Hepatopancreaticobiliary Research Articles

EASIER trial (Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room): a single-centre open-label cohort-based randomised controlled trial analysing the efficacy of the ultrasound-guided erector-spinae plane block compared with intravenous morphine in the treatment of acute hepatopancreaticobiliary pain in the emergency department

BackgroundUltrasound-guided (USG) erector-spinae plane block (ESPB) may be better than intravenous opioids in treating acute hepatopancreaticobiliary (HPB) pain in the ED.MethodsThis open-label randomised controlled trial was conducted in the ED...

See one, do one, teach one - Trends in resident autonomy and teaching assistant cases during general surgery residency in the United States: A nationwide retrospective analysis

IntroductionAutonomy during residency is crucial to the training and development of competent surgeons. An essential component of this process is the ‘teaching assistant (TA)’ case, an indispensable opportunity for residents to gain confidence and hone intraoperative skills. However, high-quality data on the volume and diversity of cases that graduates perform are scarce. MethodsA retrospective analysis was performed from publicly collected data of operative case logs from general surgery residents graduating from ACGME-accredited programs from 2006 to 2023. Data on the median overall number of surgeon chief and TA cases were retrieved. Collected data were organized based on sub-specialties. The Mann-Kendall trend test was used to investigate trends in TA cases and surgeon chief operative volume. ResultsBetween 2007 and 2023, the surgeon chief cases gradually increased from 229 to 274 (19.6 ​% increase; τ ​= ​0.610, p ​= ​0.001). There was a concurrent 72.7 ​% increase in TA cases from a median of 22–38 (τ ​= ​0.574, p ​= ​0.001). Surgeon chief (283 per resident) and TA cases (43 per resident) peaked in 2018–2019 and 2016–2017.The uptrend in TA cases was associated with the significant increase in colorectal (τ ​= ​0.559, p ​= ​0.001), general surgery-other (τ ​= ​0.404, p ​= ​0.018), and hepatopancreaticobiliary (HPB) (τ ​= ​0.596, p ​= ​0.001) subspecialties. Trauma and vascular surgery did not change significantly. With respect to total chief cases, general surgery-other (τ ​= ​0.956, p=<0.001), HPB (τ ​= ​0.713, p=<0.001) and colorectal (τ ​= ​0.522, p ​= ​0.004) volume increased. There was no significant change in trauma and foregut volume, while the volume of endocrine (τ ​= ​−0.485, p ​= ​0.006) and vascular surgery (τ ​= ​0.603, p ​= ​0.001) dropped significantly.The procedural category with the highest chief and TA volume was ‘colorectal tract - large intestine.’ Most procedural categories (53.49 ​%) retained a median of 0 teaching cases. No chief cases were logged for the specialties generally not considered part of general surgery (genitourinary, nervous system, orthopedics, and gynecology), although a median of 1 surgeon chief genitourinary case was recorded from 2018 to 2023. ConclusionsOver the past seventeen years, there has been a gradual uptrend in the number of surgeon chief and TA cases. While this is a positive indicator of improved autonomy, further research must focus on strategies to improve resident autonomy to train well-rounded surgeons safely.

Anti-phosphohistone H3 (PHH3) as a proliferation marker to assess mitotic activity and to grade neuroendocrine neoplasms of hepatopancreaticobiliary (HPB) system.

