1,721,114 research outputs found
ASO Author Reflections: Re-resection of Positive Bile Duct Margin for Hilar Cholangiocarcinoma
No full textAuthor Reflections: Re-resection of Positive Bile Duct Margin for Hilar Cholangiocarcinom
ASO Author Reflections: Minimally Invasive Surgery for Hepatocellular Carcinoma in the Setting of Portal Vein Hypertension
No full textMinimally Invasive Surgery for Hepatocellular Carcinoma in the Setting of Portal Vein Hypertensio
Liver transplantation in patients with liver metastases from neuroendocrine tumors
No full textThe prevalence of metastatic disease in neuroendocrine tumors (NETs) is very high (60-80%) and cancer-related death among these patients is generally due to metastatic disease. Numerous treatment options for cure and disease control have been investigated for patients with neuroendocrine liver metastases (NELM). Despite the success of liver directed therapy on slowing tumor progression and palliating symptoms, the chance of being cured by liver resection is 40-50% and only roughly 20% of patients have potentially resectable disease. As such, there has been interest in liver transplantation (LT) as a potentially curative option for patients with unresectable disease. Several criteria have been proposed in order to balance long-term outcomes of patients with NELM and the problem of organ shortage including the Milan-NET criteria, the UNOS criteria and the ENETS guidelines. In the most representative studies, recurrence rate after LT has ranged from 30% to 60% with a 5-year OS ranging from 50% to 97%. This large variability is due to the retrospective nature of the studies available, which used different inclusion criteria. As such, outcomes and the prognostic factors associated with LT for NELM warrant further investigation
Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand?
No full textPancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence
Cholangiocarcinoma risk factors and the potential role of aspirin
No full textChoi et al. are to be congratulated on their work that adds to an already abundant literature on the topic of aspirin and cancer prevention. However, the retrospective design of the study, as well as the relative lack of detailed data on dosing, duration of usage, and concomitant other medications, do not allow for definitive evidence to support routine recommendations for daily aspirin usage. In an era of individualized medicine, future, prospective trials should aim to identify those subsets of patients who might benefit the most from aspirin usage, as well as further delineate the underlying mechanism of action related to this potential chemopreventative approach
Management and outcomes among patients with mixed hepatocholangiocellular carcinoma: A population-based analysis
No full textBackground: We sought to define the management of mixed hepatocellular carcinoma-intrahepatic cholangiocarcinoma (HCC-ICC) as well as characterize short- and long-term outcomes of patients with mixed HCC-ICC. Methods: Patients diagnosed with HCC-ICC, HCC, or ICC between 2004 and 2015 were identified from the National Cancer Data Base using the International Classification of Diseases for Oncology codes. Short- and long-term outcomes were assessed using univariate and multivariate analyses. Results: Among 174 454 patients, 86.8% had HCC, 12.1% ICC, and 1.1% HCC-ICC. The incidence of lymphadenectomy was 55.6% among ICC patients vs 15.1% and 34.2% for HCC and HCC-ICC patients, respectively (P < 0.001). A 90-day mortality was comparable among patients with HCC (9.1%), ICC (8.8%), and HCC-ICC (10.5%) (all P > 0.2). While 42.0% of ICC patients received adjuvant chemotherapy, adjuvant chemotherapy among HCC and HCC-ICC patients was 13.1% and 27.4%, respectively (P < 0.001). A 5-year survival was 43.5% (95% CI, 42.5-44.5), 33.3% (95% CI, 31.4-35.3), 34.4% (95% CI, 29.1-39.8) for HCC, ICC, and HCC-ICC patients, respectively. Conclusion: Patients who underwent resection of mixed HCC-ICC had a prognosis that was comparable to ICC, yet worse than HCC. Utilization of lymphadenectomy and adjuvant therapy were low. HCC-ICC remains a rare disease with a guarded prognosis that should be treated in a multidisciplinary setting
'Recurrence of cholangiocarcinoma after surgical treatment: an analysis of modes of occurrence, risk factors, and results of treatment.
