Hepatopancreatobiliary Surgery Research Articles

Intermittent regional hepatic vascular inflow occlusion for laparoscopic right anterior sectionectomy

Objective To compare the efficacy and safety of intermittent regional hepatic vascular inflow occlusion with Pringle’s maneuvre for laparoscopic anterior sectionectomy. Methods From January 2014 to December 2018, 54 patients who underwent laparoscopic right anterior sectionectomy at the Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital, Soochow University were recruited into this study. The patients were 40 to 60 years old, and 27 were males and 27 females. Intermittent regional hepatic vascular inflow occlusion was carried out in 24 patients (the intermittent occlusion group). The remaining patients underwent Pringle’s maneuvre (the Pringle group). Postoperative liver function, intraoperative blood loss, intraoperative blood transfusion, operation time and postoperative complications between the two groups were compared. Results Intraoperative hemorrhage and blood transfusion of the Pringle group (534±42)ml, (2.88±0.54)U were significantly higher than the intermittent occlusion group (374±21)ml, (1.86±0.29)U (all P 0.05). Conclusion Intermittent regional hepatic vascular inflow occlusion reduced intra-operative hemorrage and hepatic impairment, and shortened hospital stay. However, it required higher operation skills and it should gradually be promoted. Key words: Hepatectomy; Laparoscopes; Inflow occlusion; Liver function

Characteristics of Subcutaneous Drainage Fluid in Patients After Hepatopancreatobiliary Surgery

The beneficial effect of subcutaneous drainage has been challenged. Here, we evaluated subcutaneous drainage fluid characteristics in patients without complications after hepatopancreatobiliary surgery. We aimed to provide useful information for addressing this issue. We included 59 patients that underwent hepatopancreatobiliary surgery for hepatic (n = 33), biliary (n = 12), and pancreatic (n = 14) disorders. We recorded the total volume of drainage liquid. We analyzed drainage fluid characteristics (biochemical test, cells, etc.) and patient demographic and clinical characteristics. Differences in characteristics were assessed among hepatic, biliary, and pancreatic surgery groups. Pearson correlation coefficient analyses were performed to assess associations between preoperative parameters and drainage volume. The median body mass index was 24.01 kg/m2. The mean blood loss and operation time were 371 ml and 406 min, respectively. Three (5.1%) patients required transfusions. The median drainage fluid volume was 37.34 ml, and the median density was 1.0217. The total numbers of white and red blood cells were 4.38*105/L and 30.5*103/L, respectively. The protein, glucose, and adenosine deaminase contents were 34.41 g/L, 1.22 mmol/L, and 103.09 U/L, respectively. The Rivalta test and lactate dehydrogenase were positive in 14 (77.8%) and 16 (88.9%) patients, respectively. All parameters were similar between the three surgical groups. Preoperative erythrocyte and hemoglobin levels were weakly positively correlated with subcutaneous drainage fluid volumes. We found a substantial amount of protein in subcutaneous drainage fluid. Removing the fluid might reduce the risks of incision fat liquefaction and infection. At minimum, subcutaneous drainage reduced the frequency of incisional dressing changes.

Variations of the celiac trunk investigated by multidetector computed tomography: Systematic review and meta-analysis with clinical correlations.

In recent years multidetector computed tomography (MDCT) has been used to investigate vascular anatomy for scientific and diagnostic purposes. These studies allow for much larger sample sizes than traditional cadaveric studies. The aim of this research was to perform a systematic review and meta-analysis on studies investigating the variations of the celiac trunk using MDCT. Major medical databases were used to find studies investigating celiac trunk anatomy using MDCT. Extracted information included demographic details, number of normal celiac trunks, and number of each variant celiac trunk. Using a random effects meta-analysis the pooled prevalence of each variation was calculated. A total of 36 studies from 14 countries and four continents were included in the meta-analysis. The total number of subjects included was 17,391. The total prevalence of variant celiac trunks was 10.85%. The different types of celiac trunk variations with their prevalences were: gastrosplenic trunk (3.46%), hepatosplenic trunk (3.88%), hepatogastric trunk (0.24%), absent celiac trunk (0.28%), celiacomesenteric trunk (0.46%), hepatosplenomesenteric trunk (0.26%), gastrosplenomesenteric trunk (0.07%), and celiacomesenteric anastomosis (0.09%). A total of 61 cases (0.19%) were either not described or not described adequately to be included in our classification. Major variations of the celiac trunk are not uncommon and should be anticipated before radiological and surgical interventions. Knowledge of celiac trunk anatomy is important in hepatopancreatobiliary surgery, transplantology, and interventional radiology.