The world health organization (WHO) classification of neuroendocrine neoplasms (NENs, i.e. neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs)) of the gastrointestinal system involves grading of these tumors by mitotic count (i.e. H and E mitotic index or Haematoxylin and Eosin mitotic index [HE-MI] and Mindbomb E3 ubiquitin protein ligase 1 labelling index (MIB1-LI) into Grade 1 (G1), Grade 2 (G2), or Grade 3 (G3). However, the assessment of HE-MI and MIB1-LI is hindered by several factors that contribute to discordance between these two grading methods. Clinical data demonstrate the dependency of prognosis on grade. The objective of this study was to compare the grading of NENs of the hepatopancreatobiliary (HPB) system using Anti-phosphohistone H3 mitotic index (i.e. PHH3-MI), HE-MI and MIB1-LI. In a cohort of 140 NENs selected from January 2011 to August 2019, the concordance and correlation between HE-MI, MIB1-LI and PHH3-MI grading methods were analysed using Cohen's weighted kappa (κ) statistics and Spearman's correlation (ρ), respectively. Receiver operating characteristic (ROC) curve and cut-off analyses were done to determine optimal PHH3-MI cut-off values to grade NENs. The rates of discordance between HE-MI vs. MIB1-LI, PHH3-MI vs. MIB1-LI and PHH3-MI vs. HE-MI were 52% (κ =0.416), 29% (κ =0.64) and 41% (κ =0.508), respectively. There was a significant correlation between the grading methods. PHH3-MI had good overall sensitivity and specificity at cut-offs 2 and 17 in distinguishing between G1 vs. G2, and G2 vs. G3 tumors, respectively. PHH3 immunolabeling allowed for quick and easy identification of mitotic figures (MF). It had the highest concordance with MIB1-LI. At cut-off values of 2 and 17, there was good overall sensitivity and specificity. The interobserver agreement was excellent.

Not all MDTs are created equal: international survey of HPB MDT practices

BackgroundIn order to identify opportunities to streamline hepatopancreaticobiliary (HPB) multidisciplinary teams (MDT) for cancer care, it is important to first document variability in MDT team practices worldwide. We aimed to develop a comprehensive checklist of parameters to evaluate existing practices and guide the development of MDTs for new cancer services. MethodsParticipants were recruited via the International Hepato-Pancreato-Biliary Association (IHPBA) and European-African HPB Association (E-AHPBA) and emailed an anonymised online survey. The survey comprised 29 questions, including a combination of closed-ended and open-ended questions. Responses were analysed using descriptive statistics and inductive content analysis. ResultsAnalysing 72 responses from 31 countries, we found substantial variations in HPB MDT practices across regions. Notable variability was found in core team composition, chairing practices, caseload planning, information practices and MDT audit practices. Issues impacting efficiency were common to many MDTs. DiscussionMDT care is understood and applied differently across the world. There is a lack of standardisation of practice, and an apparent need for better case preparation, effective specialist contribution, improved audit frequency and metrics to improve performance. It may be valuable to consider human factors while designing MDTs to support team decision processes, minimise errors, and enhance efficiency.

Role of liver augmentation prior to hepatic resection – a survey on standards, procedures, and indications in Germany, Switzerland, and Austria

PurposeFor primary and secondary liver tumors oncological resection remains a chance of cure. Augmentation of functional liver tissue may be necessary to preserve sufficient future liver remnant (FLR). Clinical decision-making on liver augmentation techniques and indications may differ internationally. Thus, this study aims to identify standards of liver augmentation in hepato-pancreatico-biliary (HPB) centers in Germany, Switzerland, and Austria.MethodsUsing a web-based survey, 48 hospitals in Germany, Switzerland, and Austria were invited to report their surgical indication, standard procedures, and results of liver augmentation.ResultsForty (83.3%) of the hospitals invited participated. Most of the hospitals were certified liver centers (55%), performing complex surgeries such as liver transplantation (57.5%) and ALPPS (80%). The standard liver augmentation technique in all countries was portal vein embolization (PVE; 56%), followed by ALPPS (32.1%) in Germany or PVE with hepatic vein embolization (33.3%) in Switzerland and Austria. Standard procedure for liver augmentation did not correlate with certification as liver center, performance of liver transplantation or ALPPS. Surgical indication for PVE varied depending on tumor entity. Most hospitals rated the importance of PVE before resection of cholangiocarcinoma or colorectal metastases as high, while PVE for hepatocellular carcinoma was rated as low.ConclusionThe survey gives an overview of the clinical routine in HPB centers in Germany, Austria, and Switzerland. PVE seems to dominate as standard technique to increase the FLR. However, there is a variety in the main indication for liver augmentation. Further studies are necessary evaluating the differing PVE techniques for liver augmentation.

Stereotactic Radiosurgery for Patients with Brain Metastases from Hepatopancreaticobiliary Cancers.

