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Behman R, Auer RC, Bubis L, Xu G, Coburn NG, Martel G, Hallet J, Balaa F, Law C, Bertens KA, Abou Khalil J, Karanicolas PJ. Hepato pancreaticobiliary Resection Arginine Immuno modulation (PRIMe) trial: protocol for a randomised phase II trial of the impact of perioperative immunomodulation on immune function following resection for hepatopancreaticobiliary malignancy. BMJ Open 2024; 14:e072159. [PMID: 38580363 PMCID: PMC11002425 DOI: 10.1136/bmjopen-2023-072159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/28/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Surgical stress results in immune dysfunction, predisposing patients to infections in the postoperative period and potentially increasing the risk of cancer recurrence. Perioperative immunonutrition with arginine-enhanced diets has been found to potentially improve short-term and cancer outcomes. This study seeks to measure the impact of perioperative immunomodulation on biomarkers of the immune response and perioperative outcomes following hepatopancreaticobiliary surgery. METHODS AND ANALYSIS This is a 1:1:1 randomised, controlled and blinded superiority trial of 45 patients. Baseline and perioperative variables were collected to evaluate immune function, clinical outcomes and feasibility outcomes. The primary outcome is a reduction in natural killer cell killing as measured on postoperative day 1 compared with baseline between the control and experimental cohorts. ETHICS AND DISSEMINATION This trial has been approved by the research ethics boards at participating sites and Health Canada (parent control number: 223646). Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov (identifier: NCT04549662). Any modifications to the protocol will be communicated via publications and ClinicalTrials.gov. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT04549662.
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Affiliation(s)
- Ramy Behman
- Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca C Auer
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Lev Bubis
- Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Grace Xu
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Guillaume Martel
- Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Julie Hallet
- Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Fady Balaa
- Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Calvin Law
- Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | | | - Paul Jack Karanicolas
- Surgery, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Lee A, Al-Arnawoot A, Rajendran L, Lamb T, Turner A, Reid M, Rekman J, Mimeault R, Abou Khalil J, Martel G, Bertens KA, Balaa F. Feasibility and Safety of a "Shared Care" Model in Complex Hepatopancreatobiliary Surgery: A 5-year Observational Study of Outcomes in Pancreaticoduodenectomy. Ann Surg 2023; 278:994-1000. [PMID: 36805373 DOI: 10.1097/sla.0000000000005826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy. BACKGROUND SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery. METHODS Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative. RESULTS Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals. CONCLUSIONS SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.
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Affiliation(s)
- Alex Lee
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Ahmed Al-Arnawoot
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Luckshi Rajendran
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tyler Lamb
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Anastasia Turner
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Morgann Reid
- Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Janelle Rekman
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Mimeault
- Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Jad Abou Khalil
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Kimberly A Bertens
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Fady Balaa
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Canadian Medical Protective Association, Ottawa, Ontario, Canada
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Ellis RJ, Brajcich BC, Bertens KA, Chan CH, Castillo CFD, Karanicolas PJ, Maithel SK, Reames BN, Weber SM, Vidri RJ, Pitt HA, Thompson VM, Gonen M, Seo SK, Yopp AC, Ko CY, D’Angelica MI. Association Between Biliary Pathogens, Surgical Site Infection, and Pancreatic Fistula: Results of a Randomized Trial of Perioperative Antibiotic Prophylaxis in Patients Undergoing Pancreatoduodenectomy. Ann Surg 2023; 278:310-319. [PMID: 37314221 PMCID: PMC10838195 DOI: 10.1097/sla.0000000000005955] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis. BACKGROUND Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined. METHODS Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent. RESULTS Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888). CONCLUSIONS Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.
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Affiliation(s)
- Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, NY
- American College of Surgeons, Chicago, IL
- Indiana University Health, Indianapolis, IN
| | | | | | | | | | | | | | | | - Sharon M. Weber
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Roberto J. Vidri
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Henry A. Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, IL
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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D’Angelica MI, Ellis RJ, Liu JB, Brajcich BC, Gönen M, Thompson VM, Cohen ME, Seo SK, Zabor EC, Babicky ML, Bentrem DJ, Behrman SW, Bertens KA, Celinski SA, Chan CHF, Dillhoff M, Dixon MEB, Fernandez-del Castillo C, Gholami S, House MG, Karanicolas PJ, Lavu H, Maithel SK, McAuliffe JC, Ott MJ, Reames BN, Sanford DE, Sarpel U, Scaife CL, Serrano PE, Smith T, Snyder RA, Talamonti MS, Weber SM, Yopp AC, Pitt HA, Ko CY. Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial. JAMA 2023; 329:1579-1588. [PMID: 37078771 PMCID: PMC10119777 DOI: 10.1001/jama.2023.5728] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
Importance Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood. Objective To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics. Design, Setting, and Participants Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment. Intervention The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care). Main Outcomes and Measures The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program. Results The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32). Conclusions and Relevance In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy. Trial Registration ClinicalTrials.gov Identifier: NCT03269994.
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Affiliation(s)
| | - Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, New York
- American College of Surgeons, Chicago, Illinois
| | - Jason B. Liu
- American College of Surgeons, Chicago, Illinois
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Mithat Gönen
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily C. Zabor
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | | | | | | | | | | | | | | | - Paul J. Karanicolas
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harish Lavu
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Umut Sarpel
- Mount Sinai Medical Center, New York, New York
| | | | | | | | | | | | | | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas
| | - Henry A. Pitt
- American College of Surgeons, Chicago, Illinois
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
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5
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Rajendran L, Lenet T, Shorr R, Abou Khalil J, Bertens KA, Balaa FK, Martel G. Should Cell Salvage Be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis. Ann Surg 2023; 277:456-468. [PMID: 35861339 PMCID: PMC9891298 DOI: 10.1097/sla.0000000000005612] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%]. CONCLUSION IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.
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Affiliation(s)
- Luckshi Rajendran
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jad Abou Khalil
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Kimberly A. Bertens
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K. Balaa
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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6
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Martel G, Lenet T, Wherrett C, Carrier FM, Monette L, Workneh A, Brousseau K, Ruel M, Chassé M, Collin Y, Vandenbroucke-Menu F, Hamel-Perreault É, Perreault MA, Park J, Lim S, Maltais V, Leung P, Gilbert RWD, Segedi M, Abou-Khalil J, Bertens KA, Balaa FK, Ramsay T, Fergusson DA. Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial. Trials 2023; 24:38. [PMID: 36653812 PMCID: PMC9848035 DOI: 10.1186/s13063-022-07008-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.
