Incipient Intracholecystic Papillary Neoplasm of the Gallbladder Without Dysplasia.

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a rare tumor described as a mucosal exophytic neoplastic lesion that projects into the gallbladder lumen. In regards to the size, lesions that did not make the arbitrary 1cm cutoff are described as "incipient" ICPN. Not much is known about these incipient ICPNs, as they are often excluded in ICPN studies, given the attempted adherence to the traditional 1cm cutoff. We present the youngest reported case of incipient, non-mucinous gastric-pylorus type ICPN who underwent cholecystectomy. Resection with negative margin for ICPN appears to be sufficient treatment and post resection imaging surveillance could be of value but further studies are required.

Minimally Invasive Lower Anterior Resections - Better than Open But Not All the Same.

Background/Objective: Optimal approach for lower anterior resection has been closely debated. The relatively new addition of the robotic approach adds a layer of complexity to this topic. The majority of the literature has compared the possible approaches between two techniques; however, only a few studies have comprehensively compared all 3 approaches at the same time, especially in a non-academic center.Study Design: This is a retrospective cohort study of a prospectively maintained database of data from a large group of private-practice colorectal surgeons in a large metropolitan area. Specifically, rectal resections using open, laparoscopic, and robotic approaches were queried. A total of 130 patients underwent open, laparoscopic, or robotic oncological lower anterior resection from 2016 to January 2020.Results: Statistical significance of length of stay was noted between the three approaches with the mean length of stay for open being 8.08 days, laparoscopic being 7.04 days, and robotic being 4.96 days (P < .005). No statistical significance was noted for estimated blood loss, operating time, or postoperative complications including anastomotic leak, ileus, pneumonia, pulmonary embolism, surgical site infection, and urinary tract infection. When directly comparing any minimally invasive surgery approach to open, estimated blood loss was decreased in addition to the shortened length of stay (P < .05).Conclusions: This study demonstrates that MIS LAR has significant benefit over the open approach. However, finding that robotic surgery had was superior to laparoscopic LAR which was surprising and important. This experience in the private world raises the question as to whether robotic LAR should be considered the standard of care.

"Infiltrative" Versus "Mass-Forming" Pancreatic Cancer: A New Radiological Classification System for Pancreatic Head Ductal Carcinoma and Its Pathological Correlation.

Purpose: Resectability in localized pancreatic ductal adenocarcinoma (PDAC) is deemed through radiological criteria. Despite initial evaluation classifying tumors as "resectable," they often have ill-defined borders that can result in more extensive cancer than predicted on final pathology analysis. We attempt to categorize these tumors radiologically and define them as "infiltrative" and contrast them to more well-defined or "mass-forming" tumors and assess their correlation with surgical oncological outcomes. We hypothesize that mass-forming lesions will result in fewer positive resection margins. Methods: Patients diagnosed with PDAC of the head of the pancreas and who underwent subsequent curative intent resection between 2016 and 2018 were included. A retrospective chart review of patients was conducted and computed tomography images at the time of diagnosis were reviewed by two radiologists and scored as "mass forming" or "infiltrative" using a newly developed classification system. These classifications were then correlated with margin status. Results: Sixty-eight consecutive pancreatoduodenectomies performed for PDAC from 2016 to 2018 were identified. After screening, 54 patients were eligible for inclusion. Radiologically defined mass-forming lesions had a trend toward a lower rate of positive resection margins (35.7% vs. 50.0%; p = 0.18), specifically the bile duct margin and pancreas margin as well as an overall larger size (4.03 cm vs. 3.25 cm, p = 0.02) compared with infiltrative lesions. Conclusion: We propose a new radiological definition of PDAC into "mass forming" and "infiltrative," a nomenclature that resonates with other tumor sites. Infiltrative lesions trended toward a higher rate of positive resection margins. This classification may help tailor therapy for infiltrative tumors toward a neoadjuvant approach even if they appear resectable.

Hepatopancreatobiliary Fellowship Graduates: Where Do They Stand today?