The role of stereotactic radiosurgery (SRS) for patients with brain metastases from hepatopancreaticobiliary (HPB) cancers has yet to be established. The authors present a single-institution experience of patients with HPB cancers who underwent SRS when their cancer spread to the brain. We surveyed our Gamma Knife SRS data base of 18,000 patients for the years 1987-2022. In total, 19 metastatic HPB cancer patients (13 male) with 76 brain metastases were identified. The median age at SRS was 61 years (range: 48-83). The primary cancer sites were hepatocellular carcinoma (HCC, 11 patients), cholangiocarcinoma (CCC, 2 patients), and pancreatic carcinoma (PCC, 6 patients). The median Karnofsky Performance Score (KPS) was 80 (range: 50-90). Two patients underwent pre-SRS whole-brain fractionated radiation therapy (WBRT) and eight patients underwent pre-SRS surgical resection. All SRS was delivered in single session. The median margin dose was 18 Gy (range: 15-20). The median cumulative tumor volume was 8.1 cc (range: 1.0-44.2). The median patient overall survival (OS) after SRS was 7 months (range 1-79 months). Four patients had documented local tumor progression after SRS at a median time of 8.5 months (range: 2-15) between SRS and progression. Out of 76 treated tumors, 72 tumors exhibited local control. The local tumor control rate per patient was 78.9%. The local tumor control per tumor was 94.7%. Four patients developed new brain metastases at a median of 6.5 months (range: 2-17) after SRS. No patient experienced adverse radiation effects (AREs). At the last follow-up, 18 patients had died, all from systemic disease progression. Metastatic spread to the brain from HPB cancers occurs late in the course of the primary disease. In this study, all deceased patients ultimately died from primary disease progression. SRS is a non-invasive strategy that maximally preserves quality of life, and our results reported favorable outcomes compared to the existing literature. SRS should be considered as one of the primary management strategies for patients with brain metastatic spread from HPB cancer.

Weighing the outcomes: the role of BMI in complex robotic esophageal and hepatobiliary operations.

The correlation between body mass index (BMI) and surgical outcomes has emerged as a critical consideration in complex abdominal operations. While elevated BMI is often associated with increased perioperative risk, its specific effects on the outcomes of robotic surgeries remain inadequately explored. This study assesses the impact of BMI on perioperative variables of complex esophageal and hepatopancreaticobiliary (HPB) robotic operations. Following IRB approval, we prospectively followed 607 patients undergoing pancreaticoduodenectomy, trans-hiatal esophagectomy (THE), major liver resection or distal pancreatectomy with splenectomy, all performed robotically. Perioperative data retrieved included operative duration, estimated blood loss (EBL), intraoperative and postoperative complications, conversions to an 'open' operation and length of stay (LOS). Z scores were assigned to each variable to standardize operations, and the variables were then regressed against BMI. For illustrative purposes, data are presented as median(mean ± standard deviation). Between 2012 and 2020, surgeries included 71 THE, 122 distal pancreatectomies with splenectomies, 129 major hepatectomies and 285 pancreaticoduodenectomies. Median age was 67(65 ± 12.5) years old, and BMI was 27(28 ± 5.5) kg/m2. Operative duration for all operations was 349(355 ± 124.5) min and had a positive correlation with increasing BMI (p = 0.004), specifically for robotic THE and robotic pancreaticoduodenectomy, with both operative durations having positive correlation with increasing BMI (p = 0.02 and p = 0.05). No significant correlation with BMI was found for EBL, intraoperative or postoperative complications, conversion to 'open' surgery, or LOS. Elevated BMI is associated with longer operative durations in select robotic surgeries, such as trans-hiatal esophagectomy and pancreaticoduodenectomy, and highlights the need for strategic planning in these patients.

