A Randomized Controlled Trial of Postoperative Thoracic Epidural Analgesia Versus Intravenous Patient-controlled Analgesia After Major Hepatopancreatobiliary Surgery.

Objectives: The primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient-controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization, and complications.

Background: Although adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial.

Tips and tricks of splenic vessel preservation during laparoscopic distal pancreatectomy.

Background: While a laparoscopic approach can minimize postoperative morbidity in splenic vessel preserving (SVP) distal pancreatectomy (DP), this procedure can be technically challenging. A systematic approach to SVP minimizes the chances of vascular injury and maximizes the chances of successful splenic preservation. This video demonstrates a laparoscopic DP with SVP, highlighting technical tips and tricks that optimize the chances for SVP.

Association of Clinical Factors With a Major Pathologic Response Following Preoperative Therapy for Pancreatic Ductal Adenocarcinoma.

Importance: We previously demonstrated that a major pathologic response to preoperative therapy, defined histopathologically by the presence of less than 5% viable cancer cells in the surgical specimen, is an important prognostic factor for patients with pancreatic ductal adenocarcinoma. However, to our knowledge, the patients most likely to experience a significant response to therapy are undefined.

Objective: To identify clinical factors associated with major pathologic response in a large cohort of patients who underwent preoperative therapy and pancreatectomy for pancreatic ductal adenocarcinoma.

Neutrophil-to-lymphocyte ratio predicts prognosis after neoadjuvant chemotherapy and resection of intrahepatic cholangiocarcinoma.

Background: Previous studies have demonstrated a strong association between the preoperative neutrophil-to-lymphocyte ratio and the outcomes of patients with resected hepatocellular carcinoma and colorectal liver metastases. However, the predictive ability of neutrophil-to-lymphocyte ratio in patients with intrahepatic cholangiocarcinoma, especially those treated with preoperative chemotherapy, has been less well described.

Methods: The clinicopathological characteristics, overall survival, and recurrence free survival of all patients with intrahepatic cholangiocarcinoma resected between 2000-2015, were compared between those with elevated (≥3.

Natural History of T1N0M0 Hepatocellular Carcinoma: Large-Scale Study in the United States.

Background: Hepatocellular carcinoma (HCC) prognosis depends on clinicopathological features in addition to the treatment provided. We aimed to assess the natural history of TNM stage I HCC tumors which received different treatment over a period of 20 years.

Methods: Between 1992 and 2011, a total of 397 stage I HCC patients were included.

Portal Vein Embolization Reduces Postoperative Hepatic Insufficiency Associated with Postchemotherapy Hepatic Atrophy.

Background: The risk of postoperative hepatic insufficiency (PHI) is increased among patients with significant postchemotherapy hepatic atrophy. The primary aim of this study was to evaluate whether the liver regeneration stimulated by portal vein embolization (PVE) can protect against PHI.

Methods: Clinicopathological features of 177 patients treated with preoperative chemotherapy followed by PVE and hepatectomy were reviewed.

RAS Mutation Clinical Risk Score to Predict Survival After Resection of Colorectal Liver Metastases.

Objective: To determine the impact of RAS mutation status on the traditional clinical score (t-CS) to predict survival after resection of colorectal liver metastases (CLM).

Background: The t-CS relies on the following factors: primary tumor nodal status, disease-free interval, number and size of CLM, and carcinoembryonic antigen level. We hypothesized that the addition of RAS mutation status could create a modified clinical score (m-CS) that would outperform the t-CS.

Using MRI to non-invasively and accurately quantify preoperative hepatic steatosis.

Background: The obesity epidemic has significantly increased the incidence and severity of hepatic steatosis in liver surgery patients and liver donors, potentially impacting postoperative liver regeneration and function. Development of a non-invasive means to quantify hepatic steatosis would facilitate selection of candidates for liver resection and transplant donation.

Methods: An IRB-approved protocol prospectively enrolled 28 patients with liver tumors requiring hepatic resection.

Total Laparoscopic Management for Stage IV Colorectal Cancer Requiring Multivisceral Resection.

Background: Surgical resection of all sites of disease, in combination with effective systemic chemotherapy, offers the only potential chance for cure for patients with stage IV colorectal cancer (CRC). Coordinated multistage resection using a minimally invasive approach may provide optimal oncologic outcome while potentially offering the benefit of decreased morbidity.

Patient: A 66-year-old women presented with transverse colon cancer and synchronous metastasis (CRLM) in segment IV involving the middle hepatic vein and main left portal pedicle, as well as the left adrenal gland.

Management of unresectable intrahepatic cholangiocarcinoma: how do we decide among the various liver-directed treatments?

Intrahepatic cholangiocarcinoma often causes death due to obstruction of the biliary system or interruption of the vascular supply of the liver. This fact emphasizes the critical need for local tumor control in this disease. Successful local tumor control has traditionally been achievable through surgical resection for the small proportion of patients with operable tumors.

