Hepatopancreatobiliary Research Articles

Video-Based Skill Assessment Does Not Predict Postoperative Outcomes in Robotic Upper Gastrointestinal (UGI) and Hepatopancreatobiliary (HPB) Surgery

Favazza, Nicholas James; Rubinov, Yossef BA; Benjamin, Alexis V BS; Shanja-Grabarz, Xhesika MD; Deutsch, Gary MD, FACS Author Information

Americas Hepato-Pancreato-Biliary Association HPB Ultrasound and Advanced Technology post-graduate course: Overview and review

BackgroundAmericas Hepato-Pancreato-Biliary Association (AHPBA) established the Hepato-Pancreato-Biliary (HPB) ultrasound (US) and Advanced Technology Post-Graduate Course in 2012 in response to a perceived gap in training and practice. MethodsThe HPB US and Advanced Technology Post-Graduate Course consists of both didactic and hands-on skills sessions. The didactic sessions are divided into foundational, organ-focused, and application content. Hands-on sessions are constructed to immediately practice skills in the simulation setting which were taught during the didactic sessions. Course participant demographic data (practice location and practice type) and participant evaluations were reported. ResultsSince the first course in 2012, 298 participants have taken the post-graduate course. Most participants reported the content quality, delivery effectiveness, and practice relevance to be either excellent or above average (93.6 %, 91.1 %, 93.6 %, respectively). Participants' motivations to take the course included to enhance skills, knowledge, to incorporate US into practice, or to obtain formal training or qualification/certification, or to teach. ConclusionThe HPB US and Advanced Technology Post-Graduate Course has filled a gap in HPB US training for practicing HPB surgeons. The annual course has been well-received by participants (Kirkpatrick Level 1 Program Evaluation) and will continue to fill the gap in training in operative US for the HPB surgeon. Key messageAmericas Hepato-Pancreato-Biliary Association established the HPB Ultrasound and Advanced Technology Post-Graduate Course in 2012. The Course has been well-received by participants and will continue to address a gap in surgical HPB training.

Outcomes of National Survey of the Practice of Hepatocellular Carcinoma Surveillance.

HCC has significantly improved outcomes when detected early. Guidelines recommend biannual surveillance with ultrasound (US) and/or AFP in at-risk individuals. This survey aimed to describe HCC surveillance adherence/practices amongst the NHS hospitals in the UK. An electronic survey was sent to 79 NHS hospitals via the British Association for the Study of the Liver distribution list. The responses were captured from July 2021 to January 2022. Centres were divided into hepato-pancreato-biliary (HPB) and non-HPB centres, depending on whether the hospital undertakes major liver surgeries. A total of 39 (49.3%) centres responded: 15 HPB and 24 non-HPB centres from across the UK. HCC surveillance eligibility criteria were universally applied, but heterogeneous approaches occur outside these criteria. Eighty per cent of patients undergoing surveillance were estimated to have cirrhosis. Eighty-five per cent of centres do 6-monthly US and AFP requested by clinicians and liver clinical nurse specialists. Compliance was estimated at 80% but not routinely audited. In most centres, general sonographers and/or radiologists perform surveillance US scans without a standard reporting template, although structured reporting was viewed as desirable by the majority. Poor views on US are approached heterogeneously, with patients variably offered ongoing US, CT, or MRI with different protocols. Most responding NHS hospitals follow 6-monthly HCC surveillance guidance. Data recording is variable, with limited routine data collection regarding compliance, yield, and quality. Surveillance US is mostly performed by non-HPB specialists without standardised reporting. There is an inconsistent approach to poor views with US surveillance. Even in a universal healthcare system such as NHS, which is free at the point of care, delivery of HCC surveillance has not improved over the last decade and remains variable.

Total portal vein replacement with peritoneal interposition graft during Whipple’s procedure for extrahepatic cholangiocarcinoma: a technical report

BackgroundAggressive surgical resection in locally advanced hepatopancreatobiliary (HPB) malignancies is frequently advocated as the only potentially curative treatment. In recent years, advances in chemotherapy regimens and surgical techniques have led to improved oncologic outcomes and overall survival, by increasing the rates of radical (R0) resections. Vascular resections are increasingly reported to further increase disease clearance rates. Within this perspective, the issue of vascular reconstruction has raised growing interest, drawing particular attention to vascular substitutes and surgical techniques for reconstruction.Case presentationA case of extrahepatic cholangiocarcinoma with high clinical suspicion of vascular infiltration of the portal trunk at preoperative assessment is reported. An autologous interposition graft, harvested from diaphragmatic peritoneum, was chosen as a vascular substitute leading to successful portal trunk reconstruction and overcoming all possible drawbacks associated with cadaveric and artificial grafts reconstructions.ConclusionThis solution was strategic to ensure complete oncologic clearance averting the risk of positive margins (R1) at final pathology.

