HPB Blog, November 2018

The Art and Science of HPB Surgery

One of the great aspects of a practice in HPB surgery is the constant drive to identify better ways to care for our patients in an evidence-based manner, while having to simultaneously adapt to unique circumstances and cases. In this month’s issue of HPB, there are a balance of articles focused on sharpening our evidence-base for improved care for our patients, while also highlighting the variable manner in which they present.

A series of studies this month focused on diagnostic dilemmas in the field of HPB Surgery. Lv and colleagues explored the clinical characteristics of diffuse versus focal autoimmune pancreatitis, finding that focal AIP in the head and diffuse type AIP behave in a very different manner than focal AIP presenting in the body and tail of the pancreas. Two review articles report on the rare anatomic finding of multiple gallbladders and the therapeutic implication of such, and the diagnosis and management of the intra-pancreatic accessory spleen mimicking pancreatic neuroendocrine tumor. Lastly, Concors and colleagues explore the sequelae of sub-total cholecystectomy performed for cholecystitis in a select group of patients requiring a repeat procedure for symptomatic recurrence in the remnant. Despite the difficulty of this secondary procedure, the overall incidence is unknown and the risk for recurrent symptoms must be weighed against the risk for a major biliary injury at the time of the initial procedure.

A large population-based propensity score adjusted study by Köhn et al. evaluated the role of lymphadenectomy for T1a gallbladder cancers. This study evaluated the credence of the current guidelines which state that lymphadenectomy is not necessary following cholecystectomy for incidentally identified T1a neoplasms. Interestingly, though this national study demonstrated higher rates of nodal positivity as compared to historic studies, lymphadenectomy did not impact overall survival in T1a lesions. Lymphadenectomy did lead to improved overall survival in T1b and T2 lesions, providing support for current guidelines.

Two European studies evaluate the impact of using the updated International Study Group Pancreatic Fistula definition in patients undergoing distal pancreatectomy and the impact of pancreatic texture on the development of post-operative pancreatic fistulat (POPF) using the updated definition. Colleagues from the Netherlands demonstrated improved discrimination between POPF grades using the new definition following distal pancreatectomy. Swiss colleagues advocated for the additional measure of pancreatic texture to be added to the algorithm for assessing risk for the development of POPF.

Two excellent studies sought to evaluate the outcomes following pancreaticoduodenectomy with respect to centralization of care within a large country and the impact of preoperative malnutrition on the longterm outcomes for patients. Interestingly, ninety day mortality when evaluated in a mature centralized system for the care of patients undergoing pancreaticoduodenectomy did not demonstrate significant differences in mortality between high and very high volume centers, however, the data clearly demonstrated a phenomena of a concentration of the sickest patients at the very high volume centers who would be predicted to have increased mortality otherwise. These data lend support to the effectiveness of regionalization of care for these complex operations being performed in patients with advanced age and multiple co-morbidities. A second study by Kim and colleagues followed 355 patients longitudinally for a year, serially collecting a rich dataset on nutritional parameters and quality of life. They identify that poor preoperative nutritional status predicts longterm sequelae and poor clinical outcomes. This study challenges us to do a better job identifying and intervening in a patient’s nutritional health prior to pancreaticoduodenectomy and afterwards.

And finally in this month’s issue, a focus on cholangiocarcinoma. An original investigation by Ma and colleagues evaluates the impact of recurrent pyogenic cholangitis (RPC) on outcomes for patients with resectable intrahepatic cholangiocarcinoma, identifying RPC as an independent risk factor for poor outcomes following hepatectomy. Martin and colleagues evaluate the role of irreversible electroporation (IRE) in the treatment of obstructive jaundice in patients with unresectable hilar cholangiocarcinoma. They report a benefit of IRE in increasing catheter-free days for patients and increasing quality of life.

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


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