HepatoPancreatoBiliary Association Research Articles

A snapshot on current approaches to lymphadenectomy in liver resection for intrahepatic cholangiocarcinoma: results from an international survey.

The use of lymphadenectomy (LND) during resection of intrahepatic cholangiocarcinoma (ICC) is still debated, leading to differing practices in different centers and countries. The aim of this study was to assess such differences. A survey on LND for ICC was distributed to the members of the International Hepato-PancreatoBiliary Association (IHPBA) and the Italian Chapter of IHPBA (AICEP). Two-hundred thirty-four surgeons completed the survey (88% males; median age 46 years). Preoperative nodal staging was deemed mandatory/very important by 65%. Adequate LND was defined as hepatoduodenal ligament LND by 33%, LND at specific nodal stations by 28% and retrieval of > 5 nodes by 28%. The decision to perform LND was influenced by comorbidities (48%), chronic liver disease (38%) and satellitosis (32%). Most participants modify perioperative management in case of clinically positive nodes, 50% stating they would give neoadjuvant therapy. The role of LND in clinically node negative disease was adequate staging for 88%, survival benefit for 50.5% and clinical trials eligibility for 18.5%. Our survey confirms heterogeneity in the evaluation of role and extent of LND for ICC, how this relates to subjective perception of importance of LND, and need of a systematic approach in this area.

Risk Perceptions and Risk Thresholds Among Surgeons in the Management of Intraductal Papillary Mucinous Neoplasms.

We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasm (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. Surgeons vary widely in management of IPMN. We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. One hundred fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs 5%) more likely to recommend resection than those who were below the median (95% CI: 11%-4%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs 15.0, P =0.06; V2: 7.0 vs 15.0, P =0.05). The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.

The Influence of Patient Preference on Surgeons' Treatment Recommendations in the Management of Intraductal Papillary Mucinous Neoplasms.

We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasms (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. Surgeons vary widely in management of IPMN. We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. One hundred and fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20%-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs. 5%) more likely to recommend resection than those who were below the median (95% CI: 11.34%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs. 15.0, P =0.06; V2: 7.0 vs. 15.0, P =0.05). The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey.

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies. A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies. Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites. Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Posthospital discharge venous thromboembolism prophylaxis among colorectal and hepatobiliary surgeons: A practice survey

BackgroundRecent practice guidelines recommend venous thromboembolism prophylaxis for 28 days after cancer surgery. We sought to characterize and compare awareness, agreement, adoption, and adherence to these guidelines among surgeons. MethodsWe electronically surveyed Canadian hepatobiliary surgeons registered with the Canadian Hepatopancreatobiliary Association, general and colorectal surgeons registered with the College of Physicians and Surgeons of Ontario and the Canadian Society of Colorectal Surgeons who provide colorectal cancer care with a pilot-tested questionnaire. Attitudes to relevant guideline recommendations and perceived barriers to postdischarge venous thromboembolism prophylaxis were assessed on a 5-point Likert scale. ResultsThere were 128 responses (response rate 60%, 128 of 213), including 60 general/colorectal and 68 hepatobiliary surgeons. Most surgeons were aware (122 of 128, 95%), agreed (101 of 122, 83%), adopted (78 of 101, 77%), and adhered (74 of 78, 95%) with guidelines. Preexisting venous thromboembolism-prophylaxis hospital programs, hepatobiliary surgeons, and geographical region were associated with increased likelihood of adherence. Among respondents that did not agree, insufficient evidence (median Likert: 4, interquartile range 3−5) and low incidence of venous thromboembolism (median Likert: 4, interquartile range 3−4) were cited as the strongest barriers. Surgeons who agreed but did not adopt these programs reported that the most significant barriers were “drug cost” (median Likert: 4, interquartile range 3−4) and “subcutaneous injections” (median Likert: 4, interquartile range 3−4). Surgeons that adhered additionally reported “logistical challenges of prescribing” as the greatest implementation barrier. ConclusionSurgeons who remain apprehensive about postdischarge venous thromboembolism prophylaxis cite poor evidence and cost of the medication as the major barriers. Adherence was higher among hepatobiliary surgeons and at hospitals with existing venous thromboembolism-prophylaxis programs.

