Assessment and Optimization of the Future Liver Remnant

Safe liver resection is a vital element in the management of primary and secondary hepatic malignancies. The indications for resection have evolved Over time, and this has in part been due to the ability to improve the future liver remnant (FLR). This chapter reviews the current and future methods used for assessing the future liver remnant volume and function in order to minimize the risk of post-hepatectomy liver failure (PHLF). Current and evolving methods used in augmenting the future liver remnant are also considered. Since its introduction in the 1990s, portal venous embolization (PVE) has become the most widely used method of augmenting the FLR. The factors that affect hypertrophy following embolization as well as techniques used in portal venous embolization will be reviewed. Other methods of augmentation discussed include portal vein ligation (PVL) and the emerging method of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). The chapter also considers the various methods in the context of limiting tumour progression in the future liver remnant and attempts to integrate newer techniques such as ALPPS into current treatment algorithms

Fast Track Liver Resection: The Effect of a Comprehensive Care Package and Analgesia with Single Dose Intrathecal Morphine with Gabapentin or Continuous Epidural Analgesia

Background. A comprehensive care package for patients undergoing hepatectomy was developed with the aim of minimal physiological disturbance in the peri-operative period. Peri-operative analgesia with few gastrointestinal effects and reduced requirement for intravenous (IV) fluid therapy was central to this plan. Methods. Data on 100 consecutive patients managed with continuous epidural infusion (n = 50; bupivicaine 0.125% and fentanyl 2 μg/mL at 0.1 mL/kg/hr) or intrathecal morphine (n = 50; 300 μg in combination with oral gabapentin 1200 mg preoperatively and 400 mg bd postoperatively) was compared. Results. The epidural and intrathecal morphine groups were equivalent in terms of patient demographics, procedures and complications. Patients receiving intrathecal morphine received less intra-operative IV fluids (median 1500 mL versus 2200 mL, P = .06), less postoperative IV fluids (median 1200 mL versus 4300 mL, P = .03) than patients receiving epidural infusion. Patients managed with intrathecal morphine established a normal dietary intake sooner (16 hours versus 20 hours, P = .05) and had shorter hospital stays than those managed with epidural infusions (4.7 ± 0.9 days versus 6.8 ± 1.2 days, P = .02). Conclusions. Single dose intrathecal morphine is a safe and effective means of providing peri-operative analgesia. Patients managed with intrathecal morphine have reduced peri-operative physiological disturbance and return home within a few days of hepatic resection

Simulation in Complex Laparoscopic Digestive Surgery

The adoption of laparoscopic techniques for complex digestive surgical procedures, such as hepatectomy and pancreatectomy, has been slow in comparison to other areas of surgery. Laparoscopy presents the surgeon with several challenges including ergonomics, lack of haptic feedback, altered fields of vision, and teamwork meaning that there is a significant learning curve for complex laparoscopic digestive surgery, even for the surgeon experienced in open procedures. Simulation is a useful method to train surgeons in complex procedures and has been suggested as a potential mechanism to decrease the duration of the surgeon learning curve in laparoscopic surgery. This chapter will explore current concepts in simulation for complex laparoscopic digestive surgery. Readers will develop an understanding of the role of simulation in surgical procedural training and evidence-based techniques that may be implemented in their own institution

Risk of stomach cancer in Aotearoa/New Zealand: A Māori population based case-control study.

Māori, the indigenous people of New Zealand, experience disproportionate rates of stomach cancer, compared to non-Māori. The overall aim of the study was to better understand the reasons for the considerable excess of stomach cancer in Māori and to identify priorities for prevention. Māori stomach cancer cases from the New Zealand Cancer Registry between 1 February 2009 and 31 October 2013 and Māori controls, randomly selected from the New Zealand electoral roll were matched by 5-year age bands to cases. Logistic regression was used to estimate odd ratios (OR) and 95% confidence intervals (CI) between exposures and stomach cancer risk. Post-stratification weighting of controls was used to account for differential non-response by deprivation category. The study comprised 165 cases and 480 controls. Nearly half (47.9%) of cases were of the diffuse subtype. There were differences in the distribution of risk factors between cases and controls. Of interest were the strong relationships seen with increased stomach risk and having >2 people sharing a bedroom in childhood (OR 3.30, 95%CI 1.95-5.59), testing for H pylori (OR 12.17, 95%CI 6.15-24.08), being an ex-smoker (OR 2.26, 95%CI 1.44-3.54) and exposure to environmental tobacco smoke in adulthood (OR 3.29, 95%CI 1.94-5.59). Some results were attenuated following post-stratification weighting. This is the first national study of stomach cancer in any indigenous population and the first Māori-only population-based study of stomach cancer undertaken in New Zealand. We emphasize caution in interpreting the findings given the possibility of selection bias. Population-level strategies to reduce the incidence of stomach cancer in Māori include expanding measures to screen and treat those infected with H pylori and a continued policy focus on reducing tobacco consumption and uptake

Germline CDH1 mutations are a significant contributor to the high frequency of early-onset diffuse gastric cancer cases in New Zealand Māori.

New Zealand Māori have a considerably higher incidence of gastric cancer compared to non-Māori, and are one of the few populations worldwide with a higher prevalence of diffuse-type disease. Pathogenic germline CDH1 mutations are causative of hereditary diffuse gastric cancer, a cancer predisposition syndrome primarily characterised by an extreme lifetime risk of developing diffuse gastric cancer. Pathogenic CDH1 mutations are well described in Māori families in New Zealand. However, the contribution of these mutations to the high incidence of gastric cancer is unknown. We have used next-generation sequencing, Sanger sequencing, and Multiplex Ligation-dependent Probe Amplification to examine germline CDH1 in an unselected series of 94 Māori gastric cancer patients and 200 healthy matched controls. Overall, 18% of all cases, 34% of cases diagnosed with diffuse-type gastric cancer, and 67% of cases diagnosed aged less than 45 years carried pathogenic CDH1 mutations. After adjusting for the effect of screening known HDGC families, we estimate that 6% of all advanced gastric cancers and 13% of all advanced diffuse-type gastric cancers would carry germline CDH1 mutations. Our results demonstrate that germline CDH1 mutations are a significant contributor to the high frequency of diffuse gastric cancer in New Zealand Māori