0.56; P = 0.048).
                       What's new?
• Acute liver failure (ALF) is a disease with a high mortality
• Standard therapy at present is liver transplantation.
• Liver transplantation is hampered by the increasing shortage of organ
  donors,
• BAL therapy is marked as the most promising solution to bridge ALF
  patients to liver transplantation or to liver regeneration,

•    Bioartificial liver therapy for bridging patients with ALF to liver
    transplantation or liver regeneration is promising. Its clinical value
    awaits further improvement of BAL devices, replacement of
    hepatocytes of animal origin by human hepatocytes, and assessment in
    controlled clinical trials.
Ann Surg. 2004 Sep;240(3):438-47;
Five-year survival after resection of hepatic metastases from colorectal cancer in
patients screened by positron emission tomography with F-18 fluorodeoxyglucose
(FDG-PET).
Fernandez FG, Drebin JA, Linehan DC, Dehdashti F, Siegel BA, Strasberg SM.

Section of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Division of Nuclear Medicine, Mallinckrodt Institute of
Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.


RESULTS: One hundred patients (56 men, 44 women) were studied.
Metastases were synchronous in 52, single in 63, unilateral in 78, and <5
cm in diameter in 60. Resections were major (>3 segments) in 75 and
resection margins were > or = 1 cm in 52. Median follow up was 31
months, with 12 actual greater than 5-year survivors. There was 1
postoperative death. The actuarial 5-year overall survival was 58%
(95% confidence interval, 46-72%). Primary tumor grade was the only
prognostic variable significantly correlated with overall survival.
                      Reasons
• 19 studies (6070 patients)
    – 30% median 5-year survival
• Results not improved in recent studies
• Operative mortality <2%
• FDG-PET scan detects 25% extrahepatic disease
• Primary tumor grade was the only prognostic
  variable significantly correlated with overall
  survival
• A resection margin which was often less than 1cm
  but microscopically negative
• Poor for HCC and false negative for patients on
  chemotherapy
Annals of Surgery. 240(6):1002-1012, December 2004.

One Hundred Thirty-Two Consecutive Pediatric Liver
Transplants Without Hospital Mortality: Lessons Learned and
Outlook for the Future
Departments of Surgery, Pediatrics, Radiology, and Anesthesiology, University Hospital
Eppendorf, University of Hamburg, Hamburg, Germany.


Conclusions: Progress during the past 15 years has enabled
us to perform pediatric liver transplantation with near
perfect patient survival. Advances in post transplant care of
the recipients, technical refinements, standardization of
surgery and monitoring, and adequate choice of the donor
organ and transplantation technique enable these results,
which mark a turning point at which immediate survival after
transplantation will be considered the norm. The long-term
treatment of the transplanted patient, with the aim of
avoiding late graft loss and achieving optimal quality of
life, will become the center of debate.
                      Highlights
• Most important prognostic factor
   – Multivariate analysis the year of transplantation
• Only 3 recipients (2%) died during further follow-up
• Sixteen children (12%) had to undergo
  retransplantation
• This paper marks a turning point at which immediate
  survival after transplantation will be considered the
  norm!
Annals of Surgery. 239(1):87-92, January 2004.
Abt, Peter L et al
Department of Surgery, University of Pennsylvania, Philadelphia, PA; and University of Colorado Health Sciences Center,
Division of Gastroenterology-Hepatology, Denver, CO.
Survival Following Liver Transplantation From Non-Heart-Beating
Donors


     Conclusions: Graft and patient survival is inferior among
     recipients of NHBD livers. NHBD donors remain an
     important source of hepatic grafts; however, judicious use
     is warranted, including minimization of cold ischaemia and
     use in stable recipients.
      Important paper
           NHBD     HBD

n          144      26,856

One year    70.2%   80%
survival
3-year      63%     72%
survival
Primary non 11.8%   6.4%
function
•   Scarce resource
•   Prolonged cold ischaemia
•   Recipient on life support
•   Importance can not be ignored in India
    – Where very few brain dead donors
Annals of Surgery. 240(1):82-88, July 2004.
Three-Dimensional Virtual Cholangioscopy: A Reliable Tool for the
Diagnosis of Common Bile Duct Stones.
Simone, Michele
Strasbourg, France
• Detailed preoperative reconstruction of biliary
  anatomy and
• Reliable identification of choledocholithiasis
• Acceptable sensitivity and specificity in a clinical
  setting.
• Newer software developments may further enhance its
  accuracy
• Replace more invasive diagnostic measures in the near
  future.
Annals of Surgery. 240(1):95-101, July 2004.
Kondo, Satoshi et al
Department of Surgical Oncology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo,
Japan.
Forty Consecutive Resections of Hilar Cholangiocarcinoma With No
Postoperative Mortality and No Positive Ductal Margins: Results of a
Prospective Study

    Results: Hospital or 30-day mortality and morbidity rates were 0% and 48%,
    respectively. Hepatic failure was not encountered. Histopathologic
    examination revealed no positive ductal margins in all 40 patients, but 2
    showed positive separation margins from the right hepatic artery. The overall
    3-year survival rate and median survival time were 40% and 27 months.
    Survival of patients with Bismuth type III or IV tumors or of patients who
    underwent right hepatectomy was significantly better. Survival of patients who
    underwent concomitant vascular resection was similar to survival of those who
    did not. Univariate analysis indicated the type of hepatectomy, histopathologic
    grade, Bismuth classification, concomitant hepatic artery resection, and
    International Union Against Cancer stage as significant prognostic factors.
• Preoperative biliary decompression
• Portal vein embolization
• No positive ductal margins
Annals of Surgery. 239(6):741-751, June 2004.
Nealon, William
Departments of Surgery and Radiology, University of Texas Medical Branch, Galveston, TX.