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Affiliation(s)
- Guillaume Martel
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Tori Lenet
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christopher Wherrett
- grid.28046.380000 0001 2182 2255Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON Canada
| | - François-Martin Carrier
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada ,grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Leah Monette
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Aklile Workneh
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Karine Brousseau
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada ,grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Monique Ruel
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Michaël Chassé
- grid.410559.c0000 0001 0743 2111Department of Medicine, Critical Care Division, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC Canada
| | - Yves Collin
- grid.411172.00000 0001 0081 2808Division of General Surgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Franck Vandenbroucke-Menu
- grid.410559.c0000 0001 0743 2111Hepato-Pancreato-Biliary and Liver Transplantation Surgery Unit, Department of Surgery - Centre Hospitalier de l’Université de Montréal, Montréal, QC Canada
| | - Élodie Hamel-Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Michel-Antoine Perreault
- grid.411172.00000 0001 0081 2808Departement of Anesthesiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC Canada
| | - Jeieung Park
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Shirley Lim
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Véronique Maltais
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Philemon Leung
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Richard W. D. Gilbert
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Maja Segedi
- grid.17091.3e0000 0001 2288 9830Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC Canada
| | - Jad Abou-Khalil
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A. Bertens
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Fady K. Balaa
- grid.28046.380000 0001 2182 2255Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital– General Campus, University of Ottawa, 501 Smyth Road, CCW 1667, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Dean A. Fergusson
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
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7
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Lenet T, Baker L, Vered M, Workneh A, Zahrai A, Rajendran L, Abou-Khalil J, Balaa FK, Bertens KA, McIsaac DI, Tinmouth A, Fergusson DA, Martel G. Red blood cell transfusions in liver surgery. Br J Surg 2023; 110:269-270. [PMID: 36448200 DOI: 10.1093/bjs/znac389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 10/24/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Laura Baker
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Vered
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Aklile Workneh
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Amin Zahrai
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Luckshi Rajendran
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jad Abou-Khalil
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Fady K Balaa
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Kimberly A Bertens
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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8
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Lenet T, Gilbert RWD, Smoot R, Tzeng CWD, Rocha FG, Yohanathan L, Cleary SP, Martel G, Bertens KA. ASO Visual Abstract: Does Intraoperative Frozen Section and Revision of Margins Lead to Improved Survival for Patients Undergoing Resection of Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis. Ann Surg Oncol 2022; 29:7603-7604. [PMID: 35896924 DOI: 10.1245/s10434-022-12119-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Tori Lenet
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Richard W D Gilbert
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Rory Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Lavanya Yohanathan
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Guillaume Martel
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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9
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Gilbert RWD, Lenet T, Cleary SP, Smoot R, Tzeng CWD, Rocha FG, Martel G, A Bertens K. ASO Visual Abstract: Does Caudate Resection Improve Outcomes inPatients Undergoing Curative Resection forPerihilar Cholangiocarcinoma? ASystematic Review and Meta-analysis. Ann Surg Oncol 2022; 29:6772-6773. [PMID: 35831520 DOI: 10.1245/s10434-022-12044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Richard W D Gilbert
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON, Canada
| | - Tori Lenet
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Guillaume Martel
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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10
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Lenet T, Gilbert RWD, Smoot R, Tzeng CWD, Rocha FG, Yohanathan L, Cleary SP, Martel G, Bertens KA. Does Intraoperative Frozen Section and Revision of Margins Lead to Improved Survival in Patients Undergoing Resection of Perihilar Cholangiocarcinoma? A Systematic Review and Meta-analysis. Ann Surg Oncol 2022; 29:7592-7602. [PMID: 35752725 DOI: 10.1245/s10434-022-12041-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/06/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Perihilar cholangiocarcinoma (PHC) is a rare malignancy that arises at the biliary confluence. Achieving a margin-negative resection (R0) is challenging given the anatomic location of tumors and remains the most important prognostic indicator of long-term survival. The objective of this study is to review the impact of intraoperative revision of positive biliary margins in PHC on oncologic outcomes. PATIENTS AND METHODS Electronic databases were searched from inception to October 2021. Studies comparing three types of patients undergoing resection of PHC with intraoperative frozen section of the proximal and/or distal bile ducts were identified: those who were margin-negative (R0), those with an initially positive margin who had revised negative margins (R1R0), and those with a persistently positive margin with or without revision of a positive margin (R1). The primary outcome was overall survival (OS). Secondary outcomes included risk of postoperative complication. RESULTS A total of 449 studies were screened. Ten retrospective observational studies reporting on 1955 patients were included. Patients undergoing successful revision of a positive proximal and/or distal bile duct margin (R1R0) had similar OS to those with a primary margin-negative resection (R0) [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.72-1.19, p = 0.56, I2 = 84%], and significantly better OS than patients with a positive final bile duct margin (R1) (HR 0.52, 95% CI 0.34-0.79, p = 0.002, I2 = 0%). There was no increase in the risk of postoperative complications associated with additional resection, although postoperative morbidity was inconsistently reported. CONCLUSIONS This review supports routine intraoperative biliary margin evaluation during resection of PHC with revision if technically feasible.
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Affiliation(s)
- Tori Lenet
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Richard W D Gilbert
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Rory Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Lavanya Yohanathan
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA.,Multi-organ Transplant Center, Beaumont Health, Royal Oak, MI, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Guillaume Martel
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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11
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Gilbert RWD, Lenet T, Cleary SP, Smoot R, Tzeng CWD, Rocha FG, Martel G, Bertens KA. Does Caudate Resection Improve Outcomes of Patients Undergoing Curative Resection for Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis. Ann Surg Oncol 2022; 29:6759-6771. [PMID: 35705775 DOI: 10.1245/s10434-022-11990-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/25/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Margin-negative (R0) resection is the strongest positive prognostic factor in perihilar cholangiocarcinoma (PHC). Due to its anatomic location, the caudate lobe is frequently involved in PHC. This review aimed to examine the impact of caudate lobe resection (CLR) in addition to hepatectomy and bile duct resection for patients with PHC. METHODS The MEDLINE, EMBASE, and Cochrane databases were systematically reviewed from inception to October 2021 to identify studies comparing patients undergoing surgical resection with hepatectomy and bile duct resection with or without CLR for treatment of PHC. Outcomes included the proportion of patients achieving R0 resection, overall survival (OS), and perioperative morbidity. RESULTS Altogether, 949 studies were screened. The review included eight observational studies reporting on 1137 patients. The patients who underwent CLR had a higher likelihood of R0 resection (odds ratio [OR], 5.85; 95% confidence interval [CI], 2.64-12.95) and a better OS (hazard ratio [HR], 0.65; 95% CI, 0.54-0.79) than those who did not. The use of CLR did not increase the risk of perioperative morbidity (OR, 1.03; 95% CI, 0.65-1.63). CONCLUSIONS Given the higher likelihood of R0 resection, improved OS, and no apparent increase in perioperative morbidity, this review supports routine caudate lobectomy in the surgical management of PHC. These results should be interpreted with caution given the lack of high-quality prospective data and the high probability of selection bias.