Impact of mutant RAS on prognosis of patients after hepatic resection for colorectal cancer liver metastases

Objective To study the impact of RAS status on prognosis of patients after liver resection for colorectal cancer liver metastases (CRLM). Methods The data of 545 consecutive CRLM patients who underwent liver resection at the Hepatopancreatobiliary Surgery Department I, Peking University Cancer Hospital between January 1st, 2008 and December 31st, 2016, were retrospectively reviewed. According to the inclusion and exclusion criteria, 356 patients were eventually included into this study. There were 232 males and 124 females, with ages ranging from 21 to 83 years. The clinical and follow-up data of patients with wild-type and mutant RAS were compared. Survival was estimated by the Kaplan-Meier method, and the difference was compared by the log-rank test. Factors influencing survival of these patients were assessed by univariate and multivariate Cox regression analyses. Results There were 247 patients with wild-type RAS and 109 patients with mutant RAS, respectively. The median overall survival of patients with wild-type and mutant RAS were 74 and 30 months respectively. Compared with mutant RAS patients, wild-type RAS patients had significantly better cumulative survival and disease free survival rates (both P 5 cm (HR=1.717, 95%CI: 1.102-2.637), and mutant RAS (HR=1.836, 95%CI: 1.322-2.550) were independent risk factors for patients with colorectal cancer liver metastases after hepatic resection. Conclusion Mutant RAS was a poor prognostic factor of survival after liver resection in CRLM patients Key words: Colorectal neoplasms; Hepatectomy; Liver metastases; RAS gene

How Many Steps Per Day are Necessary to Prevent Postoperative Complications Following Hepato-Pancreato-Biliary Surgeries for Malignancy?

The current study was designed to investigate the association between the average preoperative physical activity and postoperative outcomes in patients undergoing surgeries for hepato-pancreato-biliary (HPB) malignancy. Patients who were scheduled to undergo open abdominal surgeries for HPB malignancies (major hepatectomy, pancreatoduodenectomy, or hepato-pancreatoduodenectomy) between 2016 and 2017 were included. The average steps per day were recorded by a pedometer and calculated for each patient during the preoperative waiting period. Physical activity levels were classified according to the average number of daily steps as poor (< 5000 steps/day) and good (≥ 5000 steps/day). Of the 105 eligible patients, 78 met the inclusion criteria. The median number of steps per day was 6174. There were 48 patients (62%) with good physical activity and 30 patients (38%) with poor physical activity. Patients with poor physical activity revealed a significantly higher rate of major complications with Clavien grade ≥ 3 (63% vs. 35%, p = 0.016), a higher rate of infectious complications (53% vs. 23%, p = 0.006), and a longer postoperative hospital stay (median, 30 vs. 21days, p < 0.001) compared with those with good physical activity. After a multivariate analysis, poor physical activity was identified as an independent risk factor for the development of major complications (odds ratio, 2.842, p = 0.042) and infectious complications (odds ratio, 3.844, p = 0.007). The current study demonstrated that preoperative physical activity levels are associated with the incidence of major postoperative complications following HPB surgery for malignancy.

A hepatopancreaticobiliary surgery practice at a non-university tertiary care center (NU-TCC)

Presenter: Terence Jackson MD | Methodist Richardson Medical Center Background: There is data to suggest that more graduates from Hepatopancreatobiliary (HPB) surgery fellowships go into private practice than anticipated. Fellowships do not prepare them for this environment. In a world where HPB surgery services have typically existed in large academic institutions only, we are also now seeing an increasing number of hybrid models within these institutions. We would like to present a novel way of defining the growth of an HPB practice outside the traditional academic setting. Methods: We examined the nuances of starting and developing a NU-TCC for HPB surgery and present them in a simplified fashion. Not much data is available to guide fellows and young HPB surgeons in this regard and most learn on the job. The information presented here is based on anecdotal data and experiences garnered over several years of running a successful HPB practice. Results: Upon examining the nuances of starting and growing an HPB practice in the private setting the following four pillar of a surgical service were identified – Referral base, Outpatient growth, Practice management and Inpatient growth. The minutia of practice management including finances, billing, coding and staff management, the list of services that need to be secured to provide easy and timely care for our patients in the outpatient setting were identified and detailed. The essentials needed to maintain a certified HPB service include training of nursing and operating room staff, multidisciplinary consulting services and hospitalists. To maintain growth the referral base needs to be continuously maintained and increased. Having a broad based practice, saying “Yes!!” to each problem that is presented, being available/affable/able and being timely in taking care of patients are all crucial aspects. (Image included) Conclusion: With this we hope to provide a road map for our trainees to start their own practices, clear myths and enable them with the tools to venture forth into any scenario knowing the way to succeed.

