Background: An understanding of the incidence and treatment of biliary stricture after major hepatectomy (MH) with bile duct resection (BDR) is limited by small-volume series and/or lack of long-term follow-up. The aim of this study was to evaluate the incidence, risk factors, and treatment strategy of biliary stricture after MH with BDR. We hypothesized that biliary stricture after MH with BDR is more common than previously appreciated and is successfully managed with percutaneous interventions.

BACKGROUND:The decision to routinely leave a nasogastric tube after pancreatoduodenectomy remains controversial. We sought to determine the impact of immediate nasogastric tube removal versus early nasogastric tube removal (<24 h) on postoperative outcomes. METHODS:A retrospective review of our institution's prospective ACS-NSQIP database identified patients that underwent pancreatoduodenectomy from 2015 to 2018. Outcomes were compared among patients with immediate nasogastric tube removal versus early nasogastric tube removal. RESULTS:A total of 365 patients were included in primary analysis (no nasogastric tube, n = 99; nasogastric tube removed <24 h, n = 266). Thirty-day mortality and infectious, renal, cardiovascular, and pulmonary morbidity were similar in comparing those with no nasogastric tube versus early nasogastric tube removal on univariable and multivariable analyses (P > 0.05). Incidence of delayed gastric emptying (11.1 versus 13.2%) was similar between groups. Patients with no nasogastric tube less frequently required nasogastric tube reinsertion (n = 4, 4%) compared to patients with NGT <24 h (n = 39, 15%) (OR = 3.83, 95% CI [1.39-10.58]; P = 0.009). CONCLUSION:Routine gastric decompression can be safely avoided after uneventful pancreaticoduodenectomy.

Background: The accuracy of hepatobiliary scintigraphy to assess gallbladder function remains controversial. National supply shortages of pharmaceutical-grade cholecystokinin led to the use of an oral fatty meal to stimulate gallbladder contraction during hepatobiliary scintigraphy. The goal of this study was to compare the predictive indices of cholecystokinin and fatty meal ingestion for stimulation of gallbladder contraction. Methods: Patients evaluated with hepatobiliary iminodiacetic acid scan from 2014 to 2017 were reviewed and grouped based on testing stimulant (fatty meal versus cholecystokinin). Patients who later underwent cholecystectomy were selected for analysis. Hepatobiliary iminodiacetic acid results were correlated with surgical pathology and postoperative resolution of symptoms. Two-way statistical analysis was performed. Results: A total of 359 patients underwent hepatobiliary iminodiacetic acid scan followed by cholecystectomy for biliary dyskinesia. Patients who received fatty meal stimulant (n = 86) were compared to those that received cholecystokinin (n = 273). Mean gallbladder ejection fraction during hepatobiliary iminodiacetic acid was 38% and 44% for the cholecystokinin and fatty meal groups, respectively, P = .073. Predictive metrics were not statistically different between groups with regard to pathology, symptomatic improvement, or accuracy. Symptomatic resolution (cholecystokinin-hepatobiliary iminodiacetic acid 78%, fatty meal-hepatobiliary iminodiacetic acid 68%; P = 0.058) and specificity (cholecystokinin-hepatobiliary iminodiacetic acid 26%, fatty meal-hepatobiliary iminodiacetic acid 44%, P = 0.417) were comparable in both testing groups. Conclusion: Stimulation of gallbladder contraction with a fattymeal during hepatobiliary iminodiacetic acid testing is a more affordable and reliable alternative to cholecystokinin for patients undergoing evaluation for gallbladder dysmotility. (C) 2020 The Author(s). Published by Elsevier Inc.