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Affiliation(s)
- Richard W D Gilbert
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada
| | - Tori Lenet
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Flavio G Rocha
- Division of Surgical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Guillaume Martel
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Surgical Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, General Campus, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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12
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Tran A, Fernando SM, Rochwerg B, Inaba K, Bertens KA, Engels PT, Balaa FK, Kubelik D, Matar M, Lenet TI, Martel G. Prognostic factors associated with development of infected necrosis in patients with acute necrotizing or severe pancreatitis-A systematic review and meta-analysis. J Trauma Acute Care Surg 2022; 92:940-948. [PMID: 34936587 DOI: 10.1097/ta.0000000000003502] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
PURPOSE Acute pancreatitis is a potentially life-threatening condition with a wide spectrum of clinical presentation and illness severity. An infection of pancreatic necrosis (IPN) results in a more than twofold increase in mortality risk as compared with patients with sterile necrosis. We sought to identify prognostic factors for the development of IPN among adult patients with severe or necrotizing pancreatitis. METHODS We conducted this prognostic review in accordance with systematic review methodology guidelines. We searched six databases from inception through March 21, 2021. We included English language studies describing prognostic factors associated with the development of IPN. We pooled unadjusted odds ratio (uOR) and adjusted odds ratios (aOR) for prognostic factors using a random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the GRADE approach. RESULTS We included 31 observational studies involving 5,210 patients. Factors with moderate or higher certainty of association with increased IPN risk include older age (uOR, 2.19; 95% confidence interval [CI], 1.39-3.45, moderate certainty), gallstone etiology (aOR, 2.35; 95% CI, 1.36-4.04, high certainty), greater than 50% necrosis of the pancreas (aOR, 3.61; 95% CI, 2.15-6.04, high certainty), delayed enteral nutrition (aOR, 2.09; 95% CI, 1.26-3.47, moderate certainty), multiple or persistent organ failure (aOR, 11.71; 95% CI, 4.97-27.56, high certainty), and invasive mechanical ventilation (uOR, 12.24; 95% CI, 2.28-65.67, high certainty). CONCLUSION This meta-analysis confirms the association between several clinical early prognostic factors and the risk of IPN development among patients with severe or necrotizing pancreatitis. These findings provide the foundation for the development of an IPN risk stratification tool to guide more targeted clinical trials for prevention or early intervention strategies. LEVEL OF EVIDENCE Systematic review and meta-analysis, Level IV.
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Affiliation(s)
- Alexandre Tran
- From the Department of Surgery (A.T., K.A.B., F.K.B., D.K., M.M., T.I.L., G.M.), School of Epidemiology and Public Health (A.T., T.I.L., G.M.), Division of Critical Care, Department of Medicine (A.T., S.M.F., D.K.), Department of Emergency Medicine (S.M.F.), University of Ottawa, Ottawa; Department of Medicine (B.R.), Department of Health Research Methods, Evidence, and Impact (B.R.), McMaster University, Hamilton, ON, Canada; Division of Acute Care Surgery, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Division of General Surgery, Department of Surgery (P.T.E.), and Division of Critical Care, Department of Medicine (P.T.E.), McMaster University, Hamilton, Canada
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13
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Kelly D, Jonker DJ, Ko YJ, Karanicolas PJ, Bertens KA, Jayaraman S, Abou-Khalil J, Moulton CA, Raphael MJ, Tsang M, Welch S, Kavan P, Biagi J, Renouf DJ, Fischer S, Kalimuthu S, Khalili K, Dodd A, Gallinger S, Knox JJ. GATA6 Expression as a predictor of response to perioperative chemotherapy in resectable pancreatic adenocarcinoma: A multicenter Canadian phase II study (NeoPancONE). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.tps638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS638 Background: Prospective studies of the benefit of neoadjuvant chemotherapy in resectable pancreatic adenocarcinoma (PDAC) have been reported. The ideal peri-operative regimen is yet to be determined. Adjuvant FOLFIRINOX (mFFX) in resected PDAC has been proven to improve overall survival (OS) relative to adjuvant gemcitabine. An accepted perioperative approach involves delivering the majority of chemotherapy (6-8 cycles) in the pre-operative setting, while the remainder (of 12 cycles) is administered post-operatively. This pre-operative treatment period may allow for chemosensitivity assessment, and better patient selection for surgery, thereby improving R0 resection rates and reducing the frequency of early post-operative recurrence. Data from the COMPASS trial (NCT02750657) has shown that shown that low levels of the transcription factor GATA6 expression is a putative surrogate for the RNA Moffit signature and predictive of a chemoresistant phenotype in advanced PDAC. NeoPancONE will evaluate clinical outcomes and molecular biomarkers including GATA6 and radiomic biomarkers in pts with resectable PDAC treated with perioperative mFFX. Methods: NeoPancONE is a Phase 2, open-label, single arm study in pts with resectable PDAC. Tissue and serum are collected for biomarker testing, including GATA6 by FISH and IHC (1) with expression levels measured by RNAseq, and longitudinal ctDNA analysis. Pts with histologically confirmed, resectable PDAC and ECOG PS 0-1 will be recruited over 2.5 years. Resectability will be determined by central review as per NCCN guidelines. The primary objective is to evaluate disease-free survival in resectable PDAC treated with peri-operative mFFX according to baseline tumor GATA6 expression level. The ratio of GATA6-high to low is expected to be approximately 4:1[1]. Assuming 1-year disease-free survival of 65% in the GATA6-high, compared to 34% in the GATA6-low cohort, this corresponds to a hazard ratio of 2.5. With 80% power and a 5% 2-sided significance level, a total of 84 patients will be enrolled with 67 events expected in the GATA6 high cohort and 17 in GATA6 low. Participants will receive up to 6 cycles of neoadjuvant mFFX. After neoadjuvant chemotherapy, definitive surgical resection will proceed as deemed appropriate by a hepatobiliary surgeon. Post-operatively, pts will receive up to 6 cycles of adjuvant chemotherapy. Secondary objectives include determination of overall response rate, incidence of R0 resection, OS, Moffit gene expression profiling (RNAseq), ctDNA, and radiomic signatures to predict outcomes. Enrolment for NeoPancONE began in October 2020 and is being conducted at 8 sites across Canada. To date, 23 pts have been recruited. The study duration will be five years. Reference: O’Kane G M et al. Clin Can Res Sep 2020. Clinical trial information: NCT04472910.