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Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database
No full textBackground: Objectives were to determine the causes of readmission and assess the cost-effectiveness of high (HQ) and low quality (LQ) hospitals in performing pancreatic resection, by using readmission rates as the measure of quality. Methods: We identified 53,572 pancreatic resection cases from National Readmission Database from 2010 through 2014. Hospitals were risk adjusted and ranked based on readmission. Top 20% HQ hospitals having the lowest readmission rates were compared to the bottom 20% LQ hospitals with the highest readmission rates. Results: The 90-day readmission rate was 27.2% (HQ: 25.7%, LQ: 30.9%, p < 0.001). Compared to LQ, HQ hospitals had lower mortality (2.1% vs 10.2%, p < 0.001) and major complication (10.5% vs 53%, p < 0.001). Major complication during index operation was a major predictor of readmission (RR: 1.6, 95% CI: 1.6–1.7, p < 0.001). The optimal cut point of hospital volume associated with low mortality was 70 or more cases/year. Per year of survival benefit at HQ hospitals, the costs were lower by 6.98 million/year. Conclusion: HQ hospitals were cost-effective at performing pancreatic resection and achieved substantial cost-savings by avoiding major complications during index operation and having lower rates of readmissions. Hospital readmission rate is a strong marker of quality of care
Patterns and prognostic significance of lymph-node dissection for surgical treatment of peri-hilar and intrahepatic cholangiocarcinoma
No full textBACKGROUND Lymph node (LN) metastasis is a major negative prognostic factor for intrahepatic (ICC) and peri-hilar (PCC) cholangiocarcinoma. Prognostic significance of LN dissection (LND), number of metastatic LN, LN stations and lymph-node ratio (LNR) are still under debate for cholangiocarcinoma. AIMS The aims of this study are to evaluate the prognostic value of LND, of the number of LNs harvested, of number of positive LNs, of LN stations and of LNR in ICC and PCC. METHODS Extension of LND, according with Japanese Society of Biliary Surgery (JSBS), number and status of harvested LNs were retro- spectively evaluated in patients cholangiocarcinoma submitted to surgical resection with curative intent between 1990 and December 2010. RESULTS One hundrend and thirty patients were submitted to surgical resection with curative intent; 61 were ICC and 69 PCC. Lymph-node dissection (LND) was performed in 71% of patients with ICC and in 96% with PCC. Median survival of patients with 0, 1 to 3 and more than 3 LNs retrieved was respectively 31, 37 and 36 months for ICC (p=0.53) and 3, 18 and 34 for PCC (p<0.01respectively. Median survival of patients with negative LN (N0) and with LN metastasis (N+) was 43 and 19 months in ICC (p=0.03) and 42 and 20 months in PCC (p=0.01), respectively. Median survival of patients with up to 3 N+ and more than 3 N+ was 52 and 7 months in ICC (p<0.01), and 26 and 11 months in PCC (p<0.01). Median survival of patients with LNR up to 0.25 and greater than 0.25 was 42 and 14 months in ICC (p= 0.01), and 37 and 11 months in PCC, respectively (p<0.01). At multivariate survival analysis LNR and macroscopic vascular invasion were significantly related to survival with hazard ratios of 3.00 (95% CI 1.69 - 5.34; p < 0.001) and of 1.90 (95% CI 1.17 - 3.07; p=0.009) respectively. CONCLUSIONS LN metastasis is a major prognostic factor for survival after surgical resection of ICC and PCC. Lymphadenectomy should be performed because number of LN retrieved and LNR showed high prognostic value. LNR can stratify patients with positive LNs and identify patients with not favourable prognosis that might be feasible of adiuvant therapy.
A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population
No full textIntroduction: Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach. Methods: The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures. Results: A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3 ± SD 7.3) versus open (mean 9.3 ± SD 9.1) surgery (p 0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p = 0.01); in contrast, there was no difference in the overall payment for hepatic resection (p > 0.05). Conclusion: The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures
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