Latin American hepatopancreatobiliary fellowships accreditation: Assessing desire and barriers

Presenter: Morgan Bonds MD | Virginia Mason Medical Center Background: Hepatopancreatobiliary (HPB) surgery is a challenging field, both clinically and technically. Latin America has a significant burden of HPB disease which has fostered a number of fellowships. However, despite belonging to the Americas Hepatopancreatobiliary Association (AHPBA), there are no Latin American HPB fellowship programs participating in AHPBA fellow certification through Fellowship Council program accreditation. The purpose of this study is to assess whether interest in this process exists among Latin American fellowship program directors and what barriers exist to their participation. Methods: This was a prospective mixed-methods study. Initially, a 20 item survey was constructed to assess the demographics of Latin American HPB fellowships and attitudes toward the accreditation process. The survey was validated by consensus of 2 North American and 2 Latin American HPB fellowship directors. Latin American HPB fellowship directors were identified through the International Hepatopancreatobiliary Association website or by contacting local AHPBA chapters. Surveys were administered electronically. Statistical analysis was performed on the survey responses. An interview was requested of all participants to further assess attitudes and barriers to fellowship accreditation. Interview responses were analyzed using a validated qualitative thematic network technique. Results: Nineteen Latin American fellowship program directors were identified, and 13 (68.4%) responded to the survey. All program directors were members of AHPBA. Most programs reported having 3 or more clinical fellows each year. Five (38.5%) programs had an adequate number of pancreas cases per fellow for certification, 9 (69.2%) had adequate major liver cases, and 7 (53.8%) had adequate biliary cases. Laparoscopic HPB was practiced by 69.2% of the programs. The majority of program directors were interested in AHPBA certification (10/13) and the other respondents reported neutral feelings toward the process. All participants reported that certification and accreditation would be beneficial to the fellowship program and the fellows. Interviews were conducted with 8/13 (61.5%) survey respondents. The interviews revealed there was a desire among Latin American HPB fellowship directors to pursue certification because outside critique provides structured quality improvement for their program. They also felt the fellows would benefit from the international recognition and collaboration that the North American HPB fellows experience. Benefits to HPB societies were also identified as a positive consequence of accrediting Latin American fellowships. No negative consequences were identified. The primary barriers to meeting certification requirements were financial as well as concerns regarding clinical case volumes. Conclusion: Latin American HPB fellowship program directors show a high level of interest in AHPBA certification through Fellowship Council accreditation. Several positive outcomes of participating in this process were identified and align with previous research on the benefits of accreditation. Strategies should be developed to reduce the barriers to Latin American HPB programs that seek to participate in this process.

Spanish survey on pancreatic surgery units

Background: The technical, human, scientific and assistance characteristics of the Units that attend a complex pathology are little studied and known. Material and Methods: Multi-institutional descriptive study (survey) developed jointly by the Hepatobiliopancreatic Section of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain. Results: 82 surveys were sent. 69 centres responded (84%) belonging to 16 autonomous communities. The sum of inhabitants of their own areas was 23,183,262 (50% of Spain) but as referral center they attend 95% of the population. The average number of beds per hospital was 673. The unit that performs the CP is a Hepatobiliopancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 in the centres surveyed was 1315 cephalic duodenopancreatectomies (PD), 566 distal pancreatectomies (DP) and 178 total duodenopancreatectomies (TP). The mean number per centre was: 19.1 PD, 8.2 DP and 2.6 TP. The most frequent PD technique was performed using a classic approach, with pancreatojejunal anastomosis, one loop technique, antecolic gastrojejunostomy and using two drainages. Only 7 Units perform the PD by laparoscopy (10%) and thirteen units (18%) do not perform laparoscopic distal pancreatectomy. Conclusions: This survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain, and could also serve as a starting point for prospective multicenter studies.

