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Surgical site infections (SSI) cause significant morbidity. Prophylactic negative pressure wound therapy (NPWT) may promote wound healing and decrease SSI. The objective is to evaluate the effect of prophylactic NPWT on SSI in patients undergoing pancreatectomy.Electronic databases were searched from inception until April 2022. Randomized controlled trials (RCTs) comparing prophylactic NPWT to standard dressings in patients undergoing pancreatectomy were included. The primary outcome was the risk of SSI. Secondary outcomes included the risk of superficial and deep SSI and organ space infection (OSI). Random effects models were used for meta-analysis.Four single-centre RCTs including 309 patients were identified. Three studies were industry-sponsored, and two were at high risk of bias. There was no significant difference in the risk of SSI in patients receiving NPWT vs. control (14% vs. 21%, RR = 0.72, 95%CI = 0.32-1.60, p = 0.42, IProphylactic NPWT does not significantly decrease the risk of SSI among patients undergoing pancreatectomy. Insufficient evidence exists to justify the routine use of NPWT.

Genitourinary cancers are common. Liver metastases from genitourinary cancers are uncommon; isolated liver metastasis is rare. Liver resection in select patients with metastatic renal cell carcinoma can lead to prolonged survival. Patients with metachronous and low-burden disease are most likely to benefit. Chemotherapy is first-line treatment of metastatic germ cell tumors. Liver resection is dependent on germ cell lineage and initial response to chemotherapy. Prognosis with liver metastases from prostate cancer is poor; liver-only lesions are rare. Liver resection generally is not indicated. Cumulative experience with liver resection for metastatic bladder cancer is limited. Liver metastases are poor prognostic indicators for metastasectomy.

Highlights • Xanthogranulomatous cholecystitis (XGC) is a benign disease that can mimic cancer. • Management is complicated by uncharacteristic presentation and imaging findings. • Surgeons must ensure counselling includes the possibility of both XGC and carcinoma., Introduction Xanthogranulomatous cholecystitis (XGC) is a rare and benign chronic inflammatory disease of the gallbladder that can mimic carcinoma on presentation, imaging, and gross pathology. The aim of this case report is to describe the considerations involved in navigating the diagnostic and surgical dilemma of managing XGC in a patient with findings equivocal to gallbladder cancer. Presentation of case A 64-year-old female patient presented with an incidental, suspicious gallbladder mass on imaging. Due to her asymptomatic presentation and high risk features for carcinoma on imaging, an oncologic, en-bloc resection of the mass involving the gallbladder, liver, wall of duodenum, and hepatic flexure of the colon was performed. On pathological examination, the gallbladder specimen showed marked lymphohistiocytic inflammatory infiltrate of XGC that extended into adjacent structures without dysplasia. The patient had an uncomplicated postoperative course. Discussion Considerations around management of XGC must include the potential consequences associated with overtreating a benign entity or undertreating a potentially curable malignancy. Imaging findings that may be more suggestive of XGC include continuous mucosal lines and the presence of pericholecystic infiltration or fat stranding. Pitfalls of biopsy include potential tumour spillage and false negative results, especially when both XGC and cancer are present. Intraoperatively, macroscopic examination of the mass can also be misleading. Conclusion Surgeons must ensure that preoperative counselling includes the possibility of both XGC and gallbladder carcinoma, especially when findings are uncharacteristic. XGC must be managed with careful consideration of all findings and multidisciplinary input from a team of surgeons, radiologists, and pathologists.

Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD. All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF). In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44–0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance. The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.

ImportanceDespite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.ObjectiveTo define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.Design, Setting, and ParticipantsPragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment.InterventionThe intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care).Main Outcomes and MeasuresThe primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program.ResultsThe trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, −13.0% [95% CI, −19.1% to −6.9%]; P P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, −6.3% [95% CI, −11.4% to −1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, −1.2% [95% CI, −3.1% to 0.7%]; P = .32).Conclusions and RelevanceIn participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy.Trial RegistrationClinicalTrials.gov Identifier: NCT03269994

