HPB Blog, March 2018

The March edition of HPB leads off with two systematic reviews of subjects that challenge us all. The first from Partelli and colleagues presents a systematic review and meta analysis of the role of palliative primary resection of pancreatic neuroendocrine in patients with liver metastases. The analysis which is based on almost 900 patients from 7 trials showed an apparent survival advantage for patients who underwent primary cancer resection although the authors report that the quality of the studies was insufficient to allow any strong recommendations to be made. The second systematic review, from van Dijk and colleagues in the Netherlands investigated the impact of pancreaticoduodenectomy on quality of life in patients with pancreatic cancer. Their analysis included more than 1200 patients and showed a negative impact of pancreaticoduodenectomy in terms of physical and social quality of life domains, which recovered to baseline values by 3-6 months. This information will be useful in counseling patients particularly those with poor prognosis tumors.

The theme of neuroendocrine cancer is continued in three further articles in the March edition of HPB. Dogeas and colleagues investigated the association between echogenicity of neuroendocrine liver metastases and their pathologic characteristics and prognosis. They found that about half all such metastases were hypoechoic and these tumors were associated with poor differentiation and worse prognosis in terms of disease free survival. They suggest that echogenicity should be considered as a prognostic factor.  Sallinen has presented a European collaborative study looking at the outcomes of resection for small non-functional pancreatic neuroendocrine tumors. The identified 220 patients who underwent resection and found all patients with tumors less than 1cm were disease free and tumors 1mm up to 2cm had 1,3 and 5 year disease free survival of 95,91 and 87% respectively. They identified the presence of pancreatic or biliary duct dilatation and WHO grade 2-3 as being the tumors in which surgical treatment had the greatest benefit with a watch and see policy recommended for other tumors. The final article looking at neuroendocrine cancer was another multi-institutional study authored by Ejaz which looked at the impact of cytoreductive debulking surgery in patients with liver metastases. Although this study didn’t have a robust control group they were able to show substantial survival in patients who underwent resection even when macroscopic evidence of tumor was left behind R2.

Two studies looked at practical resource issues with liver transplantation.  Moghadamyeghaneh and colleagues from the University of Miami interrogated the NIS database looking at re-exploration after liver transplant. They found that 1 in 8 patients returned to the operating room after liver transplantation with bleeding by far the commonest cause followed by biliary complications. Hemorrhage was more common in patients with pre-operative coagulopathy but there may be technical improvements that can also be made to reduce this complication rate. Dhar and colleagues from Cincinatti looked at the cost of achieving equivalent outcomes in sicker patients after liver transplant. They studied the SRTR database and found that while higher severity illness patients required much more investment in terms of resources and, in turn, cost, the long term benefits that these patients derived were equivalent to those of less sick and less resource demanding patients undergoing the same procedure.

Lim and colleagues from Créteil, France, report the short term outcomes after liver resection for hepatocellular carcinoma in relation to the BCLC guidelines. They found that liver resection in selected patients outwith the BCLC criteria for liver resection had acceptable morbidity and mortality and argue that these favorable short term outcomes should drive a widening of the BCLC criteria for liver resection in patients with chronic liver disease. Meanwhile Yamao and colleagues from Yumamoto Japan, looked at similar disease status patients but comparing radiofrequency ablation versus resection of hepatocellular carcinoma and found  that RFA offered comparable outcomes to resection and suggested that this might be a preferred treatment option in patients with impaired liver function.

Technological advance is a frequent feature in HPB and this month we have a paper from Mizrahi and colleagues which provides a comparative analysis of  fiberoptic versus digital single operator cholangiopancreatoscopy (DSOCP) in patients with biliary stone disease and indeterminant strictures. They found superior performance from DSOCP in terms of diagnostic yield, shorter procedure times and lower radiation exposure. Kingham and colleagues from Memorial Sloan Kettering present data on a novel image guidance system designed to assist identification of colorectal metastases visible on preoperative imaging but not visible on conventional intraoperative ultrasound. The Explorer image guidance system uses 3 D models derived from preoperative imaging which are electronically linked to landmarks around the patients liver to provide a system for focused examination of the liver in the exact region of interest identified on preoperative scanning. In this non-comparative prospective trial the system performed well and may have a useful role in assisting to identify the post-chemotherapy shrinking metastases. Finally, Halls and international colleagues representing the “Difficulty of laparoscopic liver surgery survey” which was completed by 80 international laparoscopic liver surgeons with a combined experience of 7000 laparoscopic resections present an assessment of current tools used to evaluate the difficulty of laparoscopic liver surgery. They found that commonly reported adverse factors in terms of operative difficulty such as significant obesity, neoadjuvant chemotherapy, prior liver resection and concurrent procedures were not adequately assessed by current scoring systems. They propose a widening of current scores to create a new system for evaluating difficulty of laparoscopic liver surgery.

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