Category Archives: Hepato-Biliary-Pancreatic

Air cholangiogram as effective measure for postoperative biliary complications

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One discussion this week involved air cholangiograms.

Reference: Zimmitti G, et al. Systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. Journal of the American College of Surgeons. 2013 Dec;217(6):1028-1037. doi: 10.1016/j.jamcollsurg.2013.07.392.

Summary: Advances in surgical technique and better understanding of liver anatomy and physiology have facilitated a decrease in postoperative hepatic insufficiency rates and in perioperative blood transfusion needs. However, these improvements have not been paralleled by a decrease in the rate of postoperative bile leak, which remains the Achilles’ heel of liver resection. While in many cases a postoperative bile leak can be managed successfully with drainage and antibiotics, it almost always entails longer length of stay and increased hospital costs.

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Liver transplantation in alcoholic liver disease: is a period of sobriety necessary?

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One discussion this week included early liver transplantation in patients with alcoholic liver disease (ALD).

Reference: Godfrey EL, Stribling R, Rana A. Liver transplantation for alchoholic liver disease: an update. Clinics in Liver Disease. 2019 Feb;23(1):127-139. doi: 10.1016/j.cld.2018.09.007.

Summary (quoted from the article): ALD, a major cause of global morbidity and mortality, is expected to continue to increase in the global health burden. Although several new therapies have become available for other causes of liver disease, very few effective therapies exist for ALD other than liver transplantation. To ensure good outcomes and appropriate allocation of scarce donated organs, stringent selection criteria must be used to determine who is eligible to receive a graft, and effective, integrated alcohol use treatment must be used to prevent relapse.

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A review of ICPN (by Emory pathologists!)

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One discussion this week included ICPN.

Reference: Adsay V, et al. Intracholecystic papillary-tubular neoplasms (ICPN) of the gallbladder (neoplastic polyps, adenomas, and papillary neoplasms that are ≥1.0 cm): clinicopathic and immunohistochemical analysis of 123 cases. The American Journal of Surgical Pathology. 2012 Sep;36(9):1279-1301.

Summary (from the abstract):  In this study, 123 GB cases that have a well-defined exophytic preinvasive neoplasm measuring ≥1 cm were analyzed. The patients were predominantly female (F/M=2:1) with a mean age of 61 y and a median tumor size of 2.2 cm. Half of the patients presented with pain, and in the other half the neoplasm was detected incidentally. Other neoplasms, most being gastrointestinal tract malignancies, were present in 22% of cases. Gallstones were identified in only 20% of cases. Radiologically, almost half were diagnosed as “cancer,” roughly half with polypoid tumor, and in 10% the lesion was missed.

Pathologic Findings 

  1. The predominant configuration was papillary in 43%, tubulopapillary in 31%, tubular in 26%.
  2. Each case was assigned a final lineage type on the basis of the predominant pattern (>75% of the lesion) on morphology, and supported with specific immunohistochemical cell lineage markers. The predominant cell lineage could be identified as biliary in 50% (66% of which were MUC1), gastric foveolar in 16% (all were MUC5AC), gastric pyloric in 20% (92% MUC6), intestinal in 8% (100% CK20; 75% CDX2; 50%, MUC2), and oncocytic in 6% (17% HepPar and 17% MUC6); however, 90% of cases had some amount of secondary or unclassifiable pattern and hybrid immunophenotypes.
  3. Of the cases that would have qualified as “pyloric gland adenoma,” 21/24 (88%) had at least focal high-grade dysplasia and 18% had associated invasive carcinoma. Conversely, 8 of 47 “papillary adenocarcinoma”-type cases displayed some foci of low-grade dysplasia, and 15/47 (32%) had no identifiable invasion.
  4. Overall, 55% of the cases had an associated invasive carcinoma (pancreatobiliary type, 58; others, 10). Factors associated significantly with invasion were the extent of high-grade dysplasia, cell type (biliary or foveolar), and papilla formation. Among systematically analyzed invasive carcinomas, tumoral intraepithelial neoplasia was detected in 6.4% (39/606).
  5. The 3-year actuarial survival was 90% for cases without invasion and 60% for those associated with invasion. In contrast, those associated with invasion had a far better clinical outcome compared with pancreatobiliary-type GB carcinomas (3-yr survival, 27%), and this survival advantage persisted even with stage-matched comparison. Death occurred in long-term follow-up even in a few noninvasive cases (4/55; median 73.5 mo) emphasizing the importance of long-term follow-up.