Care Fragmentation And Failure To Rescue In Readmissions Following Hepatopancreatobiliary And Gastric Oncologic Surgery: Surgical Volume At The Reamdisson Hospital Is Associated With Mortality

Presenter: David Brauer MD, MPHS | Washington University, St. Louis Background: The surgical management of hepatopancreatobiliary (HPB) and gastric malignancies regularly occurs at major referral centers and is associated with a high rate of postoperative readmissions. Prior studies have shown that care fragmentation following surgery, including readmission to a hospital other than the index surgical hospital (an ‘outside hospital’ (OSH)), is associated with worse outcomes. No prior study has examined hospital-level variables associated with outcomes following readmission in this patient population. Methods: Patients undergoing HPB or gastric oncologic surgeries were identified from select State Inpatient Databases from the Healthcare Cost and Utilization Project from 2006-2014. Follow-up occurred up to the earliest of 90 days after discharge, receipt of chemotherapy, or discharge to hospice. The primary outcome was readmission mortality, with secondary outcomes of total readmission inpatient cost and total readmission inpatient length of stay. Annual hospital surgical volume was calculated using HCUP data for oncologic and non-oncologic HPB and gastric surgeries. Additional hospital-level variables were linked using the American Hospital Association Annual Survey Database. Due to data use agreements, hospitals with less than 10 visits during the inclusion period were excluded. Kruskal-Wallis test, logistic regression, and Youden’s index were used. Results: 31,526 patients were discharged following HPB or gastric oncologic surgery. 7,536 (24%) were readmitted within 90 days to a total of 636 hospitals. 28% of readmissions (n=2,124) were to OSH. For patients readmitted to OSH, 90-day postoperative mortality was 50% higher than mortality for patients readmitted to the index surgical hospital (8.0% vs 5.4%; OR 1.5, 95% CI 1.2 – 1.9). Looking solely at the hospital the patient was readmitted to, 188 hospitals had 10 or more readmissions during the inclusion period, accounting for 75% of all readmissions. Hospital size, measured by bed count, was not associated with readmission mortality, cost, or length of stay. However, a hospital's annual volume of HPB and gastric surgeries was associated with readmission mortality: patients were 37% more likely to die during their readmission if they were readmitted to a hospital with less than 100 combined annual HPB and gastric procedures (6.4% vs. 4.7%; OR 1.37, 95% CI 1.1 – 1.7). When comparing large volume (100 or more surgeries annually) and small volume hospitals, total 90-day readmission inpatient cost was 23% higher at large volume hospitals (median $15,000 vs $12,000; p<0.01). This could be a reflection of the costs of achieving rescue through surgical intervention, as significantly more surgeries were performed at larger hospitals (8.3% vs 5.3%, p<0.01). Total 90-day readmission length of stay was no different between the groups (median 6 days; p=0.82). Conclusion: Alongside sound clinical judgement, this data should be used to inform the decision-making process for where a patient should be readmitted following HPB and gastric surgery. To promote successful rescue after complications and readmission following surgery, efforts should be made to reduce care fragmentation and to direct readmissions to hospitals performing 100 or more annual HPB and gastric surgeries.