BACKGROUND: The Americas Hepato-Pancreato-Biliary Association (AHPBA) Education and Training Committee standardized a Hepatopancreatobiliary (HPB) Surgery Fellowship certification process in 2010. Several classes of fellows have since graduated from HPB, combined Society of Surgical Oncology/AHPBA, and combined American Society of Transplant Surgeons/AHPBA fellowships, but there is little information on their career outcomes. We seek to offer long-term data on the careers of HPB fellowship graduates. METHODS: A 26-question anonymous survey was distributed among graduates of accredited programs for the last 10 years. We generated descriptive statistics from the responses. RESULTS: The respondents were evenly distributed in terms of graduation years between 2010 and 2019. Fifty-eight percent of fellows had completed a prior fellowship, 82% received 1 to 3 job offers during the fellowship, and 75% of respondents were still at their first job. The majority of graduates (>60%) were able to secure a job with a >50% HPB practice and >40 HPB cases per year within 3 years of graduation. Overall, >90% candidates rated their satisfaction with fellowship training greater than 8 out of 10. DISCUSSION: This survey helps shed light on the early formative years in the practices of HPB fellowship graduates. These data show that HPB fellowship training is essential and effective in providing job security and helps fellowship graduates develop a gratifying practice.

Hepatectomy, RFA, and Other Liver Directed Therapies for Treatment of Breast Cancer Liver Metastasis: A Systematic Review.

BACKGROUND: The liver is the second most common site of breast cancer metastasis. Liver directed therapies including hepatic resection, radiofrequency ablation (RFA), transarterial chemo- and radioembolization (TACE/TARE), and hepatic arterial infusion (HAI) have been scarcely researched for breast cancer liver metastasis (BCLM). The purpose of this review is to present the known body of literature on these therapies for BCLM. METHODS: A systematic review was performed with pre-specified search terms using PubMed, MEDLINE, EMBASE, and Cochrane Review resulting in 9,957 results. After review of abstracts and application of exclusion criteria, 51 studies were included in this review. RESULTS: Hepatic resection afforded the longest median overall survival (mOS) and 5-year survival (45 mo, 41%) across 23 studies. RFA was presented in six studies with pooled mOS and 5-year survival of 38 mo and 11-33%. Disease burden and tumor size was lower amongst hepatic resection and RFA patients. TACE was presented in eight studies with pooled mOS and 1-year survival of 19.6 mo and 32-88.8%. TARE was presented in 10 studies with pooled mOS and 1-year survival of 11.5 mo and 34.5-86%. TACE and TARE populations were selected for chemo-resistant, unresectable disease. Hepatic arterial infusion was presented in five studies with pooled mOS of 11.3 months. CONCLUSION: Although further studies are necessary to delineate appropriate usage of liver directed therapies in BCLM, small studies suggest hepatic resection and RFA, in well selected patients, can result in prolonged survival. Longitudinal studies with larger cohorts are warranted to further investigate the effectiveness of each modality.

Investigating Factors at Play in Hepatopancreatobiliary Fellowship Selection: Beliefs versus Reality.

BACKGROUND: Selection biases affecting candidate matches to fellowship programs directly influence diversity within the surgical community. The review of selection bias has never been distinctively investigated in the Hepatopancreatobiliary (HPB) surgery community. This study seeks to (i) evaluate factors affecting selection of candidates to HPB fellowships, (ii) examine explicit biases among program directors and faculty of HPB programs in North America, and (iii) compare the demography of the HPB faculty and recently graduated fellows to general surgery residents. STUDY DESIGN: An anonymous, self-reported survey consisting of 10 sets of fictional applications was distributed to 52 faculty members, including program directors, of AHPBA-affiliated HPB fellowships in North America. The respondents had to pick a preferred candidate between two abridged, fictional HPB fellow applications and give an open-ended response as to why they picked that candidate. The applications were nearly identical with one notable characteristic of interest. Demographic information of both faculty and their recent fellows was also collected. This survey was administered and collected between February and April, 2020. RESULTS: A total of 29 fully completed responses were received, comprising a 55.7% response rate. Respondents were 72.4% male, 69.0% Caucasian, and 79.3% held US medical degrees (MD). 50.0% of respondents preferred an MD candidate to a DO candidate, and 37% preferred US graduates to foreign-trained candidates. The respondents were unanimous in stating that gender, race, and family status were not a factor in their selection process. 5.0% said they would support an LGBTQ candidate when faced with otherwise similar applicants. Seventy-six HPB fellows from the past 5 years were 76.3% male, 56.6% Caucasian, and 51.3% US graduated Doctor of Medicine (US MD). CONCLUSION: This is the first study explicitly exploring the impact of demographic factors in the HPB fellowship selection process. The respondents unanimously and explicitly stated that race and gender do not play any role in their selection process. Yet, there is stark discordance between general surgery resident demographics and HPB fellow demographics. A greater effort to promote a more diverse HPB surgery community may be needed.

