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Remodeling of the coronary arteries is a common feature in severe cases of Kawasaki disease (KD). This pathology is driven by the dysregulated proliferation of vascular fibroblasts, which can lead to coronary artery aneurysms, stenosis, and myocardial ischemia. We undertook this study to investigate whether inhibiting fibroblast proliferation might be an effective therapeutic strategy to prevent coronary artery remodeling in KD.We used a murine model of KD (induced by the injection of the Candida albicans water-soluble complex [CAWS]) and analyzed patient samples to evaluate potential antifibrotic therapies for KD.We identified the mechanistic target of rapamycin (mTOR) pathway as a potential therapeutic target in KD. The mTOR inhibitor rapamycin potently inhibited cardiac fibroblast proliferation in vitro, and vascular fibroblasts up-regulated mTOR kinase signaling in vivo in the CAWS mouse model of KD. We evaluated the in vivo efficacy of mTOR inhibition and found that the therapeutic administration of rapamycin reduced vascular fibrosis and intimal hyperplasia of the coronary arteries in CAWS-injected mice. Furthermore, the analysis of cardiac tissue from KD fatalities revealed that vascular fibroblasts localizing with inflamed coronary arteries up-regulate mTOR signaling, confirming that the mTOR pathway is active in human KD.Our findings demonstrate that mTOR signaling contributes to coronary artery remodeling in KD, and that targeting this pathway offers a potential therapeutic strategy to prevent or restrict this pathology in high-risk KD patients.

A systematic review and network meta-analysis was performed to compare outcomes after living donor right hepatectomy via the following techniques: conventional open (Open), mini-laparotomy (Minilap), hybrid (Hybrid), totally laparoscopic (Lap), and robotic living donor right hepatectomy (Robotic).PubMed, EMBASE, Cochrane, and Scopus were searched from inception to August 2021 for comparative studies of patients who underwent living donor right hepatectomy.Nineteen studies comprising 2,261 patients were included. Operation time was longer in Lap versus Minilap and Open (mean difference 65.09 min, 95% confidence interval 3.40-126.78 and mean difference 34.81 minutes, 95% confidence interval 1.84-67.78), and in Robotic versus Hybrid, Lap, Minilap, and Open (mean difference 144.72 minutes, 95% confidence interval 89.84-199.59, mean difference 113.24 minutes, 95% confidence interval 53.28-173.20, mean difference 178.33 minutes, 95% confidence interval 105.58-251.08 and mean difference 148.05 minutes, 95% confidence interval 97.35-198.74, respectively). Minilap and Open were associated with higher blood loss compared to Lap (mean difference 258.67 mL, 95% confidence interval 107.00-410.33 and mean difference 314.11 mL, 95% confidence interval 143.84-484.37) and Robotic (mean difference 205.60 mL, 95% confidence interval 45.92-365.28 and mean difference 261.04 mL, 95% confidence interval 84.26-437.82). Open was associated with more overall complications compared to Minilap (odds ratio 2.60, 95% confidence interval 1.11-6.08). Recipient biliary complication rate was higher in Minilap and Open versus Hybrid (odds ratio 3.91, 95% confidence interval 1.13-13.55 and odds ratio 11.42, 95% confidence interval 2.27-57.49), and lower in Open versus Minilap (OR 0.07, 95% confidence interval 0.01-0.34).Minimally invasive donor right hepatectomy via the various techniques is safe and feasible when performed in high-volume centers, with no major differences in donor complication rates and comparable recipient outcomes once surgeons have mounted the learning curve.

BACKGROUND: Postoperative pancreatic fistula (POPF) remains a significant cause of morbidity in patients undergoing distal pancreatectomy (DP). The use of polyethylene glycol (PEG) and recombinant human albumin sealant gel applied to the transected pancreatic margin in DP may reduce POPF rates and was assessed. METHODS: A retrospective single centre cohort study of patient undergoing DP at an Australian high volume tertiary institution between January 2015 and January 2021. Rates of POPF in patients undergoing stapled pancreatic transection with PEG sealant were compared to other methods. RESULTS: A total of 54 cases were identified for analysis, with 16 undergoing stapled DP combined with staple line application of PEG (PEG group). Most patients in the control group had stapled DP 92% (35 of 38), with 47% (18 of 38) combined with a reinforcing buttress, with or without the use other glue types. Overall, 28 of 54 (52%) developed a POPF, with a significantly lower rate in the PEG group (3 of 16 vs. 25 of 38 in the Control group; p = 0.003). Clinically significant Grade B/C POPF was lower in the PEG group (0 of 16 vs. 9 of 28 in the Control group; p = 0.045), and patients in the PEG group had a shorter median (range) length of hospital stay (6 [4-14] days vs. 10 [6-41] days p = 0.04). CONCLUSION: Stapled DP with the application of PEG and recombinant human albumin sealant to the transection line appears to be associated with a lower rate of clinically significant POPF.

