Post-hepatectomy liver failure (PHLF) is the Achilles’ heel of hepatic resection for colorectal liver metastases. The most commonly used procedure to generate hypertrophy of the functional liver ...remnant (FLR) is portal vein embolization (PVE), which does not always lead to successful hypertrophy. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed to overcome the limitations of PVE. Liver venous deprivation (LVD), a technique that includes simultaneous portal and hepatic vein embolization, has also been proposed as an alternative to ALPPS. The present study aimed to conduct a systematic review as the first network meta-analysis to compare the efficacy, effectiveness, and safety of the three regenerative techniques.
A systematic search for literature was conducted using the electronic databases Embase, PubMed (MEDLINE), Google Scholar and Cochrane.
The time to operation was significantly shorter in the ALPPS cohort than in the PVE and LVD cohorts by 27 and 22 days, respectively. Intraoperative parameters of blood loss and the Pringle maneuver demonstrated non-significant differences between the PVE and LVD cohorts. There was evidence of a significantly higher FLR hypertrophy rate in the ALPPS cohort when compared to the PVE cohort, but non-significant differences were observed when compared to the LVD cohort. Notably, the LVD cohort demonstrated a significantly better FLR/body weight (BW) ratio compared to both the ALPPS and PVE cohorts. Both the PVE and LVD cohorts demonstrated significantly lower major morbidity rates compared to the ALPPS cohort. The LVD cohort also demonstrated a significantly lower 90-day mortality rate compared to both the PVE and ALPPS cohorts.
LVD in adequately selected patients may induce adequate and profound FLR hypertrophy before major hepatectomy. Present evidence demonstrated significantly lower major morbidity and mortality rates in the LVD cohort than in the ALPPS and PVE cohorts.
Background
The laparoscopic approach in distal pancreatectomy is associated with higher rates of splenic preservation compared to open surgery. Although favorable postoperative short-term outcomes ...have been reported in open spleen-preserving distal pancreatectomy when compared to distal pancreatectomy with splenectomy, it is unclear whether this observation applies to the laparoscopic approach. The aim of this study is to compare laparoscopic spleen-preserving distal pancreatectomy (LSPDP) with laparoscopic distal pancreatectomy with splenectomy (LDPS).
Study design
This is a UK wide, propensity score-matched study, including patients who underwent LSPDP or LDPS between 2006 and 2016. Short-term outcomes were compared between LSPDP and LDPS according to intention to treat. Additionally, risk factors for unplanned splenectomy were explored.
Results
A total of 456 patients were included from eleven centers (229 LSPDP and 227 LDPS). We were able to match 173 LSPDP cases to 173 LDPS cases, according to intention to treat. No differences were seen in postoperative morbidity between the groups. The only identified risk factor for unplanned splenectomy was tumor size ≥ 30 mm.
Conclusions
Preserving the spleen during laparoscopic distal pancreatectomy is not associated with a lower postoperative morbidity compared to sacrificing the spleen. Tumor size is a risk factor for unplanned splenectomy.
Background
An increasing number of minimally invasive oesophagogastrectomies (MIOG) are being performed. However, the complexity of the surgical skills required and the steep learning curve have thus ...far confined the minimally invasive approach to selected tertiary centres. The oesophagogastric and the oesophagojejunal anastomosis can be challenging and often time-consuming. The recently developed transorally inserted anvil (OrVil
™
) is a technique aimed to simplify the anastomotic procedure. The aim of the study was to evaluate the safety, feasibility, and efficacy of OrVil
™
-assisted anastomosis during laparoscopic surgery in a tertiary upper-GI cancer centre.
Methods
From July 2008 to July 2010, 53 consecutive patients underwent MIOG for cancer performed by one surgeon at our institution. Thirty patients underwent laparoscopic Ivor-Lewis oesophagectomy (ILO) and 23 patients underwent laparoscopic gastrectomy. Of the latter group, 13 had a total gastrectomy (TG) and 10 had a subtotal gastrectomy (SG). The gastrointestinal anastomosis was checked with intraoperative endoscopy in all cases.
Results
There were three in-hospital deaths. Median hospital stay was 14 days for oesophagectomies and 11 days for gastrectomies. There were three anastomotic leaks (5.6%), all in the oesophageal group, successfully treated conservatively. Two patients needed conversion to open surgery (3.7%), 3 patients (5.6%) required re-exploration (for bleeding, infected haematoma, and diaphragmatic hernia), and 18 patients (34%) had respiratory complications (pneumonia, pleural effusions, respiratory failure). Four patients developed anastomotic stricture requiring endoscopic balloon dilatation. The average number of lymph nodes harvested was 22 (range = 11–39) and 26 (range = 5–78) for oesophagectomies and gastrectomies, respectively.
Conclusions
The principles of a good anastomosis are good vascular supply, must be tension-free, and the use of a high-quality surgical technique. The use of the OrVil
™
in laparoscopic upper-gastrointestinal surgery is safe and does not have an increased complication rate. It is quicker and easier compared to the traditional purse-string technique and it may help to expand the adoption of MIOG surgery.
The best method to teach anatomy is widely debated. A shift away from cadaveric dissection in UK medical schools towards newer approaches has taken place without adequate evaluation of their ...suitability. The impact of this on future anatomical and surgical competencies is unclear. We assessed student perceptions to different methods of anatomy teaching.