Is the day-of-surgery-admission (DOSA) approach for major elective hepato-pancreatico-biliary (HPB) surgery sustainable/deliverable outside of a controlled audit environment: a retrospective review

Is the day-of-surgery-admission (DOSA) approach for major elective hepato-pancreatico-biliary (HPB) surgery sustainable/deliverable outside of a controlled audit environment: a retrospective review

Patient satisfaction survey of day of surgery admission in elective hepato-pancreatico-biliary (HPB) surgery in a resource-poor health care system

Patient satisfaction survey of day of surgery admission in elective hepato-pancreatico-biliary (HPB) surgery in a resource-poor health care system

Reinterpretation of Hepatopancreaticobiliary Imaging Exams: Assessment of Clinical Impact, Peer Learning, and Physician Satisfaction

To assess the impact on clinical management, potential for peer learning, and referring physician satisfaction with subspecialist reinterpretations of hepatopancreaticobiliary (HPB) imaging examinations. HPB CTs and MRIs from outside hospitals were reinterpreted by two subspecialty radiologists between March 2021 and August 2022. Reinterpretation reports were mailed to radiologists that issued primary reports. The electronic record was reviewed to assess for changes in clinical management based on the reinterpretations (yes/no/unavailable). To assess the potential for peer learning, a survey using a 5-point Likert scale was sent to radiologists who issued primary reports. A separate survey was sent to referring physicians to assess satisfaction with reinterpretations. Two hundred fifty imaging examinations (122 CT, 128 MRI) were reinterpreted at the request of 19 referring physicians. Ninety-sixradiologists issued primary reports. RADPEER scores 1-3 were assigned to 131/250 (52%), 86/250 (34%), and 33/250 (13%) examinations, respectively. Of 213 reinterpretations with adequate records for assessment, 75/213 (35%) were associated with a change in management; of these, 71/75 (95%) were classified as RADPEER 2 or 3. Most radiologists agreed or strongly agreed with the following: prefer to receive reinterpretations (34/36, 94%); reinterpretations changed practice of reporting HPB imaging examinations (23/36, 64%); and reinterpretations offer opportunities for peer learning (34/36, 94%). Referring physicians agreed or strongly agreed (7/7, 100%) that reinterpretations are valuable and often change or clarify management of patients with complex HPB disease,and offeran opportunity for peer learning. Radiologists and referring physicians strongly agree that HPB imaging reinterpretations help support peer learning and patient management, respectively.

Closing the patient-provider gap along the surgical journey one click at a time: results of a phase I pilot trial of a patient navigation tool

BackgroundPatients diagnosed with complex hepato-pancreaticobiliary (HPB) conditions experience a challenging journey through the healthcare system. Patient navigation is commonly offered to patients and their caregivers throughout this process. Here, we report on the development and phase I testing of a prototype web-based dual (patient and provider) navigation application ‘PatientNav.’MethodsEvidence-based recommendations were determined through a needs assessment. The PatientNav app was designed to be a highly customizable tool based on the needs of the patients, the care team, and the characteristics of the institution. Our phase I pilot trial targeted adult patients who reported the capacity to use a mobile app or desktop website presenting to our HPB transplant clinic at MedStar Georgetown University Hospital/Lombardi Comprehensive Cancer Center over two months. Usability, functionality, and reliability testing were conducted by applying multiple strategies, including biometric data analysis, task completion, questionnaires, and interviews.ResultsOut of 22 patients, 18 (81.8%) completed the in-app survey whose responses were included in the analysis. The usability rate of PatientNav among patient app users was 95.4%. Among patient app users who completed the in-app survey questionnaire, 66.6% reported that the content in the PatientNav app was relevant. In terms of the app's reliability, none of the patient app users reported technical issues with accessing PatientNav throughout the study period. To further elucidate the characteristics of individuals who exhibited high usage of the PatientNav assigned task functions, we divided our cohort based on the median number of tasks used (N = 75 total tasks). The univariable comparison showed that high function users were older, with a median (IQR) age of 61.5 (57.8, 71.3) compared to 52.2 (34.5, 65.7) years among low function users. No differences were observed based on gender, racial distribution, living condition, or occupation. However, 41.7% of low function users had Medicare/Medicaid insurance, whereas all high function users had private or combined insurance.ConclusionOur phase I pilot study showed that PatientNav is a feasible, usable, and functional technological tool that enables patients with complex HPB diagnoses and their care team to interface in real-time using patient-reported outcome measures (PROMs). PatientNav is a reliable tool that can be used by clinical and support staff to help navigate patients through surgery and aftercare and by patients to assist in navigation and self-management.Trial registrationThe trial was registered at ClinicalTrials.gov; Registration number: NCT04892927; date of registration: 5/19/2021.