Presenter: Aneil Sood | Indiana University Background: Liver directed therapy (LDT) for primary and secondary liver cancer has been increasingly utilized in patients with technically unresectable liver tumors, or in patients with surgically prohibitive underlying liver disease or medical comorbidities. Recent studies have shown that transarterial radioembolization (TARE) may reduce tumor burden and permit hepatectomy for complete tumor clearance. The short- and long-term outcomes of patients undergoing hepatectomy following TARE are reported in this study. Methods: An observational study of patients undergoing partial hepatectomy after TARE with yttrium-90 (Y90) between 2013-2018 was performed. Demographics, comorbidities, TARE specific variables, perioperative outcomes, and long-term outcomes were recorded. Variables specific to TARE included the number of procedures, arterial selectivity of embolization, and total millicurie (mCi) dose. Operative variables included the extent of hepatectomy, estimated blood loss (EBL), duration of operation, major postoperative morbidity (Clavien-Dindo Grade III-V complications), hospital readmission, and 30-day mortality. Long-term outcomes were recorded as pattern of recurrence, disease-free survival, and overall survival. Results: Eight patients (6 females, 2 males; mean age 60.4 +/- 1.8 years) underwent TARE for initially unresectable liver cancer, including hepatocellular carcinoma (n = 5), metastatic cancer (pancreatic neuroendocrine n = 1, pulmonary neuroendocrine n = 1), and cholangiocarcinoma (n = 1). The mean total dose of Y90 was 86.1 +/- 14.4 mCi during a single procedure (n = 4) or over two procedures (n = 4). Selective TARE was performed in five patients (63%) and nonselective in three patients (38%). The mean time from TARE to hepatectomy was 12.4 +/- 4 months. Six of the 8 patients (75%) required major hepatectomy (all open technique). Mean EBL was 1056 +/- 294 mL, and mean operative time was 271 +/- 43 minutes. Postoperatively, major morbidity was seen in three patients (38%) and included organ-space surgical site infection (n = 1), pneumonia requiring reintubation (n = 1), and bile leak (n = 2). Readmission occurred in four patients (50%). There were no 30-day mortalities. After a median follow-up of 37 months, recurrence was observed in four patients (50%); three patients developed hepatic recurrence, and one patient developed peritoneal recurrence. The mean disease-free survival and overall survival were 18.1 +-/ 5.0 months and 33.8 +/- 8.4 months, respectively. Conclusion: Hepatectomy following liver-directed therapy with Y90 radioembolization appears to be a safe treatment paradigm for patients with advanced stage liver cancer and can result in good long-term outcomes.

This study aimed to determine the incidence of new onset hepatic steatosis after neoadjuvant chemotherapy for pancreatic cancer and its impact on outcomes after pancreatoduodenectomy. Retrospective review identified patients who received neoadjuvant chemotherapy for pancreatic adenocarcinoma and underwent pancreatoduodenectomy from 2013 to 2018. Preoperative computed tomography scans were evaluated for the development of hepatic steatosis after neoadjuvant chemotherapy. Hypoattenuation included liver attenuation greater than or equal to 10 Hounsfield units less than tissue density of spleen on noncontrast computed tomography and greater than or equal to 20 Hounsfield units less on contrast-enhanced computed tomography. One hundred forty-nine patients received neoadjuvant chemotherapy for a median of 5 cycles (interquartile range (IQR), 4–6). FOLFIRINOX was the regimen in 78% of patients. Hepatic steatosis developed in 36 (24%) patients. The median time from neoadjuvant chemotherapy completion to pancreatoduodenectomy was 40 days (IQR, 29–51). Preoperative biliary stenting was performed in 126 (86%) patients. Neoadjuvant radiotherapy was delivered to 23 (15%) patients. Female gender, obesity, and prolonged exposure to chemotherapy were identified as risk factors for chemotherapy-associated hepatic steatosis. Compared with control patients without neoadjuvant chemotherapy-associated hepatic steatosis, patients developing steatosis had similar rates of postoperative pancreatic fistula (8% (control) vs. 4%, p = 0.3), delayed gastric emptying (8% vs. 14%, p = 0.4), and major morbidity (11% vs. 15%, p = 0.6). Ninety-day mortality was similar between groups (8% vs. 2%, p = 0.08). Hepatic steatosis developed in 24% of patients who received neoadjuvant chemotherapy but was not associated with increased morbidity or mortality after pancreatoduodenectomy.

