Topical haemostatic agents in liver surgery: do we need them?

AbstractBackgroundWorldwide, partial liver resections are increasingly being performed for primary or secondary hepatic malignancies. There are various techniques to reduce blood loss druing liver surgery. Several topical haemostatic agents have been developed to improve haemostasis of the resection surface and these agents are used more and more, even although the true effects remain unclear.MethodsThe present literature about the use of topical haemostatic agents in liver surgery was reviewed. Furthermore we conducted a Dutch national survey to explore the use of and belief in these agents in liver surgery.ResultsThe Dutch national survey among surgeons showed that topical haemostatic agents are frequently used not only to lower intra-operative blood loss or shorten time to haemostasis, but even more importantly, to reduce resection surface related complications such as bile leakage, postoperative haemorrhage and abscess formation. Although various topical haemostatic agents have been shown to reduce intra-operative time to haemostasis at the resection surface after liver resections, there is no scientific proof that these topical haemostatic agents really reduce resection surface related complications.ConclusionThis review highlights the need for more randomized clinical trials to investigate the efficacy of topical haemostatic agents in reducing resection surface related complications

Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs

INTRODUCTION: There has been a rapid development in minimally invasive pancreas surgery in recent years. The most recent innovation is robotic pancreatoduodenectomy. Several studies have suggested benefits as compared to the open or laparoscopic approach. This review provides an overview of studies concerning patient selection, volume criteria, and training programs for robotic pancreatoduodenectomy and identified knowledge gaps regarding barriers for safe implementation of robotic pancreatoduodenectomy. MATERIALS AND METHODS: A Pubmed search was conducted concerning patient selection, volume criteria, and training programs in robotic pancreatoduodenectomy. RESULTS: A total of 20 studies were included. No contraindications were found in patient selection for robotic pancreatoduodenectomy. The consensus and the Miami guidelines advice is a minimum annual volume of 20 robotic pancreatoduodenectomy procedures per center, per year. One training program was identified which describes superior outcomes after the training program and shortening of the learning curve in robotic pancreatoduodenectomy. CONCLUSION: Robotic pancreatoduodenectomy is safe and feasable for all indications when performed by specifically trained surgeons working in centers who can maintain a minimum volume of 20 robotic pancreatoduodenectomy procedures per year. Large proficiency-based training program for robotic pancreatoduodenectomy seem essential to facilitate a safe implementation and future research on robotic pancreatoduodenectomy

How to Approach Para-Aortic Lymph Node Metastases During Exploration for Suspected Periampullary Carcinoma:Resection or Bypass?

Background: Intraoperative para-aortic lymph node (PALN) sampling during surgical exploration in patients with suspected pancreatic head cancer remains controversial. Objective: The aim of this study was to assess the value of routine PALN sampling and the consequences of different treatment strategies on overall patient survival. Methods: A retrospective, multicenter cohort study was performed in patients who underwent surgical exploration for suspected pancreatic head cancer. In cohort A, the treatment strategy was to avoid pancreatoduodenectomy and to perform a double bypass procedure when PALN metastases were found during exploration. In cohort B, routinely harvested PALNs were not examined intraoperatively and pancreatoduodenectomy was performed regardless. PALNs were examined with the final resection specimen. Clinicopathological data, survival data and complication data were compared between study groups. Results: Median overall survival for patients with PALN metastases who underwent a double bypass procedure was 7.0 months (95% confidence interval [CI] 5.5–8.5), versus 11 months (95% CI 8.8–13) in the pancreatoduodenectomy group (p = 0.049). Patients with PALN metastases who underwent pancreatoduodenectomy had significantly increased postoperative morbidity compared with patients who underwent a double bypass procedure (p < 0.001). In multivariable analysis, severe comorbidity (ASA grade 2 or higher) was an independent predictor for decreased survival in patients with PALN involvement (hazard ratio 3.607, 95% CI 1.678–7.751; p = 0.001). Conclusion: In patients with PALN metastases, pancreatoduodenectomy was associated with significant survival benefit compared with a double bypass procedure, but with increased risk of complications. It is important to weigh the advantages of resection versus bypass against factors such as comorbidities and clinical performance when positive intraoperative PALNs are found

Incidence and impact of postoperative pancreatic fistula after minimally invasive and open distal pancreatectomy

