HPB Blog - December 2019

As we move towards the end of the year it is a good time for reflection. HPB has become busier and busier and I am very grateful for our expert team of editors for all their hard work over the year.  Handling more than a thousand manuscripts, both new and revisions, in a year is a tall order and so my warmest thanks and good wishes go to our expert team of Saxon Connor, Tara Kent, Ellen Hagopian, Mike D’Angelica, Ewen Harrison and David Cavallucci. As the volume of manuscripts goes up, sadly so must the rejections as we try to drive the quality of the journal higher. A massive THANKYOU to our reviewers without whom we would cease to function. We are equally grateful to our authors and encourage you to keep sending us your best work. Thanks also to our publishers Ash Allen on behalf of Elsevier and journal manager Emma Pendle. Finally thanks for the ongoing support from the IHPBA President Martin Smith and Chair of the Publications and Communications Committee Kevin Conlon.

The December issue of HPB is a bumper edition and begins with a systematic review and meta-analysis from Ratnayake et al, showing that enucleation of branch duct IPMN’s is a safe alternative to surgical resection of the pancreas however the data suggests that many enucleations are for IPMN’s that are outside of current guidelines suggesting overtreatment may be an issue. A further systematic review from Bundred and colleagues investigates the nutritional status and sarcopenia occurring among pancreas cancer patients suggesting a rationale for nutritional intervention in this cancer group. Ausania and colleagues from Barcelona report a systematic review and meta-analysis of randomized controlled trials comparing laparoscopic versus open pancreatoduodenectomy. Although the numbers were small there did not appear to be any major outcome differences between either approach although the authors are cautious over the heterogeneity between some of the studies.

Søreide and colleagues from Stavanger, and Edinburgh report a comprehensive systematic review examining the influence of pre, peri and post-operative factors in the development of pancreatic fistula after pancreatic resection. Raptis and colleagues from London report an in depth analysis of the quality of information to patients about one of the most common surgical problems that we deal with namely gall stone disease. They found that although there are large number of sites the quality of the information provided is poor and they conclude that there is a need for better public information in this area.

The E-AHPBA research collaborative study on bile duct injury also features in the December edition of HPB. This study looked specifically at the timing of repair and found that there were no particular good or bad times for repair in terms of outcome although the majority of repairs were conducted early after injury in keeping with early recognition.  The relatively low post repair complication rate suggested to me at least that the most important aspect may be to have the repair conducted in a specialist center. Two important papers focus ion bile duct cancer. The first from Bagante and colleagues in Verona looks at the influence of common gene mutation of cholangiocarcinoma on its outcome after surgery. They showed that certain gene mutations had a greater influence on outcome than staging. This brings us on to the second paper from Cheng and colleagues in Shanghai and a number of centers in China who propose a modification to the AJCC 8^th Edition staging system for intrahepatic cholangiocarcinoma to incorporate tumour markers. The analysis was based in 160 Chinese patients and then externally validated using >750 patients from the SEER database.  Another study looking at aspects of staging is one from Duke University by McCracken and colleagues. This study showed significantly inferior outcome of patients who had liver metastases resected from right sided versus left sided colorectal cancers. They make the case for tumour sidedness being introduced into prognostic or clinical risk scores.

Cipriani and colleagues from Milan, reported a propensity analysis to find the greatest benefit from laparoscopic liver surgery. They found that there was an overall benefit of laparoscopic approach but the greatest benefit was in patients with postero-superior tumours in the liver.  In a different propensity score analysis, Zhang and colleagues from Shanghai and other Chinese centres showed that patients who underwent R0 resection of hepatocellular carcinoma and went on to receive adjuvant sorafenib therapy had a superior outcome to patients who did not. This benefit seems likely to relate to recurrence of HCC and occurred across Barcelona clinic A and B stages.  Still on the subject of HCC, Ludwig and colleagues from Washington University showed that the LI-RADS  (liver imaging reporting and data system) criteria are good at distinguishing between HCC and benign lesions in patients outside of the high-risk population included in the LIRADS guidelines. In the light of this maybe they should be employed for all patients with solitary liver lesions irrespective of risk profile? Kalisvaart and colleagues from Birmingham UK, describe a useful score to predict acute kidney injury in liver transplant recipients. The score is based on donor and recipient BMI, the use of donation after circulatory death grafts, warm ischemia time and fresh frozen plasma requirements. They have used this to direct the use of renal sparing immunosuppression and renal replacement therapy. It would be interesting to see a contemporary analysis of how this score compares with urine markers such as N-gal or KIM-1.

Yang and colleagues from Seoul looked at the effect of pathological response after chemoembolization on outcomes of liver resection for hepatocellular carcinoma. Perhaps not surprisingly, patients with complete response did better and predictors for pathological response were having a single lesion and an AFP <100. Two further studies on hepatectomy came from Chacon and colleagues, Lexington, Kentucky who showed a linear relationship between infectious complications and duration of hepatectomy and van der Poel and colleagues from the Netherlands who reported the establishment of minimally invasive liver surgery in the Netherlands. They showed lower complications for patients undergoing major Mils procedures when these were done in high volume centers.

Hammad and colleagues from Toronto, report an important study on the symptom trajectories of patients with pancreatic ductal cancer near the end of their lives. They found a significant symptom burden in non-resected patients and argue for personalized supportive interventions in this period. Also on the subject of pancreatic cancer, Goel and colleagues from Temple University, present a paper on the biliary microbiome in pancreatic cancer and in particular the changes seen in neoadjuvant therapy and the influence of biliary drainage. They provide recommendations on the selection of antibiotic prophylaxis in these patients which may be important to adopt into management protocols. Lovasik and colleagues from Emory and an International consortium looked at the comparative predictive ability of Comprehensive complications index and Clavien Dindo Classification in predicting complications in overweight and obese patients undergoing major pancreatectomy. They reported improved prediction for CCI over CDC in these groups. A study from Maggino and colleagues in Philadelphia, showed that for surgeons operating in high quality centres, the outcomes of pancreatic surgery were independent of personal indicators of experience suggesting the center and the ‘team’ are maybe the important determinants of outcome. In terms of managing patients in the perioperative period, Akerberg and colleagues from Lund Sweden showed that early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy.  The question of cause and effect will of course be raised but evidence seems to point to restricting fluids or at least giving them judiciously being a positive recommendation.

We wish everyone a relaxing festive period and a happy and productive New Year. 

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Published on Tuesday 3rd December 2019