Impact of Medicaid Expansion on Surgical Care and Outcomes for Hepatobiliary Malignancies.

As part of the Patient Protection and Affordable Care Act, some states expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty line. While this resulted in an increased proportion of insured residents, its impact on the diagnosis and treatment of hepatopancreaticobiliary (HPB) cancers has not been studied. The National Cancer Database (NCDB) from 2010 to 2017 was used. Patients diagnosed with HPB malignancies in states which expanded in 2014 were compared to patients in non-expansion states. Subset analyses of patients who underwent surgery and those in high-risk socioeconomic groups were performed. Outcomes studied included initiation of treatment within 30days of diagnosis, stage at diagnosis, care at high volume or academic center, perioperative outcomes, and overall survival. Adjusted difference-in-differences analysis was performed. A total of 345,684 patients were included, of whom 55% resided in non-expansion states and 54% were diagnosed with pancreatic cancer. Overall survival was higher in states with Medicaid expansion (HR .90, 95% CI [.88-.92], P < .01). There were also better postoperative outcomes including 30-day mortality (.67 [.57-.80], P < .01) and 30-day readmissions (.87 [.78-.97], P = .02) as well as increased likelihood of having surgery in a high-volume center (1.42 [1.32-1.53], P < .01). However, there were lower odds of initiating care within 30days of diagnosis (.77 [.75-.80], P < .01) and higher likelihood of diagnosis with stage IV disease (1.09 [1.06-1.12], P < .01) in expansion states. While operative outcomes and overall survival from HPB cancers were better in states with Medicaid expansion, there was no improvement in timeliness of initiating care or stage at diagnosis.

Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions.

Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.

Laparoscopic ultrasonography along with staging laparoscopy as a tool for staging in patients with hepatopancreaticobiliary malignancy - A prospective cohort study from a tertiary care centre.

Staging laparoscopy (SL) plays an important role in avoiding unnecessary non-therapeutic laparotomy in radiologically resectable hepatopancreaticobiliary (HPB) malignancy patients. The limitation of SL is to detect deep-seated malignancy. The addition of laparoscopic ultrasonography for identifying metastatic lesions or locally unresectable disease improves the diagnostic yield of SL. This prospective, observational study was conducted in a single unit of the tertiary care centre between 2017 and 2019. All the patients of HPB malignancy who were radiologically resectable underwent SL and laparoscopic intraoperative ultrasonography. Metastatic disease patients were either underwent palliative bypass procedures or abandoned depending on the condition of the patient. Patients who had resectable disease underwent standard surgical procedures. Forty patients of HPB malignancy with potentially resectable on radiological imaging underwent SL and diagnostic ultrasonography. Out of 40, 21 patients had periampullary, 14 had carcinoma gallbladder and 5 patients had distal cholangiocarcinoma. Metastatic lesions were identified on laparoscopy in eight patients and the diagnostic yield of SL is 20%. Addition of laparoscopic ultrasonography identified one haemangioma which was false positive on laparoscopy and underwent the radical standard procedure. Four patients were unresectable so the procedure was abandoned and another three patients underwent a bypass procedure. Laparoscopic ultrasonography during SL can detect deep-seated metastatic lesions and decide the management in resectable disease.

Reliability of Medical Information Provided by ChatGPT: Assessment Against Clinical Guidelines and Patient Information Quality Instrument.