Highlights • Pancreatic acinar cell carcinoma (ACC) may present with pancreatic panniculitis. • Complete surgical resection of ACC can successfully treat pancreatic panniculitis. • Aggressive surgery for ACC can lead to prolonged disease-free survival., Introduction Pancreatic panniculitis is a rare manifestation of benign and malignant pancreatic disease. The presentation of pancreatic panniculitis is non-specific and thus diagnosis is often delayed. When associated with malignancy, pancreatic panniculitis confers a poor prognosis. This case demonstrates the successful surgical management of this paraneoplastic phenomenon following resection of the underlying pancreatic acinar cell carcinoma and associated liver metastasis. Presentation of case A 71-year-old female with debilitating subcutaneous lower limb lesions had a delayed diagnosis of pancreatic panniculitis. A formal diagnosis of pancreatic acinar cell carcinoma with liver metastasis was established and the disease was determined to be resectable. Pre-operatively, serum lipase measured 10,825 U/L. The patient proceeded to an open left hemihepatectomy and radical distal pancreatectomy with complete resection of malignant disease. Six days post-operatively the serum lipase levels normalised, and the panniculitis began to settle. The patient proceeded to adjuvant FOLFORINOX chemotherapy. Twenty months post-surgery, the patient remains disease-free and without any evidence of panniculitis. Discussion Due to the rarity of pancreatic acinar cell carcinoma, guidelines based on prospective data do not exist. Most management is based on retrospective analyses. A survival benefit may be achieved with more aggressive surgical management compared to other pancreatic cancer types. Pancreatic acinar cell carcinoma may show a slower rate of disease progression, an increased likelihood of resectability of disease at presentation and is more likely to undergo potentially curative resection. Conclusion Aggressive surgical management of resectable metastatic pancreatic acinar cell carcinoma can treat pancreatic panniculitis and provide sustained disease-free survival from pancreatic cancer.

Recent studies have established that memory B cells, largely thought to be circulatory in the blood, can take up long-term residency in inflamed tissues, analogous to widely described tissue-resident T cells. The dynamics of recruitment and retention of memory B cells to tissues and their immunological purpose remains unclear. Here, we characterized tissue-resident memory B cells (B RM ) that are stably maintained in the lungs of mice after pulmonary influenza infection. Influenza - specific B RM were localized within inducible bronchus-associated lymphoid tissues (iBALTs) and displayed transcriptional signatures distinct from classical memory B cells in the blood or spleen while showing partial overlap with memory B cells in lung-draining lymph nodes. We identified lung-resident markers, including elevated expression of CXCR3, CCR6, and CD69, on hemagglutinin (HA)– and nucleoprotein (NP)–specific lung B RM . We found that CCR6 facilitates increased recruitment and/or retention of B RM in lungs and differentiation into antibody-secreting cells upon recall. Although expression of CXCR3 and CCR6 was comparable in total and influenza-specific memory B cells isolated across tissues of human donors, CD69 expression was higher in memory B cells from lung and draining lymph nodes of human organ donors relative to splenic and PBMC-derived populations, indicating that mechanisms underpinning B RM localization may be evolutionarily conserved. Last, we demonstrate that human memory B cells in lungs are transcriptionally distinct to populations in lung-draining lymph nodes or PBMCs. These data suggest that B RM may constitute a discrete component of B cell immunity, positioned at the lung mucosa for rapid humoral response against respiratory viral infections.

The spleen is a compartmentalized organ that serves as a blood filter and safeguard of systemic immune surveillance. Labyrinthine networks of fibroblastic stromal cells construct complex niches within the white pulp and red pulp that are important for tissue homeostasis and immune activation. However, the identity and roles of the global splenic fibroblastic stromal cells in homeostasis and immune responses are poorly defined. Here, we performed a cellular and molecular dissection of the splenic reticular stromal cell landscape. We found that white pulp fibroblastic reticular cells (FRCs) responded robustly during acute viral infection, but this program of gene regulation was suppressed during persistent viral infection. Single-cell transcriptomic analyses in mice revealed diverse fibroblast cell niches and unexpected heterogeneity among podoplanin-expressing cells that include glial, mesothelial, and adventitial cells in addition to FRCs. We found analogous fibroblastic stromal cell diversity in the human spleen. In addition, we identify the transcription factor SpiB as a critical regulator required to support white pulp FRC differentiation, homeostatic chemokine expression, and antiviral T cell responses. Together, our study provides a comprehensive map of fibroblastic stromal cell types in the spleen and defines roles for red and white pulp fibroblasts for splenic function and orchestration of immune responses.

