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Importance: Patients with colorectal cancer with liver metastases undergo hepatic resection with curative intent. Positron emission tomography combined with computed tomography (PET-CT) could help avoid noncurative surgery by identifying patients with occult metastases., Objectives: To determine the effect of preoperative PET-CT vs no PET-CT (control) on the surgical management of patients with resectable metastases and to investigate the effect of PET-CT on survival and the association between the standardized uptake value (ratio of tissue radioactivity to injected radioactivity adjusted by weight) and survival., Design, Setting, and Participants: A randomized trial of patients older than 18 years with colorectal cancer treated by surgery, with resectable metastases based on CT scans of the chest, abdomen, and pelvis within the previous 30 days, and with a clear colonoscopy within the previous 18 months was conducted between 2005 and 2013, involving 21 surgeons at 9 hospitals in Ontario, Canada, with PET-CT scanners at 5 academic institutions., Interventions: Patients were randomized using a 2 to 1 ratio to PET-CT or control., Main Outcomes and Measures: The primary outcome was a change in surgical management defined as canceled hepatic surgery, more extensive hepatic surgery, or additional organ surgery based on the PET-CT. Survival was a secondary outcome., Results: Of the 263 patients who underwent PET-CT, 21 had a change in surgical management (8.0%; 95% CI, 5.0%-11.9%). Specifically, 7 patients (2.7%) did not undergo laparotomy, 4 (1.5%) had more extensive hepatic surgery, 9 (3.4%) had additional organ surgery (8 of whom had hepatic resection), and the abdominal cavity was opened in 1 patient but hepatic surgery was not performed and the cavity was closed. Liver resection was performed in 91% of patients in the PET-CT group and 92% of the control group. After a median follow-up of 36 months, the estimated mortality rate was 11.13 (95% CI, 8.95-13.68) events/1000 person-months for the PET-CT group and 12.71 (95% CI, 9.40-16.80) events/1000 person-months for the control group. Survival did not differ between the 2 groups (hazard ratio, 0.86 [95% CI, 0.60-1.21]; P = .38). The standardized uptake value was associated with survival (hazard ratio, 1.11 [90% CI, 1.07-1.15] per unit increase; P < .001). The C statistic for the model including the standardized uptake value was 0.62 (95% CI, 0.56-0.68) and without it was 0.50 (95% CI, 0.44-0.56). The difference in C statistics is 0.12 (95% CI, 0.04-0.21). The low C statistic suggests that the standard uptake value is not a strong predictor of overall survival., Conclusions and Relevance: Among patients with potentially resectable hepatic metastases of colorectal adenocarcinoma, the use of PET-CT compared with CT alone did not result in frequent change in surgical management. These findings raise questions about the value of PET-CT scans in this setting., Trial Registration: clinicaltrials.gov Identifier: NCT00265356.

Background: Mucinous cystic neoplasms of the liver (hepatobiliary cystadenomas) are rare neoplastic lesions. Such cysts are often incorrectly diagnosed and managed, and carry a risk of malignancy. The objective of this study was to review the surgical experience with these lesions over 15 years., Methods: A retrospective chart review identified consecutive patients undergoing surgery for liver cystadenomas from 1997-2011. Clinical data were collected and summarized., Results: Thirteen patients (mean age 51 years, 12/13 females) with cysts 4.6-18.1 cm were identified. Most cysts were located in the left lobe/centrally (11/12) and had septations (8/13). Mural nodularity was infrequent (3/13). Nine patients had liver resection/enucleation, whereas four had unroofing. Frozen section analysis had a high false-negative rate (4/6). All patients had cystadenomas, of which two had foci of invasive carcinoma (cystadenocarcinoma) within mural nodules. There was no 90-day mortality. All but one patient (myocardial infarction) were alive at a median follow-up of 23.1 months. No patient with unroofing has developed malignancy to date., Conclusions: Non-invasive hepatobiliary cystadenomas present as large central/left-sided cysts in young or middle-aged women. Associated malignancy was relatively uncommon and found within mural nodules. Intra-operative frozen section analysis was ineffective at ruling out cystadenomas. Complete excision is recommended, but close follow-up might be considered in patients with a prohibitive technical or medical risk, in the absence of nodularity on high-quality imaging., (© 2012 International Hepato-Pancreato-Biliary Association.)

