HPB Blog, January 2017

It is difficult to believe that we are into another New Year for HPB! We have enjoyed another solid year with quality manuscripts coming out in timely fashion each month. I again want to thank those who continue to have faith in the Journal either by submitting their best work for consideration of publication or in giving their valuable time to review and add to the quality of the journal content. I am obviously biased, but I think that the editorial team has done a pretty good job in making sure that the Journal continues to educate and deliver easily readable and balanced articles that cover the range of our HPB practice. I believe that this month’s issue illustrates this well. I am grateful to Mark Callery and Saxon Connor for making some perceptive points on some of our key articles in the January issue.

Mark always delivers a racy and provocative summary and his review of the article by Lapshyn and colleagues is no exception, highlighting the interaction and significance of aggressive biology, fibroblast activation and apparent mesenterico-portal invasion in pancreatic adenocarcinoma. He urges us to continue to be aggressive in treating this cancer and hopes that better systemic therapies will emerge. Saxon has focused on the systematic review from Zhou and colleagues. These workers identified 13 observational studies that have looked at radical antegrade modular pancreatosplenectomy (RAMPS). Only four of the studies could be incorporated into a meta-analysis and Saxon points out that some of the apparent significant advantages of RAMPS have not yet been shown to translate into survival advantage despite the theoretical strengths of the procedure. As always we lament the lack of quality evidence in the literature. I had the opportunity to look in more detail at the systematic review of Gavriilidis and colleagues on the topic of drains and liver resection. The question of routine drainage has been around for some time and this review was interesting because it looked at the primary outcomes of death and ascitic leak rather than bile leakage and the avoidance of intra-abdominal collections.  It was a stimulating review but left me with as many questions as answers. So there is a second opportunity for the readership to go out and provide some more evidence for inclusion in HPB!

We did not intend to slight the Paris/Leeds alliance by not also delivering an editorial highlight for the second systematic review in the January issue from the Gavriilidis stable. This second review could only identify five quality relevant but retrospective studies and perhaps not surprisingly showed that neither redo hepatic resection or radiofrequency ablation was superior in terms of disease free or overall survival as salvage treatment for recurrent hepatocellular carcinoma. 

January is not just all about pancreatic and liver cancer but we have Machado and his colleagues providing data on a new laparoscopic ALPPS approach. It is intriguing that the original ALPPS intervention seems to becoming less invasive in an attempt to reduce the morbidity and mortality rates that remain a concern for this type of advanced surgery.  There is certainly enough encouragement from the early experience of the Brazilian group to suggest that this approach is well worth pursuing in experienced centres. The Seattle group (Bertens et al) provides evidence that either fistula risk score and drain amylase on the first postoperative day are equally accurate in predicting clinically relevant postoperative pancreatic fistula. I guess someone will work out how the combination of preoperative and postoperative risk assessment can be used to deliver better outcomes in the future.

HPB is not just about the heavy end of HPB surgery and it is great to see Tan and colleagues from Singapore provide some practical guidance that supports early laparoscopic intervention in patients with acute cholecystitis. If you are worried about ductal stones, then the 23-year experience of Quaresima and colleagues in their laparoscopic management might reassure you that this approach to common bile duct stones is both safe and effective, and worth building into your laparoscopic practice. Good to see specialist HPB surgeons lead the way in delivering quality outcomes in gallstone disease!

There is much more – Kamal and colleagues giving an interesting message that the type of hospital is not so important in predicting outcome in the management of acute pancreatitis. A useful study to quote on a Friday night when a smaller hospital is trying to persuade you to take on the management of the sick pancreatitic patient! The report is worth reading to understand risk factors in this challenging disease. The final paper that I would highlight is that of Sturesson and colleagues from Sweden. We are always a bit challenged in having to consider the priority for managing synchronous colorectal liver metastases. It was intriguing to see that in a multidisciplinary setting a third of patients who were submitted to liver first management of metastases failed to complete treatment mainly due to tumour progression.

So, a refreshing start for HPB in 2017. Keep those manuscripts coming in and let the New Year wish be for an impact factor that surges past 3.0 by the summer!

James Garden
HPB Editor-in-Chief

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