Two-Week Wait Gastrointestinal (GI) Cancer Pathway: A Single Tertiary Centre Experience During the COVID-19 Pandemic.

This article investigated the impact of COVID-19 on the two-week wait referral pathway at the University Hospitals of Leicester NHS Trust. The conversion rate of these referrals was also explored as an indicator of the appropriateness of referrals from primary care. Two-week wait referrals to the Cancer Centre of the University Hospitals of Leicester NHS Trust from 2018 to 2020 were collected for upper gastrointestinal (UGI), lower gastrointestinal (LGI), and hepato-pancreato-biliary (HPB) surgery. The confirmed cancer cases out of these referrals were also recorded. Additionally, the outcomes of the multidisciplinary team (MDT) meetings for all patients discussed in June 2018, 2019, and 2020 were collected, and their staging and treatment data were examined. The number of two-week referrals decreased in 2020 compared to the previous two years across the three specialities. This was more pronounced in April, with a reduction of over 50%. The conversion rate of these referrals increased in 2020 compared to 2018 and 2019 among all three specialities. The increase in conversion rate was statistically significant for LGI referrals (2018 vs 2020 p = 0.0056; 2019 vs 2020 p = 0.0005). There was no significant difference in the MDT outcome across the three specialities. Two-week wait remains a cornerstone pathway in the management of patients with suspected cancer in the National Health Service. The COVID-19 pandemic appeared to have reduced inappropriate referrals, as evidenced by the increased conversion rate. This did not appear to negatively impact tumour staging and outcomes for those patients who were referred on the pathway.

Global survey on the surgical management of patients affected by colorectal cancer with synchronous liver metastases: impact of surgical specialty and geographic region

BackgroundConsensus on the best surgical strategy for the management of synchronous colorectal liver metastases (sCRLM) has not been achieved. This study aimed to assess the attitudes of surgeons involved in the treatment of sCRLM.MethodsSurveys designed for colorectal, hepato-pancreato-biliary (HPB), and general surgeons were disseminated through representative societies. Subgroup analyses were performed to compare responses between specialties and continents.ResultsOverall, 270 surgeons (57 colorectal, 100 HPB and 113 general surgeons) responded. Specialist surgeons more frequently utilized minimally invasive surgery (MIS) than general surgeons for colon (94.8% vs. 71.7%, p < 0.001), rectal (91.2% vs. 64.6%, p < 0.001), and liver resections (53% vs. 34.5%, p = 0.005). In patients with an asymptomatic primary, the liver-first two-stage approach was preferred in most respondents’ centres (59.3%), while the colorectal-first approach was preferred in Oceania (83.3%) and Asia (63.4%). A substantial proportion of the respondents (72.6%) had personal experience with minimally invasive simultaneous resections, and an expanding role for this procedure was foreseen (92.6%), while more evidence was desired (89.6%). Respondents were more reluctant to combine a hepatectomy with low anterior (76.3%) and abdominoperineal resections (73.3%), compared to right (94.4%) and left hemicolectomies (90.7%). Colorectal surgeons were less inclined to combine right or left hemicolectomies with a major hepatectomy than HPB and general surgeons (right: 22.8% vs. 50% and 44.2%, p = 0.008; left: 14% vs. 34% and 35.4%, p = 0.002, respectively).ConclusionThe clinical practices and viewpoints on the management of sCRLM differ between continents, and between and within surgical specialties. However, there appears to be consensus on a growing role for MIS and a need for evidence-based input.Graphical abstract

