Delivery of hepato-pancreato-biliary surgery during the COVID-19 pandemic: an European-African Hepato-Pancreato-Biliary Association (E-AHPBA) cross-sectional survey

Background: The extent of the COVID-19 pandemic and the resulting response has varied globally. The European and African Hepato-Pancreato-Biliary Association (E-AHPBA), the premier representative body for practicing HPB surgeons in Europe and Africa, conducted this survey to assess the impact of COVID-19 on HPB surgery. Methods: An online survey was disseminated to all E-AHPBA members to assess the effects of the pandemic on unit capacity, management of HPB cancers, use of COVID-19 screening and other aspects of service delivery. Results: Overall, 145 (25%) members responded. Most units, particularly in COVID-high countries (>100,000 cases) reported insufficient critical care capacity and reduced HPB operating sessions compared to COVID-low countries. Delayed access to cancer surgery necessitated alternatives including increased neoadjuvant chemotherapy for pancreatic cancer and colorectal liver metastases, and locoregional treatments for hepatocellular carcinoma. Other aspects of service delivery including COVID-19 screening and personal protective equipment varied between units and countries. Conclusion: This study demonstrates that the COVID-19 pandemic has had a profound adverse impact on the delivery of HPB cancer care across the continents of Europe and Africa. The findings illustrate the need for safe resumption of cancer surgery in a “new” normal world with screening of patients and staff for COVID-19

Development of biotissue training models for anastomotic suturing in pancreatic surgery

Background: Anastomotic suturing is the Achilles heel of pancreatic surgery. Especially in laparoscopic and robotically assisted surgery, the pancreatic anastomosis should first be trained outside the operating room. Realistic training models are therefore needed. Methods: Models of the pancreas, small bowel, stomach, bile duct, and a realistic training torso were developed for training of anastomoses in pancreatic surgery. Pancreas models with soft and hard tex-tures, small and large ducts were incrementally developed and evaluated. Experienced pancreatic sur-geons (n = 44) evaluated haptic realism, rigidity, fragility of tissues, and realism of suturing and knot tying. Results: In the iterative development process the pancreas models showed high haptic realism and highest realism in suturing (4.6 & PLUSMN; 0.7 and 4.9 & PLUSMN; 0.5 on 1-5 Likert scale, soft pancreas). The small bowel model showed highest haptic realism (4.8 & PLUSMN; 0.4) and optimal wall thickness (0.1 & PLUSMN; 0.4 on -2 to +2 Likert scale) and suturing behavior (0.1 & PLUSMN; 0.4). The bile duct models showed optimal wall thickness (0.3 & PLUSMN; 0.8 and 0.4 & PLUSMN; 0.8 on -2 to +2 Likert scale) and optimal tissue fragility (0 & PLUSMN; 0.9 and 0.3 & PLUSMN; 0.7). Conclusion: The biotissue training models showed high haptic realism and realistic suturing behavior. They are suitable for realistic training of anastomoses in pancreatic surgery which may improve patient outcomes.Surgical oncolog

Case Report - Breast metastases of gastric signet ring cell carcinoma: A differential diagnosis with primary breast signet ring cell carcinoma

Metastatic deposits within the breast may be difficult to distinguish from primary breast carcinoma. Radiological features and immunohistochemistry especially for steroid hormone receptors and expression of gross cystic disease fluid protein may be helpful in differentiating these two conditions. In this report, we present a case of signet ring cell stomach cancer with metastasis to the breast and discuss the differential diagnostic options

Case Report - Chest wall metastases from unknown primary hepatocellular carcinoma

Metastases of hepatocellular carcinoma (HCC) to the bones are common but bone metastases of hepatocellular carcinoma in the presence of a normal liver are an uncommon entity. A 50-year-old male patient presented with a rapidly growing tumour on the sternum. Biopsy of the lesion showed metastatic sternal tumour from a primary hepatocellular carcinoma. Radiological evaluation however, failed to detect a primary lesion in the liver. Bone metastases of hepatocellular carcinoma localized to the chest wall in the presence of a normal liver are scarcely reported as anecdotal case reports in the literature

Global Perceptions on ERAS® in Pancreatoduodenectomy.