All 2nd year students at Leeds School of Medicine were invited to complete a matrix-grid questionnaire. Participants were asked to score six methods of anatomy teaching (dissection; prosection; lectures; models; PC software packages; living & radiological anatomy) using a 5-point Likert-type scale on the ability to achieve nine learning objectives. Kruskal–Wallis and Mann–Whitney analyses suitable for non-parametric data were used to evaluate differences in scores between teaching methods.
170 students (71%) responded to the survey. Overall, dissection was the single highest scored method, followed by prosection. Newer approaches such as models, computer software packages and living & radiological anatomy scored comparatively worse. The most suitable method for achieving individual learning objectives was variable with dissection perceived as most suitable for four out of nine objectives.
Cadaveric dissection is a favourable approach for achieving important learning objectives in the field of anatomy. Further evaluation of teaching methods is required prior to changes being made in the curricula of UK medical schools.
Lymph node (LN) status is an important predictor of survival following resection of perihilar cholangiocarcinoma (PHCCA). Controversies still exist with regard to the prognostic value of optimum ...extent of lymphadenectomy, total number of nodes removed, LN ratio (LNR) and neutrophil-lymphocyte ratio (NLR) on overall survival (OS) and disease-free survival (DFS) following PHCCA resection.
From 1994 to 2010, 84 PHCCAs were resected; 78 are included in this analysis. Kaplan-Meier survival curves were studied using log-rank statistics to assess which variables affected OS and DFS. The variables that showed statistical significance (P<0.05) on Kaplan-Meier univariate analysis were subjected to multivariate analysis using Cox proportional hazards model.
Five-year OS for node-positive status (n=45) was 10%, whereas node-negative (n=33) OS was 41% (P<0.001). Similarly, 5-year DFS was worse in the node-positive group (8%) than in the node-negative group (36%, P=0.001). There was no difference in 5-year OS (31 vs. 12%, P=0.135) and DFS (22 vs. 16%, P=0.518) between those with regional lymphadenectomy and those who underwent regional plus para-aortic lymphadenectomy, respectively. On univariate analysis, patients with 20 or more LNs removed had worse 5-year OS (0%) when compared with those with less than 20 LNs removed (29%, P=0.047). Moderate/poor tumour differentiation, distant metastasis and LN involvement were independent predictors of OS. Positive LNR had no effect on OS. Vascular invasion and an LNR of at least 0.37 were independent predictors of DFS. NLR had no effect on OS and DFS.
Extended lymphadenectomy patients (≥20 LNs) had worse OS when compared with those with more limited (<20 LNs) resection. An LNR of at least 0.37 is an independent predictor of DFS.
Abstract The use of totally implantable venous devices (TIVAD) has changed the care and quality of life for cancer patients, these devices allow chemotherapy administration, and blood sampling ...without the need for repeated venipuncture. These ports are used mainly when IV access is needed only intermittently over a long period of time. We are presenting a brief overview on TIVADs, with focus on the mid and long-term complications associated with these devices with their management.
Background and Purpose Teaching in the operating room (OR) may add substantial value to undergraduate medical education but at present, the value of this as a core-learning environment is unclear. We ...assessed student attitudes to see how the experience may be improved. Methods All medical students from University of Leeds, UK were invited to complete an online-based questionnaire. The questionnaire gathered quantitative and qualitative responses relating to previous experiences, acquired benefits, and desired improvements. Students rated their overall satisfaction on a 10-point scale. Results A total of 292 students (20.8%) responded to the survey, out of whom 91.4% had previous OR experience. The median overall satisfaction was 7/10; 43.1% described bad or unfavorable experiences. Common themes included feeling intimidated, unwelcome, or ignored by staff, unrealistic expectations of knowledge, and poor or inadequate learning experiences. Benefits of attending the OR were improvements in scrub technique (82.3%), knowledge of anatomy (72.3%), anesthetics (67.5%), and surgical procedures (86.1%). Desired improvements included more opportunity to participate in the procedure (74.4%), encouragement from supervisors (73.6%), improved teaching (71.4%), and better induction to the OR environment (56%). Discussion and Conclusions Overall satisfaction of OR teaching is reasonable and many benefits are derived from attending the OR. However, bad experiences are common and this is detrimental to the student learning experience. The experience may be of increased value to undergraduate medical education within a dedicated and structured surgical teaching program.
Liver resection in patients with inferior vena cava (IVC) involvement is becoming more common with the adoption of vascular exclusion techniques and replacement of the IVC. Repeat hepatectomy and an ...aggressive surgical approach can offer satisfactory disease-free survival and a cure in selected patients. We herein describe a case of repeat hepatectomy with en bloc re-do IVC resection and reconstruction with Gore-Tex graft for recurrent colorectal liver disease. The patient had previously undergone non-anatomical right liver resection with IVC partial excision and reconstruction with a porcine pericardial patch. The patient is currently disease-free at 12 months’ follow-up. Surgical treatment of liver tumors involving the IVC offers the only hope for prolonged survival. Re-do liver surgery with concomitant re-excision of the IVC is feasible and can be contemplated when macroscopic removal of the tumor is expected. Management of these complex cases by a specialist team with expertise in liver transplantation and vascular techniques is advised.
PDF
