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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The present study was conducted to assess the preparedness of hepatopancreatobiliary ( HPB) fellows upon entering fellowship, identify challenges encountered by HPB fellows during the initial part of their HPB training, and identify potential solutions to these challenges that can be applied during residency training. Methods A questionnaire was distributed to all HPB fellows in accredited HPB fellowship programmes in two consecutive academic years ( n = 42). Reponses were then analysed. Results A total of 19 (45%) fellows responded. Prior to their fellowship, 10 (53%) were in surgical residency and the rest were in other surgical fellowships or surgical practice. Thirteen (68%) were graduates of university-based residency programmes. All fellows felt comfortable in performing basic laparoscopic procedures independently at the completion of residency and less comfortable in performing advanced laparoscopy. Eight (42%) fellows cited a combination of inadequate case volume and lack of autonomy during residency as the reasons for this lack of comfort. Thirteen (68%) identified inadequate preoperative workup and management as their biggest fear upon entering practice after general surgery training. A total of 17 (89%) fellows felt they were adequately prepared to enter HPB fellowship. Extra rotations in transplant, vascular or minimally invasive surgery were believed to be most helpful in preparing general surgery residents pursing HPB fellowships. Conclusions Overall, HPB fellows felt themselves to be adequately prepared for fellowship. Advanced laparoscopic procedures and the perioperative management of complex patients are two of the challenges facing HPB fellows. General surgery residents who plan to pursue an HPB fellowship may benefit from spending extra rotations on certain subspecialties. Focus on perioperative workup and management should be an integral part of residency and fellowship training. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Postoperative day (POD) 1 drain amylase concentration (DAC) is considered the most accurate predictor for the development of a clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Recent studies have associated drain placement with negative postoperative outcomes. This study aims to evaluate multiple biochemical markers and their associations with CR-POPF development in order to identify a reliable, non-drain dependent alternative to DAC. Methods: This is a review of 53 consecutive PD patients between 2021 and 2022. Albumin, C-reactive protein (CRP), C-reactive protein-to-albumin ratio (CAR), DAC, white blood cell count, and procalcitonin values were compared by CR-POPF status. The discriminatory abilities of CAR, CRP, and DAC for CR-POPF were compared using receiver operating characteristic (ROC) curves. Results: Six of 51 included patients developed a CR-POPF. Receiver operating characteristic curve analysis produced an area under the curve of.977 for POD 1 DAC (cut-off 5131.0 IU/L, sensitivity 100%, specificity 95.5%),.858 for POD 1 CRP (cut-off 52.5 mg/L, sensitivity 100%, specificity 72.7%), and 1.000 for POD 3 CAR (cut-off 99.2, sensitivity and specificity 100%). POD 3 CAR produced a positive and negative predictive value of 100%. Conclusion: The CAR and CRP provide early and accurate identification of patients with post-PD CR-POPFs. These markers offer a method of safe CR-POPF detection, when the gold standard DAC is unavailable, ultimately allowing for early intervention and patient rescue. [ABSTRACT FROM AUTHOR]

Development of a post-esophagectomy hiatal hernia (PEHH) is a rare, but problematic, sequela with the current reported prevalence ranging up to 20%. To determine the incidence rate of PEHH at our institution, a retrospective review of all transhiatal esophagectomies performed from 2012 to 2020 was conducted. Demographic, operative, and oncologic data were collected, rates of PEHH were calculated, and characteristics of subsequent repair were reviewed and analyzed. A total of 160 transhiatal esophagectomies were included, of which four patients (2.5%) developed a PEHH at a mean of 12 months postoperatively (range: 3-28 months) with symptomatology driving the diagnosis for three patients. The limited size of our study does not allow for statistically significant determinations regarding risk factors or method of repair. The true prevalence of a hiatal defect is likely higher than reported, as clinically asymptomatic patients are not captured in our current literature. [ABSTRACT FROM AUTHOR]

On cox regression, tumor location, SRCC, SRF tumors, and tumor response grading (TRG) were not related to DFS among our cohort, but nodal status was (Fig. There was no significant difference in DFS based on location of tumor or presence of SRCC or SRF tumors compared to nSRC tumors. [Extracted from the article]

