International Hepato-Pancreato-Biliary 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.

International Hepato-Pancreato-Billiary Association (IHPBA) registry study on COVID-19 infections in HPB surgery patients

BackgroundIn response to the pandemic, the International Hepato-Pancreato-Biliary Association (IHPBA) developed the IHPBA-COVID Registry to capture data on HPB surgery outcomes in COVID-positive patients prior to mass vaccination programs. The aim was to provide a tool to help members gain a better understanding of the impact of COVID-19 on patient outcomes following HPB surgery worldwide. MethodsAn online registry updated in real time was disseminated to all IHPBA, E-AHPBA, A-HPBA and A-PHPBA members to assess the effects of the pandemic on the outcomes of HPB procedures, perioperative COVID-19 management and other aspects of surgical care. ResultsOne hundred twenty-five patients from 35 centres in 18 countries were included. Seventy-three (58%) patients were diagnosed with COVID-19 preoperatively. Operative mortality after pancreaticoduodenectomy and major hepatectomy was 28% and 15%, respectively, and 2.5% after cholecystectomy. Postoperative complication rates of pancreatic procedures, hepatic interventions and biliary interventions were respectively 80%, 50% and 37%. Respiratory complication rates were 37%, 31% and 10%, respectively. ConclusionThis study reveals a high risk of mortality and complication after HPB surgeries in patient infected with COVID-19. The more extensive the procedure, the higher the risk. Nonetheless, an increased risk was observed across all types of interventions, suggesting that elective HPB surgery should be avoided in COVID positive patients, delaying it at distance from the viral infection.

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.

Liver Transplantation for Non-Resectable Colorectal Liver Metastases: The International Hepato-Pancreato-Biliary Association Consensus Guidelines

Introduction: Colorectal cancer remains a prevalent disease worldwide, with over 50% of patients developing liver metastases. Despite advances in improving resectability, most patients present with non-resectable colorectal liver metastases (NRCLM) only amenable to palliative systemic therapy. There is a growing interest in using liver transplantation (LT) to treat NRCLM in well-selected patients. To address the urgent need for a consensus approach, the International Hepato-pancreato-biliary Association (IHPBA) commissioned the Liver Transplantation for Colorectal Liver Metastases 2021 (LT-CoMet) working group. The aim was to standardise nomenclature and define management principles in five key domains: patient selection, evaluation of biological behaviour, graft selection, recipient considerations and outcomes. Method: A systematic review was performed and a three-step modified Delphi consensus process was undertaken between November 2020 and January 2021. Results: A final consensus of 44 statements, standardised nomenclature and a management algorithm are presented. Specific criteria for clinico-patho-radiological assessment and molecular profiling followed by an evaluation of biological behaviour via bridging therapy to transplantation is required. Sequencing of treatment in synchronous metastatic disease requires special consideration. Certain ethical dilemmas regarding organ allocation for malignant indications are discussed and the role for extended criteria grafts, living donor transplantation and machine perfusion technologies in NRCLM is reviewed. Immunosuppressive regimens and management of recurrent disease are proposed. Conclusions: This consensus guideline provides a framework by which LT for NRCLM may be safely instituted and is a meaningful step towards future evidenced-based practice for better patient selection and organ allocation to improve survival for patients with this disease.

Assessment of Textbook Outcome in Laparoscopic and Open Liver Surgery

Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR). To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis. Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated. Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin. A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a worse TOLS rate. In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

Liver Drains after Surgery, a Real-life Snapshot among the HPB Community: the LI.DR.A.S. World-wide Survey