Acute pancreatitis is a potentially life-threatening condition with a wide spectrum of clinical presentation and illness severity. An infection of pancreatic necrosis (IPN) results in a more than twofold increase in mortality risk as compared with patients with sterile necrosis. We sought to identify prognostic factors for the development of IPN among adult patients with severe or necrotizing pancreatitis.We conducted this prognostic review in accordance with systematic review methodology guidelines. We searched six databases from inception through March 21, 2021. We included English language studies describing prognostic factors associated with the development of IPN. We pooled unadjusted odds ratio (uOR) and adjusted odds ratios (aOR) for prognostic factors using a random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the GRADE approach.We included 31 observational studies involving 5,210 patients. Factors with moderate or higher certainty of association with increased IPN risk include older age (uOR, 2.19; 95% confidence interval [CI], 1.39-3.45, moderate certainty), gallstone etiology (aOR, 2.35; 95% CI, 1.36-4.04, high certainty), greater than 50% necrosis of the pancreas (aOR, 3.61; 95% CI, 2.15-6.04, high certainty), delayed enteral nutrition (aOR, 2.09; 95% CI, 1.26-3.47, moderate certainty), multiple or persistent organ failure (aOR, 11.71; 95% CI, 4.97-27.56, high certainty), and invasive mechanical ventilation (uOR, 12.24; 95% CI, 2.28-65.67, high certainty).This meta-analysis confirms the association between several clinical early prognostic factors and the risk of IPN development among patients with severe or necrotizing pancreatitis. These findings provide the foundation for the development of an IPN risk stratification tool to guide more targeted clinical trials for prevention or early intervention strategies.Systematic review and meta-analysis, Level IV.

Major liver resection is associated with blood loss and transfusion. Observational data suggest that hypovolaemic phlebotomy can reduce these risks. This feasibility RCT compared hypovolaemic phlebotomy with the standard of care, to inform a future multicentre trial.Patients undergoing major liver resections were enrolled between June 2016 and January 2018. Randomization was done during surgery and the surgeons were blinded to the group allocation. For hypovolaemic phlebotomy, 7-10 ml per kg whole blood was removed, without intravenous fluid replacement. Co-primary outcomes were feasibility and estimated blood loss (EBL).A total of 62 patients were randomized to hypovolaemic phlebotomy (31) or standard care (31), at a rate of 3·1 patients per month, thus meeting the co-primary feasibility endpoint. The median EBL difference was -111 ml (P = 0·456). Among patients at high risk of transfusion, the median EBL difference was -448 ml (P = 0·069). Secondary feasibility endpoints were met: enrolment, blinding and target phlebotomy (mean(s.d.) 7·6(1·9) ml per kg). Blinded surgeons perceived that parenchymal resection was easier with hypovolaemic phlebotomy than standard care (16 of 31 versus 10 of 31 respectively), and guessed that hypovolaemic phlebotomy was being used with an accuracy of 65 per cent (20 of 31). There was no significant difference in overall complications (10 of 31 versus 15 of 31 patients), major complications or transfusion. Among those at high risk, transfusion was required in two of 15 versus three of nine patients (P = 0·326).Endpoints were met successfully, but no difference in EBL was found in this feasibility study. A multicentre trial (PRICE-2) powered to identify a difference in perioperative blood transfusion is justified. Registration number: NCT02548910 ( http://www.clinicaltrials.gov).La resección hepática mayor se asocia con pérdida de sangre y necesidad de transfusión. Datos observacionales sugieren que la flebotomía hipovolémica (hypovolaemic phlebotomy, HP) puede reducir estos riesgos. Este ensayo clínico aleatorizado (randomised clinical trial, RCT) de factibilidad comparó HP con el tratamiento estándar con el fin de proporcionar información para un futuro ensayo multicéntrico. MÉTODOS: Se reclutaron pacientes sometidos a resecciones hepáticas mayores entre junio 2016 y enero 2018. La aleatorización se realizó durante el intraoperatorio y los cirujanos eran ciegos al resultado de la asignación. Para la HP, se extrajeron 7-10 mL/kg de sangre total, sin reposición de líquidos intravenosos. Los resultados primarios fueron la factibilidad y la pérdida de sangre estimada (estimated blood loss, EBL).Un total de 62 pacientes se aleatorizaron a HP (n = 31) y a tratamiento estándar (n = 31), a un ritmo de 3,1 pacientes/mes, cumpliendo el co-objetivo primario de la factibilidad. La mediana de la diferencia de EBL fue 11 mL (P = 0,46). Entre los pacientes con alto riesgo de transfusión, la mediana de la diferencia de EBL fue 448 mL (P = 0,069). Los objetivos secundarios de factibilidad se consiguieron: reclutamiento (89%), cegamiento (98%), y objetivo de la flebotomía (7,6 ± 1,9 mL/kg). Los cirujanos que fueron cegados percibieron que la resección fue más fácil con la HP (52% versus 32%) y acertaron el uso de HP con una exactitud del 65%. No hubo diferencia significativa en las complicaciones globales (32% versus 48%), complicaciones mayores y transfusión. Entre aquellos pacientes de alto riesgo, la trasfusión se realizó en un 13% versus 33% (P = 0,33). CONCLUSIÓN: Se cumplieron los objetivos, pero no se identificó diferencia en EBL en este estudio de factibilidad. Ello justifica un ensayo multicéntrico (PRICE-2) con poder estadístico para identificar una diferencia en la transfusión de sangre perioperatoria.

Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation.

TPS638 Background: Prospective studies of the benefit of neoadjuvant chemotherapy in resectable pancreatic adenocarcinoma (PDAC) have been reported. The ideal peri-operative regimen is yet to be determined. Adjuvant FOLFIRINOX (mFFX) in resected PDAC has been proven to improve overall survival (OS) relative to adjuvant gemcitabine. An accepted perioperative approach involves delivering the majority of chemotherapy (6-8 cycles) in the pre-operative setting, while the remainder (of 12 cycles) is administered post-operatively. This pre-operative treatment period may allow for chemosensitivity assessment, and better patient selection for surgery, thereby improving R0 resection rates and reducing the frequency of early post-operative recurrence. Data from the COMPASS trial (NCT02750657) has shown that shown that low levels of the transcription factor GATA6 expression is a putative surrogate for the RNA Moffit signature and predictive of a chemoresistant phenotype in advanced PDAC. NeoPancONE will evaluate clinical outcomes and molecular biomarkers including GATA6 and radiomic biomarkers in pts with resectable PDAC treated with perioperative mFFX. Methods: NeoPancONE is a Phase 2, open-label, single arm study in pts with resectable PDAC. Tissue and serum are collected for biomarker testing, including GATA6 by FISH and IHC (1) with expression levels measured by RNAseq, and longitudinal ctDNA analysis. Pts with histologically confirmed, resectable PDAC and ECOG PS 0-1 will be recruited over 2.5 years. Resectability will be determined by central review as per NCCN guidelines. The primary objective is to evaluate disease-free survival in resectable PDAC treated with peri-operative mFFX according to baseline tumor GATA6 expression level. The ratio of GATA6-high to low is expected to be approximately 4:1[1]. Assuming 1-year disease-free survival of 65% in the GATA6-high, compared to 34% in the GATA6-low cohort, this corresponds to a hazard ratio of 2.5. With 80% power and a 5% 2-sided significance level, a total of 84 patients will be enrolled with 67 events expected in the GATA6 high cohort and 17 in GATA6 low. Participants will receive up to 6 cycles of neoadjuvant mFFX. After neoadjuvant chemotherapy, definitive surgical resection will proceed as deemed appropriate by a hepatobiliary surgeon. Post-operatively, pts will receive up to 6 cycles of adjuvant chemotherapy. Secondary objectives include determination of overall response rate, incidence of R0 resection, OS, Moffit gene expression profiling (RNAseq), ctDNA, and radiomic signatures to predict outcomes. Enrolment for NeoPancONE began in October 2020 and is being conducted at 8 sites across Canada. To date, 23 pts have been recruited. The study duration will be five years. Reference: O’Kane G M et al. Clin Can Res Sep 2020. Clinical trial information: NCT04472910.

To evaluate the effect of intraoperative blood salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery.Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery.Electronic databases were searched from inception until May 2021. All studies comparing IBSA use to control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival (OS) and disease-free survival (DFS), transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis.Twenty-one observational studies were included (16 transplant, 5 resection, n=3,433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion (MD -1.81, 95% CI[-3.22, -0.40], P=0.01, I2=86%, very-low certainty). Few resection studies reported on transfusion for meta-analysis. No significant difference existed in OS or DFS in liver transplant (HR=1.12[0.75, 1.68], P=0.59, I2=0%; HR=0.93[0.57, 1.48], P=0.75, I2=0%) and liver resection (HR=0.69[0.45, 1.05], P=0.08, I2=0%; HR=0.93[0.59, 1.45], P=0.74, I2=0%).IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.

