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.

Barbed sutures: a manufacturer’s indications for use, and a study of use in anastamotic closures

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One discussion this week involved the appropriate use of V-LOC sutures.

References: Davis J. Global Value Dossier for V-LOC Wound Closure Device: Technology and Surgical Applications (version 2.0). 2018 Apr 20. Germany: Coreva-Scientific

Tsukata T, et al. Use of barbed sutures in laparoscopic gastrointestinal single-layer sutures. JSLS. 2016 Jul-Sep;20(3): pii: e2016.00023. doi: 10.4293/JSLS.2016.00023.

Summary: When contemplating the best use for a technology, it helps to ask the creator, or in this case, the manufacturer. In section 2.4 (p.12) of their Global Value Dossier for V-LOC Wound Closure Device, Medtronic describes the indications for use as follows:

“Always refer to the package insert for indications and instructions for use of V-LocTM wound closure devices appropriate for your jurisdiction. Absorbable (V-LocTM 90 and 180), and nonabsorbable (V-LocTM PBT), devices are indicated for use in soft tissue approximation wherever the use of standard, non-barbed absorbable or non-absorbable sutures is appropriate, respectively. The product is contraindicated for patients with allergies to its components and should not be secured by tying surgical knots, or used with interrupted suturing patterns, or for ligating vessels or luminal structures. The technology has not been established for use in fascial closures (abdominal wall, thoracic, extremity fascial closures), gastrointestinal anastomoses, cardiovascular anastomoses, neurological, ophthalmic, orthopedic or microsurgery applications.”

(Davis, 2018).

In a 2016 study out of Japan, Tsukada, Kaji, Kinoshita, and Shimizu analyzed the results of 40 laparoscopic anastomoses that involved V-LOC sutures.

METHODS: Between August 2012 and March 2014, 15-cm-long barbed sutures (V-Loc 180; Covidien, Mansfield, MA, USA) were used for laparoscopic intestinal anastomoses, including intestinal hole closure for esophagojejunal and gastrojejunal anastomoses after mechanical anastomoses and gastric wall closure after partial resection.

RESULTS: 38 patients underwent 40 laparoscopic anastomoses

( 26 esophagojejunostomies; 7 gastrojejunostomies; 7 simple closure of gastric defect)

  • No cases required conversion to open surgery.
  • Two cases exhibited positive air leak test results during surgery (1 case of esophagojejunostomy and 1 case of simple closure of gastric defect)
  • Two cases of intestinal obstruction were noted; of those, one patient with postoperative intestinal paresis (grade II) was managed conservatively, and the other underwent repeat laparoscopic surgery (grade IIIb) for internal herniation unrelated to V-Loc use.
  • No postoperative complications at the anastomosis site and no surgery-related deaths were noted.

CONCLUSION: Single-layer entire-thickness running suturing with the V-Loc 180 barbed suture after stapled side-to-side intestinal anastomosis was found to be safe and feasible in the reported cases.

HAP vs VAP treatment: a flowchart

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One discussion this week involved treatment for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP).

Reference: Kenny JES. IDSA Guidelines 2016: HAP, VAP & It’s the End of HCAP as We Know It (And I Feel Fine) [website]. 2016 Jul 30. Retrieved from https://pulmccm.org/infectious-disease-sepsis-review/idsa-guidelines-2016-hap-vap-end-hcap-know-feel-fine/

Summary: “While the current [IDSA 2016] guidelines discuss a number of issues germane to HAP and VAP including: microbiological evaluation, ventilator-associated tracheobronchitis, the use of biomarkers and clinical prediction scores, inhaled antibiotics, etc. this post will focus on standard, empiric therapy as this is a common clinical quandary [see figure 1]” (Kenny 2016).

hap vap

“The current guidelines recommend 7 days of antimicrobial therapy for both HAP and VAP.  The authors conducted their own meta-analysis and found no difference in mortality or recurrence between long and short-courses of therapy.  This is incongruent with an often referenced trial in 2003 which noted a higher pneumonia recurrence rate if non-fermenting gram negative bacilli [e.g. pseudomonas] were isolated and patients were treated with 8 days versus 15 days of anti-microbials” (Kenny 2016).

Foley or no Foley? Criteria for perioperative Foley placement

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One discussion this week included the use of Foley catheters.

Reference: Meddings J, et al. Michigan Appropriate Periopeartive (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method. BMJ Quality & Safety. 2019 Jan;28(1):56-66. doi:10.1136/bmjqs-2018-008025

Summary: Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.

Meddings et al (2019) used the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method 21 to formally rate the appropriateness of urinary catheter placement and timing for removal across routine general and
orthopaedic surgical procedures in adults, as rated by clinicians in different clinical settings across the US and informed by the available literature involving perioperative urinary catheter use.

foley

(Meddings et al, 2019, p.61)

Open vs closed hemorrhoidectomy: a systematic review and meta-analysis of RCTs

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One discussion this week included open versus closed hemorrhoidectomy.

Reference: Bhatti M, Sajid MS, Baig MK. Milligan-Morgan (open) versus Ferguson haemorrhoidectomy (closed): A systematic review and meta-analysis of published randomized, controlled trails. World Journal of Surgery. 2016 Jun;40(6):1509-1519. doi:10.1007/s00268-016-3419-z.

Summary: In Europe, the Milligan-Morgan procedure or open haemorrhoidectomy (OH) is more frequently practised, whereas in the United States of America the closed haemorrhoidectomy (CH) procedure, as described by Ferguson and Heaton, is the most popular. CH is purported to be a less painful procedure and associated with faster wound healing due to primary wound closure. However, the conflicting outcomes following both procedures have been debated in the published literature and several controversies around post-operative pain still need clarification.

Relevant prospective randomized, controlled trials (irrespective of type, language, gender, blinding, sample size or publication status) on CH versus OH for the management of HD until May 2014 were included in this review.

Ultimately, 11 RCTs encompassing 1326 patients were included in the systematic review and meta-analysis. Significant heterogeneity was found among included trials.

CONCLUSIONS: Variables of pain on defecation, length of hospital stay, post-operative complications, HD recurrence and risk of surgical site infection were similar in both groups.

Based upon the findings of this review, CH was associated with a reduced post-operative pain, faster wound healing, lesser risk of post-operative bleeding but prolonged duration of operation.

Findings of this review are contradictory to a 2007 meta-analysis of six randomized, controlled trials.

 

To view full data analyses (3 tables and 11 figures!) click on the link in the reference at the top of this post.