Background: Although several trials have been conducted, the management of liver drains remains controversial among HPB surgeons. We conducted a world-wide survey to define actual clinical drain practices adopted by liver surgeons in the EA-HPBA, A-HPBA and AP-HPBA communities. Methods: An open survey consisting of 30 questions was prepared and then published on Google – Form, which was then delivered by email to members of the three major chapters of the international hepato-pancreato-biliary association (IHPBA). Results: 191 HPB surgeons responded to the web-survey. Twenty (10.5%) respondents were from the Asian-Pacific region, while 15 (7.9%) were from North America, 13 (6.8%) from South America and 143 (74.9%) from Europe and Africa. One hundred-twelve surgeons (58.6%) reported routine use of abdominal drains liver resection. Eighty-eight (46.1%) respondents responded that drain removal was driven by low volume and low bilirubin levels in the drains; 85 (44.5%) surgeons usually consider removal of the drain on 2-3 post-operative days (POD). In case of minor liver resection, 97 (50.8%) surgeons reported using drains only in select cases. When a major resection (>=3 liver segments) is performed, 134 (70.2%) surgeons preferred to always use a drain. Among patients with cirrhosis, 87 (45.5%) surgeons reported the routine use of drains, while 84 (44.0%) respondents considered drains only selectively. The lack of drains was most prevalent among surgeons from North America (12, 80%); in contrast, 14 (70.0%) surgeons in Asian-Pacific region, 87 (60.8%) in Europe and Africa and 8 (61.5%) in South America were more inclined to employ liver drains routinely (p=0.014). Among surgeons whose practice is mostly mini-invasive liver surgery (n=31), 23 (74.2%) reported draining only in selected cases, while the proportion of surgeons who use drains selectively among surgeons who performed mainly open liver resections was lower (n=56, 35.0%)(p<0.001). Conclusion: Despite several RCTs, use of drains at the time of liver resection remains highly variable. In particular, surgeons from North America, as well as surgeons who predominantly perform minimally-invasive hepatectomy, are much less likely to employ abdominal drains at the time of liver resection.

IHPBA: the first 25 years

BackgroundThe International Hepato-Pancreato-Biliary Association (IHPBA) was established in 1994. In the prior 16 years, considerable international hepatic, pancreatic and biliary association activity had been undertaken. In the subsequent 25 years, the association has grown and evolved dramatically. The aim of this historical account is to document how the IHPBA has advanced from 1994 through 2019. MethodsOriginal materials written by the founders of the precursor societies and Regional Associations were collected. Input from the first five Secretary Generals was solicited. Numerous documents provided by the Management Associations were gathered. ResultsThe IHPBA's origins, vision and mission are documented. The leadership, committee evolution and World Congresses are chronicled. The Regional Associations, National Chapters, membership growth and logos are detailed. The IHPBA's official journal, HBP, and learning platform, myHPB, are discussed. The Warren Fellowship and the IHPBA's Foundation are described. The education and training, research and outreach missions are reported. The HPB Medallion recipients are acknowledged. The financial growth, corporate partners and harmonization efforts are documented. Thoughts about the future are expressed. ConclusionIn 25 years, the IHPBA has matured into an international organization devoted to relief of worldwide suffering caused by hepato-pancreato-biliary disorders by improving education, training and patient care.

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.

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.

Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons

BackgroundThere is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons. MethodsA web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks. ResultsIn total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support. ConclusionManagement of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.

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.

Advances in hepatopancreatobiliary surgery of the 13th World Congress of the International Hepato-Pancreato-Biliary Association

The 13th World Congress of the International Hepato-Pancreato-Biliary Association was held from 4th to 7th September 2018 in Geneva, Switzerland. Thousands of well-known specialists and scholars from 96 countries around the world were invited for the great event. The congress aimed to explore the latest achievements of diagnosis and treatment of hepatobiliary and pancreatic diseases from both the clinical and basic perspective. In this article, authors reviewed and analyzed the up-to-date research information and combined clinical researches of the author team, in order to share the experience and achievements in the field of hepato-pancreato-biliary surgery with colleagues and provide new information and inference for optimization of diagnosis and treatment in this field. Key words: Liver surgery; Biliary surgery; Pancreatic Surgery; The International Hepato-Pancreato-Biliary Association; Precision medicine; Translational medicine

