Surgical resection techniques for locally advanced hilar cholangiocarcinoma

Background

Resection of perihilar cholangiocarcinoma involves major hepatectomy including caudate lobectomy. It is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures in the liver hilum. Resectability rates vary from 30 to 80 % and about one third of patients have microscopically involved margins. However, adequately performed resections provide 5-year survival of 30–40 % and are worth pursuing.

Purpose

Better understanding of anatomy, better imaging, improved surgical techniques and progress in perioperative care of these patients have pushed the limits of resection of these tumours. Many of the traditional indicators of inoperability such as bilateral involvement of second-order hepatic ducts, contralateral biliary and vascular involvement, and need for arterial resection have been overcome or are being challenged. This review discusses techniques that may increase margin-free resectability of Bismuth–Corlette type III and IV perihilar cholangiocarcinoma.

Conclusion

Advanced perihilar cholangiocarcinoma requires extended liver resection and often vascular resection, despite which the margin may be compromised in about one third of patients. Right sided tumours are likely to need right trisectionectomy and portal vein resection, best served by an en bloc hilar resection or Rex-recess approach. Left-sided tumours often involve contralateral blood vessels and require left trisegmentectomy with possible right portal vein or right hepatic artery reconstruction. These tumours are best tackled by hepatobiliary surgeons with experience in microvascular techniques. Salvage procedures when arterial reconstruction is not feasible are still under evaluation.     

Patterns of Failure and Determinants of Outcomes Following Radical Re-resection for Incidental Gallbladder Cancer

Background

Better appreciation of the course and factors that influence incidental gallbladder cancer is needed to develop treatment strategies aimed at improved outcomes. The purpose of this study was to determine pattern of disease recurrence and influencing factors in patients undergoing radical re-resection for incidental gallbladder cancer.

Methods

Patients undergoing radical re-resection from February 2003 to May 2010 were analyzed. Influence of variables (lymph node ratio, ASA grade, gender, adjuvant treatment, time interval between cholecystectomy and radical re-resection (in months), and TNM stage) on disease-free survival was assessed.

Results

Of 163 patients, 127 (92 female and 35 male patients; median age 50 years) underwent successful radical re-resection. Median duration between two surgeries was 2 months (range 1–10). Twenty-five percent of patients with pT1b disease had lymph node metastases. Two-year disease-free survival rate was 79.6 % (median follow-up, 16 months). On follow-up, 18 of 24 patients developed recurrences at distant sites. Lymph node metastasis was the single variable significantly influencing disease-free survival. Adjusting for disease stage when analyzing time interval between cholecystectomy and radical re-resection on a continuous scale as a prognostic factor for recurrence revealed no significant impact of increasing interval between surgeries (hazard ratio 1.12; 95 % confidence interval 0.95–1.34; p = 0.17).

Conclusions

The most important predictor of disease recurrence is lymph node metastases. In patients who undergo curative radical re-resection for incidental gallbladder cancer, recurrent disease is more likely to occur at distant sites. Patients with pT1b disease should be offered radical re-resection with a radical lymphadenectomy. It is not the delay in revision surgery but TNM stage that influences outcomes in incidental gallbladder cancer.     

WNT pathway signaling is associated with microvascular injury and predicts kidney transplant failure

Microvascular injury is associated with accelerated kidney transplant dysfunction and allograft failure. Molecular pathology can identify new mechanisms of microvascular injury while improving on the diagnostic and prognostic capabilities of traditional histology. We conducted a case‐control study of archived kidney biopsy specimens stored up to 10 years with microvascular injury (n = 50) compared with biopsy specimens without histologic injury (n = 45) from patients of similar age, race, and sex. We measured WNT gene expression with a multiplex quantification platform by using digital barcoding, given the importance of WNT reactivation to the response to wounding in the kidney microvasculature and other compartments. Of 210 genes from a commercial WNT panel, 71 were associated with microvascular injury and 79 were associated with allograft failure, with considerable overlap of genes between each set. Molecular pathology identified 46 biopsy specimens with molecular evidence of microvascular injury; 18 (39%) were either C4d negative, donor‐specific antibody negative, or had no microvascular injury by histology. The majority of cases with molecular evidence of microvascular injury had poor long‐term outcomes. We identified novel WNT pathway genes associated with microvascular injury and allograft failure in residual clinical biopsy specimens obtained up to 10 years earlier. Further mechanistic studies may identify the WNT pathway as a new diagnostic and therapeutic target.     

