International Hepato-Pancreato-Biliary Association
HPB Blog, November 2014
In the November issue of HPB, 2 important themes are evident. Both relate to improving quality in HPB surgery. The first focuses on the complications following HPB surgery. Li et al describe a large series of over 32000 liver resections from a single centre looking at the incidence of significant post-operative haemorrhage requiring return to theatre (0.2%). Over 60% of patients declared bleeding within 8 hours and >80% within 24 hours. The most common cause for the haemorrhage was oozing from the cut surface of the hepatic parenchyma. Following on from this, Spolverato et al describe risk factors for readmission following hepatic resection. Interestingly, patients who had a complicated post-operative course and longer initial hospital stay were more likely to require readmission. Desolneux et al describe their experience with intraoperative RFA and conclude that although the risk of complications is low there was increased risk in those having associated bowel resection. By recognising and reporting complications in a standard way it should allow the tailoring of post-operative care to the individual so that those at high risk of complications or readmission can either have pre-emptive intervention or a pathway allows for early identification and “rescue” to minimise the subsequent insult to the patient. The ability minimise the impact of the persistent high morbidity associated with HPB surgery is likely to be where major gains in patient outcomes and reducing health care costs will come from rather than new technological innovations.
The second theme relates to calculating risk associated with HPB surgery in patients with increasing preoperative comorbidity. Barbas et al describe outcomes for patient undergoing HPB surgery with coexisting end stage renal disease and observe that the mortality was double that of the non ESD group (p=0.08) there was 3 fold increase in risk of postoperative sepsis. Yang et al provide a decision analysis trying to assist in answering the question on how best to manage colorectal liver metastases in elderly patients.
Finally, it is also worth highlighting two papers dealing with preoperative imaging. Leung et al describe the utility of PET in preoperative staging of gallbladder cancer while Torzill et al describe the benefit of intraoperative contrast enhanced ultrasound for hepatic assessment prior to resection for colorectal liver metastases. Both papers may influence your practice but for different reasons.
To view the table of contents of this issue, click here.