Background The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has not be quantified. The aim of this study was to determine the uptake of the ISGPF definition and evaluate its use in the surgical literature. Methods A sample of primary studies, review articles, and textbooks were identified through screening of literature searches. Included citations were assessed for their definition of POPF and use of the ISGPF criteria. Results From 2006 to 2009, 6%–63% of primary papers were compliant with the ISGPF definition compared to 84%–98% from 2010 onwards. Of the primary studies compliant with the ISGPF criteria, 36% focused on grade B and C fistula and 15% did not report grade A fistula. 88% of European papers used the criteria compared to 77% and 72% of Asian and North American papers, respectively (p = 0.033). 46% of review articles and textbooks did not define POPF. Among those that defined POPF, 74% cited the ISGPF definition exclusively while 26% mentioned other definitions. Conclusion The ISGPF criteria have been widely adopted and accepted as the standard for defining POPF, although the utility of grade A fistulas is questionable.

Background Early drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol. Methods The Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation). Results 42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively). Conclusions Implementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.

"The anatomy of the biliary tree is notoriously variable. This variation is the bane of the hepatobiliary surgeon, to whom an understanding of biliary anatomic variation is key to the planning and safe conduct of liver surgery, from oncological resections to split-liver transplantation. The hepatic diverticulum, also termed "the liver bud," is the first semblance of the biliary system in the human embryo. A variety of techniques used in the mid twentieth century for imaging the biliary tree have since been abandoned in favor of more practical, safer, less invasive, and more sensitive and specific contemporary methods."

Highlights • Paraduodenal pancreatitis is a rare form of focal chronic or recurrent pancreatitis that can present as gastric outlet obstruction. • Endoscopic ultrasound and fine needle aspiration biopsy provides the best diagnostic modality. • Key histopathologic features include Brunner gland hyperplasia, myofibroblastic proliferation, spindle cells and foamy cells. • Cross-sectional imaging demonstrates a fibrotic, sheet-like mass with cystic change between the duodenal wall and pancreatic head. • The optimal treatment for refractory symptoms is pancreaticoduodenectomy., Introduction Paraduodenal pancreatitis (PP) is an under-recognized form of focal chronic or recurrent pancreatitis. Since PP presents with non-specific symptoms and shares radiological and histopathological features with other entities, it can be challenging to diagnose. Presentation of case report Herein, a case of a 64 year-old Caucasian male with PP presenting with recurrent gastric outlet obstruction (GOO) is detailed. Over the course of two years, he underwent multiple balloon dilatations for symptom management. His diagnostic course was complicated by inconclusive and misleading biopsies. Conclusion PP can rarely present as GOO in otherwise asymptomatic patients. A preoperative pathologic diagnosis can be difficult to obtain, and in this case delayed definitive surgical management. The case is discussed in detail, and a concise review the current literature was undertaken.

Highlights • Ingested foreign bodies are a common presentation. • Ingested foreign bodies can migrate/penetrate to the liver. • Patients can present with symptoms including epigastric abdominal pain. • In some cases hepatic foreign bodies can be extracted through a laparoscopic approach., Introduction Less than 1% of ingested foreign bodies will require surgical management. An uncommon complication of ingested foreign body is migration to the liver. We present a case of laparoscopic removal of an intrahepatic foreign body. Presentation of case 32-year-old female presented with a four month history of epigastric abdominal pain following suspected foreign body ingestion. CT scan demonstrated a metallic object lying in the left lateral segment of the liver. The patient was brought to the operating room where the object was removed laparoscopically and was found to be a sewing needle. Discussion Hepatic foreign bodies are an uncommon entity and typically result from a transcutaneous or ingested (e.g., gastrointestinal) source. Symptoms are often vague and can develop remote from the time of ingestion. Surgical management is warranted for symptomatic intrahepatic foreign bodies. Conclusion Laparoscopy is an effective surgical method for removal of intrahepatic foreign bodies in some cases.