Prognostic value of incidental hypervascular micronodules detected on cone-beam computed tomography angiography of patients with liver metastasis.

Purpose: To determine the clinical relevance of incidentally-found hypervascular micronodules (IHM) on cone-beam computed tomography angiography (CBCTA) in patients with liver metastasis undergoing transarterial (chemo)embolization (TACE/TAE).

Material And Methods: This was a HIPAA-compliant institutional review board-approved single-institution retrospective review of 95 non-cirrhotic patients (52 men; mean age, 60 years) who underwent CBCTA prior to (chemo)embolic delivery. IHM were defined by the presence of innumerable subcentimetre hepatic parenchymal hypevascular foci not detected on pre-TACE/TAE contrast-enhanced cross-sectional imaging.

NCCN Guidelines Insights: Hepatobiliary Cancers, Version 1.2017.

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

Incidental Gallbladder Cancer: Residual Cancer Discovered at Oncologic Extended Resection Determines Outcome: A Report from High- and Low-Incidence Countries.

Background: Gallbladder cancer detected incidentally after cholecystectomy (IGBC) currently is the most common diagnosis of gallbladder cancer, and oncologic extended resection (OER) is recommended for tumors classified higher than T1b. However, the precise prognostic significance of residual cancer (RC) found at the time of OER has not been well established. This analysis aimed to determine the prognostic impact of RC found in patients with IGBC undergoing OER.

APC and PIK3CA Mutational Cooperativity Predicts Pathologic Response and Survival in Patients Undergoing Resection for Colorectal Liver Metastases.

Objective: The aim of the study was to determine the prognostic impact of co-existence of APC and PIK3CA mutations in patients undergoing preoperative chemotherapy and resection for colorectal liver metastases (CLM).

Background: Co-occurring genetic events have been shown to drive carcinogenesis in multiple malignancies.

Methods: We identified 396 patients with primary colorectal cancer and known somatic mutation status by next-generation sequencing who underwent hepatectomy for CLM (2005-2015).

Local tumour progression after percutaneous ablation of colorectal liver metastases according to RAS mutation status.

Background: Percutaneous ablation is a common treatment for colorectal liver metastasis (CLM). However, the effect of rat sarcoma viral oncogene homologue (RAS) mutation on outcome after ablation of CLMs is unclear.

Methods: Patients who underwent image-guided percutaneous ablation of CLMs from 2004 to 2015 and had known RAS mutation status were analysed.

Hepatic atrophy following preoperative chemotherapy predicts hepatic insufficiency after resection of colorectal liver metastases.

Background & Aims: For patients with colorectal liver metastases (CLM) undergoing major hepatectomy, extensive preoperative chemotherapy has been associated with increased morbidity and mortality. The impact of extensive chemotherapy on total liver volume (TLV) change is unclear. The aims of the current study were twofold: (1) to determine the change of TLV following preoperative chemotherapy in patients undergoing resection for CLM and (2) to investigate the correlations among TLV change, postoperative hepatic insufficiency (PHI), and death from liver failure.

Embryonic origin of primary colon cancer predicts survival in patients undergoing ablation for colorectal liver metastases.

Background: In patients with primary colorectal cancer (CRC) or unresectable metastatic CRC, midgut embryonic origin is associated with worse prognosis. The impact of embryonic origin on survival after ablation of colorectal liver metastases (CLM) is unclear.

Methods: We identified 74 patients with CLM who underwent percutaneous ablation during 2004-2015.

Effective Laparoscopic Management Lymph Node Dissection for Gallbladder Cancer.

Background: Part of optimal prognostication of gallbladder cancer is optimal lymph node staging. Accurate laparoscopic lymph node staging is dependent on a systematic approach to sampling N1 and N2 lymph node stations. Stations with the highest risk of involvement are 12a, b, p and c, 13 and 16, as well as 8 and 9.

Influence of Preoperative Therapy on Short- and Long-Term Outcomes of Patients with Adenocarcinoma of the Ampulla of Vater.

Introduction: Although preoperative therapy is increasingly administered to patients with pancreatic adenocarcinoma, the role of preoperative therapy for patients with adenocarcinoma of the ampulla of Vater is undefined.

Methods: All patients with ampullary cancer who were evaluated between 1999 and 2014 were retrospectively reviewed. Differences in clinicopathologic characteristics, perioperative complications, and overall survival were compared between patients who underwent surgery de novo and those who received preoperative therapy before pancreatoduodenectomy.

Comparative effectiveness of first-line radiofrequency ablation versus surgical resection and transplantation for patients with early hepatocellular carcinoma.

Background: Significant controversy exists as to which treatment modality is most effective for small, solitary hepatocellular carcinomas (HCCs): radiofrequency ablation (RFA), surgical resection (RXN), or transplantation (TXP). Size cutoff values ranging from 20 to 50 mm have been proposed to achieve complete ablation. The current study compares outcomes between RFA, RXN, and TXP as first-line therapy for patients with HCC tumors measuring as large as 50 mm.