Role of the Pfannenstiel Incision in Robotic Hepato-Pancreato-Biliary Surgery

Studies remain limited on the role of the Pfannenstiel incision in minimally invasive hepato-pancreato-biliary (HPB) surgery, especially robotic surgery. The role of various extraction sites in robotic HPB surgery should be understood. Herein, we describe the surgical techniques, outcomes, advantages, and disadvantages of the Pfannenstiel incision in robotic pancreatic surgery. Seventy patients underwent robotic pancreatectomy at our institution between September 2020 and October 2022. The Pfannenstiel incision was used for specimen retrieval in 55 patients. Advantages of the Pfannenstiel incision include less pain, cosmetic benefits, and a lower incidence of complications. Moreover, the specimen could be removed using the robotic system docked. However, all complex reconstructions should be performed intra-abdominally during robotic pancreatoduodenectomies. The incidence of mortality and postoperative pancreatic fistula (grade B) was 0% and 9.1%, respectively. During the median follow-up (11.2 months) after surgery, complications at the Pfannenstiel incision site included surgical site infection (n = 1, 1.8%) and incisional hernia (n = 1, 1.8%). The Pfannenstiel incision can be a useful option for specimen retrieval in minimally invasive HPB surgery, according to the surgeon's preferences and the patient's condition.

Protocol for the CoNoR Study: A prospective multi-step study of the potential added benefit of two novel assessment tools in colorectal liver metastases technical resectability decision-making

IntroductionLiver resection is the only curative treatment for colorectal liver metastases (CLM). Resectability decision-making is therefore a key determinant of outcomes. Wide variation has been demonstrated in resectability decision-making, despite...

Measures to Achieve Quality in Minimally Invasive Hepato-Pancreato-Biliary (HPB) Surgery: A Perspective From a Low-Volume Country.

Measures to Achieve Quality in Minimally Invasive Hepato-Pancreato-Biliary (HPB) Surgery: A Perspective From a Low-Volume Country.

Impact of Dietary Counseling on Health-Related Quality of Life in Patients with Cancer Awaiting Hepato-Pancreato-Biliary Surgery

We examined the effectiveness of dietary counseling performed within a trimodal prehabilitation study for patients with cancer awaiting hepato-pancreato-biliary (HPB) surgery. Additionally, we explored relationships between nutritional status and health-related quality of life (HRQoL). The dietary intervention aimed to achieve a protein intake of 1.5 g/kg/day and reduce nutrition-impact symptoms. Patients received dietary counseling 4 weeks prior to surgery (prehabilitation group); the rehabilitation group just before surgery. We used 3-day food journals to calculate protein intake and the abridged Patient-generated Subjective Global Assessment questionnaire (aPG-SGA) to determine nutritional status. We utilized the Functional Assessment of Cancer Therapy-General questionnaire to measure HRQoL. Sixty-one patients participated in the study (30 = prehabilitation). Dietary counseling achieved a significant increase in preoperative protein intake (+0.3 ± 0.1 g/kg/day, P = 0.007), with no change in the rehabilitation group. Dietary counseling did not mitigate a significant increase in aPG-SGA postoperatively (prehabilitation: +5.8 ± 1.0; rehabilitation: +3.3 ± 1.0; P < 0.05). aPG-SGA was predictive of HRQoL (β = –1.77, P < 0.0001). HRQoL remained unchanged in both groups over the study period. Dietary counseling within a HPB prehabilitation program improves preoperative protein intake, but not aPG-SGA, which is predictive of HRQoL. Future studies should examine whether specialized medical management of nutrition-impact symptoms would improve HRQoL outcomes within a prehabilitation model.

Advantages of Total Bilirubin for Predicting Malignant Obstructive Jaundice, A Combination of the Pandemic Era and Limited Resources Settings

BACKGROUND: Hepatopancreatobiliary (HPB) cancer incidence and mortality are increasing worldwide. An initial diagnostic predictor is needed for recommending further diagnostic modalities, referral, and curative or palliative decisions. There were no studies conducted in area with limited accessibility setting of the COVID-19 pandemic, coupled with limited human resources and facilities. AIM: We aimed to investigate the advantages of total bilirubin for predicting malignant obstructive jaundice, a combination of the pandemic era and limited resources settings. METHODS: Data from all cholestasis jaundice patients at M. Djamil Hospital in Pandemic COVID-19 period from July 2020 to May 2022 were retrospectively collected. The data included demographics, bilirubin fraction results, and final diagnosis. Bivariate analysis for obtain demographic risk factor, and Receiver Operating Characteristics (ROC) analysis for getting bilirubin value. RESULTS: Of a total 132 patients included, 35.6% were malignant obstructive jaundice, and Pancreatic adeno ca was the most malignant etiology (34.4%). Bivariate analysis showed a significant correlation between age and malignant etiology (p = 0,024). Direct and total Bilirubin reach the same level of Area Under Curve (AUC). Total bilirubin at the cutoff point level of 10.7 mg/dl had the most optimal results on all elements of ROC output, AUC 0.88, sensitivity 76.6%, specificity 90.1%, +LR 8.14, and -LR 0.26. CONCLUSION: The bilirubin fraction is a good initial indicator for differentiating benign and malignant etiology (AUC 0.8–0.9) in pandemic era and resource-limited areas to improve diagnostic effectiveness and reduce referral duration.