Background Perioperative red blood cell (RBC) transfusion is associated with poor outcomes in liver surgery. Hypovolemic phlebotomy (HP) is a novel intervention hypothesized to decrease transfusion requirements. The objective of this study was to examine this hypothesis. Methods Consecutive patients who underwent liver resection at one institution (2010–2016) were included. Factors found to be predictive of transfusion on univariate analysis and those previously published were modeled using multivariate logistic regression. Results A total of 361 patients underwent liver resection (50% major). HP was performed in 45 patients. Phlebotomized patients had a greater proportion of primary malignancy (31% vs 18%) and major resection (84% vs 45%). Blood loss was significantly lower with phlebotomy in major resections (400 vs 700 mL). Nadir central venous pressure was significantly lower with HP (2.5 vs 5 cm H2O). On multivariate logistic regression, HP (OR 0.20, 95% CI 0.068–0.57, p = 0.0029), major liver resection (OR 2.91, 95% CI 1.64–5.18, p = 0.0003), preoperative hemoglobin Conclusion Hypovolemic phlebotomy appears to be strongly associated with a reduction in RBC transfusion requirements in liver resection, independent of other known risk factors.

There is significant interest and controversy surrounding the effect of restrictive fluid management on outcomes in major gastrointestinal surgery. This has been most studied in colorectal surgery, although the literature relating to pancreaticoduodenectomy (PD) patients is growing. The aim of this paper was to generate a comprehensive review of the available evidence for restrictive perioperative fluid management strategies and outcomes in PD. MEDLINE/PubMed, Embase, and the Cochrane Library were searched from inception to April 2017. A review protocol was utilized and registered with PROSPERO. Primary citations that evaluated perioperative fluid management in PD, including those as part of a clinical pathway, were considered. The primary outcome was postoperative pancreatic fistula (POPF). Secondary outcomes included delayed gastric emptying (DGE), complication rate, length of stay (LOS), mortality, and readmission. A total of six studies involving 846 patients were included (2009–2015), of which four were RCTs. Pooled analysis of RCTs and high-quality observational studies found no effect of restrictive intraoperative fluid management on POPF, DGE, complication rate, LOS, mortality, and readmission. Only one study assessed postoperative fluid management exclusively and found prolonged LOS in patients in the restricted fluid group. Based on results of RCTs and high-quality observational studies, intraoperative fluid restriction in PD has not been shown to significantly affect postoperative outcomes. There are too few studies assessing postoperative fluid management to draw conclusions at this time.

Background Propensity score (PS) analysis is a statistical method commonly used in observational trials to account for confounding. Improper use of PS analysis can bias the effect estimate. The aim of this study is to review the use and reporting of PS methods in high-impact surgical journals with a focus on propensity score matching (PSM). Study Design The 10 surgical journals with the highest impact factors were searched to identify studies using PS analysis from January 1, 2016 to December 14, 2018. We selected evaluation criteria for the conduct of PS analysis based on previous reports. Two authors systematically appraised the quality of reporting of PS analyses. Univariate and multivariate regression was performed to determine the relationship between appropriate use of PSM and study conclusion. Results Three hundred and three studies using PS analysis were included. Ninety-one percent (n = 275) of studies included the covariates used to generate the PS and 79% (n = 239) included the type of regression model used. Ninety percent (n = 272) of studies did not justify the covariates included in their PS. Eighty-four percent of studies used PSM (n = 254), with 48% (n = 123) failing to assess covariate balance between groups. We found that justification of the selection of covariates included in the PS and the characterization of unmatched patients were both associated with lower odds of the study finding a significant result (odds ratio 0.37; 95% CI 0.16 to 0.87; p = 0.02 and odds ratio 0.35; 95% CI 0.17 to 0.75; p = 0.007, respectively, at multivariate logistic regression). Conclusions This study demonstrates that even in research published in high-quality surgical journals, several studies report their PS methodology inadequately. The inadequate conduct of PS analysis can impact a study's conclusion.