We aimed to facilitate the donation of tissue samples for research by establishing a centralized system integrated in the organ donation program for collection, storage, and distribution of samples (the Australian Donation and Transplantation Biobank [ADTB]).Feasibility of a research biobank integrated within the deceased organ and tissue donation program was assessed. DonateLife Victoria sought consent for ADTB donation after consent was received for organ donation for transplantation from the donor's senior available next of kin. ADTB samples were collected during donation surgery and distributed fresh to researchers or stored for future research. The main outcome measures were ADTB donation rates, ADTB sample collection, ADTB sample use, and to identify ethical considerations.Over 2 y, samples were collected for the ADTB from 69 donors (28% of 249 donors). Samples were obtained from the spleen (n = 59, 86%), colon (n = 57, 83%), ileum (n = 56, 82%), duodenum (n = 55, 80%), blood (n = 55, 80%), bone marrow (n = 55, 80%), skin (n = 54, 78%), mesenteric lymph nodes (n = 56, 81%), liver (n = 21, 30%), lung (n = 29, 42%), and lung-draining lymph node (n = 29, 42%). Heart (n = 20), breast (n = 1), and lower urinary tract (n = 1) samples were obtained in the second year. Five hundred fifty-six samples were used in 19 ethics-approved research projects spanning the fields of immunology, microbiology, oncology, anatomy, physiology, and surgery.The integration of routine deceased donation and transplantation activities with a coordinated system for retrieval and allocation of donor samples for use in a range of research projects is feasible and valuable.

BACKGROUND Blood removed from organs during deceased donor organ procurement is routinely discarded but is a potential resource for donor-specific transfusion (DST) in subsequent liver transplantation (LT). This study retrospectively analyses the impact of DST on intraoperative bank blood product usage, long-term graft, and patient survival, as well as frequency of rejection post-LT. METHODS A total of 992 adult LT performed from 1993 to 2018 in a single quaternary center were included. Intraoperative blood product usage, patient, and graft survival, as well as acute and chronic rejection were assessed in patients who received blood retrieved from the organ donor, the "donor blood" (DB) group (n = 437) and patients who did not, the "no donor blood" (NDB) group (n = 555). RESULTS Processing of DB ensured safe levels of potassium, magnesium, and insulin. There were fewer units of bank red blood cells transfusion required in the DB group compared to NDB group (2 vs. 4 units, P = .01). Graft survival was significantly superior in the DB group (10-year survival 75% vs. 69%, respectively, P = .04) but DST was not an independent predictor of graft survival. There was no significant difference in patient survival or rejection between the groups. There was no difference in treated, biopsy-proven rejection between the two groups. CONCLUSIONS This is the first large-cohort study assessing long-term outcomes of intraoperative DST in LT. The collection of organ donor blood and subsequent use in LT recipients appeared feasible with appropriate quality checks ensuring safety. DST resulted in a reduction in the use of packed red blood cells. There was no difference in the rate of rejection or graft or patient survival.

BACKGROUND: Acute liver failure (ALF) is a life-threatening syndrome with varying aetiologies requiring complex care and multidisciplinary management. Its changing incidence, aetiology and outcomes over the last 16 years in the Australian context remain uncertain. AIM: To describe the changing incidence, aetiology and outcomes of ALF in South Eastern Australia. METHODS: The database of the Victorian Liver Transplant Unit was interrogated to identify all cases of ALF in adults (> 16 years) in adults hospitalised between January 2002 and December 2017. Overall, 169 patients meeting criteria for ALF were identified. Demographics, aetiology of ALF, rates of transplantation and outcomes were collected for all patients. Transplant free survival and overall survival (OS) were assessed based on survival to discharge from hospital. Results were compared to data from a historical cohort from the same unit from 1988-2001. RESULTS: Paracetamol was the most common aetiology of acute liver failure, accounting for 50% of cases, with an increased incidence compared with the historical cohort (P = 0.046). Viral hepatitis and non-paracetamol drug or toxin induced liver injury accounted for 15% and 10% of cases respectively. Transplant free survival (TFS) improved significantly compared to the historical cohort (52% vs 38%, P = 0.032). TFS was highest in paracetamol toxicity with spontaneous recovery in 72% of cases compared to 31% of non-paracetamol ALF (P < 0.001). Fifty-nine patients were waitlisted for emergency liver transplantation. Nine of these died while waiting for an organ to become available. Forty-two patients (25%) underwent emergency liver transplantation with a 1, 3 and 5 year survival of 81%, 78% and 72% respectively. CONCLUSION: Paracetamol toxicity is the most common aetiology of ALF in South-Eastern Australia with a rising incidence over 30 years. TFS has improved, however it remains low in non-paracetamol ALF.