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Affiliation(s)
- Deirdre Kelly
- Wallace McCain Centre for Pancreatic Cancer, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Derek J. Jonker
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Yoo-Joung Ko
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Paul Jack Karanicolas
- Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Kimberly A. Bertens
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Shiva Jayaraman
- St. Joseph's Health Center, University of Toronto, Toronto, ON, Canada
| | | | - Carol-Anne Moulton
- Hepatobiliary/Pancreatic Surgical Oncology Program, University Health Network, Toronto, ON, Canada
| | - Michael J. Raphael
- Sunnybrook Health Sciences Centre -Odette Cancer Centre, Toronto, ON, Canada
| | | | | | - Petr Kavan
- Jewish General Hospital, McGill University Health Centre, Montréal, QC, Canada
| | - Jim Biagi
- Kingston Health Sciences Centre, Kingston, ON, Canada
| | | | - Sandra Fischer
- Laboratory Medicine Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sangeetha Kalimuthu
- Laboratory Medicine Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Korosh Khalili
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Anna Dodd
- Wallace McCain Center for Pancreatic Cancer, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
| | - Steven Gallinger
- Wallace McCain Centre for Pancreatic Cancer, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jennifer J. Knox
- Wallace McCain Center for Pancreatic Cancer, Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada
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14
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Lemke M, Martel G, Bertens KA. Authors' Reply: Passive Versus Active Intra-Abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using the American College of Surgeons NSQIP Database. World J Surg 2021; 45:3473-3474. [PMID: 34420092 DOI: 10.1007/s00268-021-06257-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Affiliation(s)
- M Lemke
- University of Ottawa, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - G Martel
- University of Ottawa, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - K A Bertens
- University of Ottawa, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
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15
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Park LJ, Baker L, Smith H, Lemke M, Davis A, Abou-Khalil J, Martel G, Balaa FK, Bertens KA. Passive Versus Active Intra-Abdominal Drainage Following Pancreatic Resection: Does A Superior Drainage System Exist? A Systematic Review and Meta-Analysis. World J Surg 2021; 45:2895-2910. [PMID: 34046692 DOI: 10.1007/s00268-021-06158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/14/2022]
Abstract
Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation.
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Affiliation(s)
- Lily J Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Laura Baker
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Heather Smith
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Madeline Lemke
- Division of General Surgery, Department of Surgery, Western University, London, Canada
| | - Alexandra Davis
- Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Jad Abou-Khalil
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Guillaume Martel
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Fady K Balaa
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Kimberly A Bertens
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada. .,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada.
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16
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Abstract
Genitourinary cancers are common. Liver metastases from genitourinary cancers are uncommon; isolated liver metastasis is rare. Liver resection in select patients with metastatic renal cell carcinoma can lead to prolonged survival. Patients with metachronous and low-burden disease are most likely to benefit. Chemotherapy is first-line treatment of metastatic germ cell tumors. Liver resection is dependent on germ cell lineage and initial response to chemotherapy. Prognosis with liver metastases from prostate cancer is poor; liver-only lesions are rare. Liver resection generally is not indicated. Cumulative experience with liver resection for metastatic bladder cancer is limited. Liver metastases are poor prognostic indicators for metastasectomy.
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Affiliation(s)
- Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada.
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. https://twitter.com/BertensK
| | - Christina Canil
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
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17
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Lemke M, Park L, Balaa FK, Martel G, Khalil JA, Bertens KA. Passive Versus Active Intra-Abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using The American College of Surgeons NSQIP Database. World J Surg 2020; 45:554-561. [PMID: 33078216 DOI: 10.1007/s00268-020-05823-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD. METHODS All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF). RESULTS In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44-0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance. CONCLUSIONS The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.
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Affiliation(s)
- Madeline Lemke
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Lily Park
- School of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Fady K Balaa
- School of Medicine, University of Ottawa, Ottawa, ON, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Guillaume Martel
- School of Medicine, University of Ottawa, Ottawa, ON, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Jad Abou Khalil
- School of Medicine, University of Ottawa, Ottawa, ON, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Kimberly A Bertens
- School of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
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18
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Zwiep TM, Gilbert RWD, Moloo H, Touchie D, Martel G, Wallace T, Bertens KA. Improving the treatment of pre-operative anemia in hepato-pancreato-biliary patients: a quality improvement initiative. Patient Saf Surg 2020; 14:18. [PMID: 32346397 PMCID: PMC7181477 DOI: 10.1186/s13037-020-00239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery. Methods This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin. Results A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%. Conclusions This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.
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Affiliation(s)
- Terry M Zwiep
- 1Department of Surgery, London Health Sciences Centre, London, Canada
| | - Richard W D Gilbert
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Husein Moloo
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Donna Touchie
- 3Surgical Blood Management Program, The Ottawa Hospital, Ottawa, Canada
| | - Guillaume Martel
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Tom Wallace
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
| | - Kimberly A Bertens
- 2Department of Surgery, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, ON K1H 8 L6 Canada
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19
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Handy NM, Crown A, Bertens KA, Clanton J, Alseidi A, Biehl T, Helton WS, Rocha FG. Does aberrant hepatic arterial anatomy impact the complication rate or survival following resection of pancreatic adenocarcinoma? J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
775 Background: Patients with aberrant hepatic arterial anatomy (AHAA) are susceptible to tumor invasion and/or ligation during resection of the pancreatic head. The purpose of this study is to determine if AHAA negatively impacts perioperative outcomes or survival. Methods: All patients who underwent either pancreaticoduodenectomy or total pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) between 2005 and 2014 at our center were retrospectively reviewed. Univariate logistic regression was used to compare outcomes between patients with conventional hepatic arterial anatomy to those with AHAA. Survival analysis was performed by Kaplan-Meier method with log rank test. Results: During the study period, 330 patients underwent resection for PDAC, 69 (20.9%) with aberrant hepatic arterial anatomy. The presence of AHAA does not significantly increase operative time (p= 0.110) or length of stay (p=0.518). The overall frequency of complications (49.3% vs 37.9%, p=0.088) was higher in the AHAA group, but not significantly so. Certain postoperative complications are more common in the AHAA group, namely superficial surgical site infection (18.8% vs. 8.8%, p=0.018) and pancreatic fistula (18.8% vs. 10.0%, p=0.042). However, deep SSI, need for blood transfusion, respiratory failure, DGE, bleed from GDA/pseudoaneurysm, biliary fistula, chyle leak, PV thrombus, fascial dehiscence, and reoperation are not statistically different between the two groups. There is a trend for reduced overall survival in the AHAA group that is not statistically significant (p=0.11). Conclusions: Aberrant hepatic arterial anatomy is encountered in greater than 20% of pancreatic surgery patients, and its presence may increase the rate of certain postoperative complications such as superficial surgical site infection and pancreatic fistula.
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Affiliation(s)
| | | | | | | | - Adnan Alseidi
- Virginia Mason Hospital and Medical Center, Seattle, WA
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20
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Martel G, Baker L, Wherrett C, Fergusson DA, Saidenberg E, Workneh A, Saeed S, Gadbois K, Jee R, McVicar J, Rao P, Thompson C, Wong P, Abou Khalil J, Bertens KA, Balaa FK. Phlebotomy resulting in controlled hypovolaemia to prevent blood loss in major hepatic resections (PRICE-1): a pilot randomized clinical trial for feasibility. Br J Surg 2020; 107:812-823. [PMID: 31965573 DOI: 10.1002/bjs.11463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/28/2019] [Accepted: 11/15/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial. METHODS Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL). RESULTS A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326). CONCLUSION Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- G Martel
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - L Baker
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - C Wherrett
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - D A Fergusson
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - E Saidenberg
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - A Workneh
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S Saeed
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - K Gadbois
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - R Jee
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J McVicar
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Rao
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - C Thompson
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - P Wong
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - J Abou Khalil
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - K A Bertens
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - F K Balaa
- Liver and Pancreas Unit, Department of Surgery, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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21
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Smith H, Balaa FK, Martel G, Abou Khalil J, Bertens KA. Standardization of early drain removal following pancreatic resection: proposal of the "Ottawa pancreatic drain algorithm". Patient Saf Surg 2019; 13:38. [PMID: 31827615 PMCID: PMC6889288 DOI: 10.1186/s13037-019-0219-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023] Open
Abstract
Background Early drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol. Methods The Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation). Results 42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively). Conclusions Implementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.