A paradigm shift toward non-operative management (NOM) of blunt hepatic trauma has occurred. With advances in percutaneous interventions, even severe liver injuries are being managed non-operatively. However, although overall mortality is decreased with NOM, liver-related morbidity remains high. This study was undertaken to explore the morbidity and mortality of blunt hepatic trauma in the era of angioembolization (AE). A retrospective cohort of trauma patients with blunt hepatic injury who were assessed at our centre between 1999 and 2011 were identified. Logistic regression was undertaken to identify factors increasing the likelihood of operative management (OM) and mortality. We identified 396 patients with a mean ISS of 33 (±14). Sixty-two (18 %) patients had severe liver injuries (≥AAST grade IV). OM occurred in 109 (27 %) patients. Logistic regression revealed high ISS (OR 1.07; 95 % CI 1.05−1.10), and lower systolic blood pressure on arrival (OR 0.98; 95 % CI 0.97−0.99) to be associated with OM. The overall mortality was 17 %. Older patients (OR 1.05; 95 % CI 1.03−1.07), those with high ISS (OR 1.11; 95 % CI 1.08−1.14) and those requiring OM (OR 2.89; 95 % CI 1.47−5.69) were more likely to die. Liver-related morbidities occurred in equal frequency in the OM (23 %) and AE (29 %) groups (p = 0.32). Only 3 % of those with NOM experienced morbidity. The majority of patients with blunt hepatic trauma can be successfully managed non-operatively. Morbidity associated with NOM was low. Patients requiring AE had morbidity similar to OM.

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) is the most common cause of major morbidity following pancreatic resection. Intra-abdominal drains are frequently positioned adjacent to the pancreatic anastomosis or transection margin at the time of surgery to aid in detection and management of CR-POPF. Drains can either evacuate fluid by passive gravity (PG) or be attached to a closed suction (CS) system using negative pressure. There is controversy as to whether one of these two systems is superior. The objective of this review is to identify and compare the incidence of adverse events (AEs) and resource utilisation associated with PG and CS drainage following pancreatic resections.Methods and analysisMEDLINE, EMBASE, CINAHL and Cochrane Central Registry of Controlled Trials will be searched from inception to April 2019, to identify interventional and observational studies comparing PG and CS drains following pancreatic resection. The primary outcome is POPF as defined by the International Study Group for Pancreatic Fistula in 2017. Secondary outcomes include postoperative AE, resource utilisation (length of stay, return to emergency department, readmission and reintervention), time to drain removal and quality of life. Study selection, data extraction and risk of bias assessment will be performed independently, by two reviewers. A meta-analysis will be conducted if deemed statistically appropriate. Subgroup analysis by study design will be performed. Study heterogeneity will be calculated with the χ2test and reported as I2statistics. Statistical analyses will be conducted and displayed using RevMan V.5.3Ethics and disseminationEthics approval is not required. The results of this study will be submitted to relevant conferences for presentation and peer-reviewed journals for publication.PROSPERO registration numberCRD42019123647.

Introduction : Hepatic resection for malignancy is limited by the amount of liver parenchyma left behind. As a result, two-staged hepatectomy and portal vein occlusion (PVO) have become part of the treatment algorithm. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently described as a method to stimulate rapid and profound hypertrophy. Materials and methods : A systematic review of the literature pertaining to ALPPS was undertaken. Peer-reviewed articles relating to portal vein ligation (PVL) and in situ split (ISS) of the parenchyma were included. Results : To date, ALPPS has been employed for a variety of primary and metastatic liver tumors. In early case series, the perioperative morbidity and mortality was unacceptably high. However with careful patient selection and improved technique, many centers have reported a 0% 90-day mortality. The benefits of ALPPS include hypertrophy of 61–93% over a median 9–14 days, 95–100% completion of the second stage, and high likelihood of R0 resection (86–100%). Discussion : ALPPS is only indicated when a two-stage hepatectomy is necessary and the future liver remnant (FLR) is deemed inadequate ( 70 years) is cautioned. Discretion should be used when considering this in patients with pathology other than colorectal liver metastases (CRLM), especially hilar tumors requiring biliary reconstruction. Biliary ligation during the first stage and routine lymphadenectomy of the hepatoduodenal ligament should be avoided. Conclusions : A consensus on the indications and contraindications for ALPPS and a standardized operative protocol are needed.