Setting Mastery Standards In Hepato-Pancreato-Biliary Surgical Ultrasound

Presenter: Ellen Hagopian MD | Hackensack Meridian School of Medicine at Seton Hall University Background: A standardized curriculum in Hepato-Pancreato-Biliary (HPB) ultrasound (US), grounded in a Mastery skills framework, was developed in 2014 for HPB fellows in Americas Hepato-Pancreato-Biliary Association-Fellowship Council accredited programs. We previously developed two assessment tools for laparoscopic (LAPUS) and open US (IOUS) in HPB Surgery, each of which contains 14 items (skills) and a global performance item, using the O-Score entrustment scale, in which 1=“I had to do it”, 2= “I had to talk them through”, 3= “I had to prompt them from time to time”; 4=”I needed to be in the room just in case” and 5=“I did not need to be there.” A formative skills practicum utilizing these tools is offered annually to HPB fellows approaching graduation to provide individual performance feedback. The aim of this work was to establish Mastery standards for our two assessments, and to apply those standards to a sample of graduating fellows, providing consequential validity evidence within Messick’s framework. Methods: Standard setting: Faculty with expertise in HPB Surgery and HPB US from the membership of Americas Hepato-Pancreato-Biliary Association participated in standard setting exercises. Faculty were asked to rate each item and global US performance for both IOUS and LAPUS: What is the probability that a graduating HPB fellow, who is well-prepared for independent practice, is able to perform this skill? Please rate as a percentage. Item-level Mastery Angoff cut scores were determined as the mean rating across all judges. The overall Mastery Angoff cut score was determined as the mean cut score across all items. Mastery Angoff cut scores were converted to the 5-point entrustment scale (i.e., cut score*5). ellow performance: At the 2019 annual US skills practicum, fellow performances were evaluated using the assessment tools and the Mastery Angoff standards. This study met criteria for exemption by the University of Illinois-Chicago Institutional Review Board (2019-0265). Results: A total of 15 faculty were invited to participate, 12 of whom returned the questionnaire. To account for outliers, the highest and lowest faculty ratings were removed, thus standards were based on 10 faculty experts. For IOUS, the overall mean cut score across all items was 91.48% (SD 0.04) and for LAPUS, the overall mean cut score across all items was 89.96% (SD 0.04). The mean global IOUS performance cut score was 96.00% (SD 0.07), whereas the mean global LAPUS performance cut score was 87.80% (SD 0.14). (See Table) A total of 13 of 18 fellows who participated in the 2019 US skills practicum agreed to have their de-identified data evaluated. Overall, fellows did not meet standards in 11/14 IOUS items and in 13/14 LAPUS items. The mean global performance entrustment score was 3.62 (SD 0.65, range 2-4) in IOUS and 3.62 (SD 0.77, range 2-5) in LAPUS, which did not meet the entrustment standards of 4.80 and 4.39, respectively. Conclusion: AHPBA-FC HPB fellows prior to graduation are not meeting Mastery Standards for HPB US performance determined by a panel of expert faculty. A change in educational policy or curriculum may be needed to improve fellow performance.

Factors Affecting Stress Levels in Hospitalized Patients after Implementation of Fast.track Protocol in Hepatopancreatobiliary Surgery

Objective:The objective was to explore factors affecting stress levels in hospitalized patients after implementation of fast-track (FT) protocol in hepatopancreatobiliary surgery.Methods:This was a prospective cross-sectional study, where 90 patients were included. Exploration of environmental postoperative stress levels was conducted by serum adrenocorticotropic hormone and cortisol levels, the Intensive Care Unit Environmental Stressor Scale, and three self-reported Numeric Analog Scale questions, with regard to emotional/stress level, specifically “How sad do you feel right now?” “How stressed do you feel right now?” and “How optimistic do you feel right now, about the future?” at 3 time points: (T1) Before surgery, (T2) the day of surgery, and (T3) the 3rd postoperative day. The trial profile is conformed according to the CONSORT guidelines. Statistical analysis was carried out by SPSS software version 22 (IBM SPSS software, Chicago, Illinois, USA) at a significance level of 0.05.Results:Serum cortisol T2 levels were positively correlated with the day of removal the drainage tube (rho = 0.235, P = 0.027). Furthermore, serum cortisol T3 levels were positively correlated with age and body mass index and negatively with the day of drainage tube removal (rho = 0.231, P = 0.028, rho = 0.235, P = 0.026, and rho = −0.279, P = 0.008, respectively).Conclusions:The findings of this study highlight that after evaluation of stress levels; nurses could interfere and reduce stress levels, knowing the factors which cause the increased stress levels, after the implementation of FT protocols.