Background Central hepatectomy (CH) is more difficult than extended hepatectomy (EH) and is associated with greater morbidity. In this modern era of liver management with aims to prevent post-hepatectomy liver failure (PHLF), there is a need to assess outcomes of CH as a parenchyma-sparing procedure for centrally located liver tumors. Methods A total of 178 major liver resections performed by specialist surgeons from two Australian tertiary institutions between June 2009 and March 2017 were reviewed. Eleven patients had CH and 24 had EH over this study period. Indications and perioperative outcomes were compared between the groups. Results The main indication for performing CH was colorectal liver metastases. There was no perioperative mortality in the CH group and four (16.7%) in the EH group (P = 0.285). No group differences were found in median operative time [CH vs. EH: 450 min (290–840) vs. 523 min (310–860), P = 0.328], intraoperative blood loss [850 mL (400–1500) vs. 650 mL (100–2000), P = 0.746] or patients requiring intraoperative blood transfusion [1 (9.1%) vs. 7 (30.4%), P = 0.227]. There was a trend towards fewer hepatectomy-specific complications in the CH group [3 (27.3%) vs. 13 (54.2%), P = 0.167], including PHLF (CH vs. EH: 0 vs. 29.2%, P = 0.072). Median length of stay was similar between groups [CH vs. EH: 9 days (5–23) vs. 12 days (4–85), P = 0.244]. Conclusions CH has equivalent postoperative outcomes to EH. There is a trend towards fewer hepatectomy-specific complications, including PHLF. In appropriate patients, CH may be considered as a safe parenchyma-sparing alternative to EH.

Objective: To assess long term graft and patient survival after donor liver retransplantation in children in Australia and New Zealand during 1986–2017; to determine the factors that influence survival. Design: Retrospective cohort analysis (registry data). Setting, participants: Australia and New Zealand Liver Transplant Registry data for all liver retransplantations in children (under 18 years of age), 1986–2017, in all four paediatric and six adult liver transplantation centres in the two countries. Main outcome measures: Graft and patient survival at one, 5, 10 and 15 years. Results: 142 liver retransplantations were undertaken in children (59 during 1986–2000, 83 during 2001–2017). Kaplan–Meier survival analysis indicated that survival was significantly greater during 2001–2017 than 1986–2000 (P

BACKGROUND: Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia. METHODS: This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy. RESULTS: A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P < 0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P < 0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P < 0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P < 0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P < 0.001). There was a decline in policy adherence in the later cohort. CONCLUSION: Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.

BACKGROUND: Pancreaticoduodenectomy (PD) is associated with high morbidity, which is perceived to be increased in the elderly. To our knowledge there have been no Australian series that have compared outcomes of patients over the age of 80 undergoing PD to those who are younger. METHODS: Patients who underwent PD between January 2008 and November 2015 were identified from a prospectively maintained database. RESULTS: A total of 165 patients underwent PD of whom 17 (10.3%) were aged 80 or over. The pre-operative health status, according to American Society of Anesthesiologists class was similar between the groups (P = 0.420). The 90-day mortality rates (5.9% in the elderly and 2% in the younger group; P = 0.355) and the post-operative complication rates (64.7% in the elderly versus 62.8% in the younger group; P = 0.88) were similar. Overall median length of hospital stay was also similar between the groups, but older patients were far more likely to be discharged to a rehabilitation facility than younger patients (47.1 versus 12.8%; P

Acute biliary pain is the most common presentation of gallstone disease. Untreated patients risk recurrent pain, cholecystitis, obstructive jaundice, pancreatitis and multiple hospital presentations. We examine the outcome of implementing a policy to offer laparoscopic cholecystectomy on index presentation to patients with biliary colic in a tertiary hospital in Australia.This is a retrospective cohort study of adult patients presenting to the emergency department (ED) with biliary pain during three 12-month periods. Outcomes in Group A, 3 years prior to policy implementation, were compared with groups 2 and 7 years post implementation (Groups B and C). Primary outcomes were representations to ED, admission rate and time to cholecystectomy.A total of 584 patients presented with biliary colic during the three study periods. Of these, 391 underwent cholecystectomy with three Strasberg Type A bile leaks and no bile duct injuries. The policy increased admission rates (A = 15.8%, B = 62.9%, C = 29.5%, P0.001) and surgery on index presentation (A = 12.0%, B = 60.7%, C = 27.4%, P0.001). There was a decline in time to cholecystectomy (days) (A = 143, B = 15, C = 31, P0.001), post-operative length of stay (days) (A = 3.6, B = 3.2, C = 2.0, P0.05) and representation rates to ED (A = 42.1%, B = 7.1%, C = 19.9%, P0.001). There was a decline in policy adherence in the later cohort.Index hospital admission and cholecystectomy for biliary colic decrease patient representations, time to surgery, post-operative stay and complications of gallstone disease. This study demonstrates the impact of the policy with initial improvement, the dangers of policy attrition and the need for continued reinforcement.

Patent ductus venosus (PDV) is an uncommon but important congenital portocaval shunt that can lead to numerous complications if untreated. This case describes the successful management of a 17-year-old male with symptomatic PDV. Doppler ultrasonography and contrast-enhanced computed tomography (CT) confirmed a large communication between the left portal vein and the inferior vena cava. Angiography demonstrated a large and high flow PDV which precluded its therapeutic embolization. Based on these findings, laparoscopic closure of the PDV was elected and successfully performed. Perioperative indocyanine green (ICG) clearance was performed and marked improvement was observed following the occlusion of the PDV. The patient showed immediate resolution of symptoms post-operatively and remains asymptomatic 2 years after his surgery. Laparoscopic approach to the management of PDV is feasible. ICG clearance, for the first time, was demonstrated in this setting to be a useful and rapid bedside test for the real-time assessment of liver function.