Two hundred two patients (77.1%) underwent first-time repair of their PEH and 60 patients (22.9%) underwent repeat repair for recurrence. Although risk factors including obesity have been implicated in paraesophageal hernia (PEH) repair failure, much of the basis for this has been anecdotal. [Extracted from the article]

Keywords: Esophagectomy; Transhiatal Esophagectomy; Anastomotic Leak EN Esophagectomy Transhiatal Esophagectomy Anastomotic Leak 398 401 4 03/02/23 20230201 NES 230201 Shankar Logarajah and Shawn Cudworth contributed equally to this work. Anastomotic leak (leak) remains a source of significant morbidity and accounts for approximately 40% of postoperative mortality after esophagectomy.[2] We sought to examine the risk factors associated with the development of leak after transhiatal esophagectomy (THE) at our institution. [Extracted from the article]

Background: Primary repair failure rates for hiatal hernias (HH) can reach up to 40%, this is especially high in the morbidly obese patient. There is no clear data on how to manage this patient subset. This paper evaluates the efficacy of Roux-N-Y Gastrojejunostomy (RNY GJ) for treatment of symptomatic HH. Methods: A retrospective analysis of all patients who received a Roux-en-Y Gastrojejunostomy (RNY GJ) for HH at our institution between January 2016 and January 2021 was performed. Patient demographics, symptoms, and post-operative outcomes were recorded and univariate analysis was performed between preoperative and postoperative symptoms. Results: Thirty-seven patients with a mean age of 56.9 years (SD 11.8) underwent RNY GJ. Patients were mostly female (81.1%) with a mean BMI of 36.8 (SD 8.4). An 78.4% reduction in symptoms of either heartburn, dysphagia, or regurgitation was noted at follow up (p < 0.001). Conclusions: RNY GJ represents a safe procedure for morbidly obese patients with hiatal hernias with no mortalities amongst our patient cohort along with a significant reduction in pre-operative symptoms and no symptomatic recurrences. RNY GJ should be considered as the operation of choice for repair for this patient population. [ABSTRACT FROM AUTHOR]

Background: Accurate detection of colorectal liver metastasis is paramount in the role of management. This study aims to compare magnetic resonance imaging (MRI) with gadoxetate disodium (a hepatocyte-specific agent-Eovist®) to triple-phase enhanced computed tomography in detecting colorectal liver metastases.Methods: A retrospective chart analysis of 30 patients from 2011 to 2013 with colorectal liver metastases was performed. Patients with more than 6 weeks or two cycles of chemotherapy between the two imaging modalities were excluded. The number of lesions identified on triple-phase enhanced computed tomography vs. MRI with Eovist® was compared.Results: Of the 30 patients that met the inclusion criteria, 12 (40 %) patients had more lesions identified on MRI with Eovist® compared to triple-phase enhanced computed tomography. Eighteen (60 %) had no change in the number of lesions identified. When MRI with Eovist® detected more lesions, the mean number of additional lesions detected was 1.5. Eovist® MRI changed the surgical management in 36.7 % of patients.Conclusion: MRI with Eovist® is superior to enhanced computed tomography in identifying colorectal liver metastases. The increased number of lesion identified on MRI with Eovist® can profoundly change the surgeon's management. It should be considered the "imaging modality of choice" in preoperative imaging for liver metastases in these patients. [ABSTRACT FROM AUTHOR]