Hepatopancreatoduodenectomy –a controversial treatment for bile duct and gallbladder cancer from a European perspective

BackgroundHepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. MethodMembers of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. ResultsIn total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. ConclusionHPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy – an E-AHPBA multi-center study

BackgroundTreatment of bile duct injuries (BDI) during cholecystectomy depends on the severity of injury and the timing of diagnosis. Standard of care for severe BDIs is hepaticojejunostomy. The aim of this retrospective multi-center study was to assess the optimal timing for repair of BDI with hepaticojejunostomy. MethodsMembers of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients with hepaticojejunostomy after BDI from January 2000 to June 2016. Patients were stratified according to the timing of biliary reconstruction with hepaticojejunostomy: early (day 0–7), intermediate (1–6 weeks) and late (6 weeks–6 months). Primary endpoint was re-intervention >90 days after the hepaticojejunostomy and secondary endpoints were severe 90-day complications and liver-related mortality. ResultsIn total 913 patients from 48 centers were included in the analysis. In 401 patients (44%) the bile duct injury was diagnosed intraoperatively, and 126 patients (14%) suffered from concomitant vascular injury. In multivariable analysis the timing of hepaticojejunostomy had no impact on postoperative complications, the need for re-intervention after 90 days nor liver-related mortality. The rate of re-intervention more than 90 days after the hepaticojejunostomy was significantly increased in male patients but decreased in older patients. Severe co-morbidity increased the risk for liver-related mortality (HR 3.439; CI 1.37–8.65; p = 0.009). ConclusionAfter BDI occurring during cholecystectomy, the timing of biliary reconstruction with hepaticojejunostomy did not have any impact on severe postoperative complications, the need for re-intervention or liver-related mortality. Individualised treatment after iatrogenic bile duct injury is still advisable.

Opinions and use of neoadjuvant therapy for resectable, borderline resectable, and locally advanced pancreatic cancer: international survey and case-vignette study

BackgroundSeveral new treatment options have become available for pancreatic ductal adenocarcinoma (PDAC), but the support for their use for resectable, borderline resectable and locally advanced PDAC is unclear.MethodsA survey was distributed to the members of the European-African Hepato-Pancreato Biliary Association (E-AHPBA) and the pancreas group of the European Organization for Research and Treatment of Cancer (EORTC) regarding 1) definitions of local resectability, 2) indications for neoadjuvant therapy and 3) case-vignettes regarding the resectability and treatment of PDAC.ResultsIn total, 114 participants from 37 countries were registered. About 35% of respondents, each, were of the opinion that borderline resectability is defined by any venous tumor contact and venous involvement < 180° or > 180°, respectively. The majority (75.4%) of participants believed that borderline resectable PDAC has a high risk for R1 resection and that neoadjuvant therapy might increase the R0-resection rate (79.8%) and improve oncological patient selection (84.2%). Chemotherapy was regarded useful to convert locally advanced to resectable PDAC by 55.7% of respondents. In the cases with resectable, borderline resectable, and locally advanced PDAC, 10 (8.8%), 78 (68.4%), 55 (48.2%) of participants would start with chemotherapy, respectively.ConclusionsAlthough definitions for borderline resectability differ among European surgeons, there seems to be a rather strong support for preoperative chemotherapy in PDAC aiming at minimizing R1 resections while increasing resection rates.

National Survey on Pancreatic Surgery Units

IntroductionThe technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth. MethodsMulti-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain. Results82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23183262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 units performed PD laparoscopically and only 13 units did not perform laparoscopic DP. ConclusionsThis survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies.

Encuesta nacional sobre las Unidades de Cirugía Pancreática

IntroductionThe technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth. MethodsMulti-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain. Results82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23,183,262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1,315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 Units performed PD laparoscopically and only 13 units did not perform laparoscopic DP. ConclusionsThis survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies.

Sri Lanka guidelines for the management of hepatic metastases from colorectal cancer

Guidelines to manage liver metastases were developed at a meeting jointly organized by the Sri Lanka Hepato Pancreato Biliary Association (SLHPBA) and the International Hepato Pancreato Biliary Association (IHPBA). Existing evidence was used in the development of guidelines, as recommended by the AGREE II consortium. Guidelines are provided for diagnosis, pre-operative workup, multi-disciplinary team review, surgery, anaesthesia, post-operative care and follow up. Consideration was given to the limitations of facilities available in the country.