Dynamic gadolinium-enhanced echo-planar MR imaging of the liver: Effect of pulse sequence and dose on enhancement

To develop guidelines for clinical magnetic resonance imaging of the liver, the authors undertook an animal study to investigate the effect of dose and pulse sequence on liver signal intensity in gadopentetate dimeglumine—enhanced echo-planar imaging. Serial imaging of the liver was performed in anesthetized rats after intravenous administration of five different doses (0.01, 0.05, 0.1, 0.2, and 0.5 mmol/kg) of contrast agent, with six different pulse sequences. The results show that gadopentetate dimeglumine—enhanced echo-planar images obtained during the perfusion phase can yield either positive (due to increased T1 relaxation rates) or negative (due to susceptibility-induced increased T2 relaxation rates) liver enhancement depending on choice of pulse sequence and dose. At the current clinically recommended dose of 0.1 mmol/kg, maximal liver signal enhancement was seen with a T1-weighted inversion-recovery sequence, while maximal liver signal diminution was seen with a T2*-weighted gradient-echo sequence. The authors conclude that gadopentetate dimeglumine—enhanced echo-planar imaging can provide T1, T2, and T2* contrast that may be exploited for both lesion detection and lesion characterization.     

Bilateral simultaneous laparoscopic adrenalectomy in Cushing's syndrome: safe, effective, and curative

INTRODUCTION: Surgical morbidity and mortality rates are high in patients with Cushing's syndrome. Nevertheless, simultaneous bilateral laparoscopic adrenalectomy (LA) is feasible in these patients with less morbidity and good long-term results. BACKGROUND AND RESULTS: Consecutive 22 patients who underwent LA for Cushing's syndrome between 2003 and 2010 in our institute were retrospectively studied. Ninteen patients underwent bilateral simultaneous and three underwent unilateral LA. Seven patients had Cushing's syndrome after failed pituitary surgery and five each had ectopic adrenocorticotrophic hormone dependent syndrome and bilateral macronodular hyperplasia respectively. LA was bilaterally done by lateral transabdominal adrenalectomy in 15 patients and retroperitoneal endoscopic adrenalectomy in 4 on the right side. Mean operative time for simultaneous bilateral cases was 199.45±72.43 minutes with mean blood loss of 72.72±48.6 mL. Patients were fit for discharge by the fifth postoperative day from the surgical aspect. Surgical complication rate was 26% that included wound infections in two, port site hernia, pleural effusion, and atelectasis in one each. One patient died of sepsis (5% mortality). Satisfactory metabolic control was achieved in all observable patients in the long term although Addisonian crisis and Nelson syndrome were seen in 26% and 15% respectively. CONCLUSION: LA has all advantages of minimal access surgery in patients with Cushing's syndrome who are immunocompromised and at high risk of delayed wound healing and infections. Magnification decreases the risk of retained adrenal remnants. Despite advances in minimal access surgery, perioperative morbidity continues to be significant for the procedure.     

Extracorporeal management of poisonings

Extracorporeal methods have been an integral part in the management of poisonings. The elimination of a drug or toxin by extracorporeal techniques (ECT) is governed by the properties of the toxin and the chosen extracorporeal therapy. The various ECT include hemodialysis, hemoperfusion, hemofiltration, continuous renal replacement therapy and peritoneal dialysis, all of which have been used some time or another for the management of poisonings. This review highlights the concepts forming the basis for selecting one modality over the others.     