Conclusion

Tumoral preinvasive neoplasms (≥1 cm) in the GB are analogous to their pancreatic and biliary counterparts (biliary intraductal papillary neoplasms, pancreatic intraductal papillary mucinous neoplasms, and intraductal tubulopapillary neoplasms). They show variable cellular lineages, a spectrum of dysplasia, and a mixture of papillary or tubular growth patterns, often with significant overlap, warranting their classification under 1 unified parallel category, intracholecystic papillary-tubular neoplasm. Intracholecystic papillary-tubular neoplasms are relatively indolent neoplasia with significantly better prognosis compared with pancreatobiliary-type GB carcinomas. In contrast, even seemingly innocuous examples such as those referred to as “pyloric gland adenomas” can progress to carcinoma and be associated with invasion and fatal outcome.

Epidurals, DVTs, and chemical prophylaxis in the setting of oncologic surgery

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One discussion this week involved preoperative epidurals and chemical prophylaxis.

Reference: Manguso N, et al. The impact of epidural analgesia on the rate of thromboembolism without chemical thromboprophylaxis in major oncologic surgery. The American Surgeon. 2018 Jun 1;84(6):851-855.

Summary: General surgery patients are at a particularly high risk of developing deep vein thrombosis (DVT) without prophylaxis and some data suggest their risk increases 2-fold if an underlying malignancy is present. A meta-analysis by Leonardi et al (2007) found that without chemical prophylaxis, the rate of DVT is as high as 35%, which drops to 12% if a patient receives chemical prophylaxis.

Although the use of chemical prophylaxis to reduce the risk of thromboembolic events has been validated in numerous studies, these drugs increase the risk of bleeding. Risk of bleeding in the setting of epidural analgesia may put the patient at risk for the potentially catastrophic complication of epidural hematoma which may lead to long-term paralysis.

Manguso et al (2018) evaluated the rate of thromboembolic events in cancer patients undergoing major oncologic abdominal and/or pelvic surgery who had a preoperative epidural catheter (EC) placed for postoperative pain control.

The aim of this study was to evaluate the need for chemical thromboprophylaxis in patients undergoing major abdominal or pelvic oncologic surgery with preoperative EC placement for postoperative pain control. Of the 285 patients for whom data were collected over this five-year period, the rates of above knee and below-knee DVTs were 3.2 and 5.2%, respectively. These patients were all asymptomatic and had no serious adverse events occur secondary to the identified thromboses.

A secondary finding was that 2.5% of patients had above-knee DVT before undergoing surgery; thus, it is important to consider the patient’s risk factors for DVT and screen preoperatively if there is concern.

Our data suggest that patients undergoing major open operations with epidural analgesia have low rates of DVT and may obviate the need for chemical prophylaxis. However, larger studies are required to determine the overall effects of epidural analgesia on the development of DVTs postoperatively.

Effectiveness of pyloric exclusion (PEX) in treating duodenal trauma

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One discussion this week involved the use of pyloric exclusion (PEX) for management of severe duodenal injuries.

References: DuBose JJ, et al. Pyloric exclusion in the treatment of severe duodenal injuries: results from the National Trauma Data Bank. The American Surgeon. 2008 Oct;74(10):925-929.

Malhotra A, et al. Western Trauma Assoication Critical Decisions in Trauma: Diagnosis and management of duodenal injuries. Journal of Trauma and Acute Care Surgery. 2015 Dec;79(6):1096-1101. doi: 10.1097/TA.0000000000000870

Summary: Using the American College of Surgeons National Trauma Data Bank (v 5.0), DuBose et al (2008) evaluated adult patients with severe duodenal injuries [AAST Grade > or = 3] undergoing primary repair only or repair with PEX within 24 hours of admission.  Of the 147 patients, 28 (19.0%) underwent PEX [15.9% (11/69) Grade III vs 34.0% (17/50) Grade IV-V]. Their main findings were:

  • PEX was associated with a longer mean hospital stay (32.2 vs 22.2 days, P = 0.003).
  • PEX was not associated with a mortality benefit.
  • There was a trend toward increased development of septic abdominal complications (intra-abdominal abscess, wound infection, or dehiscence) with PEX that was not statistically significant.
  • After multivariable analysis using propensity score, no statistically significant differences in mortality or occurrence of septic abdominal complications was noted between those patients undergoing primary repair only or PEX.