Overcoming the Arduous Transition for Robotic Hepatopancreatobiliary Cases: A Multi-Procedure Learning Curve Study Utilizing CUSUM Analysis.

BACKGROUND/OBJECTIVE: Quick optimization and mastery of a new technique is an important part of procedural medicine, especially in the field of minimally invasive surgery. Complex surgeries such as robotic pancreaticoduodenectomies (RPD) and robotic distal pancreatectomies (RDP) have a steep learning curve; therefore, findings that can help expedite the burdensome learning process are extremely beneficial. This single-surgeon study aims to report the learning curves of RDP, RPD, and robotic Heller myotomy (RHM) and to review the results' implications for the current state of robotic hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: This is a retrospective case series of a prospectively maintained database at a non-university tertiary care center. Total of 175 patients underwent either RDP, RPD, or RHM with the surgeon (DRJ) from January 2014 to January 2020. RESULTS: Statistical significance of operating room time (ORT) was noted after 47 cases for RDP (p < 0.05), 51 cases for RPD (p < 0.0001), and 18 cases for RHM (p < 0.05). Mean ORT after the statistical mastery of the procedure for RDP, RPD, and RHM was 124, 232, 93 min, respectively. No statistical significance was noted for estimated blood loss or length of stay. CONCLUSIONS: Robotic HPB procedures have significantly higher learning curves compared to non-HPB procedures, even for an experienced HPB surgeon with extensive laparoscopic experience. Our RPD curve, however, is quicker than the literature average. We suggest that this is because of the simultaneous implementation of HPB (RDP and RPD) and non-HPB robotic surgeries with a shorter learning curve-especially foregut procedures such as RHM-into an experienced surgeon's practice. This may accelerate the learning process without compromising patient safety and outcomes.

Pancreas Cystic Lesions.

This article outlines the principles behind the management of pancreatic cystic lesions. We outline what the general surgeon needs to know in managing and triaging these patients. It is our feeling that the general surgeon is often the first line of evaluation of these complex patients and a working knowledge of the different types of cysts is critical to safe care of the patient.

Teacher and Trainee Learning Together-Dual Console and the 3 Arms.

OBJECTIVE: The purpose of this paper is to propose a method by which the trainer and the trainee can overcome their learning curves together. DESIGN/SETTING/PARTICIPANTS: At a tertiary care facility where we have completely done away with the mandatory bedside procedure requirements, residents and fellows start all cases on the console and have graduated responsibilities assigned to them. Bedside assist cases were felt to take away from trainee precious console time when there were only on service for a limited period while providing laparoscopic skill training without any robot-specific experience. This is a cumulative experience of teaching residents and fellows under this system and its results. RESULTS: All trainees at a PG 3 level or greater were able to perform advanced hiatal dissection within 5 cases. CONCLUSIONS: The authors propose a paradigm that uses all 3 arms of the robot and a dual console system.

Undiagnosed Liver Fibrosis in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma.