Umbilical hernia is a common complication in patients with cirrhosis. Early studies have reported a high morbidity and mortality associated with hernia repair. The traditional approach has been to non-operatively manage umbilical hernias in patients with cirrhosis. There are emerging data suggesting that an elective repair is a preferable approach. This study examined the outcomes of umbilical hernia repair in patients with advanced liver disease and compared this with a control group of non-cirrhotic patients. Prospective data were collected regarding the outcome of umbilical hernia repairs performed between 2004 and 2013 at the Austin Hospital, Melbourne, Australia. Outcomes at 90 days were compared between patients with and without cirrhosis. 79 patients with cirrhosis and 249 controls were analysed. Of the patients with cirrhosis, 9% were classified as Child–Pugh A, 61% were Child–Pugh B and 30% were Child–Pugh C. Emergency repairs for complicated hernias was undertaken in 18% of the cirrhosis population and 10% in controls (P = 0.10). Post-operative complications occurred more commonly in patients with cirrhosis (26%) compared with controls (11%) (P

Background Portal vein resection (PVR) with pancreatectomy is now accepted practice in cases with involvement by tumour. We present our experience of this procedure with particular emphasis on morbidity and survival. Methods A retrospective case-control analysis of a prospectively maintained database between 2004 and 2012 was undertaken. A total of 17 patients had pancreatic resections with PVR for cancer and were compared with 17 patients with identical tumour type and stage who underwent pancreatic resection without PVR next in chronological order. Information obtained included patient demographics, radiological and histological evidence of major vein involvement and post-operative morbidity. Disease- and recurrence-free survival were calculated using Kaplan–Meier curves. Results Procedures associated with PVR included pancreatico-duodenectomy in 11 and total pancreatectomy in six. Three patients underwent pancreatic resection as a re-operation. Pathological staging showed 2× T2N0, 5× T3N0, 1× T1N1, 2× T2N1 and 7× T3N1 tumours. Seven PVR patients (41%) had post-operative morbidity Clavien 3 and 4, compared with none in no-PVR group, but rates of Clavien 1 and 2 complications were similar. Six PVR patients developed PV thrombosis (35%), all with significant clinical consequences. Comparing the PVR group with the no-PVR group, there was significantly reduced median overall survival in (13.8 versus 43.1 months; P = 0.028) and recurrence-free survival (7.5 months versus 39.7; P = 0.004). Conclusions Survival of patients after pancreatectomy with PVR was reduced and morbidity was high compared with no-PVR. Delayed portal vein thrombosis due to recurrence was common. Routine post-operative anticoagulation may be indicated in this group.

Pancreaticoduodenectomy (PD) is associated with high morbidity, which is perceived to be increased in the elderly. To our knowledge there have been no Australian series that have compared outcomes of patients over the age of 80 undergoing PD to those who are younger.Patients who underwent PD between January 2008 and November 2015 were identified from a prospectively maintained database.A total of 165 patients underwent PD of whom 17 (10.3%) were aged 80 or over. The pre-operative health status, according to American Society of Anesthesiologists class was similar between the groups (P = 0.420). The 90-day mortality rates (5.9% in the elderly and 2% in the younger group; P = 0.355) and the post-operative complication rates (64.7% in the elderly versus 62.8% in the younger group; P = 0.88) were similar. Overall median length of hospital stay was also similar between the groups, but older patients were far more likely to be discharged to a rehabilitation facility than younger patients (47.1 versus 12.8%; P 0.0001). Older patients with pancreatic adenocarcinoma (n = 10) had significantly lower median survival than the younger group (n = 69) (16.6 versus 22.5 months; P = 0.048).No significant differences were seen in the rate of complications following PD in patients aged 80 or over compared to younger patients, although there appears to be a shorter survival in the elderly patients treated for pancreatic cancer. Careful selection of elderly patients and optimal peri-operative care, rather than age should be used to determine whether surgical intervention is indicated in this patient group.