Patient-Specific Opioid Volume Calculations Reduce Discharge Prescriptions After Hepato-Pancreato-Biliary Surgery

Presenter: Ryan Day MD | The University of Texas MD Anderson Cancer Center Background: Patients who undergo hepato-pancreato-biliary (HPB) surgery and receive discharge opioid prescriptions beyond their actual needs are at risk for persistent use and diversion to family and community. In the context of the United States opioid epidemic, this study’s aim was to quantify and compare HPB surgery discharge prescribing patterns balanced against 30-day refill rates to compare a novel standardized prescription calculation vs. usual care. Methods: This is a non-randomized retrospective cohort study of consecutive HPB operations at a Comprehensive Cancer Center (September 2018 – June 2019). These dates were based on departmental opioid reduction education initiatives in August 2018, which included the introduction of a novel patient-specific “5x multiplier” concept, wherein patients received 5-times their actual opioid use in the last 24 hours of their inpatient stay. This concept was adopted by a voluntary proportion of our individual HPB providers. Thus, there were two prescribing patterns: a usual care group which typically received a round number of opioid pills based on provider preference vs. the “5x multiplier” calculation. Refills were abstracted from the electronic medical record. Actual opioid doses (oral morphine equivalents, OME) in the last 24 hours of inpatient stay and discharge prescriptions were recorded and converted with institution-approved conversion tables (e.g. one 50-mg tramadol equals 5mg OME, and one 5-mg oxycodone equals 7.5mg OME). Descriptive statistics were used to summarize and compare the usual care and 5x-multiplier cohorts. Results: There were 278 consecutive HPB operations for 276 unique patients. These included 152 (55%) liver and 126 (45%) pancreas resections. Of 278 operations, 125 (45%) were in the 5x-multiplier cohort. Both groups had similar demographic and peri-operative characteristics including length of stay and use of non-opioid medication bundles. The median OME consumed during the last 24 hours before discharge was 10mg (range 0-360mg; IQR 4-20mg) in the total 278 index hospitalizations. The median last 24-hr OME was 10mg (range 0-200mg, interquartile range [IQR] 5-20mg) for usual care vs. 10mg (range 0-360mg, IQR 0-20mg) for the 5x-multiplier. The median discharge prescription OME was 3-times higher in the usual care group (150mg, range 0-3,150mg, IQR 100-150mg) vs. 50mg (0-1,800mg, IQR 0-100mg, p<0.001). Despite this reduction, rates of opioid refills within 30 days were similar for the usual care and 5x-multiplier groups (20.9% vs. 16.8%, p=0.385). Pancreas surgery patients were more likely to receive a postoperative 30-day refill compared to liver surgery patients (32/126, 25%, vs. 21/152, 14%, p<0.001). Among all patients, 69 (25%) patients used zero OME in the last 24 hours. However, 31/69 (45%), were still discharged with opioids. Using the 5x multiplier for the 153 usual care discharge prescriptions would have hypothetically saved 15,761mg OME, or 3,152 pills of 50-mg tramadol over this 10-month study period. Conclusion: In patients undergoing HPB operations, a simple, reproducible strategy using a patient-specific 5x-multiplier of actual last 24-hour inpatient opioid consumption reduced median discharge opioid prescriptions by 67% over usual care, with no measurable increase in refills. The next step will be a department-wide prospective quality improvement project implementing this novel 5x multiplier.

HPB fellowship graduates: where do they stand today? Results from a survey study

Presenter: Terence Jackson MD | Methodist Richardson Medical Center Background: Standardized HepatoPancreatoBiliary (HPB) Surgery fellowship certification process was initiated by the AHPBA and Fellowship council in 2010. Several classes of fellows have since graduated from HPB, SSO/HPB and ASTS/HPB programs but there is a information on their career outcomes. We seek to offer long term data on the careers of HPB fellowship graduates. Methods: A 26 question survey was distributed among graduates of HPB certificate programs for the last 10 years, for responses in an anonymous fashion. We generated descriptive statistics from the responses. Results: The respondents were 82% male and evenly distributed in terms of graduation years between 2010-2019; 58% graduated 4 years or less ago. 49% of fellows had completed a prior fellowship before starting the HPB fellowship. 71% of respondents held only 1 job, 25% held 2 jobs after graduation from fellowship. 40% had been at their current job for 4 years or more. “Not enough HPB”, “more dedicated HPB practice”, “better opportunity”, moving for “family/location” and “lack of support” were the most common reasons for moving from (in descending order). 56% of graduates desired an academic practice and 33% wanted a mixed practice after fellowship; 53% ended up in academic jobs and 24% in mixed jobs. 22% of fellowship ended up in private practice jobs compared to 11% who wished for such a set up. 31% of respondents stated that their practice was >50% HPB, 29% had a Surgical oncology/HPB practice while 33% had a case mix of at least 50% general surgery. 65% of respondents in the first three years of practice performed >40 HPB cases per year and 71% of respondents with 4 or greater years of practice performed >40 HPB cases per year. Conclusion: This anonymous survey helps shed light on the early formative years in practice of HPB fellowship graduates. With this preliminary data we can clearly see that almost twice the number of graduates end up in private practice as compared to expected. Non university/academic practices are more common than anticipated. Most graduates stay at their first job for at least 4 years. Even though most graduates performed >40 HPB cases per year even in their first 3 years of practice, general surgery form a significant part the practice for most graduates.