Background The role of liver resection for non-colorectal, non-neuroendocrine, non-sarcoma (NCNNNS) metastases is ill-defined. This study aimed to examine the oncologic outcomes of liver resection in such patients. Methods A retrospective analysis of liver resection for NCNNNS metastases was performed at two large centers. Liver resection was offered selectively in patients with stable disease. Oncologic outcomes were examined using the Kaplan-Meier method. Results Fifty-two patients underwent liver resection for NCNNNS metastases. Overall 5-year survival was 58%. Five-year survival was 85% for breast metastases, 66% for ocular melanoma, 83% for other melanomas, 50% for gastro-esophageal metastases, and 0% for renal cell carcinoma metastases. A contemporary colorectal liver metastasis cohort had a survival of 63% (p=0.89). Conclusions Liver resection is an effective option in the management of selected patients with NCNNNS metastases which have been deemed stable. Five-year survival rates were comparable to that of a contemporary cohort of patients with colorectal liver metastases in carefully selected patients. Further, larger studies are required to help identify potential prognostic variables and aid in decision-making in this heterogeneous population.

Liver resections with negative margins improve survival in patients with colorectal liver metastases (CRLM). Intraoperative ultrasound (IOUS) is a valuable tool that gives information about lesions that ultimately changes surgical strategy to ensure complete removal, which subsequently improves disease free survival (DFS).A retrospective review of patients who underwent a resection for CRLM from 2009 to 2012 was completed to determine the impact of IOUS.A total of 103 patients had a hepatic resection for CRLM. All patients had preoperative imaging to assist with operative planning. IOUS was performed in 72 cases. Surgical strategy changed in 31 (43.1%) cases with IOUS, compared to three (9.7%) with no IOUS (P0.001). A new lesion was detected in 13 (18.1%) of the cases. A higher proportion of nonanatomic liver resections were performed in the IOUS group (N = 27, 37.5%) compared to the non-IOUS group (N = 6, 19.4%) (P = 0.07).Achievement of a negative resection margin was comparable between the two groups. However, there was a trend toward improved DFS in the IOUS group. Despite advances in preoperative imaging, IOUS demonstrates utility in providing novel information that allows removal of the entire tumor burden, using parenchymal-preserving techniques when feasible, leading to improved DFS.

Background Meticulous selection of patients who can undergo the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure safely will be paramount to minimize the associated morbidity and mortality. Methods We collected data prospectively on 14 consecutive patients who underwent the ALPPS procedure for planned resection of colorectal liver metastases at London Health Sciences Centre, Canada, between April 2012 and November 2013. Results The median relative increase of the standardized future liver remnant after the ALPPS procedure was 93 ± 28%. The standardized future liver remnant rate of volume increase was 35 ± 13 mL/day. Biopsies of the FLR were taken during stage 1 and 2. These biopsies showed a mean preregeneration Ki-67 index of 0% and a postregeneration index of 14 ± 3%. All 14 ALPPS patients completed the 2-stage hepatectomy. No complications occurred after ALPPS stage 1. After ALPPS stage 2, 5 patients had complications (36%), with 2 patients (14%) having a severe complication (Clavien-Dindo ≥ IIIB). Median follow-up was 9 months. Overall survival at the time of follow-up was 100%. Recurrence developed in 2 patients. One patient had recurrence in the liver and lungs 5 months after stage 2 and was offered more chemotherapy. The other patient developed recurrence in the liver remnant 9 months after stage 2 and underwent additional chemotherapy with a possible future resection of the recurrence. Conclusion Low morbidity and negligible mortality can be achieved with the ALPPS procedure, and the high rates published in previous reports can be improved with refinements in technique and patient selection. The ALPPS approach may be a valid option to enable resection in selected patients with colorectal liver metastases considered unresectable previously by standard techniques.