ChatGPT-4 is the latest release of a novel artificial intelligence (AI) chatbot able to answer freely formulated and complex questions. In the near future, ChatGPT could become the new standard for health care professionals and patients to access medical information. However, little is known about the quality of medical information provided by the AI. We aimed to assess the reliability of medical information provided by ChatGPT. Medical information provided by ChatGPT-4 on the 5 hepato-pancreatico-biliary (HPB) conditions with the highest global disease burden was measured with the Ensuring Quality Information for Patients (EQIP) tool. The EQIP tool is used to measure the quality of internet-available information and consists of 36 items that are divided into 3 subsections. In addition, 5 guideline recommendations per analyzed condition were rephrased as questions and input to ChatGPT, and agreement between the guidelines and the AI answer was measured by 2 authors independently. All queries were repeated 3 times to measure the internal consistency of ChatGPT. Five conditions were identified (gallstone disease, pancreatitis, liver cirrhosis, pancreatic cancer, and hepatocellular carcinoma). The median EQIP score across all conditions was 16 (IQR 14.5-18) for the total of 36 items. Divided by subsection, median scores for content, identification, and structure data were 10 (IQR 9.5-12.5), 1 (IQR 1-1), and 4 (IQR 4-5), respectively. Agreement between guideline recommendations and answers provided by ChatGPT was 60% (15/25). Interrater agreement as measured by the Fleiss κ was 0.78 (P<.001), indicating substantial agreement. Internal consistency of the answers provided by ChatGPT was 100%. ChatGPT provides medical information of comparable quality to available static internet information. Although currently of limited quality, large language models could become the future standard for patients and health care professionals to gather medical information.

Impact of Food Insecurity on Outcomes Following Resection of Hepatopancreaticobiliary Cancer.

Food insecurity (FI) may predispose individuals to suboptimal nutrition, leading to chronic disease and poor health outcomes. We sought to assess the impact of county-level FI on postoperative outcomes among patients undergoing resection of hepatopancreaticobiliary (HPB) cancer. Patients who were diagnosed with HPB cancer between 2010 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data on annual county-level FI were obtained from the Feeding America: Mapping the Meal Gap report and were categorized into tertiles. Textbook outcome was defined as no extended length of stay, perioperative complications, 90-day readmission, and 90-day mortality. Multiple logistic regression and Cox regression models were used to assess outcomes and survival relative to FI. Among 49,882 patients (hepatocellular: n = 11,937, 23.9%; intrahepatic cholangiocarcinoma: n = 2111, 4.2%; extrahepatic cholangiocarcinoma: n = 4047, 8.1%; gallbladder: n = 2853, 5.7%; pancreatic: n = 28,934, 58.0%), 6702 (13.4%) patients underwent a surgical resection. Median age was 75 years (interquartile range 69-82), and most patients were male (n = 25,767, 51.7%) and self-identified as White (n = 36,381, 72.9%). Overall, 5291 (10.6%) and 39,664 (79.5%) individuals resided in low or moderate FI counties, respectively, while 4927 (9.8%) patients resided in high FI counties. Achievement of textbook outcome (TO) was 56.3% (n = 6702). After adjusting for competing risk factors, patients residing in high FI counties had lower odds to achieve a TO versus individuals living in low FI counties (odds ratio 0.69, 95% confidence interval [CI] 0.54-0.88, p = 0.003). In addition, patients residing in moderate and high FI counties had a greater risk of mortality at 1- (referent, low, moderate: hazard ratio [HR] 1.09, 95% CI 1.05-1.14; high: HR 1.14, 95% CI 1.08-1.21), 3- (referent, low, moderate: HR 1.09, 95% CI 1.05-1.14; high: HR 1.14, 95% CI 1.08-1.21), and 5- (referent, low, moderate: HR 1.05, 95% CI 1.01-1.09; high: HR 1.07, 95% CI 1.02-1.13) years versus individuals from low FI counties. FI was associated with adverse perioperative outcomes and long-term survival following resection of an HPB malignancy. Interventions directed towards mitigating nutritional inequities are needed to improve outcomes among vulnerable HPB populations.

Association between sarcopenia and postoperative complications in patients undergoing surgery for gastrointestinal or hepato-pancreatico-biliary cancer.