Background: Accurate detection of colorectal liver metastasis is paramount in the role of management. This study aims to compare magnetic resonance imaging (MRI) with gadoxetate disodium (a hepatocyte-specific agent-Eovist®) to triple-phase enhanced computed tomography in detecting colorectal liver metastases. Methods: A retrospective chart analysis of 30 patients from 2011 to 2013 with colorectal liver metastases was performed. Patients with more than 6 weeks or two cycles of chemotherapy between the two imaging modalities were excluded. The number of lesions identified on triple-phase enhanced computed tomography vs. MRI with Eovist® was compared. Results: Of the 30 patients that met the inclusion criteria, 12 (40 %) patients had more lesions identified on MRI with Eovist® compared to triple-phase enhanced computed tomography. Eighteen (60 %) had no change in the number of lesions identified. When MRI with Eovist® detected more lesions, the mean number of additional lesions detected was 1.5. Eovist® MRI changed the surgical management in 36.7 % of patients. Conclusion: MRI with Eovist® is superior to enhanced computed tomography in identifying colorectal liver metastases. The increased number of lesion identified on MRI with Eovist® can profoundly change the surgeon's management. It should be considered the 'imaging modality of choice' in preoperative imaging for liver metastases in these patients. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Hiatal hernias are observed in approximately 15% to 20% of the population in Western society. Most patients are diagnosed with a sliding-type hiatal hernia, of which gastroesophageal reflux is the predominant driving symptom. Surgical repair of these types of hernias often involves a wrap procedure during the index operation as standard of care. For type 2, 3, and 4 hernias, also known as paraesophageal hernias (PEHs), the symptom complexes vary and often involve symptoms other than reflux, including dysphagia, anemia, shortness of breath, and chest pain. We sought to evaluate whether patients who underwent PEH repair without fundoplication reported different rates of postoperative symptoms compared with those who did. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Purpose: 68Ga-DOTATATE PET is becoming a popular imaging technique for detecting neuroendocrine tumors (NETs). The sensitivity and specificity of 68Ga-DOTATATE PET compared to standard cross-sectional imaging with triple phase CT or MRI with Eovist has not been studied extensively. Methods: 68Ga-DOTATATE PET scans ordered at our institution between 11/2017 and 7/2018 were reviewed. Patients with evidence of liver metastases were sorted and cross-sectional imaging results were reviewed. Specifically, the number of lesions detected by standard cross-sectional imaging versus 68Ga-DOTATATE PET was compared. Results: 32 patients with 68Ga-DOTATATE PET scans and a corresponding MRI or CT were identified. Primary tumors were pancreatic (43.8%), small bowel (25%), hepatic (9.4%), gastric (6.3%), appendiceal (3.1%), and not localized (12.5%). 26/32 (81%) patients had CT scans and 17/32 (53%) had MRI scans. 25/32 (78%) patients had at least equal or increased number of lesions identified on 68Ga-DOTATATE PET when compared with CT or MRI. 7/32 (21.9%) had fewer lesions on 68Ga-DOTATATE PET compared to CT or MRI. However, 3 of these cases had numerous liver lesions. The overall sensitivity and specificity of 68Ga-DOTATATE PET are 92.9% and 75% respectively. Conclusion: 68Ga-DOTATATE PET appears to have superior sensitivity in detecting metastatic NET to the liver. Further studies are needed to determine if it should be considered the test of choice for evaluating patients with metastatic NET to the liver. While standard cross-sectional imaging will be needed for surgical planning, 68Ga-DOTATATE PET will identify lesions that may not be seen on other imaging modalities. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Fellowship training after surgery residency has become commonplace. The concept of an advanced gastrointestinal (AGI) surgical fellowship has been implemented through the SSAT and Fellowship Council (FC). Newer and more competitive requirements are being proposed through a taskforce inclusive of many surgical societies. This study was designed to measure the interest in hiring graduates of AGI fellowship.Method: This is a SSAT sponsored 20-question survey which was sent out to the Society members in general surgery practices (mix of hospital based and private) across the USA through an online electronic survey software (SurveyMonkey, Palo Alto, Ca.). Descriptive statistics were generated from aggregate survey responses.Results: We had a total of 285 responses. Majority (92%) preferred hiring a surgeon who has completed a post-graduate fellowship. Type of fellowship preferred by the prospective employers varied depending on the focus and the need of the individual practice. Most important characteristic that the employers sought were references, letters of recommendation, and work ethic, followed by technical skills, and completion of fellowship. Most of the responders felt that a complex GI surgery fellowship may be an attractive qualification in prospective job candidates.Conclusion: Our survey showed that the majority of surgery practices in the US prefer fellowship-trained candidates as potential hires. Only a small minority (< 20%) of those surveyed felt that completing an AGI fellowship would not give prospective candidates an advantage in obtaining a job. Our results indicate a growing need for a AGI surgery fellowship. [ABSTRACT FROM AUTHOR]

The article describes the case of mixed neuroendocrine-nonneuroendocrine neoplasms (MiNEN) in Barrett's esophagus (BE) with dysplasia that was treated with transhiatal esophagectomy. Topics discussed include description of the male patient, diagnosis of MiNEN, and treatment protocol for MiNENs.