HPB Blog, August 2016

Elevating the Quality of our Surgical Science in HPB Surgery

As surgeons, we are positioned at the bedside of patients and are poised to ask important questions to move our field forward. In the current issue of HPB, many important questions are raised through collective clinical experiences, and several authors now challenge us to elevate our inquiries to the next level to truly answer them.  

In a thoughtful leader authored by Dr. Michael D’Angelica, he challenges us to beware of selection bias in our reported surgical series. Selecting the correct patients an operation, particularly for high risk HPB surgical procedures, is the mark of an excellent surgeon, however, when we report our outcomes it must be in the context of the entire patient population. Otherwise, we risk messaging the benefit of a high risk procedure for many/most patients who will not benefit, and worse could be subjected to harm. Ball, Dixon, and Vollmer  also highlight the importance of high quality clinical research in HPB surgery in their review of the trends over time in the AHPBA scientific program – calling for an increase in prospective studies and randomized controlled trials.

Two interesting studies explore the application of current technology to the diagnosis and management of patients with hepatocellular carcinoma (HCC). Adler and colleagues  report on the results of a multi-centre Italian study exploring the use of transient elastography to assess liver stiffness in cirrhotic patients and to evaluate their risk for developing HCC. In an intention to treat analysis, Ronot and colleagues  explored the long-term oncological outcomes of patients with resectable HCC who underwent sequential transarterial chemoembolization (TACE) and portal vein embolization (PVE).

Cieslak et al identify and explore an important question regarding the impact of aging on liver function. This is a critically important question for liver surgeons more aggressive resections for the treatment of primary and metastatic liver cancer are considered in elderly patients. The literature has been mixed on this topic, and the current study lends further support to the need to evaluate this in a robust manner – suggesting that aging may in fact lead to decline in liver function and may be a factor in considering the necessary future liver remnant.

In the realm of pancreatic surgery, HPB’s associate editor, Saxon Connor , explores the impact of post-operative pancreatitis on the development of post-operative pancreatic fistula (POPF). In a systematic review using PRISMA guidelines, he finds evidence of a link between post-operative pancreatitis and POPF – calling for increased attention and recognition of this entity to try to develop strategies to mitigate this morbid complication. A second systematic review by our Australian colleagues using PRISMA and REMARK guidelines evaluated the value of existing biomarkers for predicting specific outcomes in pancreatic adenocarcinoma, and identified which biomarkers may be worthy of ongoing validation and exploration in translational studies.

Read all of these articles and more in the August Issue of HPB!

Rebecca Minter, MD

 

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