Epidemiological Study of Hepatopancreatobiliary Sarcoma in Iran, 2010 - 2014

Background: Hepatopancreatobiliary (HPB) malignancies are a relatively rare but important type of cancer with usually poor prognosis. Prompt diagnosis and treatment are crucial to improving the patient’s outcome. For this issue, acknowledgment of epidemiological characteristics is helpful. Objectives: In this study, the epidemiological characteristics of cases with HPB sarcoma among Iranian patients were assessed. Methods: In this epidemiological study, 133 consecutive cases with HPB sarcoma in Iran from 2010 to 2014 were evaluated, including gallbladder, pancreas, hepatic, pancreatic body and head, and other biliary tumors. Results: Nine gallbladder sarcoma cases were reported between 2010 and 2014, accounting for 6.7% of all HPB sarcoma cases, and leiomyosarcoma was the most common. A total of 16 patients of pancreatic origin were reported during this period, with the highest rate of 6 cases in 2011; in this sarcoma category, malignant type spindle cell tumor was the most common type accounting for 12.5% of all cases. Ninety-five cases of liver sarcomas were reported generally. Non-specified and desmoplastic small round cell tumors were the most common types. Five cases of pancreatic head sarcomas were reported during 2010 - 2013. There was no predominant tumor type. Five cases of pancreatic head sarcoma were reported during 2010 - 2013. There was no dominant tumor type. About the other biliary tract sites, six patients were reported. Gastrointestinal stromal sarcoma was the most common type. Conclusions: Hepatopancreatobiliary sarcoma in the Iranian population generally has diverse types, and there are different patterns according to the age and sex distribution in patients according to the initial location of the tumor and also their pathological subtypes.

Canadian coaching program leads to successful transition from open to laparoscopic HPB surgery

Background: While laparoscopic techniques for Hepatopancreatobiliary (HPB) surgery emerged in the 1990s, the adoption of minimally invasive surgery (MIS) in this field has been slow. MIS HPB procedures can be technically challenging and associated with learning curves. Surgical coaching is a growing concept in the field of continuous professional development. We discuss a unique, interactive coaching program aimed for practicing HPB surgeons who wished to introduce advanced MIS skills. We aim to explore the perception of coaching among these surgeons, to assess surgeons’ experience in the coaching program, and to explore the role of coaching in the uptake of MIS in the field of HPB.

Cost analysis of laparoscopic versus open hepatobiliary surgery: A Canadian single-center experience

Background: In general, Minimally Invasive Surgery (MIS) has been associated with fewer postoperative complications, shorter hospital stays, decreased blood loss, better postoperative pain control, and lower readmission rates compared to open surgery. However, the uptake of laparoscopic approaches in hepato-pancreato-biliary (HPB) surgery has been slower compared to other areas of general surgery due to higher case complexity and bleeding risk, leading to concerns regarding safety and effectiveness of these approaches. Moreover, there is concern that minimal access approaches might increase complication rates in HPB surgery given the overall case complexity compounded by the effects of an MIS approach. Our center has increasingly applied the laparoscopic approach to HPB surgery, and have noted at least anecdotally improved length of stay and seemingly improved patient outcomes. Here we present the financial impact of this approach through the analysis of cost data in our initial experience with the adoption of the MIS approach to HPB cases.