Reconstructive challenges in war wounds

War wounds are devastating with extensive soft tissue and osseous destruction and heavy contamination. War casualties generally reach the reconstructive surgery centre after a delayed period due to additional injuries to the vital organs. This delay in their transfer to a tertiary care centre is responsible for progressive deterioration in wound conditions. In the prevailing circumstances, a majority of war wounds undergo delayed reconstruction, after a series of debridements. In the recent military conflicts, hydrosurgery jet debridement and negative pressure wound therapy have been successfully used in the preparation of war wounds. In war injuries, due to a heavy casualty load, a faster and reliable method of reconstruction is aimed at. Pedicle flaps in extremities provide rapid and reliable cover in extremity wounds. Large complex defects can be reconstructed using microvascular free flaps in a single stage. This article highlights the peculiarities and the challenges encountered in the reconstruction of these ghastly wounds.KEY WORDS: Delayed reconstruction, reconstructive challenges, war wound, wound debridement     

Synchronous Tricompartmental Benign CNS Tumors with Tonsillar Herniation, Cervicodorsal Syringomyelia and Hydrocephalus

In this study, three primary central nervous system tumors of different histological cell types occurring together without neurofibromatosis are reported. These included a sellar pituitary adenoma with apoplexy, a large torculo-tentorial meningioma in the posterior fossa, and a cervical spinal intramedullary schwannoma. Displacement of primitive multipotent cells in different central nervous system compartments or the oncogenic effects of activated signaling of growth factor receptors are the proposed pathophysiological mechanisms for the simultaneous genesis of different types of tumors. There was associated tonsillar herniation, cervicodorsal syringomyelia, and hydrocephalus. The radiological features and treatment strategy of these rare synchronous tumors are highlighted.     

Breast Surgery Outcomes as Quality Measures According to the NSQIP Database

Background

The National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted database designed to benchmark quality initiatives. NSQIP captures uniform morbidity variables for all operations and calculates expected morbidity probabilities. Given the frequent need for reoperation following breast-conserving surgery (BCS) and mastectomy, we hypothesized that NSQIP may inaccurately reflect surgical morbidity after breast cancer operations.

Methods

Using the 2008 NSQIP database, we identified 24,447 breast surgery patients. We calculated the observed versus expected (O/E) morbidity ratios, compared them to other general surgery procedures, and analyzed the O/E morbidity ratios among benign and malignant breast diagnoses.

Results

The NSQIP database shows that breast surgery has an O/E morbidity ratio of 3.11, which is higher than other general surgery procedures. Additionally, breast operations for malignancy have higher O/E morbidity ratios (3.22) than those performed for benign disease (2.59). Analysis of malignant patients by CPT code revealed that BCS patients had an O/E morbidity ratio of 7.75 and attributed 89?% of morbidity to reoperation, whereas mastectomy patients had an O/E morbidity ratio of only 1.7. Elimination of the reoperation variable from morbidity calculations in breast surgery reduces the O/E morbidity ratio to less than expected in all breast procedures.

Discussion

Breast surgery has a higher O/E morbidity ratio than other general surgery procedures. Reoperations are expected in BCS for positive margins and in mastectomy for completion ALND. Breast surgeons should advocate for benchmarking by surgical site-specific metrics, because current NSQIP criteria may negatively affect the quality assessment of high-volume breast centers.     

The United Kingdom and Ireland Trauma & Orthopaedic eLogbook-An evidence base for enhancing training

The United Kingdom and Ireland Trauma and Orthopaedic (T&O) eLogbook was originally conceived over ten years ago in order to provide individual surgeon support and allow national analysis of surgical training experience. Since 2003 every trainee in T&O has been required to submit data recording their operative experience throughout the six years of higher specialist training. We describe how orthopaedic surgeons are using the evidence from the eLogbook to improve training, set operative standards and support consultant (post-specialist registration) revalidation.