373 Background: AT with chemotherapy (CT) + radiation (RT) has been shown to improve PDAC survival over surgery alone. Although race and socioeconomic status can affect outcomes in PDAC, the impact of rural or remote residence on the delivery and effect of AT has not been studied. Methods: Patients undergoing pancreatectomy for PDAC were identified from the National Cancer Data Base between 2006 and 2013. Individuals were classified as living in a metro area, urban/rural adjacent to metro area (URA), and urban/rural remote area (URR). Patients with less than 6 months follow-up were excluded. Logistic regression was performed to assess residence as a predictor of receiving AT. Overall survival (OS) as a function of inhabitance was estimated by the method of Kaplan and Meier and prognostic factors were identified by Cox regression. Results: A total of 32,521 individuals underwent pancreatectomy for PDAC. The majority of AT was delivered in academic research facilities in 56% of patients while only 29% of patients received both CT and RT. Univariate analysis demonstrated individuals in URR were less likely to receive CT (55% vs 58%, p < 0.01) but not RT (30% vs 31%, p < 0.261) and had a longer interval to AT (82 vs 75 days, p < 0.009) than those in metro areas. However on multivariate analysis URR inhabitance was no longer predictive of any form of AT (OR = 0.892, 95% CI: 0.792-1.006, p = 0.062). Hispanic ethnicity, Medicaid insurance, uninsured status, and lower education were all predictive of decreased likelihood of receiving AT. Median OS was inferior for URR dwellers with pathologic T2 and T3 tumors compared to those in metro areas (19.8 vs. 24.4 months, p = 0.044 and 17.5 vs. 19.4 months, p < 0.001). Cox regression revealed URR location remained independently associated with poorer OS (HR 1.076, 95% CI: 1.008-1.149, p < 0.029). Conclusions: While living in a URR does not lead to reduced access to AT, it is associated with a worse OS in resected PDAC. This may be due to inadequate AT or other socioeconomic factors present in URR patients. Attention must be focused on improving oncologic care for groups susceptible to treatment disparities.

Many Canadians use complementary and alternative medicines (CAMs) to treat their chronic diseases. The objective of this study was to report patients' use of CAM for chronic rhinosinusitis (CRS) and to determine factors predictive of CAM use.A cross-sectional survey was conducted. Self-report questionnaires were administered to patients with CRS using strict inclusion and exclusion criteria. The questionnaire included demographic information, questions pertaining to disease severity, and CAM use for CRS treatment. Statistical analysis was used to compare gender, age range, symptom duration, pharmacotherapy use, and surgical frequency among CAM users and nonusers. A binomial logistic regression model was developed to predict CAM use. Secondary outcome measures included factors predictive of CAM use, type of CAM used, and reasons for using CAM.Data were obtained from 288 patients. Forty-five respondents (15.6%) had used CAM as a treatment for their CRS. CAM users were more likely to be females and more likely to have used each class of pharmacotherapy. On logistic regression, female gender and use of nasal corticosteroids were predictive of CAM use.The use of CAM as treatment of CRS is common. Females and those who have used the various classes of pharmacotherapy are more likely to use CAM. Both female gender and nasal corticosteroid use are predictive of CAM use. Physicians should routinely inquire about CAM use from their patients with CRS.

Aim: To investigate whether the long-term outcomes of hepatocellular carcinoma (HCC) was adversely impacted by intermittent hepatic inflow occlusion (HIO) during hepatic resection. Methods: 1549 HCC patients who underwent hepatic resection between 1998 and 2008 were identified from a prospectively maintained database. Intermittent HIO was performed in 931 patients (HIO group); of which 712 patients had a Pringle maneuver as the mechanism for occlusion (PM group), and 219 patients had selective hemi-hepatic occlusion (SO group). There were 618 patients that underwent partial hepatectomy without occlusion (occlusion-free, OF group). Results: The 1-, 3-, and 5- year overall survival (OS) rates were 79%, 59%, and 42% in the HIO group, and 83%, 53%, and 35% in the OF group, respectively. The corresponding recurrence free survival (RFS) rates were 68%, 39%, and 22% in the HIO group, and 74%, 41%, and 18% in the OF group, respectively. There was no significant difference between the 2 groups in OS or RFS (P = 0.325 and P = 0.416). Subgroup analysis showed patients with blood loss over 3000 mL and those requiring transfusion suffered significantly shorter OS and RFS. Blood loss over 3000 mL and blood transfusion were independent risk factors to OS and RFS. Conclusions: The application of intermittent HIO (PM and SO) during hepatic resection did not adversely impact either OS or RFS in patients with HCC. Intermittent HIO is still a valuable tool in hepatic resection, because high intraoperative blood loss resulting in transfusion is associated with a reduction in both OS and RFS.