Minimally invasive pancreatic resections: cost and value perspectives

BackgroundThe number of minimally invasive pancreatic resections (MIPR) performed for benign or malignant disease, have increased in recent years. However, there is limited information regarding cost/value implications. MethodsAn international conference evaluating MIPR was held during the 12th Bi-Annual International Hepato-Pancreato-Biliary Association (IHPBA) World Congress in Sao Paulo, Brazil, on April 20th, 2016. This manuscript summarizes the presentations that reviewed current topics in cost and value as they pertain to MIPR. ResultsCompared to the open approach, MIPR's are associated with higher operative costs but lower postoperative costs. However, measurements of patient value (defined as improvement in both quantity and quality of life) and financial value (using incremental cost-effectiveness ratio) are required to determine the true value at societal level. ConclusionChallenges remain as to how the potential benefits, both to the patient and the healthcare system as a whole, are measured. Research comparing MIPR versus other techniques for pancreatectomy will require appropriate and valid measurement tools, some of which are yet to be refined. Nonetheless, the experience to date would support the continued development of MIPR by experienced surgeons in high-volume pancreatic centers, married with appropriate review and recalibration.

Hilar Cholangiocarcinoma: expert consensus statement

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists met on 15 January 2014 to review current evidence on the management of hilar cholangiocarcinoma in order to establish practice guidelines and to agree consensus statements. It was established that the treatment of patients with hilar cholangiocarcinoma requires a coordinated, multidisciplinary approach to optimize the chances for both durable survival and effective palliation. An adequate diagnostic and staging work-up includes high-quality cross-sectional imaging; however, pathologic confirmation is not required prior to resection or initiation of a liver transplant trimodal treatment protocol. The ideal treatment for suitable patients with resectable hilar malignancy is resection of the intra- and extrahepatic bile ducts, as well as resection of the involved ipsilateral liver. Preoperative biliary drainage is best achieved with percutaneous transhepatic approaches and may be indicated for patients with cholangitis, malnutrition or hepatic insufficiency. Portal vein embolization is a safe and effective strategy for increasing the future liver remnant (FLR) and is particularly useful for patients with an FLR of <30%. Selected patients with unresectable hilar cholangiocarcinoma should be evaluated for a standard trimodal protocol incorporating external beam and endoluminal radiation therapy, systemic chemotherapy and liver transplantation. Post-resection chemoradiation should be offered to patients who show high-risk features on surgical pathology. Chemoradiation is also recommended for patients with locally advanced, unresectable hilar cancers. For patients with locally recurrent or metastatic hilar cholangiocarcinoma, first-line chemotherapy with gemcitabine and cisplatin is recommended based on multiple Phase II trials and a large randomized controlled trial including a heterogeneous population of patients with biliary cancers.

Gallbladder Cancer: expert consensus statement

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists was convened on 15 January 2014 to review current evidence on the management of gallbladder carcinoma in order to establish practice guidelines. In summary, within high incidence areas, the assessment of routine gallbladder specimens should include the microscopic evaluation of a minimum of three sections and the cystic duct margin; specimens with dysplasia or proven cancer should be extensively sampled. Provided the patient is medically fit for surgery, data support the resection of all gallbladder polyps of >1.0 cm in diameter and those with imaging evidence of vascular stalks. The minimum staging evaluation of patients with suspected or proven gallbladder cancer includes contrasted cross-sectional imaging and diagnostic laparoscopy. Adequate lymphadenectomy includes assessment of any suspicious regional nodes, evaluation of the aortocaval nodal basin, and a goal recovery of at least six nodes. Patients with confirmed metastases to N2 nodal stations do not benefit from radical resection and should receive systemic and/or palliative treatments. Primary resection of patients with early T-stage (T1b–2) disease should include en bloc resection of adjacent liver parenchyma. Patients with T1b, T2 or T3 disease that is incidentally identified in a cholecystectomy specimen should undergo re-resection unless this is contraindicated by advanced disease or poor performance status. Re-resection should include complete portal lymphadenectomy and bile duct resection only when needed to achieve a negative margin (R0) resection. Patients with preoperatively staged T3 or T4 N1 disease should be considered for clinical trials of neoadjuvant chemotherapy. Following R0 resection of T2–4 disease in N1 gallbladder cancer, patients should be considered for adjuvant systemic chemotherapy and/or chemoradiotherapy.

