HPB Blog, June 2014

In the June issue of HPB there is a “Benign” focus with several key articles addressing topical and ethical issues related to important benign diseases that an HPB surgeon encounters.

A systematic review of the management of FNH by Navarro et al provides an up to date assessment of the literature. The key question that comes from reading this paper is that although surgery can be performed with an acceptable morbidity and extremely low mortality, is it actually justified? In the “symptomatic” patient it would appear that there are reported improvements in symptoms postoperatively. However are these data robust? It has also been reported that there are significant numbers of patients who undergo spontaneous resolution of symptoms with time and no intervention.  Along similar lines, D’Haese et al perform a systematic review of the treatment options for chronic pancreatitis. For surgeons who provide care for patients with this difficult condition, this paper is well worth reading. It succinctly lays out the evidence for the various treatment options including medical, endoscopic and surgical therapy.

What strikes this author about the results from both these papers is the lack of placebo controlled trials when assessing the proposed surgical intervention.  It would seem this is a major weakness of the surgical literature. The significance of the placebo effect should not be under estimated. There are reports of an up to a 30% effect associated with placebo surgical intervention. Placebo controlled trials are well accepted when comparing medical treatments but less so for surgery. The problem for the surgical community is to grapple with the ethics of offering placebo surgery as well as having the equipoise to perform it. Going forward, surgeons will need to overcome the ethical and professional barriers if the profession is to understand the true effect of surgical interventions aimed at improving quality of life.

In continuing the ethical dilemma theme, Molinari et al provide an insight into the thoughts of potential liver donors and what is personally important in determining what would prompt them to donate and secondly what risks they were prepared to take. Again stimulating food for thought for those involved in living donor programmes. 

To view the table of contents of this issue, click here.

Saxon Connor

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