Laparoscopic liver resection in cirrhotics: feasibility and short-term outcomes compared to non-cirrhotics.

BACKGROUND: Laparoscopic liver resection (LLR) is increasingly common worldwide but its suitability in patients with cirrhosis is not clearly defined. There are minimal data in the western literature on this topic and previous work has compared LLR to open hepatectomy rather than to LLR in non-cirrhotic patients. This study compared short-term outcomes of LLR in cirrhotic patients to LLR in non-cirrhotic patients. METHODS: Retrospective review of minor LLR at the Royal Infirmary of Edinburgh from January 2006 to January 2018 was conducted. Patients were stratified by whether they had cirrhosis - defined as per radiological appearances and liver function tests. Variables of interest included baseline clinicopathological information with short-term outcomes (length of stay and complications) regarded as the primary outcome of interest. RESULTS: Out of 1207 liver resections in the study period, there were 120 LLR with 30 patients having cirrhosis. Patients with cirrhosis were more likely to be male and have higher median American Society of Anesthesiologists scores (3 versus 2; P < 0.01). The most common operation was left lateral sectionectomy (n = 67). There was no difference in duration of surgery (cirrhosis 88 min versus no cirrhosis 99 min; P = 0.64) and patients in the cirrhosis arm had no conversions to open (0% versus 12%; P = 0.06). There was no difference in complications (12% versus 13%; P = 0.75) or median length of stay (4 versus 4 days; P = 0.14) and no difference in survival between both groups. CONCLUSION: With careful patient selection, LLR is feasible in patients with cirrhosis and provides comparable outcomes to non-cirrhotic patients undergoing LLR.

Comparative Effectiveness of Management Strategies for Renal Artery Stenosis: An Updated Systematic Review.

BACKGROUND: Atherosclerotic renal artery stenosis (ARAS) is associated with high blood pressure (BP), decreased kidney function, renal replacement therapy (RRT), and death. PURPOSE: To compare benefits and harms of percutaneous transluminal renal angioplasty with stent placement (PTRAS) versus medical therapy alone in adults with ARAS. DATA SOURCES: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1993 to 16 March 2016; gray literature; and prior systematic reviews. STUDY SELECTION: Randomized, controlled trials (RCTs); nonrandomized, comparative studies (NRCSs); single-group studies; and selected case reports that reported all-cause and cardiovascular mortality, RRT, kidney function, BP, and adverse events. DATA EXTRACTION: Six researchers extracted data on design, interventions, outcomes, and study quality into a Web-based database. DATA SYNTHESIS: Eighty-three studies met eligibility criteria. In 5 of 7 RCTs, PTRAS and medical therapy led to similar BP control in patients with ARAS, and no RCTs showed statistically significant differences in kidney function, mortality, RRT, cardiovascular events, or pulmonary edema. Eight NRCSs had more variable results, finding mostly no significant differences in mortality, RRT, or cardiovascular events but heterogeneous effects on kidney function and BP. Procedure-related adverse events were rare, and medication-related adverse events were not reported. Two RCTs found no patient characteristics that were associated with outcomes with either PTRAS or medical therapy. Single-group studies found various but inconsistent factors that predict outcomes. Case reports provided examples of clinical improvement after PTRAS in patients with acute decompensation. LIMITATION: Limited clinical applicability and power in RCTs, and possible publication bias and lack of adjusted analyses in NRCSs. CONCLUSION: The strength of evidence regarding the relative benefits and harms of PTRAS versus medical therapy alone for patients with ARAS is low. Studies have generally focused on patients with less severe ARAS. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Development of an international online learning platform for hepatopancreatobiliary surgical training: a needs assessment.

BACKGROUND: The Americas Hepato-Pancreato-Biliary Association (AHPBA) and the Australian and New Zealand Hepatic, Pancreatic and Biliary Association (ANZHPBA) are developing an online distance learning curriculum to facilitate an interactive didactic experience for hepatopancreatobiliary (HPB) fellows in the operationalization of existing HPB fellow curricula. Two needs assessment surveys were carried out to identify the optimal structure and process for deployment in fellow education. METHODS: A 22-question survey querying fellows' learning styles and current and anticipated use of learning tools was disseminated electronically to 38 North American and Australasian HPB fellows. A follow-up 20-question survey was administered to assess fellows' feelings regarding online content. RESULTS: Response rates were 55% (n = 21) for the first survey and 42% for the second (n = 16). In the first survey, 67% of respondents claimed familiarity with the required HPB curriculum, and 43% indicated dissatisfaction with current personal study strategies. A total of 62% (n = 13) reported studying with focused clinical relevance versus using a prescribed curriculum (n = 1, 5%). Fellows anticipated participating using online tools once (n = 10, 48%) or two or three times (n = 5, 24%) per week. Most respondents (n = 18, 86%) would meaningfully follow one or two discussions per month. The second survey identified themes for improvement such as discussion topics of interest, avoidance of holiday timing and mandatory participation. CONCLUSIONS: An international online distance learning format is an appealing mechanism for improved dissemination and operationalization of the established HPB fellow curricula. Fellows will engage in interactive discussions monthly. Controversial topics or those requiring complex decision making are best suited to this learning format.

The value of immunophenotyping hepatocellular adenomas: consecutive resections at one UK centre.

AIMS: To determine the utility of immunophenotyping for classification of hepatocellular adenomas resected at one Scottish centre. METHODS AND RESULTS: This study comprised a retrospective review and immunophenotyping of consecutive resected benign hepatocellular tumours. Fifty-five patients (seven men) had 64 adenomas and 26 focal nodular hyperplasias (FNHs) resected. Map-like glutamine synthetase (GS) staining was specific for FNH. Immunophenotyping changed the morphological typing for three adenomas and resolved 16 of 18 unclassified or equivocal cases, revealing GS positivity in these (seven) and four others. Steatotic/liver fatty acid binding protein-deficient adenomas were the commonest type in women (12/29 women, 41%) but were absent from men. Where one of multiple adenomas was morphologically unclassified, there was still a shared immunophenotype. Diffuse CD34 positivity correlated with GS positivity or unclassified status (P < 0.0001). Supervised cluster analysis identified morphological discriminants for FNH and predictors of adenoma type and their insensitivity in predicting GS status. Forty per cent of men and 7% of women with adenomas had a specific adenoma risk, including danazol and portal venopathies. Inflammatory adenomas were associated with metabolic syndrome, steatosis, or alcohol (P = 0.053). Four patients showed carcinoma ex-adenoma. CONCLUSIONS: The distribution of adenoma types in this population matches that in others, and immunoprofiling is required for accurate typing. Carcinoma ex-adenoma is uncommon and fits the published risk profile (large size and GS-positive).

Alvimopan (Adolor/GlaxoSmithKline).

Alvimopan is a potent, peripherally active, mu-opioid receptor antagonist being developed by Adolor and GlaxoSmithKline (GSK) as a potential treatment for post-operative ileus and opioid bowel dysfunction.