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.

Whipple's Whipples: How insulinomas changed the course of hepatopancreatobiliary surgery

Whipple's Whipples: How insulinomas changed the course of hepatopancreatobiliary surgery

The successful management of Thirty-six hepatopancreatobiliary surgeries under the intensive protective arrangements during the COVID-19 pandemic.

Background:During the pandemic of COVID-19, the overwhelm of infected patients created an exponential surge for ICU and ward beds. As a result, a major proportion of elective surgeries was postponed. However, various emergency and urgent procedures were allowed. Due to the mortality complications of hepatopancreatobiliary issues, we decided to afford urgent procedures under intensive protective arrangements.Method and results:In our ward (liver transplant), 4 ICU beds and 16 ward beds were allocated to non-COVID-19 patients. A total of 36 hepatopancreatobiliary procedures were managed for one month. All the surgeries were afforded under personal protective equipment and other intensive protective arrangements for personnel and patients. During 6 weeks following the surgery, all patients were followed up through telemedicine and no new case of COVID-19 was detected.Conclusion:In general, it appears that intensive protections could significantly reduce the number of COVID-19 incidence among patients with co-morbidities who undergo invasive procedures. (www.actabiomedica.it)

Myosteatosis is associated with poor physical fitness in patients undergoing hepatopancreatobiliary surgery

Background: Body composition assessment, measured using single computed tomography (CT) slide at L3 level, and aerobic physical fitness, objectively measured using cardiopulmonary exercise testing (CPET), are each independently used for perioperative risk assessment. Both sarcopenia (i.e. low skeletal muscle mass), myosteatosis (i.e. low skeletal muscle radiation attenuation) and impaired objectively measured aerobic fitness (reduced oxygen uptake) have been associated with poor post-operative outcomes and survival in various cancer types. However, the association between CT body composition and physical fitness has not been explored. In this study, we assessed the association of CT body composition with selected CPET variables in patients undergoing hepatobiliary and pancreas surgery. Methods: A pragmatic prospective cohort of 123 patients undergoing hepatobiliary and pancreas surgery were recruited. All patients underwent preoperative CPET. Preoperative CT-scans were analysed using a single CT-slice at L3 level. Multivariate linear regression was used to test the association between CPET variables and body composition. Main outcomes were oxygen uptake at anaerobic threshold (VO2 at AT), oxygen uptake at peak exercise (VO2 peak), skeletal muscle mass and skeletal muscle radiation attenuation (SM-RA). Results: One-hundred-and-thirteen patients were included. Of the CT-body composition variables, SM-RA had the strongest correlation with VO2 peak (r=0.57, p<0.001) and VO2 at AT (r=0.45, p<0.001) while skeletal muscle mass was only weakly associated with VO2 peak (r=0.24, p<0.010). In multivariate analysis, only SM-RA was associated with VO2 Peak (B=0.25, 95%-CI 0.15-0.34, p<0.001, R2=0.42) and VO2 at AT (B=0.13, 95%-CI 0.06-0.18, p<0.001, R2=0.26). Conclusion: There is a positive association between preoperative CT SM-RA and preoperative physical fitness (VO2 at AT and at Peak). This study demonstrates that myosteatosis, and not sarcopenia, is associated with reduced aerobic physical fitness. Combining both myosteatosis and physical fitness variables may provide additive risk stratification accuracy and guide interventions during the perioperative period.