Background Acute cholecystitis is a common surgical problem that is optimally managed by early laparoscopic cholecystectomy when possible. Percutaneous cholecystostomy (PC) has been used in certain high-risk cases as a bridge to surgery or for definitive therapy. The aim of this study was to determine the short-term and long-term outcomes of patients with acute cholecystitis treated by PC. Study design Patients with acute cholecystitis treated by PC between 2005 and 2011 in a tertiary hospital were identified from a prospectively maintained database. Outcome differences between patients with acalculous acute cholecystitis (AAC) and those with acute cholecystitis relating to gallstones were determined. Results There were 32 cases from a total of 443 patients with acute cholecystitis treated by PC during the study period. The overall 30-day mortality rate after PC was 9%. There were 8 patients with AAC in this series. Ischemic heart disease and chronic renal failure were noted in 47% and 41% of patients, respectively. In all cases, patients were considered unfit for surgery. AAC was more common in male patients. In all other aspects patients with AAC had similar characteristics to those with gallstones. Patients underwent percutaneous drainage a median of 3 days after admission with a direct transperitoneal route used in 16 (75%) cases. Positive bile cultures from the gallbladder were noted in 60% of cases tested. Complications were noted in 53% of patients and were related to the cholecystostomy tube in 19% of cases. Subsequent cholecystectomy was performed in 9 (28%) patients, at a median of 73 days after initial tube insertion. No differences in morbidity and mortality were noted between patients with AAC and those with gallstones. The overall mean and 12 months survival was 43 months and 72%, respectively. Hypotension at presentation (odds ratio 9.2; 95% confidence interval, 1.4-59.8; P=0.019) and absence of bile duct filling on cholecystography (odds ratio 4.6; 95% confidence interval, 1.2-16.3; P=0.017) were independently associated with decreased survival. Conclusions PC can be performed safely in patients considered unfit for surgery at presentation. Outcomes are similar in patients with or without gallstones. Hypotension and absence of common bile duct filling on initial cholangiography are markers of decreased long-term survival. A significant number of patients require subsequent definitive cholecystectomy.

Background The independent influence of advanced age on outcomes in contemporary series treated by early cholecystectomy is undetermined. Methods Elderly patients, aged 80 years and older, with histology proven acute cholecystitis treated by cholecystectomy on initial presentation between 2005 and 2011 were compared to all others. Results In total, 411 patients had histologically proven acute cholecystitis, of whom 71 (17%) were aged 80 years and older. Elderly patients were more likely to have ischaemic heart disease, underlying diabetes and chronic renal failure. There was greater conversion from laparoscopic to open surgery in the elderly (21% versus 7%; P = 0.001). Elderly patients were more likely to have gangrenous cholecystitis (44% versus 31%; P = 0.033) and common bile duct stones (27% versus 17%; P = 0.048). Elderly patients had more complications (31% versus 13%; P < 0.001), a higher mortality rate (4% versus 1%; P = 0.038) and a longer median post-operative length of stay (7 days versus 3 days; P < 0.001). Age ≥ 80 (P = 0.004) was an independent risk factors for complications. Conclusion Age 80 years and older is independently associated with increased morbidity following cholecystectomy for treatment acute cholecystitis at initial presentation.

Several series have reported differences in characteristics, severity, operative complexity, and outcomes of patients with symptomatic gallstone disease according to sex. Whether sex truly influences outcomes of patients with acute cholecystitis in the current era of early laparoscopic cholecystectomy for acute cholecystitis is unknown.Patients with histologically confirmed acute cholecystitis treated by a specialized unit in a tertiary hospital between November 2005 and January 2011 were identified. Retrospective review of data was undertaken and patients were compared according to sex.There were 386 cases of confirmed acute cholecystitis in this series, with 181 (47%) occurring in male patients. Male patients with acute cholecystitis tended to be older (66 vs. 57 y; P0.001) and were more likely to have underlying diabetes (21% vs. 9%; P = 0.001), ischemic heart disease (24% vs. 8%; P0.001), chronic liver disease (6% vs. 1%; P = 0.015), and chronic obstructive airways disease (11% vs. 5%; P = 0.025). They were also more likely to be febrile, tachycardic, hypotensive, and exhibit right upper quadrant rigidity at presentation than females (P0.05), despite similar duration of symptoms before presentation (P = 0.970). The operative technique, operative time, and rate of conversion to open surgery were similar between the sexes. Gangrenous pathology was, however, more common in male patients (45% vs. 23%; P0.001). The overall complication, mortality, and readmission rates were similar between the 2 groups. Males, however, had a longer postoperative length of stay (4 vs. 3 d; P = 0.001).Male patients with acute cholecystitis are older, have more comorbidities, and are more likely to have gangrenous cholecystitis than female patients. Despite these differences, operative outcomes and postoperative morbidity and mortality are similar between male and female patients.

Background Acute acalculous cholecystitis (AAC) is traditionally described in the setting of critical illness, where the diagnosis is based on clinical assessment and imaging criteria. Very few studies have assessed the features and outcomes of AAC in patients treated by cholecystectomy. Methods Patients with histologically confirmed acute cholecystitis treated in a specialized unit in a tertiary hospital between 2005 and 2011 were identified from prospectively maintained database. Retrospective review of data was undertaken and patients with AAC were compared with those patients with acute cholecystitis and confirmed gallstones. Results AAC was identified in 35 of 412 (8.5%) patients with acute cholecystitis. These patients were older (69 years versus 61 years; P = 0.004) and were more likely to be febrile (46% versus 21%; P = 0.001) and hypotensive (23% versus 5%; P < 0.001) at initial presentation. There was a higher incidence of chronic obstructive airways disease (COAD) in the AAC group (26% versus 6%; P < 0.001). Other co-morbidities were similar among the groups. Operative outcomes were similar between the groups. There were no overall differences in postoperative complications between AAC and calculous acute cholecystitis patients (17% versus 16%; P = 0.063). However, the postoperative length of stay was higher in the AAC group (5 days versus 3 days; P = 0.026). Conclusion AAC more commonly occurs in older patients and those with COAD. The operative outcomes and complications of AAC treated by cholecystectomy are similar to cases of acute calculous cholecystitis.