Background: The multidisciplinary management of metastatic melanoma now occasionally includes major hepatic resection. The objective of this work was to conduct a systematic review of the literature on liver resection for metastatic melanoma., Methods: MEDLINE, Embase, the Cochrane Library and Scopus were searched (1990 to December 2012). Studies with at least ten patients undergoing liver resection for metastatic melanoma were included. Data on the outcomes of overall survival (OS) and/or disease-free survival (DFS) were abstracted and synthesized. Hazard ratios (HRs) were derived from survival curves and subjected to meta-analysis using random-effects models., Results: Twenty-two studies involving 579 patients (13 per cent weighted resection rate) who underwent liver resection were included. Study quality was poor to moderate. Median follow-up ranged from 9 to 59 months. Median DFS ranged from 8 to 23 months, and median OS ranged from 14 to 41 months (R0, 22-66 months, R2, 10-16 months; R0 versus R1/R2: HR 0.52, 95 per cent confidence interval (c.i.) 0.37 to 0.73). The OS rate was 56-100 per cent at 1 year, 34-53 per cent at 3 years and 11-36 per cent at 5 years. Median OS with non-operative management ranged from 4 to 12 months. Comparison of OS with resection and non-operative management favoured resection (HR 0.32, 95 per cent c.i. 0.22 to 0.46)., Conclusion: Radical resection of liver metastases from melanoma appears to improve overall survival compared with non-operative management or incomplete resection, but this observation requires future confirmation as selection bias may have confounded the results., (© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Choledocholithiasis is a complex problem in patients with Roux-en-Y gastric bypass anatomy. Several techniques of biliary clearance have been described, but these can be limited by intra-abdominal adhesions., Patient and Methods: A 36-French surgical gastrostomy was created and was allowed to mature for 10 weeks. It was exchanged for a 15-mm laparoscopic surgery trocar under fluoroscopic guidance. Endoscopic retrograde cholangiopancreatography (ERCP) was carried out using the trocar as a stable access point. Complete biliary clearance was achieved in one sitting using sphincterotomy, large-diameter biliary orifice balloon dilation, and balloon/basket sweeps., Results: Total endoscopy time was 120 minutes. There were no complications associated with the procedure. The postprocedure length of stay was 2 days. The total bilirubin level at discharge was 1.2 mg/dL (20 μmol/L)., Conclusions: In patients with gastric bypass anatomy and severe adhesions, successful salvage therapeutic ERCP can be achieved using a gastrostomy tract and a large-bore laparoscopy trocar for access to the defunctioned stomach.

Background: The resectability of colorectal liver metastases is in part largely based on the surgeon's assessment of cross-sectional imaging. This process, while guided by principles, is subjective. The objective of the present study was to assess agreement between hepatic surgeons regarding the resectability of colorectal liver metastases., Methods: Forty-six hepatic surgeons across Canada were invited. A patient with biologically favourable disease was presented after having received neoadjuvant chemotherapy. The scenario was matched with 10 different scrollable abdominal CT scans representing a maximum response after six cycles of chemotherapy. Surgeons were asked to offer an opinion on resectability of liver metastases, and whether they would use adjunct modalities to hepatic resection., Results: Twenty-six surgeons participated. Twenty responses were complete. The median number of scenarios deemed resectable was 6/10 (range 3-8). Two control scenarios demonstrated perfect agreement. Agreement on resectability was poor for 4/8 test scenarios, of which one scenario demonstrated complete disagreement. Among resectable cases, the pattern of use of adjunct modalities was variable. A median ratio of 0.87 adjunct modality per resectable scenario per surgeon was used (range 0.25-1.75)., Conclusion: A significant lack of agreement was identified among surgeons on the resectability and use of adjunct modalities in the treatment of colorectal liver metastases., (© 2012 International Hepato-Pancreato-Biliary Association.)

