HPB Blog, February 2018

In its February 2018 issue now available on line, HPB offers its readership an exciting blend of original articles sure to please.  During editorial review and now better while reading the published content, I have been struck by the depth and quality of the studies as well as the practical and timely knowledge they provide.  I’m sure this trend has contributed to the terrific climb of our Impact Factor to 3.29!

February offers three systematic reviews for your evidence-based appetite.  Lahat et al systematically review available outcomes of non-hepatic surgery in cirrhotic patients with portal hypertension prepared with trans jugular intrahepatic portosystemic shunts (TIPS).  Without the TIPS, these patients were considered non-operable.  Nineteen studies provided 64 patients, 38 of whom underwent surgery for gastrointestinal cancer.  The results were excellent, supporting the role of TIPS as a bridge for such carefully selected patients.  Liang et al evaluate and compare trans arterial chemoembolization (TACE) against surgical resection in Asian patients being treated for BCLC intermediate stage hepatocellular carcinoma.  Over 2600 patients are evaluated across 9 available studies.  Surgical resection had better overall survival rates than TACE for these select tumors with no increase seen in post-treatment complications or 30-day mortality rates.  The authors suggest further studies to validate these results in Western patients.  Today, there appears to be no clear consensus on what imaging modality is most effective and reliable in predicting chemotherapy responses of colorectal cancer liver metastases.  Beckers et al provide a systematic review of 16 studies which evaluate the traditional modalities PET, PET-CT, CT and MRI.  While the apparent diffusion coefficient (ADC) that MRI provides may be the most promising predictor of response and survival, this interesting review raises as many questions as it answers.

For P- Pancreas, we offer some terrific and high-impact papers.  Pak et al provide a bit of a shocking evaluation of the crossover utility, or not, of serum Immunoglobulin G subclass testing across autoimmune pancreatitis (AIP) and pancreatic cancer (PDAC).  Of course, the target IgG4 elevation is the issue.  A large number of patients are presented, and 9% of elevated IgG4 patients had pancreatic cancer.  A blind eye concluding the diagnosis is de facto AIP will risk missing proper care of PDAC.  And so, shocking.  Heerkens et al  compare the long-term quality of life impacts across patients who do and do not suffer significant complications following pancreatectomy for PDAC.  During the first 12 months, there were no differences!  Would you have expected that?  Kantor et al evaluate whether the extent of vascular resection contributes to ultimate outcomes and morbidity following Whipple w/ vein resection.  In other words, are bigger vein resections, graft repairs and associated issues linked to worse outcomes?  This study says yes.  Sahakyan et al test the standardized pathology examination (SPE) of pancreatectomy specimens and the impact on lymph node yield following laparoscopic left pancreatectomy for PDAC.  It is a story of equivalent resection oncologic efficacy for minimally-invasive left pancreatectomy.  This however is not breaking news.  We have accumulating data indicating such for both laparoscopic and robotic-assisted left pancreatectomy.  You might dive deeper into the IHPBA website to capture this information via the proceedings of the Sao Paolo 2016 conference on Minimally-Invasive pancreatic surgery.

For L- Liver, Zhao et al seek to validate the reported inverse relationship between chemotherapy-associated liver injury (CALI) and tumor response to the chemotherapy.  They examine 166 consecutive patients across 2008-2014, and reveal that CALI was not directly related to survival after all.  CALI was however related to diminished complete tumor response, which was associated with decreased survival.  Seems these results are in the eyes of beholders.  Silva et al update us on why MIS-Hepatectomy cases convert to open procedures, and do so in terms of risk factors and outcomes.  Laurenzi et al  teach us that totally intracorporeal Pringle maneuver is safe and feasible during laparoscopic liver resection.  Given where we are today with minimally invasive HPB surgery, this should really not come as any surprise to readership.  That said, the authors provide some terrific graphics and intraoperative photographs that will familiarize you with this “simple, reproducible and inexpensive method” of vascular inflow occlusion during laparoscopic hepatectomy.

Enjoy your February 2018 issue, and thanks for supporting HPB!  Our usual bounty of biliary topics will return in months ahead!  Also, please take a look at our Virtual Journal Club offerings for HPB.  We hope they will facilitate learning and updating for our readership.  Finally, we hope to see many colleagues next month in sunny Miami Beach for the 2018 AHPBA meeting.

Mark P. Callery, MD, FACS
Professor of Surgery
Harvard Medical School

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