Does attending a Delphi consensus conference impact surgeon attitudes? Survey results from the Americas HepatoPancreatoBiliary Association consensus conference on small asymptomatic pancreatic neuroendocrine tumors

BackgroundManagement of asymptomatic small well-differentiated (panNET) <2 cm remains controversial. A consensus conference was held on this topic. The impact of attending the conference and participating in the audience response survey on surgeon's clinical approach to pancreatic neuroendocrine tumors was assessed. MethodsAudience members were surveyed using a smartphone real-time response system at the beginning and end of the conference. ResultsThe majority of 75 attendees underwent fellowship training, and 30% had >10 years experience as attending surgeons. Previously published consensus statements on the topic were considered insufficient to guide surgical practice by 82% of attendees, and over 96% desired additional data. After review of the data, consensus statements, and decision-making process, a significant number of participants changed their opinions regarding indications for tissue biopsy (p = 0.001), size thresholds for excision (p = 0.002), and regional lymph node dissection (p = 0.002) independent of whether a consensus was reached by the content-expert panel. ConclusionsThis represented the first Delphi process consensus on the topic, and the survey confirmed the topic as well-chosen and timely. Attendees changed opinions on management of panNET regardless of whether formal consensus was reached. Therefore, statements of consensus combined with presentation of literature and live discussion served to impact attendees’ approach to this disease.

A survey of current practices and barriers to expanding laparoscopic HPB surgery in Canada

BackgroundThe purpose of this survey was to determine the extent to which laparoscopy is used in hepatopancreatobiliary (HPB) resections in Canada, and to assess HPB surgeons' attitudes and their perceived barriers to its further adoption. MethodsUsing an electronic questionnaire, 68 Canadian Hepatopancreatobiliary Association (CHPBA) surgical members were surveyed. The questionnaire consisted of 12 questions regarding: surgeon demographics, the use and limitations of laparoscopy in their practice, and interest in increasing the use of laparoscopic techniques. ResultsThe survey response rate was 75%. Of the 51 respondents, 86% reported performing minor laparoscopic resections such as hepatic wedge resections. Only 23% of surgeons reported performing laparoscopic liver lobectomies. Eighty-two percent of respondents indicated a wish to increase the use of laparoscopy in their practice. Barriers identified included operating time constraints (61%), a lack of equipment (41%) and lack of adequate training (43%). DiscussionThis survey demonstrates that currently, most Canadian HPB surgeons use laparoscopy for minor HPB resections; however, there is a strong desire to expand the use of minimally invasive techniques amongst Canadian HPB surgeons. Training centered on addressing the limitations and barriers to the uptake of minimally invasive techniques in HPB surgery are needed.

Living legend in surgery: Professor Stig Bengmark.

The editorial board of HepatoBiliary Surgery and Nutrition (HBSN) was honored to have Prof. Stig Bengmark (Figure 1) join the editorial board as one of the founding members when HBSN was launched in 2012. As a world-renowned surgeon in the last few decades, Prof. Bengmark has made great contributions to hepatobiliary surgery and the nutritional field during his career. He has earned numerous titles and honors among which, he was the second surgeon in history to become a member of Academia Europea. Prof. Bengmark was the founder and president of the World Association of Hepato-Pancreato-Biliary (HPB) Surgery, which afterwards merged with the International Biliary Association (IBA) in 1994 to create the biggest HPB society, currently known as the World HPB Association. He is one of the three greatest European surgeons in recent history who were nick-named the “three Bs” (surnames start with B)—the Bach, Beethoven, and Brahms of hepatic surgery— Bengmark, Bismuth, and Blumgart (once coined by the renowned German HPB surgeon Michael Trede). “Stig has always had unlimited, unexpected, broad-spectrum, bright new ideas based on his unique observations that ordinary researchers would have ignored.” said Prof. Yilei Mao, the editor of HBSN, who worked with Prof. Bengmark as his PhD candidate in the early 1990s.

