Indocyanine green retention is a potential prog-nostic indicator after splenectomy and pericar-dial devascularization for cirrhotic patients

BACKGROUND: Splenectomy and pericardial devasculariza-tion (SPD) is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension. Indocyanine green retention at 15 minutes (ICGR15) was reported to offer better sensitivity and speciifc-ity than the Child-Pugh classiifcation in hepatectomy, but few reports describe ICGR15 in SPD. The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.
METHODS: From January 2012 to January 2015, 43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD. The ICGR15, Child-Pugh classiifcation, model for end-stage liver disease (MELD) score, and perioperative characteristics were analyzed retrospectively.
RESULTS: Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of 13.6%-43.0% and MELD score of 7-20; 8 patients were class B with ICGR15 of 22.8%-40.7% and MELD score of 7-17; 1 patient was class C with ICGR15 of 39.7% and MELD score of 22. The optimal ICGR15 threshold for liver function com-pensation was 31.2%, which offered a sensitivity of 68.4% and a speciifcity of 70.8%. Univariate analysis showed preopera-tive ICGR15, MELD score, surgical procedure, intraoperative blood loss, and autologous blood transfusion were signiifcant-ly different between postoperative liver function compensated and decompensated groups. Multivariate regression analysis revealed that ICGR15 was an independent risk factor of post-operative liver function recovery (P=0.020).
CONCLUSIONS: ICGR15 has outperformed the Child-Pugh classiifcation for assessing liver function in cirrhotic patients with portal hypertension. ICGR15 may be a suitable prognos-tic indicator for cirrhotic patients after SPD.     

Laparoscopic right hemicolectomy

Over the past 20 years, laparoscopic colectomy has become a well-established technique in the surgical armamentarium of colorectal operations, with proven reductions in postoperative pain, time to return of bowel function, and length of hospital stay. After early concerns over its oncologic effects, large prospective, multicenter trials have proven its safety in colorectal adenocarcinoma, with equivalence in nodal harvest, recurrence rates, disease-free survival, and overall survival. Laparoscopic right hemicolectomy in particular is a relatively accessible technique which may be performed by a single surgeon and an assistant/camera operator; this operation serves as an excellent method to develop laparoscopic skills for more complicated colorectal procedures. In this article, we describe the technical aspects of our approach to laparoscopic right hemicolectomy, which utilizes a medial-to-lateral, no-touch technique and either an intracorporeal or extracorporeal anastomosis.     

Lack of definitive presurgical pathological diagnosis is associated with inadequate surgical margins in breast-conserving surgery

PurposeTo determine the impact of definitive presurgical diagnosis on surgical margins in breast-conserving surgery (BCS) for primary carcinomas; clinicopathological features were also analyzed.MethodsThis retrospective study included women who underwent BCS for primary carcinomas in 2016 and 2017. Definitive presurgical diagnosis was defined as having a presurgical core needle biopsy (CNB) and not being upstaged between biopsy and surgery. Biopsy data and imaging findings including breast density were retrieved. Inadequate surgical margins (IM) were defined per latest ASCO and ASTRO guidelines. Univariable and multivariable analyses were performed.Results360 women (median age, 66) met inclusion criteria with 1 having 2 cancers. 82.5% (298/361) were invasive cancers while 17.5% (63/361) were ductal carcinoma in situ (DCIS). Most biopsies were US-guided (284/346, 82.0%), followed by mammographic (60/346, 17.3%), and MRI-guided (2/346, 0.6%). US and mammographic CNB yielded median samples of 2 and 4, respectively, with a 14G needle. 15 patients (4.2%) lacked presurgical CNB. The IM rate was 30.0%. In multivariable analysis, large invasive cancers (>20 mm), dense breasts, and DCIS were associated with IM (p = 0.029, p = 0.010, and p = 0.013, respectively). Most importantly, lack of definitive presurgical diagnosis was a risk factor for IM (OR, 2.35; 95% CI: 1.23–4.51, p = 0.010). In contrast, neither patient age (<50) nor aggressive features (e.g., LVI) were associated with IM.ConclusionLack of a definitive presurgical diagnosis was associated with a two-fold increase of IM in BCS; other risk factors were dense breasts, large invasive cancers, and DCIS.     

Update on endoscopic enteral access

Enteral access is a common procedure in managing patients in need of enteral nutrition and decompression. Enhancements of technology and improvements in operator skills have resulted in the development of several techniques of enteral access including endoscopic-guided, imaging-guided, laparoscopic-assisted, or combined techniques. Endoscopic enteral access techniques are the most commonly used and preferred method. These include endoscopy-guided nasoenteric tube placement and percutaneous endoscopic enterostomy. These techniques can be safely performed even in challenging conditions such as prior operative intervention, ascites, and head and neck obstructions. However, each type of procedure has its unique set of indication as well as complications. The decision to use endoscopic enteral access should be carefully considered and individualized based on the patient's specific anatomical limitations, preference, overall health status, and disease. In this article, we review current knowledge focusing on endoscopic enteral feeding access including indications, contraindications, preprocedural preparation, procedure technique, enteral access in specific conditions, postprocedural care, and prevention and management of associated complications.