BackgroundThis study evaluated closure techniques and incisional surgical site complications (SSCs) and incisional surgical site infections (SSIs) after pancreaticoduodenectomy (PD).MethodsRetrospective review of open PDs from 2015 to 2018 was performed. Outcomes were compared among closure techniques (subcuticular + topical skin adhesive (TSA); staples; subcuticular only). SSCs were defined as abscess, cellulitis, seroma, or fat necrosis. SSIs were defined according to the National Surgical Quality Improvement Program (NSQIP).ResultsPatients with subcuticular + TSA (n = 205) were less likely to develop an incisional SSC (9.8%) compared to staples (n = 139) (20.1%) and subcuticular (n = 74) (16.2%) on univariable analysis (P = 0.024). Multivariable analysis revealed no statistically significant difference in incisional SSC between subcuticular + TSA and subcuticular (P = 0.528); a significant difference remained between subcuticular + TSA and staples (P = 0.014). Unadjusted median length of stay (LOS) (days) was significantly longer for staples (9) vs. subcuticular (8) vs. subcuticular + TSA (7); P < 0.001. Incisional SSIs were evaluated separately according to the NSQIP definition. When comparing rates, the subcuticular + TSA group experienced lower incisional SSIs compared to the other two techniques (4.9% vs. 10.1%, 10.8%). However, this difference was not statistically significant by either univariable or multivariable analysis.ConclusionsSubcuticular suture + TSA reduces the risk of incisional SSCs when compared to staples alone after pancreaticoduodenectomy.

Background: Surgical site complications are one of the most closely monitored and prevalent post-operative problems, occurring in as many as 15 to 28% of patients that undergo pancreaticoduodenectomy. Wound complications not only affect patient recovery and quality of life, but also negatively impact quality metrics like cost and hospital length of stay. With many closure techniques available, we sought to determine if any closure method (subcuticular stitch vs. subcuticular stitch + skin sealant vs. staples) provided a benefit of reduced post-pancreatoduodenectomy wound complications. Methods: All patients that underwent open pancreatoduodenectomy from June 2015 to June 2018 were reviewed and grouped based on wound closure (subcuticular stitch vs. subcuticular stitch + skin sealant vs. staples). We performed a retrospective review of our institution’s prospective ACS-NSQIP database and augmented it through medical record review for wound closure method and superficial surgical site complications (SSSC). These included cellulitis, seroma, abscess, fat necrosis, and other. Closure groups were compared using independent samples t-test/analysis of variance and chi-square test for continuous and categorical variables respectively. Univariable analysis and multivariable regression models were used to examine the effect of wound closure method on the various post-operative outcomes, while controlling for pre-operative and peri-operative covariables. Results: A total of 418 pancreatoduodenectomies were included on study (N=74 subcuticular stitch, N= 205 subcuticular stitch + skin sealant, N=139 stapled). Operative time did not differ between groups. There was a significant difference in the incidence of SSSC between wound closure methods. Patients with subcuticular stitch + skin sealant (9.8%) were significantly less likely to develop a SSSC compared to patients with stapled closure (20.1%) on univariable (p=0.009) and multivariable analyses (p=0.016; OR 0.37). A similar though insignificant trend was seen for patients with subcuticular stitch + skin sealant (9.8%) compared to suture alone closure (16.2%) on univariable (p=0.142) analysis. Unadjusted length of stay was significantly longer for stapled closure (11.9 days) compared to subcuticular stich + skin sealant (9.6 days) and subcuticular stitch alone (9.8 days) (p<0.05), but did not reach significance on multivariable analysis. Conclusion: Subcuticular suture with skin sealant after pancreaticoduodenectomy appears to be the preferred method for skin closure to reduce the risk of superficial surgical site complications. A change of practice and prospective study of this technique is warranted in light of this data.