Appropriate Timing of Cholecystectomy in Patients Who Present With Moderate to
Severe Gallstone-Associated Acute Pancreatitis With Peripancreatic Fluid Collections




   Conclusion: Cholecystectomy should be delayed in patients who
   survive an episode of moderate to severe acute biliary pancreatitis
   and demonstrate peripancreatic fluid collections or pseudocysts
   until the pseudocysts either resolve or persist beyond 6 weeks, at
   which time pseudocyst drainage can safely be combined with
   cholecystectomy.
• Delaying cholecystectomy may aggravate another
  episode of pancreatitis
• If pseudocyst does not resolve, may need surgery
• Early ERCP in biliary pancreatitis may improve
  outcome
• No data was available to guide timing of
  cholecystectomy
• Complication rates were higher in the early
  group(5.5% versus 44%)
Annals of Surgery. 239(2):265-271, February 2004.
Spanish Experience in Liver Transplantation for Hilar and Peripheral
Cholangiocarcinoma


   Results: The actuarial survival rate for hilar cholangiocarcinoma at 1,
   3, and 5 years was 82%, 53%, and 30%, and for peripheral
   cholangiocarcinoma 77%, 65%, and 42%. The main cause of death,
   with both types of cholangiocarcinoma, was tumor recurrence (present
   in 53% and 35% of patients, respectively). Poor prognosis factors were
   vascular invasion (P < 0.01) and IUAC classification stages III-IVA (P
   < 0.01) for hilar cholangiocarcinoma and perineural invasion (P <
   0.05) and stages III-IVA (P < 0.05) for peripheral cholangiocarcinoma.
                    Comments
• Requires correct staging, no lymph nodes, essentially those
  with vascular invasion, or poor liver function
• Unresectable cholangiocarcinoma no 5 year survival
• 30% five year survival and 42% for peripheral
  cholangiocarcinoma
• Good results by oncology standards but not for liver
  transplant operation
• Is it right to subject a healthy donor to risks?
Annals of Surgery. 239(5):722-732, May 2004.
Vauthey, Jean-Nicolas
Departments of Surgical Oncology and Anesthesiology, the University of Texas
M.D. Anderson Cancer Center, Houston, TX.
Is Extended Hepatectomy for Hepatobiliary Malignancy Justified?
   Results: The patients underwent extended hepatectomy for colorectal metastases (n =
   86; 67.7%), hepatocellular carcinoma (n =12; 9.4%), cholangiocarcinoma (n =14;
   11.0%), and other malignant diseases (n =15; 11.5%). Thirty-two left and ninety-five
   right extended hepatectomies were performed. Eight patients also underwent
   caudate lobe resection, and 40 patients underwent a synchronous
   intraabdominal procedure. Twenty patients underwent radiofrequency ablation, and 31
   underwent preoperative portal vein embolization. The median blood loss was 300 mL for right
   hepatectomy and 600 mL for left hepatectomy (P = 0.02). Thirty-six patients (28.3%) received a
   blood transfusion. The overall complication rate was 30.7% (n = 39), and the operative mortality rate
   was 0.8% (n = 1). Significant liver insufficiency (total bilirubin level > 10 mg/dL or international
   normalized ratio > 2) occurred in 6 patients (4.7%). Multivariate analysis showed that a synchronous
   intraabdominal procedure was the only factor associated with an increased risk of morbidity (hazard
   ratio [HR], 4.9; P = 0.02). The median survival was 41.9 months. The overall 5-year survival rate
   was 25.5%.

   Conclusions: Extended hepatectomy can be performed with a near-zero operative mortality rate and
   is associated with long-term survival in a subset of patients with malignant hepatobiliary disease.
   Combining extended hepatectomy with another intraabdominal procedure increases the risk of
   postoperative morbidity.
• 127 patients with more than 5 segment resection
• Median survival 42 months
• 5 year survival 26%
• Operative mortality 0.8%
• Adverse outcome if combined with any other
  intraabdominal procedure
• Behari A, (SGPGI) extended resection for CaGb
  also showed good long term results (BJS)
              What's not ?
• Preoperative biliary decompression
• Intraarterial chemotherapy for colorectal
  mets
• PVE alone without TACE in HCC
• Wait, wait, wait for biliary fistula
               What’s hot?
•   LRLT for HCC
•   NHBD of liver
•   Staging with FDG-PET for colorectal mets
•   Near zero mortality for liver resection

				
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