BACKGROUND: Previous studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is unknown whether the clinical impact of postoperative pancreatic fistula after minimally invasive distal pancreatectomy is comparable with that after open distal pancreatectomy. We aimed to compare not only the incidence of postoperative pancreatic fistula, but more importantly, also its clinical impact. METHODS: This is a post hoc analysis of a multicenter randomized trial investigating a possible beneficial impact of a fibrin patch on the rate of clinically relevant postoperative pancreatic fistula (International Study Group for Pancreatic Surgery grade B/C) after distal pancreatectomy. Primary outcomes of the current analysis are the incidence and clinical impact of postoperative pancreatic fistula after both minimally invasive distal pancreatectomy and open distal pancreatectomy. RESULTS: From October 2010 to August 2017, 252 patients undergoing distal pancreatectomy were randomized, and data of 247 patients were available for analysis: 87 minimally invasive distal pancreatectomy and 160 open distal pancreatectomies. The postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was significantly higher than that after open distal pancreatectomy (28.7% vs 16.9%, P = .029). More patients were discharged with an abdominal surgical drain after minimally invasive distal pancreatectomy compared to open distal pancreatectomy (30/87, 34.5% vs 26/160, 16.5%, P = .001). In patients with postoperative pancreatic fistula, additional percutaneous catheter drainage procedures were performed less often (52% vs 84.6%, P = .012), with fewer drainage procedures (median [range], 2 [1-4] vs 2, [1-7], P = .014) after minimally invasive distal pancreatectomy. CONCLUSION: In this post hoc analysis, the postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was higher than that after open distal pancreatectomy, whereas the clinical impact was less

Endovascular treatment of a patient with an aneurysm of the proper hepatic artery and a duodenal fistula

Aneurysms of the proper hepatic artery comprise a rare but potentially dangerous entity for which treatment is performed both surgically and endovascularly. Covered stents are generally used for endovascular treatment of such aneurysms. When the aneurysm is contaminated due to an enteric fistula, however, use of a covered stent is considered inappropriate. This case report describes the endovascular repair of a proper hepatic artery aneurysm using overlapping bare metal stents after the patient was surgically treated for duodenal hemorrhage

C-reactive protein is superior to white blood cell count for early detection of complications after pancreatoduodenectomy: a retrospective multicenter cohort study

Background: Early detection of major complications after pancreatoduodenectomy could improve patient management and decrease the “failure-to-rescue” rate. In this retrospective cohort study, we aimed to compare the value of C-reactive protein (CRP) and white blood cell count (WBC) in the early detection of complications after pancreatoduodenectomy. Methods: We assessed pancreatoduodenectomies between January 2012 and December 2017. Major complications were defined as grade III or higher according to the Clavien-Dindo classification. Postoperative pancreatic fistula (POPF) was a secondary endpoint. ROC-curve and logistic regression analysis were performed for CRP and WBC. Results were validated in an external cohort. Results: In the development cohort (n = 285), 103 (36.1%) patients experienced a major complication. CRP was superior to WBC in detecting major complications on postoperative day (POD) 3 (AUC:0.74 vs. 0.54, P < 0.001) and POD 5 (AUC:0.77 vs. 0.68, P = 0.031), however not on POD 7 (AUC:0.77 vs. 0.76, P = 0.773). These results were confirmed in multivariable analysis and in the validation cohort (n = 202). CRP was also superior to WBC in detecting POPF on POD 3 (AUC: 0.78 vs. 0.54, P < 0.001) and POD 5 (AUC: 0.83 vs. 0.71, P < 0.001). Conclusion: CRP appears to be superior to WBC in the early detection of major complications and POPF after pancreatoduodenectomy

National consensus on a new resectability classification for perihilar cholangiocarcinoma - A modified Delphi method

Background: Currently, no practical definition of potentially resectable, borderline or unresectable perihilar cholangiocarcinoma (pCCA) is available. Aim of this study was to define criteria to categorize patients for use in a future neoadjuvant or induction therapy study. Method: Using the modified DELPHI method, hepatobiliary surgeons from all tertiary referral centers in the Netherlands were invited to participate in this study. During five online meetings, predefined factors determining resectability and additional factors regarding surgical resectability and operability were discussed. Results: The five online meetings resulted in 52 statements. After two surveys, consensus was reached in 63% of the questions. The main consensus included a definition regarding potential resectability. 1) Clearly resectable: no vascular involvement (≤90°) of the future liver remnant (FLR) and expected feasibility of radical biliary resection. 2) Clearly unresectable: non-reconstructable venous and/or arterial involvement of the FLR or no feasible radical biliary resection. 3) Borderline resectable: all patients between clearly resectable and clearly unresectable disease. Conclusion: This DELPHI study resulted in a practical and applicable resectability, or more accurate, an explorability classification, which can be used to categorize patients for use in future neoadjuvant therapy studies.</p

Risk factors for complications after surgery for pancreatic neuroendocrine tumors