BACKGROUND: Chronic obstruction of the biliary system may cause hepatic fibrosis and liver failure. The purpose of this study was to define the incidence of unrecognized liver fibrosis in patients undergoing pancreaticoduodenectomy (PD). METHODS: Retrospective data were collected on patients undergoing PD during a 21-month period. Each patient had a core needle biopsy at the time of surgery by a hepatobiliary surgeon. RESULTS: This study identified 36 consecutive patients who were referred to a tertiary center and underwent pancreatoduodenectomy during a period of 21 months. The majority of patients, 32 (88.8%), were diagnosed with pancreatic adenocarcinoma. Liver fibrosis was diagnosed in 23 (63.9%) patients. A total of 25 (69.4%) patients were found to have pathological evidence of cholestasis consistent with bile obstruction. Patients that were found to have evidence of obstruction had significantly increased odds that fibrosis stage 2 would be found on pathological diagnosis (OR 6.75, 95% CI 1.20-38.02, Fisher's exact test P value = 0.0312). There was no significant association in patients who were stented compared to non-stented patients and their diagnosis of high-grade fibrosis stage 2 (OR 1.5238, 95% CI 0.4019-5.7769, Fisher's exact test P value = 0.7360). CONCLUSIONS: An astonishing 63.9% of patients who underwent PD were diagnosed with stage 1-4 liver fibrosis and half (47.2%) had fibrosis stage of 2 or more. Further, stent status had no significant impact on the degree of liver fibrosis. Liver fibrosis is currently underrecognized in patients undergoing PD, which is important for physicians to be conscious of as it is known that liver fibrosis increases morbidity and mortality.

Perception of training in hepatopancreatobiliary surgery among general surgery residents in the Americas.

BACKGROUND: Hepatopancreatobiliary (HPB) surgery experience during residency in the Americas is limited. Residents interested in HPB surgery have different options available for further training. This study evaluated training in HPB surgery received during general surgery (GS) residency, and sought to determine the perception of fellowship training in HPB surgery. METHODS: An anonymous survey was distributed to all 259 GS residency programs in the United States. Questions evaluated demographics, program structure, overall training & HPB experience in particular during residency, plans for fellowship training and understanding of training in HPB surgery. RESULTS: Of the 340 respondents, 162 (48%) were from university programs, 145 (43%) from community hospitals and 48 (14%) from independent medical centers. 117 (34%) were residents in postgraduate year 4 or 5 (PGY4/PGY5). 275 (81%) respondents were planning to pursue fellowship training after finishing residency. Three quarters of all respondents did not feel comfortable about performing liver, biliary and pancreatic procedures. Fellowships accredited by the Americas Hepato-Pancreatico-Biliary Association (AHPBA) are the most common pathway considered by residents for HPB training. CONCLUSIONS: GS residents are not comfortable in considering performing complex HPB cases on completion of residency training. GS residents consider AHPBA accredited fellowships to be more suitable for advanced training in HPB surgery.

T2 Gallbladder Cancer-Aggressive Therapy Is Warranted.

Treatment of gall bladder cancer (GBC) has traditionally been viewed with pessimism and lymph node positivity has been associated with worse prognosis. The aim of this study is to analyze the role of radical cholecystectomy in T2 tumors. All patients who underwent surgery for GBC between September 2005 and June 2014 were identified retrospectively. Data collected included clinical presentation, operative findings, and histopathological data. Twenty-five patients had incidental GBC diagnosis after cholecystectomy. Ten patients were T2 on initial cholecystectomy pathology and all underwent radical resection. Two patients were N1 on initial cholecystectomy pathology. Four were upstaged to N1 and two patients were upstaged to T3 after further surgery. Overall, 60 per cent patients with T2 disease had node positivity and 60 per cent were upstaged by further surgery. Eleven patients were diagnosed on imaging. Four of these patients were unresectable and six were either stage T3 or higher or node positive. Sixty per cent of T2 GBC was node positive and 60 per cent were upstaged with radical cholecystectomy. This finding supports the call for radical resection in patients with incidental diagnosis of T2 tumor on cholecystectomy. This study also emphasizes the role of radical surgery in accurate T staging.

Duodenal Neuroendocrine Tumors: Location Matters!

