HPB Blog, October 2017

It is a pleasure to use this blog to reflect on the changing and ever increasing quality content of our Journal for which I have had the pleasure of editing for almost ten years. The systematic review by Yang and colleagues from Yuhan represents just one of an increasing number of published articles from the Asia-Pacific region and highlights the way in which the pattern of tumor detection within the liver can impact on survival following resection of HCC. The meta-analysis of Huang and Lu from Nanjing provides qualified support for anatomical resection of HCC but also has me considering the relationship of the separate observations from these two related reviews!

The study from Olthof and colleagues turns our attention to possible improvements in the prediction of post-hepatectomy liver failure by means of 99mTc-mebrofenin hepatobiliary scintigraphy. Look at Steve Wigmore’s editorial highlight for his thoughts as to whether we should embrace this approach. We do tend to get somewhat obsessed with surgical technique and immediate operative outcome but have generally embraced the need for an enhanced recovery programme for our patients. Roberts and colleagues go one step further by suggesting that exocrine replacement therapy delivers better long-term outcomes following pancreatoduodenectomy. The journal content has greater bredth this month with an article from Bhutiani and colleagues from Louisville which looks at endoscopic ultrasound in predicting symptom severity and the need for surgery in chronic pancreatitis. Stirling and co-workers also publish on the subject of pancreatitis but show a role for C-reactive protein interval change in helping to predict the severity of acute disease. 

Rystedt et al return to that old chestnut of routine cholangiography during laparoscopic cholecystectomy! She and her colleagues use the extensive Swedish GallRiks database to put forward the case that routine cholangiography is cost effective when bile duct injury is the issue. It is often difficult to secure useful data that assist in the management approach of pyogenic liver abscess but Rismiller and colleagues show that non-operative approaches are the rule with infrequent, but specific roles for surgery. I always marvel at the collective dynamism of Dutch colleagues in showing us just how new technology can be introduced in a safe and controlled manner. The study by van der Poel and colleagues is also highlighted in Saxon Connor’s editorial  highlight. It is always good to see colleagues collaborate and pool data to attempt to address important management questions when prospective trials may be challenging to conduct. Reames and co-workers have assessed the outcomes across 14 institutions to suggest a survival benefit with adjuvant chemotherapy in ‘high risk’ subgroups of patients following resection of intrahepatic cholangiocarcinoma. We need to now watch that space to see if this global collaborative will deliver the prospective studies so needed in this area.

Donadon et al return to the use of a scoring system to predict post-hepatectomy morbidity. Although it has a catchy name, the Humanitas Score will only work if it can be used prospectively in that institution or, more importantly, can translate to a meaningful assessment of risk in other institutions. Such scores are so dependent on the type of patients included for analysis as well as the management approach of the group. The score is now there to be validated or shot down! We look forward to further reports to see if it works with large numbers of patients undergoing resection for HCC or CRLM specifically.

Our issue finishes strongly. Czosnyka and others report ACS-NSQIP outcomes for neoadjuvant therapy post-pancreatectomy. The NSQIP initiative has been driving quality improvement in the US and, as in this report, provides much data for analysis of trends and in identifying associations. It does suffer a bit from a top-down view of clinical practice in those centres that have embraced audit and it is not always evident what the next steps in management change will be.  But for me, the big paper in October comes from van Rijssen and colleagues. It is featured in Mark Callery’s editorial highlight. Again, the Dutch set the standard with an impressive series! An almost complete nationwide audit of 1785 pancreatic resections over two years records excellent outcomes as good as anywhere in the world. We need to watch this space to see how this audit impacts in delivery of best practice in the Netherlands. This Dutch Pancreatic Audit Group are really well placed and well ahead of others globally in being able to add to our evidence based practice in the future. We are indeed fortunate to have them on our side!
James Garden, Editor-in-Chief, HPB

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