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Affiliation(s)
- Heather Smith
- Division of General Surgery, The Ottawa Hospital, University of Ottawa, 725 Parkdale Ave, Ottawa, ON K1Y4E9 Canada
| | - Fady K Balaa
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada
| | - Guillaume Martel
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada.,3Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y4E9 Canada
| | - Jad Abou Khalil
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada
| | - Kimberly A Bertens
- Hepatopancreaticobiliary Subunit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, General Campus, 501 Smyth Road, CCW 1667b, Ottawa, ON K1H 8L6 Canada.,3Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y4E9 Canada
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22
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Park L, Baker L, Smith H, Davies A, Abou Khalil J, Martel G, Balaa F, Bertens KA. Passive versus active intra-abdominal drainage following pancreatic resection: does a superior drainage system exist? A protocol for systematic review. BMJ Open 2019; 9:e031319. [PMID: 31530619 PMCID: PMC6756355 DOI: 10.1136/bmjopen-2019-031319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most common cause of major morbidity following pancreatic resection. Intra-abdominal drains are frequently positioned adjacent to the pancreatic anastomosis or transection margin at the time of surgery to aid in detection and management of CR-POPF. Drains can either evacuate fluid by passive gravity (PG) or be attached to a closed suction (CS) system using negative pressure. There is controversy as to whether one of these two systems is superior. The objective of this review is to identify and compare the incidence of adverse events (AEs) and resource utilisation associated with PG and CS drainage following pancreatic resections. METHODS AND ANALYSIS MEDLINE, EMBASE, CINAHL and Cochrane Central Registry of Controlled Trials will be searched from inception to April 2019, to identify interventional and observational studies comparing PG and CS drains following pancreatic resection. The primary outcome is POPF as defined by the International Study Group for Pancreatic Fistula in 2017. Secondary outcomes include postoperative AE, resource utilisation (length of stay, return to emergency department, readmission and reintervention), time to drain removal and quality of life. Study selection, data extraction and risk of bias assessment will be performed independently, by two reviewers. A meta-analysis will be conducted if deemed statistically appropriate. Subgroup analysis by study design will be performed. Study heterogeneity will be calculated with the χ2 test and reported as I2 statistics. Statistical analyses will be conducted and displayed using RevMan V.5.3 ETHICS AND DISSEMINATION: Ethics approval is not required. The results of this study will be submitted to relevant conferences for presentation and peer-reviewed journals for publication. PROSPERO REGISTRATION NUMBER CRD42019123647.
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Affiliation(s)
- Lily Park
- School of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura Baker
- General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Heather Smith
- General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Jad Abou Khalil
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Fady Balaa
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kimberly A Bertens
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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23
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Baker L, Bennett S, Rekman J, Workneh A, Wherrett C, Abou-Khalil J, Bertens KA, Balaa FK, Martel G. Hypovolemic phlebotomy in liver surgery is associated with decreased red blood cell transfusion. HPB (Oxford) 2019; 21:757-764. [PMID: 30501988 DOI: 10.1016/j.hpb.2018.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/25/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis. METHODS Consecutive patients who underwent liver resection at one institution (2010-2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression. RESULTS A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H2O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068-0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64-5.18, p = 0.0003), preoperative hemoglobin < 125 g/L (OR 6.02, 95% CI 3.44-10.56, p < 0.0001), and underlying liver disease (OR 2.24, 95% CI 1.27-3.95, p = 0.0051) were significantly associated with perioperative RBC transfusion. CONCLUSION Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.
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Affiliation(s)
- Laura Baker
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Janelle Rekman
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Aklile Workneh
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christopher Wherrett
- Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Jad Abou-Khalil
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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24
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Abstract
"The anatomy of the biliary tree is notoriously variable. This variation is the bane of the hepatobiliary surgeon, to whom an understanding of biliary anatomic variation is key to the planning and safe conduct of liver surgery, from oncological resections to split-liver transplantation. The hepatic diverticulum, also termed "the liver bud," is the first semblance of the biliary system in the human embryo. A variety of techniques used in the mid twentieth century for imaging the biliary tree have since been abandoned in favor of more practical, safer, less invasive, and more sensitive and specific contemporary methods."
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Affiliation(s)
- Jad E Abou-Khalil
- Hepatobiliary and Pancreatic Surgery Unit, The University of Ottawa, The Ottawa Hospital, 501 Smyth Road, Box 202, Ottawa, Ontario K1H8L6, Canada.
| | - Kimberly A Bertens
- Hepatobiliary and Pancreatic Surgery Unit, The University of Ottawa, The Ottawa Hospital, 501 Smyth Road, Box 202, Ottawa, Ontario K1H8L6, Canada
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25
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Carver D, Bruckschwaiger V, Martel G, Bertens KA, Abou-Khalil J, Balaa F. Laparoscopic retrieval of a sewing needle from the liver: A case report. Int J Surg Case Rep 2018; 51:376-378. [PMID: 30268064 PMCID: PMC6170216 DOI: 10.1016/j.ijscr.2018.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/20/2018] [Accepted: 09/12/2018] [Indexed: 02/06/2023] Open
Abstract
Ingested foreign bodies are a common presentation. Ingested foreign bodies can migrate/penetrate to the liver. Patients can present with symptoms including epigastric abdominal pain. In some cases hepatic foreign bodies can be extracted through a laparoscopic approach.
Introduction Less than 1% of ingested foreign bodies will require surgical management. An uncommon complication of ingested foreign body is migration to the liver. We present a case of laparoscopic removal of an intrahepatic foreign body. Presentation of case 32-year-old female presented with a four month history of epigastric abdominal pain following suspected foreign body ingestion. CT scan demonstrated a metallic object lying in the left lateral segment of the liver. The patient was brought to the operating room where the object was removed laparoscopically and was found to be a sewing needle. Discussion Hepatic foreign bodies are an uncommon entity and typically result from a transcutaneous or ingested (e.g., gastrointestinal) source. Symptoms are often vague and can develop remote from the time of ingestion. Surgical management is warranted for symptomatic intrahepatic foreign bodies. Conclusion Laparoscopy is an effective surgical method for removal of intrahepatic foreign bodies in some cases.
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Affiliation(s)
- David Carver
- University of Ottawa, The Ottawa Hospital, Canada
| | | | | | | | | | - Fady Balaa
- University of Ottawa, The Ottawa Hospital, Canada.