BACKGROUND: Surgical resection is the only potentially curative treatment for pancreatic neuroendocrine tumors. The choice for the type of procedure is influenced by the expected oncological benefit and the anticipated risk of procedure-specific complications. Few studies have focused on complications in these patients. This cohort study aimed to assess complications and risk factors after resections of pancreatic neuroendocrine tumors. METHODS: Patients undergoing resection of a pancreatic neuroendocrine tumor were identified within 2 centers of excellence. Complications were assessed according to the Clavien-Dindo classification and the comprehensive complication index. Logistic regression was performed to compare surgical procedures with adjustment for potential confounders (Clavien-Dindo ≥3). RESULTS: The cohort comprised 123 patients, including 12 enucleations, 50 distal pancreatectomies, 51 pancreatoduodenectomies, and 10 total/combined pancreatectomies. Mortality was 0.8%, a severe complication occurred in 41.5%, and the failure-to-rescue rate was 2.0%. The median comprehensive complication index was 22.6 (0-100); the comprehensive complication index increased after more extensive resections. After adjustment, a pancreatoduodenectomy, as compared to a distal pancreatectomy, increased the risk for a severe complication (odds ratio 3.13 [95% confidence interval 1.32-7.41]). Of the patients with multiple endocrine neoplasia type 1 or von Hippel-Lindau, 51.9% developed a severe complication vs 38.5% with sporadic disease. After major resections, morbidity was significantly higher in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau (comprehensive complication index 45.1 vs 28.9, P = .029). CONCLUSION: Surgery for pancreatic neuroendocrine tumors is associated with a high rate of complications but low failure-to-rescue in centers of excellence. Complications are procedure-specific. Major resections in patients with multiple endocrine neoplasia type 1/von Hippel-Lindau appear to increase the risk of complications

Minimally invasive versus open pancreatoduodenectomy (LEOPARD-2): Study protocol for a randomized controlled trial

Background: Data from observational studies suggest that minimally invasive pancreatoduodenectomy (MIPD) is superior to open pancreatoduodenectomy regarding intraoperative blood loss, postoperative morbidity, and length of hospital stay, without increasing total costs. However, several case-matched studies failed to demonstrate superiority of MIPD, and large registry studies from the USA even suggested increased mortality for MIPDs performed in low-volume (< 10 MIPDs annually) centers. Randomized controlled multicenter trials are lacking but clearly required. We hypothesize that time to functional recovery is shorter after MIPD compared with open pancreatoduodenectomy, even in an enhanced recovery setting. Methods/design: LEOPARD-2 is a randomized controlled, parallel-group, patient-blinded, multicenter, phase 2/3, superiority trial in centers that completed the Dutch Pancreatic Cancer Group LAELAPS-2 training program for laparoscopic pancreatoduodenectomy or LAELAPS-3 training program for robot-assisted pancreatoduodenectomy and have performed ≥ 20 MIPDs. A total of 136 patients with symptomatic benign, premalignant, or malignant disease will be randomly assigned to undergo minimally invasive or open pancreatoduodenectomy in an enhan

Surgical Outcome of Children with a Malignant Liver Tumour in The Netherlands:A Retrospective Consecutive Cohort Study

INTRODUCTION: Six to eight children are diagnosed with a malignant liver tumour yearly in the Netherlands. The majority of these tumours are hepatoblastoma (HB) and hepatocellular carcinoma (HCC), for which radical resection, often in combination with chemotherapy, is the only curative treatment option. We investigated the surgical outcome of children with a malignant liver tumour in a consecutive cohort in the Netherlands. METHODS: In this nationwide, retrospective observational study, all patients (age &lt; 18 years) diagnosed with a malignant liver tumour, who underwent partial liver resection or orthotopic liver transplantation (OLT) between January 2014 and April 2021, were included. Children with a malignant liver tumour who were not eligible for surgery were excluded from the analysis. Data regarding tumour characteristics, diagnostics, treatment, complications and survival were collected. Outcomes included major complications (Clavien-Dindo ≥ 3a) within 90 days and disease-free survival. The results of the HB group were compared to those of a historical HB cohort. RESULTS: Twenty-six children were analysed, of whom fourteen (54%) with HB (median age 21.5 months), ten (38%) with HCC (median age 140 months) and one with sarcoma and a CNSET. Thirteen children with HB (93%) and three children with HCC (30%) received neoadjuvant chemotherapy. Partial hepatic resection was possible in 19 patients (12 HB, 6 HCC, and 1 sarcoma), whilst 7 children required OLT (2 HB, 4 HCC, and 1 CNSET). Radical resection (R0, margin ≥ 1.0 mm) was obtained in 24 out of 26 patients, with recurrence only in the patient with CNSET. The mean follow-up was 39.7 months (HB 40 months, HCC 40 months). Major complications occurred in 9 out of 26 patients (35% in all, 4 of 14, 29% for HB). There was no 30- or 90-day mortality, with disease-free survival after surgery of 100% for HB and 80% for HCC, respectively. Results showed a tendency towards a better outcome compared to the historic cohort, but numbers were too small to reach significance. CONCLUSION: Survival after surgical treatment for malignant liver tumours in the Netherlands is excellent. Severe surgical complications arise in one-third of patients, but most resolve without long-term sequelae and have no impact on long-term survival