Concurrent Sessions Posters

This journal suppl. entitled: Special Issue: Abstracts of the Fourth Biennial Congress of the Asian-Pacific Hepato-Pancreato Biliary Association ... 2013

Concurrent Sessions Orals

This journal suppl. entitled: Special Issue: Abstracts of the Fourth Biennial Congress of the Asian-Pacific Hepato-Pancreato Biliary Association ... 2013

Advances in hepato–pancreato biliary surgery

The Americas Hepato–Pancreato Biliary Association (AHPBA) Annual 2011 Meeting provided a forum for discussion of multidisciplinary advances surrounding six tracks including the liver, biliary system, liver transplantation, pancreas, imaging and biomedical engineering and general hepato–pancreato biliary (HPB) surgical disease. The meeting and postgraduate courses attracted the largest ever attendance and participation in the AHPBA annual meeting, including field leaders and participants from across North, Central and South America who interchanged clinical and scientific knowledge, and discussed advances in technology, care and outcomes for treatment of HPB diseases. The AHPBA Foundation, established in 2010, announced progress toward support of meritorious research in HPB disease and enrichment of educational programs. HPB fellowship graduates were recognized, marking successful establishment of the AHPBA as an important body guiding HPB education and training in the USA and the Americas.

AHPBA/SSO/SSAT Consensus Conference on Resectable and Borderline Resectable Pancreatic Cancer: Rationale and Overview of the Conference

On January 24, 2008, the American Hepato-PancreatoBiliary Association convened a Consensus Conference on Resectable and Borderline Resectable Pancreatic Cancer. The conference was cosponsored by the Society of Surgical Oncology, the Society for Surgery of the Alimentary Tract, The University of Texas M. D. Anderson Cancer Center, and the Gastrointestinal Symposium Steering Committee. The goals of this conference were to define resectable and borderline resectable pancreatic cancer and to review the indications and contraindications for surgery, neoadjuvant therapy, and adjuvant therapy for these lesions. The meeting took place over 1 day and was divided into three sessions addressing (1) pretreatment assessment, (2) surgical treatment, and (3) combined-modality treatment. This issue of Annals of Surgical Oncology has three articles outlining the consensus statements, each accompanied by an editorial. The methods used in this consensus conference have been described previously. After consultation among experts from the three sponsoring societies, a group of experts was identified and invited to participate in this conference. Each expert was asked to present on a given area and to outline two or three consensus statements at the end of his or her presentation. A panel of content experts commented on the consensus statements, and then the audience was given the opportunity to comment on the consensus statements. After the symposium, three manuscripts, each summarizing one of the sessions, were written by the speakers and session cochairs. Each manuscript was then given to the corresponding session panelists, who wrote a brief editorial highlighting areas of controversy and importance and providing alternative perspectives. The consensus statements define ‘‘resectable’’ and ‘‘borderline resectable.’’ This important first step provides a starting point for discussion regarding the appropriate use of surgery, neoadjuvant therapy, and adjuvant therapy. Use of consistent definitions of resectable and borderline resectable will facilitate comparison between institutions and future published works, which currently is limited because of the variety of definitions used in the published literature dealing with pancreatic cancer. The consensus statements also highlight the acceptable methods of radiologic and endoscopic assessment of resectable and borderline resectable pancreatic tumors, the clinical settings in which preoperative biopsy is needed, and the specific indications for the selective use of laparoscopic staging. Further, the consensus statements recommend against extended lymphadenectomy, define the clinical setting in which vascular reconstruction may be necessary, and recommend that operating surgeons have facility with these techniques. There is also a call for standardized margin definitions and a description of the limited role of ‘‘palliative’’ pancreaticoduodenectomy. The consensus statements identify the clinical setting in which before-surgery systemic therapy and radiation therapy may be warranted and highlight the conflicting evidence regarding postoperative chemotherapy alone versus combined chemoradiotherapy. Finally, areas requiring further study are identified and highlighted. The conference participants and the consensus statements generated reflect the importance of ongoing collaborative multidisciplinary care of patients with pancreatic cancer. Society of Surgical Oncology 2009