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26
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Bertens KA, Massman JD, Helton S, Garbus S, Mandelson MM, Lin B, Picozzi VJ, Biehl T, Alseidi AA, Rocha FG. Initiation of adjuvant therapy following surgical resection of pancreatic ductal adenocarcinoma (PDAC): Are patients from rural, remote areas disadvantaged? J Surg Oncol 2018; 117:1655-1663. [DOI: 10.1002/jso.25060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/03/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Kimberly A. Bertens
- Liver and Pancreas Surgical Unit; Division of General Surgery; The Ottawa Hospital; Ottawa Ontario
| | - John D. Massman
- Section of General, Thoracic and Vascular Surgery; Virginia Mason Medical Center; Seattle Washington
| | - Scott Helton
- Section of General, Thoracic and Vascular Surgery; Virginia Mason Medical Center; Seattle Washington
| | - Samuel Garbus
- Section of General, Thoracic and Vascular Surgery; Virginia Mason Medical Center; Seattle Washington
| | - Margaret M. Mandelson
- Section of Hematology and Oncology; Cancer Institute; Virginia Mason Medical Center; Seattle Washington
| | - Bruce Lin
- Section of Hematology and Oncology; Cancer Institute; Virginia Mason Medical Center; Seattle Washington
| | - Vincent J. Picozzi
- Section of Hematology and Oncology; Cancer Institute; Virginia Mason Medical Center; Seattle Washington
| | - Thomas Biehl
- Section of General, Thoracic and Vascular Surgery; Virginia Mason Medical Center; Seattle Washington
| | - Adnan A. Alseidi
- Section of General, Thoracic and Vascular Surgery; Virginia Mason Medical Center; Seattle Washington
| | - Flavio G. Rocha
- Section of General, Thoracic and Vascular Surgery; Virginia Mason Medical Center; Seattle Washington
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27
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Chen BP, Bennett S, Bertens KA, Balaa FK, Martel G. Use and acceptance of the International Study Group for Pancreatic Fistula (ISGPF) definition and criteria in the surgical literature. HPB (Oxford) 2018; 20:69-75. [PMID: 28927654 DOI: 10.1016/j.hpb.2017.08.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/07/2017] [Accepted: 08/13/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has not be quantified. The aim of this study was to determine the uptake of the ISGPF definition and evaluate its use in the surgical literature. METHODS A sample of primary studies, review articles, and textbooks were identified through screening of literature searches. Included citations were assessed for their definition of POPF and use of the ISGPF criteria. RESULTS From 2006 to 2009, 6%-63% of primary papers were compliant with the ISGPF definition compared to 84%-98% from 2010 onwards. Of the primary studies compliant with the ISGPF criteria, 36% focused on grade B and C fistula and 15% did not report grade A fistula. 88% of European papers used the criteria compared to 77% and 72% of Asian and North American papers, respectively (p = 0.033). 46% of review articles and textbooks did not define POPF. Among those that defined POPF, 74% cited the ISGPF definition exclusively while 26% mentioned other definitions. CONCLUSION The ISGPF criteria have been widely adopted and accepted as the standard for defining POPF, although the utility of grade A fistulas is questionable.
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Affiliation(s)
- Brian P Chen
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Sean Bennett
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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28
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Larjani S, Bruckschwaiger VR, Stephens LA, James PD, Martel G, Mimeault R, Balaa FK, Bertens KA. Paraduodenal pancreatitis as an uncommon cause of gastric outlet obstruction: A case report and review of the literature. Int J Surg Case Rep 2017; 39:14-18. [PMID: 28783521 PMCID: PMC5545816 DOI: 10.1016/j.ijscr.2017.07.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 12/18/2022] Open
Abstract
Paraduodenal pancreatitis is a rare form of focal chronic or recurrent pancreatitis that can present as gastric outlet obstruction. Endoscopic ultrasound and fine needle aspiration biopsy provides the best diagnostic modality. Key histopathologic features include Brunner gland hyperplasia, myofibroblastic proliferation, spindle cells and foamy cells. Cross-sectional imaging demonstrates a fibrotic, sheet-like mass with cystic change between the duodenal wall and pancreatic head. The optimal treatment for refractory symptoms is pancreaticoduodenectomy.
Introduction Paraduodenal pancreatitis (PP) is an under-recognized form of focal chronic or recurrent pancreatitis. Since PP presents with non-specific symptoms and shares radiological and histopathological features with other entities, it can be challenging to diagnose. Presentation of case report Herein, a case of a 64 year-old Caucasian male with PP presenting with recurrent gastric outlet obstruction (GOO) is detailed. Over the course of two years, he underwent multiple balloon dilatations for symptom management. His diagnostic course was complicated by inconclusive and misleading biopsies. Conclusion PP can rarely present as GOO in otherwise asymptomatic patients. A preoperative pathologic diagnosis can be difficult to obtain, and in this case delayed definitive surgical management. The case is discussed in detail, and a concise review the current literature was undertaken.
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Affiliation(s)
- Soroush Larjani
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Vanessa R Bruckschwaiger
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Leslie A Stephens
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Paul D James
- Division of Gastroenteretology, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Guillaume Martel
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Richard Mimeault
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Fady K Balaa
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Kimberly A Bertens
- Liver and Pancreas Unit, Division of General Surgery, The Ottawa Hospital, University of Ottawa, Ontario, Canada.
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Bertens KA, Massman J, Garbus S, Mandelson MT, Lin B, Picozzi VJ, Alseidi A, Biehl T, Helton WS, Rocha FG. Adjuvant therapy (AT) following resection of pancreatic ductal adenocarcinoma (PDAC): Are patients from rural, remote areas disadvantaged? J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
373 Background: AT with chemotherapy (CT) + radiation (RT) has been shown to improve PDAC survival over surgery alone. Although race and socioeconomic status can affect outcomes in PDAC, the impact of rural or remote residence on the delivery and effect of AT has not been studied. Methods: Patients undergoing pancreatectomy for PDAC were identified from the National Cancer Data Base between 2006 and 2013. Individuals were classified as living in a metro area, urban/rural adjacent to metro area (URA), and urban/rural remote area (URR). Patients with less than 6 months follow-up were excluded. Logistic regression was performed to assess residence as a predictor of receiving AT. Overall survival (OS) as a function of inhabitance was estimated by the method of Kaplan and Meier and prognostic factors were identified by Cox regression. Results: A total of 32,521 individuals underwent pancreatectomy for PDAC. The majority of AT was delivered in academic research facilities in 56% of patients while only 29% of patients received both CT and RT. Univariate analysis demonstrated individuals in URR were less likely to receive CT (55% vs 58%, p < 0.01) but not RT (30% vs 31%, p < 0.261) and had a longer interval to AT (82 vs 75 days, p < 0.009) than those in metro areas. However on multivariate analysis URR inhabitance was no longer predictive of any form of AT (OR = 0.892, 95% CI: 0.792-1.006, p = 0.062). Hispanic ethnicity, Medicaid insurance, uninsured status, and lower education were all predictive of decreased likelihood of receiving AT. Median OS was inferior for URR dwellers with pathologic T2 and T3 tumors compared to those in metro areas (19.8 vs. 24.4 months, p = 0.044 and 17.5 vs. 19.4 months, p < 0.001). Cox regression revealed URR location remained independently associated with poorer OS (HR 1.076, 95% CI: 1.008-1.149, p < 0.029). Conclusions: While living in a URR does not lead to reduced access to AT, it is associated with a worse OS in resected PDAC. This may be due to inadequate AT or other socioeconomic factors present in URR patients. Attention must be focused on improving oncologic care for groups susceptible to treatment disparities.