Prognostic value of positive surgical margins after resection of cholangiocarcinoma. Experience at a high-volume hospital center specializing in hepatopancreatobiliary surgery

Introduction and aimsCholangiocarcinoma accounts for 3% of gastrointestinal tumors and is the second most frequent hepatic neoplasia after hepatocellular carcinoma. The primary aim was to evaluate the median disease-free period and survival in patients with cholangiocarcinoma diagnosis through the comparison of R0 and R1 resection margins. Materials and methodsA retrospective analysis was conducted on 36 patients that underwent some type of surgical resection due to cholangiocarcinoma diagnosis, within the time frame of 2000-2017, at a center specializing in hepatopancreatobiliary surgery. Population, preoperative, and oncologic variables were included. The IBM Statistical Package for the Social Sciences for Mac, version 16.0, software (IBM SPSS Inc., Chicago, IL, USA) was employed. ResultsThirty-one patients underwent hepatectomy, the Whipple procedure, or bypass surgery, depending on tumor location. The statistical significance of survival between patients with positive margins and those with negative margins was evaluated through the Mann-Whitney U test, with a P<.05 as the reference value. No statistically significant difference was found. The overall morbidity rate was 58.06% (n=18) and the mortality rate was 12.9% (n=4). ConclusionsNo statistically significant difference in relation to the incidence of disease recurrence or general survival resulted from the comparison of microscopically positive surgical margins (R1) and negative surgical margins (R0). There was also no correlation between preoperative CA 19-9 levels and disease prognosis.

Hepatopancreatobiliary Surgery: the Role of Clinical Resources and Variation in Performance of Hospitals Located in “Distressed” Communities

IntroductionThe USA has one of the largest known income-based health disparities, with low-income adults being up to five times more likely to report being in poor health. We evaluated the association of hospital zip-code-based distressed communities index (DCI) with post-surgical outcomes following hepatopancreatobiliary (HPB) surgery. MethodsAdults undergoing HPB surgery were identified in the National Inpatient Sample. The association between hospital socioeconomic distress and outcomes including complications, mortality, failure to rescue (FTR), and never events were compared between high-distress facilities (HDF) and low-distress facilities (LDF). ResultsA total of 11,119 (37.8%) patients underwent an operation at an HDF. Patients treated at HDF were younger (18–39 years, HDF: n = 1261, 11.3% vs. LDF: n = 966, 9.0%; p < 0.001), Black/Hispanic (HDF: n = 2060, 18.5% vs. LDF: n = 1440, 11.4%; p < 0.001) and in the lowest income quartile (HDF: n = 2825, 25.4% vs. LDF: n = 1116, 10.8%; p < 0.001). While complications were comparable at HDF versus LDF (HDF: n = 2483, 22.3% vs. LDF: n = 2370, 22.0%; p = 0.28), patients treated at HDF had higher odds of in-hospital mortality (OR, 1.31; 95% CI, 1.07–1.59), FTR (OR, 1.24; 95% CI, 1.02–1.52), and a never event (OR, 1.76; 95% CI, 1.29–2.39; all p < 0.001). Hospitals having advanced internal medicine services had reduced odds of mortality (OR, 0.61; 95% CI, 0.47–0.80) whereas high nurse-to-patient ratio was associated with reduced odds of a complication (OR, 0.89; 95% CI, 0.81–0.98). ConclusionApproximately 40% of patients were admitted to HDF. These patients were more likely to be Black/Hispanic and underinsured. Perioperative outcomes were worse at HDF following HPB surgery.

Female Authorship in Hepatopancreatobiliary Surgery

Female Authorship in Hepatopancreatobiliary Surgery

Complex hepato-pancreato-biliary caseload during general surgery residency training: are we adequately training the next generation?

BackgroundInformation on procedure volume of graduating chief residents (GCRs) for hepato-pancreato-biliary(HPB) surgical procedures may inform assessments of resident training. This study sought to characterize trends in operative volumes over a 19-year period to define the degree to which general surgery residents gain exposure to HPB procedures during training. MethodsThe ACGME was queried for all HPB operations performed by GCR between 2000-2018. Total procedures as well as means and fold change was calculated and reported for each year. ResultsBetween 2000–2018, the number of general surgery residency programs varied between 240 and 254. A total of 411,383 HPB procedures (36.2% liver, 42.8% pancreas, 21% complex biliary) were performed by 22,229 GCR. Each year of the study, GCR had similar mean number total procedures:liver 7.4, pancreas 8.7, and complex biliary 4.4. For liver procedures there was no difference in the fold change over time, however for pancreas there was an increase in the fold change from 2.25 to 3.25. ConclusionMost GCRs are graduating with a low number of HPB procedures and trends suggesting a decrease in the mean number of procedures per GCR and an increasing variability among residents.

Combined transversus abdominis plane and rectus sheath catheters for postoperative analgesia following major hepatopancreatobiliary surgery.

Combined transversus abdominis plane and rectus sheath catheters for postoperative analgesia following major hepatopancreatobiliary surgery.