HPB Blog: January 2016

A Happy New Year of more HPB excellence!

We look forward to 2016 with great optimism and enthusiasm as we start to see the product of a busy few months of working behind the scenes with our new publishers, Elsevier B. V. You will now be able to access our new website 
(http://www.hpbonline.org)
which should provide excellent access to the Journal content. The Highlights section is prominently displayed and readers should be able to move seamlessly from the current volume to articles in press. You can keep up to date by seeing what the hot topics are in the most read and most cited lists (these tabs are below the Issue Highlights section on the journal homepage). Those at ease with social media can use our twitter link to keep colleagues informed of controversial and educational topics. We hope also that the website will complement well myHPB and encourage greater use of the Virtual Journal Club. We look forward to feedback on how we can further improve our window to the readership.

Reports of individual case series in pancreatic surgery may underestimate outcomes for any given procedure. For this reason, the report on total pancreatectomy for invasive carcinoma by Johnson and colleagues is most welcome in providing an informative review derived from the National Cancer Database. This report gives great insight into US clinical practice mapping improvements in operative mortality over time. Despite this radical surgery, it is disappointing to see that a substantial number of patients operated on presumably with curative intent had advanced disease which seems to translate into poor long-term outcomes. Aggressive combined pancreatic and liver resection is the theme of the systematic review of Zhou et al who show that this combination for biliary and gallbladder cancers, is associated with perioperative death in one of every 10 operated patients. No patient undergoing incomplete resection of tumour survived to five years. At the other end of the ‘aggressive’ spectrum, Schneider and colleagues from Heidelberg reopen the debate on the role of surgical ampullectomy for ampullary lesions. Short-term outcomes were in this substantial series and recurrence rates low in this substantial series but the challenge for us all will be to best determine which patients will benefit most from this more conservative approach. 

Other interesting pancreatic learning points for me in this issue, included a potential role for PET-CT in the detection of possible recurrence following pancreatic cancer resection and in patients with unresectable periampullary malignancy (Jung and colleagues) , good palliation from endoscopic placement of self-expanding metal stents (Williamsson and colleagues) and an on-going role for selective use of staging laparoscopy in patients with resectable pancreatic cancer (De Rosa et al). Although previously a strong proponent of laparoscopy and laparoscopic ultrasound staging of pancreatic cancer, I had appreciated that advances in imaging had cast doubt on its value. This review suggests that laparoscopy will be most effective in patients with tumours greater than 3 cm in size and with elevated CA 19.9 levels. An online survey from van Grinsven et al provides some evidence that the step-up approach to managing infected necrotising pancreatitis is most favoured by surgeons although there seems poor agreement on the precise form of intervention and its timing. A great little study looks at post-operative fluid collections following pancreatic resection. Tjaden et al systematically evaluated patients undergoing distal pancreatectomy in the post-operative period and demonstrated that such collections were frequent and normally of no clinical consequence. Only one in 10 patients required therapeutic intervention. 

The January issue is not just restricted to pancreatic gems! Teo et al looked at the impact of Y90 SIRT on liver atrophy and hypertrophy. They delivered collective evidence from a systematic review that Y90 SIRT results in significant hypertrophy of the contralateral untreated liver lobe but many factors appear to impact on the rate of hypertrophy. I also liked the report from Lee et al who showed that PET – CT can be adapted for use in evaluating benign liver pathology. Although useful interpretation of the data is limited, it seems to me that PET may have promise in avoiding unnecessary intervention in some patients.

Vilchez and colleagues interrogated the UNOS database to compare outcomes following liver transplantation in patients with hepatoma, cholangiocarcinoma or mixed tumours. As might be expected, those patients with cholangiocarcinoma as a component of their tumour faired worse. The debate as to whether resection or transplantation should be considered for hepatoma continues. Na et al make a case for down-staging HCC beyond Milan criteria before living donor liver transplantation. Kirichenko et al introduce the concept of stereotactic body radiotherapy as a safe and effective treatment for isolated inoperable hepatic malignancy whereas Koh et al suggest that ablation and embolization are equally effective in dealing with post-resection recurrence of hepatoma.  Finally, an analysis by Jutric et al of the National Cancer Database confirms the poor outlook for patients with lymph node metastases in the surgical treatment of intrahepatic cholangiocarcinoma. They suggest a benefit for adjuvant therapy and therefore a role for routine lymphadenectomy.

These are all great articles with which to open the New Year. We have much to look forward to in 2016 and hope to keep in touch through the Journal until we meet in Sao Paolo at the World Congress in April. Make sure that you have registered and arranged your accommodation!

James Garden

CLICK HERE for the Janaury Table of Contents

CLICK HERE for the latest Virtual Journal Club discussion

 

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