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Affiliation(s)
| | | | | | | | - Bruce Lin
- Virginia Mason Medical Center, Seattle, WA
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Bertens KA, Crown A, Clanton J, Alemi F, Alseidi AA, Biehl T, Helton WS, Rocha FG. What is a better predictor of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD): postoperative day one drain amylase (POD1DA) or the fistula risk score (FRS)? HPB (Oxford) 2017; 19:75-81. [PMID: 27825541 DOI: 10.1016/j.hpb.2016.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/25/2016] [Accepted: 10/02/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Both fistula risk score (FRS) and drain amylase in postoperative day 1 (POD1DA) have been promoted as tools to guide placement and removal of surgical drains following pancreaticoduodenectomy (PD). However, their individual utility has not been compared. METHODS A consecutive cohort of PD patients from 2013 to 2015 were identified from a prospectively collected institutional database. Pearson correlation coefficients and receiver operating characteristic (ROC) curves were calculated for FRS (negligible/low vs. moderate/high) and POD1DA of 600 U/L and 5000 U/L as predictors of clinically relevant postoperative pancreatic fistula (CR-POPF). RESULTS The incidence of CR-POPF was 27% in 216 patients. Sensitivity and specificity of FRS, POD1DA >600 U/L, and POD1DA >5000 U/L for predicting CR-POPF were 83% and 55%, 94% and 60%, 33% and 90%. The ROC area under the curve (AUC) for POD1DA >600 U/L (0.764) and FRS (0.749) were not significantly different (p = 0.713). However, POD1DA >5000 U/L (0.615) was significantly worse at predicting CR-POPF (p = 0.015). When FRS and POD1DA >600 U/L were combined; there was no improvement (p = 0.624). DISCUSSION FRS and POD1DA are equally accurate in predicting CR-POPF. Patients with negligible/low FRS or POD1DA <600 U/L should be considered for drain removal.
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Affiliation(s)
- Kimberly A Bertens
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Angelena Crown
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Jesse Clanton
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Farzad Alemi
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Adnan A Alseidi
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Thomas Biehl
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - William S Helton
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Flavio G Rocha
- Section of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
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Knowles SA, Bertens KA, Croome KP, Hernandez-Alejandro R. The current role of intraoperative ultrasound during the resection of colorectal liver metastases: A retrospective cohort study. Int J Surg 2015; 20:101-6. [PMID: 26070252 DOI: 10.1016/j.ijsu.2015.05.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 03/06/2015] [Accepted: 05/29/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Liver resections with negative margins improve survival in patients with colorectal liver metastases (CRLM). Intraoperative ultrasound (IOUS) is a valuable tool that gives information about lesions that ultimately changes surgical strategy to ensure complete removal, which subsequently improves disease free survival (DFS). METHODS A retrospective review of patients who underwent a resection for CRLM from 2009 to 2012 was completed to determine the impact of IOUS. RESULTS A total of 103 patients had a hepatic resection for CRLM. All patients had preoperative imaging to assist with operative planning. IOUS was performed in 72 cases. Surgical strategy changed in 31 (43.1%) cases with IOUS, compared to three (9.7%) with no IOUS (P < 0.001). A new lesion was detected in 13 (18.1%) of the cases. A higher proportion of nonanatomic liver resections were performed in the IOUS group (N = 27, 37.5%) compared to the non-IOUS group (N = 6, 19.4%) (P = 0.07). CONCLUSION Achievement of a negative resection margin was comparable between the two groups. However, there was a trend toward improved DFS in the IOUS group. Despite advances in preoperative imaging, IOUS demonstrates utility in providing novel information that allows removal of the entire tumor burden, using parenchymal-preserving techniques when feasible, leading to improved DFS.
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Affiliation(s)
- Sarah A Knowles
- Western University, Division of General Surgery, 339 Windermere Rd, PO Box 5339, London, ON N6A 5A5, Canada.
| | - Kimberly A Bertens
- Western University, Division of General Surgery, 339 Windermere Rd, PO Box 5339, London, ON N6A 5A5, Canada
| | - Kristopher P Croome
- Mayo Clinic, Division of Gastroenterologic and General Surgery, 15, 1st Street SE 501, Rochester, MN 55904, USA
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Bertens KA, Hawel J, Lung K, Buac S, Pineda-Solis K, Hernandez-Alejandro R. ALPPS: challenging the concept of unresectability--a systematic review. Int J Surg 2014; 13:280-287. [PMID: 25496851 DOI: 10.1016/j.ijsu.2014.12.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 12/07/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. MATERIALS AND METHODS A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. RESULTS To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61-93% over a median 9-14 days, 95-100% completion of the second stage, and high likelihood of R0 resection (86-100%). DISCUSSION ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate (<30%). Use in patients with poor functional status, or advanced age (>70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. CONCLUSIONS A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.
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Affiliation(s)
- Kimberly A Bertens
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Kalvin Lung
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Suzana Buac
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Karen Pineda-Solis
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, 339 Windermere Road, London, ON, Canada N6A 5A5; Multi-Organ Transplant Program, London Health Sciences Centre, 339 Windermere Road, London, ON, Canada N6A 5A5.
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Huang J, Tang W, Hernandez-Alejandro R, Bertens KA, Wu H, Liao M, Li J, Zeng Y. Intermittent hepatic inflow occlusion during partial hepatectomy for hepatocellular carcinoma does not shorten overall survival or increase the likelihood of tumor recurrence. Medicine (Baltimore) 2014; 93:e288. [PMID: 25526466 PMCID: PMC4603114 DOI: 10.1097/md.0000000000000288] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate whether the long-term outcomes of hepatocellular carcinoma (HCC) was adversely impacted by intermittent hepatic inflow occlusion (HIO) during hepatic resection. METHODS 1549 HCC patients who underwent hepatic resection between 1998 and 2008 were identified from a prospectively maintained database. Intermittent HIO was performed in 931 patients (HIO group); of which 712 patients had a Pringle maneuver as the mechanism for occlusion (PM group), and 219 patients had selective hemi-hepatic occlusion (SO group). There were 618 patients that underwent partial hepatectomy without occlusion (occlusion-free, OF group). RESULTS The 1-, 3-, and 5- year overall survival (OS) rates were 79%, 59%, and 42% in the HIO group, and 83%, 53%, and 35% in the OF group, respectively. The corresponding recurrence free survival (RFS) rates were 68%, 39%, and 22% in the HIO group, and 74%, 41%, and 18% in the OF group, respectively. There was no significant difference between the 2 groups in OS or RFS (P=0.325 and P=0.416). Subgroup analysis showed patients with blood loss over 3000 mL and those requiring transfusion suffered significantly shorter OS and RFS. Blood loss over 3000 mL and blood transfusion were independent risk factors to OS and RFS. CONCLUSIONS The application of intermittent HIO (PM and SO) during hepatic resection did not adversely impact either OS or RFS in patients with HCC. Intermittent HIO is still a valuable tool in hepatic resection, because high intraoperative blood loss resulting in transfusion is associated with a reduction in both OS and RFS.