BackgroundGangrenous cholecystitis (GC) is considered a more severe form of acute cholecystitis. The risk factors associated with this condition and its impact on morbidity and mortality compared with those of non-gangrenous acute cholecystitis (NGAC) are poorly defined and based largely on findings from older studies.MethodsPatients with histologically confirmed acute cholecystitis treated in specialized units in a tertiary hospital between 2005 and 2010 were identified from a prospectively maintained database. Data were reviewed retrospectively and patients with GC were compared with those with NGAC.ResultsA total of 184 patients with NGAC and 106 with GC were identified. The risk factors associated with GC included older age (69 years vs. 57 years; P= 0.001), diabetes (19% vs. 10%; P= 0.049), temperature of >38°C (36% vs. 16%; P < 0.001), tachycardia (31% vs. 15%; P= 0.002), detection of muscle rigidity on examination (27% vs. 12%; P= 0.01) and greater elevations in white cell count (WCC) (13.4 × 109/l vs. 10.7 × 109/l; P < 0.001), C-reactive protein (CRP) (94mg/l vs. 17mg/l; P= 0.001), bilirubin (19µmol/l vs. 17µmol/l; P= 0.029), urea (5.3mmol/l vs. 4.7mmol/l; P= 0.016) and creatinine (82µmol/l vs. 74µmol/l; P= 0.001). The time from admission to operation in days was greater in the GC group (median = 1 day, range: 0–14 days vs. median = 1 day, range: 0–10 days; P= 0.029). There was no overall difference in complication rates between the GC and NGAC groups (22% vs. 14%; P= 0.102). There was a lower incidence of common bile duct stones in the GC group (5% vs. 13%; P= 0.017). Gangrenous cholecystitis was associated with increased mortality (4% vs. 0%; P= 0.017), but this was not an independent risk factor on multivariate analysis.ConclusionsGangrenous cholecystitis has certain clinical features and associated laboratory findings that may help to differentiate it from NGAC. It is not associated with an overall increase in complications when treated in a specialized unit.Case series which identifies patients at risk of having gangrenous cholecystitis when presenting with acute gallstone disease

Published in Transplantation 208; 102 (7 Supplement 1): S149. Date of Publication: July 2018.

Background. The most significant risk following major hepatectomy is postoperative liver insufficiency. Current preoperative assessment of the future liver remnant relies upon assumptions which may not be valid in the setting of advanced resection strategies. This paper reports the feasibility of the ALIIVE technique which assesses the liver remnant with ICG clearance intraoperatively during vascular exclusion. Methods. 10 patients undergoing planned major liver resection (hemihepatectomy or greater) were recruited. Routine preoperative assessment included CT and standardized volumetry. ICG clearance was measured noninvasively using a finger spectrophotometer at various time points including following parenchymal transection during inflow and outflow occlusion before vascular division, the ALIIVE step. Results. There were one case of mortality and three cases of posthepatectomy liver failure. The patient who died had the lowest ALIIVE ICG clearance (7.1%/min versus 14.4 ± 4.9). Routine preoperative CT and standardized volumetry did not predict outcome. Discussion/Conclusion. The novel ALIIVE technique is feasible and assesses actual future liver remnant function before the point of no return during major hepatectomy. This technique may be useful as a check step to offer a margin of safety to prevent posthepatectomy liver failure and death. Further confirmatory studies are required to determine a safety cutoff level.

Background: Hepatic resection is the standard treatment for resectable colorectal cancer liver metastases. There is evidence that lymphatics play a role in disease recurrence post-surgery. The aim of this retrospective study is to assess patterns of lymph node recurrence after liver resection. Methods: Patients who had liver resection for colorectal cancer metastasis between 1 January 2010 and 31 December 2015 at 2 institutions in Melbourne, Australia were included. Data was collected from databases located at the 2 surgical centres.Results: Seventy-four patients were included in the study. Follow-up period was for a mean of 31.4 months. Lymph node recurrence was seen in 39.2% of patients during follow-up. Initial recurrence sites after hepatectomy was mainly in visceral-site only. Lymph node recurrences became more prominent during subsequent Recurrence Stages (RS) (RS1 – 22.4%, RS2 – 50.0%, RS3 – 50.0%, RS4 – 71.4%, RS5 – 66.7%, and RS6 – 0%). No predictive factor showed statistically significant relation to development of nodal recurrence. Conclusion: Lymph node recurrences after hepatic resection for liver metastases usually occur subsequent to a visceral-site only metastasis. There is no predictive factor as to which nodal group would be involved due to the complexity of liver lymphatic drainage.