Duodenal neuroendocrine tumors (NETs) are rare. Historically, when feasible a less aggressive surgical approach is considered. The aim of this study was to identify factors associated with prognosis and the necessity for more aggressive surgical procedures. All patients who underwent surgery for duodenal NETs between September 2005 and June 2014 were identified retrospectively. Data collected included clinical presentation, operative findings, and histopathological data. Eighteen patients underwent surgical management for duodenal NETs. Two patients underwent transduodenal excision (11%), two patients had partial duodenal resection (11%), two patients had antrectomy including 1st part of duodenum (D1) resection (33%), and eight underwent pancreaticoduodenectomy [PD (44%)]. On analysis, 2nd part of duodenum (D2) location was the most common site of duodenal NETs (n = 9, 50%). The odds of having a PD were 10 times higher when the lesion was in D2 location. The odds of having a positive lymph node are nine times higher when the lesion is in D2 region. The odds of having a positive lymph node are three times higher when lesion is greater than T1. D2 location of NETs is associated with higher odds of lymph node positivity and need for more extensive procedures like PD.

The current state of hepatopancreatobiliary fellowship experience in North America.

AIM: The face of hepatopancreatobiliary (HPB) training has changed over the past decade. The growth of focused HPB fellowships, which are vetted with a rigorous accreditation process through the Fellowship Council (FC), has established them as an attractive mode of training in HPB surgery. This study looks at the volumes of HPB cases performed during these fellowships in North America. METHODS: After approval by the FC research committee, data from all HPB fellowships that had 3 years worth of complete fellow case log data were tabulated and reported (n = 12). For 2-year fellowships, the fellow logs were tabulated at the completion of both years. Those programs that had transplant experience (n = 9) were reported. RESULTS: Data for the current fellows' case numbers show that graduating fellows have a median of 26 biliary cases, 19 major liver cases (hemilivers), 28 other liver cases, 40 pancreaticoduodenectomies,18 distal pancreatectomies, and 9 other pancreas cases. The programs that provided transplantation experience had 10 cases for each fellow. CONCLUSION: This study validates that FC-accredited HPB fellowships have a robust exposure to complex HPB surgery. Fellows completing these fellowships should be well versed in the management and surgical treatment of HPB patients.

Ki-67 labeling: a more sensitive indicator of malignant phenotype than mitotic count or tumor size?

BACKGROUND AND OBJECTIVES: The Ki-67 index has been incorporated into The World Health Organization's classification system of pancreatic neuroendocrine tumors. However, pathologists continue to question the utility of Ki-67 index over that of mitotic count as an indicator of proliferative activity. The intent of the current study is to compare K-i67 index with tumor size and mitotic rate for the association of each with lymph node metastasis and survival. METHODS: The current study is a review of 24 patients with pancreatic neuroendocrine tumors. RESULTS: Regional LNM were present in 100% of tumors with Ki-67 index >10%, while only 25% of tumors with <10% Ki-67 had LNM (P = 0.003). No tumors <2 cm had >10% Ki-67 labeling. Of patients with tumors showing ≥ 10% Ki-67 labeling, 80% died during the observation period of this study, while during the same time period, no patients with <10% Ki-67 labeling died. CONCLUSION: Ki-67 index of >10% is a sensitive indicator of malignant behavior and mortality. Future advances in management of pNETs will require development of staging guidelines with higher predictive value. Inclusion of Ki-67 labeling >10% as an indicator of aggressive disease may contribute to such improvements.

Pancreaticoduodenectomy after a Roux-en-Y gastric bypass.

BACKGROUND: The surgical management of periampullary lesions, status post-Roux-en-Y gastric bypass procedure (RYGBP), poses a challenge. The strategy should focus on managing the gastric remnant. METHODS: We propose a technique of managing the gastric remnant while doing a pancreaticoduodenectomy (PD) in a patient with a previous RYGBP. From September 2005 to June 2008, two patients with a previous RYGBP underwent PD with a modified technique. The records were reviewed with respect to preoperative, intraoperative, and postoperative data. RESULTS: Both patients were operated for a carcinoma of the head of pancreas. Neither patient underwent a preoperative endoscopic ultrasound. The operating times were 315 and 218 min. There was no mortality or morbidity seen. Neither patient was re-operated. The mean length of stay was 6 days. CONCLUSIONS: The technique suggests an approach of managing the gastric remnant and preventing delayed gastric emptying which resulted in a decreased length of hospital stay.