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Affiliation(s)
- Jiwei Huang
- From the Department of Liver Surgery, Division of Liver Transplantation, West China Hospital, Sichuan University, Chengdu, China (JH, HW, ML, JL, YZ); Department of Hepato-Biliary-Pancreatic Surgery, University of Tokyo Hospital, University of Tokyo, Tokyo, Japan (WT); Department of Hepato-Biliary-Pancreatic Surgery, London Health Sciences Centre, Western University, London, Canada (RHA, KAB)
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Hernandez-Alejandro R, Bertens KA, Pineda-Solis K, Croome KP. Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases? Surgery 2014; 157:194-201. [PMID: 25282528 DOI: 10.1016/j.surg.2014.08.041] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 08/15/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Meticulous selection of patients who can undergo the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure safely will be paramount to minimize the associated morbidity and mortality. METHODS We collected data prospectively on 14 consecutive patients who underwent the ALPPS procedure for planned resection of colorectal liver metastases at London Health Sciences Centre, Canada, between April 2012 and November 2013. RESULTS The median relative increase of the standardized future liver remnant after the ALPPS procedure was 93 ± 28%. The standardized future liver remnant rate of volume increase was 35 ± 13 mL/day. Biopsies of the FLR were taken during stage 1 and 2. These biopsies showed a mean preregeneration Ki-67 index of 0% and a postregeneration index of 14 ± 3%. All 14 ALPPS patients completed the 2-stage hepatectomy. No complications occurred after ALPPS stage 1. After ALPPS stage 2, 5 patients had complications (36%), with 2 patients (14%) having a severe complication (Clavien-Dindo ≥ IIIB). Median follow-up was 9 months. Overall survival at the time of follow-up was 100%. Recurrence developed in 2 patients. One patient had recurrence in the liver and lungs 5 months after stage 2 and was offered more chemotherapy. The other patient developed recurrence in the liver remnant 9 months after stage 2 and underwent additional chemotherapy with a possible future resection of the recurrence. CONCLUSION Low morbidity and negligible mortality can be achieved with the ALPPS procedure, and the high rates published in previous reports can be improved with refinements in technique and patient selection. The ALPPS approach may be a valid option to enable resection in selected patients with colorectal liver metastases considered unresectable previously by standard techniques.
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Affiliation(s)
| | - Kimberly A Bertens
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada
| | - Karen Pineda-Solis
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada
| | - Kristopher P Croome
- Department of Surgery, Division of General Surgery, Western University, London, Ontario, Canada; Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
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Bertens KA, Livingston M, Quan D, Leslie K, Zorzi A, Bütter A. Neuroendocrine tumor of the pancreas causing biliary obstruction in a 12 year-old girl: A case report and literature review. Journal of Pediatric Surgery Case Reports 2014. [DOI: 10.1016/j.epsc.2014.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Bertens KA, Vogt KN, Hernandez-Alejandro R, Gray DK. Non-operative management of blunt hepatic trauma: Does angioembolization have a major impact? Eur J Trauma Emerg Surg 2014; 41:81-6. [PMID: 26038170 DOI: 10.1007/s00068-014-0431-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 07/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE A paradigm shift toward non-operative management (NOM) of blunt hepatic trauma has occurred. With advances in percutaneous interventions, even severe liver injuries are being managed non-operatively. However, although overall mortality is decreased with NOM, liver-related morbidity remains high. This study was undertaken to explore the morbidity and mortality of blunt hepatic trauma in the era of angioembolization (AE). METHODS A retrospective cohort of trauma patients with blunt hepatic injury who were assessed at our centre between 1999 and 2011 were identified. Logistic regression was undertaken to identify factors increasing the likelihood of operative management (OM) and mortality. RESULTS We identified 396 patients with a mean ISS of 33 (± 14). Sixty-two (18%) patients had severe liver injuries (≥ AAST grade IV). OM occurred in 109 (27%) patients. Logistic regression revealed high ISS (OR 1.07; 95% CI 1.05-1.10), and lower systolic blood pressure on arrival (OR 0.98; 95% CI 0.97-0.99) to be associated with OM. The overall mortality was 17%. Older patients (OR 1.05; 95% CI 1.03-1.07), those with high ISS (OR 1.11; 95% CI 1.08-1.14) and those requiring OM (OR 2.89; 95% CI 1.47-5.69) were more likely to die. Liver-related morbidities occurred in equal frequency in the OM (23%) and AE (29%) groups (p = 0.32). Only 3% of those with NOM experienced morbidity. CONCLUSIONS The majority of patients with blunt hepatic trauma can be successfully managed non-operatively. Morbidity associated with NOM was low. Patients requiring AE had morbidity similar to OM.
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Affiliation(s)
- K A Bertens
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada,
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Rotenberg BW, Bertens KA. Use of complementary and alternative medical therapies for chronic rhinosinusitis: a canadian perspective. J Otolaryngol Head Neck Surg 2010; 39:586-593. [PMID: 20828524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Many Canadians use complementary and alternative medicines (CAMs) to treat their chronic diseases. The objective of this study was to report patients' use of CAM for chronic rhinosinusitis (CRS) and to determine factors predictive of CAM use. METHOD A cross-sectional survey was conducted. Self-report questionnaires were administered to patients with CRS using strict inclusion and exclusion criteria. The questionnaire included demographic information, questions pertaining to disease severity, and CAM use for CRS treatment. Statistical analysis was used to compare gender, age range, symptom duration, pharmacotherapy use, and surgical frequency among CAM users and nonusers. A binomial logistic regression model was developed to predict CAM use. Secondary outcome measures included factors predictive of CAM use, type of CAM used, and reasons for using CAM. RESULTS Data were obtained from 288 patients. Forty-five respondents (15.6%) had used CAM as a treatment for their CRS. CAM users were more likely to be females and more likely to have used each class of pharmacotherapy. On logistic regression, female gender and use of nasal corticosteroids were predictive of CAM use. CONCLUSION The use of CAM as treatment of CRS is common. Females and those who have used the various classes of pharmacotherapy are more likely to use CAM. Both female gender and nasal corticosteroid use are predictive of CAM use. Physicians should routinely inquire about CAM use from their patients with CRS.
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Affiliation(s)
- Brian W Rotenberg
- Department of Otolaryngology, St. Joseph’s Health Care, 268 Grosvenor Street, London, ON N6A 4V2.
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