Hepatocellular carcinoma represents one of the most challenging frontiers in liver surgery. Surgeons have to face a broad spectrum of aspects, from the underlying liver disease to the new surgical techniques. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%, offering good long-terms results in selected patients. With the advances in laparoscopic surgery, major liver resections can be performed with minimal harm, avoiding the wound and leak complications related to the laparotomies. Studies have shown that oncological margins are the same as in open surgery. In patients submitted to liver resection (either laparoscopic or open) who experience recurrence, re-resection or salvage liver transplantation has been showing to be an alternative approach in well selected cases. The decision making approach to the cirrhotic patient is becoming more complex and should involve hepatologists, liver surgeons, radiologists and oncologists. Better understanding of the different risk factors for recurrence and survival should be aimed in these multidisciplinary discussions. We here in discuss the hot topics related to surgical risk factors regarding the surgical treatment of hepatocellular carcinoma: anatomical resection, margin status, macrovascular tumor invasion, the place of laparoscopy, salvage liver transplantation and liver transplantation.

Portal vein resection (PVR) with pancreatectomy is now accepted practice in cases with involvement by tumour. We present our experience of this procedure with particular emphasis on morbidity and survival.A retrospective case-control analysis of a prospectively maintained database between 2004 and 2012 was undertaken. A total of 17 patients had pancreatic resections with PVR for cancer and were compared with 17 patients with identical tumour type and stage who underwent pancreatic resection without PVR next in chronological order. Information obtained included patient demographics, radiological and histological evidence of major vein involvement and post-operative morbidity. Disease- and recurrence-free survival were calculated using Kaplan-Meier curves.Procedures associated with PVR included pancreatico-duodenectomy in 11 and total pancreatectomy in six. Three patients underwent pancreatic resection as a re-operation. Pathological staging showed 2× T2N0, 5× T3N0, 1× T1N1, 2× T2N1 and 7× T3N1 tumours. Seven PVR patients (41%) had post-operative morbidity Clavien 3 and 4, compared with none in no-PVR group, but rates of Clavien 1 and 2 complications were similar. Six PVR patients developed PV thrombosis (35%), all with significant clinical consequences. Comparing the PVR group with the no-PVR group, there was significantly reduced median overall survival in (13.8 versus 43.1 months; P = 0.028) and recurrence-free survival (7.5 months versus 39.7; P = 0.004).Survival of patients after pancreatectomy with PVR was reduced and morbidity was high compared with no-PVR. Delayed portal vein thrombosis due to recurrence was common. Routine post-operative anticoagulation may be indicated in this group.

The independent influence of advanced age on outcomes in contemporary series treated by early cholecystectomy is undetermined.Elderly patients, aged 80 years and older, with histology proven acute cholecystitis treated by cholecystectomy on initial presentation between 2005 and 2011 were compared to all others.In total, 411 patients had histologically proven acute cholecystitis, of whom 71 (17%) were aged 80 years and older. Elderly patients were more likely to have ischaemic heart disease, underlying diabetes and chronic renal failure. There was greater conversion from laparoscopic to open surgery in the elderly (21% versus 7%; P = 0.001). Elderly patients were more likely to have gangrenous cholecystitis (44% versus 31%; P = 0.033) and common bile duct stones (27% versus 17%; P = 0.048). Elderly patients had more complications (31% versus 13%; P0.001), a higher mortality rate (4% versus 1%; P = 0.038) and a longer median post-operative length of stay (7 days versus 3 days; P0.001). Age ≥ 80 (P = 0.004) was an independent risk factors for complications.Age 80 years and older is independently associated with increased morbidity following cholecystectomy for treatment acute cholecystitis at initial presentation.

Acute acalculous cholecystitis (AAC) is traditionally described in the setting of critical illness, where the diagnosis is based on clinical assessment and imaging criteria. Very few studies have assessed the features and outcomes of AAC in patients treated by cholecystectomy.Patients with histologically confirmed acute cholecystitis treated in a specialized unit in a tertiary hospital between 2005 and 2011 were identified from prospectively maintained database. Retrospective review of data was undertaken and patients with AAC were compared with those patients with acute cholecystitis and confirmed gallstones.AAC was identified in 35 of 412 (8.5%) patients with acute cholecystitis. These patients were older (69 years versus 61 years; P = 0.004) and were more likely to be febrile (46% versus 21%; P = 0.001) and hypotensive (23% versus 5%; P0.001) at initial presentation. There was a higher incidence of chronic obstructive airways disease (COAD) in the AAC group (26% versus 6%; P0.001). Other co-morbidities were similar among the groups. Operative outcomes were similar between the groups. There were no overall differences in postoperative complications between AAC and calculous acute cholecystitis patients (17% versus 16%; P = 0.063). However, the postoperative length of stay was higher in the AAC group (5 days versus 3 days; P = 0.026).AAC more commonly occurs in older patients and those with COAD. The operative outcomes and complications of AAC treated by cholecystectomy are similar to cases of acute calculous cholecystitis.