Uptake of ERAS <sup>®</sup> pathways for pancreatic surgery have been slow and impacted by low compliance. To explore global awareness, perceptions and practice of ERAS <sup>®</sup> peri-pancreatoduodenectomy (PD). A structured, web-based survey (EPSILON) was administered through the ERAS <sup>®</sup> society and IHPBA membership. The 140 respondents included predominantly males (86.4%), from Europe (45%), practicing surgery (95%) at academic/teaching hospitals (63.6%) over a period of 10-20 years (38.6%). Most respondents identified themselves as general surgeons (68.6%) with 40.7% reporting an annual PD volume of 20-50 cases, practicing post-PD clinical pathways (37.9%), with 31.4% of respondents auditing their outcomes annually. Reduced medical complications, cost and hospital length of stay, and improved patient satisfaction were perceived benefits of compliance to enhancing-recovery. Multidisciplinary co-ordination was considered the most important factor in the implementation and sustainability of peri-PD ERAS <sup>®</sup> pathways, while reluctance to change among health care practitioners, difficulties in data collection and audit, lack of administrative support, and recruitment of an ERAS <sup>®</sup> dedicated nurse were reported to be important barriers. The EPSILON survey highlighted global clinician perceptions regarding the benefits of compliance to peri-PD ERAS <sup>®</sup> , the importance of individual components, perceived facilitators and barriers, to the implementation and sustainability of these pathways

Is there a role for estrogen and progesterone receptors in gall bladder cancer?

Background/Aims. The concept of metaplastic and non-metaplastic types of gall bladder cancer and the likelihood of hormone receptor expression in the nuclei of tumour cells raised the possibility of a potential role for anti-estrogen therapy in gall bladder cancer. This study was carried out to determine the hormone receptors (ER/PR) expression level in gall bladder cancer using specific immunohistochemical assays and correlate it with patient and tumour histopathological characteristics. Patients and methods. Histopathological tumour specimens of 62 patients who underwent a radical cholecystectomy were analysed. Pronase pretreatment and primary monoclonal antibodies were used to perform immunohistochemical analysis for ER and PR. Results. The histology was adenocarcinoma – predominantly, moderately to poorly differentiated (91%). Gallstones were present in 90% of the individuals. Of the 62 specimens analysed, 62 (100%) and 61 (98%) were negative for ER and PR, respectively. Conclusion. The high incidence of gallstone-related gall bladder cancer in India is associated with metaplasia and a tendency to poorer differentiation in the tumour histology. These tumours are consequently less likely to express hormone receptors. Thus, there does not seem to be a role for anti-hormone therapy in patients with histogenesis similar to that seen in India

Revision surgery for incidental gallbladder cancer: factors influencing operability and further evidence for T1b tumours

Background and aim. There is a need to increase the available data on revision radical surgery for incidental gallbladder cancer and to determine factors influencing operability. We aimed to assess the impact of stage of disease (pT) and the type of primary surgery (laparoscopy versus open) on resectability rates. Material and methods. The data of 90 consecutive patients referred to the Tata Memorial Hospital between 1 January 2003 and 30 April 2007 for revision radical surgery for incidental gallbladder cancer were reviewed retrospectively. Results. Of the 90 patients who underwent revision surgery, accurate data on T-stage was available in 76, and of these 76 patients, 44 (57.8%) had prior laparoscopic simple cholecystectomy, while 32 (42.2%) had undergone open surgery. The median time interval between the two surgeries was 2 months (range 4 weeks to 11 months). By T-stage, 23 patients had T1b disease, while 33 and 20 patients had T2 and T3 disease, respectively. Successful revision surgery could be undertaken in 71% of patients (54/76) and 29.6% of these had residual disease confirmed by histopathological examination. Conclusions. T-stage is an important factor in determining operability as confirmed by our study. As the T-stage of the disease increased, the chances of finding residual disease increased, while operability decreased. Furthermore, the case for revision surgery is strengthened because the incidence of lymph nodal disease is high even for pT1b cancers. The type of primary surgery does not affect operability in patients undergoing revision radical surgery for incidental gallbladder cancer