Intrahepatic Cholangiocarcinoma: expert consensus statement

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists met on 15 January 2014 to review current evidence on the management of intrahepatic cholangiocarcinoma (ICC) in order to establish practice guidelines and to agree on consensus statements. The treatment of ICC requires a coordinated, multidisciplinary approach to optimize survival. Biopsy is not necessary if the surgeon suspects ICC and is planning curative resection, although biopsy should be obtained before systemic or locoregional therapies are initiated. Assessment of resectability is best accomplished using cross-sectional imaging [computed tomography (CT) or magnetic resonance imaging (MRI)], but the role of positron emission tomography (PET) is unclear. Resectability in ICC is defined by the ability to completely remove the disease while leaving an adequate liver remnant. Extrahepatic disease, multiple bilobar or multicentric tumours, and lymph node metastases beyond the primary echelon are contraindications to resection. Regional lymphadenectomy should be considered a standard part of surgical therapy. In patients with high-risk features, the routine use of diagnostic laparoscopy is recommended. The preoperative diagnosis of combined hepatocellular carcinoma and cholangiocarcinoma (cHCC–CC) by imaging studies is extremely difficult. Surgical resection remains the mainstay of treatment, but survival is worse than in HCC alone. There are no adequately powered, randomized Phase III trials that can provide definitive recommendations for adjuvant therapy for ICC. Patients with high-risk features (lymphovascular invasion, multicentricity or satellitosis, large tumours) should be encouraged to enrol in clinical trials and to consider adjuvant therapy. Cisplatin plus gemcitabine represents the standard-of-care, front-line systemic therapy for metastatic ICC. Genomic analyses of biliary cancers support the development of targeted therapeutic interventions.

Analysis and implications of changing hepatopancreatobiliary (HPB) case loads in general surgery residency training for HPB surgery accreditation

ObjectiveThis study was conducted to determine whether residents are receiving enough hepatopancreatobiliary (HPB) training during general surgery residencies to exclude the necessity of pursuing formal fellowships in HPB surgery. MethodsTrends in HPB surgery training were examined using Accreditation Council for Graduate Medical Education (ACGME) operative log data for the academic years 1999/2000 to 2009/2010. ResultsOf 800000 HPB operations performed annually in the USA, the proportion of HPB procedures performed by general surgery residents increased from 15% (122007) to 18% (143000) between the periods under study. Numbers of pancreatic, liver and biliary procedures performed by graduating general surgery residents increased by 47% (from 8185 to 12006), 31% (from 7468 to 9765), and 14% (from 106354 to 121239), respectively. The mean number of operations undertaken by a graduating resident increased from 8.3 to 11.5 (38% increase) for pancreatic surgeries, from 7.6 to 9.4 (24% increase) for liver surgeries, and from 107.5 to 116.6 (8% increase) for biliary surgeries. Total numbers of complex pancreatic, liver and biliary procedures increased by 91% (from 4768 to 9129) and 24% (from 6649 to 8233), and decreased by 29% (from 6581 to 4648), respectively. ConclusionsThe overall trend shows an increase in the number of HPB procedures undertaken by graduating general surgery residents. The mean number of procedures exceeds ACGME requirements, but falls short of association guidelines. However, certain residents exceed International Hepato-Pancreato-Biliary Association (IHPBA) fellowship requirements for total and complex procedures during residency. Consideration should be given to those residents to allow them to bypass fellowship training provided that they meet other IHPBA standards.

10th World Congress of the International Hepato-Pancreato-Biliary Association(IHPBA)(1)

10th World Congress of the International Hepato-Pancreato-Biliary Association(IHPBA)(1)