Objectives: To determine the population-based incidence of splenic injuries in the Province of Ontario, the proportion of splenic injuries treated by observation, splenectomy and splenorrhaphy, changes in management over time and the variation in management of splenic injuries among Ontario hospitals., Design: A retrospective cohort study., Patients: All adults (older than 16 years) admitted with a diagnosis of splenic injury (clinical modification of the International Classification of Diseases, 9th revision) to acute care hospitals in Ontario between 1991 and 1994, identified from the Ontario Trauma Registry., Results: The incidence of splenic injury was 1.7 cases per 1000 trauma admissions per year. Patients with splenic injury were young (median age 32 years) and male (71%), and the death rate was 8%. Observation was the commonest method of treatment (69%), followed by splenectomy (28%) and splenorrhaphy (4%). The use of observation increased over the study period from 59% to 75% (p < 0.001). There was significant variation in the use of observation among hospitals (range 11% to 100%, p < 0.0001)., Conclusions: The majority of splenic injuries are managed by observation with an acceptable hospital death rate. The use of observation has increased over time, confirming the growing adoption of this management approach by most hospitals in the province when feasible. Splenorrhaphy was infrequently performed despite reports to the contrary from many centres in the United States. There was significant variation in splenic injury management, suggesting the need for further refinement and dissemination of practical guidelines for splenic salvage.

Background: The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time., Patients and Methods: Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively., Results: Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%., Conclusion: We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.

Background: Whether or not to perform intraoperative cholangiography (IOC) with laparoscopic cholecystectomy is controversial. The decision to perform IOC should depend on the individual surgeon's preference for the management of choledocholithiasis., Patients and Methods: An initial experience of 525 patients undergoing laparoscopic cholecystectomy done without IOC is reviewed., Results: Suspected or proven choledocholithiasis was managed by endoscopic retrograde cholangiography with sphincterotomy if necessary. There were no bile duct injuries or bile leaks, and 9% (47) of patients underwent endoscopic investigation or treatment. There have been no secondary operations for duct stones., Conclusion: We think that the use of IOC to avoid bile duct injuries is not essential, and that the key to avoiding such injuries is meticulous demonstration of anatomic detail at operation. We have been satisfied with selective use of endoscopic cholangiography and sphincterotomy for the management of choledocholithiasis.

Peripheral parenteral nutrition avoids the use of central lines and is a useful means of nutritional support for selected patients. Amino acids alone have been used for peripheral parenteral nutrition and have been shown to give near nitrogen equilibrium. The addition of small amounts of dextrose to amino acids further improves nitrogen balance, but at the expense of making the solutions unsterilizable and unstable by standard techniques. Glycerol is a nonprotein calorie source that can be autoclaved with amino acids and stored. Fasting patients about to undergo major abdominal surgery were randomly allocated to receive 3% amino acids with or without 3% glycerol. The solution was infused by peripheral vein for 5 days, starting the morning following surgery. Routine monitoring, blood tests, and nitrogen balance tests were performed during this time. No adverse reactions to either solution were encountered. Liver function tests, electrolytes, and hematologic values were similar in both groups. The cumulative nitrogen balance was better in the amino acid plus glycerol group (+5 +/- 3.3 gm) than in the amino acid group (-9.7 +/- 3 gm) (P less than 0.02). Serum insulin levels were higher and serum free fatty acids lower in the amino acid plus glycerol group. Glycerol levels rose and plateaued by the third day in the amino acid plus glycerol patients. Amino acids plus glycerol is safe solution to administer by peripheral vein. The addition of glycerol improves nitrogen balance as compared to amino acids alone.

A feeding jejunostomy may be performed with ease and safety under local anesthesia. The authors describe their technique. The tube is easy to maintain and replace and avoids some of the problems of feeding gastrostomies. In patients with major nutritional problems and a functioning intestinal tract the need for parenteral nutrition may be eliminated.