System for the safe deployment of minimally invasive pancreaticobiliary surgery in Japan

The Japanese healthcare system is characterized by universal coverage and free access. It is an excellent social system that allows everyone to receive advanced medical care at a low cost. Minimally invasive hepato-pancreato-biliary (HPB) surgery in Japan is now covered by insurance. However, after experiencing a series of serious medical accidents, Japan’s government requested a more advanced system to safely promote highly advanced surgery including laparoscopic HBP surgery. As a practical measure, the academic societies of HPB surgery established a new prospective registration system for all cases of minimally invasive HPB for highly advanced hepatobiliary and pancreatic surgery while utilizing the existing technical certification system. Under these systems, hepatobiliary and pancreatic surgeries in Japan are now being undertaken gradually but safely.

The role of virtual reality in hepato-pancreato-biliary surgical education: A systematic review

Background: Virtual reality (VR) is a technology that can be used as a tool to create 3-dimensional graphics for surgical education, including anatomy and surgical skills teaching. Hepato-pancreato-biliary (HPB) surgery requires specialized surgical skill training and is characterized by cases of complex anatomical variations, which might be difficult to appreciate and conceptualize for trainees in their early stages of education. We performed this systematic review to summarize evidence on real-world VR implementation in surgical education for HPB surgical trainees and to understand the effects of VR on HPB trainees.

Hepatobiliary anastomotic leakage: a narrative review of definitions, grading systems, and consequences of leaks.

Hepatobiliary diseases are a longstanding and significant medical challenge which, despite advances in surgical techniques, still carry risks for postoperative complications such as anastomotic leaks (ALs), which can include both postoperative pancreatic fistula (POPF) and bile leaks (BL). These complications incur significant human and economic costs on all those involved, including the patient, healthcare providers, and hospital systems. The aim of this study was to construct a narrative review of literature surrounding definitions and grading systems for ALs in the context of hepato-pancreato-biliary (HPB) procedures, and consequences of POPF and BL. A literature review was conducted by examining databases including PubMed, Web of Science, OVID Embase, Google Scholar, and Cochrane library databases. Searches were performed with the following search criteria: (((((((anastomosis) OR (anastomotic leak*)) OR (postoperative pancreatic fistula)) OR (bile leak*)) OR (pancreaticoduodenectomy)) OR (whipple)) AND ((hepatobiliary) OR (hepato-pancreato-biliary)) AND ((definition) OR (grading system*) OR (consequences) OR (outcomes) OR (risk factor*) OR (morbidity) OR (mortality))). Publications that were retrieved underwent further assessment to ensure other relevant publications were identified and included. A universally accepted definition and grading system for POPF and BL continues to be lacking, leading to variability in reported incidence in the literature. Various groups have worked to publish guidelines for defining and grading POPF and BL, with the International Study Group in Pancreatic Surgery (ISGPS) and International Study Group for Liver Surgery (ISGLS) definitions the current most recommended definitions for POPF and BL, respectively. The burden of AL on patients, healthcare providers, and hospitals is well documented in evidence from leak consequences, such as increased morbidity and mortality, higher reoperation rates, and increased readmission rates, among others. AL remains a significant challenge in HPB surgery, despite medical advancements. Understanding the progress made in defining and grading leaks, as well as the range of negative outcomes that arise from AL, is crucial in improving patient care, reduce surgical mortality, and drive further advancements in earlier detection and treatment of AL.

Transport-delayed medical care in a nationally representative sample of hepatopancreatobiliary cancer patients

Background: Transportation barriers are a potentially modifiable and often overlooked barrier to cancer care. While patients with hepatopancreatobiliary (HPB) cancers require reliable transportation for various aspects of their healthcare, the burden of transport-delayed care among this patient population is understudied. We examined the prevalence and predictors of transportation barriers to healthcare in a nationally representative sample of HPB cancer patients.

Outcome comparisons of laparoscopic distal pancreatectomy vs open in pancreas cancer

Background: As minimally invasive (MIS) approaches continue to advance within the field of hepato-pancreato-biliary (HPB) surgery, it is imperative to ensure that equivalent oncologic outcomes can be achieved as compared to open surgery. In the setting of left sided pancreatic adenocarcinoma (PDAC), limited long-term data is available regarding the oncologic outcomes of patients undergoing laparoscopic resection, particularly in patients necessitating multivisceral or vascular resection. The purpose of this study was to compare the oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP for PDAC.

Trends and disparities in chemotherapy utilization for metastatic hepatopancreatobiliary cancers

Background: We described trends and disparities of utilizing systemic chemotherapy in patients with metastatic hepato-pancreato-biliary (HPB) malignancies.