DuBose et al (2008) conclude that the use of PEX in patients with severe duodenal injuries may contribute to longer hospital stay and confers no survival or outcome benefit.

The Western Trauma Association guidelines for management of duodenal injuries (Malhotra et al, 2015) include the algorithm below for determining management:

duodenal screenshot

Additional reading: Ginzburg E, et al. Pyloric exclusion in the management of duodenal trauma: is concomitant gastrojejunostomy necessary? The American Surgeon. 1997 Nov;63(11):964-966.

Early vs late drain removal after pancreatectomy

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One discussion this week included early vs late drain removal in pancreatectomy.

References: Beane JD, et al. Variation of drain management after pancreatoduodenectomy: early versus delayed removal. Annals of Surgery. 2017 Oct. doi: 10.1097/SLA.0000000000002570

Deminski J, et al. Early removal of intraperitoneal drainage after pancreatoduodenectomy in patients without postoperative fistula at POD3: results of a randomized clinical trial. Journal of Visceral Surgery. 2019 Jan 31. pii: S1878-7886(18)30084-5. doi: 10.1016/j.jviscsurg.2018.06.006

Summary:  Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF).

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Perioperative fluid management: restrictive vs liberal regimens

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One discussion this week included restrictive vs liberal perioperative fluid management on the development of perioperative acute kidney injury.

References: Brandstrup B, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Annals of Surgery. 2003 Nov;238(5):641-648.

Myles PS, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. NEJM. 2018 Jun 14;378:2263-2274. doi:10.1056/NEJMoa1801601

Summary: Traditional intravenous-fluid regimens administered during abdominal surgery deliver up to 7 liters of fluid on the day of surgery. Some small trials have shown that a more restrictive fluid regimen led to fewer complications and a shorter hospital stay. However, the evidence for fluid restriction during and immediately after abdominal surgery is inconclusive. Fluid restriction could increase the risk of hypotension and decrease perfusion in the kidney and other vital organs, leading to organ dysfunction, but excessive intravenous-fluid infusion may increase the risk of pulmonary complications, acute kidney injury, sepsis, and poor wound healing (Myles 2018).

Each of the RCTs below compare restrictive vs liberal fluid management, with conflicting conclusions.

BRANDSTRUB ET AL (2003)

This multicenter RCT involved 172 patients allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects.

Results: The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, P = 0.013) and per-protocol (30% versus 56%, P = 0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, P = 0.007) and tissue-healing complications (16% versus 31%, P = 0.04) were significantly reduced. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P = 0.12). No harmful adverse effects were observed.

Conclusion: The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection.

MYLES ET AL (2018)

This international trial randomly assigned 3000 patients who had an increased risk of complications while undergoing major abdominal surgery to receive a restrictive or liberal intravenous-fluid regimen during and up to 24 hours after surgery. The primary outcome was disability-free survival at 1 year. Key secondary outcomes were acute kidney injury at 30 days, renal-replacement therapy at 90 days, and a composite of septic complications, surgical-site infection, or death.

Results: Up to 24 hours after surgery, 1490 patients in the restrictive fluid group had a median intravenous-fluid intake of 3.7 liters, as compared with 6.1 liters in 1493 patients in the liberal fluid group. The rate of disability-free survival at 1 year was 81.9% in the restrictive fluid group and 82.3% in the liberal fluid group. The rate of AKI was 8.6% in the restrictive fluid group and 5.0% in the liberal fluid group. The rate of septic complications or death was 21.8% in the restrictive fluid group and 19.8% in the liberal fluid group; rates of surgical-site infection (16.5% vs. 13.6%) and renal-replacement therapy (0.9% vs. 0.3%) were higher in the restrictive fluid group, but the between-group difference was not significant after adjustment for multiple testing.

Conclusion: Among patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury.

Additional Reading: Romagnoli S, Ricci Z, Ronco C. Perioperative acute kidney injury: prevention, early recognition, and supportive measures. Nephron. 2018;140(2):105-110.

Salmasi V, et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: a retrospective cohort analysis. Anesthesiology. 2017;126:47-65. doi:10.1097/ALN.0000000000001432

OpenAnesthesia. Encyclopedia: Fluid Management. OpenAnesthesia. 2019. International Anesthesia Research Society. Retrieved from: http://www.openanesthesia.org/fluid-management/