Despite surgical advances, postoperative complications persist, affecting oncologic outcomes and increasing treatment costs. It is important to identify a marker that can predict postoperative complications, which can help prehabilitate patients before surgery. This study evaluated sarcopenia as a predictive marker of postoperative complications in patients undergoing surgery for gastrointestinal (GI) or hepato-pancreatico-biliary (HPB) cancer. Sarcopenia was assessed using the skeletal muscle index at the third lumbar vertebra on abdominal computed tomography. The predictive ability of sarcopenia was evaluated by adjusting for other clinicopathological factors. Of the 210 patients, 81 (38.57%) were sarcopenic. The overall morbidity and mortality were 33.81% and 2.86%, respectively. Major complications (Clavien-Dindo Grade ≥ III) were observed in 10.95% patients and sarcopenic patients were significantly more likely to develop major complications (p = 1.42 × 10-10 ). Sarcopenia (p = 6.13 × 10-6 ; odds ratio = 12.29) independently predicted postoperative complications and prolonged hospital stay (p = 0.01). Sarcopenia objectively predicted the development of postoperative complications and prolonged hospital stay in patients undergoing surgery for GI or HPB cancer. This may facilitate the prehabilitation of patients planned for surgery to reduce the risk of complications.

A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery

BackgroundSurgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures. MethodsA systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review. ResultsSeven “core” indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries. ConclusionsThis work presents a core set of internationally agreed QPI for HPB surgery.

Disparities in Socioeconomic Factors Mediate the Impact of Racial Segregation Among Patients With Hepatopancreaticobiliary Cancer.

Structural racism within the U.S. health care system contributes to disparities in oncologic care. This study sought to examine the socioeconomic factors that underlie the impact of racial segregation on hepatopancreaticobiliary (HPB) cancer inequities. Both Black and White patients who presented with HPB cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2005-2015) and 2010 Census data. The Index of Dissimilarity (IoD), a validated measure of segregation, was examined relative to cancer stage at diagnosis, surgical resection, and overall mortality. Principal component analysis and structural equation modeling were used to determine the mediating effect of socioeconomic factors. Among 39,063 patients, 86.4 % (n = 33,749) were White and 13.6 % (n = 5314) were Black. Black patients were more likely to reside in segregated areas than White patients (IoD, 0.62 vs. 0.52; p < 0.05). Black patients in highly segregated areas were less likely to present with early-stage disease (relative risk [RR], 0.89; 95 % confidence interval [CI] 0.82-0.95) or undergo surgery for localized disease (RR, 0.81; 95% CI 0.70-0.91), and had greater mortality hazards (hazard ratio 1.12, 95% CI 1.06-1.17) than White patients in low segregation areas (all p < 0.05). Mediation analysis identified poverty, lack of insurance, education level, crowded living conditions, commute time, and supportive income as contributing to 25 % of the disparities in early-stage presentation. Average income, house price, and income mobility explained 17 % of the disparities in surgical resection. Notably, average income, house price, and income mobility mediated 59 % of the effect that racial segregation had on long-term survival. Racial segregation, mediated through underlying socioeconomic factors, accounted for marked disparities in access to surgical care and outcomes for patients with HPB cancer.

Contemporary practice and perception of autologous blood salvage in hepato-pancreatico-biliary operations: an international survey

BackgroundThis study aimed to assess contemporary knowledge, attitudes and behaviors around transfusion of intraoperative salvaged blood (sRBCt) during hepato-pancreatico-biliary (HPB) operations. Findings are meant to inform the design of future studies that address provider concerns to change behaviors and improve patient outcomes. MethodsA survey was designed and assessed for relevance, readability and content, and distributed to an international audience of surgeons performing HPB operations. ResultsThe 237 respondents were predominantly distributed across North America (37.55%), Europe (27.43%) and Asia (19.83%). Roughly one-half (52.74%) of respondents had used sRBCt in HPB surgery before. Transplantation surgeons were more likely than HPB surgeons to have previously used sRBCt [odds ratio = 5.18 (95% CI 1.89–14.20)]. More respondents believed sRBCt was safe for non-cancer versus cancer operations (68.57% vs. 24.17%, p < 0.0001). Less than half (45.71%) of respondents believed that sRBCt was safe in clean-contaminated fields. Most did not utilize preoperative strategies to avoid donor transfusion. ConclusionPractices related to sRBCt in HPB operations vary widely and there is no consensus on its use. Concerns seem primarily related to cancer-specific and infectious outcomes. While further studies are pursued, surgeons may increase their utilization of preoperative strategies to boost hemoglobin levels for at risk patients.